Effect of Spiritual Care on Care Burden of families of Individual with Severe and Chronic Mental Disorders

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Method : A randomized, controlled, clinical trial was conducted with a three-phase design (pre-intervention, post-intervention, and one-month follow-up) involving 60 family caregivers from psychiatric treatment centers in Isfahan, Iran. Participants were randomly assigned to either an intervention group or a control group. The intervention group received eight weekly educational sessions focusing on spirituality, during 2 months. The Zarit Caregiver Burden Interview was used to measure the caregiving burden before, immediately after, and one month following the intervention. Statistical analyses, including the Mann-Whitney U test, Friedman test, and two-way repeated measures ANOVA, were employed to evaluate the data. Results : Findings showed no significant difference in caregiving burden between the groups prior to the intervention (p > 0.05). However, the intervention group experienced a significant reduction in caregiving burden immediately after and one month following the intervention (p 0.05). Conclusion : The findings suggest that spiritually-based interventions can effectively alleviate the caregiving burden among family members of individuals with severe mental disorders. Integrating spiritual approaches into mental health care may enhance the psychological well-being of caregivers and improve their capacity to provide support and caregiving. Spiritual care care Burden Family caregivers Mental Disorders Introduction Mental disorder refers to conditions characterized by alterations in thinking, mood, or behavior (or sometimes a combination of these), accompanied by distress or impairment in functioning (1). Among mental disorders, a specific group is classified as severe and chronic or persistent mental disorders, marked by prolonged and recurrent episodes of illness. These include schizophrenia, bipolar disorder, and major depression (2, 3). This category of disorders leads to significant disability in affected individuals, to the extent that they are often unable to fulfill their duties and responsibilities. Such patients require long-term care, either in treatment facilities or through family support (4). Following the deinstitutionalization movement in the latter half of the 20th century, care for individuals with mental disorders has predominantly shifted from psychiatric institutions to community-based settings and, more specifically, to families (5). Today, over 60% of patients discharged from psychiatric facilities return to their nuclear families (6-8). Consequently, families have become a pivotal component in the care of individuals with severe mental disorders, playing a crucial role in their recovery and well-being (8-10). However, the burden of caregiving primarily falls on family members, who face significant challenges due to the cognitive and functional impairments associated with these disorders. These factors complicate psychiatric care and impose a heavy caregiving burden on family caregivers (11, 12). The concept of caregiving burden is a complex and multifaceted phenomenon, often described as a negative reaction experienced by caregivers as a result of providing care (13, 14). In essence, caregiving burden arises when there is an imbalance between the demands of caregiving and the support available to the caregiver (15). Care burden, particularly in the context of mental disorders, represents one of the key challenges associated with such conditions. Family members who care for individuals with psychiatric illnesses are at risk of experiencing high levels of burden, which can lead to a decline in their own health (16, 17). Research has demonstrated various consequences of caregiving burden, including mental health issues such as depression, anxiety, stress, and burnout, as well as physical health problems like diabetes and other chronic conditions. Additionally, caregivers may experience family dysfunction, social isolation, overuse of healthcare services, and financial difficulties (16, 18). Other significant sources of caregiving stress for families of individuals with mental illness include loss of employment, reduced household income, lack of support, and insufficient education or training regarding how to manage the condition (11, 19). Evidence suggests that compared to other chronic illnesses, caregivers of individuals with psychiatric disorders experience significantly higher levels of caregiving burden (16, 20). For instance, Haresabadi et al. found that most caregivers of mentally ill patients experience severe levels of caregiving stress (12). The cognitive and functional impairments experienced by individuals with mental disorders, along with factors such as lack of independence, self-harm tendencies, suicidal risks, low quality of life, severe anorexia, higher rates of complications and mortality, vulnerability to exploitation by others, and numerous other challenges, further exacerbate the difficulties faced by both patients and their families. These issues can impose a heavy burden on families and caregivers, compounding existing challenges and leading to significant distress (4, 21). Given the inherently challenging nature of caring for individuals with severe mental disorders, family caregivers need developing cognitive and behavioral coping strategies to better manage chronic stress and adapt to these challenges (5, 22). One effective approach to coping with illness and a significant factor influencing caregiving burden is the presence of spirituality and spiritual well-being, as well as fostering and enhancing the sense of spiritual health within the family (13). The unique nature and characteristics of spiritual actions and processes have led researchers such as Gall and colleagues to propose religious/spiritual coping as a specific framework for dealing with stress. According to this framework, when individuals encounter a stressor, they evaluate the situation under the influence of personal factors, the meaning of life, spiritual connections, and spiritual coping behaviors (5, 23). In other words, spirituality, as one of the existential dimensions of human life, becomes prominently evident during times of crisis and stress, creating meaning in life and serving as a source of inspiration for individuals facing challenges. Individuals with strong spiritual well-being are empowered, resilient, and possess greater control and access to social support (7- Barakhordary et al., 2022). Moreover, spiritual well-being is the core of human health, representing a complex and evolving process that fosters harmonious relationships between internal forces. It is characterized by stability in life, peace, close connections with the Creator, oneself, society, and the environment (11- Nehavandi et al., 2024). Indeed, spiritual well-being is the unifying force that coordinates the physical, psychological, and social dimensions of health, which is essential for promoting harmony between the patient and their family (3- Nehavandi et al., 2024). Spiritual interventions have gained attention in recent years as an effective therapeutic approach. Such interventions can assist patients' relatives by shifting their perspectives on the illness, symptoms, and behavioral signs, thereby reducing the psychological stress and emotional burden experienced by caregivers and promoting their mental well-being (23-25). Furthermore, alignment between coping strategies and religious or spiritual values reinforces the sustainability of therapeutic effects (26). Consequently, mental health practices, in order to achieve their goals across all levels of prevention, require integration with religious and spiritual frameworks (27, 28). Findings indicate that caregivers of individuals with chronic illnesses rely on spirituality as a significant source of support. Additionally, spiritual well-being is considered one of the meaningful factors influencing caregivers' quality of life (29, 30). Previous studies have demonstrated a significant inverse relationship between spiritual well-being and caregiving burden among caregivers (15, 31-33). A systematic review examining the spiritual aspects of family caregivers of individuals with severe mental illness identified both the spiritual needs and coping strategies employed by these caregivers. The study revealed that caregivers facing stressful situations often turn to sacred practices, engage in spiritual/religious rituals, and adhere to formal religious beliefs (34). Overall, research highlights that spiritual/religious coping strategies positively influence mental health and quality of life, and considering spirituality as a complementary approach can enhance caregivers' ability to provide better care (23, 29, 34). Despite the recognized importance of therapeutic spirituality in improving the mental health of families caring for individuals with severe mental disorders, this intervention has received limited attention in clinical practice and research. This is particularly concerning given that families of mentally ill individuals experience significant psychological stress and caregiving burdens, which can negatively impact their quality of life. In Iran, 98% of the population are Muslim, with approximately 90% being Shia Muslims. Religious culture is deeply intertwined with the lifestyle of Muslims, and religious beliefs play a crucial role in coping with crisis situations (35). In Islam, spirituality and religion are inseparable, and Islamic rituals shape spirituality based on faith and good deeds (36). According to reports from Iran, spirituality can significantly assist individuals in various aspects of life, particularly in dealing with severe and exhausting illnesses (35). Given the critical role of families and family caregivers in providing support and care for individuals with severe mental disorders, and considering the limited research conducted in Iran on the impact of spiritually-based interventions on the caregiving burden of families with mentally ill members, this study was undertaken to investigate the effect of spiritual intervention on the caregiving burden of family caregivers of patients with mental disorders. Material and Methods This study was designed as a two-group, three-phase (pre-intervention, post-intervention, and one-month follow-up) randomized clinical trial, conducted with both an intervention group and a control group. The research setting included psychiatric treatment centers in the city of Isfahan, Iran. The study population consisted of family caregivers of individuals with severe mental disorders whose patients had been hospitalized due to a diagnosed psychiatric condition by a specialist physician. Inclusion criterias were: 1. Willingness to participate in the study, as evidenced by signed informed consent, 2. Ability to read, write, and communicate effectively, 3. Non-dependence on psychoactive substances by the caregiver. 4. Absence of any significant physical, psychological, or cognitive impairments in the caregiver, 5. Age of 18 years or older, 6. A minimum of six months having passed since the definitive diagnosis of a psychiatric disorder (schizophrenia, bipolar disorder type 1, or major depression) in the patient, as confirmed by a psychiatrist, 7. No experience of a sudden accident or crisis in the past six months among the family caregivers, 8. No participation in a similar program during the previous six months, and 9. Being solely responsible for caring for one patient within the family. Exclusion criterias include: 1. Withdrawal of consent or unwillingness to continue participating in the sessions, 2. Missing more than two sessions, and 3. Development of severe psychological problems or stress during the course of the intervention. The participants were selected using a convenience sampling method and then randomly allocated to either the intervention or control group through simple random assignment. To calculate the sample size, the formula for comparing two independent samples was utilized. Based on this formula, the required sample size was estimated to be 25.3 individuals per group. Considering a potential dropout rate of 20% during the study, an additional 20% was added to the calculated sample size. Consequently, 30 participants were ultimately included in each group, resulting in a total of 60 participants for the entire study. The data collection tool in this study consisted of a two-part questionnaire, including: a) Demographic characteristics of the participants (age, gender, etc.), and b) The Zarit Caregiver Burden Interview. Zarit Caregiver Burden Interview: This questionnaire was developed in 1988 by Zarit and colleagues to measure the caregiving burden experienced by family caregivers. The instrument includes 22 items that assess personal, social, emotional, and economic pressures faced by caregivers. Responses are rated on a 5-point Likert scale as; never (0), rarely (1), sometimes (2), often (3), and always (4). The total score ranges from 0 to 88, with lower scores indicating a lesser caregiving burden (37-39). The validity and reliability of the Zarit Caregiver Burden Interview have been established for use within the Iranian cultural context by Navidian and colleagues. Content validity was confirmed through expert review, and test-retest reliability yielded a reliability coefficient of 94% (38-40). This demonstrates the questionnaire's suitability for assessing caregiving burden among Iranian family caregivers. To conduct the intervention, the researcher first obtained ethical approval and then visited the selected centers to recruit participants. A total of 60 individuals were selected using convenience sampling. For the participating caregivers, the objectives, schedule, benefits of attending the sessions, methods for withdrawal from the study, and potential research implications were explained in detail, and their questions were answered thoroughly. Following this, informed consent was obtained from all participants for their involvement in the study. After completing the initial questionnaires at the start of the study, participants were randomly assigned to either the intervention group (30 individuals) or the control group (30 individuals). To ensure randomization, the researcher numbered the names of the caregivers and allocated even numbers to the intervention group and odd numbers to the control group. The educational sessions were conducted face-to-face, utilizing instructional aids such as a laptop and slides containing spiritual content. The intervention group participated in 8 educational sessions, each lasting approximately 70 minutes, held twice a week over four weeks. Prior to each session, the researcher reminded the participants of the class schedule via text messages and phone calls to ensure their attendance. To encourage consistent participation in the spiritually-based program, the researcher employed motivational strategies to engage the participants. Participants in the intervention group were also encouraged to practice spiritual skills as homework outside of the sessions. The content of the sessions was developed based on credible sources, including Quranic verses, hadiths, and narrations from the infallible Imams, with input from seminary and university scholars (Table 1). In contrast, the control group did not receive the spiritually-based educational intervention. Instead, they attended two group education sessions covering general information about mental disorders. Following the completion of the intervention in the eight week, the researcher re-administered the post-test questionnaires, including the demographic and Zarit Caregiver Burden Interview, to both groups. The completed questionnaires were collected, placed in a packet, and submitted for analysis. To adhere to ethical principles, upon the conclusion of the study, the researcher provided the control group with the educational materials used in the spiritual intervention program in the form of a CD, ensuring that all participants had access to the content regardless of their group assignment. To determine the appropriate statistical test for comparing the main variables between the two groups, the normality of the variable distributions was first assessed using the Shapiro-Wilk test. To compare the two groups in terms of quantitative normal variables, the independent t-test was used, while for non-normal quantitative variables, the Mann-Whitney U test was employed. For within-group tests and to compare the three phases (pre-intervention, immediately post-intervention, and one month after the intervention), repeated measures ANOVA was used for normally distributed variables, and the Friedman test was applied for non-normal variables. In cases where significant differences were found across the three phases, post-hoc pairwise comparisons were conducted using the Bonferroni test for normal variables and the Dunn test for non-normal variables. A significance level of 5% was considered for all tests conducted in this study. Results The mean and standard deviation of the age of family caregivers of patients with mental disorders were 41.15 ± 11.5 years in the intervention group and 36.80 ± 10.0 years in the control group. Additionally, the mean and standard deviation of the duration of illness in the family member were 9.45 ± 5.9 years in the intervention group and 8.13 ± 5.3 years in the control group. The Mann-Whitney U test did not indicate any significant differences between these variables in the two groups (p > 0.05). In terms of gender distribution, 53.3% of patients in the intervention group and 56.7% in the control group were female. Other demographic characteristics of the participants are presented in Table 2. According to the results and analysis, there were no statistically significant differences in the demographic and background variables of family caregivers of patients with mental disorders between the intervention and control groups (Table 2). Therefore, the two groups were homogeneous in terms of demographic and background variables. Before the intervention, the mean and standard deviation of the caregiving burden for family caregivers of patients with mental disorders were 41.20 ± 18.0 in the intervention group and 38.62 ± 20.2 in the control group. The Mann-Whitney U test did not indicate a significant difference between the two groups (p > 0.05). Immediately after the intervention, the mean and standard deviation of the caregiving burden were 13.20 ± 8.0 in the intervention group and 39.20 ± 19.2 in the control group. One month after the intervention, these values were 13.20 ± 8.0 in the intervention group and 39.00 ± 19.0 in the control group. The Mann-Whitney U test revealed statistically significant differences between the two groups at both time points (p < 0.001) (Table 3). Furthermore, an intra-group analysis of the mean scores in the intervention group using the Friedman test showed a significant difference across the three assessment phases (pre-intervention, immediately post-intervention, and one month after the intervention) (p < 0.001). Post-hoc analysis using the Dunn test indicated that there was a significant difference between the pre-intervention phase and immediately post-intervention (p < 0.001), as well as between the pre-intervention phase and one month after the intervention (p < 0.001). However, no significant difference was found between immediately post-intervention and one month after the intervention (p = 0.100). In contrast, the Friedman test for the control group did not reveal any significant differences across the data collection phases (p > 0.05) (Table 3). Additionally, the results of the two-way repeated measures ANOVA demonstrated significant effects of time (p < 0.001), group (p < 0.001), and the interaction between group and time (p < 0.001) (Table 3). Discusion Families caring for individuals with mental disorders consistently face numerous physical, psychological, social, and familial challenges. Among the factors contributing to these challenges are the chronic and long-term nature of mental disorders, the complex and severe symptoms exhibited by patients, their disconnection from reality, difficulties in maintaining employment and effective social interactions, and the resultant problems related to treatment and its costs. Amidst these challenges, one of the most critical issues is the psychological well-being of family members themselves. Neglecting this aspect can pave the way for the onset of disorders among family members, leading to further complications. The primary focus of the present study was to investigate the impact of a spiritually-based intervention on the caregiving burden of those caring for individuals with mental disorders. The determination and comparison of the mean scores of caregiving burden among family caregivers of individuals with mental disorders before, immediately after, and one month following the intervention in both the experimental and control groups revealed that there was no significant difference in the mean caregiving burden score between the two groups prior to the intervention (p >0.05). However, in the intervention group, the caregiving burden score significantly decreased both immediately after and one month following the intervention compared to before the intervention (p 0.05). Based on these findings, the spiritually-based intervention appears to be an effective therapeutic approach in reducing the caregiving burden for those caring for individuals with mental disorders. The results of numerous studies conducted worldwide have highlighted religion as a supportive force in reducing psychological stress (7, 41-43). For instance, Qorbani et al. (2024) reported the effectiveness of religious spiritual care training on enhancing the physical, psychological, and behavioral resilience of caregivers for elderly individuals during the COVID-19 pandemic (44).Davari and their colleagues also emphasized the impact of spiritual therapy as an effective resource for coping with physical and psychological tentions of serious medical illnesses (45). Hefti (2011) demonstrated that 70-80% of people rely on their spirituality, religious beliefs, and religious counselors to cope with daily challenges and disappointments (46). Homer (2010) provided evidence showing that strong religious beliefs, spiritual aspirations, prayer, and acts of devotion positively influence both mental and physical health. Quine (2012) further revealed that religious individuals recover more quickly from illnesses compared to non-religious individuals, experience lower levels of negative emotions and depression, report less anxiety, and enjoy higher levels of social support. Sharifi and colleagues (2012) investigated the relationship between religious coping and depression and caregiver burnout among family caregivers. Their study indicated a significant relationship between dimensions of religious coping and depression as well as caregiver burnout among family caregivers (p <0.01). Additionally, resilient caregivers reported higher levels of positive religious coping and lower levels of negative religious coping compared to non-resilient caregivers. Regression analysis results showed that active coping strategies, passive religious coping, and negative emotions toward God were strong and significant predictors of depression among family caregivers (p < 0.005). The findings of the present study confirm the role of religious coping as an important source of adaptive coping with caregiving stress (47). In general, religion and spirituality can influence individuals' adaptation to high-pressure situations by providing a framework for understanding the meaning and cause of negative events, as well as offering an optimistic outlook on life. Indeed, religious commitment acts as a shield against stress, mitigating the detrimental effects of caregiving stress on caregivers' health. On this basis, religion and religious coping have been proposed as empowering resources for individuals dealing with the stressors associated with caring for patients (48, 49). Individuals who consider themselves more religious tend to perceive greater support, encouragement, and approval from friends and family. These social-spiritual connections can enhance feelings of security and attachment, positively influencing health and well-being. According to Richards and Bergin's perspective, spirituality has a positive impact on mental health, with the most significant factor being its role in improving an individual's attitude and interpretation of life and stress. This model provides a framework for integrating spiritual approaches with scientific theories and methods of psychotherapy (44). Based on this model, psychotherapists with diverse spiritual backgrounds can describe a practical process for implementing spiritual dimensions in therapy within an ethically and culturally appropriate structure. This strategy has universal applicability, allowing all monotheistic religions with various spiritual and religious traditions to act according to this framework while aligning with their own religious teachings (44, 50). Conclusion Based on these findings, the spiritually-based intervention appears to be an effective therapeutic approach in reducing the caregiving burden for those caring for individuals with mental disorders. This suggests that incorporating spiritual interventions into care strategies can play a pivotal role in alleviating the psychological and emotional strain experienced by family caregivers, thereby enhancing their overall well-being and capacity to provide effective care. Declarations Availability of data and material The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. This statement has been aligned with the data availability section in the submission system. Author’s contributions SGF, MFM, FKN, and RD were involved in Conceptualization, and FKN collected the dates. SGF, MFM, FKN, and RD analyzed the data. SGF, MFM, FKN, and RD were involved in the methodology. MFM was project administrators and supervised the project. SGF and FKN validated all stages of the project. SGF wrote the original draft of the manuscript and review and editing was done by MFM, FKN, and RD. Conflict of Interests There have been no conflicts of interest disclosed by any of the authors involved in this study. Acknowledgements The authors would like to thanks the participants of the study. Ethical Considerations This study was conducted in accordance with the principles of the Declaration of Helsinki. The Ethics Committee of Isfahan University of Medical Sciences approved the study (Ethics Code: IR.MUI.RESEARCH.REC.1398.015). Informed consent was obtained in writing from all participants involved in the study. The objectives and methodologies of the research were thoroughly explained to the participants, who were also informed of their right to withdraw from the study at any point. Confidentiality of participants’ information was guaranteed by the researchers. Clinical trial number Not applicable Consent to participate Informed consent was provided by patients and participants in this study in both written and verbal forms. 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The Effect of a Spirituality-Based Program on Stress, Anxiety, and Depression of Caregivers of Patients with Mental Disorders in Iran. J Relig Health. 2022;61(1):93-108. Sharma D. Spirituality in Psychotherapy: A Hidden Dimension. 2025. p. 158-71. Tables Table 1: Titles and Descriptions of Spiritual Care Sessions in the Study Session description Session title Introduction of group members to one another, explanation of the group’s objectives and member responsibilities, outlining group rules, definition and explanation of psychological disorders, detailed description of severe psychological disorders, presentation of a summary of therapeutic and care interventions specific to these patients, and an elucidation of the challenges involved in caring for such patients . Familiarity with members, introduction of objectives, presentation of a summary of psychological disorders Review of the previous session, obtaining feedback, describing spirituality and explaining its various aspects, awareness of the implicit and personal meaning of spirituality, and discussing the role of spirituality and religious activities in life and in coping with stress . Definition of spirituality, dimensions of spirituality, and the role of spirituality in life . Review of the previous session, definition of self-awareness and self-esteem, explanation of the importance of self-awareness and its role in life, and group discussion on the impacts of self-awareness in coping with stressful situations. Definition of self-awareness and self-esteem, and their importance in daily life . Review of the previous session, definition of gratitude and appreciation, explanation of the importance and role of gratitude in relation to God in life, and group discussion on the effects of gratitude in coping with stress. Description of Gratitude Expression and Its Role and Importance in Life Review of the previous session, gathering feedback, and discussion on forgiveness and its types, the role and importance of pardoning and forgiveness in life, their effects on improving emotional states, and encouraging individuals to share their experiences of forbearance, forgiveness, and subsequent emotional states. Forgiveness and Its Impact on Life Understanding the concepts of prayer (supplication) and invocation, their benefits, and their role in life events. Prayer and the importance of supplication and invocation in coping with unpleasant experiences. Understanding the concept of patience, instruction in the stages of patience, and recognizing the importance of patience and perseverance in accepting unpleasant situations in daily life. Patience and perseverance and their importance in daily life Review of the discussed topics, gathering feedback from therapy sessions, expressing members' opinions and emotions, and responding to questions. Comprehensive Summary of All Topics Table 2: Demographic characteristics of the participants in the study Variable Group p-value Control number (Percent) Intervention number (Percent) Gender Female 17 (56.7) 16 (53.3) p= 0.8 Chi-square test Male 13(43.3) 14 (46.7) Job Housewife 14(46.7) 11 (36.7) p= 0.7 Chi-square test Employed 10(33∙3) 8 (26.7) Unemployed 2(6.7) 5 (16.7) Retired 1(3.3) 2 (6.7) Free 3(10.0) 4 (13.3) Marital status Single 4(13.3) 7 (23.3) p= 0. 46 Chi-square test Married 23(76.7) 17 (56.7) Divorced 1(3.3) 1 (3.3) Wife died 2(6.7) 5 (16.7) Level of education High school 10 (33.3) 12 (40.0) p= 0.92 Mann Whitney test Diploma 13 (43.3) 8 (26.7) Associate degree 2 (6.7) 3 (10.0) Bachelor 4 (13.3) 6 (20.0) Master of Science 1(3.3) 1(3.3) Table 3: Mean and standard deviation of care burden in family caregivers of patients with mental disorders before and after the intervention in the intervention and control groups Variable Group Test result Control (n = 30) Mean ± standard deviation Intervention (n = 30) Mean ± standard deviation Before intervention 38.6± 20.2 41.2± 18.0 Z= -0.5, p= 0.604 Mann-Whitney test Immediately after the intervention 39.3± 19.2 13.2± 8.0 Z=-5.9, p< 0.001 Mann-Whitney test One month after the intervention 39.6± 19.0 13.3± 8.1 Z=-5.8, p< 0.001 Mann-Whitney test In-group test result Chi= 15.1, df=2, p= 0.321 Friedman test Chi= 50.3, df=2, p< 0.001 Friedman test Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6317765","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451447438,"identity":"3edbb316-3ad1-45a9-b3d9-b07abc2f1a50","order_by":0,"name":"Sara Ghafarfaraji","email":"","orcid":"","institution":"- Department of Psychology and Counseling, ARYAN institute of science and technology, Babol, Iran","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Ghafarfaraji","suffix":""},{"id":451447439,"identity":"bd12354a-a00c-4d04-b08d-e122576824b0","order_by":1,"name":"Malek Fereidooni-Moghadam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYFAC5gbGBhsQzWAAJCXk4BJsOLUwArWkIbQYk6CFAayFIbGBkLN02w82PpyRYJPPz8688cHHHRbp82dkJ35gqLFj4JM+gFWL2ZnEZsMNCWmWM5vZig1nnpHI3XAjd7MEw7FkBja+BOxaDiS2ST78cdjA4DCPmTRvG1ALCDGwHWBg48HuMLPzD9t/Pkj4b2AP1ZIuPyN38w+Gf3i03EhsY9yQcMDAgBmiJYHhRu42CcY2fFoeNkvOSEg2kDgM8kubhOGGM2+3WST2JfPgdljywY89CXYG/P2HgSHWVicv3567+caHb3Zy8j3YteAACQwMOOwYBaNgFIyCUUAMAACMZloG2Y7Q0wAAAABJRU5ErkJggg==","orcid":"","institution":"Community Based Psychiatric Care Research Center; School of Nursing and Midwifery; Shiraz University of Medical Sciences; Shiraz; Iran","correspondingAuthor":true,"prefix":"","firstName":"Malek","middleName":"","lastName":"Fereidooni-Moghadam","suffix":""},{"id":451447440,"identity":"ace8ec7e-0800-49bd-9441-b06cd35ad124","order_by":2,"name":"Fatemeh Khosravi Najafabadi","email":"","orcid":"","institution":"Nursing and Midwifery Care Research Center; Isfahan University of Medical Sciences; Isfahan; Iran","correspondingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"Khosravi","lastName":"Najafabadi","suffix":""},{"id":451447441,"identity":"2e62b3c2-36a4-4600-80ef-9e636ed753d6","order_by":3,"name":"Raziye Dehbozorgi","email":"","orcid":"","institution":"Community Based Psychiatric Care Research Center; School of Nursing and Midwifery; Shiraz University of Medical Sciences; Shiraz; Iran","correspondingAuthor":false,"prefix":"","firstName":"Raziye","middleName":"","lastName":"Dehbozorgi","suffix":""}],"badges":[],"createdAt":"2025-03-27 07:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6317765/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6317765/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82279345,"identity":"fc0c4a49-1009-46fd-85cd-d7afcf66bd34","added_by":"auto","created_at":"2025-05-08 15:02:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":719604,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6317765/v1/39d68eac-2b63-4883-ba2a-f63959d86452.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Spiritual Care on Care Burden of families of Individual with Severe and Chronic Mental Disorders","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental disorder refers to conditions characterized by alterations in thinking, mood, or behavior (or sometimes a combination of these), accompanied by distress or impairment in functioning (1). Among mental disorders, a specific group is classified as severe and chronic or persistent mental disorders, marked by prolonged and recurrent episodes of illness. These include schizophrenia, bipolar disorder, and major depression (2, 3). This category of disorders leads to significant disability in affected individuals, to the extent that they are often unable to fulfill their duties and responsibilities. Such patients require long-term care, either in treatment facilities or through family support \u0026nbsp;(4).\u003c/p\u003e\n\u003cp\u003eFollowing the deinstitutionalization movement in the latter half of the 20th century, care for individuals with mental disorders has predominantly shifted from psychiatric institutions to community-based settings and, more specifically, to families (5). Today, over 60% of patients discharged from psychiatric facilities return to their nuclear families (6-8). Consequently, families have become a pivotal component in the care of individuals with severe mental disorders, playing a crucial role in their recovery and well-being (8-10). However, the burden of caregiving primarily falls on family members, who face significant challenges due to the cognitive and functional impairments associated with these disorders. These factors complicate psychiatric care and impose a heavy caregiving burden on family caregivers (11, 12).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe concept of caregiving burden is a complex and multifaceted phenomenon, often described as a negative reaction experienced by caregivers as a result of providing care (13, 14). In essence, caregiving burden arises when there is an imbalance between the demands of caregiving and the support available to the caregiver (15). Care burden, particularly in the context of mental disorders, represents one of the key challenges associated with such conditions. Family members who care for individuals with psychiatric illnesses are at risk of experiencing high levels of burden, which can lead to a decline in their own health (16, 17).\u003c/p\u003e\n\u003cp\u003eResearch has demonstrated various consequences of caregiving burden, including mental health issues such as depression, anxiety, stress, and burnout, as well as physical health problems like diabetes and other chronic conditions. Additionally, caregivers may experience family dysfunction, social isolation, overuse of healthcare services, and financial difficulties (16, 18). Other significant sources of caregiving stress for families of individuals with mental illness include loss of employment, reduced household income, lack of support, and insufficient education or training regarding how to manage the condition (11, 19).\u003c/p\u003e\n\u003cp\u003eEvidence suggests that compared to other chronic illnesses, caregivers of individuals with psychiatric disorders experience significantly higher levels of caregiving burden (16, 20). For instance, Haresabadi et al. found that most caregivers of mentally ill patients experience severe levels of caregiving stress (12).\u0026nbsp;The cognitive and functional impairments experienced by individuals with mental disorders, along with factors such as lack of independence, self-harm tendencies, suicidal risks, low quality of life, severe anorexia, higher rates of complications and mortality, vulnerability to exploitation by others, and numerous other challenges, further exacerbate the difficulties faced by both patients and their families. These issues can impose a heavy burden on families and caregivers, compounding existing challenges and leading to significant distress (4, 21).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the inherently challenging nature of caring for individuals with severe mental disorders, family caregivers need developing cognitive and behavioral coping strategies to better manage chronic stress and adapt to these challenges (5, 22). One effective approach to coping with illness and a significant factor influencing caregiving burden is the presence of spirituality and spiritual well-being, as well as fostering and enhancing the sense of spiritual health within the family (13). The unique nature and characteristics of spiritual actions and processes have led researchers such as Gall and colleagues to propose religious/spiritual coping as a specific framework for dealing with stress. According to this framework, when individuals encounter a stressor, they evaluate the situation under the influence of personal factors, the meaning of life, spiritual connections, and spiritual coping behaviors (5, 23).\u003c/p\u003e\n\u003cp\u003eIn other words, spirituality, as one of the existential dimensions of human life, becomes prominently evident during times of crisis and stress, creating meaning in life and serving as a source of inspiration for individuals facing challenges. Individuals with strong spiritual well-being are empowered, resilient, and possess greater control and access to social support (7- Barakhordary et al., 2022). Moreover, spiritual well-being is the core of human health, representing a complex and evolving process that fosters harmonious relationships between internal forces. It is characterized by stability in life, peace, close connections with the Creator, oneself, society, and the environment (11- Nehavandi et al., 2024).\u0026nbsp;Indeed, spiritual well-being is the unifying force that coordinates the physical, psychological, and social dimensions of health, which is essential for promoting harmony between the patient and their family (3- Nehavandi et al., 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSpiritual interventions have gained attention in recent years as an effective therapeutic approach. Such interventions can assist patients\u0026apos; relatives by shifting their perspectives on the illness, symptoms, and behavioral signs, thereby reducing the psychological stress and emotional burden experienced by caregivers and promoting their mental well-being (23-25). Furthermore, alignment between coping strategies and religious or spiritual values reinforces the sustainability of therapeutic effects (26). Consequently, mental health practices, in order to achieve their goals across all levels of prevention, require integration with religious and spiritual frameworks (27, 28).\u003c/p\u003e\n\u003cp\u003eFindings indicate that caregivers of individuals with chronic illnesses rely on spirituality as a significant source of support. Additionally, spiritual well-being is considered one of the meaningful factors influencing caregivers\u0026apos; quality of life (29, 30). Previous studies have demonstrated a significant inverse relationship between spiritual well-being and caregiving burden among caregivers (15, 31-33). A systematic review examining the spiritual aspects of family caregivers of individuals with severe mental illness identified both the spiritual needs and coping strategies employed by these caregivers. The study revealed that caregivers facing stressful situations often turn to sacred practices, engage in spiritual/religious rituals, and adhere to formal religious beliefs (34).\u003c/p\u003e\n\u003cp\u003eOverall, research highlights that spiritual/religious coping strategies positively influence mental health and quality of life, and considering spirituality as a complementary approach can enhance caregivers\u0026apos; ability to provide better care (23, 29, 34). Despite the recognized importance of therapeutic spirituality in improving the mental health of families caring for individuals with severe mental disorders, this intervention has received limited attention in clinical practice and research. This is particularly concerning given that families of mentally ill individuals experience significant psychological stress and caregiving burdens, which can negatively impact their quality of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Iran, 98% of the population are Muslim, with approximately 90% being Shia Muslims. Religious culture is deeply intertwined with the lifestyle of Muslims, and religious beliefs play a crucial role in coping with crisis situations (35). In Islam, spirituality and religion are inseparable, and Islamic rituals shape spirituality based on faith and good deeds (36). According to reports from Iran, spirituality can significantly assist individuals in various aspects of life, particularly in dealing with severe and exhausting illnesses (35).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the critical role of families and family caregivers in providing support and care for individuals with severe mental disorders, and considering the limited research conducted in Iran on the impact of spiritually-based interventions on the caregiving burden of families with mentally ill members, this study was undertaken to investigate the effect of spiritual intervention on the caregiving burden of family caregivers of patients with mental disorders.\u0026nbsp;\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eThis study was designed as a two-group, three-phase (pre-intervention, post-intervention, and one-month follow-up) randomized clinical trial, conducted with both an intervention group and a control group. The research setting included psychiatric treatment centers in the city of Isfahan, Iran. The study population consisted of family caregivers of individuals with severe mental disorders whose patients had been hospitalized due to a diagnosed psychiatric condition by a specialist physician. Inclusion criterias were: 1. Willingness to participate in the study, as evidenced by signed informed consent, 2. Ability to read, write, and communicate effectively, 3. Non-dependence on psychoactive substances by the caregiver. 4. Absence of any significant physical, psychological, or cognitive impairments in the caregiver, 5. Age of 18 years or older, 6. A minimum of six months having passed since the definitive diagnosis of a psychiatric disorder (schizophrenia, bipolar disorder type 1, or major depression) in the patient, as confirmed by a psychiatrist, 7. No experience of a sudden accident or crisis in the past six months among the family caregivers, 8. No participation in a similar program during the previous six months, and 9. Being solely responsible for caring for one patient within the family. Exclusion criterias include: 1. Withdrawal of consent or unwillingness to continue participating in the sessions, 2. Missing more than two sessions, and 3. Development of severe psychological problems or stress during the course of the intervention.\u003c/p\u003e\n\u003cp\u003eThe participants were selected using a convenience sampling method and then randomly allocated to either the intervention or control group through simple random assignment. To calculate the sample size, the formula for comparing two independent samples was utilized. Based on this formula, the required sample size was estimated to be 25.3 individuals per group. Considering a potential dropout rate of 20% during the study, an additional 20% was added to the calculated sample size. Consequently, 30 participants were ultimately included in each group, resulting in a total of 60 participants for the entire study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data collection tool in this study consisted of a two-part questionnaire, including: a) Demographic characteristics of the participants (age, gender, etc.), and b) The Zarit Caregiver Burden Interview.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eZarit Caregiver Burden Interview: This questionnaire was developed in 1988 by Zarit and colleagues to measure the caregiving burden experienced by family caregivers. The instrument includes 22 items that assess personal, social, emotional, and economic pressures faced by caregivers. Responses are rated on a 5-point Likert scale as; never (0), rarely (1), sometimes (2), often (3), and always (4). The total score ranges from 0 to 88, with lower scores indicating a lesser caregiving burden (37-39).\u003c/p\u003e\n\u003cp\u003eThe validity and reliability of the Zarit Caregiver Burden Interview have been established for use within the Iranian cultural context by Navidian and colleagues. Content validity was confirmed through expert review, and test-retest reliability yielded a reliability coefficient of 94% (38-40). This demonstrates the questionnaire\u0026apos;s suitability for assessing caregiving burden among Iranian family caregivers.\u003c/p\u003e\n\u003cp\u003eTo conduct the intervention, the researcher first obtained ethical approval and then visited the selected centers to recruit participants. A total of 60 individuals were selected using convenience sampling. For the participating caregivers, the objectives, schedule, benefits of attending the sessions, methods for withdrawal from the study, and potential research implications were explained in detail, and their questions were answered thoroughly. Following this, informed consent was obtained from all participants for their involvement in the study. After completing the initial questionnaires at the start of the study, participants were randomly assigned to either the intervention group (30 individuals) or the control group (30 individuals). To ensure randomization, the researcher numbered the names of the caregivers and allocated even numbers to the intervention group and odd numbers to the control group.\u003c/p\u003e\n\u003cp\u003eThe educational sessions were conducted face-to-face, utilizing instructional aids such as a laptop and slides containing spiritual content. The intervention group participated in 8 educational sessions, each lasting approximately 70 minutes, held twice a week over four weeks. Prior to each session, the researcher reminded the participants of the class schedule via text messages and phone calls to ensure their attendance. To encourage consistent participation in the spiritually-based program, the researcher employed motivational strategies to engage the participants. Participants in the intervention group were also encouraged to practice spiritual skills as homework outside of the sessions. The content of the sessions was developed based on credible sources, including Quranic verses, hadiths, and narrations from the infallible Imams, with input from seminary and university scholars (Table 1).\u003c/p\u003e\n\u003cp\u003eIn contrast, the control group did not receive the spiritually-based educational intervention. Instead, they attended two group education sessions covering general information about mental disorders. Following the completion of the intervention in the eight week, the researcher re-administered the post-test questionnaires, including the demographic and Zarit Caregiver Burden Interview, to both groups. The completed questionnaires were collected, placed in a packet, and submitted for analysis.\u003c/p\u003e\n\u003cp\u003eTo adhere to ethical principles, upon the conclusion of the study, the researcher provided the control group with the educational materials used in the spiritual intervention program in the form of a CD, ensuring that all participants had access to the content regardless of their group assignment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo determine the appropriate statistical test for comparing the main variables between the two groups, the normality of the variable distributions was first assessed using the Shapiro-Wilk test. To compare the two groups in terms of quantitative normal variables, the independent t-test was used, while for non-normal quantitative variables, the Mann-Whitney U test was employed. For within-group tests and to compare the three phases (pre-intervention, immediately post-intervention, and one month after the intervention), repeated measures ANOVA was used for normally distributed variables, and the Friedman test was applied for non-normal variables. In cases where significant differences were found across the three phases, post-hoc pairwise comparisons were conducted using the Bonferroni test for normal variables and the Dunn test for non-normal variables. A significance level of 5% was considered for all tests conducted in this study.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean and standard deviation of the age of family caregivers of patients with mental disorders were 41.15 \u0026plusmn; 11.5 years in the intervention group and 36.80 \u0026plusmn; 10.0 years in the control group. Additionally, the mean and standard deviation of the duration of illness in the family member were 9.45 \u0026plusmn; 5.9 years in the intervention group and 8.13 \u0026plusmn; 5.3 years in the control group. The Mann-Whitney U test did not indicate any significant differences between these variables in the two groups (p \u0026gt; 0.05). In terms of gender distribution, 53.3% of patients in the intervention group and 56.7% in the control group were female. Other demographic characteristics of the participants are presented in Table 2. According to the results and analysis, there were no statistically significant differences in the demographic and background variables of family caregivers of patients with mental disorders between the intervention and control groups (Table 2). \u0026nbsp;Therefore, the two groups were homogeneous in terms of demographic and background variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBefore the intervention, the mean and standard deviation of the caregiving burden for family caregivers of patients with mental disorders were 41.20 \u0026plusmn; 18.0 in the intervention group and 38.62 \u0026plusmn; 20.2 in the control group. The Mann-Whitney U test did not indicate a significant difference between the two groups (p \u0026gt; 0.05). Immediately after the intervention, the mean and standard deviation of the caregiving burden were 13.20 \u0026plusmn; 8.0 in the intervention group and 39.20 \u0026plusmn; 19.2 in the control group. One month after the intervention, these values were 13.20 \u0026plusmn; 8.0 in the intervention group and 39.00 \u0026plusmn; 19.0 in the control group. The Mann-Whitney U test revealed statistically significant differences between the two groups at both time points (p \u0026lt; 0.001) (Table 3).\u003c/p\u003e\n\u003cp\u003eFurthermore, an intra-group analysis of the mean scores in the intervention group using the Friedman test showed a significant difference across the three assessment phases (pre-intervention, immediately post-intervention, and one month after the intervention) (p \u0026lt; 0.001). Post-hoc analysis using the Dunn test indicated that there was a significant difference between the pre-intervention phase and immediately post-intervention (p \u0026lt; 0.001), as well as between the pre-intervention phase and one month after the intervention (p \u0026lt; 0.001). However, no significant difference was found between immediately post-intervention and one month after the intervention (p = 0.100). In contrast, the Friedman test for the control group did not reveal any significant differences across the data collection phases (p \u0026gt; 0.05) (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, the results of the two-way repeated measures ANOVA demonstrated significant effects of time (p \u0026lt; 0.001), group (p \u0026lt; 0.001), and the interaction between group and time (p \u0026lt; 0.001) (Table 3).\u0026nbsp;\u003c/p\u003e"},{"header":"Discusion","content":"\u003cp\u003eFamilies caring for individuals with mental disorders consistently face numerous physical, psychological, social, and familial challenges. Among the factors contributing to these challenges are the chronic and long-term nature of mental disorders, the complex and severe symptoms exhibited by patients, their disconnection from reality, difficulties in maintaining employment and effective social interactions, and the resultant problems related to treatment and its costs. Amidst these challenges, one of the most critical issues is the psychological well-being of family members themselves. Neglecting this aspect can pave the way for the onset of disorders among family members, leading to further complications. The primary focus of the present study was to investigate the impact of a spiritually-based intervention on the caregiving burden of those caring for individuals with mental disorders.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe determination and comparison of the mean scores of caregiving burden among family caregivers of individuals with mental disorders before, immediately after, and one month following the intervention in both the experimental and control groups revealed that there was no significant difference in the mean caregiving burden score between the two groups prior to the intervention (p \u0026gt;0.05). However, in the intervention group, the caregiving burden score significantly decreased both immediately after and one month following the intervention compared to before the intervention (p \u0026lt; 0.001). In contrast, the caregiving burden score in the control group did not show any significant change during the same time periods (p \u0026gt;0.05). Based on these findings, the spiritually-based intervention appears to be an effective therapeutic approach in reducing the caregiving burden for those caring for individuals with mental disorders.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of numerous studies conducted worldwide have highlighted religion as a supportive force in reducing psychological stress (7, 41-43). For instance, Qorbani et al. (2024) reported the effectiveness of religious spiritual care training on enhancing the physical, psychological, and behavioral resilience of caregivers for elderly individuals during the COVID-19 pandemic (44).Davari and their colleagues also emphasized the impact of spiritual therapy as an effective resource for coping with physical and psychological tentions of \u0026nbsp; serious medical illnesses (45). Hefti (2011) demonstrated that 70-80% of people rely on their spirituality, religious beliefs, and religious counselors to cope with daily challenges and disappointments (46).\u0026nbsp;Homer (2010) provided evidence showing that strong religious beliefs, spiritual aspirations, prayer, and acts of devotion positively influence both mental and physical health. Quine (2012) further revealed that religious individuals recover more quickly from illnesses compared to non-religious individuals, experience lower levels of negative emotions and depression, report less anxiety, and enjoy higher levels of social support.\u003c/p\u003e\n\u003cp\u003eSharifi and colleagues (2012) investigated the relationship between religious coping and depression and caregiver burnout among family caregivers. Their study indicated a significant relationship between dimensions of religious coping and depression as well as caregiver burnout among family caregivers (p \u0026lt;0.01). Additionally, resilient caregivers reported higher levels of positive religious coping and lower levels of negative religious coping compared to non-resilient caregivers. Regression analysis results showed that active coping strategies, passive religious coping, and negative emotions toward God were strong and significant predictors of depression among family caregivers (p \u0026lt; 0.005). The findings of the present study confirm the role of religious coping as an important source of adaptive coping with caregiving stress\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e (47).\u003c/p\u003e\n\u003cp\u003eIn general, religion and spirituality can influence individuals\u0026apos; adaptation to high-pressure situations by providing a framework for understanding the meaning and cause of negative events, as well as offering an optimistic outlook on life. Indeed, religious commitment acts as a shield against stress, mitigating the detrimental effects of caregiving stress on caregivers\u0026apos; health. On this basis, religion and religious coping have been proposed as empowering resources for individuals dealing with the stressors associated with caring for patients (48, 49).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIndividuals who consider themselves more religious tend to perceive greater support, encouragement, and approval from friends and family. These social-spiritual connections can enhance feelings of security and attachment, positively influencing health and well-being. According to Richards and Bergin\u0026apos;s perspective, spirituality has a positive impact on mental health, with the most significant factor being its role in improving an individual\u0026apos;s attitude and interpretation of life and stress. This model provides a framework for integrating spiritual approaches with scientific theories and methods of psychotherapy (44). Based on this model, psychotherapists with diverse spiritual backgrounds can describe a practical process for implementing spiritual dimensions in therapy within an ethically and culturally appropriate structure. This strategy has universal applicability, allowing all monotheistic religions with various spiritual and religious traditions to act according to this framework while aligning with their own religious teachings (44, 50).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on these findings, the spiritually-based intervention appears to be an effective therapeutic approach in reducing the caregiving burden for those caring for individuals with mental disorders. This suggests that incorporating spiritual interventions into care strategies can play a pivotal role in alleviating the psychological and emotional strain experienced by family caregivers, thereby enhancing their overall well-being and capacity to provide effective care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. This statement has been aligned with the data availability section in the submission system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSGF, MFM, FKN, and RD\u0026nbsp;were involved in Conceptualization, and FKN collected the dates.\u0026nbsp;SGF, MFM, FKN, and RD\u0026nbsp;analyzed the data.\u0026nbsp;SGF, MFM, FKN, and RD\u0026nbsp;were involved in the methodology. MFM was project administrators and supervised the project.\u0026nbsp;SGF and FKN\u0026nbsp;validated all stages of the project. SGF wrote the original draft of the manuscript and review and editing was done by\u0026nbsp;MFM, FKN, and RD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere have been no conflicts of interest disclosed by any of the authors involved in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thanks the participants of the study.\u003cbr\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. The Ethics Committee of Isfahan University of Medical Sciences approved the study (Ethics Code: IR.MUI.RESEARCH.REC.1398.015). Informed consent was obtained in writing from all participants involved in the study. The objectives and methodologies of the research were thoroughly explained to the participants, who were also informed of their right to withdraw from the study at any point. Confidentiality of participants\u0026rsquo; information was guaranteed by the researchers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was provided by patients and participants in this study in both written and verbal forms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStein DJ, Palk AC, Kendler KS. What is a mental disorder? An exemplar-focused approach. Psychol Med. 2021;51(6):894-901.\u003c/li\u003e\n\u003cli\u003eWittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jonsson B, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology. 2011;21(9):655-79.\u003c/li\u003e\n\u003cli\u003eZumstein N, Riese F. Defining Severe and Persistent Mental Illness-A Pragmatic Utility Concept Analysis. Front Psychiatry. 2020;11:648.\u003c/li\u003e\n\u003cli\u003eMolu NG, Ozkan B, Icel S. Quality of life for chronic psychiatric illnesses and home care. Pakistan journal of medical sciences. 2016;32(2):511.\u003c/li\u003e\n\u003cli\u003eCasaleiro T, Caldeira S. Spiritual aspects of the family caregivers\u0026rsquo; experiences when caring for a community-dwelling adult with severe mental illness: a qualitative systematic review protocol. JBI Evidence Synthesis. 2019;17(5):654-9.\u003c/li\u003e\n\u003cli\u003eAmusoltani H, Pahlavanzadeh S, Maghsudi ganjeh J. Vest gating knowledge and attitudes of caregivers of patients affected by mental disorders towards complementary medicine treatments in health centers affiliated to Isfahan University of Medical Sciences in 2014. Journal of Islamic and Iranian Traditional Medicine. 2017;8(1):117-23.\u003c/li\u003e\n\u003cli\u003eAsadi P, Fereidooni-Moghadam M, Dashtbozorgi B, Masoudi R. Relationship between care burden and religious beliefs among family caregivers of mentally ill patients. Journal of religion and health. 2018;58(4):1125-34.\u003c/li\u003e\n\u003cli\u003eKarimirad MR, Seyedfatemi N, Noghani F, Amini E, Kamali R. Resilience of Family Caregivers of People with Mental Disorders in Tehran, Iran. Iranian Journal of Nursing Research (IJNR). 2017;13(1):56-62.\u003c/li\u003e\n\u003cli\u003eAhmadvand A, Sepehrmanesh Z, Ghoreishi FS, Afshinmajd S. Prevalence of psychiatric disorders in the general population of Kashan, Iran. Archives of Iranian Medicine, . 2012;15:205-9.\u003c/li\u003e\n\u003cli\u003eGhanei M, Chilosi M, Mohammad Hosseini Akbari H, Motiei-Langroudi R, Harandi AA, Shamsaei H, et al. Use of immunohistochemistry techniques in patients exposed to sulphur mustard gas. Pathology research international. 2011;2011:7.\u003c/li\u003e\n\u003cli\u003eHaghgoo A, Zoladl M, Afroughi S, Rahimian H, Saeid Mirzaee M. Assessment of the Burden on Family Caregivers of Patients with Mental Disorders Hospitalized in Shahid Rajai Hospital in Yasuj, 2016. Journal of Nursing Education. 2017;5(2):39-44.\u003c/li\u003e\n\u003cli\u003eHaresabadi M, Bibak B, Hosein zadeh E, Bayati M, Arki M, Akbari H. Assessing burden of family caregivers of patients with schizophrenia Admitted in IMAM REZA hospital- Bojnurd 2010. 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BMC Psychiatry. 2017;17(1):353.\u003c/li\u003e\n\u003cli\u003eChang H-Y, Chiou C-J, Chen N-S. Impact of mental health and caregiver burden on family caregivers\u0026rsquo; physical health. Archives of gerontology and geriatrics. 2010;50(3):267-71.\u003c/li\u003e\n\u003cli\u003eMohammed S, Priya SS, George C. Caregiver Burden in a Community Mental Health Program-a Cross Sectional Study. Kerala Journal of Psychiatry. 2015;28(1):26-33.\u003c/li\u003e\n\u003cli\u003eLee K, Martin P, Poon LW. Predictors of caregiving burden: impact of subjective health, negative affect, and loneliness of octogenarians and centenarians. Aging Ment Health. 2017;21(11):1214-21.\u003c/li\u003e\n\u003cli\u003eAmpalam P, Gunturu S, Padma V. A comparative study of caregiver burden in psychiatric illness and chronic medical illness. Indian journal of psychiatry. 2012;54(3):239-43.\u003c/li\u003e\n\u003cli\u003eCorrigan P, Pickett S, Kraus D, Burks R, Schmidt A. Community-based participatory research examining the health care needs of African Americans who are homeless with mental illness. Journal of health care for the poor and underserved. 2015;26(1):119.\u003c/li\u003e\n\u003cli\u003eDaliri DB, Aninanya GA, Laari TT, Abagye N, Afaya A. Coping strategies used by informal family caregivers of individuals living with mental illness in the Upper East Region of Ghana: a qualitative study. BMJ Open. 2024;14(7):e084791.\u003c/li\u003e\n\u003cli\u003eCasaleiro T, Martins H, Caldeira S. Promoting Spiritual Coping of Family Caregivers of an Adult Relative with Severe Mental Illness: Development and Test of a Nursing Intervention. Healthcare (Basel). 2024;12(13).\u003c/li\u003e\n\u003cli\u003eUzun U, Başar S, Saritaş A. Spiritual needs of family caregivers in palliative care. BMC Palliative Care. 2024;23(1):256.\u003c/li\u003e\n\u003cli\u003eBehdar Mr, Sheikh R. Investigating the effect of Salat (Muslim prayer) on mental health in the results of clinical studies: A mini review. Sport Sciences and Health Research. 2023;15(2):267-74.\u003c/li\u003e\n\u003cli\u003eYaghubi H, Karimi M, Omidi A, Mesbah N, Kahani Sh A-Q-QM. Prevalence of mental disorders and demographic factors that influence the freshmen students of Tehran City Universities of Medical Sciences. Journal of Clinical Psychology. 2014;6(2):95-104.\u003c/li\u003e\n\u003cli\u003eVaillant G, Templeton J, Ardelt M, Meyer SE. The natural history of male mental health: Health and religious involvement. Social science \u0026amp; medicine. 2008;66(2):221-31.\u003c/li\u003e\n\u003cli\u003eAggarwal S, Wright J, Morgan A, Patton G, Reavley N. Religiosity and spirituality in the prevention and management of depression and anxiety in young people: a systematic review and meta-analysis. BMC Psychiatry. 2023;23(1):729.\u003c/li\u003e\n\u003cli\u003eBarkhordari-Sharifabad M, Mousavi N-S. The Effect of Spiritual Skills Training on the Quality of Life of Family Caregivers of Hemodialysis Patients. Avicenna Journal of Nursing and Midwifery Care. 2022;30(4):280-7.\u003c/li\u003e\n\u003cli\u003eR\u0026oslash;en I, Brenne AT, Brunelli C, Stifoss-Hanssen H, Grande G, Solheim TS, et al. Spiritual quality of life in family carers of patients with advanced cancer-a cross-sectional study. Support Care Cancer. 2021;29(9):5329-39.\u003c/li\u003e\n\u003cli\u003eSpurlock WR. Spiritual well-being and caregiver burden in Alzheimer\u0026apos;s caregivers. Geriatr Nurs. 2005;26(3):154-61.\u003c/li\u003e\n\u003cli\u003eSpatuzzi R, Giulietti MV, Ricciuti M, Merico F, Fabbietti P, Raucci L, et al. Exploring the associations between spiritual well-being, burden, and quality of life in family caregivers of cancer patients. Palliat Support Care. 2019;17(3):294-9.\u003c/li\u003e\n\u003cli\u003ePareeth MC, Anbu K. Spiritual well-being and caregivers\u0026apos; strain in dementia caregiving. International Journal of Research. 2016;12.\u003c/li\u003e\n\u003cli\u003eCasaleiro T, Caldeira S, Cardoso D, Apostolo J. Spiritual aspects of the family Caregivers\u0026rsquo; experiences when caring for a Community‐Dwelling adult with severe mental illness: a systematic review of qualitative evidence. Journal of Psychiatric and Mental Health Nursing. 2022;29(2):240-73.\u003c/li\u003e\n\u003cli\u003eAsadzandi M, Shahrabi Farahany S, Abolghasemy H, Saberi M, Ebadi A. Effect of spiritual care on the care burden of families of children with cancer: a randomized controlled trial. Family Medicine \u0026amp; Primary Care Review. 2021;23(3):279-83.\u003c/li\u003e\n\u003cli\u003eAsadzandi M, Abolghasemi H. Reinforcing faith, the main care and method of maintaining and improving the spiritual health of patients and clients. 2018;1.\u003c/li\u003e\n\u003cli\u003eTabrizi L, Nawab E, Farokhnezhad Afshar P, Asadi Noghabi A, Haqqan H. The effect of cognitive behavioral training interventions on family caregivers burden of care for the elderly Alzheimer\u0026apos;s. Faculty of Nursing and Midwifery, Tehran University of Medical Sciences Journal. 2015;21 (1):1-2.\u003c/li\u003e\n\u003cli\u003eZarit SH RK, Bach-Peterson J. Development of the Zarit Burden Interview. The Gerontologist. 1988;28(6):919-26.\u003c/li\u003e\n\u003cli\u003eCJ BCAFKRAGATCZSL. Zarit Caregiver Interview for Alzheimer\u0026apos;s Disease 27 (ZCI-AD-27) 2023 [updated January 2025. Available from: https://eprovide.mapi-trust.org/instruments/zarit-caregiver-interview-for-alzheimer-s-disease-27.\u003c/li\u003e\n\u003cli\u003eNavidian A, Bahari F. Burden experienced by family caregivers of patients with mental disorders. Pakistan Journal of Psychological Research. 2008;23(1-2):19-29.\u003c/li\u003e\n\u003cli\u003eKashfi M. The relationship between religious attitude and mental health in students of Shiraz University of Medical Sciences. 2015.\u003c/li\u003e\n\u003cli\u003eHeshmati A. Religious Belives and Mental Health. contemporary psychology. 2015;10.\u003c/li\u003e\n\u003cli\u003eTriana L, Sudjatmiko IG. The Role of Religious Coping in Caregiving Stress. Religions. 2021;12(6):440.\u003c/li\u003e\n\u003cli\u003eQorbani A, Pouladi S, Farhadi A, Bagherzadeh R, Shekariyan M. The Impact of Religious Spiritual Care Training on the Ability and Spiritual Health of the Family Caregivers of Older Adults during the COVID-19 Pandemic: A Field Trial. Iranian South Medical Journal. 2024;27(1):80-98.\u003c/li\u003e\n\u003cli\u003eDavari S, Boogar IR, Talepasand S, Evazi MR. The Effect of Religious-Spiritual Psychotherapy on Illness Perception and Inner Strength among Patients with Breast Cancer in Iran. J Relig Health. 2022;61(6):4302-19.\u003c/li\u003e\n\u003cli\u003eHefti R. Integrating religion and spirituality into mental health care, psychiatry and psychotherapy. Religions. 2011;2(4):611-27.\u003c/li\u003e\n\u003cli\u003eSharifi M, Fatehizade M. Correlation between religious coping with deppression and caregiver burnout in family caregivers. Modern Care Journal. 2012;9(4).\u003c/li\u003e\n\u003cli\u003eTarakeshwar N, Pearce MJ, Sikkema KJ. Development and implementation of a spiritual coping group intervention for adults living with HIV/AIDS: A pilot study. Mental health, religion \u0026amp; culture. 2005;8(3):179-90.\u003c/li\u003e\n\u003cli\u003eKhosravi F, Fereidooni-Moghadam M, Mehrabi T, Moosavizade SR. The Effect of a Spirituality-Based Program on Stress, Anxiety, and Depression of Caregivers of Patients with Mental Disorders in Iran. J Relig Health. 2022;61(1):93-108.\u003c/li\u003e\n\u003cli\u003eSharma D. Spirituality in Psychotherapy: A Hidden Dimension. 2025. p. 158-71.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Titles and Descriptions of Spiritual Care Sessions in the Study\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable dir=\"rtl\" border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"628\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 437px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eSession description\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eSession title\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 437px;\"\u003e\n \u003cp dir=\"LTR\"\u003eIntroduction of group members to one another, explanation of the group\u0026rsquo;s objectives and member responsibilities, outlining group rules, definition and explanation of psychological disorders, detailed description of severe psychological disorders, presentation of a summary of therapeutic and care interventions specific to these patients, and an elucidation of the challenges involved in caring for such patients\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFamiliarity with members, introduction of objectives, presentation of a summary of psychological disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 437px;\"\u003e\n \u003cp dir=\"LTR\"\u003eReview of the previous session, obtaining feedback, describing spirituality and explaining its various aspects, awareness of the implicit and personal meaning of spirituality, and discussing the role of spirituality and religious activities in life and in coping with stress\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp dir=\"LTR\"\u003eDefinition of spirituality, dimensions of spirituality, and the role of spirituality in life\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 437px;\"\u003e\n \u003cp dir=\"LTR\"\u003eReview of the previous session, definition of self-awareness and self-esteem, explanation of the importance of self-awareness and its role in life, and group discussion on the impacts of self-awareness in coping with stressful situations.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp dir=\"LTR\"\u003eDefinition of self-awareness and self-esteem, and their importance in daily life\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 437px;\"\u003e\n \u003cp dir=\"LTR\"\u003eReview of the previous session, definition of gratitude and appreciation, explanation of the importance and role of gratitude in relation to God in life, and group discussion on the effects of gratitude in coping with stress.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp dir=\"LTR\"\u003eDescription of Gratitude Expression and Its Role and Importance in Life\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp dir=\"LTR\"\u003eReview of the previous session, gathering feedback, and discussion on forgiveness and its types, the role and importance of pardoning and forgiveness in life, their effects on improving emotional states, and encouraging individuals to share their experiences of forbearance, forgiveness, and subsequent emotional states.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp dir=\"LTR\"\u003eForgiveness and Its Impact on Life\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp dir=\"LTR\"\u003eUnderstanding the concepts of prayer (supplication) and invocation, their benefits, and their role in life events.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp dir=\"LTR\"\u003ePrayer and the importance of supplication and invocation in coping with unpleasant experiences.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp dir=\"LTR\"\u003eUnderstanding the concept of patience, instruction in the stages of patience, and recognizing the importance of patience and perseverance in accepting unpleasant situations in daily life.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp dir=\"LTR\"\u003ePatience and perseverance and their importance in daily life\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 436px;\"\u003e\n \u003cp dir=\"LTR\"\u003eReview of the discussed topics, gathering feedback from therapy sessions, expressing members\u0026apos; opinions and emotions, and responding to questions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp dir=\"LTR\"\u003eComprehensive Summary of All Topics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp dir=\"RTL\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDemographic characteristics of the participants in the study\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003enumber (Percent)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003enumber (Percent)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e17 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e16 (53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003ep= 0.8\u003c/p\u003e\n \u003cp\u003eChi-square test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e13(43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e14\u0026nbsp;(46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJob\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousewife\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e14(46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e11 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003ep= 0.7\u003c/p\u003e\n \u003cp\u003eChi-square test\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e10(33∙3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e8 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnemployed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e2(6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e5 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetired\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e1(3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e2 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e3(10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e4 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e4(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e7 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003ep= 0. 46\u003c/p\u003e\n \u003cp\u003eChi-square test\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e23(76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e17 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDivorced\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e1(3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;1 (3.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWife died\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e2(6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e5 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh school\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e10 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e12 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003ep= 0.92\u003c/p\u003e\n \u003cp\u003eMann Whitney test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiploma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e13 (43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e8 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssociate degree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e2 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e3 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBachelor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e4 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e6 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaster of Science\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e1(3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e1(3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003cspan dir=\"RTL\"\u003e\u003c/span\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Mean and standard deviation of \u0026nbsp; care burden in family caregivers of \u0026nbsp; patients with mental disorders before and after the intervention in the intervention and control groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest result\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(n = 30)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Mean\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;standard deviation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(n = 30)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Mean\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;standard deviation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore intervention\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e38.6\u0026plusmn; 20.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e41.2\u0026plusmn; 18.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eZ= -0.5,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ep= 0.604\u003c/p\u003e\n \u003cp\u003eMann-Whitney test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImmediately after the intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e39.3\u0026plusmn; 19.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e13.2\u0026plusmn; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eZ=-5.9,\u003c/p\u003e\n \u003cp\u003ep\u0026lt; 0.001\u003c/p\u003e\n \u003cp\u003eMann-Whitney test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOne month after the intervention\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e39.6\u0026plusmn; 19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e13.3\u0026plusmn; 8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eZ=-5.8,\u003c/p\u003e\n \u003cp\u003ep\u0026lt; 0.001\u003c/p\u003e\n \u003cp\u003eMann-Whitney test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn-group test result\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eChi= 15.1, df=2,\u003c/p\u003e\n \u003cp\u003ep= 0.321\u003c/p\u003e\n \u003cp\u003eFriedman test\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eChi= 50.3, df=2,\u003c/p\u003e\n \u003cp\u003ep\u0026lt; 0.001\u003c/p\u003e\n \u003cp\u003eFriedman test\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Spiritual care, care Burden, Family caregivers, Mental Disorders","lastPublishedDoi":"10.21203/rs.3.rs-6317765/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6317765/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study aimed to investigate the effect of spiritual care on the caregiving burden of families caring for individuals with severe and chronic mental disorders.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethod\u003c/b\u003e: A randomized, controlled, clinical trial was conducted with a three-phase design (pre-intervention, post-intervention, and one-month follow-up) involving 60 family caregivers from psychiatric treatment centers in Isfahan, Iran. Participants were randomly assigned to either an intervention group or a control group. The intervention group received eight weekly educational sessions focusing on spirituality, during 2 months. The Zarit Caregiver Burden Interview was used to measure the caregiving burden before, immediately after, and one month following the intervention. Statistical analyses, including the Mann-Whitney U test, Friedman test, and two-way repeated measures ANOVA, were employed to evaluate the data.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e: Findings showed no significant difference in caregiving burden between the groups prior to the intervention (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, the intervention group experienced a significant reduction in caregiving burden immediately after and one month following the intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas no significant change was observed in the control group (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: The findings suggest that spiritually-based interventions can effectively alleviate the caregiving burden among family members of individuals with severe mental disorders. Integrating spiritual approaches into mental health care may enhance the psychological well-being of caregivers and improve their capacity to provide support and caregiving.\u003c/p\u003e","manuscriptTitle":"Effect of Spiritual Care on Care Burden of families of Individual with Severe and Chronic Mental Disorders","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 08:49:12","doi":"10.21203/rs.3.rs-6317765/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"df7f54a9-7510-4b57-a26c-3ead235c32bc","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-08T14:54:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-05 08:49:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6317765","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6317765","identity":"rs-6317765","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}