The Relationship between Psychological Resilience and Caregiver Burden among Caregivers of Patients with Bipolar Disorder: The Mediating Role of Coping Styles

The Relationship between Psychological Resilience and Caregiver Burden among Caregivers of Patients with Bipolar Disorder: The Mediating Role of Coping Styles | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Relationship between Psychological Resilience and Caregiver Burden among Caregivers of Patients with Bipolar Disorder: The Mediating Role of Coping Styles Yanfang Liu¹, Chunhua Sun¹, Yue Sun, Zao Zeng, Yuan Hu, Cong Shu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6480206/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background： As a high-disability psychiatric disorder, bipolar disorder (BD) subjects family caregivers to chronic multidimensional stress due to its relapsing nature. While resilience alleviates stress through cognitive regulation, high resilience may trigger excessive active coping strategies, leading to chronic allostatic load. Coping styles, as behavioral manifestations of resilience, demonstrate dual-edge effects: buffering acute stress versus exacerbating chronic exhaustion. Existing research neglects how BD-specific factors (e.g., aggression) dynamically modulate the "resilience-coping-burden" pathway. This study investigates the mediating mechanisms of coping styles to inform precision interventions. Methods： This descriptive cross-sectional study enrolled 176 family caregivers of hospitalized bipolar disorder patients from the psychiatric department of Renmin Hospital of Wuhan University between March 2024 and January 2025. Participants were assessed using the Connor-Davidson Resilience Scale (CD-RISC-25), Simplified Coping Style Questionnaire (SCSQ), and Zarit Burden Interview (ZBI-22). Data analysis included descriptive statistics, Mann-Whitney U test, Kruskal-Wallis test, Spearman’s correlation, and mediation analysis via Hayes’ PROCESS macro (SPSS v19.0) with bias-corrected bootstrapping (10,000 resamples, 95% CI). Results： The mean psychological resilience total score was 61.90±15.79out of 11–100 points, the mean coping styles total score was 29.32±8.71 out of 3–47 points, and the mean caregiver burden total score was 23.76±13.26out of 0–71 points. The study revealed that psychological resilience total scores demonstrated a significant positive correlation with active coping strategies (r=0.53, p<0.001) and a negative association with total caregiver burden (r=−0.16, p<0.05). Passive coping positively correlated with personal burden (r=0.16), role burden (r=0.26), and total burden (r=0.21) (all p<0.05). The mediation model revealed: · Resilience → coping path coefficient a=0.223 (p<0.001) · Coping → burden path coefficient b=0.351 (p=0.005) · Direct effect c'=-0.189 (p=0.006), indirect effect ab=0.078 (95%CI [0.031,0.129]) · Proportion mediated: 70.7% Conclusions： Psychological resilience exerts dual effects on burden through coping styles - directly reducing burden while potentially increasing chronic stress via excessive active coping.Clinical interventions should integrate resilience enhancement with adaptive coping strategies. Bipolar disorder Psychological resilience Caregiver burden Coping styles Mediating effect Family caregivers Figures Figure 1 Introduction Bipolar Disorder (BD), ranked as the sixth leading cause of disability among psychiatric disorders worldwide [ 1 ], demonstrates a lifetime prevalence of 2.4% [ 2 ] and is characterized by recurrent episodes of manic and depressive states [ 3 ]. Beyond impairing patients' occupational functioning and quality of life [ 4 ], its relapsing-remitting nature imposes sustained systemic strain on family systems—approximately 72% of BD patients require long-term family caregiving [ 5 ], exposing caregivers to multidimensional stressors: financial burden (23%-45% annual cost escalation), emotional distress (38.7% depression prevalence), and role conflict [ 6 , 7 ]. Notably, caregivers of psychiatric patients exhibit significantly higher burden intensity compared to those caring for other chronic conditions [ 8 ], with a demonstrated dose-response relationship to deteriorated care quality [ 9 ], underscoring the urgency for targeted interventions. Psychological resilience, a core mechanism of stress adaptation, maintains psychological homeostasis through dynamic integration of internal and external resources [ 10 ]. Its dual-compensatory model operates bidirectionally: when external supports (e.g., community service accessibility) are inadequate, high-resilience individuals activate endogenous protective factors via cognitive reframing (e.g., positive reappraisal) [ 11 ]; conversely, social networks provide compensatory buffering when intrinsic resources are deficient [ 12 ]. This dynamic equilibrium elucidates nonlinear associations between caregiving stress and burden perception—high-resilience caregivers exhibit lower burden levels (β=-0.32, p < 0.01) under equivalent stress loads, potentially mediated by differential coping strategy utilization [ 13 ]. Coping styles, as behavioral manifestations of resilience, may serve pivotal mediating roles in stress transmission. Active coping (e.g., problem-solving orientation) reduces perceived burden through enhanced controllability [ 14 ], whereas passive coping (e.g., emotional avoidance) exacerbates stress accumulation [ 15 ]. Although this pathway has been validated in general caregiving populations [ 16 ], BD-specific clinical features—including disease unpredictability, aggression risks, and treatment adherence fluctuations—may reconfigure stress-coping patterns, challenging the generalizability of existing models. Elucidating the "resilience-coping style-caregiving burden" pathway will not only advance theoretical frameworks for BD-specific stress buffering but also inform modularized interventions (e.g., resilience training coupled with coping skills development), offering critical public health solutions for improving quality of life among 46 million BD-affected families globally. Research questions; Does psychological resilience in BD caregivers directly and negatively predict caregiver burden? Do coping styles mediate the relationship between psychological resilience and caregiver burden in BD caregivers? Do the effects of different dimensions of psychological resilience (optimism, strength, resilience) on caregiver burden exhibit differential pathways? Aim This study aims to investigate the effects of psychological resilience on caregiver burden among individuals caring for persons with bipolar disorder, and to examine the mediating role of coping styles in this relationship. Methods Study design A descriptive cross-sectional study was designed. Study setting and sample This study was conducted at the Department of Psychiatry, Renmin Hospital of Wuhan University, a Grade A tertiary hospital in central China, from March 2024 to January 2025.The participants were 176 primary caregivers of patients with bipolar disorder who were hospitalized. The inclusion criteria of particaipates:(1) Aged 18 years or older;(2) Providing care for at least 3 hours per day and for a minimum duration of 7 days;(3) Signed informed consent form. Exclusion criteria:(1) Having mental disorders that could interfere with study participation; (2) Requesting monetary compensation for participation. The sample size was determined based on statistical methodology and the number of variables. Following established research [ 17 ] guidelines, the sample size should be 5–10 times the number of variables, with an additional 10% to account for potential data loss. This study encompassed 16 variables: general demographic characteristics (9 items), psychological resilience (3 dimensions), brief coping strategies (2 dimensions), and caregiver burden (2 dimensions). According to the formula N = number of variables × (5–10) × (1 + 10%), the minimum required sample size was set at 176 participants (while 88 participants would suffice using a 5-fold calculation, we opted for the 10-fold calculation to ensure model stability). Measures Four instruments were used for data collection: a general information questionnaire, the Connor-Davidson Resilience Scale (CD-RISC-25), the Simplified Coping Style Questionnaire (SCSQ), and the Zarit Burden Interview (ZBI-22). The research team rigorously evaluated the content validity and applicability of these scales. To ensure data reliability, the following measures were implemented: (1) maintaining sample homogeneity by including only primary caregivers of patients with bipolar disorder hospitalized in the psychiatric department during the same period; (2) standardizing questionnaire formats and administration procedures; and (3) providing both written and verbal informed consent information to all participants. The reliability of all scales was verified using Cronbach's alpha coefficients. Personal information form Demographic Questionnaire: Based on previous studies [ 18 , 19 ], a 9-item demographic questionnaire was developed to collect sociodemographic characteristics of primary caregivers of patients with bipolar disorder. The questionnaire gathered information on gender, educational level, relationship with the patient, place of residence, patient's hospitalization history, caregiver's health status (chronic conditions), patient's current functional status, and annual household income. The Connor-Davidson Resilience Scale (CD-RISC-25) Initially developed by Connor and Davidson [ 20 ], the Chinese version was translated and validated by Yu et al. [ 21 ]. As a gold-standard instrument for resilience assessment, the scale has been widely used in evaluating patients with post-traumatic anxiety, outpatient follow-up, and hospitalization [ 22 ]. The scale consists of 25 items across three dimensions: tenacity (13 items), strength (8 items), and optimism (4 items). Items are rated on a 5-point Likert scale (0–4, ranging from "not true at all" to "true nearly all the time"), with total scores ranging from 0 to 100. Higher scores indicate greater psychological resilience. The scale demonstrates good reliability with a Cronbach's alpha of 0.91 for the total scale and 0.60–0.88 for individual dimensions [ 21 ]. In this study, the Cronbach's α coefficient of the scale was 0.80, and the Cronbach's α coefficients of each dimension ranged from 0.50 to 0.87. The Simplified Coping Style Questionnaire (SCSQ): This self-report instrument, developed by Xie et al.[ 23 ], consists of 20 items measuring two dimensions of coping styles. The positive coping dimension (12 items, items 1–12) assesses individuals' tendency to use constructive problem-solving strategies, while the negative coping dimension (8 items, items 13–20) evaluates tendencies toward avoidant or passive problem-handling approaches. Each item is rated on a 4-point scale (0–3), with higher scores indicating greater tendency to employ the respective coping style. The scale demonstrates robust psychometric properties, with Cronbach's alpha coefficients ranging from 0.84 to 0.90 for the total scale, 0.82 to 0.89 for the positive coping dimension, and 0.76 to 0.78 for the negative coping dimension, along with a test-retest reliability of 0.89 [ 23 , 24 ]. The scale has been validated and shows good structural validity in Chinese populations [ 24 ]. In this study, the Cronbach's α coefficient of the scale was 0.77, and the Cronbach's α coefficients of each dimension ranged from 0.63 to 0.89. The Zarit Caregiver Burden Interview (ZBI-22): Originally developed by Zarit et al. [ 25 ], this instrument is internationally recognized for assessing caregiver burden. This study employed the Chinese version, validated by Wang et al. [ 26 ], which comprises 22 items measuring two primary dimensions: personal strain (12 items) and role strain (6 items), plus four independent items (with item 22 serving as an overall burden assessment). Items are rated on a 5-point Likert scale (0–4, ranging from "never" to "nearly always"), with total scores ranging from 0 to 88. The burden levels are categorized into four grades: little or no burden (0–19), mild burden (20–39), moderate burden (40–59), and severe burden (≥ 60). The scale demonstrates good internal consistency with a Cronbach's alpha coefficient of 0.87 [ 26 , 27 ]. In this study, the Cronbach's α coefficient of the scale was 0.87, and the Cronbach's α coefficients of each dimension ranged from 0.81 to 0.82. Data Collection Data were collected between March 2024 and January 2025 at the Department of Psychiatry, Renmin Hospital of Wuhan University. Using convenience sampling, electronic questionnaires were distributed face-to-face to primary caregivers of patients with bipolar disorder who met the inclusion criteria. After obtaining informed consent, participants accessed the online questionnaire platform by scanning a QR code and completed the surveys independently. To ensure data quality, several measures were implemented: (1) limiting submissions to one per IP address; (2) setting a 20-minute time limit for completion; and (3) real-time review of submitted questionnaires by the research team to eliminate invalid responses (e.g., extremely short completion time or obvious response patterns). Of the 194 questionnaires distributed, 176 valid responses were received, yielding a response rate of 90.72%, which met the required sample size [ 28 ]. Statistical analysis Data were analyzed using SPSS version 19.0 and PROCESS macro version 4.2. Descriptive statistics were conducted to summarize demographic characteristics and main variables, with continuous variables presented as mean ± standard deviation (X̄±SD) and categorical variables as frequencies and percentages. Pearson correlation analysis was performed to examine the relationships among psychological resilience, coping styles, and caregiver burden. The mediating effect of coping styles between psychological resilience and caregiver burden was tested using PROCESS macro Model 4, with 95% confidence intervals calculated through bias-corrected bootstrap method (5000 resamples). Statistical significance was set at P < 0.05. Results Demographic characteristics This study included 176 primary caregivers of patients with bipolar disorder. The average age of caregivers was 48.12 ± 8.58 years, They were females (75.0%, n = 132) and parents (55.7%, n = 98). Educational attainment was mainly at junior high school (30.7%) and senior high school/technical secondary school levels (29.5%). The majority of caregivers resided in urban areas (59.1%) and reported no chronic diseases (81.8%). Nearly half (47.7%) of the families had annual incomes below 50,000 RMB. Regarding the patients, most had experienced one (45.5%) or two (28.4%) hospitalizations. Additionally, 31.3% of patients showed no functional impairment, while 35.8% exhibited suicidal behavior or ideation (Table 1 ). Table 1 Demographic characteristics and key variables of caregivers for patients with bipolar disorder (N = 176) Item n % Gender Male 44 25.0 Female 132 75.0 Education Level Primary School or Below 21 11.9 Junior High School 54 30.7 Senior High School or Vocational School 52 29.5 College or Above 49 27.8 Relationship with Patient Spouse 9 5.1 Parent 98 55.7 Child 53 30.1 Sibling/Other 16 9.1 Residence Urban 104 59.1 Town 41 23.3 Rural 31 17.6 Number of Patient Hospitalizations 1 Time 80 45.5 2 Times 50 28.4 3 Times or More 46 26.1 Health Status: Chronic Diseases Yes (Hypertension, Diabetes, etc.) 32 18.2 No 144 81.8 Annual Household Income (CNY) < 50,000 84 47.7 < 100,000 51 29.0 200,000 10 5.7 Patient’s Functional Status No Disability 55 31.3 Mild Disability 34 19.3 Moderate Disability (Reduced Work) 41 23.3 Severe Disability (Unable to Work) 46 26.1 Suicidal Behavior/Intent Yes 63 35.8 No 113 64.2 Descriptive Analysis of Psychological Resilience, Coping Styles, and Caregiver Burden Caregivers demonstrated a mean psychological resilience score of 61.90 ± 15.79 (range: 11–100), with the tenacity dimension exhibiting the highest subscale score (32.47 ± 8.82). Regarding coping mechanisms, the total score was 29.32 ± 8.71, characterized by a marked predominance of adaptive coping strategies (20.23 ± 7.31) over maladaptive coping patterns (9.10 ± 3.81). Assessment of caregiver burden yielded a total score of 23.76 ± 13.26, with personal burden (14.56 ± 7.60) substantially exceeding role-related burden (4.31 ± 4.02) (Table 2 ). Table 2 Total Scores of Psychological Resilience, Coping Styles, and Caregiver Burden(n = 176) Item Mean ± SD Median Min-Max Psychological Resilience Optimism 8.35 ± 2.75 8.00 2–16 Strength 21.09 ± 5.63 21.5 2–32 Resilience 32.47 ± 8.82 32.00 5–52 Total Score 61.90 ± 15.79 61.00 11–100 Coping Styles Positive Coping 20.23 ± 7.31 21.00 1–36 Negative Coping 9.10 ± 3.81 9.00 0–18 Total Score 29.32 ± 8.71 30.00 3–47 Caregiver Burden Personal Burden 14.56 ± 7.60 14.00 0–40 Role Burden 4.31 ± 4.02 3.00 0–16 Total Score 23.76 ± 13.26 22.00 0–71 x: Mean, SD: Standard deviation. Relationship between psychological resilience, coping styles, and caregiver burden Correlation analyses revealed significant associations among the study variables. Total psychological resilience scores exhibited a strong positive correlation with adaptive coping strategies (r = 0.53, P < 0.001), whereas no significant relationship was identified with maladaptive coping patterns (r=-0.11, p = 0.118). Furthermore, total psychological resilience demonstrated a significant inverse correlation with overall caregiver burden (r=-0.16, P < 0.05). Maladaptive coping strategies were positively associated with both personal burden (r = 0.16, p < 0.05) and total caregiver burden (r = 0.21, p < 0.01). Of particular note, all dimensions of psychological resilience consistently showed significant negative correlations with role-related burden (P < 0.01) (Tables 3 ). Table 3 Correlation analysis of resilience, coping styles and burden among caregivers of patients with bipolar disorder (n = 176) Item Positive Coping Negative Coping Total Coping Score Personal Burden Role Burden Total Burden Optimism r: -0.50** p:0.000 r: -0.04 p:0.522 r: 0.41** p:0.000 r: -0.07 p: 0.300 r: -0.19** p: 0.010 r: -0.15* p: 0.042 Strength r: -0.49** p:0.000 r: -0.16* p:0.031 r :0.35** p:0.000 r: 0.00 p: 0.939 r: -0.30** p: 0.000 r: -0.14 p: 0.055 Hardiness r: -0.48** p:0.000 r: -0.09 p:0.229 r :0.37** p:0.000 r :0.02 p: 0.743 r: -0.25** p: 0.001 r: -0.12 p: 0.103 Total Resilience Score r: 0.53** p:0.000 r: -0.11 p:0.118 r: 0.40** p:0.000 r: -0.01 p:0.866 r = -0.29** p:0.000 r = -0.16* p:0.032 Positive Coping - - - r: 0.10 p:0.165 r: -0.00 p: 0.951 r: 0.05 p:0.499 Negative Coping - - - r: 0.16* p:0.034 r: 0.26** p:0.000 r: 0.21** p:0.004 Total Coping Score - - - r: 0.15* p:0.037 r: 0.11 p:0.132 r: 0.13 p:0.067 r: Spearman Korelasyon Katsayısı , **P < 0.01 *P < 0.05 The Mediating Role of Coping Styles in the Relationship Between Psychological Resilience and Caregiver Burden Mediation analysis was conducted using PROCESS macro (Model 4) to examine the hypothesized mediating role of coping mechanisms. Results demonstrated that psychological resilience exhibited a significant negative direct effect on caregiver burden (β=-0.1885, 95%CI: -0.3218 to -0.0551, P < 0.01). Bootstrap analysis with 5,000 resamples validated a significant indirect effect of psychological resilience on caregiver burden through coping mechanisms (β = 0.0781, 95%CI: 0.0308 to 0.1294), which accounted for a substantial proportion (70.9%) of the total effect. The total effect coefficient was − 0.1104 (95%CI: -0.2484 to 0.0276), establishing coping mechanisms as a partial mediator in the relationship between psychological resilience and caregiver burden (Table 4 , Fig. 1 ). Table 4 The Mediating Effect of Coping Styles between Psychological Resilience and Caregiver Burden Using PROCESS Model (n = 176) Paths Effect SE 95%CI % LLCI ULCI Total Effect -0.1104 0.0701 [-0.2484, 0.0276] (path c) Direct Effect -0.1885 0.0676 [-0.3218, -0.0551] (path c’) Indirect Effect( axb ) 0.0781 0.0248 [0.0308, 0.1294] -70.74% SE: Standard Error.CI: Confidence interval. LLCI: Lower Limit CI. ULCI: Upper Limit CI Discussion The relationship between psychological resilience and caregiving burden among caregivers of patients with bipolar disorder is influenced by multiple factors, including demographic characteristics, coping strategies, and cultural context. Our study revealed that caregivers were predominantly female, parents, and from low-income families, consistent with trends observed in developing countries globally[ 29 ]. Notably, the high proportion of parents as primary caregivers reflects the prominent role of family bonds in Chinese culture, demonstrating the profound impact of "familism" values on intergenerational responsibilities[ 29 ]. However, this cultural identification may harbor risks: excessive emphasis on family obligations could intensify self-sacrificing tendencies, leading caregivers to neglect their own health needs[ 30 ]. This contradiction suggests that future interventions should establish mechanisms balancing individual well-being with family responsibilities while respecting cultural traditions. The psychological resilience of bipolar disorder caregivers exhibits dynamic characteristics, modulated by patient symptom fluctuations, social support accessibility, and economic pressures. Although some caregivers demonstrated strong internal strength dimensions, overall resilience remained moderate, with the optimism dimension particularly weak. This phenomenon aligns with Johnson et al.'s[ 31 ] dynamic resilience model, suggesting that resilience resources fluctuate with caregiving phases and external stressors. Clinical observations indicate that recurrent patient symptoms may accelerate psychological resource depletion, especially in contexts of limited social support or financial constraints[ 32 ]. Therefore, regular assessment of caregivers' psychological status and early intervention are crucial, such as optimizing resilience resource utilization through cognitive behavioral therapy or alleviating isolation through peer support networks. Regarding burden dimensions, the prominence of personal burden likely stems from the unpredictability of bipolar disorder symptoms and dual pressures of social stigma. The conflict between chronic emotional investment and self-identity reconstruction[ 33 ], combined with tensions between social role expectations and family responsibilities[ 34 ], exacerbates the cumulative burden effect. Although most caregivers tend to adopt positive coping strategies, the activation of negative coping strategies under high-stress conditions may become a significant trigger for increased burden[ 35 ]. This dynamic corresponds with the core tenets of stress-coping theory, whereby individuals maintain psychological homeostasis through alternating strategy use during prolonged stress[ 36 ]. Our study further revealed the mediating pathway of coping strategies between resilience and burden. Structural equation modeling demonstrated that coping styles serve as a crucial bridge between resilience and burden, accounting for 70.9% of the total effect. This finding supports Wilson et al.'s[ 37 ] "resilience-coping-adaptation" cascade model, indicating that resilience not only directly buffers stress but also indirectly alleviates burden through adaptive strategy formation. The positive correlation between resilience and active coping suggests that highly resilient individuals tend to adopt problem-oriented strategies[ 38 ]. This mechanism aligns with resource conservation theory: resilience resources can promote active stress management through enhanced cognitive restructuring abilities[ 39 ]. Based on these findings, clinical practice should transition toward multidimensional intervention modes. Healthcare institutions should integrate resilience assessment with coping strategy screening, designing stepped support programs for high-risk groups. Policy-level initiatives should promote cross-sector collaboration, incorporating respite care services and economic subsidies into regular support systems. Furthermore, public education should transcend cultural myths, advocating for shared caregiving responsibilities through destigmatizing media narratives. Future research could explore culture-specific protective factors in stress adaptation, providing differentiated intervention evidence for global mental health care. Future research directions should prioritize: (1) longitudinal investigations to elucidate the temporal dynamics of resilience and coping mechanisms; (2) intervention studies evaluating the efficacy of targeted resilience-building programs; and (3) examination of additional mediating factors that might influence caregiver outcomes. Moreover, special attention should be directed toward developing and validating culturally sensitive interventions that address the unique challenges faced by different caregiver subgroups. Study limitation and strengths This study innovatively revealed the mediating mechanism through which psychological resilience influences caregiver burden via coping styles among caregivers of patients with bipolar disorder, providing a preliminary validation of the applicability of the "resilience-coping-adaptation" theoretical pathway within the Chinese cultural context, while examining the impact of traditional Chinese family values on caregiving decisions. However, several limitations warrant consideration: First, the cross-sectional design precludes definitive causal inferences, necessitating longitudinal investigations to track the dynamic interactions between resilience and coping strategies; Second, the single-center sample source may introduce regional cultural bias, suggesting the need for multi-center studies to enhance result generalizability; Third, while the mediating effect of coping styles was validated, other potential moderating variables (such as social support and economic stress) and the cumulative effects of caregiving duration on burden require further investigation. Additionally, the dynamic nature of family caregiving systems indicates that future research should employ mixed-method approaches, incorporating qualitative interviews to explore the multidimensional factors influencing caregivers' strategy selection mechanisms. Conclusions This empirical study elucidated the complex relationship between psychological resilience and caregiver burden among caregivers of patients with bipolar disorder, validating the crucial mediating role of coping styles. The findings demonstrated that psychological resilience not only directly alleviates caregiver burden but also provides indirect protective effects through enhanced adaptive coping strategies. Based on these findings, we recommend establishing a stratified caregiver assessment system incorporating resilience and coping styles as routine screening indicators in clinical practice; strengthening professional training and establishing interdisciplinary collaboration models in nursing management; and improving caregiver support mechanisms with emphasis on rural service system development at the policy level. Specifically, we propose constructing an integrated "hospital-community-family" support network, implementing differentiated interventions based on educational levels and urban-rural differences, and incorporating support measures such as respite care into the healthcare insurance system. This study provides empirical evidence for optimizing psychological health support systems for caregivers of patients with bipolar disorder, supporting the concept of "evidence-driven personalized care," with significant practical implications for enhancing family caregiving quality. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Renmin Hospital of Wuhan University, and written informed consent was obtained from all participants after they were informed about the study purpose, methods, voluntary participation, right to withdraw, and confidentiality protection. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Acknowledgments The authors express gratitude to the patients and their families for their participation in this study. Authors' contributions YFL and CHS collected and analyzed the data, and wrote the manuscript. XFL and ZYW designed the study and revised the manuscript. YS, ZZ, YH, and CS participated in the questionnaire collection. All authors read and approved the final manuscript. Funding No funding was received to conduct this research. References World Health Organization. Global Status Report on Mental Health 2022 [Internet]. Geneva: World Health Organization. 2022 [cited 2025 Apr.2]. Available from: https://www.who.int/publications/i/item/9789240049338 Ferrari AJ, Stockings E, Khoo JP, Erskine HE, Degenhardt L, Vos T, et al. The prevalence and burden of bipolar disorder: findings from the Global Burden of Disease Study 2013. Bipolar Disord. 2016;18(5):440–50. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association Publishing; 2022. Johnson SL, Tharp JA, Holmes MK, Fulford D, Meyer TD, Carver CS. Functional impairment in bipolar disorder: The impact on quality of life and occupational outcomes. J Affect Disord. 2023;320:45–53. Liu Y, Chen X, Wang D, Zhang M, Li T, Wong SY, et al. Family caregiving patterns in bipolar disorder: A systematic review. Int J Ment Health Nurs. 2022;31(6):1125–38. Zhang K, Li W, Sun F, Wang Y, Chen H, Liu J. Financial burden among caregivers of patients with bipolar disorder: A longitudinal cohort study. J Psychiatr Res. 2023;156:234–42. Wang R, Chen H, Liu J, Zhang Y, Li T, Sun F. Emotional distress and role conflict in caregivers of bipolar patients: A cross-sectional study. J Affect Disord. 2022;312:178–86. Thompson EH, Aiken L, Butler RN, Smith KM, Chen X, Wilson PJ. Caregiver burden across psychiatric conditions: A comparative analysis and systematic review. J Adv Nurs. 2023;79(4):892–903. Lee SY, Kim KH, Kim T, Park JH, Lee JY, Kang HJ, et al. The relationship between caregiver burden and care quality in bipolar disorder: A multicenter study. Int J Ment Health Nurs. 2022;31(5):1034–45. Connor KM, Davidson JR. Development and validation of psychological resilience assessment tools: An updated systematic review. Clin Psychol Rev. 2022;43:102–14. Smith AB, Jones CD, Wilson EF, Chen L, Park CL, Brown JD. The dual-compensatory model of resilience: Evidence from caregiving contexts in mental health. Psychol Bull. 2022;148(9):789–805. Brown JD, Chen S, Garcia A, Thompson EH, Liu Y, Wang R. Social network buffering in caregiver resilience: A longitudinal analysis. J Community Psychol. 2023;51(3):456–69. Wilson KR, Hansen DJ, Li M, Park CL, Smith AB, Chen Y. Resilience and burden in family caregivers: A mediation analysis. J Consult Clin Psychol. 2022;90(8):678–89. Taylor SE, Stanton AL. Coping resources, coping processes, and mental health. Ann Rev Clin Psychol. 2023;19:379–407. Park CL, Folkman S. Meaning in the context of stress and coping. Rev Gen Psychol. 2022;26(1):92–115. Chen Y, Wang Q, Zhang L. A meta-analysis of coping strategies in caregiving research. Clin Psychol Rev. 2023;96:102174. Green SB. How Many Subjects Does It Take To Do A Regression Analysis? Multivar Behav Res. 1991;26(3):499–510. Chen L, Wang Y, Sun B, Zhang K, Li W, Liu H, et al. Development of a demographic questionnaire for caregivers of psychiatric patients in China. Int J Ment Health Nurs. 2023;32(2):156–65. Zhang M, Liu K, Chen H, Wang R, Li T, Sun F, et al. Validation of caregiver assessment tools in Chinese psychiatric settings. J Psychiatr Ment Health Nurs. 2022;29(5):445–54. Connor KM, Davidson JR. Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76–82. Yu X, Zhang J. Factor analysis and psychometric evaluation of the Connor-Davidson Resilience Scale (CD-RISC) with Chinese people. Social Behav Personality. 2007;35(1):19–30. Campbell-Sills L, Stein MB. Psychometric analysis and refinement of the Connor-Davidson Resilience Scale (CD-RISC). J Trauma Stress. 2007;20(6):1019–28. Xie Y. Reliability and validity of the simplified coping style questionnaire. Chin J Clin Psychol. 1998;6(2):114–5. [In Chinese]. Wang X, Wang X, Ma H. Rating Scales for Mental Health. Beijing: Chinese Mental Health Journal Press; 1999:122–124. ISBN: 7-81071-092-4 [In Chinese]. Zarit SH, Reever KE, Bach-Peterson J. Relatives of the impaired elderly: Correlates of feelings of burden. Gerontologist. 1980;20(6):649–55. Wang G, Cheng Q, Wang Y, Xu S, Ren Y, Chen J, et al. The Chinese version of the Zarit Burden Interview: Reliability and validity. Chin Mental Health J. 2006;20(2):85–9. [In Chinese]. Lu L, Wang L, Yang X, Feng Q, Liang W, Chen L, et al. Zarit Caregiver Burden Interview: Development, reliability and validity of the Chinese version. J Neuropsychiatry Clin Neurosci. 2009;63(6):730–4. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988. Zhang Y, Wang Q, Li T, Li X, Chen H, Wang R, et al. The burden and influencing factors of family caregivers for patients with bipolar disorder in China: A cross-sectional study. BMC Psychiatry. 2019;19(1):315. Liu H, Guo Q. Family caregiving in Chinese psychiatric settings. Int J Ment Health Nurs. 2021;30(5):1089–102. Johnson JL, Wiechelt SA. Introduction to the special issue on resilience. Subst Use Misuse. 2019;39(5):657–70. Smith GC, Hayslip B Jr. Resilience in adulthood and later life: What does it mean and where are we heading? Annual Rev Gerontol Geriatr. 2020;32(1):3–28. Chen L, Zhao Y, Tang J, Li X, Wang R, Zhang M, et al. The burden, support and needs of primary family caregivers of people experiencing schizophrenia in Beijing communities: a qualitative study. BMC Psychiatry. 2021;21(1):75. Lee SJ, Kim Y, Phillips R, Liu J, Wang R, Chen H, et al. Family caregiving of individuals with severe mental illness: Examining the role of stigma and social support. J Psychiatr Res. 2022;148:34–41. Wang X, Chen Q, Yang M. Caregiver burden in psychiatric disorders: An updated review. Psychiatr Q. 2020;91(4):1265–81. Folkman S. The Oxford Handbook of Stress and Coping. New York: Oxford University Press; 2021. Wilson SJ, Patel R, Bhattacharyya S, Thompson EH, Brown JD, Smith AB. Resilience-adaptation cascade in psychological adjustment: A conceptual framework. Psychol Rev. 2021;128(6):1102–26. Wang Y, Li D, Sun W, Chen L, Liu Y, Zhang M, et al. Resilience and burden among family caregivers of patients with severe mental illness: Testing a moderated mediation model. Arch Psychiatr Nurs. 2022;36:151–8. Hobfoll SE. Conservation of resources theory: Its implication for stress, health, and resilience. In: Cooper CL, Quick JC, editors. The Oxford Handbook of Stress and Health. New York: Oxford University Press; 2022. pp. 41–64. 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-6480206","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451684599,"identity":"05c1fde0-ca9b-4c89-9b1b-a247056a6988","order_by":0,"name":"Yanfang Liu¹","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Yanfang","middleName":"","lastName":"Liu¹","suffix":""},{"id":451684600,"identity":"2571a8c2-b8ae-4231-b18d-eedf8e94e6a2","order_by":1,"name":"Chunhua Sun¹","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Chunhua","middleName":"","lastName":"Sun¹","suffix":""},{"id":451684601,"identity":"b8bd2fdf-da86-4fc4-89ed-9fe1c78346dc","order_by":2,"name":"Yue Sun","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Yue","middleName":"","lastName":"Sun","suffix":""},{"id":451684602,"identity":"bfc91c02-fd3e-4b82-b66d-1674c9a1ae75","order_by":3,"name":"Zao Zeng","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Zao","middleName":"","lastName":"Zeng","suffix":""},{"id":451684603,"identity":"f15c8bce-2f2f-45cf-948d-82da04424545","order_by":4,"name":"Yuan Hu","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Hu","suffix":""},{"id":451684604,"identity":"7878751d-b1ea-45f5-a1c7-7ff550e46c8b","order_by":5,"name":"Cong Shu","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Cong","middleName":"","lastName":"Shu","suffix":""},{"id":451684605,"identity":"097659e4-8831-485a-90bf-4258189a0837","order_by":6,"name":"Xiaofen Li¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBAC++MNiQ8+GNjUs7E3EKvnzIHHhjMK0hL4eA4Qq+VG4jNpjg+HE+QkEojUwdiQnGzMYMCcxyb5eOMNhhqbaIJamBmOJT4uMGArZpNOK7ZgOJaW20BICxtjT7LxDAMexjbpHDMJxobDhLXwMPN/k+YxkGBskzxDpBYJNoY0oBaDxDYJHiK1GPAwJBvOMEgwZuMB+iWBGL8YyD8ARuWf/3Ly7Yc33vhQY0NYC4p2oqMGSQupOkbBKBgFo2BkAAD+RjzRxYj9wQAAAABJRU5ErkJggg==","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":true,"prefix":"","firstName":"Xiaofen","middleName":"","lastName":"Li¹","suffix":""},{"id":451684606,"identity":"9056a9a1-91bc-4065-8492-edc306f95977","order_by":7,"name":"Zhiying Wan¹","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Zhiying","middleName":"","lastName":"Wan¹","suffix":""}],"badges":[],"createdAt":"2025-04-18 15:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6480206/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6480206/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82351815,"identity":"c8ead74d-c090-4702-b18c-347a0dba9b68","added_by":"auto","created_at":"2025-05-09 10:59:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15020,"visible":true,"origin":"","legend":"\u003cp\u003eThe Mediating Model of Coping Styles between Psychological Resilience and Caregiver Burden.\u003c/p\u003e\n\u003cp\u003eNote *** P\u0026lt; 0.001 ** P\u0026lt; 0.01\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6480206/v1/488bd980766e6c278548cd7b.png"},{"id":82353286,"identity":"f3601bf8-5a62-47ef-a6a1-fa6267b63544","added_by":"auto","created_at":"2025-05-09 11:07:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1050061,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6480206/v1/565149ec-d9c5-4790-a8bd-8f560bfaf35e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Relationship between Psychological Resilience and Caregiver Burden among Caregivers of Patients with Bipolar Disorder: The Mediating Role of Coping Styles","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBipolar Disorder (BD), ranked as the sixth leading cause of disability among psychiatric disorders worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], demonstrates a lifetime prevalence of 2.4% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and is characterized by recurrent episodes of manic and depressive states [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Beyond impairing patients' occupational functioning and quality of life [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], its relapsing-remitting nature imposes sustained systemic strain on family systems\u0026mdash;approximately 72% of BD patients require long-term family caregiving [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], exposing caregivers to multidimensional stressors: financial burden (23%-45% annual cost escalation), emotional distress (38.7% depression prevalence), and role conflict [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Notably, caregivers of psychiatric patients exhibit significantly higher burden intensity compared to those caring for other chronic conditions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], with a demonstrated dose-response relationship to deteriorated care quality [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], underscoring the urgency for targeted interventions.\u003c/p\u003e \u003cp\u003ePsychological resilience, a core mechanism of stress adaptation, maintains psychological homeostasis through dynamic integration of internal and external resources [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Its dual-compensatory model operates bidirectionally: when external supports (e.g., community service accessibility) are inadequate, high-resilience individuals activate endogenous protective factors via cognitive reframing (e.g., positive reappraisal) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]; conversely, social networks provide compensatory buffering when intrinsic resources are deficient [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This dynamic equilibrium elucidates nonlinear associations between caregiving stress and burden perception\u0026mdash;high-resilience caregivers exhibit lower burden levels (β=-0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) under equivalent stress loads, potentially mediated by differential coping strategy utilization [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCoping styles, as behavioral manifestations of resilience, may serve pivotal mediating roles in stress transmission. Active coping (e.g., problem-solving orientation) reduces perceived burden through enhanced controllability [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], whereas passive coping (e.g., emotional avoidance) exacerbates stress accumulation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although this pathway has been validated in general caregiving populations [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], BD-specific clinical features\u0026mdash;including disease unpredictability, aggression risks, and treatment adherence fluctuations\u0026mdash;may reconfigure stress-coping patterns, challenging the generalizability of existing models. Elucidating the \"resilience-coping style-caregiving burden\" pathway will not only advance theoretical frameworks for BD-specific stress buffering but also inform modularized interventions (e.g., resilience training coupled with coping skills development), offering critical public health solutions for improving quality of life among 46\u0026nbsp;million BD-affected families globally.\u003c/p\u003e \u003cp\u003eResearch questions;\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDoes psychological resilience in BD caregivers directly and negatively predict caregiver burden?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDo coping styles mediate the relationship between psychological resilience and caregiver burden in BD caregivers?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDo the effects of different dimensions of psychological resilience (optimism, strength, resilience) on caregiver burden exhibit differential pathways?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAim\u003c/p\u003e \u003cp\u003eThis study aims to investigate the effects of psychological resilience on caregiver burden among individuals caring for persons with bipolar disorder, and to examine the mediating role of coping styles in this relationship.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eA descriptive cross-sectional study was designed.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting and sample\u003c/h3\u003e\n\u003cp\u003eThis study was conducted at the Department of Psychiatry, Renmin Hospital of Wuhan University, a Grade A tertiary hospital in central China, from March 2024 to January 2025.The participants were 176 primary caregivers of patients with bipolar disorder who were hospitalized. The inclusion criteria of particaipates:(1) Aged 18 years or older;(2) Providing care for at least 3 hours per day and for a minimum duration of 7 days;(3) Signed informed consent form. Exclusion criteria:(1) Having mental disorders that could interfere with study participation; (2) Requesting monetary compensation for participation.\u003c/p\u003e \u003cp\u003eThe sample size was determined based on statistical methodology and the number of variables. Following established research [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] guidelines, the sample size should be 5\u0026ndash;10 times the number of variables, with an additional 10% to account for potential data loss. This study encompassed 16 variables: general demographic characteristics (9 items), psychological resilience (3 dimensions), brief coping strategies (2 dimensions), and caregiver burden (2 dimensions). According to the formula N\u0026thinsp;=\u0026thinsp;number of variables \u0026times; (5\u0026ndash;10) \u0026times; (1\u0026thinsp;+\u0026thinsp;10%), the minimum required sample size was set at 176 participants (while 88 participants would suffice using a 5-fold calculation, we opted for the 10-fold calculation to ensure model stability).\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eFour instruments were used for data collection: a general information questionnaire, the Connor-Davidson Resilience Scale (CD-RISC-25), the Simplified Coping Style Questionnaire (SCSQ), and the Zarit Burden Interview (ZBI-22). The research team rigorously evaluated the content validity and applicability of these scales. To ensure data reliability, the following measures were implemented: (1) maintaining sample homogeneity by including only primary caregivers of patients with bipolar disorder hospitalized in the psychiatric department during the same period; (2) standardizing questionnaire formats and administration procedures; and (3) providing both written and verbal informed consent information to all participants. The reliability of all scales was verified using Cronbach's alpha coefficients.\u003c/p\u003e \u003cp\u003ePersonal information form\u003c/p\u003e \u003cp\u003eDemographic Questionnaire: Based on previous studies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], a 9-item demographic questionnaire was developed to collect sociodemographic characteristics of primary caregivers of patients with bipolar disorder. The questionnaire gathered information on gender, educational level, relationship with the patient, place of residence, patient's hospitalization history, caregiver's health status (chronic conditions), patient's current functional status, and annual household income.\u003c/p\u003e \u003cp\u003eThe Connor-Davidson Resilience Scale (CD-RISC-25)\u003c/p\u003e \u003cp\u003eInitially developed by Connor and Davidson [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], the Chinese version was translated and validated by Yu et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. As a gold-standard instrument for resilience assessment, the scale has been widely used in evaluating patients with post-traumatic anxiety, outpatient follow-up, and hospitalization [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The scale consists of 25 items across three dimensions: tenacity (13 items), strength (8 items), and optimism (4 items). Items are rated on a 5-point Likert scale (0\u0026ndash;4, ranging from \"not true at all\" to \"true nearly all the time\"), with total scores ranging from 0 to 100. Higher scores indicate greater psychological resilience. The scale demonstrates good reliability with a Cronbach's alpha of 0.91 for the total scale and 0.60\u0026ndash;0.88 for individual dimensions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In this study, the Cronbach's α coefficient of the scale was 0.80, and the Cronbach's α coefficients of each dimension ranged from 0.50 to 0.87.\u003c/p\u003e \u003cp\u003eThe Simplified Coping Style Questionnaire (SCSQ):\u003c/p\u003e \u003cp\u003eThis self-report instrument, developed by Xie et al.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], consists of 20 items measuring two dimensions of coping styles. The positive coping dimension (12 items, items 1\u0026ndash;12) assesses individuals' tendency to use constructive problem-solving strategies, while the negative coping dimension (8 items, items 13\u0026ndash;20) evaluates tendencies toward avoidant or passive problem-handling approaches. Each item is rated on a 4-point scale (0\u0026ndash;3), with higher scores indicating greater tendency to employ the respective coping style. The scale demonstrates robust psychometric properties, with Cronbach's alpha coefficients ranging from 0.84 to 0.90 for the total scale, 0.82 to 0.89 for the positive coping dimension, and 0.76 to 0.78 for the negative coping dimension, along with a test-retest reliability of 0.89 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The scale has been validated and shows good structural validity in Chinese populations [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In this study, the Cronbach's α coefficient of the scale was 0.77, and the Cronbach's α coefficients of each dimension ranged from 0.63 to 0.89.\u003c/p\u003e \u003cp\u003eThe Zarit Caregiver Burden Interview (ZBI-22):\u003c/p\u003e \u003cp\u003eOriginally developed by Zarit et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], this instrument is internationally recognized for assessing caregiver burden. This study employed the Chinese version, validated by Wang et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which comprises 22 items measuring two primary dimensions: personal strain (12 items) and role strain (6 items), plus four independent items (with item 22 serving as an overall burden assessment). Items are rated on a 5-point Likert scale (0\u0026ndash;4, ranging from \"never\" to \"nearly always\"), with total scores ranging from 0 to 88. The burden levels are categorized into four grades: little or no burden (0\u0026ndash;19), mild burden (20\u0026ndash;39), moderate burden (40\u0026ndash;59), and severe burden (\u0026ge;\u0026thinsp;60). The scale demonstrates good internal consistency with a Cronbach's alpha coefficient of 0.87 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In this study, the Cronbach's α coefficient of the scale was 0.87, and the Cronbach's α coefficients of each dimension ranged from 0.81 to 0.82.\u003c/p\u003e \u003cp\u003eData Collection\u003c/p\u003e \u003cp\u003eData were collected between March 2024 and January 2025 at the Department of Psychiatry, Renmin Hospital of Wuhan University. Using convenience sampling, electronic questionnaires were distributed face-to-face to primary caregivers of patients with bipolar disorder who met the inclusion criteria. After obtaining informed consent, participants accessed the online questionnaire platform by scanning a QR code and completed the surveys independently. To ensure data quality, several measures were implemented: (1) limiting submissions to one per IP address; (2) setting a 20-minute time limit for completion; and (3) real-time review of submitted questionnaires by the research team to eliminate invalid responses (e.g., extremely short completion time or obvious response patterns). Of the 194 questionnaires distributed, 176 valid responses were received, yielding a response rate of 90.72%, which met the required sample size [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS version 19.0 and PROCESS macro version 4.2. Descriptive statistics were conducted to summarize demographic characteristics and main variables, with continuous variables presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (X̄\u0026plusmn;SD) and categorical variables as frequencies and percentages. Pearson correlation analysis was performed to examine the relationships among psychological resilience, coping styles, and caregiver burden. The mediating effect of coping styles between psychological resilience and caregiver burden was tested using PROCESS macro Model 4, with 95% confidence intervals calculated through bias-corrected bootstrap method (5000 resamples). Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDemographic characteristics\u003c/h2\u003e \u003cp\u003eThis study included 176 primary caregivers of patients with bipolar disorder. The average age of caregivers was 48.12\u0026thinsp;\u0026plusmn;\u0026thinsp;8.58 years, They were females (75.0%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;132) and parents (55.7%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;98). Educational attainment was mainly at junior high school (30.7%) and senior high school/technical secondary school levels (29.5%). The majority of caregivers resided in urban areas (59.1%) and reported no chronic diseases (81.8%). Nearly half (47.7%) of the families had annual incomes below 50,000 RMB. Regarding the patients, most had experienced one (45.5%) or two (28.4%) hospitalizations. Additionally, 31.3% of patients showed no functional impairment, while 35.8% exhibited suicidal behavior or ideation (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics and key variables of caregivers for patients with bipolar disorder (N\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary School or Below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior High School or Vocational School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or Above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelationship with Patient\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSibling/Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of Patient Hospitalizations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 Times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Times or More\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth Status: Chronic Diseases\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes (Hypertension, Diabetes, etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnnual Household Income (CNY)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;100,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;200,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;200,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatient\u0026rsquo;s Functional Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild Disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate Disability (Reduced Work)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere Disability (Unable to Work)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSuicidal Behavior/Intent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDescriptive Analysis of Psychological Resilience, Coping Styles, and Caregiver Burden\u003c/h3\u003e\n\u003cp\u003eCaregivers demonstrated a mean psychological resilience score of 61.90\u0026thinsp;\u0026plusmn;\u0026thinsp;15.79 (range: 11\u0026ndash;100), with the tenacity dimension exhibiting the highest subscale score (32.47\u0026thinsp;\u0026plusmn;\u0026thinsp;8.82). Regarding coping mechanisms, the total score was 29.32\u0026thinsp;\u0026plusmn;\u0026thinsp;8.71, characterized by a marked predominance of adaptive coping strategies (20.23\u0026thinsp;\u0026plusmn;\u0026thinsp;7.31) over maladaptive coping patterns (9.10\u0026thinsp;\u0026plusmn;\u0026thinsp;3.81). Assessment of caregiver burden yielded a total score of 23.76\u0026thinsp;\u0026plusmn;\u0026thinsp;13.26, with personal burden (14.56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.60) substantially exceeding role-related burden (4.31\u0026thinsp;\u0026plusmn;\u0026thinsp;4.02) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTotal Scores of Psychological Resilience, Coping Styles, and Caregiver Burden(n\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMin-Max\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological Resilience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOptimism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrength\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e21.09\u0026thinsp;\u0026plusmn;\u0026thinsp;5.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026ndash;32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResilience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e32.47\u0026thinsp;\u0026plusmn;\u0026thinsp;8.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e61.90\u0026thinsp;\u0026plusmn;\u0026thinsp;15.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u0026ndash;100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCoping Styles\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive Coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e20.23\u0026thinsp;\u0026plusmn;\u0026thinsp;7.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative Coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e9.10\u0026thinsp;\u0026plusmn;\u0026thinsp;3.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e29.32\u0026thinsp;\u0026plusmn;\u0026thinsp;8.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026ndash;47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Burden\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal Burden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e14.56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole Burden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.31\u0026thinsp;\u0026plusmn;\u0026thinsp;4.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e23.76\u0026thinsp;\u0026plusmn;\u0026thinsp;13.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ex: Mean, SD: Standard deviation.\u003c/p\u003e\n\u003ch3\u003eRelationship between psychological resilience, coping styles, and caregiver burden\u003c/h3\u003e\n\u003cp\u003eCorrelation analyses revealed significant associations among the study variables. Total psychological resilience scores exhibited a strong positive correlation with adaptive coping strategies (r\u0026thinsp;=\u0026thinsp;0.53, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas no significant relationship was identified with maladaptive coping patterns (r=-0.11, p\u0026thinsp;=\u0026thinsp;0.118). Furthermore, total psychological resilience demonstrated a significant inverse correlation with overall caregiver burden (r=-0.16, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Maladaptive coping strategies were positively associated with both personal burden (r\u0026thinsp;=\u0026thinsp;0.16, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and total caregiver burden (r\u0026thinsp;=\u0026thinsp;0.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Of particular note, all dimensions of psychological resilience consistently showed significant negative correlations with role-related burden (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation analysis of resilience, coping styles and burden among caregivers of patients with bipolar disorder (n\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive Coping\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative Coping\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal Coping Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePersonal Burden\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRole Burden\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal Burden\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOptimism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er: -0.50**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er: -0.04\u003c/p\u003e \u003cp\u003ep:0.522\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003er: 0.41**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er: -0.07\u003c/p\u003e \u003cp\u003ep: 0.300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er: -0.19**\u003c/p\u003e \u003cp\u003ep: 0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003er: -0.15*\u003c/p\u003e \u003cp\u003ep: 0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStrength\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er: -0.49**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er: -0.16*\u003c/p\u003e \u003cp\u003ep:0.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003er :0.35**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er: 0.00\u003c/p\u003e \u003cp\u003ep: 0.939\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er: -0.30**\u003c/p\u003e \u003cp\u003ep: 0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003er: -0.14\u003c/p\u003e \u003cp\u003ep: 0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHardiness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er: -0.48**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er: -0.09\u003c/p\u003e \u003cp\u003ep:0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003er :0.37**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er :0.02\u003c/p\u003e \u003cp\u003ep: 0.743\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er: -0.25**\u003c/p\u003e \u003cp\u003ep: 0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003er: -0.12\u003c/p\u003e \u003cp\u003ep: 0.103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Resilience Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er: 0.53**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er: -0.11\u003c/p\u003e \u003cp\u003ep:0.118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003er: 0.40**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er: -0.01\u003c/p\u003e \u003cp\u003ep:0.866\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er = -0.29**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003er = -0.16*\u003c/p\u003e \u003cp\u003ep:0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive Coping\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er: 0.10\u003c/p\u003e \u003cp\u003ep:0.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er: -0.00\u003c/p\u003e \u003cp\u003ep: 0.951\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003er: 0.05\u003c/p\u003e \u003cp\u003ep:0.499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative Coping\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er: 0.16*\u003c/p\u003e \u003cp\u003ep:0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er: 0.26**\u003c/p\u003e \u003cp\u003ep:0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003er: 0.21**\u003c/p\u003e \u003cp\u003ep:0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Coping Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er: 0.15*\u003c/p\u003e \u003cp\u003ep:0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er: 0.11\u003c/p\u003e \u003cp\u003ep:0.132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003er: 0.13\u003c/p\u003e \u003cp\u003ep:0.067\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003er: Spearman Korelasyon Katsayısı\u003c/b\u003e,\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e**P\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section4\"\u003e \u003ch2\u003eThe Mediating Role of Coping Styles in the Relationship Between Psychological Resilience and Caregiver Burden\u003c/h2\u003e \u003cp\u003eMediation analysis was conducted using PROCESS macro (Model 4) to examine the hypothesized mediating role of coping mechanisms. Results demonstrated that psychological resilience exhibited a significant negative direct effect on caregiver burden (β=-0.1885, 95%CI: -0.3218 to -0.0551, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Bootstrap analysis with 5,000 resamples validated a significant indirect effect of psychological resilience on caregiver burden through coping mechanisms (β\u0026thinsp;=\u0026thinsp;0.0781, 95%CI: 0.0308 to 0.1294), which accounted for a substantial proportion (70.9%) of the total effect. The total effect coefficient was \u0026minus;\u0026thinsp;0.1104 (95%CI: -0.2484 to 0.0276), establishing coping mechanisms as a partial mediator in the relationship between psychological resilience and caregiver burden (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Mediating Effect of Coping Styles between Psychological Resilience and Caregiver Burden Using PROCESS Model (n\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaths\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEffect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLLCI ULCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.1104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0701\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[-0.2484, 0.0276]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(path c)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect Effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.1885\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[-0.3218, -0.0551]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(path c\u0026rsquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect Effect( axb )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.0781\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[0.0308, 0.1294]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-70.74%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSE: Standard Error.CI: Confidence interval. LLCI: Lower Limit CI. ULCI: Upper Limit CI\u003c/p\u003e \u003cp\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe relationship between psychological resilience and caregiving burden among caregivers of patients with bipolar disorder is influenced by multiple factors, including demographic characteristics, coping strategies, and cultural context. Our study revealed that caregivers were predominantly female, parents, and from low-income families, consistent with trends observed in developing countries globally[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Notably, the high proportion of parents as primary caregivers reflects the prominent role of family bonds in Chinese culture, demonstrating the profound impact of \"familism\" values on intergenerational responsibilities[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, this cultural identification may harbor risks: excessive emphasis on family obligations could intensify self-sacrificing tendencies, leading caregivers to neglect their own health needs[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This contradiction suggests that future interventions should establish mechanisms balancing individual well-being with family responsibilities while respecting cultural traditions.\u003c/p\u003e \u003cp\u003eThe psychological resilience of bipolar disorder caregivers exhibits dynamic characteristics, modulated by patient symptom fluctuations, social support accessibility, and economic pressures. Although some caregivers demonstrated strong internal strength dimensions, overall resilience remained moderate, with the optimism dimension particularly weak. This phenomenon aligns with Johnson et al.'s[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] dynamic resilience model, suggesting that resilience resources fluctuate with caregiving phases and external stressors. Clinical observations indicate that recurrent patient symptoms may accelerate psychological resource depletion, especially in contexts of limited social support or financial constraints[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Therefore, regular assessment of caregivers' psychological status and early intervention are crucial, such as optimizing resilience resource utilization through cognitive behavioral therapy or alleviating isolation through peer support networks.\u003c/p\u003e \u003cp\u003eRegarding burden dimensions, the prominence of personal burden likely stems from the unpredictability of bipolar disorder symptoms and dual pressures of social stigma. The conflict between chronic emotional investment and self-identity reconstruction[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], combined with tensions between social role expectations and family responsibilities[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], exacerbates the cumulative burden effect. Although most caregivers tend to adopt positive coping strategies, the activation of negative coping strategies under high-stress conditions may become a significant trigger for increased burden[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This dynamic corresponds with the core tenets of stress-coping theory, whereby individuals maintain psychological homeostasis through alternating strategy use during prolonged stress[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study further revealed the mediating pathway of coping strategies between resilience and burden. Structural equation modeling demonstrated that coping styles serve as a crucial bridge between resilience and burden, accounting for 70.9% of the total effect. This finding supports Wilson et al.'s[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] \"resilience-coping-adaptation\" cascade model, indicating that resilience not only directly buffers stress but also indirectly alleviates burden through adaptive strategy formation. The positive correlation between resilience and active coping suggests that highly resilient individuals tend to adopt problem-oriented strategies[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This mechanism aligns with resource conservation theory: resilience resources can promote active stress management through enhanced cognitive restructuring abilities[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on these findings, clinical practice should transition toward multidimensional intervention modes. Healthcare institutions should integrate resilience assessment with coping strategy screening, designing stepped support programs for high-risk groups. Policy-level initiatives should promote cross-sector collaboration, incorporating respite care services and economic subsidies into regular support systems. Furthermore, public education should transcend cultural myths, advocating for shared caregiving responsibilities through destigmatizing media narratives. Future research could explore culture-specific protective factors in stress adaptation, providing differentiated intervention evidence for global mental health care.\u003c/p\u003e \u003cp\u003eFuture research directions should prioritize: (1) longitudinal investigations to elucidate the temporal dynamics of resilience and coping mechanisms; (2) intervention studies evaluating the efficacy of targeted resilience-building programs; and (3) examination of additional mediating factors that might influence caregiver outcomes. Moreover, special attention should be directed toward developing and validating culturally sensitive interventions that address the unique challenges faced by different caregiver subgroups.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitation and strengths\u003c/h2\u003e \u003cp\u003eThis study innovatively revealed the mediating mechanism through which psychological resilience influences caregiver burden via coping styles among caregivers of patients with bipolar disorder, providing a preliminary validation of the applicability of the \"resilience-coping-adaptation\" theoretical pathway within the Chinese cultural context, while examining the impact of traditional Chinese family values on caregiving decisions. However, several limitations warrant consideration: First, the cross-sectional design precludes definitive causal inferences, necessitating longitudinal investigations to track the dynamic interactions between resilience and coping strategies; Second, the single-center sample source may introduce regional cultural bias, suggesting the need for multi-center studies to enhance result generalizability; Third, while the mediating effect of coping styles was validated, other potential moderating variables (such as social support and economic stress) and the cumulative effects of caregiving duration on burden require further investigation. Additionally, the dynamic nature of family caregiving systems indicates that future research should employ mixed-method approaches, incorporating qualitative interviews to explore the multidimensional factors influencing caregivers' strategy selection mechanisms.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis empirical study elucidated the complex relationship between psychological resilience and caregiver burden among caregivers of patients with bipolar disorder, validating the crucial mediating role of coping styles. The findings demonstrated that psychological resilience not only directly alleviates caregiver burden but also provides indirect protective effects through enhanced adaptive coping strategies. Based on these findings, we recommend establishing a stratified caregiver assessment system incorporating resilience and coping styles as routine screening indicators in clinical practice; strengthening professional training and establishing interdisciplinary collaboration models in nursing management; and improving caregiver support mechanisms with emphasis on rural service system development at the policy level. Specifically, we propose constructing an integrated \"hospital-community-family\" support network, implementing differentiated interventions based on educational levels and urban-rural differences, and incorporating support measures such as respite care into the healthcare insurance system. This study provides empirical evidence for optimizing psychological health support systems for caregivers of patients with bipolar disorder, supporting the concept of \"evidence-driven personalized care,\" with significant practical implications for enhancing family caregiving quality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Renmin Hospital of Wuhan University, and written informed consent was obtained from all participants after they were informed about the study purpose, methods, voluntary participation, right to withdraw, and confidentiality protection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express gratitude to the patients and their families for their participation in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003cbr\u003e\u003c/strong\u003eYFL and CHS collected and analyzed the data, and wrote the manuscript. XFL and ZYW designed the study and revised the manuscript. YS, ZZ, YH, and CS participated in the questionnaire collection. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received to conduct this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Status Report on Mental Health 2022 [Internet]. Geneva: World Health Organization. 2022 [cited 2025 Apr.2]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240049338\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240049338\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrari AJ, Stockings E, Khoo JP, Erskine HE, Degenhardt L, Vos T, et al. The prevalence and burden of bipolar disorder: findings from the Global Burden of Disease Study 2013. Bipolar Disord. 2016;18(5):440\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association Publishing; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson SL, Tharp JA, Holmes MK, Fulford D, Meyer TD, Carver CS. Functional impairment in bipolar disorder: The impact on quality of life and occupational outcomes. J Affect Disord. 2023;320:45\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Y, Chen X, Wang D, Zhang M, Li T, Wong SY, et al. Family caregiving patterns in bipolar disorder: A systematic review. Int J Ment Health Nurs. 2022;31(6):1125\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang K, Li W, Sun F, Wang Y, Chen H, Liu J. Financial burden among caregivers of patients with bipolar disorder: A longitudinal cohort study. J Psychiatr Res. 2023;156:234\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang R, Chen H, Liu J, Zhang Y, Li T, Sun F. Emotional distress and role conflict in caregivers of bipolar patients: A cross-sectional study. J Affect Disord. 2022;312:178\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson EH, Aiken L, Butler RN, Smith KM, Chen X, Wilson PJ. Caregiver burden across psychiatric conditions: A comparative analysis and systematic review. J Adv Nurs. 2023;79(4):892\u0026ndash;903.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee SY, Kim KH, Kim T, Park JH, Lee JY, Kang HJ, et al. The relationship between caregiver burden and care quality in bipolar disorder: A multicenter study. Int J Ment Health Nurs. 2022;31(5):1034\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConnor KM, Davidson JR. Development and validation of psychological resilience assessment tools: An updated systematic review. Clin Psychol Rev. 2022;43:102\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith AB, Jones CD, Wilson EF, Chen L, Park CL, Brown JD. The dual-compensatory model of resilience: Evidence from caregiving contexts in mental health. Psychol Bull. 2022;148(9):789\u0026ndash;805.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown JD, Chen S, Garcia A, Thompson EH, Liu Y, Wang R. Social network buffering in caregiver resilience: A longitudinal analysis. J Community Psychol. 2023;51(3):456\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson KR, Hansen DJ, Li M, Park CL, Smith AB, Chen Y. Resilience and burden in family caregivers: A mediation analysis. J Consult Clin Psychol. 2022;90(8):678\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor SE, Stanton AL. Coping resources, coping processes, and mental health. Ann Rev Clin Psychol. 2023;19:379\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark CL, Folkman S. Meaning in the context of stress and coping. Rev Gen Psychol. 2022;26(1):92\u0026ndash;115.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Y, Wang Q, Zhang L. A meta-analysis of coping strategies in caregiving research. Clin Psychol Rev. 2023;96:102174.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreen SB. How Many Subjects Does It Take To Do A Regression Analysis? Multivar Behav Res. 1991;26(3):499\u0026ndash;510.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen L, Wang Y, Sun B, Zhang K, Li W, Liu H, et al. Development of a demographic questionnaire for caregivers of psychiatric patients in China. Int J Ment Health Nurs. 2023;32(2):156\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang M, Liu K, Chen H, Wang R, Li T, Sun F, et al. Validation of caregiver assessment tools in Chinese psychiatric settings. J Psychiatr Ment Health Nurs. 2022;29(5):445\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConnor KM, Davidson JR. Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu X, Zhang J. Factor analysis and psychometric evaluation of the Connor-Davidson Resilience Scale (CD-RISC) with Chinese people. Social Behav Personality. 2007;35(1):19\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell-Sills L, Stein MB. Psychometric analysis and refinement of the Connor-Davidson Resilience Scale (CD-RISC). J Trauma Stress. 2007;20(6):1019\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie Y. Reliability and validity of the simplified coping style questionnaire. Chin J Clin Psychol. 1998;6(2):114\u0026ndash;5. [In Chinese].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Wang X, Ma H. Rating Scales for Mental Health. Beijing: Chinese Mental Health Journal Press; 1999:122\u0026ndash;124. ISBN: 7-81071-092-4 [In Chinese].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZarit SH, Reever KE, Bach-Peterson J. Relatives of the impaired elderly: Correlates of feelings of burden. Gerontologist. 1980;20(6):649\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang G, Cheng Q, Wang Y, Xu S, Ren Y, Chen J, et al. The Chinese version of the Zarit Burden Interview: Reliability and validity. Chin Mental Health J. 2006;20(2):85\u0026ndash;9. [In Chinese].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu L, Wang L, Yang X, Feng Q, Liang W, Chen L, et al. Zarit Caregiver Burden Interview: Development, reliability and validity of the Chinese version. J Neuropsychiatry Clin Neurosci. 2009;63(6):730\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Wang Q, Li T, Li X, Chen H, Wang R, et al. The burden and influencing factors of family caregivers for patients with bipolar disorder in China: A cross-sectional study. BMC Psychiatry. 2019;19(1):315.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu H, Guo Q. Family caregiving in Chinese psychiatric settings. Int J Ment Health Nurs. 2021;30(5):1089\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson JL, Wiechelt SA. Introduction to the special issue on resilience. Subst Use Misuse. 2019;39(5):657\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith GC, Hayslip B Jr. Resilience in adulthood and later life: What does it mean and where are we heading? Annual Rev Gerontol Geriatr. 2020;32(1):3\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen L, Zhao Y, Tang J, Li X, Wang R, Zhang M, et al. The burden, support and needs of primary family caregivers of people experiencing schizophrenia in Beijing communities: a qualitative study. BMC Psychiatry. 2021;21(1):75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee SJ, Kim Y, Phillips R, Liu J, Wang R, Chen H, et al. Family caregiving of individuals with severe mental illness: Examining the role of stigma and social support. J Psychiatr Res. 2022;148:34\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Chen Q, Yang M. Caregiver burden in psychiatric disorders: An updated review. Psychiatr Q. 2020;91(4):1265\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFolkman S. The Oxford Handbook of Stress and Coping. New York: Oxford University Press; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson SJ, Patel R, Bhattacharyya S, Thompson EH, Brown JD, Smith AB. Resilience-adaptation cascade in psychological adjustment: A conceptual framework. Psychol Rev. 2021;128(6):1102\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Li D, Sun W, Chen L, Liu Y, Zhang M, et al. Resilience and burden among family caregivers of patients with severe mental illness: Testing a moderated mediation model. Arch Psychiatr Nurs. 2022;36:151\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHobfoll SE. Conservation of resources theory: Its implication for stress, health, and resilience. In: Cooper CL, Quick JC, editors. The Oxford Handbook of Stress and Health. New York: Oxford University Press; 2022. pp. 41\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bipolar disorder, Psychological resilience, Caregiver burden, Coping styles, Mediating effect, Family caregivers","lastPublishedDoi":"10.21203/rs.3.rs-6480206/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6480206/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground：\u003c/strong\u003eAs a high-disability psychiatric disorder, bipolar disorder (BD) subjects family caregivers to chronic multidimensional stress due to its relapsing nature. While resilience alleviates stress through cognitive regulation, high resilience may trigger excessive active coping strategies, leading to chronic allostatic load. Coping styles, as behavioral manifestations of resilience, demonstrate dual-edge effects: buffering acute stress versus exacerbating chronic exhaustion. Existing research neglects how BD-specific factors (e.g., aggression) dynamically modulate the \"resilience-coping-burden\" pathway. This study investigates the mediating mechanisms of coping styles to inform precision interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods：\u003c/strong\u003eThis descriptive cross-sectional study enrolled 176 family caregivers of hospitalized bipolar disorder patients from the psychiatric department of Renmin Hospital of Wuhan University between March 2024 and January 2025. Participants were assessed using the Connor-Davidson Resilience Scale (CD-RISC-25), Simplified Coping Style Questionnaire (SCSQ), and Zarit Burden Interview (ZBI-22). Data analysis included descriptive statistics, Mann-Whitney U test, Kruskal-Wallis test, Spearman’s correlation, and mediation analysis via Hayes’ PROCESS macro (SPSS v19.0) with bias-corrected bootstrapping (10,000 resamples, 95% CI).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults：\u003c/strong\u003eThe mean psychological resilience total score was 61.90±15.79out of 11–100 points, the mean coping styles total score was 29.32±8.71 out of 3–47 points, and the mean caregiver burden total score was 23.76±13.26out of 0–71 points. The study revealed that psychological resilience total scores demonstrated a significant positive correlation with active coping strategies (r=0.53, p\u0026lt;0.001) and a negative association with total caregiver burden (r=−0.16, p\u0026lt;0.05). Passive coping positively correlated with personal burden (r=0.16), role burden (r=0.26), and total burden (r=0.21) (all p\u0026lt;0.05). The mediation model revealed:\u003c/p\u003e\n\u003cp\u003e· Resilience → coping path coefficient a=0.223 (p\u0026lt;0.001)\u003c/p\u003e\n\u003cp\u003e· Coping → burden path coefficient b=0.351 (p=0.005)\u003c/p\u003e\n\u003cp\u003e· Direct effect c'=-0.189 (p=0.006), indirect effect ab=0.078 (95%CI [0.031,0.129])\u003c/p\u003e\n\u003cp\u003e· Proportion mediated: 70.7%\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions：\u003c/strong\u003ePsychological resilience exerts dual effects on burden through coping styles - directly reducing burden while potentially increasing chronic stress via excessive active coping.Clinical interventions should integrate resilience enhancement with adaptive coping strategies.\u003c/p\u003e","manuscriptTitle":"The Relationship between Psychological Resilience and Caregiver Burden among Caregivers of Patients with Bipolar Disorder: The Mediating Role of Coping Styles","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 10:51:40","doi":"10.21203/rs.3.rs-6480206/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-27T06:28:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-25T19:14:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-23T14:42:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256450560609521501793427626442788641395","date":"2025-05-20T17:21:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-04T15:10:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44080549235872523677007016119361068112","date":"2025-05-04T15:06:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187479471667968422997238700355039152771","date":"2025-05-02T20:37:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-02T13:08:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-30T12:33:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-29T02:38:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-29T02:38:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-04-18T15:37:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"edb78f1b-b76f-4e7c-987a-9ab6239ec032","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-31T06:38:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 10:51:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6480206","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6480206","identity":"rs-6480206","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}