Emotion Regulation Strategies and Mental Health in Dementia Caregivers: The Moderating Role of Gender Free

Approximately 11 million people care for a loved one with dementia in the USA [1, 2]. Although caregiving is a meaningful and fulfilling experience for many [3], caregivers often experience distressing emotions (e.g., sadness, fear) that may lead to elevated levels of depression and anxiety [4‒7]. To promote better mental health, caregivers can attempt to regulate or manage their emotions using a variety of emotion regulation (ER) strategies [8, 9]. For example, caregivers can reframe the way they think about an emotionally evocative situation to alter their emotional response (i.e., cognitive reappraisal [CR]) or they can inhibit or suppress their emotional behaviors (i.e., expressive suppression [ES]) [10]. CR is generally viewed as beneficial for mental health, while ES is often viewed as maladaptive [11]. However, the context in which these two strategies are deployed may determine their utility and associations with mental health [12]. Importantly, societal influences differ for men and women who face unique expectations regarding emotional expression and obligations to become caregivers [13]. As a result, the use of certain ER strategies and how they are associated with depression and anxiety may differ for men and women, which could inform more tailored interventions.

In the context of dementia caregiving, there are well-established gender differences. Compared to men, women caregivers experience higher rates of both anxiety and depression [14]. This may result from men taking on less demanding and less stressful caregiving tasks, adopting different approaches for managing these tasks (e.g., completing tasks in sequence rather than multitasking), receiving more instrumental support, experiencing less emotional distress, and feeling less obligated to provide care [15, 16]. Given these differences, men and women likely experience caregiving demands differently and should ostensibly employ different ER strategies to cope with these demands.

The research on gender differences in ER strategies is somewhat inconsistent. For example, several studies report that men report greater use of ES than women [10, 17] and women report greater use of CR than men [18, 19]. Such findings can be explained in terms of men being socialized to suppress their emotions [20, 21] and women being socialized to have greater awareness of their emotional experiences [22‒24]. However, other studies have found no gender differences in emotion regulation strategies [8, 25]. Importantly, no research to our knowledge has examined whether men and women adopt different ER strategies in the context of dementia caregiving.

The relationship between ER and mental health in caregivers has received growing attention. For example, caregivers who learned CR techniques to up-regulate positive emotions experienced decreases in depressive symptoms [9]. In another study, ER in caregivers was found to reduce psychological distress [8]. However, neither of these studies examined gender differences in the association between ER strategies and mental health.

Although not tested with dementia caregivers, there is evidence that gender moderates the effect of ER strategies on mental health. A recent study of non-caregiving older adults found that greater use of CR and less use of ES was associated with less anxiety and depression in women, but not in men [26]. Women (compared to men) have demonstrated greater control over their emotional experiences [22‒24, 27], and so women’s ER tendencies may have a stronger effect on their mental health. Thus, ER strategies may have closer ties to the mental health of women than men dementia caregivers.

The present study uses questionnaire data obtained from three independent samples of informal caregivers for people with dementia or mild cognitive impairment to examine the role of gender in the use of ER strategies and the association between ER strategies and mental health. We tested two hypotheses: Hypothesis I – women will use more CR and less ES compared to men caregivers; and Hypothesis II – gender will moderate the association between ER and mental health (i.e., anxiety and depression) such that greater use of CR and lower use of ES will be associated with lower anxiety and depression in women, but not in men caregivers.

Informal caregivers (total N = 460) living with a person with dementia (PWD) or mild cognitive impairment were recruited for three separate studies including a study of emotional functioning (study 1, N = 170), and two randomized controlled trials evaluating in-home technology designed to reduce caregiver burden (studies 2 [N = 75] and 3 [N = 215]) [28]. All questionnaires were completed online either in the laboratory (study 1) or in the participant’s home (studies 2 and 3). For studies 2 and 3, all data were obtained at a “baseline” assessment prior to the assignment to intervention conditions. All procedures were approved by an Institutional Review Board, and all caregivers consented to participate. Demographic characteristics of all samples are presented in Table 1. Additional details for each study including care recipient diagnoses are provided in online supplementary Material 1 (for all online suppl. material, see https://doi.org/10.1159/000538398).

Depression was measured using the 20-item Center for Epidemiological Studies Depression Scale (CES-D) [29, 30]. Caregivers used a 4-point scale ranging from 0 (rarely or none of the time) to 3 (most or all the time) to indicate how often they experienced symptoms over the past week (e.g., “I felt depressed”).

Anxiety was measured using the 21-item Beck Anxiety Inventory (BAI) [31]. Caregivers used a 4-point scale ranging from 0 (not at all) to 3 (severely) to report how much they were bothered by symptoms in the past month (e.g., “unable to relax”).

Emotion regulation was measured using the 10-item Emotion Regulation Questionnaire (ERQ) [10, 32]. Caregivers used a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree) to report their tendencies to use CR (e.g., “when I want to feel more positive emotion, I change what I’m thinking about”) and ES (e.g., “when I am feeling positive emotions, I am careful not to express them”).

To increase our statistical power to detect significant effects, we merged the three independent samples into one dataset [33]. We conducted a series of preliminary analyses to examine whether the samples differed on any of the primary variables of interest (see online suppl. Table 1). Because we observed significant differences in our primary variables, study was included as a covariate in all analyses (with study 1 as the reference). To test for demographic and socioeconomic differences that may also account for differences in depression and anxiety between men and women, we performed χ² tests of independence for race, household income, education level, and relationship to the PWD. Men and women significantly differed on education level and relationship to the PWD and were included as covariates in all analyses (with “No High School Diploma” and “Romantic Partner or Spouse” as reference groups, respectively). We considered combining anxiety and depression into a single mental health variable, and we considered combining CR and ES into one model. As is often the case [34], anxiety and depression were correlated in our dataset (see Table 2). Given the size of this correlation [r(430) = 0.671, p < 0.001] and the clinical utility of understanding the unique associations these symptoms have with caregivers’ ER abilities, we analyzed them as distinct dependent variables. Combining CR and ES into one model did not alter the interpretation of our results (see online suppl. Table 2), and because our hypotheses were not related to the combined effects of ES and CR, we report two separate models in the analysis below.

Hypothesis I: we conducted two ANOVAs with gender (coded as a binary variable) as the independent variable and education, relationship to PWD, and study as covariates. Each model included either CR or ES as the dependent variable.

Hypothesis II: we conducted a series of four linear regressions with either depression or anxiety as the dependent variable. For all models, we included gender as the dependent variable and education, relationship to PWD, and study as covariates. Each model examined the interaction between gender and one of the two ER strategies, and we examined the simple slopes for men and women for significant interactions [35].

Table 1 displays demographic characteristics by gender. Women reported using more CR (M = 29.88, SD = 6.35) than men (M = 28.16, SD = 5.82) (F(1, 439) = 8.20, p = 0.004, η_p² = 0.018) and less ES (M = 12.65, SD = 4.93) than men caregivers (M = 14.57, SD = 4.46) (F(1, 439) = 14.54, p < 0.001, η_p² = 0.032).

Gender significantly moderated the association between CR and depression (β = −0.257, t(414) = −2.62, p = 0.009) but did not significantly moderate the association between ES and depression (β = 0.144, t(413) = 1.44, p = 0.150). Gender did not moderate the association between CR and anxiety (β = −0.168, t(418) = −1.68, p = 0.094) or ES and anxiety (β = 0.117, t(419) = 1.15, p = 0.252). See Table 3 for all regression statistics.

We examined the simple slopes to understand the moderating effect of gender on the association between CR and depression. For women caregivers, greater CR was associated with less depression (β = −0.320, t(432) = −5.55, p < 0.001), whereas for men caregivers, CR use was not associated with depression (β = −0.070, t(432) = −0.82, p =. 420; see Figure 1).

Supporting Hypothesis I, women caregivers reported less use of ES and greater use of CR compared to men caregivers. Partially supporting Hypothesis II, gender moderated the relationship between CR and depression, with CR associated with less depression for women caregivers, while for men caregivers, levels of depression were not associated with their use of CR. Gender did not moderate the association between either ER strategy and anxiety. Given that gendered societal expectations make women more likely to be caregivers and more likely to experience emotional distress related to caregiving tasks [15, 16], CR may be an effective strategy for reducing depressive symptoms in women caregivers of PWDs, but not for men caregivers.

Our study used self-report of ER tendencies rather than the successful use of these strategies, which could also explain the lack of association between mental health and CR in men. Future research should explore caregivers’ ability to successfully use ER strategies using multi-method approaches (e.g., emotion-related physiology and behavior) [36] and use longitudinal designs to investigate gender differences in the temporal relationships between ER strategies and mental health.

Clinicians working with these individuals, as well as researchers assessing the efficacy of ER strategies, should bear these gender differences in mind because ER strategies may differentially impact men and women’s mental health. Further research is needed to understand how best to support the mental well-being of both women and men dementia caregivers.

The authors would like to thank Gene Wang, David Moss, and other employees at Care Daily for their assistance with recruitment of studies 2 and 3, and the Memory and Aging Center at the University of California, San Francisco, for their assistance with recruitment of study 1. We would also like to thank all members, both past and present, of the Berkeley Psychophysiology Laboratory for their assistance with data collection. Finally, we would like to thank all our participants for dedicating their time to this research.

The study was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. The study protocols were reviewed and approved by the Institutional Review Boards of the University of California, Berkeley, for studies 1 and 2 (IRB#: 2018-10-11485) and study 3 (IRB#: 2010-02-861).

Written informed consent to participate in the study was obtained for all participants, and all participants provided either a written or digital signature. Caregivers provided consent themselves, and people with dementia were evaluated for their capacity to provide consent using the UCLA Decision Assessment Tool. For all persons with dementia deemed capable, they provided consent themselves. For all deemed not capable, consent was provided by the caregiver or a legally authorized representative on their behalf.

The authors have no conflicts to declare.

Manuscript preparation was supported by a National Institute on Aging grant (R00AG073617) awarded to Casey Brown. Data collection was supported by National Institute on Aging grants (R01AG007476, R01AG041762, R44AG059458). The views expressed in this manuscript are the authors’ and do not reflect the views of the National Institutes of Health.

Concept and design: Bullard and Brown; acquisition, analysis, or interpretation of data: Bullard, Brown, Scheffer, and Levenson; drafting of the manuscript, critical revision of the manuscript for important intellectual content, and administrative, technical, or material support: Bullard, Brown, Toledo, Scheffer, and Levenson; statistical analysis: Bullard, Brown, and Scheffer; and supervision: Brown and Levenson.

The data that support the findings of this study are available through OSF [https://osf.io/mv3jx/?view_only=cd2af11870104433a2366fcab4f0319e]. Further inquiries can be directed to the corresponding author.