This study showed that most of the caregivers of children with mental disorders were female. Research shows that women, especially mothers, are more often the primary caregivers of children with autism. Several social and cultural factors can explain this phenomenon. Women are usually expected to focus more on social and family aspects than men, an expectation that has been ingrained since early childhood. They also tend to have a stronger orientation towards interpersonal relationships and care, which may make them more likely to take on the role of caregiver.12,13
In some cases, women may have more flexible jobs or choose to reduce their work hours to care for children with special needs. Some studies also suggest that mothers may have a stronger emotional bond with their children, influencing their decision to become primary caregivers. It is important to note that individuals largely determine views on ASD diagnosis, symptoms, and treatment. This suggests that while there is a general tendency for women to be primary caregivers, each family's experiences and perceptions of caring for a child with autism can vary greatly. These findings emphasize the importance of a personalized approach in providing support to caregivers of children with ASD, considering individual, social, and cultural factors that influence their caregiving experiences. 12,13
The most common diagnosis of children in this study was ASD or Autism Spectrum Disorder. The epidemiology of autism, based on a recent systematic review, shows significant variation in global prevalence. The median prevalence of autism is 100 per 10,000 individuals, with a wide range from 1.09 to 436.0 per 10,000. The median male-to-female ratio is 4.2:1, indicating a higher prevalence in males, and approximately 33% of autism cases are accompanied by intellectual disability. Differences in prevalence estimates likely reflect complex interactions between community awareness, service capacity, help-seeking behavior, and sociodemographic factors. There is a measurable trend of increasing prevalence of autism globally, possibly due to increased public awareness, public health response, case identification and definition advances, and community capacity.14,15
As many as 14 respondents reported being unemployed because they cared for their children and could not balance work and family responsibilities. Caregivers are often the target of frustration and misbehavior of patients. Caregivers are exposed to high levels of stress, and many report feelings of social isolation, stigma, sadness, shame, guilt, anger, and helplessness. In addition, additional challenges arise from unpredictable and problematic behaviors associated with the patient's illness, such as hyperactivity, aggression, and self-destructive behaviors. Regardless of the patient's age (whether child, adolescent, or adult), the role of the caregiver is always associated with feelings of burden, health-related difficulties, and decreased well-being. Studies showed that caregivers face various significant emotional and psychological challenges, which can negatively impact their overall health and quality of life, regardless of the specific characteristics of the patient they are caring for.16–19
A study by Sun et al. investigated the prevalence of depressive and anxiety symptoms among caregivers of inpatient psychiatric patients during the final stages of the COVID-19 pandemic using a network analysis perspective. This study included 1101 caregivers using PHQ-9 to assess depression and GAD-7 for anxiety. The results showed significant prevalence, with 32.4% having depression, 28.0% having anxiety, and 24.9% having comorbidities of both.20 Network analysis identified “Fatigue”, “Difficulty Relaxing”, and “Restlessness” as the most central symptoms, while “Restlessness”, “Uncontrollable Worry”, and “Suicidal Ideation” were the most highly connected symptoms. The network model proved stable with no significant differences across gender or education levels. Sun et al. concluded that these central and connected symptoms should be a primary focus in the mental health management of caregivers of psychiatric patients, especially in the context of a prolonged pandemic.20
Mehmood et al. (2022) conducted a study to assess the levels of depression and anxiety among caregivers of patients with schizophrenia. This cross-sectional study involved 65 participants recruited from a private hospital's inpatient and outpatient units. The researchers used the Hamilton Rating Scale to assess depression and anxiety in caregivers. The results showed significant levels of depression and anxiety among caregivers. For anxiety, 24.6% of caregivers were in the moderate to severe category, while 38.5% were in the mild category. Meanwhile, for depression, 61.5% of caregivers were in the moderate to severe category. Mehmood et al. concluded that caregivers of patients with severe mental disorders experience high levels of depression and anxiety. They emphasized the importance of appropriate interventions to improve the psychological well-being of caregivers, given the emotional, psychological, and financial burdens they face, including the stigma associated with mental illness.21
Radu et al. (2022) investigated predictors of burden, stigma, and well-being experienced by caregivers of family members with psychiatric disorders. This cross-sectional study included 168 caregivers and assessed perceived burden, stigma, well-being, knowledge, illness perception, and medical variables. The results identified several correlates related to caregiver burden, stigma, and well-being. An integrative predictive model showed that the caregiver's emotional representation of illness was the best predictor of burden (β = 0.38, p < 0.001), stigma (β = 0.53, p < 0.001), and well-being (β = −0.36, p < 0.001). These findings have important practical implications, as they may assist health professionals in designing more appropriate psychosocial interventions for family members of individuals living with psychiatric conditions. By understanding the factors that influence caregiver experiences, interventions can be designed more effectively to reduce burden and stigma and improve their well-being.22
Studies on caregiver burden in pediatric patients with mental disorders are rare in Indonesia and Bali. Alibekova et al.'s (2022) study investigated the prevalence of stress, anxiety, and depressive symptoms among 146 caregivers of children with autism spectrum disorders in Kazakhstan. This cross-sectional study showed that parents who felt their needs for social acceptance were unmet experienced higher levels of stress and depression. In contrast, parents who were employed and had better peer support showed lower symptoms of stress, anxiety, and depression.23
Niekerk et al.'s study (2023) investigated the sociodemographic profile and levels of burden experienced by caregivers of children with ASD in an Academic Hospital in Johannesburg, South Africa. This quantitative, descriptive, cross-sectional study involved 77 caregivers who completed a sociodemographic questionnaire and the 12-item Zarit Burden Interview. The results showed that the majority of caregivers were female (72.3%), mothers of children with ASD (64.3%), and Christian (p < 0.001). Most caregivers had secondary or higher education and were employed. The levels of caregiver burden varied, with 41.6% experiencing mild to moderate burden, 33.8% experiencing high burden, and only 24.9% reporting no to mild burden.24
Pranayama's mechanism for reducing anxiety is multifaceted. It involves physiological changes in the autonomic nervous system, biochemical alterations in neurotransmitter and hormone levels, and psychological shifts in attention and emotional regulation. At its core, pranayama involves the conscious control and regulation of breath, which directly links the body and mind. This connection is rooted in the intricate relationship between breathing patterns and the autonomic nervous system.6,25,26
When an individual experiences anxiety, the sympathetic nervous system becomes activated, triggering the "fight or flight" response. This increases heart rate, rapid shallow breathing, and heightened muscle tension. Pranayama techniques work to counteract these effects by deliberately slowing and deepening the breath, activating the parasympathetic nervous system – often called the "rest and digest" system. This activation leads to decreased heart rate, lowered blood pressure, and reduced muscle tension, effectively reversing the physiological symptoms of anxiety.27
On a biochemical level, pranayama practice has been shown to influence neurotransmitter levels in the brain. Regular practice can increase the production of gamma-aminobutyric acid (GABA), a neurotransmitter crucial in reducing neuronal excitability throughout the nervous system. Higher levels of GABA are associated with lower anxiety levels. Additionally, pranayama may help regulate the hypothalamic-pituitary-adrenal (HPA) axis, responsible for the body's stress response. This regulation can lead to decreased production of stress hormones like cortisol, further reducing anxiety.28,29
Psychologically, pranayama is a form of mindfulness practice that encourages practitioners to focus on the present moment through breath awareness. This focused attention can help break the cycle of anxious thoughts and rumination that often characterize anxiety disorders. By redirecting attention to the breath, individuals can create a mental space that allows for greater emotional regulation and a sense of control over their physiological state. Moreover, the rhythmic nature of pranayama breathing techniques can induce a meditative state, promoting relaxation and calmness. This state is characterized by increased alpha wave activity in the brain, associated with relaxation and reduced anxiety. Regular pranayama practice can lead to neuroplastic changes in the brain, potentially strengthening neural pathways associated with calm and relaxation, making it easier for individuals to access these states even in challenging situations.6,27
The practicality of pranayama as an anxiety-reduction tool lies in its accessibility and the sense of agency it provides to practitioners. Unlike some interventions that rely on external factors, pranayama empowers individuals to participate in their anxiety management actively. This sense of control can be particularly beneficial for caregivers of children with mental disorders, who often face unpredictable and stressful situations.25
The strengths of this study lie in its straightforward design, using a standardized instrument (HARS), and a structured intervention. This study focused on a specific study subject with a diverse participant characteristic. Appropriate statistical analysis was used, resulting in significant findings regarding the effectiveness of yoga pranayama in reducing anxiety levels.
The findings of this study could have significant implications for healthcare policy and practice in Denpasar and beyond. As it is proven effective, pranayama could be integrated into existing support programs for caregivers, offering a non-pharmacological approach to anxiety management. This could not only improve the mental health and quality of life for caregivers but also potentially enhance the care provided to children with mental disorders, creating a positive ripple effect throughout the family system and the broader community. Moreover, this research contributes to the growing body of evidence on the efficacy of traditional practices in addressing modern health challenges. It aligns with the World Health Organization's emphasis on exploring and integrating conventional and complementary medicine into national health systems, particularly in regions where these practices are culturally significant.
The main limitations of this study include the relatively small sample size (36 participants) and the absence of a control group, which may limit the generalizability of the results. The short duration of the study (4 weeks) may not be sufficient to assess long-term effects, and the lack of follow-up limits the understanding of the sustainability of the intervention's effects. This study did not consider potential confounding variables and was limited to one geographic location.