STRESS WITHIN FAMILIES OF PATIENTS WITH PSYCHOTIC DISORDERS: INITIAL STUDY

Psychotic disorders are the most severe form of mental illness. The family is the primary supporter of patients with psychosis; as such, the family is likely to experience stress when caring for psychotic patients and assisting in their recovery. Data analysis regarding stress within families could inform the types of support that family members receive. This study aimed to determine stress within families of psychotic patients in Garut, Indonesia. A descriptive study was carried out using a quantitative approach. The samples collected were of the families who visited an outpatient clinic in Garut. A purposive sample of 70 respondents using the Slovin formula (10%) was recruited. Data were collected using the 42 Depression Anxiety Stress Scale (DASS) questionnaire, and univariate analysis was conducted. Results showed that 5.7% of the respondents experienced medium stress, 54.4% experienced mild stress, 41.4% did not experience stress, and only one person (1.4%) experienced severe stress. The findings suggest that families with psychotic patients experience stress. Further research is recommended to examine the factors and levels of stress within families of longterm acute psychotic patients.


Introduction
Many people experience mental disorders globally. In Indonesia, people ranging from children and adolescents to adults and the elderly suffer from a mental disorder. Tough, Siegrist, and Fekete (2017) reported that mental disorders are caused by negative emotional, psy-chological, and social conditions in different human relationships.
Mental health is a psychological condition that allows a harmonious and productive life as an integral part of one's quality of life, considering all aspects of human life. Mental disorder is a change in the function of the soul, which causes suffering to individuals and/or obstacles in carrying out social roles (Keliat, Akemat, Daulima, & Nurhaeni, 2011).
Analysis of mental health data processed by the Ministry of Health Republic of Indonesia (2013) included psychotic and emotional disorders and their treatment. Psychosis is a mental disorder that disrupts the ability of a person to judge a bad reality. Symptoms of this disorder include hallucinations, illusions, delusions, thought process disorders, ability to think, and strange behavior, such as fighting or behaving in an extreme manner. A psychotic study in Indonesia showed that psychosis affects 0.3%-1% in the age groups of 18-45 and 11-12 years. Indonesia has a population of 264 million, of which 2.5 million people are affected by psychotic disorders. Garut has a population of 2,569,505, of which 1,343,307 are patients with mental disorders who receive outpatient care (Health Department of Garut, 2016).
In low-income communities, families generally take care of their own mentally ill family members. This situation is very common in Indonesia where the core family ties are still strong. Families with schizophrenic patients experience several problems, such as fellow family members blaming each other, poor understanding of the disorder, lack of acceptance, and dysregulated family time, energy, and resources in caring for members with mental disorders. Thus, families with schizophrenic patients experience psychological problems, including increased stress and family anxiety (Tiur, Simanjuntak, & Daulay, 2006).
Psychotic episodes can be triggered by one offspring who has a mental disorder caused by a separate hereditary issue that is shared or associated with other clinical syndromes (Arnedo et al., 2015). A psychotic episode may occur because of a disruption from the surrounding physical environment, which may complicate the ability to identify with one's emotional needs and the ability to connect with others and express thoughts clearly, or because of reacting emotionally toward others (Green, Horan, & Lee, 2015).
MacFarlane (2013) stated that the task of the family in maintaining good mental health involves identifying any developmental disruption of the health of all family members, deciding good and proper health action behavior, providing adequate care of all sick family members, maintaining a clean and healthy home environment, and ensuring good communication with all family members. Public perceptions need to be changed to eliminate stigma, and psychotic patients should be supported rather than discriminated against to improve quality of life (Mac-Farlane, 2013).
The family is a collection of two or more people who live together and are emotionally connected, and each person has a character that is part of a family group. According to MacFarlane (2013), a family is an open group, which means that a change or disturbance in one part will affect other parts and cause interference. Therefore, during the healing process of a psychotic patient, the family naturally becomes a factor in the patient's recovery. The pace of patient recovery can be assessed in either medical or psychological terms; however, empathy on the part of the family also contributes to patient recovery. Affection and positive attention are needed by psychotic patients so that they are recognized and feel that they are needed.
In treating patients with mental disorders, families can experience stress. Stress can be divided into several types, including physical, chemical, and physiological stress; growth and developmental stress; and physical and emotional stress. Psychological stress is caused by several factors, including emotional pressure (Wood, Valentino, & Wood, 2016;Strohmeier, Scholte, & Ager, 2018). Other factors, such as social prejudice and ignorance toward patients with mental disorders, can also contribute negatively to the condition of patients with a mental disorder or their family and may cause physical disrup-tion (somatic) and psychological stress. Distress is a type of stress that affects the interference of more than one body organ and prevents one from enjoying normal activities or performing work properly. Two factors influence stress, namely, biological factors (e.g., heredity, physical condition) and sociocultural factors (e.g., personality development, experience, and other conditions) (Wood et al., 2016;Strohmeier et al., 2018). Handayani and Nurwidawati (2013) showed that the family's emotions toward the situation and lack of understanding in how to care for family members with mental disorders cause recurrence. Sitinjak (2016) found that 70% of families dealing with a mentally ill patient experience moderate anxiety when the patient relapses. Besides, a family's coping strategy is strongly influenced by many factors, including beliefs, finances, knowledge, communication patterns, and social support (Wardaningsih, Rochmawati, & Sutarjo, 2016). Therefore, improving knowledge, economic, and emotional factors can positively influence family support in caring for patients with mental disorders and can prevent recurrence.
From the results of a preliminary study on the patient's family, families who experience mild stress are characterized by feeling tired, also families with moderate stress are characterized by complaints of insomnia and difficulty relaxing, families with severe stress are characterized by slight irritability. This family experienced many complaints but was not felt for the care of sheep. He also agreed with the family and for treatment with parents of patients with psychotic disorders, this always gets money for parents of patients who need psychotic drugs do not require permanent treatment. Lowyck et al. (2004) reported that family members with schizophrenic patients carry the financial and emotional burden of caring for patients.
This study aimed to describe the stress within families of psychotic patients at the psychiatric mental clinic in Garut, West Java, Indonesia.

Methods
Descriptive research with a quantitative approach was used in this study. This study included families in Garut, West Java, Indonesia, who visited an outpatient clinic treating psychotic patients. Purposive sampling was used to analyze 70 respondents using the Slovin formula (10%). Data collection techniques were performed using the 42 Depression Anxiety Stress Scale (DASS) questionnaire and univariate analysis where the researcher describes each variable. Families of psychotic patients were included in this study. Families of non-psychotic patients were excluded. Data were collected by distributing questionnaires to families who visited Poli to seek treatment or to consult with a doctor. A descriptive research design was used in this study, and purposive sampling was performed. Seventy families of psychotic patients who visited the Polyclinic Clinic of the X Hospital in Garut, to take medicine or seek treatment were selected as respondents.
For balancing harms and benefits in this study, no adverse treatments to respondents were administered and no specific action were taken. Researchers were expected to not harm the respondent, and no treatment was detrimental to the respondent. Data were used only for the development of science.

Results
Data were obtained using the DASS 42 questionnaire. The results of the study are presented in the form of descriptive statistics with frequency distribution.
The stress level of the respondents was characterized, and mild stress was the most reported stress level of 36 people (Table 1). In terms of age, a small proportion of 13 people (18.5%) experienced mild stress in the vulnerable adult age of late 36-45 years. Almost half of the 21 females (30.0%) experienced mild stress, and 9 families of patients under mild stress were mothers. A large proportion of the respondents last atten-ded elementary school education, had < 5 years since time of patient diagnosis, and had a monthly family income of less than IDR500,000.
As shown in Table 2, 5.7% of the 70 respondent families of patients at the Psychiatric Clinic in Garut experienced medium stress. By strong comparison, 36 families (54.4%) experienced light stress. Nearly half of the families of the patients included in the normal range amounted to 29 (41.4%), and only 1.4% of the families experienced severe stress.

Discussion
Stress is naturally experienced by many people. However, if unacknowledged, stress can affect health negatively and result in mental disorders. Stress is a response to the environment when an expectation or desire is determined or the demands cannot be fulfilled, leading to poor defenses (PH, Daulima, & Mustikasari, 2018). Communication factors are important in addressing issues with stress and mental illness, as well as the conditions of the surrounding environment. High stress levels and disturbed physical and emotional environment can trigger a psychotic episode (Wulansih & Widodo, 2008). Suryani, Komariah, and Karlin (2014) revealed that family perceptions regarding a psychotic patient are mostly positive, but some are negative. However, a family's opinion about psychotic treatment is still low. Therefore, nurses should educate families about processes in a patient's recovery. Saragih and Indriati (2016) argued that family members tend to have poor knowledge and negative views about the care of a psychotic family member, resulting in ineffective communication by families when engaging with a member with a mental illness.
Results of the present study showed that a small number of families (4/70, 5.7%) experienced moderate stress. A large number of (36/70, 54.4%) families experienced mild stress. Nearly half of the families (29/70, 41.4%) of the patients experienced normal stress, whereas only one family (1.4%) suffered severe stress.
In addition, 36 people experienced mild stress with late adulthood (36-45 years). The last education with the majority in mild stress was elementary school, the majority of patients was diagnosed with < 5 years, and the most income was < IDR500,000/month. The patient's family is the elderly who are susceptible to disease with weak strength, and even for work, some people who would accept it or not. They have an income of less than IDR500,000/month, for daily food costs and other needs. A relationship exists between stress level and parental socioeconomic status (Rohman, 2010).
One family member, specifically a patient's mother, in the age range of 36-45 years experienced severe stress. Mubin and Andriani (2017) found that menopause with symptoms of uncontrolled emotions, mood swings, anxiety, and difficulty sleeping occurs because of the increasing levels of follicle-stimulating hormone and luteinizing hormone. They stated that a woman aged 36-60 years tends to experience stress because they believe that mental disorders in their children cannot be cured and that people with mental disorders always depend on drugs.
In the present study, moderate stress was recorded in four families, including elderly. The elderly not only need to support themselves but also must pay for their family's daily expenses and treatment and even for the treatment of schizophrenic patients in their family. Factors that cause stress for the elderly can be due to changes in family and work (Indriana, Kristiana, Sonda, & Intanirian, 2010). According to Riandita (2018), families with moderate levels of stress can take longer in a few hours to several days. However, the results study also found that families did not experience stress as many as 29 people, which is the duration of patients suffering from psychotic more than 10 years with a calm state. Besides, the results of direct interviews with families of patients with psychotic disorders feel grateful for the situation and are a test for him.
The research of Mubin and Andriani (2017) entitled "An overview of stress levels in families who have mental disorders in dr. H. Soewondo Hospital of Kendal" uses descriptive exploratory to focus at the community level. The population recorded was as many as 349 patients with mental disorder living with their family. Accidental sampling produced a sample size of 78 people, and the results showed that most families experienced moderate stress (52/78, 66.7%). Severe stress was reported by 18 people (23.1%), and mild stress was reported by 8 people (10.3%). Their study included patients with family age in the range of 36-60 years old (49/78, 62.8%), and the majority being female (51/78, 65.4%).
The difference in research was that the previous study focused on patients who experienced mental disorders, whereas this study focused on families with schizophrenic patients only. The population in Kendal General Hospital totaled 349 patients in the last month, and that in Garut Hospital totaled 235 patients in the last month. Mubin and Andriani (2017) used accidental sampling where one was chosen as a sample, whereas the present study used consecutive sampling. That is, each patient who fulfilled the research criteria was sampled until the specified time, and the family culture or environment in Kendal and Garut can also be different.

Conclusion
The description of occurrences of stress in families with psychotic patients in Garut prevailed at the light/mild levels, suggesting that most experienced mild stress, almost half experienced normal stress, and a small proportion experienced moderate and severe stress.