Discussion

Based on paired data from 763 patients with SMDs and their family caregivers in rural China, we found that psychiatric symptom severity was significantly associated with the frequency of both verbal and physical abuse by caregivers. Moreover, moderate-to-severe tobacco dependence among caregivers was not only directly associated with a higher risk of abuse but also significantly strengthened the association between psychiatric symptom severity and verbal abuse. To our knowledge, this is the first study in rural China to demonstrate both the association between psychiatric symptom severity and caregiver abuse, and the moderating role of tobacco dependence, thereby providing empirical grounds for family-based interventions and public health strategies.

Few studies have specifically assessed caregiver-perpetrated abuse of SMD patients in China, and available findings vary by region and study design. Li et al. reported a prevalence of verbal abuse ranging from 15.9% to 21.5% and physical abuse of 4.2% among caregivers of schizophrenia patients in southern China (Li et al., Reference Li, Qiu, Wu, Ni, Tang and Xiao2023). Wang et al. (Reference Wang, Hou, Wang, Huang, Huang, Zhang and Jia2020) found that 18.9% of rural patients experienced at least one violent incident within 6 months, though the perpetrators were not specified. By contrast, our study documented higher prevalence rates in rural areas, with 25.7% for verbal abuse and 14.9% for physical abuse, suggesting that caregiver abuse may be particularly concerning in these settings.

International comparisons indicate that the prevalence of abuse in rural China is at an intermediate level globally. In Ethiopia, 36.3% of patients with SMDs reported caregiver violence, without differentiation of abuse types (Wale et al., Reference Wale, Addisu, Belete, Fekadu, Wassie and Chekol2025). In India, 39% of patients experienced physical abuse by family members, and the overall prevalence of any abuse reached 72% (Bhatia et al., Reference Bhatia, Srivastava, Khyati and Kaushik2016). In Israel, 66% of patients reported verbal abuse within a year, most commonly by friends and parents (Karni-Vizer & Salzer, Reference Karni-Vizer and Salzer2016). A systematic review further showed wide variation, with the prevalence of family violence against SMDs patients ranging from 14.8% to 95.2% in men and 10% to 67% in women(Rani et al., Reference Rani, Raman, Singh, Antony, Ammapattian, C and Prabhu2022), showing significant variations. In rural areas of China, the causes of abuse may be linked to caregivers’ limited understanding of mental illnesses (Li & Reavley, Reference Li and Reavley2021). They often misinterpret the patients’ symptoms as intentional behavior or moral issues, thereby rationalizing their abusive actions. Deep-rooted Confucian familism, which emphasizes family responsibility and regards caregiving as a private duty (Yang, Reference Yang2004), further reinforces the invisibility of abuse by limiting external oversight and intervention.

Our finding that psychiatric symptom severity was associated with caregiver abuse is consistent with prior evidence in dementia research (Fang et al., Reference Fang, Liu and Yan2021), but evidence among SMDs patients remains scarce. This study extends the literature by demonstrating that psychiatric symptom severity is not only associated with poor clinical outcomes but also linked to a higher risk of abuse within family settings. Mechanisms are likely multifaceted. Psychologically, worsening symptoms heighten both the emotional and physical caregiving burden, increasing frustration and hostility in unsupported caregivers (Kochhar et al., Reference Kochhar, Mishra, Chadda, Sood and Bhargava2024). Within the stress–coping framework, persistent symptoms act as chronic stressors; in the absence of adaptive coping and social support, caregivers may resort to abusive behaviors as maladaptive outlets (Pearlin et al., Reference Pearlin, Mullan, Semple and Skaff1990; Pickering et al., Reference Pickering, Yefimova and Maxwell2018; Umer et al., Reference Umer, Tong, Rodak, Xu, Dennis, Naeem and Husain2025). Sociologically, patients’ behavioral symptoms can disrupt family roles, dynamics, and power structures (Kochhar et al., Reference Kochhar, Mishra, Chadda, Sood and Bhargava2024; Labrum & Solomon, Reference Labrum and Solomon2015; Lin & Giles, Reference Lin and Giles2013), prompting caregivers to use verbal or physical force in an attempt to regain control (Lin & Giles, Reference Lin and Giles2013; Pillemer & Finkelhor, Reference Pillemer and Finkelhor1989). Biologically, chronic exposure to severe psychiatric symptoms may dysregulate caregivers’ hypothalamic–pituitary–adrenal axis and promote systemic inflammation (Bamber et al., Reference Bamber, Solatikia, Gaillard and Spratling2023; Beadle & Jain, Reference Beadle and Jain2021), diminishing emotional regulation and increasing aggressive reactivity. Taken together, these perspectives suggest that stress, strain, and self-control processes jointly shape the mechanisms underlying caregiver abuse. Within the stress–coping framework (Biggs et al., Reference Biggs, Brough, Drummond, Cooper and Quick2017), persistent patient symptoms act as chronic stressors that erode caregivers’ coping resources. As strain theory posits (Zhang et al., Reference Zhang, Wieczorek, Conwell and Tu2011; Zhang, Reference Zhang2019), accumulated frustration and perceived caregiving failure generate psychological tension, which caregivers may attempt to relieve through smoking or aggressive expression. Concurrently, the self-control perspective (Gottfredson & Hirschi, Reference Gottfredson and Hirschi1990) highlights that nicotine dependence compromises emotional regulation and inhibitory capacity, thereby lowering the threshold for impulsive or abusive reactions. This integrated model suggests that caregiver abuse represents not only a behavioral manifestation of stress overload but also a consequence of impaired self-regulation under chronic strain.

We also observed that moderate-to-severe tobacco dependence significantly moderated the association between psychiatric symptom severity and verbal abuse. Physiologically, nicotine dependence reshapes the brain’s reward and stress-regulation systems, rendering dependent individuals more vulnerable to mood fluctuations and impulsivity during nicotine depletion (Bruijnzeel, Reference Bruijnzeel2012). Nicotine withdrawal is also associated with cognitive deficits – including impairments in attention, working memory, and inhibitory control – that compromise caregivers’ ability to regulate responses to patients’ symptoms (Ashare et al., Reference Ashare, Falcone and Lerman2014). Furthermore, smokers display marked deficits in inhibitory control under tobacco-related cues (Hou et al., Reference Hou, Zhang, Liu, Chen, Gao, Chen and Zhou2024), suggesting that caregivers with nicotine dependence may be more prone to loss of control when psychiatric symptoms worsen. At the behavioral level, while smoking is often perceived by caregivers and health professionals as a coping strategy for stress and severe psychiatric symptoms, such beliefs sustain smoking culture (Cookson et al., Reference Cookson, Strang, Ratschen, Sutherland, Finch and McNeill2014; Sheals et al., Reference Sheals, Tombor, McNeill and Shahab2016). In reality, the short-term relief derives largely from alleviation of withdrawal symptoms, while the long-term effects of smoking are detrimental to brain and mental health (Taylor et al., Reference Taylor, Lindson, Farley, Leinberger-Jabari, Sawyer, Te Water Naudé and Aveyard2021; Taylor & Treur, Reference Taylor and Treur2023). Compared with non-dependent caregivers, those with moderate-to-severe dependence are more vulnerable within the stress–coping balance (Bruijnzeel, Reference Bruijnzeel2012; Pietras et al., Reference Pietras, Witusik, Panek, Szemraj and Górski2011); even minor symptom exacerbations may exceed their tolerance thresholds, substantially elevating the risk of verbal abuse. Conceptually, we treated tobacco dependence as a moderator rather than a mediator, given that it represents a relatively stable tendency shaping caregivers’ emotional and behavioral responses to stress. Within the stress-coping and self-control frameworks, tobacco dependence may alter the strength of the association between patients’ psychiatric symptom severity and abusive behaviors by lowering caregivers’ inhibitory control and emotional regulation thresholds. This conceptualization aligns with moderation logic, which focuses on effect modification rather than causal transmission.

This study highlights the unique challenges of rural contexts, where mental health resources are scarce and caregivers often lack access to professional guidance, psychiatric support, respite care, or psychological assistance. Structural deficiencies leave caregivers isolated and solely responsible for intensive caregiving, contributing to exhaustion and burnout (Adelman et al., Reference Adelman, Tmanova, Delgado, Dion and Lachs2014; Hu et al., Reference Hu, Hu and Xu2023). Economic fragility further compounds this burden: medical costs, loss of household labor, and time constraints collectively increase strain. Interestingly, we found higher abuse risk among households with greater annual income, possibly reflecting heightened sensitivity to stigma and reputational concerns, which intensify psychological stress (Wang et al., Reference Wang, Meng, Zhang, Weng, Li, Luo and Ran2023; Yin et al., Reference Yin, Wardenaar, Xu, Tian and Schoevers2020). Longer daily caregiving hours also directly erode physical and emotional reserves, lowering thresholds for emotional regulation and elevating risk of abusive responses (Adelman et al., Reference Adelman, Tmanova, Delgado, Dion and Lachs2014).

These findings offer practical implications for public health strategies, particularly within the context of rural China. First, caregiver-centered interventions, such as family education programs (Farhall et al., Reference Farhall, Cugnetto, Mathews, Ratcliff, Farnan, Higgins and Constantine2020), psychoeducation, stress management, and behavioral counseling, should be systematically integrated into primary mental health services to enhance caregivers’ knowledge, emotional regulation, and coping capacity. The existing community-based service network, which includes the family doctor contract service and basic public health programs, provides a feasible delivery platform: family doctors and community health workers can screen caregivers for tobacco dependence, provide brief advice, offer follow-up support, and link dependent caregivers to specialized cessation or mental health services. Second, tobacco control should be prioritized within mental health care and primary care for caregivers. Evidence-based smoking-cessation strategies that combine behavioral counseling, such as cognitive behavioral therapy (Malbos et al., Reference Malbos, Borwell, Einig-Iscain, Korchia, Cantalupi, Boyer and Lancon2023), pharmacotherapy where appropriate, and sustained follow-up improve quit rates and can mitigate nicotine-related emotional dysregulation that increases the risk of abusive responses. Training primary-care teams and family doctors to deliver brief interventions and establishing referral pathways to more intensive cessation services would be pragmatic steps in resource-limited rural settings. Community-based navigators and outreach programs have been shown to increase uptake of cessation treatments among disadvantaged smokers and may be adapted to reach caregiving populations. Third, formalized community-based peer support and mutual-aid networks deserve strengthening as complementary strategies. Peer groups, caregiver support programs, and community mental-health interventions can reduce isolation, normalize help-seeking, and provide practical coping skills that decrease reliance on maladaptive behaviors such as smoking; interventions targeting caregivers in low- and middle-income countries have demonstrated medium-to-large effects on caregiver outcomes (perceived burden, depression, and anxiety) and are therefore promising models for scale-up (Chen et al., Reference Chen, Hu, Li, Zheng, Li and Salcher-Konrad2025). Embedding peer support within the family-doctor and community-health frameworks can create low-cost, sustainable platforms for ongoing psychosocial support. Finally, cross-sectoral policy coordination is essential: aligning mental health, tobacco control, primary care, and social welfare policies will create a more supportive environment for both patients and caregivers. In the long run, addressing caregiver abuse requires a coordinated, system-level response. Given the documented global burden of household violence and the elevated risk of abuse among people with severe mental disorders, caregiver-focused interventions that combine addiction treatment, psychosocial support, and routine risk screening could reduce family violence and improve patient outcomes at a population scale. Although developed within the context of China’s primary-care reforms, these strategies may also inform similar efforts in other low- and middle-income countries.

This study has several strengths. The use of paired data from both patients and caregivers enhanced validity and explanatory power. The innovative inclusion of tobacco dependence as a moderator provided novel insights into mechanisms of abuse. Nonetheless, limitations should be acknowledged. First, as this is a cross-sectional study, the findings represent associations rather than established causal relationships. We therefore cannot fully exclude the possibility that caregivers’ tobacco dependence may also act as a mediating factor between psychiatric symptom severity and abusive behaviors. For instance, more severe psychiatric symptoms could heighten caregiving stress, which in turn increases smoking severity and subsequently elevates the risk of abuse. Future longitudinal or interventional studies are warranted to establish the temporal sequence and to test this potential mediating pathway through causal mediation analyses. Second, our measurement of abusive behaviors relied primarily on patient or relative reports and, in most cases, patients and their primary caregivers were interviewed in the same setting with a family doctor present to facilitate understanding and ensure safety. Although this procedure was necessary, given the communication difficulties and safety concerns inherent in interviewing some patients with severe mental disorders, it may have introduced social desirability and reporting biases. Caregivers might underreport abusive acts because of shame or stigma, while patients’ accounts could be affected by symptom severity or by caregivers’ presence during interviews. These factors may together lead to an underestimation of the true prevalence of abuse. To mitigate these issues, future studies should implement triangulated, multimodal assessment strategies. This approach would leverage multiple informants and methods, including separate patient interviews, caregiver reports, standardized assessments, and ethical observational methods, to significantly enhance measurement validity and reliability. Moreover, future research should also examine relatively stable and temporally antecedent background factors, such as caregivers’ educational attainment and socioeconomic status, as potential moderators of the relationship between patient symptoms and abusive behaviors. These characteristics are typically established prior to the caregiving context and remain stable over time, thus offering a clearer and more theoretically grounded understanding of effect modification across sociodemographic strata. Finally, because the majority of caregivers in our sample were family members (spouses, children, or parents), our findings may not fully capture the experiences and motivations of non-family caregivers, whose emotional involvement and caregiving roles may differ; future work should therefore explicitly compare family versus non-family caregivers. Despite these limitations, our study contributes new evidence on the interplay between psychiatric symptom severity and caregiver abuse in rural Chinese families and, importantly, identifies tobacco dependence as a significant moderator. These findings provide fresh perspectives for family interventions and public health strategies.