Introduction
According to the report of the World Health Organization (WHO), one in four families has a member affected by a mental disorder, with family members typically serving as the primary caregivers. Following the process of deinstitutionalization over recent decades, the primary setting for healthcare in many countries has shifted from hospitals to community-based outpatient service centers. The community-based service centers often support family caregivers and have a significant impact on the lives of individuals with mental illness. One mental disorder that presents numerous challenges for caregivers is bipolar disorder (BD), a chronic, cyclical mood disorder that persists throughout a person’s life, and has long-term effects on patients’ lives, especially visible in their social functioning and quality of life (QoL). Relatives and close friends who provide unpaid assistance to patients on a weekly or daily basis are defined as caregivers. Notably, compared to caregivers of the elderly or individuals with cancer, those who care for people suffering from mental disorders face a much broader range of challenges. For example, the early onset of certain mental illnesses can lead to severe impairments in the patient’s functioning, resulting in a high level of dependency on the caregiver and, consequently, increased stress and difficulties experienced by the caregiver. 
Given the healthcare system changes over the past two decades and the increasing emphasis on community-based service provision, families now play an even more central role in caring for individuals with BD. Family members and close friends are the primary sources of support for individuals with this condition. They often face unpredictable mood fluctuations, including episodes of depression, mania, and the risk of suicide. Research on caregivers of individuals with BD shows that they experience a wide range of physical health problems, anxiety, and depression. These issues adversely affect their QoL, occupational and social functioning, interpersonal relationships, and even increase their risk of mortality. Ultimately, these factors alter the way caregivers cope with and respond to the challenges posed by the disorder.
Studies have identified multiple factors that influence how family members confront the reality of having a loved one with a chronic mental illness. These include the stigma surrounding mental health services, the nature of the patient’s needs, illness severity, patient’s gender, caregivers’ demographic and personality traits, the nature of the illness itself, and prevailing cultural values. This study aims to explore the lived experiences of caregivers of individuals with BD in Iran, focusing on the outcomes, facilitators, and inhibitors they encounter. Focusing on the caregiving process for those with BD not only highlights the stress, pain, complex challenges, and psychological burdens faced by these families and the need to prioritize caregivers’ mental well-being, but also brings attention to key variables within the family that play a significant role in the patient’s treatment process.

Methods 
This is a qualitative study using the grounded theory approach based on Strauss and Corbin’s (2015) analytical framework. Sampling began purposively and continued until reaching theoretical saturation. Data were collected through 18 unstructured interviews with caregivers and 3 semi-structured interviews with experts in the related fields. Simultaneous coding and data analysis were conducted following the theoretical model.

Results 
The analysis identified “role entanglement” as the core theme, and eight categories that explained the caregiving process for individuals with BD (Table 1).


These categories included: Harmful family context, inhibiting cognitions (contextual factors), initial confronting, incongruent feedback, positive/negative attitudes toward treatment (causal factors), loneliness, adversity, dissociation/coherence (consequences).

Conclusion 
The findings underscore that caregiving for individuals with BP in Iran is a prolonged and exhausting journey, deeply influenced by personal and cultural variables. Most caregivers struggle to manage the chronic and unpredictable nature of the disorder, which often endangers their mental and physical health. Key challenges included a lack of knowledge about BD among caregivers and significant shortcomings in the diagnosis and treatment of the condition. Addressing these issues is essential to improve the well-being of both caregivers and BD patients. The results of this study indicate that the caregivers’ process of confronting BD begins from the emergence of the first warning signs. However, these signs are often ignored by caregivers for various reasons until a crisis occurs and the situation becomes unmanageable. It is also important to consider that confrontation is a dynamic process shaped by cultural, social, and economic factors and continues in interaction with them. After receiving a diagnosis, the patient’s family members often take on the role of caregiver and face ongoing challenges and confusion as they try to fulfill both their previous and current responsibilities. These challenges are frequently exacerbated by shortcomings in the healthcare system. Since the family function as a dynamic system, maintaining a balance in relationships with the patient and other family members is one of the main challenges caregivers face. This often leads to a constant sense of confusion about the type and extent of appropriate support for the patient, whether to continue the support or let it go, and whether to blame oneself or others. Ultimately, the acceptance of the disorder as a reality in the caregivers’ lives plays a key role. It can either facilitate the process of coping with the various positive and negative consequences they experience or, conversely, lead to serious difficulties. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Tarbiat Modares University, Tehran, Iran (Code: IR.MODARES.REC.1401.032).

Funding
This article was a extracted from PhD dissertation master's thesis of Mohya Ebrahimi Jamarani, Psychology, Faculty of Humanities, Tarbiat Modares University.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors

Authors contributions
Design, implementation, data collection and analysis: Mohya Ebrahimi Jamarani; Supervision, review and editing: Parviz Azadfallah; Methodology and supervision: Hojjatollah Farahani.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank all participants for their time and cooperation in this study.

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