Psychiatric morbidity and marital satisfaction among spouses of men with alcohol dependence.

BACKGROUND: Alcohol dependence has adverse health and social consequences; Alcohol related problems primarily occur within the family context and maximum impact is felt on spouses, given the intimate nature of their relationship. Spouses play an important role in treatment programs related to alcohol. There is thus a need to study psychiatric morbidity and marital satisfaction in spouses of alcohol dependent patients in order to understand and address such issues. AIMS: The aim of this study was to assess the pattern of psychiatric morbidity, marital satisfaction in spouses of men with alcohol dependence syndrome and explore the association.
MATERIALS AND METHODS: For psychiatric morbidity, 60 spouses of men with alcohol dependence syndrome were evaluated. Marital satisfaction was assessed using the marital satisfaction scale. Severity of alcohol dependence in the husbands and consequences of drinking was assessed using short alcohol dependence data and drinkers inventory of consequences respectively.
RESULTS: More than half of the spouses (65%) had a psychiatric disorder. Primarily mood and anxiety disorder were present. Major depressive disorder was present in 43%. Psychiatric morbidity, marital dissatisfaction in spouses and higher adverse consequences alcohol dependence in their husbands, were found to be significantly correlated with each other and their association was robust particularly when problems in the physical, interpersonal and intrapersonal domains were high.
CONCLUSION: Psychological distress and psychiatric morbidity in spouses of alcohol dependent men is high, with marital satisfaction being low. Addressing these issues will be beneficial as spouses are known to play an important role in the treatment of alcohol dependence syndrome.

INTRODUCTION

Alcoholism is a major public health problem around the world.[1] The magnitude of the problem in our country is considerable given that India has the second largest population in the world, with 33% of its population consuming alcohol.[23] It is also a matter of concern that the annual rise in consumption is substantial according to the latest report by World Health Organization.[4]

Traditionally, studies on problems associated with alcohol have focused on the individual consuming alcohol. In recent times however, concerns about the wider impact of alcohol consumption have increased[4] and have received some attention in research. Despite this, there is a striking paucity of studies on the impact on spouses in psychiatric literature; though it has been reported in public media.[1]

Alcoholism is considered as an ongoing stressor, not only for the individual, but for family members as well.[56] Spouses are particularly affected given the intimate nature of their relationship and the constant exposure to the behavior of the alcoholic.[7] The negative social consequences of alcohol consumption and stressful life events may trigger psychological, biological, behavioral responses, which interact to diminish the individual's ability to adapt leading to emotional distress reactions and thereby increasing the likelihood of psychological problems.[8]

Spouses of alcoholics are known to be exposed to high rates of domestic violence, which could be physical, verbal or sexual.[91011] Low martial satisfaction,[121314] maladaptive coping skills[151617] and poor social support,[18] in addition to economic burden[19] and social stigma, are the other major issues among the spouses. Though significant levels of psychological distress seem to be apparent from such factors, surprisingly, very few studies have specifically explored this, either in Western or Indian research. Those studies, which have looked into these factors have found high rates of psychiatric morbidity,[202122] especially mood and anxiety disorders in the spouses.

With psychological well-being comprised, spouses are likely to cope less efficiently,[2316] thereby adversely affecting their social and functional roles as a mother,[24] sister, homemaker etc., as well as impacting the family harmony.[14]

Understanding and addressing the mental health issues of spouses of alcoholics will not only decrease their burden, improve their coping skills and overall quality-of-life, but is also likely to have a bearing on the treatment and outcome of alcoholics.[2526]

On this background, the present study was designed with the following objectives:

To assess the pattern of psychiatric morbidity in wives of patients with alcohol dependence syndrome.

To examine the severity of alcohol dependence and related problems among their husbands.

To assess the degree of marital satisfaction among wives of patients with alcohol dependence.

To explore the association between psychiatric morbidity, marital satisfaction and severity of alcohol dependence.

MATERIALS AND METHODS

Sixty spouses of men with alcohol dependence syndrome diagnosed according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV),[27] who presented to the Department of Psychiatry of a Medical College Hospital and who were aged 18 years and above were included in the study. Informed consent was obtained from the index patients as well as their spouses.

Severity of alcohol dependence in the husbands and consequences of drinking was assessed using short alcohol dependence data (SADD)[28] and drinkers inventory of consequences (DrInC)[29] respectively.

SADD is a measure of the present state of dependence, which is sensitive across the full range of dependence and changes occurring over time. It has 15 items, each with four possible responses, scored as 0, 1, 2 and 3. The maximum score on the scale is 45 and dependence is categorized based on scores, into low (0-9), moderate (10-19) and high (>19) dependence.

DrInC, is a scale devised to assess the consequences of drinking in five domains viz., physical, intrapersonal, interpersonal, impulse control and social responsibility. It comprises of 50 items with four possible responses, which are scored as 0-3. There are many versions of the scale, ranging from those, which examine the past 3 months to those examining lifetime consequences. In this study, we have used the one which considers the past 1 year. Higher total scores or in each of its domains indicate greater negative consequences or problems.

General Health Questionnaire (GHQ) 12 item version[30] was used to screen for the possible presence of psychological distress among spouses of alcohol dependent patients and subsequently, structured clinical interview for DSM-IV (SCID I and SCID II) was administered to discern both Axis I and Axis II disorders.

Marital satisfaction among the spouses was assessed using the marital satisfaction scale (MSS).[31] This scale has been developed and standardized for use among Indian population and has good validity and reliability. It has 30 items with three responses categories, which are scored as 0, 1 and 2. The maximum possible score on the scale is 60 and higher scores imply greater marital satisfaction.

RESULTS

Data were analyzed using software Statistical Package for Social Sciences (SPSS) version 16. SPSS Inc., 1989-2007.

First, the descriptive statistics were computed. These included the range, mean and standard deviation for quantitative variables and category frequency counts and percentages for qualitative variables. The median and mode were also computed and class interval frequencies were obtained, wherever relevant. The independent sample (Student's) t-test was employed to compare the means of two independent groups and modified degrees of freedom, (two-tailed) F-max test were used when required. When distribution were significantly non-normal, quantitative variables were ranked and compared between two groups using the Mann-Whitney test with Z corrected for ties.

One-way analysis of variance (ANOVA) was used to compare means of more than two groups. The Student-Newman-Keuls multiple comparison (post-hoc) was applied when omnibus ANOVA was significant. The Chi-square test was used to compare frequency distributions; Fisher's exact (two-tailed) probability was obtained when requirements for 2 × 2 Chi-square were not met. Correlations was obtained to test the strength, those between quantitative variables were performed using the Pearson's product moment correlation coefficient.

Alpha for significance for all inferences was defined at P< 0.05, except when multiple correlations were examined, it was set at P< 0.01.

Socio-demographic characteristics of alcohol dependent men

The age of the men in the sample ranged between 24 and 55 years, with the mean age being 39 years (±7). Most of them were educated less than 10th standard; they were self-employed (unskilled) or agriculturists (70%). Majority of them had an annual income less than Rs. 60,000 and were from a urban background (70%) [Table 1].

Table 1

Socio-demographic characteristics of alcohol dependent men and their spouses

Socio-demographic characteristics of spouses

The age of wives in the sample ranged between 21 and 50 years, with the mean age being 32 years (±5.8). Majority were educated up to 10th standard (87%). Almost all of them were either housewives or unskilled employees (97%) [Table 1].

Characteristics of alcohol dependence

Duration of alcohol dependence ranged from 1 to 20 years for the sample, with a mean duration of 4 years (±3.4). Scores on the SADD ranged from 5 to 39, with a mean score of 19.9, indicating significant dependence. Equal numbers were found in the moderate (45%) and high dependence range (46.7%) with very few in the low dependence range (8.3%) [Table 2]. DrInC scores were in range of 4-90 (mean = 52.6±18.7) on total index. The interpersonal and intrapersonal domains were most affected followed by physical problems; social responsibility and impulse control [Table 3].

Table 2

Scores on SAD

Table 3

Scores on DrInC

Psychiatric morbidity among spouses

Most of the spouses (54 [90%]) scored positive on the GHQ 12 with a score of 2/12 or more.

The profile of psychiatric diagnoses on SCID I is outlined in Table 4, which indicates predominant presence of depressive disorders. None of the spouses had a positive diagnosis of personality disorders on SCID II.

Table 4

Psychiatric morbidity among spouses (SCID I and SCID II)

Marital satisfaction among spouses

The scores were in the range of 1-57 and majority of the spouses had scores at the lower end of the scale indicating lesser degree of marital satisfaction (mean 26.7±12.8). Scores decreased as severity of dependence increased [Table 5].

Table 5

Correlation between marital satisfaction on MSS in spouses and type of dependence in SADD and severity of dependence in men

Inferential analysis suggests the following

The severity of alcohol dependence as the measure through SADD was strongly associated with marital dissatisfaction in the spouses, but not with duration of alcoholism. Greater the severity of problems consequent to alcohol dependence in the physical, inter and intrapersonal domains, greater was the dissatisfaction in marital life [Table 6]. Similarly, the spouses who screened positive in GHQ had partners who scored high on problems pertaining to the interpersonal, intrapersonal and the social domains [Table 7]. The spouses who scored positive on SCID I, had husbands who were more severely dependent and with greater negative consequences in various domains attributable to the alcohol consumption [Table 8].

Table 6

Correlation of marital satisfaction on MSS with adverse consequences of alcohol on DrInC

Table 7

Association of GHQ status with duration of dependence, severity of dependence on SADD and adverse consequences of alcohol on DrInC

Table 8

Association between SCID I diagnosis with severity of dependence on SADD, adverse consequences of alcohol on DrInC and marital satisfaction on MSS

DISCUSSION

In the present study, we found that the majority of spouses of alcohol dependent men received an Axis I diagnosis when evaluated using SCID I. The diagnoses were primarily mood and anxiety disorders, the most common being major depressive disorder, followed by dysthymia, double depression and panic disorder. There have been very few Indian studies and even fewer have specifically examined the presence of psychiatric morbidity in spouses.[3233]

The high rates of mood and anxiety disorders are in agreement with western literatures.[223435] One of the striking findings in the current study is the absence of substance abuse among spouses, which has been commonly reported from the West.[3637] It must be noted however, that alcohol abuse in Indian women is comparatively less,[3839] though there are concerns currently about the rising rates of alcoholism among this population subsequent to the process of westernization.[40]

There has been a high degree of correlation between GHQ positivity and the presence of Axis I diagnosis in the spouses of alcoholics studied. The tool has thus proved to be highly sensitive in identifying morbidity in spouses and could thus be used for similar purposes in other samples as well.

There was no evidence of any personality disorders among the spouses on SCID II. An earlier Indian study,[41] which explored the personality profile of the spouses in our context, reported that they were submissive, conservative and dependent and that their profiles did not differ from those of spouses of non-alcoholic men. It appears from the world literature currently that rates of personality disorders in spouses of alcoholics are no higher than in the general population.[4243]

Marital satisfaction of the wives in this study is significantly lower when compared to the normative sample of women on whom it has been standardized.[31] There is a significant relationship between marital dissatisfaction and psychiatric morbidity in the spouse wherein spouses with psychiatric morbidity experienced lower marital satisfaction. However, this association is a complex one, probably of a bidirectional nature with each influencing the other which has also been observed in western studies.[134445]

Marital satisfaction negatively correlated with the severity of alcohol dependence in men, satisfaction being lower as severity of dependence increases. Western studies have found a correlation between duration of alcohol dependence and marital discord,[1245] while one Indian study had found a positive correlation between duration of dependence in men and higher levels of distress in their spouses.[18] This however, was not replicated in the present study.

Higher adverse consequences of alcoholism, marital dissatisfaction and psychiatric morbidity in spouses were found to be significantly correlated with each other and their association was robust particularly when problems in the physical, interpersonal and intrapersonal domains were high. However, it is likely that these variables share a complex inter-relationship and hence the findings need to be replicated especially in the Indian context.

Limitations of the study

The major limitation of the study is that the sample was selected from patients who sought help at a general hospital. It is likely that such patients have more serious physical and psychiatric conditions, which necessitate consultation at a hospital. Hence, the findings may not be generalized to patients with similar problems in the community or who seek help in other kinds of settings.

Implications of the study

Psychiatric problems in the spouses are often given insufficient attention or overlooked altogether. The findings of the present study draw attention to the fact that the distress among the spouses is considerable and warrant attention. Thus, the high rates of psychological distress and morbidity among women whose partners have alcohol problems, need to be addressed either as part of alcohol treatment programs or independently. These issues need to be addressed not only to improve outcomes for the dependent individuals, but also as potentially reversible risk factors that could significantly impact women's own health outcomes. Hence, it is important that treatment programs for patients with alcohol dependence should also include a formal assessment of mood and anxiety disorders among their spouses. Such an initiative will not only address the needs of this often marginalized population, but also enhance their effective engagement in the treatment process.