Factors associated with resilience in wives of individuals with alcohol dependence syndrome.

BACKGROUND AND OBJECTIVES: Mental health and resilience of family members of individuals with alcohol dependence affect their ability to cope with stress, maintain emotional well-being, and to positively adapt to their difficult life circumstances. This study attempted to study resilience among wives of men with alcohol dependence syndrome.
MATERIALS AND METHODS: Consecutive patients with a diagnosis of alcohol dependence and their wives attending the Department of Psychiatry, MOSC Medical College, Kolenchery, Kerala, over a 1-year period were recruited. The wives were assessed using the Resilience Scale for Adults and the Hamilton Depressive Rating Scale, whereas their spouses were evaluated using severity of alcohol dependence questionnaire and a proforma to collect sociodemographic and clinical characteristics. Women with good resilience were compared to those with low scores using a case-control framework to evaluate factors associated with resilience. Multivariable analysis to adjust for common confounders was done using multiple linear regression.
RESULTS: Eighty patients and their spouses were recruited and evaluated. Resilience was inversely related to the severity of alcohol dependence, years of drinking in dependence pattern, history of domestic violence, and severity of depression in wives. Involvement in support groups was protective.
CONCLUSION: Assessment of resilience in wives of individuals with alcohol dependence and identification and management of those with poor resilience should go hand in hand with their husband's treatment program.

INTRODUCTION

Alcohol dependence syndrome (ADS) is a cluster of physiological, behavioral, and cognitive symptoms indicating that the individual continues to use the alcohol despite significant substance–related problems.[1] Alcohol use is a public health issue worldwide and is a significant problem in India.[2] Despite the fact that problem drinking significantly affects families and the community, much of the focus of the treatment is centered on individuals. Mental health of the wives, who form one of the supporting pillars of the family and who seem to bear the brunt of the problems, is a neglected area of research. According to an Indian study on wives of alcohol-dependent individuals, about 65% of the subjects had a psychiatric illness, primarily mood, and anxiety disorders with 43% having a diagnosis of depressive disorder.[3]

Resilience defined as the ability of an individual to withstand stressors and not to manifest psychological dysfunction[4] is crucial for families in coping with extreme stress and trauma related to living with people with significant interpersonal, familial, marital, social, and occupational dysfunction. It is said that “Resilience” constitutes not just recovery but growth and strengthening from adversity. Resilience has also been described as a measure of stress-coping ability and sustained competence under stress. Some individuals manage to endure and recover fully because of an interplay of resilient factors leading to positive adaptation.[3] According to an Indian study on coping behavior of wives of alcohol-dependent individuals,[5] the most common coping behaviors resorted to by the wives were discord, avoidance, indulgence, and fearful withdrawal. The study also showed that breakdown of marriage, taking special action, assertiveness, and sexual withdrawal were the mechanisms less commonly used.

However, a literature search revealed a dearth of information on resilience in wives of alcohol-dependent individuals. This study aimed to study resilience and factors associated with it among wives of individuals with ADS.

MATERIALS AND METHODS

The study was conducted from August 2014 to August 2015 in the Department of Psychiatry, MOSC Medical College, Kolenchery, Kerala. It employed cross-sectional assessments and used a case–control framework for analyzing factors associated with resilience.

Consecutive patients admitted with the diagnosis of ADS according to the International Classification of Diseases 10 Classification of Mental Health and Behavioural Disorders, and their wives were recruited for the study. The nature of the study was explained and informed consent was obtained.

Wives of patients with ADS who were in the age group of 18–60 years were included in the study. A history of a diagnosed psychiatric illness, intellectual disability, neurological deficits, or cognitive impairments in wife or history of psychiatric illness in their first degree relatives were the criteria for exclusion. Women who had any chronic or debilitating illnesses such as diabetes mellitus, hypertension, and physical disability were also excluded from the study. Wives of patients who had other psychiatric illnesses or who had used psychoactive substances other than tobacco and alcohol were also excluded.

The following assessments were done on wives:

The resilience scale for adults

The scale was developed by Friborg et al. in 2003 to assess resilience in adults.[6] It is used to examine intrapersonal and interpersonal protective factors presumed to facilitate adaptation to psychosocial adversities. It is a self-administered instrument. High scores indicate resilience. Permission to use the scale in the study was obtained from the developer through E-mail correspondence.

Hamilton rating scale for depression

The 21-item Hamilton Depression Rating Scale (HAMD-21) developed by Max Hamilton in 1960 is one of the most widely used instruments in depression assessment and research.[7] It is an interviewer-rated instrument for evaluation of the severity of depression without significant somatic or organic brain comorbidity.

The following instruments were used to assess the patients with alcohol dependence:

Severity of alcohol dependence questionnaire

Developed by Edwards and Gross (1976) at the Addiction Research Unit at the Maudsley Hospital, Severity of Alcohol Dependence Questionnaire (SADQ) is a short, easy-to-complete, 20-item questionnaire designed to measure the severity of dependence on alcohol.[8] Answers to each question are rated on a four-point scale. A score of 31 or higher indicates “severe alcohol dependence.” A score of 16–30 indicates “moderate dependence” and a score below 16 usually indicates only a mild physical dependence.

Kuppuswami's socioeconomic status scale

Takes account of education, occupation, and income of the family to classify study groups into high-, middle-, and low-socioeconomic status.[9]

A specially designed intake proforma was used for assessing the sociodemographic and clinical details.

The husbands were administered SADQ after their withdrawal period to assess the level of dependence. In order to avoid bias, the severity of alcohol dependence was assessed only after assessing the level of resilience in their wives.

Descriptive statistics (mean and standard deviation) were used to describe continuous variables, while frequencies and percentages were employed for categorical data. Student t-test and Pearson's correlation coefficient were used to assess the statistical significance of factors associated with resilience. Multiple linear regression was used to adjust the effect of age. The statistical significance was fixed at 5% level (P < 0.05). Statistical analysis was done using the software SPSS version 20 (IBM, United States of America). The sample size was calculated based on another study done using Resilience Scale for Adults in Indian population.[10]

Approval from the Institutional Review Board and Ethics Committee was obtained prior to data collection.

RESULTS

Eighty consecutive patients and their wives who satisfied study criteria were recruited. The sociodemographic and clinical details are recorded in Table 1. The majority of wives were middle-aged, educated, employed, from nuclear families, and from the lower-socioeconomic class. The majority of wives also had support from the family and also sought help from other support groups. The majority of the men was older, had a continuous pattern of drinking, uncomplicated withdrawal, without medical complications of alcohol, moderate severity of dependence, and had a history of domestic violence toward wife.

Table 1

Sociodemographic and clinical characteristics of the sample (n=80)

The resilience scores ranged from 125 to 162 in this study population with a mean value of 148.2 and median value of 150. Mean HAMD score and SADQ score were 8.81 and 23.2, respectively.

Table 2 documents the factors associated with resilience. Resilience was associated with a shorter duration and lower severity of alcohol dependence, an absence of domestic violence and the involvement in external support groups. Poor resilience was associated with higher depression scores. These factors remained significant after adjusting for age using multiple linear regression.

Table 2

Factors associated with resilience

DISCUSSION

This study adds to the meagre literature on resilience among wives of alcohol-dependent men. The strengths of the study include the selection of consecutive cases, reasonable number of subjects, and detailed and systematic assessments. Its limitations include cross-sectional assessments precluding the recognition of the direction of causality.

ADS has a significant negative impact not just on the individual but also on the spouse, family, and the community. The inverse relationship between the resilience of the wife and the severity and duration of dependence and the presence of domestic violence suggests that despite reserves of strength, women are subjected to persistent trauma due to problem drinking. The relationship between depression and poor resilience also documents helplessness over time. On the other hand, external supports seem to help improve resilience and suggest their usefulness in assisting women to cope with men who continue to drink despite significant harm to themselves and their families. As social support minimizes effects of stressors, its paucity can lead to more negative influences which in turn can give rise to the development of codependence in the wives of individuals with alcohol dependence.[11]

The problems faced by women are particularly more so in patriarchal societies like India, which restrict the options for married women who live with men who have a chronic dependence to alcohol. Societal pressures and the lack of financial independence seem to force them to continue to live, often against their will, with extremely dysfunctional men.

CONCLUSION

Factors associated with resilience need to be addressed during therapy not only to improve the outcome of treatment for the alcohol dependent individuals but also as to manage potentially reversible risk factors that could significantly impact women's own mental health. Addressing these needs will enhance their effective engagement in the treatment process.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.