Quality of life and marital adjustment in spouses of schizophrenia patients.

BACKGROUND: With the availability of potent antipsychotics, the prognosis of schizophrenia has improved. As a result, there is increasing interest in assessing the quality of life (QOL) and marital adjustment of patients with schizophrenia. However, there is a paucity of Indian data in this area. AIM: To evaluate and compare the QOL and marital adjustment in spouses of patients with schizophrenia and controls.
MATERIALS AND METHODS: This cross-sectional, hospital-based study comprised of consenting female individuals of the age group of 20-40 years. The study group included 30 spouses of male patients with schizophrenia (according to ICD 10-DCR) and control group included 30 age-matched spouses of male participants without psychiatric disorders. The participants were selected from the psychiatry ward and outpatient department and neighboring areas of the Dr. D. Y. Patil Medical College, Pune, India. Only couples married for at least 5 years were included in the study. Wives with a history of any major psychiatric or major medical disorders were excluded. All the participants were evaluated with a sociodemographic data sheet, the World Health Organization QOL (WHOQOL)-BREF, and the Marital Adjustment Questionnaire. The statistical analysis was done using descriptive frequency, Chi-square, and Mann-Whitney U-test.
RESULTS: Wives of patients with schizophrenia had significantly lower scores on psychological, social, and environmental domains of WHOQOL BREF and on sexual adjustment, social adjustment, emotional adjustment, and total score on the marital adjustment questionnaire as compared to the control group.
CONCLUSION: Wives of patients with schizophrenia have lower QOL and marital adjustment compared to controls. Copyright:

Schizophrenia is a major psychiatric disorder that affects around 1% of the population, and its point prevalence is 2.7–8.3 cases per 1000 population.[12] Care giving in psychiatric illness is an exhausting and challenging activity that typically involves a considerable amount of energy, time, and money over considerably long periods of time, in tasks that may be unpleasant or uncomfortable and could be psychologically and physically stressful and tiring.[3]

Caregiving to mentally unstable people can be particularly challenging in traditional societies such as India. The close-knit family structure and lack of adequate government resources to support people with mental illness place the burden of care on the family which is perceived to be the “natural” caregiver. Sociocultural expectations envision care giving as an obligation and moral binding which is to be given by parents, children or the spouse. Religious-cultural beliefs frequently blame spirits, ghosts, and other supernatural factors for the appearance of psychiatric disorders.[4] Due to these beliefs, families often seek the help of faith healers and charlatans who perform elaborate and expensive rituals to “cure” the person. However, the scenario is changing and more and more people are aware of, and seek modern psychiatric treatment at the beginning or after completing the rituals prescribed by faith healers.[5] Illiteracy, ignorance, and superstition paint the perception of mental illness, and stigma and oppression become a daily challenge in lives of the families of psychiatric patients. The onset of schizophrenia is most commonly in late adolescence or early adulthood. The disorder manifests with profound disorder in thought, language, and personality along with characteristic symptoms of psychosis, such as hearing voices or delusions.[6] The volatile nature of the disorder and its accompanying debilitating consequences burdens the family in multiple domains causing social, emotional, and financial problems.[7]

Marital adjustment, a “condition in which there is an overall feeling in husband and wife of pleasure and contentment with their marriage and with each other,”[8] is a part of psychosocial well-being. Poor marital relationship has an adverse impact on both physical and mental health as well as the quality of life (QOL) of individuals.[9] Few studies have reported the high rates of poor marital adjustment and divorces in schizophrenia.[10] QOL has been defined as an “individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.”[11] It is an important outcome measure of major psychiatric disorders which are often chronic, disabling, and has multiple effects of psychosocial functioning. Several studies carried out all over the world shows that caregivers of schizophrenia have high level of burden, social isolation, and stigma along with poor QOL and psychological distress in the form of anxiety and depression.[12131415] In addition to poor QOL, spouses of patients with schizophrenia also have troubled marriages, but there is a paucity of studies in this area,[1617] and only a few studies have assessed QOL and marital adjustments in caregivers of schizophrenia.[18] Due to the limited data available in the Indian context, the present study was undertaken to evaluate the QOL and marital adjustment in spouses of schizophrenia patients.

MATERIALS AND METHODS

This cross-sectional, hospital-based study was conducted in the inpatient psychiatry settings of a tertiary care hospital and research center in a suburban area of Maharashtra during August 2017 to September 2018. The research proposal was submitted to the Institutional Ethics Committee and work commenced after obtaining the necessary approval from them.

Sample

The sample for this study comprised of consenting female spouses of male patients with schizophrenia (according to ICD 10-DCR)[19] in the age group of 20–40 years. The control group included the equal number of age-matched spouses of individual without psychiatric disorders (General Health Questionnaire[20] 12 score ≤2). The participants were selected from wards and outpatient department of Dr D Y Patil Medical College and neighboring areas.

The inclusion criteria for the study and control group:

Education level minimum primary school

The age range of the spouse was 20–40 years

Individuals who had given consent

Married and staying together for at least 5 years.

Exclusion criteria for study and control group

History of any major psychiatric or any neurological or major medical condition in the spouse.

Tools used

Sociodemographic datasheet

It was a self-prepared, sociodemographic data sheet to obtain background information of the participants on different dimensions such as age, education level, family size, types of family, profession, income, and duration of marriage.

Marital adjustment questionnaire

Marital Adjustment Questionnaire (MAQ) identifies couples who make poor marriage. The questionnaire is developed in a way as to provide a more meaningful single composite marital adjustment score for the couple unlike other available scales which give separate marital adjustment scores for the two. It consists of 25 highly discrimination yes-no type items (Yes-1, No.-0). The higher the total score, the higher would be the marital adjustment. The questionnaire has good test-retest reliability (0.84) and the face validity was fairly high. The split-half reliability, correlating odd-even items, applying the Spearman-Brown formula for doubling the test length, was found to be 49 (n = 60) with an index of reliability of 0.70.[21]

The World Health Organization quality of life-BREF

The World Health Organization QOL-BREF (WHOQOL-BREF) comprises of 26 items, which measure the following broad domains: Physical health, psychological health, social relationships, and environment. The WHOQOL-BREF is a shorter version of the original instrument. All items are rated on 5-point Likert scale. The internal consistency of the four domains of the WHOQOLBref ranged from 0.66 to 0.80. Domain scores of the WHOQOL-BREF correlated around 0.92 with the WHOQOL-100 domain scores.[11]

Procedure

At first, samples were selected according to the inclusion and exclusion criteria. Participants were interviewed when their spouse had stabilized with treatment and not having acute symptoms of schizophrenia. After obtaining written informed consent from the participants, the sociodemographic data and clinical information were gathered. All the participants were evaluated with the WHOQOL-BREF and the MAQ. The scoring of the scales was done as per the manual of the scale.

Statistical analysis

The statistical analysis was done using descriptive frequency (mean and standard deviation), Chi-square test, and Mann–Whitney U-test utilizing SPSS 20 (IBM, Chicago, USA).

RESULTS

There were no significant differences in age distribution, education, occupation, domicile, religion, and duration of marriage of spouses of individuals with schizophrenia and spouses of individual without psychiatric disorders [Table 1]. Comparison of marital adjustment (domain wise) among the spouses of individual with schizophrenia and no psychiatric illness revealed significant group differences in terms of sexual adjustment, social adjustment, and emotional adjustment between the groups. The total score of marital adjustment is significantly higher in spouses of individual without psychiatric disorders. It indicates that the spouses of individual without psychiatric illness have better marital adjustment than the spouses of individual with schizophrenia [Tables 2 and 3]. On the WHOQOL-BREF spouses of individual without psychiatric illness obtained significantly higher scores compared to wives of schizophrenia patients, which denote higher QOL [Table 4]. This study found that there is a significant difference in all four domains of QOL, i.e., physical, psychological, social, and environment. Spearman's Correlation test was done to establish a relationship between marital adjustment and QOL. It was found that, there was significant positive correlation between the marital adjustment score and QOL score of schizophrenia (Spearman's rho = 0.628; P = 0.000).

Table 1

Comparison of sociodemographic profile of spouses of individual with and without schizophrenia

Characteristics	Spouse of participants with schizophrenia (n=30), n (%)	Spouse of participants with no psychiatric illness (n=30), n (%)	Chi square test	P
Age
21-30	16 (53.33)	17 (56.67)	0.07	0.80 (NS)
31-40	14 (46.67)	13 (43.33)
Occupation
Service	4 (13.33)	4 (13.33)	1.93	0.38 (NS)
Housewife	11 (36.67)	16 (53.33)
Others	15 (50.00)	10 (33.33)
Education
Primary	5 (16.67)	4 (13.33)	0.78	0.86 (NS)
Middle	13 (43.33)	11 (36.67)
High school	11 (36.67)	13 (43.33)
Above	1 (3.33)	2 (6.67)
Domicile
Urban	8 (26.67)	9 (30.00)	0.09	0.95 (NS)
Rural	15 (50.00)	14 (46.67)
Semi-urban	7 (23.33)	7 (23.33)
Religion
Hindu	24 (80.00)	25 (83.33)	0.13	0.93 (NS)
Muslim	5 (16.67)	4 (13.33)
Christian	1 (3.33)	1 (3.33)
Duration of marriage
5-6	11 (36.67)	12 (40.00)	0.11	0.99 (NS)
7-8	8 (26.67)	7 (23.33)
9-10	7 (23.33)	7 (23.33)
>10	4 (13.33)	4 (13.33)

NS – Not significant

Table 2

Comparison of marital adjustment questionnaire scores among the spouses of individual with schizophrenia and spouses of those without psychiatric illnesses

Marital adjustment questionnaire	Mean±SD		Mann-Whitney test	P
	Spouse of participants with schizophrenia (n=30)	Spouse of participants with no psychiatric illness (n=30)
Sexual adjustment	1.83±0.83	3.70±0.46	48.00	0.001 (S)
Social adjustment	4.33±1.90	7.73±1.02	56.00	0.001 (S)
Emotional adjustment	5.07±2.08	9.07±0.91	11.00	0.001 (S)
Total score	11.23±3.89	20.43±1.89	6.5	0.001 (S)

S – Significant; SD – Standard deviation

Table 3

Distribution of spouses of individual with schizophrenia and those without psychiatric illnesses as per percentile norms of marital adjustment questionnaire

Marital adjustment	Spouse of participants with schizophrenia (n=30), n (%)	Spouse of participants with no psychiatric illness (n=30), n (%)	Fisher’s exact test (P)
Very good	0	6 (20)	0 (S)
Good	0	12 (40)
Average	1 (3.33)	10 (33.33)
Poor	3 (10)	2 (6.67)
Very poor	26 (86.67)	0

S – Significant

Table 4

Comparison of scores on World Health Organization quality of life BREF (domain wise) among the spouses of individual with schizophrenia and with no psychiatric illness

WHOQOL BREF domains	Mean±SD		Mann-Whitney U-test	P
	Scores of spouse of subjects with schizophrenia (n=30)	Scores of spouse of subjects with no psychiatric illness (n=30)
Overall	3.53±1.14	6.77±1.04	22.00	0.001 (S)
Physical	11.53±1.25	15.80±4.27	78.5	0.001 (S)
Psychological	11.94±0.77	14.61±1.59	2.00	0.001 (S)
Social	8.22±1.21	12.32±1.08	12.00	0.001 (S)
Environment	12.63±1.30	15.04±2.15	105.00	0.001 (S)

S – Significant; SD – Standard deviation; WHOQOL – World Health Organization quality of life

DISCUSSION

Schizophrenia causes multiple challenges in its management. It puts a significant toll on the caregiver mostly the spouse, they suffer a great deal as the entire burden or responsibility shifts to one person in terms of managing finances, taking care of household chores, looking after the children. In long-term, the burden gets shifted to other members of family and society in general as the frequent hospitalizations and the need for long-term psychosocial and economic support reduces the productivity. It is a well-established fact that families of patients with schizophrenia face many challenges.[1422] Although much of the literature has focused on parents who have adult children with schizophrenia, it should be noted that 20%–30% of patients with schizophrenia are married or are in relationships. Spouses and partners of patients with schizophrenia experience illness burden that overlaps and extends beyond the experience of parents.[2324] Marriages can have both protective and debilitating effects on the course of schizophrenia. Researchers in our country have observed that the rate of marriages of schizophrenia patients is lower than the general population. It is generally seen that a history of psychiatric illness or schizophrenia is hidden before getting married or in some cases even after getting married. Medications are stopped around marriage, and later, the in-laws discover the presence of psychiatric illness.[25]

In our study, significant group differences were found in terms of sexual adjustment, social adjustment, and emotional adjustment between the groups. The total score of marital adjustment was seen significantly higher in spouses of individual without psychiatric illness. It indicates that the spouses of individual without psychiatric illness have better marital adjustment than the spouses of individual with schizophrenia. In sexual, social, and emotional adjustment, the P value was 0.0001 which denotes a significant difference in between spouses of patients suffering from schizophrenia as compared with spouse of subjects without psychiatric disorders. Total score of marital adjustment was also seen to be significant in our study. Kang et al. did a similar study which showed a lower rate of sexual satisfaction as compared with the general population.[26] Another study on spouses of patients suffering from schizophrenia also showed a similar result. It is obvious that burden experienced by spouses differ from those experienced by parents in many respects: At the center of the spouses' problems are those relating to the partnership – such as challenging marital intimacy and commonality, reorganization of familial and partnership tasks, and redefinition of plans for mutual life.[24]

In our study, we found QOL to be moderately low. This is similar to the findings of an Indian study which found that the QOL levels of caregivers of schizophrenia patients were either low or moderately low.[27] In addition, another study reported that high family burdens were encountered by caregivers of schizophrenia patients in various parts of the world.[28]

A study done by Kaushik and Bhatia[29] and Sharma et al.[30] reports that burden of caregiving and QOL is poor among spouses of schizophrenia patients, and gender difference is seen because in majority cases the females in terms of different relationship of mother, spouse, sister are the sole caretaker, although in recent times, males are also participating in sharing the burden but their role is limited. Our study showed similar results with QOL among the spouses. All the domains showed a significant result. Spouses of patients suffering from schizophrenia had a lower QOL as compared to the control group. P value of all the four domains was seen to be significant. Thereby, we can conclude that QOL and marital adjustment is lower in spouses of schizophrenia patients in comparison to spouses of normal individuals.

Limitations

The study has some limitations. The sample size is modest. The severity of illness in the spouse was not assessed, even though the patient was stable on medications. Due to its cross-sectional design, it is not possible to comment on causal relationship between each variable and outcome. Further studies with larger sample and longitudinal nature are recommended.

CONCLUSION

Wives of persons with schizophrenia have lower QOL and marital adjustment compared to normal controls.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.