Perceived stress, marital satisfaction, and sexual satisfaction in spouses of males having bipolar disorder with and without alcohol use disorder: A cross-sectional study.

BACKGROUND: Bipolar affective disorder (BPAD) and alcohol use disorder (AUD) are frequently comorbid and affect the social, occupational, and personal domains of patients and their spouses. AIM: This cross-sectional study was conducted to assess and compare the levels of stress, marital satisfaction, and sexual satisfaction between the spouses of males with BPAD + AUD and of those without AUD.
MATERIALS AND METHODS: Spouses of 100 males with diagnosed BPAD, currently in remission, including fifty patients having comorbid AUD, were recruited as participants. Participants were assessed with Perceived Stress Scale-10, Dyadic Adjustment Scale, and Sexuality Scale. STATISTICAL ANALYSIS: Descriptive statistics, Chi-square, t-test, analysis of variance, and correlation on SPSS were used for statistical analysis.
RESULTS: More stress (59%), poorer marital (53%) and sexual satisfaction (89%) were found in the majority participants, with significantly higher stress in the group with husbands having both BPAD + AUD (P < 0.01). Duration of cohabitation had a direct, and education and family income had inverse relations with stress.
CONCLUSIONS: BPAD worsens stress, marital satisfaction, and sexual satisfaction in the study participants, the stress increasing further with comorbid AUD. Education, family income, and duration of cohabitation have a significant bearing on stress. Copyright:

INTRODUCTION

Bipolar affective disorder (BPAD) is a severe mental illness having immense effects on patients' and their partners' lives. As per the National Mental Health Survey from 2015 to 2016, the point prevalence of BPAD across India is 0.3%.[1] The prevalence of substance abuse is as high as almost 60% in persons with BPAD, alcohol use disorder (AUD) being the most prevalent.[23] Caregivers of persons with severe mental illness like BPAD experience moderately high burden and stress.[4] With the spouse as a caregiver, it may also have a deleterious effect on intimate relationships in the form of impaired marital and sexual satisfaction.[56] This picture is furthermore complicated with the use of alcohol in the husbands,[2] making the spouses vulnerable to mental health problems. However, there is a paucity of literature on the stress, marital satisfaction, and sexual satisfaction of spouses in the context of both BPAD and AUD in husbands and the added effect of AUD, if any. Adequate knowledge can help us plan a holistic psychosocial management of the patient and the spouse. Hence, in this study, we attempt an assessment of and comparison between the levels of perceived stress and marital and sexual satisfaction in the spouses of males with BPAD with and without AUD.

MATERIALS AND METHODS

In this descriptive cross-sectional study, samples were recruited via purposive sampling from among the spouses of male patients with BPAD seeking health services in the outpatient department. Due to the unavailability of prevalence data pertaining to our hospital, an a priori calculation was done assuming a medium effect size (0.5), probability of alpha-error of 0.05, and 80% power to arrive at the required sample size, and a total of hundred samples were recruited. Fifty of the patients were diagnosed as having both BPAD and AUD, and fifty had BPAD only. Diagnosis was made by a qualified psychiatrist as per the Diagnostic and Statistical Manual-5 criteria.[7] Study participants were the spouses of male BPAD patients between the ages of 18–65 years. We included spouses of patients with BPAD, currently in remission, without any psychiatric disorder or intellectual disability, neurological deficit, major medical or surgical illness, preexisting disorders of sexual function, and cohabiting with the patient for at least the past 12 months. The operational definition of remission adopted was absence or minimal symptoms for the past 1 week and a score of Young Mania Rating Scale ≤12 and/or Hamilton-Rating Scale for Depression-17 <7.[891011] For the fifty patients with comorbid AUD, those in intoxication or withdrawal were excluded. All fifty of them were using the substance at the time of this study. Informed written consent was taken from both study participants and patients for the study, and ethical approval was taken from the institute.

After recruiting, the sociodemographic information was obtained by a semi-structured pro forma. Study participants were then assessed for perceived stress, marital satisfaction, and sexual satisfaction with Perceived Stress Scale-10 (PSS-10), Dyadic Adjustment Scale (DAS), and Sexuality Scale (SS), respectively. PSS-10 is a 10-item scale published by Cohen et al. to estimate the perceived stress where a higher score denotes more stress.[12] At the time of this study, no validated vernacular version was available. The author was contacted for the feasibility of clinician rating and permission was obtained for the same. To make the rating uniform, PSS-10 was clinician administered to all the participants. DAS is a 32-item self-administered scale for assessment of marital adjustment. A total score of <100 denotes marital distress. This scale is translated to Hindi by Kumar et al. for use in the Indian population.[1314] SS, a self-administered scale (8 items) to assess sexual satisfaction, is developed in Hindi, designed by Kumar, on the Indian population. Scores vary from 8 to 24, denoting lowest to highest sexual satisfaction, respectively.[15] We completed the assessment in a single sitting. Participants who were illiterate were assisted by a neutral Hindi and English-speaking staff for filling up the pro forma and scales. Participants were divided into Groups 1 and 2 depending on the AUD status of their BPAD patients for the data analysis.

Data obtained were analyzed using descriptive and inferential statistical methods. Qualitative variables were analyzed using the Chi-square test. Mean and standard deviations of quantitative variables were calculated and analyzed by Student's t-test and test for analysis of variance (ANOVA). Correlation analysis was carried out and the correlation coefficient was calculated. P < 0.05 was considered statistically significant at a 95% confidence level.

RESULTS

All the study participants were the primary caregivers for their patients. Most of them were illiterate (31%) and unemployed (73%). Both the groups of study participants had a similar distribution of sociodemographic variables, with no statistically significant difference between them in terms of any [Table 1]. Overall, 59% experienced higher stress than average (PSS-10 score >20). More than half (53%) had marital distress (DAS <100). The majority (89%) of the participants had below-average sexual satisfaction (SS <16.5). Group 2 had a higher average PSS-10 score than Group 1, the difference being statistically significant. DAS or SS scores between the two groups did not differ significantly [Table 2].

Table 1

Comparison of variables between-group (participants) by Student’s t-test

Variables	Mean±SD
	Total sample	BPAD only (Group 1)	BPAD + AUD (Group 2)
Age (years)	37.13±7.48	36.56±7.95	37.7±7.02
Duration of marriage (years)	17.43±8.42	17.13±8.73	17.72±8.17
Duration of cohabitation (years)	17.39±8.41	17.07±8.71	17.72±8.17
Duration of caregiving (months)	138.44±92.38	142.06±92.24	134.82±93.32

SD – Standard deviation; BPAD – Bipolar affective disorder; AUD – Alcohol use disorder

Table 2

Comparison of study variables in participants (between Groups 1 and 2) by Student’s t-test

Parameters (scores)	Scores			Remarks (t, P)
	Overall	Group 1	Group 2
PSS-10 score	21.48±6.43	19.80±6.44	23.16±6.03	−2.69, 0.008*
DAS score	96.93±23.29	95.22±22.34	98.64±24.33	−0.73, 0.47
SS score	13.22±2.66	13.42±2.73	13.02±2.59	0.75, 0.45

*Statistically significant at P <0.05. 95% CI of the Difference: PSS-10 – −5.84 (lower),−0.88 (upper); DAS – −12.69 (lower), 5.85 (upper); SS – −0.66 (lower), 1.46 (upper). CI – Confidence interval; SS – Sexuality Scale; DAS – Dyadic Adjustment Scale; PSS-10 – Perceived Stress Scale-10

PSS-10 score negatively correlated with both DAS (Pearson's correlation coefficient = −0.49; P <0.01) and SS (−0.17; P = 0.09) scores. DAS score, in turn, positively correlated with the SS score (0.26; P <0.01). On carrying out Pearson's correlations of PSS-10, DAS, and SS scores with other variables, the durations of cohabitation (−0.36; P < 0.01), caregiving (−0.40; P < 0.05), and family income (−0.29; P < 0.05) were found to have a statistically significant negative correlation with the PSS-10 score. Duration of cohabitation correlated positively with DAS (0.26; P < 0.01). The score difference, assessed with ANOVA, among the groups by education was statistically significant (F = 3.29, P < 0.01). Tukey's HSD post hoc test revealed that the statistically significant difference was lying between illiterate and graduate/postgraduate groups (P = 0.04).

DISCUSSION

Our sociodemographic findings such as mean age, educational status, and employment status were similar to those in past Indian studies.[16] In our study, 59% of the total study participants had higher stress than average, consistent with the available literature finding that majority of the caregivers of BPAD patients experience significant stress and burden.[17] The sources of stress can range from caregiver illness beliefs, ineffective coping strategies to patient role dysfunction. During interview, the major sources of stress as described by the participants were patient's role dysfunction and economic difficulties. More than half of our study participants (53%) experienced poor marital satisfaction. Several available studies have shown marital distress in the presence of BPAD in partners.[561819] In most of the study participants (89%), sexual satisfaction was low, and the mean SS scores suggested below-average sexual satisfaction,[15] consistent with previous studies, showing that relationship satisfaction in terms of both marital and sexual can be disrupted due to factors such as symptomatology, severity of symptoms, emotionality, frequency of sexual interactions, sexual dysfunction, effect of psychotropics, role dysfunction of the patient, perceived emotional and practical support from the patient, and economic burden.[56181920]

The study participants whose patients had BPAD without comorbid AUD were found to have significantly lower stress (P < 0.01) than the other group, consistent with the related literature findings.[21] However, no significant difference was found in the marital and sexual satisfaction levels between our two groups, contrary to the literature.[2223] This difference may be explained with the support of a past finding that the marital and sexual dissatisfactions occurring in independent AUD are less than that in BPAD.[6] Spouses may have poor marital and sexual satisfaction due to the presence of BPAD itself with no added effect with AUD in husbands. Another explanation may be our small sample size and the general belief of patients and their families in our catchment area that AUD is a habit and not a psychiatric disorder. This finding may also be due to the patients being in remission phase of BPAD.

In our analysis, marital satisfaction was seen to decrease with an increase in stress (P < 0.01). Previous study findings regarding this are mostly in the same line, although conflicting evidence also exists.[24] We also found that the better the marital adjustment is, the more is the sexual satisfaction. This result is supported by research works stating a link between relationship satisfaction, dyadic adjustment, and sexual satisfaction.[525] Stress correlated inversely with sexual satisfaction, but the correlation was not statistically significant, consistent with a similar past finding.[20] Thus, we may deduce that stress, marital satisfaction, and sexual satisfaction are related constructs but not exclusively dependent on each other. The factors that play a part in relationship dynamics and satisfaction can be biological, psychological, and social, such as age, education, economic status, cultural impact, emotional intimacy with partner, desire discrepancy and partner response, and side effects of psychotropic treatment.[252627] All these factors should be assessed for their association with stress, marital satisfaction, and sexual satisfaction to generate a comprehensive understanding of the link among these constructs.

Study participants with more family income were seen to have less stress (P < 0.01). It is in line with a previous study.[28] Study participants educated till graduation or postgraduation experienced less stress than those who were illiterate (P < 0.05). This finding replicates the finding of Perlick et al. where caregivers having high and moderate burden and distress due to illness were found to be less educated than those having low distress.[4] It may be possible that with better education, understanding of illness and coping skills tends to be better, leading to better adjustment, and lower stress.

We found longer durations of caregiving and cohabitation to be related to less stress (P < 0.01 for both), in line with the observation that level of burden may be sensitive to “recent” crises.[29] We also found better marital satisfaction with longer duration of cohabitation (P < 0.01), consistent with past findings.[30]

Limitations

It was a cross-sectional study. For a better understanding of the persistence of stress and observed marital and sexual dissatisfactions, a follow-up study would have been more substantial. Blinding was not done, thus increasing the risk of biases such as selection bias and information bias. Domains of sexual satisfaction were not apparent. Our relatively small sample size and the absence of a control group interfered with the generalizability of the result.

CONCLUSIONS

BPAD is found to worsen stress, marital satisfaction, and sexual satisfaction in our study participants. Comorbid AUD in the husband is shown to increase the stress significantly. However, marital and sexual satisfactions in the participants are not found to be worsened in presence of AUD in the patients. Higher stress is associated with poorer marital and sexual satisfaction, with variable statistical significance. Participants with better education, higher family income, and longer duration of cohabitation are seen to experience significantly less stress. Understanding the impact of partners' illnesses on stress level, marital satisfaction, and sexual satisfaction can be helpful in having an idea of the protective and risk factors to healthy partnership in the context of severe mental illnesses. Future studies can be designed to explore in details all the psychosocial factors impacting the lives of both patients of severe mental illness and their partners.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.