Quality of life and suicidal ideation in wives of men with alcohol dependence: A hospital-based study.

BACKGROUND: Addiction to alcohol not only affects the quality of life of the individual abusing it but also of the people living with them. Enormous research has been done on various aspects of alcoholism, but the lives of their caretakers are always considered secondary by society and researchers alike. Very few studies have been done on wives of alcoholic men in the Indian settings. AIM: This study aimed to assess the quality of life and suicide ideation in wives of men with alcohol dependence.
MATERIALS AND METHODS: This is a cross-sectional study conducted in a tertiary care hospital. A study group of 50 wives of men with alcohol dependence were included in the study along with an age-matched control group of 50 wives of nonalcoholic men without any medical comorbidities. They were assessed by the perceived quality of life scale, Hospital Anxiety and Depression Scale, and Suicidal Behaviors Questionnaire-revised and the results were then correlated.
RESULTS: Results revealed poorer perceived quality of life in the study group than in controls. The wives of alcoholic men scored significantly more on depression as compared to control group but not on anxiety. Suicidal ideation and attempts were significantly more common in wives of men dependent on alcohol.
CONCLUSION: Alcohol dependence in the husbands is associated with poorer quality of life and higher levels of depression and suicidal ideation in their wives. Copyright:

Worldwide consumption of alcohol in 2010 was equal to 6.2 l of pure alcohol consumed per person aged 15 years or older, which translates into 13.5 g of pure alcohol per day. Alcohol consumption has been identified as a major cause for more than 200 diseases, injuries, and other health conditions with International Classification of Diseases-10 (ICD-10) coding. In 2012, about 3.3 million deaths, or 5.9% of all global deaths, were attributable to alcohol consumption.[1] Alcohol dependence is one of the major health problems in India and all over the world. Alcohol use is an aspect of life which can serve as a two-sided coin, it can be a source of social enjoyment and intimacy building or, on the other hand, it can be a source of conflict, aggression, and potentially divorce. Once individuals become psychologically addicted, the abuse can become all-consuming. Individuals are often part of social networks, thus the abuse more often has a ripple effect across a person's entire network of family, friends, employers, colleagues, and anyone else who depends on the person. The abuse potential of alcohol not only affects the individual consuming it but also extends itself to the rest of the family, whether the addict is a parent, spouse, grandparent, or sibling. Worldwide by law, spouses are seen as a financial unit but, in a religious country like India, spouses are vowed to support each other unconditionally. More often than not, the female spouse is the one who is expected to be the more understanding one and bear with all of the husband's good as well as bad habits without raising a voice. Hence, they try to come to terms with it, although deep down they are suffering. A spouse's alcohol abuse can also trigger a host of emotions, such as feelings of abandonment, unworthiness, guilt, self-blame, and suicidal ideation. Enormous research has been done on men with alcohol dependence and the various aspects of their lives, but the lives of their spouse/caregivers have attracted less attention. Women in conservative countries like India are mostly ignored in context to their physical and especially mental health. Very few studies have been done on wives of men with alcohol dependence in the Indian settings. The present study was taken up in this context to assess the quality of life and suicidal ideation in wives of men with alcohol dependence.

MATERIALS AND METHODS

This was a cross-sectional, analytical study carried out in the inpatient settings of a tertiary care hospital and research center in a suburban area of Maharashtra from August 2017 to September 2018. The study proposal was put forward to the Institutional Ethics Committee and work commenced after obtaining permission from them.

Sample

The wives of fifty consecutive male patients with alcohol dependence syndrome diagnosed as per ICD 10 Diagnostic criteria for research and not having any other psychiatric or medical comorbidity admitted for deaddiction were included in the study after obtaining written informed consent. Fifty age-matched female spouses of males not suffering from substance use disorder or having any other medical or psychiatric comorbidities were selected as a control group after obtaining written informed consent. In addition, the following inclusion and exclusion criteria were fulfilled before the patients were taken up for the study.

Inclusion criteria

Females between 20 and 55 years of age who were married and residing with the husbands for at least the past 3 years were included in the study.

Exclusion criteria

Subjects having comorbid psychiatric disorders, major physical illnesses, organic brain syndrome, and mental retardation were excluded from the study.

Methods

The subjects were initially explained the purpose and design of the study and written informed consent was obtained. The interview was conducted after their respective patients were stabilized. Thereafter, they were assessed using the following tools.

Study tools

Demographic and clinical pro forma

The sociodemographic and clinical variables were recorded in a pro forma specially prepared for the study.

The perceived quality of life scale

The perceived quality of life scale (PQoL) evaluates the quality of life of the subject. The scale comprises 19 items plus a single global item. Each item has an 11 point response scale. Nineteen item scores and an overall score based on the mean or median of the 19 item scores are constructed.[2]

The Hospital Anxiety and Depression Scale

The Hospital Anxiety and Depression Scale (HADS) was devised to measure anxiety and depression in a general medical population of patients. It is a popular scale used in clinical and research settings. It has been validated in a number of languages, and settings including general practice and community settings. The questionnaire comprises seven questions for anxiety and seven questions for depression, and takes 2–5 min to complete.[3]

Suicidal Behaviors Questionnaire-revised

The Suicidal Behaviors Questionnaire-revised (SBQ-r) is a four-item scale that assesses four different dimensions of suicidality including lifetime suicidal ideation or attempt, frequency of suicidal ideas over past year, threats of attempting suicide, and future likelihood of such behavior. Cronbach alpha of the scale was 0.97. An exploratory factor analysis with varimax rotation gave a one-factor solution (89.5% of the total variance).[4]

Statistical analysis

The data thus obtained were statistically analyzed using SPSS-21 software (IBM, Atlanta, USA). The following statistical tests were used in the study to analyze the data: Chi-square test, Mann–Whitney U test, Spearman's co-relation.

RESULTS

A total of 100 subjects consisting of 50 cases and 50 controls were included. Both the test and control groups were compared and no significant differences were noted with respect to age, religion, family type, residence, literacy, and occupation. Significantly more number of subjects of the case group were employed as compared to the control group and most of them were daily wagers rather than having permanent monthly jobs. The employed females invested proportionally more work hours than control group subjects [Table 1]. When assessed on the basis of their quality of lives with PQoL scale, the case group females were found to have significantly poorer status with respect to the corresponding control group. On the SBQ-r, the case group showed to have significantly higher suicidal behavior including more lifetime suicidal ideations or attempts, more threat of suicidal attempt, and more likelihood of suicidal behavior in the future. On assessment on the HADS, the wives of alcohol-dependent males had significantly more depression than control cases, whereas anxiety rates were not statistically significantly different [Table 2].

Table 1

Characteristics of wives of patients with alcohol dependence (case group) and wives of normal control subjects (control group)

Characteristics	Case group	Control group	χ 2	P
Age distribution (years)
21-30	19	19	2.5542	0.465 (NS)
31-40	19	14
41-50	8	14
51-60	2	3
Religion
Hindu	40	37	0.5082	0.475 (NS)
Muslim	10	13
Family type
Joint	17	22	1.0509	0.305 (NS)
Nuclear	33	28
Residence
Urban	39	36	0.48	0.488 (NS)
Rural	11	14
Literacy (years)
<5	36	28	2.7778	0.095 (NS)
>5	14	22
Occupation
Skilled	18	17	0.044	0.833 (NS)
Duration of marriage (years)
<5	13	18	4.2154	0.377 (NS)
6-10	12	6
11-15	15	11
16-20	5	8
21-25	4	5
26-30	1	2
Past suicidal attempts
Yes	6	2	2.17	0.140 (NS)
No	44	48
Husband’s employment status
Unemployed	9	3	6.04	0.048 (NS)
Daily wager	21	16
Monthly job	20	31
Employment of wife before marriage
Daily wager	10	9	1.96	0.375 (NS)
Monthly job	5	10
Unemployed	35	31
Current work status of wife
Housewife	9	19	13.53	0.001 (S)
Daily wager	22	6
Monthly job	19	25
Hours invested in work by wife (h)
<6	14	34	16.02	0.000 (S)
>6	26	16
Years of husband’s alcoholism (yaers)
<10	35	0	-	-
>10	15	0
Monthly income (Rs.)
<5000	19	14	1.13	0.567 (NS)
6000-10,000	24	28
11,000-15,000	7	8

S – Significant; NS – Not significant

Table 2

Scores on the perceived quality of life, Suicidal Behavior Questionnaire, and Hospital Anxiety And Depression Scale

Scales	Score interpretation	Case group	Control group	Chi square test/Mann-Whitney U test	P
PQoL	<7.5 (dissatisfied)	36	21	χ2=9.18	0.002 (S)
	>7.5 (satisfied)	14	29
	Mean score	6.0 (2.21)	7.23 (2.38)	MW=878	0.010 (S)
SBQ-r	Total score	6.42 (3.92)	4.54 (2.40)	MW=925.00	0.021 (S)
	Lifetime suicidal ideation/attempts	1.9 (1.07)	1.42 (0.73)	MW=973.00	0.032 (S)
	Frequency of suicidal ideations over last 12 months	1.82 (0.94)	1.28 (0.51)	MW=825.00	0.001 (S)
	Threat of suicide attempt	1.50 (0.74)	1.12 (0.39)	MW=916.500	0.002 (S)
	Likelihood of suicidal behavior in the future	1.20 (1.43)	0.72 (1.11)	MW=968.00	0.037 (S)
HADS-depression	Non case (0-7)	32	41	χ2=7.340	0.025 (S)
	Borderline (8-10)	7	7
	Case (>10)	11	2
	Mean (SD)	6.42 (4.46)	4.72 (3.12)	MW=926.500	0.025 (S)
HADS-anxiety	Non case (0-7)	45	47	χ2=0.543	0.461 (NS)
	Borderline (8-10)	5	3
	Case (>10)	0	0
	Mean (SD)	3.64 (2.51)	2.94 (2.19)	MW=1033.500	0.128 (NS)

S – Significant; NS – Not significant; SD – Standard deviation; PQOL – Perceived Quality Of Life Scale; HADS – Hospital Anxiety And Depression Scale; SBQ-r – Suicidal Behaviors Questionnaire-revised

DISCUSSION

The WHO global strategy presses on the need to reduce the harmful use of alcohol, “special attention needs to be given to reducing harm to people other than the drinker.” The individual (s) affected may be a spouse or partner, child, relative, friend, neighbor, co-worker, person living in the same household, or a stranger, especially in the case of road traffic accidents.[1] Multiple researchers inferred that the psychological problems of caregivers are probably not due to their own psychopathology but as a consequence of chronic stress.[5] Yet, another study has found a positive association between the duration of alcohol dependence in men and levels of distress in their spouses.[6] A cross-sectional study on 150 wives of alcohol-dependent men and equal number of wives of nonalcohol-dependent men revealed that majority (66.7%) of wives of alcohol-dependent men had poor PQoL, while majority (66%) of wives of nonalcohol-dependent men had high PQoL.[7] Similar findings were reported by another Indian study.[8] In agreement with these studies, we also found that the wives of alcoholic men had poorer PQoL as compared to the wives of the men not dependent on alcohol.

An important finding in our study was that wives of alcohol-dependent men had significantly higher depression compared to wives of nonalcohol-dependent men. Women appear to suffer more from the drinking of others than men. Women experience some form of domestic violence in their lifetime. Specifically, the wives of alcoholic men experience manifolds of physical, psychological, and sexual threats and consequently, they develop depression, guilt, tension, fear, loss of trust, low self-esteem, and high suicide risk. A cross-sectional analysis done in the US concluded that partner alcohol problems posed diverse health threats to women which go well beyond just domestic violence and go on to affect mood, anxiety, stress, general health, and quality of life.[9] Data from Indian studies show that the prevalence of psychiatric morbidity is significantly high among spouses of alcoholics. A research group reported major depressive disorder in 43% of subjects. Among the depressed subjects, 18% had panic symptoms.[10] An Indian study that compared wives of alcohol-dependent men with controls found higher rates of depression in wives of alcoholic males.[11] Depression more often than not leads to the person isolating themselves from everyone around and this withdrawal can hence lead to feelings of anxiety and despair which then continues as a vicious cycle. An Indian study revealed that the prevalence of panic attacks plus generalized anxiety disorder is 2%, mild anxiety and depression is 4%, adjustment disorder is 4%, and somatization disorder is 3%.[12] In agreement with the above studies in our study, the wives of alcohol-dependent men had significantly higher depression, but contrary to the last study, we did not find higher anxiety in our subjects.

When assessed on suicidal behaviors, our sample revealed that lifetime suicidal ideation/attempts, frequency of suicidal ideations over the last 12 months, and threat of suicide attempt were significantly more in the wives of alcohol-dependent men as compared to the other wives. We also found that the risk of future suicidal attempts in these women was more as compared to the other wives whose husbands were not having alcohol dependence. A number of studies conclude stressful life events in the family, especially those that lead to disorders in mutual and interpersonal relationships in the family, lead to increase in the likelihood of suicidal behavior, which could be a major cause of mental disorders and one of the most common ultimate manifestations of other mental disorders.[13] Few Indian researchers have concluded that the wives of substance abusers are prone to have suicidal risk and behavior which is in agreement with our findings.[14] Studies comparing the suicidal risks with wives of nonalcoholic men also show an increased risk in wives of alcohol-dependent males.[15] An Indian study that compared wives of alcohol-dependent men with controls found that the risk of suicidal behavior is more in the wives of alcoholics as compared with controls.[11] They also found higher rates of depression in wives of alcoholic males.[11] Some studies even caution that a twofold increase in suicide likelihood should be anticipated in these conditions.[16] Our findings are in agreement with the above studies.

Limitations

Sample size used was modest and the study could have been benefitted with a larger sample for more accurate results.

CONCLUSION

The wives of alcohol-dependent men have a poorer quality of life, increased levels of depression, and suicidal behavior as compared to the women whose husbands were not dependent on alcohol. Addressing the mental health issues of spouses of alcohol-dependent husbands will not only reduce their burden but also improve their quality of life and treatment outcome of alcohol-dependent husbands.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.