|Year : 2020 | Volume
| Issue : 2 | Page : 69-75
Dissatisfaction and problems in marital life of spouses of patients with bipolar disorder: A cross-sectional study from a tertiary care hospital
Bilal Ahmad Bhat, Rouf Ahmad Mir, Arshad Hussain, Iqra Rasheed Shah
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||10-Oct-2020|
|Date of Acceptance||21-Nov-2020|
|Date of Web Publication||21-Dec-2020|
Dr. Bilal Ahmad Bhat
Institute of Mental Health and Neurosciences, Kashmir Kathidarwaza, Srinagar - 190 003, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Introduction: The objective was to understand the marital dissatisfaction/satisfaction and problems in different areas of marital life in spouses of patients with bipolar disorder (BD). Materials and Methods: In this cross sectional descriptive study on BD patients and their spouses, a semi structured questionnaire was used to collect sociodemographic details. Couple satisfaction index (CSI) was used to identify marital satisfaction or dissatisfaction, whereas problem areas questionnaire (PAQ) was used to identify areas in which spouses of BD patients were often dissatisfied or have disagreements about their partner's behavior. Results: A total of 170 BD patients, along with their spouses, were included in our study. Marital dissatisfaction was present in 104 (61.2%) and there was no significant relation with sociodemographic variables except for the number of children (P = 0.002). Mean scores on CSI and PAQ were 42.75 ± 17.32 and 28.91 ± 11.28, respectively, with a significant negative correlation between these (r =-0.712; P = 0.0001). Handling family finances; rearing children or parenting, career/job related decisions, demonstrations of affection, handling household tasks, spending recreation leisure time together, moodiness/temper/emotionality, and problems in sex relations were important areas in which partners of BD patients were facing a significant problem. Conclusions: Marital dissatisfaction was very common in spouses of BD patients and they faced a lot of problems in various areas of their lives. As clinicians, we need to evaluate and understand the issues related to the marital life of normal spouses of BD patients to provide emotional and practical support to them, individually as well as couples.
Keywords: Bipolar disorder, couple, dissatisfaction, marital, spouse
|How to cite this article:|
Bhat BA, Mir RA, Hussain A, Shah IR. Dissatisfaction and problems in marital life of spouses of patients with bipolar disorder: A cross-sectional study from a tertiary care hospital. Acta Med Int 2020;7:69-75
|How to cite this URL:|
Bhat BA, Mir RA, Hussain A, Shah IR. Dissatisfaction and problems in marital life of spouses of patients with bipolar disorder: A cross-sectional study from a tertiary care hospital. Acta Med Int [serial online] 2020 [cited 2021 Jun 21];7:69-75. Available from: https://www.actamedicainternational.com/text.asp?2020/7/2/69/304055
| Introduction|| |
Bipolar disorder (BD) is a complex psychiatric disorder characterized by episodes of hypomania/mania/mixed states and depression with inter-episodic remission phases. However, it has been realized over the years that a good proportion of BD patients have residual symptoms despite being in the phase of remission., Although there may be a quick syndromal recovery in BD patients soon after hospitalization, it is more difficult to achieve functional recovery. These patients face problems in daily events such as occupation, finance, etc. It has been found that a modest level of burden is felt by most of the persons caring for BD patients, not only during the episodes of depression or mania but also throughout the phase of remission., To overcome the problems of mental illnesses, including BD, marriage is believed to be a cure in our society. Though marriage is considered as protection against the development of psychiatric disorders divorce, separation, and marital discord are more evident in persons with psychiatric disorders., when one of the spouses suffers from BD, there are various major concerns in the marital relationship among couples. A poor marital adjustment can adversely affect both physical and mental health, quality of life (QoL), and the economic status of individuals with BD as well as their partners. It is our responsibility, as psychiatrists, to identify the problem areas related to marital life in individuals with BD and their spouses to provide necessary support and interventions, as per indication. Although there are some studies from the West which have examined marital adjustment in couples with one spouse suffering from BD a recent review suggested that the data regarding this issue is limited. In previous research, marital issues in spouses of persons with BD have largely been neglected. To fill this gap in research and to understand marital dissatisfaction/satisfaction and problems in different areas of marital life in spouses of patients with BD, we aimed to conduct this study.
| Materials and Methods|| |
Study design and setting
This was a cross-sectional descriptive study conducted from June 2019 to December 2019. Using a purposive sampling method, all married patients 18 years or older and of either sex, presenting with an assigned diagnosis of BD to the outpatient department, and their spouses were approached for inclusion in this study. BD diagnosis was reviewed by consultant psychiatrist using the fifth edition of the diagnostic and statistical manual of mental disorders criteria. Those who were not willing to participate were excluded. BD patients not accompanied by their spouse or a spouse who came without a patient to collect medications were also excluded. Spouses with known psychiatric disorders or significant physical disorders were also excluded from this study. This study was approved by the institute's ethics committee vide their letter no. IEC/PSY/IMHANS-K/22 of 2019 dated February 28, 2019. Written informed consent was obtained from the participants. The sample size was calculated using the Cochran formula, as follows: where n = minimum Sample size required, Z = Standard normal variable, which is 1.96 at 95% confidence interval, P is the estimated proportion of problem in population which was taken as 10%, d = Acceptable margin of error, which is considered as 0.05 at 95% confidence interval. Accordingly, we estimated a minimum sample size of 138.
Sixteen item format of couple satisfaction index (CSI) 16 was used to identify marital satisfaction or dissatisfaction in spouses of BD patients. Scores on CSI-16 range from 0 to 81, with a higher score indicating higher levels of satisfaction in a marital relationship. A score of <51.5 on CSI-16 indicates dissatisfaction in a marital relationship. Problem areas questionnaire (PAQ) was used to spot areas in which spouses of persons with BD were often dissatisfied with the behavior of their partner. There are 14 areas listed in PAQ in which couples are commonly dissatisfied with the behavior of each other. Each problem area item in PAQ has seven ratings ranging from completely satisfied/happy to completely dissatisfied/unhappy. Accordingly, a scoring ranging from 1 to 7 was adopted with 1 for complete satisfaction and 7 for complete dissatisfaction. Thus, the higher a score in any area, the higher is the relationship problem in that area. Both CSI-16 and PAQ were translated and validated in the Urdu language. A semi-structured questionnaire was used to collect sociodemographic details. The present clinical status of BD patients was determined as per clinical history, treatment records, and scores on the Young mania rating scale and Hamilton rating scale for depression at the time of assessment.
SPSS version 19 (Statistical Package for the Social Sciences; IBM Software, Armonk, NY, USA) was used for the data analysis. For detecting group differences between categorical variables, Pearson's Chi-square test was used. For continuous variables, nonparametric tests, i.e., Mann–Whitney U test and Kruskal–Wallis H test were used to compare scores on CSI and PAQ, as the scores on these were not normally distributed among various sociodemographic variables and present clinical state. Following a significant Kruskal–Wallis H test, the Bonferroni post hoc method was performed to determine which groups are different from others. CSI score was correlated with duration of illness (DOI), number of children, and PAQ score using Spearman's correlation coefficient. PAQ score was also correlated with DOI and the number of children using Spearman's correlation coefficient. At confidence level of 95%, P < 0.05 was considered statistically significant.
| Results|| |
A total of 170 subjects participated in our study. The mean age was 40.93 ± 10.75 years with a range of 21 years to 62 years. There was no significant difference (P = 0.18) between the mean age of participants who had marital dissatisfaction (n = 104, 40.04 ± 11.19 years) and those who had no marital dissatisfaction (n = 66, 42.33 ± 9.92 years). [Table 1] depicts the sociodemographic details of our participants. More than half of the patients were symptomatic, either in mania (21.2%) or in depression (35.3%).
[Table 2] depicts the distribution of marital satisfaction/dissatisfaction in relation to sociodemographic variables. Marital dissatisfaction was present in 104 (61.2%). There was no significant relation of these sociodemographic variables with marital dissatisfaction except for the number of children (P = 0.002).
|Table 2: Distribution of marital satisfaction/dissatisfaction in relation to sociodemographic variables|
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The mean DOI of patients was 13.54 ± 8.00 years. Mean number of children were 2.45 ± 1.16. Mean scores on CSI and PAQ were 42.75 ± 17.32 and 28.91 ± 11.28, respectively. When correlated with number of children, CSI score was found positively correlating with it (r = 0.40; P = 0.001), and negatively correlated with PAQ (r = -0.216; P = 0.005). There was also a significant negative correlation between CSI score and PAQ score (r = -0.712; P = 0.0001). DOI was not significantly correlated with either CSI (r = 0.062; P = 0.43) or PAQ (r = 0.12; P = 0.14).
[Table 3] depicts a comparison of mean ranks for scores of CSI and PAQ among sociodemographic variables and present clinical state. There was no significant difference in mean ranks on both CSI and PAQ among different age groups, gender, domicile, family type, and type of marriage. However, there was a significant difference when mean ranks of both these scores when compared with the number of children (CSI score, P = 0.001; PAQ score, P = 0.004). On post hoc multiple comparisons with Bonferroni correction for mean rank scores on CSI and PAQ for the number of children, less the number of children, less was the mean rank for CSI score, and more was the mean rank for PAQ score indicating more dissatisfaction and more problems with less number of children with statistically significant differences between groups as the number of children increases [Table 4].
|Table 3: Comparison of mean rank scores of couple satisfaction index and Problem Areas Questionnaire among sociodemographic variables|
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|Table 4: Post hoc multiple comparisons within groups for the number of children|
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When comparing mean rank scores with the present clinical state, there was a significant difference between the groups for both CSI (P = 0.005) and PAQ (P = 0.01) scores. On post hoc Bonferroni correction, those who had spouses in depression had significantly low mean rank for CSI score (P = 0.004) in comparison to those in mania and there was no significant difference between other groups. For the PAQ score, the mean rank was significantly high for those who had their spouses in remission in comparison to those in mania (P = 0.006) and there was no significant difference in other groups.
[Table 5] depicts the comparison of mean rank scores of individual items in PAQ among males and females. Handling family finances (P = 0.001), rearing children or parenting (P = 0.001), and career/job-related decisions (P = 0.001) were important areas in which male partners of BD patients were facing a significant problem. However, in demonstrations of affection (P = 0.001), handling household tasks (P = 0.001), spending recreation-leisure time together (P = 0.001) and moodiness/temper/emotionality (P = 0.001) were important areas in which female partners of BD patients were facing a significant problem. Problems in sex relations was PAQ item for which both male partners (mean score = 3.36 ± 1.72, mean rank = 89.19) as well as female partners (mean score = 3.00 ± 1.53, mean rank = 79.68) scored high with no statistically significant difference between these two groups (P = 0.21).
|Table 5: Comparison of mean scores of Problem Areas Questionnaire Items with gender|
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| Discussion|| |
On average, both mental and physical health is better in married people in comparison to unmarried people., Although the overall sense of well-being of a person is colored by quality of marital life, simply being married is not necessarily protective; marital distress has been found to elevate health risks., The relationship between marriage and psychiatric disorders is multidimensional. Though marriage is considered a protective factor against psychiatric disorders, it can be a stressful life event and can act as a precipitating factor for the onset of a new psychiatric disorder or relapse of previously remitted psychiatric disorder. Similarly, poor marital adjustment can also act as a precipitating factor for the onset of a new psychiatric disorder or relapse of previously remitted psychiatric disorder. Further, higher rates of separation, divorce, and marital discord have been found in people diagnosed with psychiatric disorders., Among the several psychiatric disorders, BD is a disorder that occurs in the age group in which people plan to marry. There is limited data regarding the impact of BD on the functioning of marital life. In our study, around 60% of spouses of BD patients had marital dissatisfaction. This is consistent with a study by Drisya et al. who reported marital dissatisfaction in 54% of the female participants and 55% of the male participants. In a recent review on the impact of BD on various aspects of relationships in married couples, most studies have found poor adjustment in marital life in couples when one partner is suffering from BD in comparison to healthy couples. A study from India compared patients of different psychiatric disorders with those suffering from epilepsy for marital adjustment and QoL. In this study, a poor marital adjustment was there among couples with one partner suffering from BD, but it does not correlate with QoL of either BD patients or their spouses. Another study from India compared patients with BD, schizophrenia, and recurrent depressive disorder for marital dissatisfaction. This study reported that marital dissatisfaction among couples with one partner suffering from schizophrenia was more than those couples with one partner suffering from BD. Our results are also in accordance with the national comorbidity data on 2538 married respondents, where a poor marital adjustment was more frequent in persons who had one partner with BD in comparison to those without this disorder. However, in a study from the United States with a small sample, it was found that there is no significant difference in the marital adjustment between couples with BD partners and healthy couples. In a recent review, when healthy couples and those couples with one partner suffering from other psychiatric disorders other than BD were compared with couples with one partner suffering from BD, it was concluded that couples with BD patients are closer to healthy couples than those couples with other psychiatric disorders in terms of maintaining marital relationships. When compared among various sociodemographic variables, there was no significant difference in the level of marital dissatisfaction with an exception of the number of children. Less the number of children more was the marital dissatisfaction in our study group. This is in accordance with Drisya et al. who did not found any significant difference in the level of marital dissatisfaction among various sociodemographic variables. There could be many reasons for more level of marital dissatisfaction with fewer children, but in the context of BD, a low fertility rate among couples with a spouse suffering from BD could explain an additional impact on the marital life of these patients., However, this issue needs further exploration. In our study, those spouses who had their patients in depression had significantly high level of marital dissatisfaction in comparison to those in mania. Drisya et al. found a high level of marital dissatisfaction in spouses of those BD patients who had their patient in mania or depression in comparison to who had their patient in remission. In general, studies in which marital adjustment of couples with one partner having BD was compared with healthy couples, a poor marital adjustment was experienced by couples with one of the partners having BD even if the patients were in a phase of remission., Higher the level of marital dissatisfaction, more were the problems in the marital life of our study group. Handling family finances, rearing children or parenting and career/job-related decisions were important areas in which male partners of BD patients were facing a significant problem in comparison to female partners of BD patients. However, in demonstrations of affection, handling household tasks, spending recreation-leisure time together, and moodiness/temper/emotionality were important areas in which female partners of BD patients were facing a significant problem. Our results are consistent with the findings of Drisya et al. who, in addition to our problem list, found many other problem areas in the marital life of spouses of BD patients. Lack of trust, anger, and a need to limit family size were seen as problems by couples when one member was a BD patient in a study from Israel. In sex relations, both male and female spouses of BD patients in our study faced problems. In a study on the sexual satisfaction of couples with one partner suffering from BD, reduced sexual satisfaction was reported by most of the partners of BD patients, which concords with our study where both male and female partners of BD patients experience problems in sexual relations. Other studies have also found similar results in the sex relations of spouses of BD patients with significantly low sexual satisfaction.,
Our study was cross-sectional in nature, which limits our ability to capture the changing dynamics of marital life as experienced by spouses of BD patients at different points in time. Cultural variations may also limit wider generalizations of our results. The lack of a control group in our study limits the specificity of our results to spouses of BD patients. BD patients form a couple with their spouses, but we ignored the impact of this disorder on their lives and their marital relationship.
| Conclusions|| |
To conclude, our research indicated that spouses of BD patients strife with the impact of BD on their relationships. Marital dissatisfaction was highly present among them and they faced a lot of problems in various areas of their lives. As clinicians, we need to evaluate and understand the issues related to the marital life of normal spouses of BD patients to provide emotional and practical support to them, individually as well as couples. When mental health professionals will provide psychosocial support to spouses of BD patients, it can help to minimize the marital problems in them and can improve their QoL.
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Conflicts of interest
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| References|| |
Grover S, Nehra R, Thakur A. Bipolar affective disorder and its impact on various aspects of marital relationship. Ind Psychiatry J 2017;26:114-20.
] [Full text]
Judd LL, Akiskal HS, Schettler PJ, Endicott J, Maser J, Solomon DA, et al
. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002;59:530-7.
Tohen M, Hennen J, Zarate CM Jr., Baldessarini RJ, Strakowski SM, Stoll AL, et al
. Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features. Am J Psychiatry 2000;157:220-8.
Gerson LD, Rose LE. Needs of persons with serious mental illness following discharge from inpatient treatment: Patient and family views. Arch Psychiatr Nurs 2012;26:261-71.
Masand PS, Tracy N. Results from an online survey of patient and caregiver perspectives on unmet needs in the treatment of bipolar disorder. Prim Care Companion CNS Disord 2014;16:(4).
Hajda M, Prasko J, Latalova K, Hruby R, Ociskova M, Holubova M, et al
. Unmet needs of bipolar disorder patients. Neuropsychiatr Dis Treat 2016;12:1561-70.
Behere PB, Rao ST, Verma K. Effect of marriage on pre-existing psychoses. Indian J Psychiatry 2011;53:287-8.
] [Full text]
Dominian J. Marriage and psychiatric illness. Br Med J 1979;2:854-5.
Muke SS, Ghanawat GM, Chaudhury S, Mishra SK, Verma AN, Singh AR. Marital adjustment of patients with substance dependence, schizophrenia and bipolar affective disorder. Med J DY Patil Univ 2014;7:133-8. [Full text]
Edition F. Diagnostic and Statistical Manual of Mental Disorders. Arlington: American Psychiatric Publishing; 2013.
Funk JL, Rogge RD. Testing the ruler with item response theory: Increasing precision of measurement for relationship satisfaction with the Couples Satisfaction Index. J Fam Psychol 2007;21:572-83.
Heavey CL, Christensen A, Malamuth NM. The longitudinal impact of demand and withdrawal during marital conflict. J Consult Clin Psychol 1995;63:797-801.
Kiecolt-Glaser JK, Newton TL. Marriage and health: His and hers. Psychol Bull 2001;127:472-503.
Robles TF, Slatcher RB, Trombello JM, McGinn MM. Marital quality and health: A meta-analytic review. Psychol Bull 2014;140:140-87.
Drisya P, Bindumol K, Saleem TK, Narayan D. Marital problems among partners of patients with bipolar affective disorder. Indian J Psychol Med 2019;41:448-54.
] [Full text]
Pandey V, Saddichha S, Akhtar S. Quality of life and marital adjustment in epilepsy and comparisons with psychiatric illnesses. Psychiatr Rehabil J 2010;14:105-12.
Vibha P, Saddichha S, Khan N, Akhtar S. Quality of life and marital adjustment in remitted psychiatric illness: An exploratory study in a rural setting. J Nerv Ment Dis 2013;201:334-8.
Whisman MA. Marital dissatisfaction and psychiatric disorders: Results from the National Comorbidity Survey. J Abnorm Psychol 1999;108:701-6.
Frank E, Targum SD, Gershon ES, Anderson C, Stewart BD, Davenport Y, et al
. A comparison of nonpatient and bipolar patient-well spouse couples. Am J Psychiatry. 1981;138(6):764-8.
Kopeykina I, Kim HJ, Khatun T, Boland J, Haeri S, Cohen LJ, et al
. Hypersexuality and couple relationships in bipolar disorder: A review. J Affect Disord 2016;195:1-4.
Bursalioglu FS, Aydin N, Yazici E, Yazici AB. The correlation between psychiatric disorders and women's lives. J Clin Diagn Res 2013;7:695-9.
Mansour H, Kandil K, Wood J, Fathi W, Elassy M, Ibrahim I, et al
. Reduced fertility and fecundity among patients with bipolar I disorder and schizophrenia in Egypt. Psychiatry Investig 2011;8:214-20.
Levkovitz V, Fennig S, Horesh N, Barak V, Treves I. Perception of ill spouse and dyadic relationship in couples with affective disorder and those without. J Nerv Ment Dis 2000;188:463-6.
Granek L, Danan D, Bersudsky Y, Osher Y. Living with bipolar disorder: The impact on patients, spouses, and their marital relationship. Bipolar Disord 2016;18:192-9.
Lam D, Donaldson C, Brown Y, Malliaris Y. Burden and marital and sexual satisfaction in the partners of bipolar patients. Bipolar Disord 2005;7:431-40.
Borowiecka-Karpiuk J, Dudek D, Siwek M, Jaeschke R. Spousal burden in partners of patients with major depressive disorder and bipolar disorder. Psychiatr Pol 2014;48:773-87.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]