Predictors of Marriage in Psychiatric Illness: A Review of Literature
Department of Psychiatry, Safdarjung Hospital and Vardhaman Mahavir Medical College, New delhi, Delhi, India
*Corresponding Author: Dr. Shaily Mina, Department of Psychiatry, Safdarjung Hospital and Vardhaman Mahavir Medical College, New delhi, Delhi, India
Received: 24 January 2019; Accepted: 07 February 2019; Published: 12 February 2019
Introduction: Marriage is the significant life event in a person. Marriage in Indian society has significant role and acts has a significant stigmatization factor if unmarried or separate or divorced. Marital pathology is considered the most stressful in comparison to other life events in an individual’s life. When psychiatric illness is taken into consideration, it has a substantial role along with other factors in causing/worsening or relapse of the illness.
Methodology: The results of the various studies in Indian context are being attempted to be compiled. Search was done through EMBASE, PsycINFO and PUBMED.
Result: Epidemiological data supports the evidence that married individuals have less chances to have psychiatric illness. Epidemiological data supports the evidence that married individuals have less chances to have psychiatric illness. Positive correlation is illustrated with marital adjustment problems and anxiety/depressive psychopathology. When severe mental illnesses are compared worse marriage outcome is reported in schizophrenia patients.
Conclusion: It has been understood from the studies done so far that marriage acts as both protecting factor and predisposing/precipitating factor for the causation of the psychiatric illness. Still huge area related to marital problems (legal issues, marital separation, divorce, infertility, intimacy issues) in individuals and their spouse is unexplored.
Marriage, Psychiatric illness, Marital adjustment, Marital satisfaction, Marital discord
Marriage is one of the most significant turning point in an individual’s life. It acts as a means of fulfilling the basic human needs in form of socially acceptable sexual gratification and also acts as foundation for procreation and establishment of the family . Marriage acts as a prestigious social factor in Indian society and therefore has significant influence on religious and culture beliefs in comparison to the western society .
Marital pathology is considered the most stressful in comparison to other life events. While assessing the social readjustment Death of spouse, Divorce and marital separation are perceived to be the most stressful circumstances (all related to marriage) . When psychiatric illness is taken into consideration, it has a substantial role along with other factors in causing/worsening or relapse of the illness. It also acts as a protective factor not only against psychiatric illness but also for global wellbeing of the family and healthy growth of the children. There is evidence suggesting higher rates of marital discord, separation, and divorce in patients with psychiatric illness. Major psychiatric illness commonly associated with marital pathology are- Personality disorders or traits of dependence, passiveness, aggression, immaturity, histrionicism, paranoia, and obsession; Depression, Phobias; Schizophrenia; Affective Disorder, Substance Dependence Mainly Alcohol .
Marriage can be assessed in terms of marital adjustment or marital satisfaction. In most of the researches, marital satisfaction, marital adjustment, marital quality and marital happiness have been used interchangeably. Marital satisfaction is a mental state that reflects the apparent yields and expenditures of marriage to an individual . Marital adjustments is defined as a marriage in which patterns of behaviour of the two persons are mutually satisfying i.e. they have come to an adjustment on interests, objectives, and values and are in harmony on demonstration of affection and sharing confidences . The qualitative assessment of marriage is assessed through externalizing and internalizing factors. The externalizing factors commonly evaluated are- demographic profile (age, gender, duration of marriage, presence of children); financial issues, religious beliefs and intensity of involvement. The internalization factors documented are conflict/problem solving interactions, support transactions, emotionally intimate transactions and balance of power and control in the relationship .
Based on the studies done so far it is seen that marriage does have a significant impact (positive and negative) on the psychiatric illness. Still very few psychiatric illnesses have been studied in detail highlighting the issues of marriage (Schizophrenia, depression, bipolar disorder, substance manly). Current review aims to assemble the researches being done so far on the role of marriage in psychiatry so that in future research focus be shifted to this issue especially in Indian context.
2. Review of Literature
Marriage is a societal establishment with sets of rules and regulation which defines the rights, duties and privileges of the husband and wife . In Indian culture, marriage is regarded as an imperative and sacred event in an individual's life, and everybody is supposed to be married to continue his progeny. Marriage is a significant aspect in individual specially women and it raises social status of the women. Being unmarried/divorced is socially unacceptable in India and causes great stigma to an individual leading to compulsivity to continue marriage despite the serious altercations . Due to this reason people avoid discussing this issue in open (family members/ treating doctor) leading to lack of exploration of psychological stress caused by marital discord.
The researches done so far strongly suggest the association of mental illness with the marital complications. This association have been evaluated in various means: marital stress acting as precipitating factor for the mental illness, marital stress worsening/maintaining the mental illness, consequences of mental illness on marriage, marriage acting as protecting factor against the mental illness, marital issues in the spouse of the mentally ill subject due to the illness per se & marriage, mental illness and the legal issues. Different terms of marital stress have been used for the assessment- marital satisfaction/dissatisfaction and marital adjustment is most commonly cited in the studies.
There have been multinational studies been done to assess the impact of marriage on psychiatric illness and vice versa. These studies reported decreasing trend of the time spend in marriage either due to more divorce rate or being unmarried . One Meta-analyses also attempted to evaluate the impact of marriage on cognition and reported highest propensity of developing dementia in individual who were single followed by widowed and least in married people .
The present review is focused on the studies on Indian society as the marriage customs and religious of Indian society markedly differs from the western society, therefore result cannot be duplicated to the Indian society. Also the aim of the present review is to compile the results of studies done so far and to assess the need for the further studies. The results have been compiled under various sub-headings:
- Role of marital stress as precipitating factor in causing the mental illness
- Consequences of mental illness on marriage
- Marriage as protecting factor in preventing psychiatric illness
- Marital issues in spouse of mentally ill
- Marriage, Mental Illness and Law
3. Role of Marital Stress As Precipitating Factor in Causing the Mental Illness
Studies done so far links casual association of marital problems and mental illness. It can lead to various major psychiatric illnesses. In one of the study assessing the risk factors for the development of common mental disorder highlighted higher incidence in divorced/widowed individual due to social isolation or stigma . In a study done in South India, showed significance of marital separation leading to psychiatric morbidity with 3/4th of the proportion showing no psychiatric problems in couples who were staying together . Majority of the studies on marital stress have reported positive association with psychiatric morbidity. Study by Ahmed et al have also reported this association to be more common with early marriages especially in females (less than 18 years) .
Exploration of the WHO data found delayed onset of the psychotic symptoms by approx. 1-2 years in married men compared to single men .
3.2 Bipolar Illness
Though very few research has been done on role of marriage in this group, findings suggest more episodes in married individual in comparison to never married group .
Research have observed depression to be more common in separated or divorced individual . Evidence suggest depression to be more common in married women in comparison to married men. Various reasons have been explored- disturbed menstruation cycle/menopause affecting the sexual life, migration to husbands place after marriage being a significant life event, marital separation due to transfer of husband, pregnancy, miscarriage/abortion and weight gain/loss . In one of the study done on married females separated from their husbands due to transfer to other place revealed, more psychopathology in females who were either staying alone wither children or her in laws in comparison to staying at her parent’s place . Risk of suicide is also more common in married individuals specially females, common reason perceived are dowry issues, domestic violence, pressure of society to avoid divorce even when going through strained marriage . In one study females with marital disharmony were assessed and it was found that common reasons for disharmony were- dowry related and substance dependence. Depression was most commonly seen in these subjects .
3.4 Anxiety Disorder
Studies have observed higher proportion of anxiety symptoms in divorce seeking couples . Divorce also increases the propensity to have alcohol abuse and depression . Prospective study of 107 subjects with obsessive-compulsive disorder reported being married suggestively increased the likelihood of partial remission .
3.5 Substance use Disorder
Alcohol is most frequently studied. It is considered as one of the major causative or associative factor leading to broken relationship. Studies have reported nearly half of the subjects to be having issues with marital adjustment. Significant correlation was found between duration of alcohol dependency and marital adjustment .
4. Consequences of Mental illness on Marriage
4.1 Personality Disorder/Traits
Dependence, passiveness, aggression, histrionicity, paranoia and obsession have higher incidence of marital stress .
10 years follow up of 76 first onset schizophrenia found more men remaining single and more women having broken marriages suggesting decreased social abilities to be the most common reason for unsuccessful marriage . It was observed that patients with schizophrenia are more likely to remain single and unmarried (mostly men) in comparison to other mental illness. Also low rate of fertility and reproduction is noted in schizophrenia group, reasons commonly explored are lack of interest in social relations, general apathy, loss of sex drive, and lack of opportunity for a sexual relationship due to hospitalization and institutionalization . Marriage has significant detrimental effect on pre-existing psychosis especially in female patients. In Indian culture due the blind belief that marriage can cure everything and stigma of the mental illness, the illness of patients is generally hidden at the time of marriage which has more effect on females than males due to male dominant society. Therefore, it leads to poor compliance to the treatment in turn affecting the marital life critically . When age of onset of illness was compared, early onset of illness being associated with poorer marital adjustment and worse prognosis .
Few studies have also attempted to compare effect of different psychiatric illness- one such study compared schizophrenia, bipolar disorder and substance dependence subjects and found substance dependence patients having better marital adjustment level than other two groups . One study compared marital adjustment and quality of life of subjects and their spouse between schizophrenia, bipolar disorder and recurrent depression and reported more marital dissatisfaction in schizophrenia than the other two groups .
4.3 Bipolar Disorder
Study comparing marital adjustment between epilepsy and bipolar disorder found poor marital adjustment in bipolar patients and their spouses . Another study compared marital adjustment among major psychiatric illness- schizophrenia, bipolar disorder and substance dependence and established poor marital adjustment among 70% of patients with bipolar disorder . One study compared marital functioning in both the phases of bipolar disorder and found poorer relationship in depressive phase. Reasons for the poor marital relationship in bipolar patients in the studies are- psychopathology and poor sexual relationship due to psychotropic medications .
Research done in developing country (Pakistan) reports majority of the subjects with depression to be having marital dissatisfaction (91.4%). Duration of illness was directly correlated to the marital satisfaction in this study . Study comparing gender difference in marital adjustment reported males more dissatisfied with their marriage in comparison to their female counter part (96.7% v/s 60%) .
Most of the studies are done on Alcohol. Studies have reported significant disruption of the family in terms of family life, sexual relationship, economic resources, well-being of the children and status within the community. Due to these reasons higher rate of domestic violence and divorce is seen in these groups .
5. Marriage As Protecting Factor in Preventing Psychiatric Illness
Study reports delayed onset of psychotic symptoms in married men. Presence of children and being married before the onset of illness has been shown to be a protective factor in the marriage in patients with schizophrenia . Married men has lower rate of depression. Marriage reinforced by children decreases suicidal risk .
6. Marital Issues in Spouse of Mentally Ill
Marital problems are most commonly studied on spouse of alcoholic men. Higher rate of domestic violence is witnessed (Physical/verbal/sexual) in this group. Major issues encountered are lower marital satisfaction, poor social support, financial issues and social stigma . Common mental illness reported in spouse of alcohol dependence were- Dysthymia (Most common), adjustment disorder, depression and mood and anxiety disorders. Strong correlation was noted between the duration of alcohol dependence, duration of marital life and psychopathology.
Study on bipolar disorder patients spouse reported more caregiver burden with marital dissatisfaction . Marital satisfactions was assessed in spouses of patients suffering from severe mental illness such as schizophrenia, mania, depression, schizoaffective disorders, organic mental disorders with a duration of greater than 2 years and almost 80% of the spouse reported unsatisfactory relationship . Research on spouse of opioid dependent individuals revealed poor quality of life in majority of the couples .
7. Marriage, Mental Illness and Law
Abandonment, vindictiveness, deceitfulness, and mental illness may interfere with the marital life, and may lead to broken marriage .
8. Critical Analysis
It is understood from the studies done so far that marriage acts as both protecting factor and predisposing/precipitating factor for the causation of the psychiatric illness. Epidemiological data supports the evidence that married individuals have less chances to have psychiatric illness. Various other factors are responsible for controlling the impact of marriage- age of marriage, past history of failed relationship, stage of illness, type of illness, support system, gender of the individual, personality of the individual, presence of children from marriage, type of psychotropic medications of the individuals (some medicines have detrimental effect on the sexual relationship, sedation). Epidemiological data supports the evidence that married individuals have less chances to have psychiatric illness. Marital stress significantly increases tendency for substance intake mainly alcohol mostly in men. Positive correlation is illustrated with marital adjustment problems and anxiety/depressive psychopathology. When severe mental illnesses are compared worse marriage outcome is reported in schizophrenia patients.
It has also been observed that in comparison to western world, proportion of marriage is more in individuals suffering from psychiatric illness in India. Major reason explored are that in Indian society being unmarried is stigmatised almost equalling any other psychiatric illness and also strong belief society has that marriage is the ultimate solution to every problem.
Still huge area related to marital problems (legal issues, marital separation, divorce, infertility, intimacy issues) in individuals and their spouse is unexplored. The research done so far significantly correlate marital discord with psychiatric illness. Further studies are needed in common psychiatric illness like anxiety disorder, somatization disorder, dissociative disorder
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Citation: Shaily Mina. Predictors of Marriage in Psychiatric Illness: A Review of Literature. Journal of Psychiatry and Psychiatric Disorders 3 (2019): 014-022.