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Marital adjustment of patients with substance dependence, schizophrenia and

bipolar affective disorder

Article · January 2014

DOI: 10.4103/0975-2870.126316

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 Original Article

Marital adjustment of patients with substance

dependence, schizophrenia and bipolar
affective disorder
Shital S. Muke, Girish M. Ghanawat, Suprakash Chaudhury1, Sujit K. Mishra, A. N. Verma, Amool R. Singh
Department of Psychiatric Social Work, Ranchi Institute of Neuropsychiatry & Allied Sciences, Ranchi, Jharkhand, 1Department of Psychiatry, Pravara
Institute of Medical Sciences (Deemed University), Rural Medical College, Loni, Maharashtra, India

ABSTRACT Access this article online

Background: Marital adjustment is considered as a part of social
well-being. Disturbed marital relationship can directly affect the
disease adjustment and the way they face disease outcomes and
complications. It may adversely affect physical health, mental
health, the quality-of-life and even economic status of individuals.
Aim: The aim of this study was to compare the marital adjustment
among patients with substance dependence, schizophrenia
and bipolar affective disorder. Materials and Methods: The
sample consisted of each 30 patients with substance dependence,
bipolar affective disorder and schizophrenia, diagnosed as per
international classification of diseases-10 diagnostic criteria
for research with a minimum duration of illness of 1 year were
evaluated using marital adjustment questionnaire. The data
was analyzed using parametric and non-parametric statistics.
Results: Prevalence of poor marital adjustment in patients
with schizophrenia, bipolar affective disorder and substance
dependence was 60%, 70% and 50% respectively. There was
a significant difference on overall marital adjustment among
substance dependence and bipolar affective disorder patients.
There was no significant difference on overall marital adjustment
among patients with substance dependence and schizophrenia as
well as among patients with schizophrenia and bipolar affective
disorder. On marital adjustment domains, schizophrenia
patients had significantly poor sexual adjustment than substance
dependence patients while bipolar affective disorder patients
had significantly poor sexual and social adjustment compared
with substance dependence patients. Conclusion: Patients with
substance dependence have significant better overall marital
adjustment compared with bipolar affective disorder patients.
Patients with substance dependence have significantly better
social and sexual adjustment than patients with bipolar affective
disorder as well as significantly better sexual adjustment than
schizophrenia patients.
Keywords: bipolar affective disorder, marital adjustment,
schizophrenia, substance dependence
Quick Response Code:
Website:
www.mjdrdypu.org
DOI:
10.4103/0975-2870.126316
Introduction
Marriage and family meet man’s deepest needs for
companionship, affection and sexual expression. It involves
the most intimate type of emotional relationship between
two individuals.
Marital adjustment is defined as, “the state in which there is
an overall feeling between husband and wife, of happiness
and satisfaction with their marriage and with each other.”[1]
It, therefore, entails experiencing satisfactory relationship
between spouses characterized by mutual concern, care,
understanding and acceptance.
Marital adjustment is considered as a part of social well-
being. Disturbed marital relationship adversely affects
physical health, mental health, the quality-of-life and even
economic status of individuals.[2,3] For several patients with
chronic illnesses, marital relationship is a serious concern.
It can directly affect the disease adjustment and the way
they face disease outcomes and complications.[4,5] In general,
there is a well-established association between marital
status and individual psychopathology. Epidemiological
data suggest that married individuals are less likely to
suffer from a psychiatric disorder than those who are

Address for correspondence:

Dr. Suprakash Chaudhury, Department of Psychiatry, Pravara Institute of Medical Sciences (Deemed University), Rural Medical College,
Loni - 413 736, Maharashtra, India. E-mail: suprakashch@gmail.com

Medical Journal of Dr. D.Y. Patil University | March-April 2014 | Vol 7 | Issue 2 133
 Muke, et al.: Marital adjustment among psychiatric patients
separated or divorced. In addition, men and women who
are married have a lower rate of presentation to out-patient
mental health services and are less likely to be admitted to
a psychiatric hospital. It is not the case that simply being
married offers protection against developing a psychological
disorder. Men and women in satisfying marriages definitely
have a lower risk for psychiatric disorder than other
segments of the population.[6] On the other hand, couples in
an unhappy marriage, the relationship can cause significant
stress with related health consequences–most frequently,
chronic, diffuse physiological arousal that manifests in
physical ailments including high blood pressure, heart
disease, anxiety, depression, suicide, violence, psychosis,
homicide and substance abuse.[7] There is growing literature
linking marital dissatisfaction with the onset, course and
treatment of adult psychiatric disorders. Although a strong
association has been reported between marital problems
and psychopathology by numerous researchers, the causal
connection remains uncertain. Several studies indicate that
marital discord may have a causal effect on psychological
disorders[8-10] while other studies suggest that psychological
disorders play a causal role in creating and maintaining
disrupted marital interactions.[11,12] Finally, some research
indicates that marital problems and psychological disorders
reciprocally influence one another.[6]
There is a strong association reported between alcohol
abuse and marital distress. A study using data from the
National Comorbidity Survey (NCS)[13] found greater marital
dissatisfaction was associated with alcohol dependence for
men.[12] In another study, one-third of couples presenting
with the marital problems reported alcohol abuse in the
male partners and over three-quarters of couples reported
frequent disagreement regarding alcohol consumption.
[14]
Numerous studies document that both men presenting
for alcoholism and their partners report low relationship
satisfaction, frequent and intense arguments, poor
sexual functioning, higher levels of maladaptive marital
interaction patterns and higher levels of marital violence.
[15-17]
Furthermore, observational studies have identified
noticeable deficits in problem solving and communication
skills in couples, in which one partner is a problem drinker.
In particular, couples in which one partner has an alcohol
problem are characterized by high rates of verbal and
non-verbal negative affect expression, few supportive and
constructive responses and male withdrawal during the
conflicts.[18]
Whisman[12] examined the association between marital
dissatisfaction and 12-month prevalence rates of common
axis I psychiatric disorders in married respondents from
the NCS. Results indicated that spouses with any disorder,
134 Medical Journal of Dr. D.Y. Patil University | March-April 2014 | Vol 7 | Issue 2
any mood disorder and any anxiety disorder reported
significantly greater marital dissatisfaction than spouses
without the corresponding groupings of disorders. The
clinical features of bipolar disorder have an impact on
intimate relationship, quality of relationship and on the
outcome among bipolar patients. Radke-Yarrow et al.[19]
interviewed bipolar women in a study of offspring and
family interactions. She found that women with bipolar
affective disorder (a mix of bipolar I and II) reported
higher rates of marital disorder at all follow-up assessment
(62-76%) compare with non-ill women (7-13%) or
women with unipolar depression (53-59%). Although the
marriages of individuals with psychosis have not been
studied extensively, there appears to be a strong association
between psychosis and marital status. Individuals with a
psychotic disorder are less likely to marry than the rest
of the population. Some of the difficulties may include
coping with severely disturbed behavior during periods
of acute psychotic episodes, disrupted household routines
(e.g., as the result irregular sleeping and eating patterns
and self-care), inappropriate interpersonal behavior, social
withdrawal and emotional unresponsiveness.[6] In view of
the paucity of Indian studies in this field, the present work
was undertaken to assess the level of marital adjustment
and to compare marital adjustment among patients with
substance dependence, schizophrenia and bipolar affective
disorder.
Materials and Methods
Settings and Design
This cross-sectional study was carried out on indoor and
outdoor patients of Ranchi Institute of Neuropsychiatry
and Allied Sciences (RINPAS), Ranchi. Ethical clearance
for the study was obtained from the Institutional Ethical
Committee.
Sample
The sample consisted of each 30 patients with substance
dependence, schizophrenia and bipolar affective disorder,
based on purposive sampling technique, from out-patient
and inpatient department of RINPAS, Ranchi. All patients
of substance dependence were dependent on alcohol and
were not abusing any other substance apart from nicotine.
None of patients with schizophrenia and bipolar disorder
had comorbid substance abuse or dependence apart from
nicotine. Patients were diagnosed as per international
classification of diseases-10 diagnostic criteria for research
criteria.[20] The three groups were age and sex matched.
The age range of the sample was 20-50 years. Patients with
other comorbid psychiatric disorders or physical disorders
were excluded.
 Muke, et al.: Marital adjustment among psychiatric patients

Tools
Table 1: Mean (±SD) of age of patients with substance dependence,
Socio-Demographic Data Sheet: Socio-demographic data schizophrenia and bipolar affective disorder
sheet was used to collect details such as sex, age, education, Patient’s group N Age mean±SD
occupation, monthly income, religion, domicile and family Substance dependence 30 34.13±7.07
type, course of illness and duration of illness. Schizophrenia 30 33.43±4.87
Bipolar affective disorder 30 31.93±6.54
Total 90 33.17±6.23
Marital adjustment questionnaire (MAQ):[21] It consists of
SD-Standard deviation
25 highly discriminating “yes-no” type items. According
to this questionnaire, the higher the score, better is the
adjustment There are three domains given as sexual (item Table 2: Analysis of variance of age of three groups of patients

9, 20, 23, 25), social (item 3, 4, 5, 6, 12, 14, 15, 18, 19) and
emotional (item 1, 2, 7, 8, 10, 11, 13, 16, 17, 21, 22, 24). 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
70. The face validity of the questionnaire appeared too high.
The questionnaire was validated against Singh’s marital
adjustment inventory and was found to be 0.71 with the
index of reliability of 0.04.
Procedure
Patients were initially interviewed to collect the socio-
demographic data. The researcher explained the study to
all subjects and informed consent was obtained prior to
completion of the questionnaires. Thereafter, the MAQ was
administered individually to patient. The questionnaires
were scored as per the test manual and the data was tabulated
and analyzed.
Statistical Analysis
The statistical analysis was performed by using the SPSS (IBM
Corp.) program. Parametric test were used for continuous data
and non-parametric tests were used for ordinal data.
Results
Age of the patients included in the study is shown in Table 1.
There was no statistically significant difference in the mean
age of the three groups of the patients [Table 2].
Socio-demographic and clinical characteristics of the sample
are given in Table 3. Majority of the respondents in all three
groups were from age group of 31-50 years, educated up
to secondary, employed, Hindu, with a rural background.
In clinical characteristics, majority of the respondents had
episodic course of illness and up to 4 years duration of illness.
Distribution of patients according to quality of marital
adjustment is given in Table 4. Poor marital adjustment was
observed in 70% of patients with bipolar affective disorder,
60% of schizophrenia patients and 50% of patients with
substance dependence.
Sum of df Mean F Significance
squares square
Between groups 0.422 2 37.900 0.975 0.381
Within groups 20.733 87 38.859
Total 21.156 89
Table 5 shows total and domain wise score on marital
adjustment. To analyses the differences in score on
marital adjustment with domain wise score between trees
groups of patients, Mann-Whitney U-test was performed
[Table 6]. Result showed that the total score on MAQ of
substance dependence patients was significantly more than
schizophrenia (P = 0.039) and bipolar affective disorder
patients. There is no significant difference noted between
patients with schizophrenia and bipolar affective disorder
on overall marital adjustment. Scores obtained by three
groups of patients in the three domains of MAQ were also
compared. The result showed a significant difference in
sexual adjustment domain among patients with substance
dependence and patients with schizophrenia and bipolar
affective disorder. There is also significant difference
found on social adjustment domain among patients with
substance dependence and bipolar affective disorder. There
is no significant difference found among three groups
on emotional adjustment domain. This indicates that
the difference in the marital adjustment score between
substance dependence patient’s and bipolar affective
disorder was mainly due to differences in the sexual and
social adjustment domain.
Discussion
The main finding of the present study is that the majority
of patients from the three groups (substance dependence,
schizophrenia and bipolar affective disorder) have poor
marital adjustment. There is a significant difference found
on overall marital adjustment among patients with substance
dependence and bipolar affective disorder, which indicates
that substance dependence patients have better marital
adjustment quality than patients with bipolar affective
disorder. There is no significant difference found on marital
adjustment among patients with substance dependence

Medical Journal of Dr. D.Y. Patil University | March-April 2014 | Vol 7 | Issue 2 135
 Muke, et al.: Marital adjustment among psychiatric patients

Table 3: Patient’s distribution according to socio demographic and Table 5: Mean (±SD) of total and domain wise scores on the marital
clinical variables adjustment questionnaire
Socio- Substance Schizophrenia Bipolar χ2 (df=2) Variables Substance Schizophrenia Bipolar affective
demographic dependence N (%) affective dependence disorder
variables N (%) disorder N (%) Mean ± SD Mean ± SD Mean ± SD
Age Sexual adjustment 2.97±0.92 2.50±0.93 2.33±1.12
Up to 30 9 (30.00) 11 (36.70) 14 (46.70) 1.796 Social adjustment 6.73±1.28 6.53±1.25 5.86±1.79
31-50 21 (70.00) 19 (63.30) 16 (53.30) Emotional
7.90±2.66 8.06±2.62 6.63±2.60
Education adjustment
Up to 23 (76.70) 17 (56.70) 18 (60) 3.006 Total 17.33±4.19 16.83±4.39 14.76±4.64
secondary SD-Standard deviation
Higher 7 (23.30) 13 (43.30) 12 (40)
secondary
and more Table 6: Comparison on overall marital adjustment and domain wise
Occupation score of marital adjustment questionnaire on Mann-Whitney U-test
Unemployed 1 (3.30) 3 (10.0) 1 (3.30) 1.694 Variables Comparison Comparison Comparison of
Employed 29 (96.70) 27 (30.0) 29 (96.70) of substance of substance schizophrenia
Religion dependence and dependence and and bipolar
Hindu 26 (86.70) 24 (80.0) 25 (83.30) 3.580 schizophrenia bipolar affective affective
disorder disorder
Muslim 2 (6.70) 5 (16.70) 5 (16.70)
Significance Significance Significance
Christian 2 (6.70) 1 (3.30) 00 (00)
Sexual 0.051* 0.028* 0.572
Domicile adjustment
Urban 11 (36.70) 8 (26.70) 5 (16.70) 2.849 Social adjustment 0.531 0.049* 0.135
Rural 17 (56.70) 21 (70.0) 23 (76.70) Emotional 0.905 0.077 0.088
Semi-urban 2 (6.70) 1 (3.30) 2 (6.70) adjustment
Course of Overall marital 0.609 0.039* 0.173
illness adjustment score
Continuous 13 (43.30) 14 (47.70) 00 (00) 19.365** *P<0.05
Episodic 17 (56.70) 16 (53.30) 30 (100)
Duration of of the patients. Individuals with substance dependence
illness
are more likely to have a pattern of conduct marked by
Up to 4 year 25 (83.30) 14 (46.30) 13 (43.30) 12.115*
More than 4 5 (16.70) 16 (53.30) 17 (56.70) impulsivity, weak resistance to frustration and focus on
year personal needs, schemes of attribution based on external
*P<0.05, **P<0.01
locus of control and focus on personal and immediate
needs. This may lead subjects to underestimate the impact
Table 4: Distribution of patients according to marital adjustment of their conduct in family and marital relationships. It
category may also lead to a bias in own evaluation of their marital
Marital Substance Schizophrenia Bipolar role. On the other hand, due to the effect of negative
adjustment dependence N (%) affective
symptoms and lack of insight schizophrenia patients may
category N (%) disorder N (%)
Good 8 (26.70) 8 (26.70) 3 (10.0) undervalue their role as husband/wife and the impact of
Average 7 (23.30) 4 (13.30) 6 (30.0) the illness. However, because of the tendency to social
Poor 15 (50.0) 18 (60.0) 21 (70.0) withdrawal, their partners may tend to replace the role
as a spouse by a role as a caregiver and by this mitigate
and schizophrenia and among schizophrenia and bipolar the degree and frequency of negative interactions in the
affective disorder patients. It can be concluded that patients marital context. In contrast to the above, Bipolar patients
with bipolar affective disorder and schizophrenia have tend to have a better global functioning between crisis;
more or less similar marital adjustment level and that is this may represent a higher level of expectations regarding
poor marital adjustment. Substance dependence patients the role as a spouse and a stronger impact of the illness
have somewhat better marital adjustment level than these both for the spouse and for the patient and by this way, a
two groups (schizophrenia and bipolar affective disorder). more realistic and more emotionally charged evaluation
These findings are broadly in agreement with the findings of the marital relationship.
of earlier studies.[6,8,11,12,15,22]
The above findings are not surprising given the various
It must be emphasized here that the results must be challenges a partner of a patient with a psychotic disorder
interpreted with caution due to the nature of the illness must meet. Some of the difficulties may include coping

136 Medical Journal of Dr. D.Y. Patil University | March-April 2014 | Vol 7 | Issue 2
 Muke, et al.: Marital adjustment among psychiatric patients
with severely disturbed behavior during periods of acute
psychotic episodes, disrupted household routines (e.g., as the
result irregular sleeping and eating patterns and self-care),
inappropriate interpersonal behavior, social withdrawal
and emotional unresponsiveness.[23] In the present study,
patients with schizophrenia showed a trend to better
marital adjustment as compared with patients with bipolar
affective disorder. This could due to the clinical features of
both the disorders. Patients with bipolar affective disorder
manifest with hyperactivity, increased energy, abusive and
assaultive behavior during the manic phase. As the manic
phase is perceived as a willful, spiteful act, the attitude of
the spouses undergoes a marked change with feeling of
betrayal and experiencing diminished self-esteem. Related
to these issues of the spouse is the problem of marital
infidelity. Often manic patients make sexual advances
to other, may engage in affairs and speak of divorce. In
all these situations, the spouse felt trapped in what they
perceived as an impossible situation. They feel caught in a
whirlwind of activity, personally threatened and powerless
to enforce their will. In consonance with the above is the
findings of a study that marital disharmony was greater
when patients with bipolar disorder were ill and worse
during manic than depressed phases. Marital disharmony
was also more likely when partners believed the patient
could control their illness, they had increased domestic
responsibilities or were sexually dissatisfied.[24] On the
other hand patients with schizophrenia most of the time
present with negative symptoms and abnormal behavior,
but violence is less common. Negative symptoms and loss of
personal functioning are important factors in high expressed
emotion in families with schizophrenia patients, being
one of the reasons precisely the fact that they have many
difficulties in acknowledge them as aspects of the illness and
not personal will. However, it is possible that in our setting
due to less violent behavior, this change in behavior may be
viewed by the spouses as an illness over, which he has little
control. As a result the spouses offer significant physical
care and emotional support. In agreement with the above,
it was reported that marital satisfaction of schizophrenics
was influenced by violence from spouse.[25]
The domain wise distribution shows significant difference
on sexual adjustment domain and social adjustment domain
between patients with substance dependence and bipolar
affective disorder. It indicates bipolar affective disorder
patients have poor sexual and social adjustment than
patients with substance dependence. These findings are
similar to findings of a previous study.[24] Similarly, there is
significant difference found on sexual adjustment domain
between substance dependence and schizophrenia patients. It
indicates schizophrenia patients have poor sexual adjustment
Medical Journal of Dr. D.Y. Patil University | March-April 2014 | Vol 7 | Issue 2 137
compared with patients with substance dependence.
Inspection of the answers on MAQ showed some interesting
trends. It appeared that the patients with bipolar affective
disorder have overall poor marital adjustment and poor
social adjustment domain due to lack of fulfillment in
marital roles and responsibilities, poor economic adjustment,
poor communication and poor problem solving. Emotional
adjustment domain, analyzed on the basis of sharing of
things and emotions, satisfaction about emotional needs,
spending time with each other, likes and dislikes, in which
the patients with schizophrenia found trend to better
emotional adjustment domain than patients with bipolar
affective disorder and patients with substance dependence.
The substance dependence patients engaged in frequent
and intense arguments have noticeable deficits in problem
solving and communication skills, high rates of verbal and
non-verbal negative affect expression, few supportive and
constructive responses and show withdrawal during conflict.
This could be the reason for the lack of emotional adjustment
among substance dependence patients.
Limitations
No symptoms or personal functioning assessment was
performed and cross-checked with the spouse for consistency.
This would have given a better characterization of the sample
considering that aspects such as marital adjustment demand a
“fine tuning” in terms of personal and inter-personal evaluation.
Conclusion
There is significant difference on overall marital adjustment
among substance dependence and bipolar affective disorder
patients. Schizophrenia patients have significantly poor sexual
adjustment than substance dependence patients. Patients with
bipolar affective disorder have significantly poor sexual and social
marital adjustment than patients with substance dependence.
Schizophrenia and bipolar affective disorders patients do not
significantly differ from each other on marital adjustment. Since
majority of the patients with schizophrenia and bipolar affective
disorder and 50% patients with substance dependence have poor
marital adjustment, marital counseling should form a part of the
psychosocial management of these patients.
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How to cite this article: 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.
Source of Support: Nil, Conflict of Interest: None declared.