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Marital problems in chronically depressed and physically ill patients and their spouses
Marital Problems in Chronically Depressed and Physically 111Patients and Their Spouses N. Bouras, P. Vanger, and P.K. Bridges The aims of this study were to investigate the degree of marital dysfunction between psychiatry and physically ill patients and to what extent the marital life of the nonpatient spouse was affected by the illness of the patient. The results suggested that the depression had a much greater impact on marital life from the patient and the spouse point of view, than rheumatoid or cardiac illness. @ 1986 by Grune & Stratton, Inc.
A
GROWING BODY of recent research has demonstrated a strong relationship between mental illnesses, and marital disharmony and dissatisfaction. Swan and Wilson’ found that 12% of their sample of outpatient psychiatric referrals had sexual and marital problems, although that was not the reason for their initial referral. Hinchliffe et al.2*3found that the communicative style of depressed patients with their spouses was considerably different from that of nonpsychiatric control couples. Also Rounsaville et al.,4 in their follow-up study, found that depressed women showed improvement in depression and social adjustment when able to improve their marital relationships during the course of their treatment. Attempts have been made to identify specific problem areas in the relationships of married couples that predispose toward the marital stresses that might create discord.5 Although it cannot be assumed that there is a direct aetiological relationship between marital problems and mental disturbance, there is a need to study the state of marital relationships between couples, one of whom has a physical illness, compared to those where one has a chronic psychiatric condition. For example, a link between heart disease and sexual problems has long been attested.6 The question then arises, whether there are specific marital problems that are more likely to be linked with a mental rather than a physical illness. For example, sexual problems might be more acceptable and easier to understand as a consequence of physical illness (e.g. heart disease) than as related to psychological disturbance (e.g. depression). Consequently, it would be expected to create less disruption in the marital relationship of the physically ill couple than of the psychiatric couple. On the other hand, it could be argued that marital problems are less likely to create a serious disruption in the couple with one who is physically ill, because it can be dealt with more adequately and efficiently than will be the case with a spouse with a psychiatric illness. The aims of the present study were to investigate the following questions: 1. Do psychiatric and physically ill patients differ in the degree of marital dysfunction caused, and are there any identifiable areas of marital dissatisfaction specifically related to either depression or to heart disease or rheumatoid arthritis?
From the Department of Psychiatry Guy’s Hospital Medical School, London. Address reprint requests to N. Bouras, M.D., Department of Psychiatry, Guy’s Hospital Medical School, London, England SE1 9RT @ 1986 by Grune & Stmtton, Inc. Wl@44OX/86/2 702- WI4$03.00/0
Comprehensive Psychiatry, Vol. 27, No. 2, (March/April) 1966: pp 127-130
127
128
BOURAS. VANGER
AND BRIDGES
2. To what extent is the marital life of the nonpatient spouse affected by the illness of the patient and are there differences between the diagnostic groups? We specifically chose patients with heart diseases and rheumatoid arthritis, as being major chronic physical illness, just as depression is a major and chronic psychiatric illness. METHOD Twelve depressed patients (ten female and two male) attending an outpatient psychiatric department, were compared with 12 patients (ten female and two male) suffering from rheumatoid arthritis, and 12 cardiac patients (four female and eight male), all in association with their spouses. The patients completed the following instruments of their mental state: Taylor’s Manifest Anxiety,’ Beck’s Inventory for Depression,* Eyseneck’s Personality Test,9 Crown-Crisp Experimental Index,‘o and Hostility and Direction of Hostility Questionnaire.” In addition, all patients and their spouses completed a devised Marital Inventory. This form included 20 questions referring to the marital relationship, sexual relationship, and work and social activities. It was scored on 0 - 8 point rating scales. Some examples of the questions are: How frequently do you think of separating from your partner? Do you feel your partner is a good or bad husband/wife? Can you confide in your partner? Are you satisfied with the present frequency of sexual intercourse? How frequently do you see friends or engage in leisure activities?,
How enjoyable etc.
is sex?
RESULTS The mean age of the depressed patients was 47.0 years(SD f 4.9) and for their spouses 46.4 years (SD + 5.0). The mean age for the rheumatoid patients was 50.0 years (SD + 3.2) and for their spouses 53.3 (SD & 1.8). The mean age for the cardiac patients was 50.8 years (SD + 10.4) and for their spouses 46.5(SD f 14.3).There was no statistically significant difference for the mean ages, neither between patients for the different diagnostic groups, nor for their spouses. The mean duration of illness in years was 4.0 years for depressed patients, 4.2 for the cardiac patients, 5.3 for the rheumatoid patients. PSYCHOMETRIC
AND PERSONALITY
TESTS
Depressed patients, as would be expected, scored higher than the cardiac and the rheumatoid patients on Taylor’s Manifest Anxiety Scale and Beck’s inventory for depression, and the mean difference was statistically significant (p < 0.001). The same findings applied on the Crown and Crisp Experimental Index for the six subscales (p < O.OOl).Similar results were obtained by the personality questionnaires, with psychiatric patients scoring significantly higher on all subscales of Eysenck’s EPI and Hostility and Direction of hostility questionnarie. MARITAL Path
INVENTORY
ts
In order to investigate differences between the three diagnostic groups on the Marital Inventory, Kruskal-Wallis one-way analyses of variance were performed. The overall scores of patients on the Marital Inventory were found to be significantly
MARITAL
PROBLEMS
IN CHRONICALLY
DEPRESSED
129
different between the three groups (H = 18.1,@ = 2p
Kruskal-Wallis one-way analyses of variance were performed on the overall scores on the Marital Inventory of the spouses of the patients of the three diagnostic groups. Spouses of depressed patients showed the highest scores of dissatisfaction on the Marital Inventory, followed by the spouses of cardiac patients and the spouses of rheumatoid patients. The differences were statistically significant (H = 16.4, df = 2, p
The findings show consistently, that the spouses of patients within the three diagnostic groups have highly significantly different marital profiles. The partners with one having a psychiatric illness have the most marital and sexual problems, and they are the most dissatisfied about their work and social activities. Depressed patients and their spouses rank highest on marital dissatisfaction, followed by rheumatoid patients and their spouses, and lastly, followed by cardiac patients and their spouses. There are three major points of interest that emerge from these findings. Firstly, the particular order in which the three diagnostic groups of patients ranked with respect to marital satisfaction. Secondly, the similarity of trends in marital satisfaction between patients and their respective spouses in all three diagnostic groups. Thirdly, the similarity in trend of spouses satisfaction with patients’ satisfaction, particularly on the work and social activities section of the inventory. With respect to the first point, the present findings suggest that depressed patients and their spouses face more intense marital problems than rhematoid and cardiac couples. It seems that depression has a much greater impact on marital life than does chronic physical illnesses. It is noteworthy that the best adjusted group was
BOURAS, VANGER AND BRIDGES
130
relatively that of the cardiac couples. The severity and seriousness of cardiac illness may make the cardiac couples more considerate with each other and thus lead them to a more balanced relationship. With respect to the second point, the findings suggest that the patients’ marital functioning and associated dissatisfaction has an immediate effect on the spouses. Spouses of depressed patients experienced more dissatisfaction than the spouses of the physically ill patients, which is similar to the trend found for patient spouses. This has great implications for effects of illness of a particular individual on persons on his immediate environment and draws attention to the spouses’ needs for support. Further support for the spouses’ vulnerability during the illness of the patient spouse is the third point to which attention is drawn by the present findings. In addition to dissatisfaction with the marital and sexual relationship, well spouses reported dissatisfaction with their work and with their social activities as well. It seems then, that even activities not directly related to the patient spouse or to the relationship between the spouses, were also disturbed. This suggests that the effects of the spouses’ illnesses, especially when psychiatric, adversely influence the healthy spouses’ social adjustments with widespread ramifications. ACKNOWLEDGMENT We are grateful to Doctors R. Grahame, E. Sowton and P. Curry for their permission patients and their constructive their participation.
criticisms.
Our thanks
are also due to our patients
to study their and their spouses for
REFERENCES 1. Swan M, Wilson LJ: Sexual and marital problems in a psychiatric outpatient population. Br J Psychiatry 135, 310-314,1979 2. Hinchliffe KM, Vaughan PW, Hooper D, et al: The melancholy marriage: An inquiry into the interaction of depression II Expressiveness. Br J Med Psycho1 50:125- 142, 1977 3. Hinchliffe MK, Vaughan PW, Roberts FJ: The Melancholy Marriage: An inquiry into the interaction of depression III Responsiveness. Br J Med Psychol: 51, l- 13,1978 4. Rounsaville BJ, Prussoff BA, Weissman MM: The cause of marital disputes in depressed women: A 48-month follow-up study. Compr Psychiatry: 21, 11l- 118, 1980 5. Ilfield FW: Understanding marital stressors. J Nerv Ment Dis 168, 375-381, 1980 6. Mackey FG: Sexuality and Heart Disease, in Comfort A (ed): Sexual Consequences of Disability. Philadelphia, GF Stickley 1978 7. Taylor JA: Taylor manifest anxiety scale. J Abnorm Sot Psycho1 48: 285-292, 1953 8. Beck AT: Depression. Harper and Row, New York, 1969 9. Eysenck HJ, Eysenck SBG: Manual of the Eysenck Personality Inventory. London, University of London Press, 1964 10. Crown S and Crisp AH: Manual of the Crown-Crisp Experimental Index. London, Hodder and Stoughton, 1979 11. Caine TM, Foulds GA, Hope K: Manual of Hostility and Direction of Hostility Questionnaire. London, University of London Press, 1967
A
GROWING BODY of recent research has demonstrated a strong relationship between mental illnesses, and marital disharmony and dissatisfaction. Swan and Wilson’ found that 12% of their sample of outpatient psychiatric referrals had sexual and marital problems, although that was not the reason for their initial referral. Hinchliffe et al.2*3found that the communicative style of depressed patients with their spouses was considerably different from that of nonpsychiatric control couples. Also Rounsaville et al.,4 in their follow-up study, found that depressed women showed improvement in depression and social adjustment when able to improve their marital relationships during the course of their treatment. Attempts have been made to identify specific problem areas in the relationships of married couples that predispose toward the marital stresses that might create discord.5 Although it cannot be assumed that there is a direct aetiological relationship between marital problems and mental disturbance, there is a need to study the state of marital relationships between couples, one of whom has a physical illness, compared to those where one has a chronic psychiatric condition. For example, a link between heart disease and sexual problems has long been attested.6 The question then arises, whether there are specific marital problems that are more likely to be linked with a mental rather than a physical illness. For example, sexual problems might be more acceptable and easier to understand as a consequence of physical illness (e.g. heart disease) than as related to psychological disturbance (e.g. depression). Consequently, it would be expected to create less disruption in the marital relationship of the physically ill couple than of the psychiatric couple. On the other hand, it could be argued that marital problems are less likely to create a serious disruption in the couple with one who is physically ill, because it can be dealt with more adequately and efficiently than will be the case with a spouse with a psychiatric illness. The aims of the present study were to investigate the following questions: 1. Do psychiatric and physically ill patients differ in the degree of marital dysfunction caused, and are there any identifiable areas of marital dissatisfaction specifically related to either depression or to heart disease or rheumatoid arthritis?
From the Department of Psychiatry Guy’s Hospital Medical School, London. Address reprint requests to N. Bouras, M.D., Department of Psychiatry, Guy’s Hospital Medical School, London, England SE1 9RT @ 1986 by Grune & Stmtton, Inc. Wl@44OX/86/2 702- WI4$03.00/0
Comprehensive Psychiatry, Vol. 27, No. 2, (March/April) 1966: pp 127-130
127
128
BOURAS. VANGER
AND BRIDGES
2. To what extent is the marital life of the nonpatient spouse affected by the illness of the patient and are there differences between the diagnostic groups? We specifically chose patients with heart diseases and rheumatoid arthritis, as being major chronic physical illness, just as depression is a major and chronic psychiatric illness. METHOD Twelve depressed patients (ten female and two male) attending an outpatient psychiatric department, were compared with 12 patients (ten female and two male) suffering from rheumatoid arthritis, and 12 cardiac patients (four female and eight male), all in association with their spouses. The patients completed the following instruments of their mental state: Taylor’s Manifest Anxiety,’ Beck’s Inventory for Depression,* Eyseneck’s Personality Test,9 Crown-Crisp Experimental Index,‘o and Hostility and Direction of Hostility Questionnaire.” In addition, all patients and their spouses completed a devised Marital Inventory. This form included 20 questions referring to the marital relationship, sexual relationship, and work and social activities. It was scored on 0 - 8 point rating scales. Some examples of the questions are: How frequently do you think of separating from your partner? Do you feel your partner is a good or bad husband/wife? Can you confide in your partner? Are you satisfied with the present frequency of sexual intercourse? How frequently do you see friends or engage in leisure activities?,
How enjoyable etc.
is sex?
RESULTS The mean age of the depressed patients was 47.0 years(SD f 4.9) and for their spouses 46.4 years (SD + 5.0). The mean age for the rheumatoid patients was 50.0 years (SD + 3.2) and for their spouses 53.3 (SD & 1.8). The mean age for the cardiac patients was 50.8 years (SD + 10.4) and for their spouses 46.5(SD f 14.3).There was no statistically significant difference for the mean ages, neither between patients for the different diagnostic groups, nor for their spouses. The mean duration of illness in years was 4.0 years for depressed patients, 4.2 for the cardiac patients, 5.3 for the rheumatoid patients. PSYCHOMETRIC
AND PERSONALITY
TESTS
Depressed patients, as would be expected, scored higher than the cardiac and the rheumatoid patients on Taylor’s Manifest Anxiety Scale and Beck’s inventory for depression, and the mean difference was statistically significant (p < 0.001). The same findings applied on the Crown and Crisp Experimental Index for the six subscales (p < O.OOl).Similar results were obtained by the personality questionnaires, with psychiatric patients scoring significantly higher on all subscales of Eysenck’s EPI and Hostility and Direction of hostility questionnarie. MARITAL Path
INVENTORY
ts
In order to investigate differences between the three diagnostic groups on the Marital Inventory, Kruskal-Wallis one-way analyses of variance were performed. The overall scores of patients on the Marital Inventory were found to be significantly
MARITAL
PROBLEMS
IN CHRONICALLY
DEPRESSED
129
different between the three groups (H = 18.1,@ = 2p
Kruskal-Wallis one-way analyses of variance were performed on the overall scores on the Marital Inventory of the spouses of the patients of the three diagnostic groups. Spouses of depressed patients showed the highest scores of dissatisfaction on the Marital Inventory, followed by the spouses of cardiac patients and the spouses of rheumatoid patients. The differences were statistically significant (H = 16.4, df = 2, p
The findings show consistently, that the spouses of patients within the three diagnostic groups have highly significantly different marital profiles. The partners with one having a psychiatric illness have the most marital and sexual problems, and they are the most dissatisfied about their work and social activities. Depressed patients and their spouses rank highest on marital dissatisfaction, followed by rheumatoid patients and their spouses, and lastly, followed by cardiac patients and their spouses. There are three major points of interest that emerge from these findings. Firstly, the particular order in which the three diagnostic groups of patients ranked with respect to marital satisfaction. Secondly, the similarity of trends in marital satisfaction between patients and their respective spouses in all three diagnostic groups. Thirdly, the similarity in trend of spouses satisfaction with patients’ satisfaction, particularly on the work and social activities section of the inventory. With respect to the first point, the present findings suggest that depressed patients and their spouses face more intense marital problems than rhematoid and cardiac couples. It seems that depression has a much greater impact on marital life than does chronic physical illnesses. It is noteworthy that the best adjusted group was
BOURAS, VANGER AND BRIDGES
130
relatively that of the cardiac couples. The severity and seriousness of cardiac illness may make the cardiac couples more considerate with each other and thus lead them to a more balanced relationship. With respect to the second point, the findings suggest that the patients’ marital functioning and associated dissatisfaction has an immediate effect on the spouses. Spouses of depressed patients experienced more dissatisfaction than the spouses of the physically ill patients, which is similar to the trend found for patient spouses. This has great implications for effects of illness of a particular individual on persons on his immediate environment and draws attention to the spouses’ needs for support. Further support for the spouses’ vulnerability during the illness of the patient spouse is the third point to which attention is drawn by the present findings. In addition to dissatisfaction with the marital and sexual relationship, well spouses reported dissatisfaction with their work and with their social activities as well. It seems then, that even activities not directly related to the patient spouse or to the relationship between the spouses, were also disturbed. This suggests that the effects of the spouses’ illnesses, especially when psychiatric, adversely influence the healthy spouses’ social adjustments with widespread ramifications. ACKNOWLEDGMENT We are grateful to Doctors R. Grahame, E. Sowton and P. Curry for their permission patients and their constructive their participation.
criticisms.
Our thanks
are also due to our patients
to study their and their spouses for
REFERENCES 1. Swan M, Wilson LJ: Sexual and marital problems in a psychiatric outpatient population. Br J Psychiatry 135, 310-314,1979 2. Hinchliffe KM, Vaughan PW, Hooper D, et al: The melancholy marriage: An inquiry into the interaction of depression II Expressiveness. Br J Med Psycho1 50:125- 142, 1977 3. Hinchliffe MK, Vaughan PW, Roberts FJ: The Melancholy Marriage: An inquiry into the interaction of depression III Responsiveness. Br J Med Psychol: 51, l- 13,1978 4. Rounsaville BJ, Prussoff BA, Weissman MM: The cause of marital disputes in depressed women: A 48-month follow-up study. Compr Psychiatry: 21, 11l- 118, 1980 5. Ilfield FW: Understanding marital stressors. J Nerv Ment Dis 168, 375-381, 1980 6. Mackey FG: Sexuality and Heart Disease, in Comfort A (ed): Sexual Consequences of Disability. Philadelphia, GF Stickley 1978 7. Taylor JA: Taylor manifest anxiety scale. J Abnorm Sot Psycho1 48: 285-292, 1953 8. Beck AT: Depression. Harper and Row, New York, 1969 9. Eysenck HJ, Eysenck SBG: Manual of the Eysenck Personality Inventory. London, University of London Press, 1964 10. Crown S and Crisp AH: Manual of the Crown-Crisp Experimental Index. London, Hodder and Stoughton, 1979 11. Caine TM, Foulds GA, Hope K: Manual of Hostility and Direction of Hostility Questionnaire. London, University of London Press, 1967