Effect of Marriage on Pre-existing Psychoses: A Convenient or Futile Solution for Severe Mental Disorders?

Abstract

Marriage can be defined as the state of being united as spouses in a consensual and contractual relationship recognized by law. The general population generally believes marriage to be a solution to mental illnesses. It can be agreed that mental disorders and marital issues have some relation.

Parents of patients with psychoses expect that marriage is the solution to the illness and often approach doctors and seek validation about the success of the marriage of their mentally ill child, which is a guarantee no doctor can give in even normal circumstances. Evidence on sexual functioning in patients of psychosis is limited and needs further understanding.

Studies show about 60%–70% women of the schizophrenia spectrum and illness to experience sexual difficulties. Based on available information, sexual dysfunction in population with psychosis can be attributed to a variety of psychosocial factors, ranging from the psychotic symptoms in itself to social stigma and institutionalization and also due to the antipsychotic treatment. Despite the decline in sexual activity and quality of life in general, it is very rarely addressed by both the treating doctor and by the patient themselves hence creating a lacuna in the patient’s care and availability of information regarding the illness’ pathophysiology. Patients become noncompliant with medications due to this undesirable effect and hence it requires to be given more attention during treatment.

It was also found that paranoid type of schizophrenia patient had lower chances of separation than patients with other types of schizophrenia. The risk of relapse in cases with later age of onset of the disease, lower education, a positive family history of psychosis or a lower income increased more than other populations.

Introduction

Marriage can be controversially defined as the state of being united as spouses in a consensual and contractual relationship recognized by law. ¹ Although people get married for various reasons, it is considered an essential milestone in a person’s life and is expected to bring joy and happiness. Marriage ceremonies are often extravagant, and anniversaries are annually celebrated. Individuals plan their lives around marriage and family.

The general population generally believes marriage to be a solution to mental illnesses. While it can be agreed that mental disorders and marital issues have some relation, which occurs first is still a matter of debate. The complicated issues between mental illness and marriage are more evident in cases of psychoses. ² Most patient of psychoses develop signs and symptoms of the illness during late adolescence or early adulthood, which is also the most common age when parents determine is the appropriate age to get their child married. ² Patients, parents, and treating psychiatrists are constantly wondering whether marriage is advisable, and once married, will it lead to the improvement or worsening of the symptoms.

Of all stressful life events, death of spouse and divorce are the most stressful circumstances. With an addition of psychiatric illness, it plays role in worsening or relapse of illness. On the other side, sometimes it is a protective factor for overall well-being of the family and against mental illness. ³

Common Beliefs in India

Marriage among the Indian population is a social affair and involves the families on both sides leading to formation of a permanent bond not just between the newlyweds but rather between both the families. Hence while looking for eligible suitors for their children, many factors hold as much of an importance if not higher as the preference of the future bride and groom. After making sure that the prospective family not only belongs to the same religion but also the same caste, usually it is required that they also do not live too far away. ³ Then the bride and groom’s social compatibility is predicted astrologically and the expected dowry amount is decided and only when the preset criteria are sufficiently fulfilled then the marriage is finally approved.

Marriage and Psychoses

Parents of patients with psychoses expect that marriage is the solution to the illness and often approach doctors and seek validation about the success of the marriage of their mentally ill child, which is a guarantee no doctor can give in even normal circumstances. Therefore, it was decided to start researches to find some direction. The pilot study started in 1989 and over a span of one year, we regularly followed up male patients with psychoses who were undergoing psychiatric treatment from psychiatric clinic of Banaras Hindu University, Varanasi and sometime during the treatment got married and final report was submitted to Indian Council of Medical Research in 1990.

Females were excluded from the pilot study due to multiple confounding biases such as the presence of postmarriage stress like leaving behind a familiar environment and having to immediately adjust with her new surroundings and new family members, each with their own personalities. Although the female and her family are not obligated by law to disclose her psychiatric illness, the secret itself could be a major precipitating or exacerbating factor.

The marriage situation in India can be perceived as mentally ill males suffer less than females and as the men and his family get the dowry and can go for divorce. Indira Sharma described the “triple tragedy” as being of the female gender, suffering from psychosis, and being separated or divorced. ⁴ Despite the presence of psychopathology, all women are required to get married, which is conveniently achieved with the common practice of arranged marriage and dowry practice in India. ⁴ Advantage of arranged marriages is that the presence of mental illness can be hidden mainly to prevent rejection from the prospective groom and his family but also to prevent other possible alliances to be disinterested. ⁵ Women get very little support from their own family and hence are socially, financially, and personally dependent on their husbands. ³ Ultimately, women with mental illness are greater victims to social stigma and are less likely to get mental care and more likely to be divorced by the husband and abandoned by their family as the burden of caring for the woman is left to her family. ⁶

Sexual Dysfunction and Psychoses

Evidence on sexual functioning in patients of psychosis is limited and needs further understanding. Studies show about 60%–70% women of the schizophrenia spectrum and illness to experience sexual difficulties.^7,8 Based on available information, sexual dysfunction in population with psychosis can be attributed to a variety of psychosocial factors, ranging from the psychotic symptoms in itself to social stigma and institutionalization and also due to the antipsychotic treatment. ⁹ The psychotic illness presents with positive symptoms like hallucinations and delusions or negative symptoms like cognitive decline with poor judgment and decreased motivation, which may directly or indirectly prevent the female from forming intimate relations or from achieving sexual satisfaction.^8,9 Society and institutions tend to seclude psychotic patients from the general masses leading to difficulty in finding partners. ¹⁰ Majority of studies have focused on the effects of antipsychotic medications on sexual functioning and shown a positive correlation between the use of antipsychotics and sexual dysfunction although confounding factors of the illness’ symptomology remain unaccounted for. ¹⁰ The influence of medications on the monoamine neurotransmitters that causes adverse somatic and sexual side-effects on the various stages of the sexual process has been studied. Results reveal Risperidone followed by typical antipsychotics, specifically Haloperidol to most frequently induces sexual dysfunction while Aripirazole causes the least dysfunctions, ¹¹ while other studies claim no significant differences in the incidence of sexual dysfunction and the antipsychotic used. ¹² Despite the decline in sexual activity and quality of life in general, it is very rarely addressed by both the treating doctor and by the patient themselves hence creating a lacuna in the patient’s care and availability of information regarding the illness’ pathophysiology. Patients become noncompliant with medications due to this undesirable effect and hence it requires to be given more attention during treatment. ¹⁰

Evidence Based Findings

Our pilot study concluded that presence of family history or previous positive history of psychotic episodes led to 33% of the sample population to be vulnerable for psychosis. The study observed that the occurrence of psychotic symptoms did not depend on the number of marriages. While one case developed symptoms during his first marriage, four cases developed them during their second marriage. ² It was further observed that while one case became symptomatic during his first marriage but maintained symptom free during his second marriage, four other cases became psychotic only after their second marriage and not their first. This led to a conclusion that other than marriage, multiple unexplored factors are involved in the surfacing of psychosis and detailed studies are needed to determine them. It means relationship of psychoses and marriage is very complex.

Following the success of the pilot study, several specific retrospective studies were conducted.

A case control study exclusively including patients of schizophrenia concluded that while the marriage itself did not influence the severity of the illness or the quality of life of the patient, males overall were predisposed to experiencing relapse of symptoms than females and the married population was more prone to be symptomatic ultimately leading to separation from their spouses within two years of the marriage. ¹³ It was also found that paranoid type of schizophrenia patient had lower chances of separation than patients with other types of schizophrenia. The risk of relapse in cases with later age of onset of the disease, lower education, a positive family history of psychosis or a lower income increased more than other populations. ¹³

The study that specifically involved cases of bipolar affective disorder also concluded similar reports as in with schizophrenia, which is that married males were affected more commonly than married females and so that it did not affect the severity of symptoms. ¹³ It also correlated marriage with a longer duration of illness and increased number of episodes as compared to unmarried population.

Another study conducted was to assess the effect of marriage on clinical outcome of persons with bipolar affective disorder, which revealed that although the mean scores of the Brief Psychiatric Rating Scale were almost equal, compared to patients of bipolar affective disorder who were never married, cases who were married had longer duration of the illness. ¹⁴

Finally, a study was dedicated exclusively to observe the effect of marriage on female persons with schizophrenia. It was found that majority of the patients and relatives were of the opinion that marriage can cure mental illness. Overall the severity of mental illness was slightly higher in cases than comparison group and that difficulty in marital adjustment was directly proportional to the severity of the illness. ¹⁵ On the positive side, child birth proved to be a protective factor for decreasing separation from husband and in laws. Overall 60% of the cases claimed that they were advised to get married by parents, and only a total of 40% of the cases had informed their spouses of their illness.^13,15

Conclusion

Based on the multiple studies conducted covering varying aspects of mental illness and marriage, it can be concluded that the belief of marriage being the solution for all is still controversial as our studies found that marriage can lead to increased difficulty in adjusting with the spouse and in laws. In addition, marriage also leads to longer episodes of illness and increased chances of relapse for asymptomatic individuals. ¹⁶ A 10-year study by Thara et al revealed that those who separated from their spouses or remained single often had relapses along with poor outcome in the socio-occupational aspects. ¹⁷ Due to difficulties such as coping with disturbed behavior especially during psychotic episodes, withdrawn behavior and emotional blunting, people with psychoses are overall less likely to get married. ¹⁸ Divorce-seeking couples have a high psychiatric morbidity in comparison to well-adjusted couples with more neurotic traits. ¹⁸ Keeping this belief in mind, different religious acts in India have passed laws to be followed. While the Parsi Marriage Law of 1936 and Muslim Marriage Act 1939 still allow the dissolution of marriage based on mental illnesses, the Hindu Marriage Act of 1955 was modified under Section 13 (1) (iii), which denies temporary and curable mental illnesses to be basis for divorce. ¹⁹

In January of 2013, the Indian Psychiatric Society published recommendations for psychiatrists to follow while managing issues related to marriages in patients with major illnesses in which they provided advice to help patient and families make informed decisions. This aspect of mental illnesses needs more time and greater study samples to further prove or disprove the correlation of marriage to mental illness.