The International Journal of Psychosocial Rehabilitation

Quality of Life (Qol) and Marital Adjustment in Epilepsy
 and Comparisons with Psychiatric Illnesses

Pandey Vibha, MA, M.Phil
Research Consultant
Emergency Management and Research Institute,
Hyderabad, India.

Sahoo Saddichha, BA, MBBS, DPM (MD)
Resident in Psychiatry
National Institute of Mental Health & Neurosciences (NIMHANS),
Bangalore, India
Email: 

Sayeed Akhtar, MD, DNB
Chief Medical Officer
Central Institute of Psychiatry,
Ranchi, India.



Citation:
Vibha P, Saddichha S & Akhtar S (2010). Quality Of Life (QOL) and Marital Adjustment in Epilepsy and
Comparisons with Psychiatric Illnesses. 
International Journal of Psychosocial Rehabilitation. Vol 14(2) 105-112  


Abstract

Background: The occurrence of psychosocial problems in epilepsy is common and has severe impact on quality of life. However, the influence of marital adjustment on quality of life in epilepsy and similarities or differences with psychiatric illnesses, with which epilepsy shares several common characteristics, is unknown. The aim of the present study was to therefore explore the relationships between epilepsy, quality of life and marital adjustment and to study differences, if any, with psychiatric illnesses.
Methods: Using a cross-sectional design, sixty consecutively seen patients with an ICD 10 DCR diagnosis of either schizophrenia or bipolar disorder and thirty consecutively seen patients diagnosed with epilepsy according to the International Classification of Epilepsy were taken up for the study and administered WHO-QOL BREF and the Marital Adjustment Inventory. The data generated was analyzed to study associations between the dependent variables of quality of life and marital adjustment and differences, if any, between the two diagnosis groups.
Results: There was significant difference in income (p<0.001), education (p=0.02), duration of illness (p=0.003) and marital status between the two groups (p=0.05). Patients with epilepsy had better social relationships (p< 0.05) and marital adjustment (p <0.001) as compared to patients with psychiatric illnesses. There was no correlation between quality of life and marital adjustment among both patients and spouses.
Conclusions: Couple interventional programs, aimed at improving marital adjustment among spouses may help in improvement of quality of life of patients suffering from epilepsy.

Key Words: Quality of life, Marital adjustment, Epilepsy, Psychiatric Illness



Introduction

Enhancing quality of life has become a major therapeutic goal of modern medicine. Literature suggests that chronic illnesses, in addition to having long treatment regimens, are also burdened by the stigma, family burden, loss of skills, poor quality of life, poor interpersonal relations and poor marital and/or sexual relations [1] associated with them. Epilepsy is one such chronic condition affecting approximately 50 million people worldwide [2] with numerous social and psychological consequences for the afflicted. Epilepsy is an illness that has a great impact on the lives of patients and their caregivers characterized in terms of social isolation, prejudice, and unemployment, or in terms of emotional influences like relationship difficulties and low self-esteem leading to social stigma [3, 4].

People with epilepsy have been observed to be more affected by the loss in quality of life (QOL) than the seizures themselves [3, 5]. Childhood onset of seizures, neurological co-morbidities, psychiatric co-morbidities, disease duration and antiepileptic drug side effects have been reported as important determinants of poor quality of life in such patients [2, 3, 6-9]. Among children, epilepsy can also limit opportunities of education and their day to day functioning [6, 7], by intermittent emotional distress heightened by epilepsy related factors such as unpredictability of seizures, profound social isolation and cognitive/academic dysfunctions due to discontinuous fragmented learning. Guevara and colleagues [11] reported that variables like female gender, poor seizure control, >6 seizures per month, depression, unemployment, sleep disorders, and antiepileptic drugs were significantly associated with lower global scores in QOLIE-31. Further, anxiety and socially avoidant behavior have also been associated with the presence of intractable epilepsy [12].

A case similar to that of epilepsy is that of chronic psychiatric illnesses such as schizophrenia or bipolar disorder. People with schizophrenia or mood disorders have been reported to suffer from distress, disability, reduced productivity and lowered quality of life [13-17]. Some determinants of poor quality of life in schizophrenia reported were age of onset of psychosis, premorbid adjustment, duration of untreated psychosis [15], and the presence of positive psychotic symptoms [18]. An Indian study also revealed that the caregivers of both long term physical illness like intractable epilepsy and psychiatric illnesses like schizophrenia experience high levels of burden in the domains of patient care, finance, physical and emotional burden, family relations and occupation [1].

Marital adjustment, defined as the “state in which there is an overall feeling in husband and wife of happiness and satisfaction with their marriage and with each other” [19] has been reported to be affected both in epilepsy [20, 21] and in psychiatric illnesses [14, 22]. It has been observed that patients with epilepsy tend to have low self esteem which can result in failure to establish good sexual relationships and a lower likelihood of marriage, especially in men. In fact, lack of marital satisfaction may also directly influence the outcome of illness [23], due to deficiencies of marital intimacy. Similarly, in schizophrenia, the duration of illness, type of onset, auditory hallucinations, simple depression at intake, unemployment and economic slide during the course of illness and a relapsing course of illness have been all reported to be related to marital outcome [14].

Therefore, although treatment, both in terms of medical and psycho-social therapies, are intended to reduce the distress and disability that patients suffer, they fail to influence these vital measures, which stays poor inspite of all remedies. Yet, little is known on marital adjustment and quality of life in persons with epilepsy. The present study aims to shed light on this unexplored area by studying quality of life and marital adjustment in epilepsy and the inter-relations between them. It also attempts to compare epilepsy with chronic psychiatric illnesses, such as schizophrenia and bipolar disorder, in the domains of quality of life and marital adjustment.

Methods
Subjects
The target population of this study included consecutive patients seen in the outpatient department of Central Institute of Psychiatry, Ranchi, India with an ICD-10 DCR diagnosis of schizophrenia or bipolar disorder, collectively grouped together as  “patients diagnosed with psychiatric illness” and Epilepsy according to the International Classification of Epilepsy [24] made by a Senior Resident or/and Consultant, between the age range of 18 to 45 years, married, with two or more than two years duration of illness, being in remission phase (taken as BPRS [25] score of less than 16 for psychiatric patients) and with no psychiatric or medical co-morbidity.

After institutional review board (IRB) approval, a purposive random sampling technique was employed for recruitment and individual patients were invited to participate after explaining the study and taking written informed consent. All ratings were done by mental health professionals trained in psychiatric social work and raters were kept blind to the diagnosis to prevent bias. The induction of patients continued till a total sample size of 90 was obtained, 30 with epilepsy and 60 with psychiatric illness, which was further subdivided into male and female to prevent representation bias. Further, spouses of these patients were also invited to take part in the study to assess their perception of marital adjustment after written informed consent. However, only patients formed the “Subject group” and the “Spouses group” were analysed with regard to marital adjustment only.

The Dependant Variable
“Quality of Life” was tapped using the WHO Quality of Life-BREF scale developed by Saxena and colleagues [26]. It is a self administered generic questionnaire developed in Hindi and is a 26 items shorter version of the WHOQOL-100 Scale. It covers the domains of physical health, Psychological functioning, Social relationship, and environmental situation. Marital Adjustment was assessed using Marital Adjustment Inventory [27]. It measures marital adjustment in domains of mutual care, mutual understanding, mutual trust, and adequate independence. It has separate questionnaires for Husband and Wife.

The Independent variables
Demographic variables included sex, age, education, religion (Hindu, Muslim, Christian, and other), residence (urban, semi-urban and rural), income, marital status (living together, separated, or divorced), years of marriage, years of separation/divorce, type of family (nuclear versus joint), duration of illness, frequency of seizures (in case of epilepsy) and diagnosis.

Data Analysis
Statistical analysis was performed using Chi- square test for categorical variables and t-test for continuous variables. Co-relations analyses were performed for studying significant variable relations using two-tailed tests. All significance was reported at p < 0.05.

Results
Socio-Demographic Characteristics of Epilepsy patients
The total sample size was 30 (table 1), with mean illness duration of 10.53 (+5.73) years. Majority (70%) of the patients were seizure free and were equally divided between males and females with a mean age of 33.96 (+ 6.77) years. They had an average of 9.7 (+ 3.36) years of education and had been married for a mean of 13.56 (+ 5.46) years. Almost all of them were living with their spouses (100%), majority of them had arranged marriage (96.7%) and earning an average of 4460.00 (+ 6687.59) rupees per month.

Socio-Demographic Characteristics of Psychiatric patients
The total sample size was 60 (table 1), with a mean age of 34.48(+ 6.81) years, and equally divided between males and females. They had a mean illness duration of 6.86 (+5.08) years and an average of 8.03(+ 3.07) years of education, being married for a mean of 14.11 (+ 6.72) years. Majority of them were living with their spouse (88.3%), their marriage arranged by the family (96.7%) and earning an average of 900.00 + 1630.74 rupees per month. Since women constituted half the sample, the respondents were mostly housewives (46.7%), and about one-fourth employed (25.0%) with a mean family income of Rs. 7366.66(+ 8043.77). Majority of them were from urban areas (58.3%) and living in a joint family setup (65%).
Comparison of socio-demographic characteristics between the groups
When the two groups were compared on socio-demographic variables (table 1), significant differences were noted in income with patients with epilepsy (p<0.001) having higher incomes, in spite of having a longer duration of illness (p=0.003) as compared to patients with psychiatric illnesses. Further, patients with epilepsy were more educated (p=0.02) and all (100%) were noted to be living together compared to just 88% of those with psychiatric illness (p=0.05).

Comparison of Quality of Life between both the groups

When the two groups were compared in terms of quality of life (table 2), no significant difference was noted between the groups, but when different domains of quality of life were compared, a majority of patients with epilepsy (60.0%) were noted to have better social relationships as compared the majority with psychiatric illness (61.7%) having poor social relations (p < 0.05).

Comparison of Marital Adjustment among patients of both the groups
In the domain of marital adjustment among patients (table 2), significant differences were noted with the majority (60%) of patients diagnosed with epilepsy showing good adjustment with their spouses as compared to the majority with psychiatric illness (73.3%) having poor adjustment (p < 0.001).

Comparison of Marital Adjustment among spouses of both the groups
Similarly, in the domain of marital adjustment among spouses of the patients (table 2), majority (73.3%) of spouses of patients with epilepsy showed a good adjustment with their counterpart as compared to a poor adjustment (47.4%) seen among spouses of patients with psychiatric illness (p<0.001).

Correlation between Quality of Life and Marital Adjustment among patients and spouses No significant co-relations (table 2) were observed between quality of life and marital adjustment among patients and spouses, although a negative non-significant trend was observed among spouses.

Discussion
The study of quality of life in various medical and psychiatric conditions is not an innovative quest; however, this study from India marks probably one of the first studies to directly compare psychiatric illness with epilepsy and to observe the influences of marital adjustment with quality of life in these two groups. With both groups of illnesses following a chronic course and being associated with similar co-morbidities, we believe that these groups are comparable when it comes to assessing quality of life and marital adjustment, both of which can have a significant impact on psychosocial functioning. Further, since we attempted to have equal representation of gender in both groups, we believe that our findings are significant enough and may be generalized for formulation of better treatment strategies that involve the aspect of marital adjustment.

When socio-demographic variables were compared, patients with epilepsy were observed to have higher income and lower unemployment rates than the psychiatric group. Since people with mental illnesses are among the most socially and economically marginalized members of the community, experience high levels of unemployment and may experience disrupted vocational training and normal career development [28], such differences may translate into poorer incomes and socio-economic status. With higher levels of education noted among our epilepsy patients in spite of a longer duration of illness, we believe that the severity and chronicity of mental illnesses can truncate primary, secondary, or tertiary education [28]. However, since other studies have observed otherwise [3, 29], we believe that perhaps cross-cultural differences or the unequal distribution of samples in our study may account for these findings.

We also observed good marital status among all patients with epilepsy. This is in contrast to Agarwal et al [30] who reported poor marital status and high divorce rates among epilepsy patients, in contrast to high rates of marriage (up to 70%) being seen in this population [31, 32]. Since remission of seizures are associated with improvement in marital status [21, 33], such variance in findings may possibly be due to the fact that most of our patients (70%) were seizure free.

Comparison of the overall quality of life revealed no significant difference between the two groups demonstrating that perhaps both illnesses are associated with similar quality of life i.e., majority of the people with psychiatric or epileptic illness have poor quality of life (61.7% and 63.3% respectively). In other words, both types of illnesses have similar impact on quality of life in the domains of psychological, physical and environmental QOL. Poor quality of life among psychiatric patients and epilepsy has already been reported in previous studies [34-37]. However, patients with epilepsy in our study were observed to have better quality of life in terms of social relationships as compared to psychiatric patients, possibly due to the higher employment rates [11] and better marital support [38] contributing to better perceptions of social support.

Marital adjustment between the two groups revealed a significant difference showing that patients with epilepsy and their spouses tend to have better perception of marital adjustment than psychiatric patients and their spouses. We hypothesize that mental illness as a whole hampers the ability of the patient to play the marital role (of husband or wife respectively) leading to poor marital adjustment [39, 40]. Since the marital role comprises cultural expectations associated with the husband or wife, inability to fulfill those expectations could lead to marital dissatisfaction [41]. It can however be argued that such expectations would necessarily be hampered even in spouses, and our study has shown similar findings.

When marital adjustment was correlated with quality of life, no significance was noted, demonstrating that the perception of better marital adjustment among patients does not translate to better quality of life. However, spouses continue to perceive a poor quality of life irrespective of marital adjustment. We hypothesize that spouses may be dissatisfied with the inhibited marital role that patients’ exhibit due to the illness, which reflects in a poorer quality of life. This needs to be confirmed by other studies, yet we believe that addressing the specific concerns of marital adjustment may play a vital role in the outcome of the illness. In such cases, marital therapy, aimed at improving relations between couples, could help the perceptions of marital adjustment thereby improving the overall quality of life.

Although our study was among the first to directly study associations of marital adjustment and quality of life and to compare these variables in two different diagnoses by using standardized and valid scientific tools, we believe that there are certain limitations to our study. The groups were not divided equally in terms of diagnosis and study was from a single-centre.  Future studies would need to be multi-centric, involving larger sample sizes, making even cross-cultural comparisons possible.

Conclusion:
Patients with epilepsy have poor quality of life, a finding similar to those suffering from psychiatric illnesses. Although marital adjustment continues to be good for both patients and spouses with epilepsy, it also influences the overall perception of quality of life, perhaps reflecting that inclusion of marital therapy, aimed at couples, may help in overall improvement of quality of life of patients with epilepsy.

 


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