IMPACT OF SCHIZOPHRENIA AND BIPOLAR AFFECTIVE DISORDER ON MARITAL SATISFACTION – A COMPARATIVE STUDY

Objectives: To compare marital satisfaction among patients with Schizophrenia and bipolar affective disorder. Methods: A cross-sectional study was conducted for 1 month. The sample was chosen by using purposive random sampling, 60 married patients with Schizophrenia and Bipolar Affective Disorder who fulfilled the ICD 10 criteria for Schizophrenia and Bipolar Affective Disorder, respectively, under remission with Clinical Global Impression-Severity Scale (CGI-S) score ≤2, and were assessed for Marital Satisfaction with The Couples Satisfaction Index (CSI) and its relationship with forgiveness is studied with the Marital Offence-Specific Forgiveness Scale (MOFS). Results: Compared to patients with Bipolar Affective Disorder, patients with Schizophrenia reported poor marital satisfaction. Conclusion: It is the first study in India to compare marital satisfaction in patients with Schizophrenia and Bipolar Affective Disorder. The present study suggests that marital satisfaction is more impaired in Schizophrenia patients compared to bipolar affective disorder patients.


INTRODUCTION
Marriage is a fundamental institution in almost all societies of the world, especially in India, and it provides the basic structure for establishing a family [1,2].Marital satisfaction is an individual's subjective evaluation of individual components within their marital relationship [3][4][5].Marital satisfaction, like in any other form of association, is influenced by various factors such as culturally determined norms, customs, and expectations [4], and it is said to have an impact on the psychological well-being of individuals in marriage [6,7].Individuals with Schizophrenia and bipolar affective disorder often experience a lower quality of life and worse functioning than the general population [1], even during clinical remission, which hinders their full participation in marriage, contrary to marriage having a positive relationship with the prognosis of Schizophrenia [4].Studies from the West suggest that marital rates are lower among patients with schizophrenia [6].
In contrast, data from the East, especially India, showed that about 70% of patients with Schizophrenia eventually get married [8].The prevalent belief in India is that marriage is a cure for different mental disorders, including psychoses [9].Forgiveness directly impacts marital satisfaction and longevity in any relationship [10].Hence, it is crucial to understand marital satisfaction and forgiveness in psychiatric illnesses.As there is a shortage of literature on marital relationships among individuals with mental illnesses in the Indian Context, the present study was undertaken to study the impact of Schizophrenia and bipolar affective disorder on marital satisfaction.The present study aims to compare marital satisfaction among patients with Schizophrenia and Bipolar Affective Disorder.The study's objectives were to know the influence of sociodemographic and psychosocial variables on marital satisfaction in both groups, assess the role of marital offense forgiveness in marital satisfaction, and compare the results.

Study Design
A cross-sectional study.

Sampling method
Purposive Random Sampling method.

Ethics clearance
The study was undertaken after obtaining approval from the Institutional Ethics Committee.

Sampling frame
Patients attending the outpatient department of GHMC, Visakhapatnam, during the stipulated period of study.
Study sample 60 patients with Schizophrenia and 60 patients with bipolar affective disorder visiting outpatient services of the Government Hospital for Mental Care, Visakhapatnam.

Inclusion criteria
• Subjects between 18 and 60 years of age.
• Subjects who are married.
• Subjects who have given valid informed written consent.
• Subjects fulfilling the criteria for Schizophrenia and bipolar affective disorder according to ICD-10 and are now in remission period with CGI-S score ≤ 2.

Exclusion criteria
• Subjects between less than 18 or more than 60 years of age.
• Subjects who did not give written consent.
• Subjects who are unmarried or single.
• Cases not fulfilling the criteria for Schizophrenia and bipolar affective disorder according to ICD-10 or having active disease currently.

Clinical assessments
Study tools of assessment included.
Semi-structured pro forma was used to record sociodemographic profiles, marriage data, and illness-related factors.

Clinical global impression-severity scale (CGI-S)
The CGI was developed for use in NIMH-sponsored clinical trials to assess the clinician's view of the patient's global functioning.It is rated on a 7-point scale.The severity of the illness scale ranges from responses of 1 (normal) through to 7 (among the most severely ill patients) [11,12].
The Marital Offence-Specific Forgiveness Scale (MOFS) was developed by Paleargid et al. and Fincham in 2002.It is a 12-item scale, each rated on a 6-point.Cronbach's alpha for both positive and negative dimensions is (0.78-0.81).

Statistical analysis
For all statistical analyses, a Statistical Package for the Social Sciences, IBM SPSS 25.0 version, was used.Univariate analysis-Means and Percentages for sociodemographic variables, scores of the Couples Satisfaction Index (CSI) and Marital Offence-Specific Forgiveness Scale (MOFS) benevolence and resentment items of patients separately in each group; Chi-square test is used for categorical data; for assessing the relationship between variables and scales, Pearson's Correlation is used.

RESULTS
Table 1 shows the sociodemographic and clinical characteristics of the study population.The Marital Offence-Specific Forgiveness Scale -benevolence item score and their frequencies in Schizophrenia and bipolar affective disorder using descriptive analytics (Table 3).The Marital Offence-Specific Forgiveness Scale -Avoidance/Resentment item score and their frequencies in Schizophrenia and bipolar affective disorder using descriptive analytics is depicted in Table 4.

DISCUSSION
Marriage is defined as a legally and socially recognized union, ideally lifelong, that includes sexual, economic, and social rights and obligations for the partners, and it is the most important and fundamental relationship because it supplies the basic structure for establishing a family and raising the next generation [16].In any marriage, marital satisfaction helps people maintain happiness in the relationship, develop intimate relationships, and, particularly, how love develops over time [16].Mental illness and marital satisfaction are intricately linked though there is controversy about their sequence.The personal, familial, and social factors could often be at a disadvantage in mentally ill individuals compared to normal individuals resulting in difficulties in getting married and sustaining marriage [17].Many studies have reported a higher marital discord, separation, and divorce rate among patients with mental illnesses [18][19][20][21][22]. Hence, the current study aimed to compare marital satisfaction among patients with Schizophrenia and bipolar affective disorder who are in remission and compared the results of both outcomes.In agreement with the findings of Shivali Aggarwal and Grover (2018) [23] in their study, which is somewhat similar to our research, the Sociodemographic profile of patients with Schizophrenia in the current study did not differ much from those with Bipolar Affective Disorder.This implied that the difference in marital satisfaction and the forgiveness toward spouses observed between both groups could not be attributed to demographic variables.Duration of marriage did not correlate statistically with either of the scales, which was in line with the findings of an earlier study by Shivali Aggarwal and Grover (2018) [23].
Regarding the impact of the onset of illness on marital satisfaction, this study showed a statistically significant correlation between The Couples Satisfaction Index (CSI) score, Marital Offence-Specific

Sri et al.
Forgiveness Scale-Benevolence Item Score (MOFS-B) implying better marital satisfaction with the onset of illness after marriage compared to the start of illness before marriage; regardless of the prevalence of illness-onset in both illnesses and vice-verse on Marital Offence-Specific Forgiveness Scale-Avoidance Item Score(MOFS-A).Keeping in mind that our study is cross-sectional and the chronicity of illnesses with varied treatment options over some time for a given patient and their potential side effects on marital satisfaction; the current study did not take into account some factors like the relationship between medications and their side effects on marital satisfaction and changing dynamics of relationship from time to time.In our study,   marital satisfaction was found to be lower in the Schizophrenia study group, with 83.33% being unhappy compared with 68.33% in the bipolar affective disorder group on The Couples Satisfaction Index (CSI) scale with probable reasons being the caregiver burden of the spouse resulting in emotional tiresome as nature of illness being continuous in schizophrenia and episodic in bipolar affective disorder and also specific symptoms of respective illnesses can be another differentiating factor.Shivali Aggarwal and Grover (2018) [23] in their study used the Dyadic Adjustment Scale (DAS) and Quality of Marriage Index (QMI), while the current study used The Couples Satisfaction Index (CSI) Scale to measure relationship quality and Marital satisfaction, which offers a more precise and efficient method of assessing marital satisfaction.The Couples Satisfaction Index (CSI) Scale is a superior tool over the Dyadic Adjustment Scale (DAS) and Quality of Marriage Index (QMI) as it has reduced measurement error and increased power without increasing the length of assessment, and it also has a smaller number of communication items comparatively, that would impact outcome variables without any inflation [23].The Marital Offence-Specific Forgiveness Scale (MOFS) has two categories of Benevolence and Avoidance items, which have a direct and inverse relationship with marital satisfaction.Ignoring the fact that both items have contradicting interpretations, Shivali Aggarwal and Grover (2018) [23] study analyzed that there is no significance in the relationship between Forgiveness and marital satisfaction, marital adjustment, and sexual satisfaction by taking total score as the basis of analysis.
The present study has been skeptical about the items.Hence, we assessed the correlation between The Marital Offence-Specific Forgiveness Scale -Benevolence items score, and Avoidance/ Resentment items score separately with The Couples Satisfaction Index.It was observed that the correlation between The Marital Offence-Specific Forgiveness Scale -Benevolence items score concerning The Couples Satisfaction Index and an inverse correlation between The Marital Offence-Specific Forgiveness Scale -Avoidance/ Resentment items score and The Couples Satisfaction Index to be significant with a p<0.01 implying that patients with higher Benevolence items score had better marital satisfaction and viceversa for Avoidance/Resentment items score respectively in both the groups.
On The Marital Offence-Specific Forgiveness Scale -Benevolence and Avoidance item scores yielded higher forgiveness scores in patients with bipolar affective disorder (MOFS-B Forgiveness Score -68.33%) and (MOFS-B Forgiveness Score -66.67%) in comparison with forgiveness score in Schizophrenia on both items that are (MOFS-B Forgiveness Score -50%) and (MOFS-A Forgiveness Score -55%), respectively.The probable explanation is bipolar affective disorder which is an episodic illness has a higher chance of good insight in patients during their inter-episodic period, which may give better scope to heal the misunderstandings and discords in a relationship and positive hope for the spouse about the future of the relationship; while on the contrary Schizophrenia being a continuous illness scope for understanding between the couple, hope for better future of relationship will be low with poor insight levels of the patient.