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Psychiatric morbidity in family members of alcohol dependence patients
Rahul Singh1, Ekram Goyal2, Suprakash Chaudhury3, Alka Puria4, Santosh Kumar5, Ajay Kumar1
1 Department of Psychiatry, Government Medical College and Rajindra Hospital, Patiala, Punjab, India
2 Department of Psychiatry, DR.B.R.Ambedkar State Institute of Medical Sciences, Mohali, Punjab, India
3 Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Center, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
4 Department of Biochemistry, DMCH, Darbhanga, Bihar, India
5 Department of Psychiatry, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
|Date of Submission||07-Sep-2020|
|Date of Acceptance||25-Jan-2022|
|Date of Web Publication||11-Jul-2022|
Department of Psychiatry, DR.B.R.Ambedkar state Institute of Medical Sciences, Mohali, Punjab
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: There is a paucity of Indian studies assessing psychiatric morbidity among family members of subjects with alcohol use disorder. Aim: To study psychiatric morbidity in wives/life partners and children of alcohol-dependent patients. Materials and Methods: Fifty consecutive index patients diagnosed to be alcohol dependent according to the International Classification of Diseases-10 classification of mental and behavioral disorders diagnostic criterion for research reporting to psychiatry department were taken. The study was conducted on family members of alcohol-dependent patients who were enrolled in the study as subjects. These included both their children and spouses and they were evaluated for any psychopathology using M. I. N. I. AND M. I. N. I.-KID scales. Results: Out of 50 spouses and 67 children enrolled in the study group. Sixty-eight percent had psychiatric morbidity in spouses which include 34% had major depressive episodes. Spouses living in the nuclear family and illiterate had more psychiatric morbidity. Total psychiatric morbidity in children above 18 years was 56.25%, maximum being in alcohol and substance dependence. Total psychiatric morbidity in children between 6 years and 18 years was 31.37%, maximum being in generalized anxiety disorder (11.76%). Conclusion: Spouses of subjects with alcohol dependence have a high prevalence of psychiatric morbidity. Spouses living in the nuclear family had a more major depressive episode and generalized anxiety disorder. Psychiatric morbidity was more in illiterate spouses. Psychiatric morbidity was also high in children. Female children between 6 years and 18 years had more generalized anxiety disorder than males.
Keywords: Alcohol dependence, alcohol use disorders, depression, dysthymia, generalized anxiety disorder, psychiatric co-morbidity
Living with an alcohol-dependent individual subjects all members of the household to constant stress and fears of various kinds. Therefore, it has often been referred to as a “family illness.” The impact of alcohol dependence reverberates through the entire family unit. Their activities, thoughts, feelings, communication, and behaviors are influenced by this phenomenon. The adolescent children of such families often feel embarrassed to talk about their experiences outside of the home and may avoid bringing friends home. They prefer to keep this a secret and to pretend that all is well for them in their families. The pathological adjustments that they make to preserve the homeostasis in their families are done at the expense of their own normal development. Satisfying the requirements of its constituents for physical, mental, societal and financial security and well-being, and the provision of a conducive atmosphere for the care, teaching and socialisation of children are the major purposes of the family. All these functions can be jeopardised by the chronic alcoholism of a family member. The negative social consequences of alcohol consumption and stressful life events may trigger psychological, biological, behavioral responses, which interact to diminish the individual's ability to adapt leading to emotional suffering and thus escalating the chances of family members developing psychiatric disorders. Various studies have examined the influence of husband's habitual drinking on a family, resulting in the disorganization of marital relations. Husband's excessive consumption of alcohol also adversely affected the wives' health, such that wives suffered from various disorders such as insomnia, depression and neurosis. The spouses of alcohol-dependent individuals were more inhibited, more withdrawn and less assertive in interpersonal relationships.
When alcohol use becomes chronic, drinking becomes the priority. The alcohol-abusing individuals' inhibitions are reduced, judgments are clouded and their ability to interpret social cues is impaired. Very often, the spouses have to perform the roles of both parents, increasing their responsibilities as parents and spouses. All this may contribute to poor marital satisfaction and may interfere with their parenting behaviors toward their children. The other parent may, as a result, become inconsistent, demanding and neglectful of the children. Violence, aggression, and the risk of being battered as a wife have often been reported with alcohol misuse.
If there is no change for the better in the alcohol abuser's drinking patterns, the relationship between the parents and the children will be severely strained and may eventually lead to separation or divorce. This in turn affects how members function as individuals as well as how they function as a family. A disorganised family situation is likely to result with predictable events and routines like meals and bedtimes, household chores and joint parent-child activities disintegrating. Discipline of the children may become lax or harsh and inconsistent. A combination of these factors leads to social, emotional, behavioral and academic problems in children of alcohol-abusing parents.
Parental alcohol dependence can adversely affect the developing child creating difficulties in the path of evolution from youth through teens to majority. As a result, the growing child may develop psychological problems that may vary from disturbed behavior, conduct disorder, emotional disorders, difficulties at school and a “precocious maturity.” Children of alcohol-abusing parents (COAs) are more at risk for alcoholism and other drug use than are children whose parents do not abuse alcohol. Furthermore, the offspring of parents diagnosed with alcoholism are up to four times more likely to develop alcohol-related problems than individuals in the general population. COAs also experience emotional difficulties such as depression, low self-esteem, and anxiety. Teenage COAs may begin to develop phobias. COAs with a history of severe parental discord and/or violence at home are more likely to exhibit conduct-disorder behavior, substance use and joining peers who were older, as was noted in early-maturing female adolescents.
Alcohol contributes to the psychopathology in the whole of the family, but most of the times, attention has been paid toward treating the psychopathology of the alcoholic subject only. Family members of these people are left untreated to suffer. Neither they themselves nor the society, along with the medical fraternity found any need to pay attention to these indirect victims of alcoholism.
The present study is an effort to bring into focus the psychiatric morbidity among family members of a subject with alcohol use disorder. While many studies have been carried out in the West with regard to psychiatric morbidity in the family members of persons with alcohol use disorder, Indian studies are scarce. In view of the paucity of Indian studies, the present investigation was undertaken to assess psychiatric morbidity in wives and children with alcohol dependence.
| Materials and Methods|| |
The cross-sectional, observational study was conducted on family members of alcoholics who were diagnosed as alcohol dependent according to the International Classification of Diseases (ICD)-10 classification of mental and behavioral disorders diagnostic criterion for research (ICD-10 DCR). The protocol of the study was approved by the Institutional Ethical Committee before starting the study. All the subjects were enrolled in the study after obtaining informed consent.
Fifty consecutive index patients diagnosed to be alcoholic according to ICD-10 DCR reporting to psychiatry department of a tertiary care centre were taken. Family members of alcohol-dependent patients were enrolled in the study as subjects. These included both children and their spouses.
- Family members of subjects who gave consent to participate
- Children of alcoholics of age 6 years and above
- Wives of alcoholics.
- Not able to give valid consent
- Mentally retarded children
- Children and wives with primary psychiatric illnesses before exposure to the alcoholics.
This short self-made questionnaire was used to record sociodemographic details of the subjects.
Mini-international neuropsychiatric interview
The MINI is a short structured clinical interview which designed to give researchers diagnoses of psychiatric disorders according to DSM-IV or ICD-10. The interview can be completed in about 15 min. The M. I. N. I. has acceptably high validity and reliability scores. It is widely accepted internationally as a diagnostic and screening tool for psychiatric disorders. This can be used for teaching and study purposes.
The mini-international neuropsychiatric interview international neuropsychiatric interview for children and adolescents
The MINI-KID is a short, structured diagnostic interview that helps the researcher to make reliable and valid psychiatric diagnoses for children and adolescents. With an administration time of 15 min, it is designed to meet the need for a short but accurate psychiatric interview.
The study was conducted on family members of alcoholics who were diagnosed as alcohol dependent according to the ICD-10 diagnostic criterion for research. 50 consecutive index patients diagnosed as alcohol dependent according to ICD–10 Classification of Mental and Behavioral Disorders reporting to psychiatry department were taken. Sociodemographic proforma was filled containing the basic information about the family members. Spouses and children above 18 years were assessed applying M. I. N. I. For children from 6 years to 18 years, M. I. N. I. KID was applied. A full psychiatric workup was done. The data were tabulated and analyzed by appropriate statistical tests.
Descriptive statistics were used to analyze the data. The z-test was applied to assess the difference between means of the values in spouses and children groups. Pearson's Chi-square test was used to assess whether distributions of categorical variables calculated differ from one another.
| Results|| |
The mean ± standard deviation (S. D.) of the age of alcohol dependence patients and their spouses was 40.98 ± 10.44 years and 38.69 ± 9.69 years respectively. The mean ± S. D. of age of the children above 18 years of alcohol dependence patients was 27.19 ± 6.06 years. The age distribution of alcohol-dependent patients, their spouses and children is given in [Table 1]. Among the patients of alcohol dependence, 30 (60%) belonged to nuclear family while 20 (40%) lived in joint family. They had a total of 16 children above the age of 18 years of which 12 (75%) were male and 4 (25%) were female. Ten (62.5%) of children above 18 years were married and 6 (37.5%) were unmarried. The distribution of children above 18 years according to the type of family showed that 12 (75%) were staying in the nuclear family and 4 (25%) were staying in joint family. Mean ± S. D. of the age of children between 6 and 18 years in our study was 12.45 ± 3.63 years and consisted of 26 (51%) males and 25 (49%) females. Distribution of children between 6 years and 18 years according to the type of family showed that 36 (70.59%) belonged to nuclear family and 15 (29.41%) were from joint family.
|Table 1: Age distribution of alcohol dependence patients, their spouses, and children|
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Total psychiatric morbidity in the spouses of the chronic alcoholic patients was 68%; the prevalence of various psychiatric disorders in the spouses and the relationship of psychiatric morbidity in spouses according to age, type of family and education is given in [Table 2]. Total psychiatric morbidity was 9 (56.25%) in the children above 18 years. [Table 3] shows the relationship of psychiatric morbidity in children above 18 years according to sex, type of family and education level. There were no significant findings. The total psychiatric morbidity in children between 6 years and 18 years was16 (31.37%). [Table 4] shows the relationship of psychiatric morbidity in children between 6 years and 18 years according to sex, type of family and education level.
|Table 2: Relationship of psychiatric morbidity in spouses of alcohol dependence patients to age, family type, and education|
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|Table 3: Relationship of psychiatric morbidity in children above 18 years of alcohol dependence patients to sex, family type, and education|
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|Table 4: Relationship of psychiatric morbidity in children between 6 and 18 years of alcohol dependence patients to sex, family type, and education|
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| Discussion|| |
Alcohol use disorder is a major public health problem around the world. The magnitude of the problem in our country is considerable given that India has the second-largest population in the world, with 33% of its population consuming alcohol. Alcohol use disorder is considered an ongoing stressor, not only for the individual but for family members as well. Due to constant exposure to the maladaptive behavior of the alcohol-dependent husband and the intimate nature of the relationship wives are particularly affected. The negative social consequences of alcohol consumption and stressful life events may trigger psychological, biological, behavioral responses, which interact to diminish the individual's ability to adapt leading to emotional suffering which increases the chances of developing psychiatric disorders.
Alcohol contributes to psychopathology in the whole family. Drinking behavior may interrupt normal family tasks, cause conflict and demand adjective and adaptive responses from the rest of the family members, who do not know how to cope with the stress problem. Most of the times, attention has been paid towards treating the psychopathology of the alcohol-dependent subject only. Family members of these people are left untreated to suffer. Neither they themselves nor the society, along with the medical fraternity failed to pay attention to these indirect victims of alcoholism.
A major finding of the present study was that 68% of the spouses of chronic alcoholic patients had psychiatric morbidity, the commonest being major depressive episodes (34%). This correlates with a study which indicated that more than half of the spouses (65%) had a psychiatric disorder. The most common diagnosis was major depressive disorder, followed by dysthymia, double depression and panic disorder. Major depressive disorder was present in 43%. Two other studies on psychiatric morbidity of spouses of male alcoholic patients showed comparative results with the depressive disorder being seen in 28.26% and 23.9% spouses., A recent study concluded that alcohol dependence in the husbands was associated with poorer quality of life and higher levels of depression and suicidal ideation in their wives.
Psychiatric morbidity was found to be higher in spouses living in nuclear families than those living in joint families. The values were particularly significant in spouses (living in nuclear families), diagnosed with major depressive episode and generalized anxiety disorder, the percentage being 46.70% and 33.3%, respectively. Analysis of family structure in a survey done in a South Indian village revealed that those living alone had the highest prevalence of psychiatric disorders, followed by those living in nuclear family, while those living in a joint family had the least number of psychiatric disorders. This might be explained by the reason that in India, social support is better among joint families as they allow for diffusion of burden and could be responsible for mediating a positive outcome regarding mental health disorders. A study carried out on the role of the family structure in relation to mental health have found that the joint family structure is less likely to be associated with psychiatric morbidity than the nuclear family structure.
Another finding of our study was that spouses who were more educated had lesser psychiatric morbidity than those who were less educated. The illiterates were found to have the most psychiatric morbidity, especially in the case of major depressive disorder. As the education of the spouses improved, their psychiatric morbidity decreased. The graduates had the least psychiatric morbidity. These findings are similar to a study which demonstrated that illiterates had a higher prevalence of psychiatric disorders compared to those educated (up to under-graduation/graduation).
Among children above 18 years in our study, 56.25% were found to have psychiatric morbidity. 25% of the children were found to have alcohol dependence. About 18.75% were found to have substance dependence (opioid and tobacco). All the alcohol and substance-dependent children were males. This data are similar to an Indian study which showed that male children of alcohol-dependent subjects had a significantly higher rate of lifetime diagnoses of alcohol and drug abuse compared to men who were not children of alcohol-dependent parents. In addition, female children of alcohol-dependent parents had a higher prevalence of generalized anxiety disorder compared to women who were not children of alcohol-dependent parents. The finding of 6.25% of generalized anxiety disorder and major depressive episodes each in children of alcohol-dependent men in our study is in agreement with the above. Increased rates of alcohol and substance dependence in the youth as indicated in our study, are even more alarming as a study done in Amritsar reported that 87.5% of urban males consumed alcohol daily. The fact of males being more dependent on alcohol and substance than females can be attributed to the fact that Indian society is a patriarchal conservative society where these things are more easily accessible to males as compared to females and it is considered as a sign of masculinity.
Among children between 6 years and 18 years in our study 31.37% had psychiatric morbidity. Among them, 11.76% were found to have generalized anxiety disorder. 5.88% had attention-deficit/hyperactive disorder combined. 3.92% were found to have a major depressive episode, panic disorder and conduct disorder each. Lastly, 1.96% were found to have motor tic disorder. An earlier study reported that children of alcoholics had a significantly higher risk than controls of attention deficit disorder/hyperactivity, depression, phobias, enuresis, tics, and generalized anxiety disorder. Another study on pre-adolescents reported that children with alcoholic fathers showed elevated rates of major depression, conduct disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, and separation anxiety disorder. Such children had higher internalizing and externalizing problem behavior scores.
Externalizing disorders consist of attention deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder whereas internalizing disorders consist of generalized anxiety disorder and major depressive disorder. These findings are consistent with other studies which showed that children of alcoholics have increased internalizing and externalizing scores than nonchildren of alcoholics., Another study conducted to study the relationship of child psychopathology to parental alcoholism, indicated that parental alcoholism was associated with increased risks for attention-deficit hyperactivity disorder, conduct disorder, and anxiety disorder in children. In our study, it was found that externalizing disorders were mainly found in males. This is consistent with a study done to examine gender differences in the influence of paternal alcoholism on children. It showed that a greater number of externalizing symptoms were found in male offspring. Our study showed that generalized anxiety disorder (24%) was reported mainly by female children which are in agreement with an earlier study.
Our study is a hospital-based study and the size of the sample is small due to which the results cannot be generalized to other patients with alcohol dependence. There is no control group in our study. This limits the generalized ability of the result to the rest of the population.
| Conclusion|| |
Spouses of subjects with alcohol dependence have a high prevalence of psychiatric morbidity. Spouses living in nuclear family had more major depressive episodes and generalized anxiety disorder. Psychiatric morbidity was more in illiterate spouses. Psychiatric morbidity was also high in children. Female children between 6 years and 18 years had more generalized anxiety disorder than males.
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Conflicts of interest
There are no conflicts of interest.
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