Psychiatric illnesses are increasingly known to be common in the recent decades and affects over 25% of people at some point in a adults at any point in time, and at least one affected individual living in one every four families—(1).

Alcohol dependence syndrome is the maladaptive patters of alcohol intake with tolerance craving, loss of control, and withdrawal symptoms (3).

Bipolar affective disorder is episodic in nature with manic or hypomanic or depressive or mixed symptoms occur. Patients exhibit fluctuating severity of any of these symptoms interspersed with a symptom free (euthymics 2) or subsyndromal periods.

Cwvently the prevalence of bipolar affective disorder (BPAD) is around 0.4-0.5%

with an 1 year prevalence of 0.5to 1.4% and a life-time prevalence of about 2.6 to 7.8% (4).

The life-time prevalence of bipolar disorder is about 20.8 per 1000 population in India (6 ±); and that of alcohol use ranges from 1.15% to upto 50% in general (8, 9).

Burden Definition (10) – Platt

Stigmatization, chronic emotional and economic burden from caring are endured by the families of individuals with psychiatric illness. The illness impact on the primary caregiver’s leisure time activities work and social relationships. These deficits evoke different reactions infifferent or expressed emotional reaction towards the patients, and a sense of insufficiency and helplessness in themselves, all of which impact on the progression and prognosis of the patient’s illness (1).

AIM

To compare the family burden, the quality of life and psychiatric morbidity between female spouses of patients with alcohol dependence syndrome, patients with schizophrenia, and patients with bipolar affective disorder

OBJECTIVES

1. To find the family burden and quality of life in female spouses of patients with alcohol dependence, schizophrenia and bipolar affective disorder
2. To evaluate the prevalence of psychiatric morbidity in female spouses of patients of these three groups
3. To study the association between symptom severity in patients, perceived apathy, significant life events and family burden, and the quality of life and psychiatric morbidity in female spouses in these groups
4. To compare psychiatric morbidity, family burden of care and quality of life in female spouses between all patient groups.

MATERIALS AND METHODS:

The sample is drawn from male patients with female spouses attending the outpatient Psychiatry department at this hospital.

Design:

Crosssectional, comparative study, including 64 patients with alcohol dependence, 64 patients with schizophrenia, and 64 patients with bipolar affective disorder, and their female spouses.

With consecutive sampling from Outpatient department, a total of 192 patients with their spouses are taken up for the study.

Duration and period of Study- 4 months

Inclusion criteria:

1. male patients with equal to or more than 10 year duration of alcohol dependence or schizophrenia or bipolar affective disorder, satisfying the criteria for the corresponding DSM IV-TR diagnoses
2. patients with onset of psychiatric symptoms/disorder after marriage
3. female spouses who provide care for the patients
4. participa nts should be not less than 60 years of age
5. participants to be willing to provide informed consent for the interview and assessment
6. patients willing to allow spouse to be assessed

Exclusion criteria:

1. those who did not give their consent
2. refusal to allow spouse to be evaluated
3. patients and/or their spouses with any chronic general medical illness
4. spouses with a history of substance abuse, suicide or previous history of psychiatric symptoms and intervention
5. spouses with a family history of psychiatric illness
6. spouses related to the patients by consanguinity

Instruments used

1. A semistructured profoma to collect the sociodemographic details, family history details and a semistructured clinical profile
2. International Classification of Diseases ICD-10
3. Shortform Alcohol Dependence Data Questionnaire SADDQ

Clinical Global Impressions CGI-BP bipolar and

CGI-SCH schizophrenia, severity scales

4. Presumptive stressful life events scale PSLES
5. Apathy inventory –caregiver version
6. Burden Assessment Scale BAS;

Caregiver Reaction Assessment -Selfesteem, High life-esteem -positive caregiving, Burnout -Negative Caregiving subscales –CRASH-BOUNCE score

7. WHO Quality Of Life WHOQOL –BREF-1
8. General Health Questionnaire GHQ-12

MINI plus 5.0.0 v Mini International Neuropsychiatric Interview –plus

Beck Depression Inventory BDI; Hospital Anxiety and Depression Scale –anxiety HADS-A

CGI-BP

Bipolar disorder is a cyclic and polymorphic disease. Patients may show manic, hipomanic, depressive or mixed symptoms, and they may be in partial or complete remission. For this reason, the assessment of the course, severity and outcome of the disorder is very complex. Most of the available psychometric instruments have been designed for the assessment of acute episodes of specific polarity.

The CGI-BP-M, a user-friendly scale for the assessment of manic, hypomanic, depressive or mixed symptoms, and long-term outcome of bipolar disorder, is a useful tool for the assessment of the efficacy of several treatments.

CGI-S:

Amongst the most widely used of extant brief assessment tools in psychiatry, the CGI is a 3-item observer-rated scale that measures illness severity (CGIS), global improvement or change (CGIC) and therapeutic response. 

The illness severity and improvement sections of the instrument are used more frequently than the therapeutic response section in both clinical and research settings.

Amongst the most widely used of extant brief assessment tools in psychiatry, the CGI is a 3-item observer-rated

scale that measures illness severity (CGIS), global improvement or change (CGIC) and therapeutic response.

The illness severity and improvement sections of the instrument are used more frequently than the therapeutic response section in both clinical and research settings.

Burden Assessment Schedule (BAS) (104): [ANNEXURE IV]

It is an instrument to assess burden on caregivers of chronic mentally ill. It was developed to assess subjective burden in Indian population, as many of the burden assessment instruments developed in the west were not culturally suited to Indian population.

This schedule has 40 items and 9 domains. The different domains are Spouse related, Physical and mental health, External support, Caregivers routine, Support of patient, Taking responsibility, Other relations, Patients, Patients behaviour and Caregivers strategy.

Each of these 40 items was rated on a 3-point scale marked 1-3. The responses were not at all, to some extent and very much. Depending on the questions were framed, the responses and the score for each of those responses would vary.

In this study the schedule was modified by arranging 40- items into the above 9 domains. Total score of each domain was calculated separately and at the end the total burden was calculated. This was done to get the domain score apart from the total score. In the spouse was replaced with either son, daughter, brother, sister, mother or father, depending of the patient to the caregiver. In the items 2 and 4, the word ‘sexual and marital’ was replaced by ‘family’ as and when needed.

The minimum total score of burden in BAS is 40 and the maximum score in 120. In this the severity of burden was categorized into 4 groups, in the following way,

• 40-60 –Minimum burden
• 61-80 –Moderate burden
• 81-100 –Severe burden
• 101-120 –Very severs burden

Method

Consecutive patients attending the Psychiatry OPDs of hospitals attached to J.J.M. Medical College, diagnosed as BPAD and Alcohol dependence according to DSM IV criteria who met the inclusion criteria and did not get excluded were included in the study.

Written informed consent was taken from the patients or from the caregivers depending on their ability to give consent, following an explanation about the nature and the purpose of the study in the language in which the patient could understand. Sociodemographic details were recorded on the self designed proforma.

The primary family care-giver was one who met at least three of the following criteria (108).

• Is a spouse, parent or spouse equivalent.
• Has the most frequent contact with the patient.
• Helps to support the patients financially.
• Has most frequently been collateral in the patient’s treatment.
• Is contacted by treatment staff in case of emergency.

Burden Assessment Scale (BAS) was administered to assess the burden on caregivers of BPAD group and ADS group. Severity of alcohol dependence was assessed using Short Alcohol Dependence Data (SADD) Questionnaire.

GHQ

Validity

Discriminative validity

There was a non-significant trend in GHQ Total scores and Depression subscales scores to be higher for carers using Admiral Nurse (AN) teams vs. carers who did not (Woods et al., 2003). On follow-up, a significant difference was found on the Anxiety and Insomnia subscale, where outcome was better for the AN group. Another study showed that carers of dementia patients showed higher levels of distress as measured by GHQ than carers for patients with depression (Rosenvinge et al., 1998).

Furthermore, significant differences in GHQ scores have been found between carers of people with anorexia and psychosis (Treasure et al., 2001). GHQ scores have also been found to differ in carers of people with a head injury according to different time intervals post-injury. The GHQ scores were higher for carers of people with a recent head injury, which indicates greater burden in this group (Sander et al., 1997).

Predictive validity

Coping style has been found to contribute significantly to GHQ score variance, with emotion-focused coping being related to GHQ scores in a study by Sander et al., (1997). Furthermore, coping accounted for more of the GHQ variance than disability scores.

Socio-demographic variables

Gender has been found to have a significant effect on GHQ scores, but neither race nor relationship to the injured person had a significant effect (Sander et al., 1997).

Dimension-specific variables

Strong positive correlations were found between the GHQ and the Relatives Stress Scale (Draper et al., 1992).

Responsiveness

The GHQ-28 has been shown to be responsive to change in a study using cognitive behavioural therapy in carers of Parkinson’s disease patients. Both the Total score and the scores for 3 of the sub-scales decreased in response to the intervention (Secker and Brown 2005). Both conventional and AN services led to lower GHQ scores overall and 2 of the 4 subscales over an 8-month period (Woods et al., 2003).