Evaluation of anxiety and depression among working women in relation to spouse alcohol dependence

Background : Spouse alcohol abuse is known to cause mental distress in their intimate partners. Behaviors exhibited by alcohol abusers are known to affect the lives of their wives adversely. Spouses of alcoholics are more likely to experience victimization, mood disorders, and ill-health. Aim : To evaluate anxiety and depression among working women with alcohol-dependent spouse compared to those with alcohol non-dependent spouse. Materials and Methods : Married working women were recruited for the study and inquired about the history of alcohol abuse in their spouse using the Family CAGE-AID questionnaire. The subjects were grouped into those whose spouse is alcohol dependent, and those whose spouse is alcohol non-dependent. The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression. Statistical analysis : Statistical analysis was done using SPSSsoftware version 21. The level of significance was set at P<0.05. Results : The total sample consisted of 56 participants, of which women whose spouse is alcohol dependent are 26 (group 1), and women whose spouse is alcohol non-dependent are 30 (group 2). The present study reveals that women whose spouse is alcohol dependent spouses had significantly higher anxiety (P<0.05) and depression (P<0.05) as compared with those whose spouse is alcohol non-dependent. Conclusion : Consumption of alcohol affects not only the individual who is alcohol dependent but their spouses as well. Stress, mood, anxiety, and general health problems of the spouses of alcoholics should be addressed during management. © This is an open access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
According to the global status report on alcohol and health released by the World Health Organization (WHO), alcohol use disorders account for 5.1% of the global burden of disease measured in disability-adjusted life years (DALYs). 1 In India, alcohol use disorder (abuse and dependence) is identified to be nearly 4.6% as per the National Mental Health Survey of India. 2 Alcohol harmful use and dependence are known to be associated with a multitude of family issues. The spouses of men with alcohol dependence syndrome bear the brunt of the dysfunctional family system and have to deal with psychosocial issues such as family conflicts, domestic violence, and financial constraints brought about by husbands' alcohol use. 3 Women with a substance-abusing partner are known to have a compromised social adjustment in life domains of work, social/leisure, primary relationship, parental, and family. 4 Women whose partners had alcohol problems are subjected to victimization and present with poor health compared to women whose partners did not have alcohol problems. 5 A strong association between alcohol abuse and marital distress has been reported, and troubled marital relationship is likely to have an adverse impact on the partner's physical health, mental health, and quality-of-life. 6 A population-based study observed that female spouses of male at-risk drinkers tend to experience considerable mental distress than spouses of controls. 7 Studies done to observe the impact of partner's alcohol problems on women's mental health revealed that women whose partners had alcohol problems were more likely to experience psychiatric disorders such as adjustment, mood, and anxiety disorders. 3,5 Significant association is found between the duration of alcohol abuse by husband and psychological morbidities in spouses. 8 Lifetime atrisk drinking is considered a risk factor for spouse's psychological distress. 9 Understanding and addressing the mental health issues of spouses of alcoholics decrease their burden, improves their coping skills, and improves the overall quality of life. Also, it is likely to have a bearing on the treatment and outcome of alcoholics. Hence, we have undertaken this study with the aim to evaluate anxiety and depression among working women with alcohol-dependent spouse compared to those with alcohol non-dependent spouse.

Materials and Methods
This is a cross-sectional observational study conducted on working women whose spouses have alcohol dependence. The study was initiated after obtaining approval from the Institutional Ethical Committee. Family CAGE-AID questionnaire was applied to assess the alcohol dependence in spouses. Working women whose spouse is alcohol-dependent were taken as group A, and the women whose spouse is not alcohol dependent were taken as group B (controls). The Hospital Anxiety and Depression Scale (HADS) was applied to evaluate anxiety and depression in the subjects. Statistical package for social sciences (SPSS), version 21.0, released in 2012 by IBM corp., Armonk, New York, United States of America, was used for analysis. A probability value of less than 0.05 was considered statistically significant.

Selection and description of participants
Family CAGE-AID questionnaire is administered to family members for screening alcohol use disorders. It has the same four questions as the CAGE-AID questionnaire. It has strong internal consistency reliability, with Cronbach's alpha coefficients of 0.84 to 0.89. 10 The Family CAGE-AID questionnaire was found to have moderate inter-rater reliability with that of the ICD-10 diagnosis of substance dependence. 11 The Hospital Anxiety and Depression Scale (HADS) comprising 14 items, seven of which relate to anxiety symptoms and seven to depressive symptoms, is used to measure anxiety and depression among the participants of this study. The HADS questionnaire is pertinent for detecting symptoms of anxiety and depression in a population of people at work. 12 Higher HADS scores demonstrate higher levels of anxiety and depression among the participants.

Results
The total sample consisted of 56 participants, of which women whose spouse is alcohol dependent are 26 (group A), and those whose spouse is alcohol non-dependent are 30 (group B).
The sample characteristics are summarized in Table ??. There was no difference between the participants in both groups in terms of age, marital years, and the number of children. Most of them were below 45 years of age. Only a few of them were married for more than 20 years, and many of them had two children. In group A, most of them attained a secondary level of education or below. Whereas in group B, many received higher education and few of them were graduates.
Results of the Hospital Anxiety and Depression Scale are shown in Table 2.
Of the 26 women in group A, 69.2% (n=18) had symptoms of anxiety, of which 46.2% (n=12) reported significant anxiety and 23.1% (n=6) borderline anxiety. Whereas in group B, 10% (n=3) had symptoms of anxiety, of which 3.3% (n=1) reported significant anxiety and 6.7% (n=2) borderline anxiety. Working women whose spouse is alcohol dependent had significantly higher anxiety (P<0.05) as compared to those whose spouse is alcohol nondependent as assessed using the Chi-square test.
On the depression subscale, 15.3% of the participants (n=4) in group A had symptoms of depression, of which 3.8% (n=1) reported significant depression and 11.6% (n=3) borderline depression. In comparison, 3.3% (n=1) of those in group B reported borderline depression. Working women whose spouse is alcohol dependent had significantly higher depression (P<0.05) than those whose spouse is alcohol non-dependent as assessed using the Chi-square test.
When compared with the prevalence of anxiety and depression using Fisher's exact test, the number of marital years and educational status showed no significant difference in terms of occurrence of the symptoms of anxiety and depression in both the groups (P>0.05).

Discussion
The present study is a cross-sectional study conducted to evaluate anxiety and depression among working women whose spouse is alcohol dependent compared to those whose spouse is alcohol non-dependent. The results of our study reveal that women whose spouse is alcohol dependent had significantly higher anxiety (P<0.05) and depression (P<0.05) when compared to women whose spouse is alcohol non-dependent, which is in concurrence with the findings of earlier studies. [13][14][15][16] In the current study, 84.6% of women whose spouse is alcohol dependent showed symptoms of either anxiety or depression, 69.2% showed symptoms of anxiety, and 15.3% showed symptoms of depression, which is in accordance with the study conducted by Rakesh R et al. 17 However, earlier studies have reported higher rates of depression, followed by anxiety in the spouses of men with alcohol dependence as compared to controls. 13,14,16,18,19 Indu PV et al., in their study exploring the prevalence of psychological morbidity in spouses of alcohol-dependent males, observed at least one psychiatric morbidity in 85.0% of the women of which adjustment disorder was seen in 53.3%, followed by major depressive disorder and anxiety disorders. 15 A study evaluating psychiatric morbidity of the spouse of male alcoholic patients from Nepal showed the highest number of cases to be depressive disorder followed by conversion disorder, anxiety disorder, and somatoform disorder. 19 In the study conducted by Shah VA et al., mild suicidal risk was identified in 6% and severe suicidal risk in 2% of spouses of men with alcohol dependence. 13 Psychopathology seen in the woman may be proportional to the degree of alcohol dependence of the spouse and his social impairments. 20 In the present study, the number of marital years compared with the prevalence of anxiety and depression showed no significant difference in terms of occurrence of the symptoms of anxiety and depression in women whose spouse is alcohol dependent. In contrast, the observations made by the study from rural communities of Sri Lanka showed that the risk of major depressive disorder in the spouse of alcohol-dependent increases with increasing age and a longer period of staying together. 18 Psy chiatric morbidity and marital dissatisfaction in spouses and poor well-being were found to be significantly high in spouses of alcohol dependents. 16 Marital and family therapy (MFT) may have a role in overall strengthening the family's coping mechanisms and improving the motivation of the unwilling alcoholic patient. Behavior couple therapy (BCT) may be effective in increasing abstinence rates and enhancing the relationship of the couple. 21 This study has certain limitations. The sample size is small. Hence, the results cannot be extrapolated to the general population. As the sample constituted of only working women, it may not represent the broader population of partners of alcohol users. Limiting the sample to wives also restricts our ability to generalize these results to other family members.

Conclusion
Consumption of alcohol affects not only the individual who is alcohol dependent but also their spouses. Women whose spouse is alcohol dependent showed anxiety and depressive symptoms, predominantly anxiety, and despite employment. Therefore, special consideration ought to be paid to the needs of the family in the management of alcohol dependence. Stress, mood, anxiety, and general health problems of the female partners of alcoholics should

Source of Funding
No financial support was received for the work within this manuscript.

Conflict of Interest
The authors declare they have no conflict of interest.