Marriage in persons with severe mental illness: A narrative review-based framework for a supported relationship

Abstract

Background:

Studies in the past have shown the effect of mental illness on marriage in persons with severe mental illnesses (SMIs). Primary care and family physicians have a major role in addressing marriage-associated dilemmas in their life.

Methods:

The literature search was conducted from databases such as PubMed, ProQuest, EBSCO, Scopus, and Google Scholar for understanding the context and the problem in-depth for bringing out the narrative-review based framework for addressing the dilemmas.

Results:

Marriage rates in persons with SMI are high in Eastern countries. Marriage in persons with SMI enhances social support and prevents the stigma of being unmarried. Disability, unemployment, stigma, and disclosure-related issues are barriers to getting desirable alliances. Evidence based interventions are available to reduce the associated distress to an extent.

Conclusion:

Published peer-reviewed literature has pointed out that marriage plays a significant role in the life of persons with SMI and their families, especially in Asian countries where marriage is an important social institution. It can have a positive impact or can lead to relapse, marital conflicts, and divorce based on contextual and clinical factors. Hence, there is a need to come up with tailor-made interventions to address marriage-related expectations in persons with SMI.

Introduction

Marriage is a union between two individuals to fulfil certain societal expectations such as entering into a sexual relationship and procreation.[1,2] It is a significant life event, which symbolises social status, achieving maturity, societal acceptance, and enhancing social support.[3,4] The concept of marriage has been identified as a major variable predicting quality of life in Asian countries.[4,5] Individuals are expected to enter into the institution of marriage once they reach adulthood.[6] Delay in marriage is a concern of families and causes a burden to primary caregivers of people living with severe mental illness (SMI), and primary care and family physicians have major role in addressing this crisis.

SMIs are major psychiatric disorders that include schizophrenia, bipolar affective disorders (BPADs), and major depressive disorders (MDDs).[7,8] SMIs affect a person's ability to perform roles in society, leading to disability and a burden on caregivers.[9]

Persons with SMI do desire to marry, fulfil their needs, form a family, and be accepted in society.[10] However, SMI is characterised by deficits in many areas of functioning and adverse outcomes such as discrimination against them. These issues have created a barrier for persons with SMI to find/get alliances for marriage, and they become vulnerable to institutionalisation.[11,12]

Family physicians and mental health professionals are often being posed with questions as to whether patients with SMI can get married or when they should get married.[10,13] Onset of SMI during the age of marriage or while seeking marital alliance or developing intimate relationships becomes a major challenge for them.[5,14]

While studies have shown that unmarried persons are likely to develop mental distress,[15,16,17] studies have found that marriage in persons with SMI can lead to poor adherence, relapse, and separation or divorce.[18,19] Also, some studies have shown marriage in persons with SMI may also be a source of support and prevent homelessness and suicide.[20,21,22] Thus, marriage may affect the treatment and recovery of a person with SMI.[23]

Marriage is emerging as a prominent right and cultural need among people living with SMI. In this context, the rate of marriage; psycho-social variables predicting marriage outcomes, dilemmas, and distress experienced by individuals and caregivers; stigma and its impact on disclosure during marriage; and perceived and reported benefits of marriage were examined in this narrative review to formulate the framework to plan supported relationship.

Materials and Methods

A literature search was conducted using databases such as PubMed, EBSCO, Scopus, ProQuest, and Google Scholar. The search terms were as follows: Marriage OR intimate relationship OR romantic relationship AND severe mental illness OR schizophrenia OR Bipolar Affective Disorders OR psychiatric disorders AND impact OR factors influencing OR effects. Observational studies from the period 1997 to 2022 were selected. Sample size and sample bias have not been considered as criteria for selecting studies since it is a narrative review as there have been limited original studies. A total of 34 articles were selected for the review. The studies which reported details of the marriage of persons with severe mental illness were included in the study. Original articles/literature which were published in the English language were included in this review.

Case reports, viewpoints, review papers, and articles on reproductive health and mental illness, caregiver burden of spouses, common mental disorders, and developmental disorders were excluded.

Findings of review

The reviewed articles, presented in Table 1, are summarised into the following themes: Perspectives of patients and caregivers, sexual dysfunction and SMI, marriage and divorce rates, gender difference, social disadvantages and marriage, and influence of marriage on SMI.

Table 1.

List of articles included for the review

Author/s	Year	Country	Sample	Description
Aggarwal et al.	2019	India	76 married persons with schizophrenia and 58 married persons with depression	This is a comparative study to find out the sexual and marital functioning of patients with schizophrenia and depressive disorders
Behere et al.	2021	India	80 samples (40 cases and 40 controls)	A case-control study among married and unmarried women with schizophrenia. They explored the effect of marriage in women with schizophrenia
Behere et al.	2020	India	80 samples, in which 40 were married and 40 were unmarried	Case-control study among persons with schizophrenia on the effect of marriage on the severity of illness and quality of life
Boysen et al.	2018	United States	Study 1 (n=113) Study 2 (n=111) Study 3 (n=162)	This consists of three studies. To find out if mental illness can lead to break up in relationships
Brand et al.	2022	Australia	14 participants	To explore the sexual experiences among persons with major mental illness
Bursalioglu et al.	2013	Turkey	65 persons with schizophrenia, 35 bipolar, 40 unipolar, and 60 healthy controls	A comparative study among women with psychiatric disorders and healthy groups in the age group of 15–49 years. The study aimed to compare the relationship between mental illness and psychosocial factors.
Deshmukh et al.	2016	India	101 patients with schizophrenia	A cross-sectional study among persons with schizophrenia in the age group of 25–65 years.
Drisya et al.	2019	India	125 partners of persons with BPAD	A cross-sectional study to understand the marital distress and marital life among partners of BPAD
Elkington et al.	2013	US	20 youths with mental illness	A qualitative study among youth with mental illness in the age group of 13–24 years. The study explored how stigma had an impact on intimate/romantic relationship
Ghormode et al.	2019	India	79 clinical stable patients 50 healthy controls	To find out the sexual dysfunction and quality of life among persons with SMI
Goel and Behere	2016	India	55 (cases) and 55 (controls)	A case-control study consists of 55 patients with BPAD who were married recruited as cases and 55 patients who were never married in the control
Heydari et al.	2017	Iran	12 patients	This is a phenomenological study on lived experiences of persons with psychiatric disorders and stigma.
Hocaoglu et al.	2014	Turkey	101 stable patients 89 healthy controls	Comparative study of the sexual functioning among persons with schizophrenia and general population
Hou et al.	2016	China	607 patients	Prevalence of sexual dysfunction and quality of life in persons with schizophrenia
Kumar et al.	2019	India	30 caregivers	A study on perception of caregivers on the marriage of persons with SMI.
Khadinavar et al.	2019	India	5 case studies and 3 focus group discussions	A qualitative study among persons with mental illness and their caregivers on the perception of marriage
Li et al.	2015	China	817 patients	A study to predict the marital status among persons with schizophrenia and social dysfunction
Loganathan and Murthy	2011	India	200 patients	A study among persons with schizophrenia on stigma and gender issues from a socio-cultural perspective
Muke et al.	2014	India	30 schizophrenia, 30 BPAD, and 30 substance use disorders	A comparative study on marital adjustment in persons with schizophrenia, substance use disorders, and BPAD
Nyer et al.	2010	US	211 patients	To find out the relationship between clinical characteristics and marital status in persons with schizophrenia
Olsson et al.	2016	Sweden	235 patients	To explore the predictors and the socio-demographic and illness profiles in persons with schizophrenia
Penubarthi et al.	2022	Indiaw	116 58 patients 58 normal controls	To find out the sexual dysfunction of females with depression and their relationship with marital satisfaction and quality of life
Ran et al.	2017	China	510 persons with schizophrenia	14-year-follow study to explore the marriage outcomes of persons with schizophrenia in a rural community
Redmond et al.	2010	UK	8 participants	A qualitative study to explore the experiences of romantic relationships among young people with psychosis
Salokangas et al.	2001	Finland	1,750 males and 1,506 females	To explore the quality of life among gender of persons with schizophrenia and how marital status moderates this relationship
Simiyon et al.	2016	India	63 women	To study sexual dysfunction among women with schizophrenia
Subramaniam et al.	2016	Singapore	600 participants	A cross-sectional study to examine the stigma among persons with mental illness
Thakurta et al.	2012	India	24 males 36 females (MDD)	To explore the sexual functioning of persons with major depressive disorder (MDD) and their quality of life
Thara and Srinivasan	1997	India	76 persons with schizophrenia	A study on the outcome of marriage in persons with schizophrenia
Thara et al.	2003	India	75 caregivers	A study on caregivers of women with schizophrenia on perception and attitude of future caregiving.
Vibha et al.	2013	India	150 persons with mental illness	A study on marital adjustment among remitted persons with psychiatric illness
White et al.	2021	UK	4 women 6 men	Experience of romantic relationship of persons with mental illness
Yang et al.	2015	China	363 persons with mental illness	A study on marriage outcomes between rural and urban persons living with psychosis
Yu and Shim	2009	China	5 couples with schizophrenia	A qualitative study on the married life of couples with schizophrenia

Marriage of persons with SMI: Perspectives of patients and caregivers

A recent study on the perception of caregivers on marriage in persons living with schizophrenia and bipolar reports 53% of the respondents felt that persons with severe mental illness should get married.[24] Similarly, another study also reports about 40–60% of caregivers have believed that marriage can cure SMI.[25] Among caregivers, 73% of them were confident that their patients would be able to take up marital roles.[24] A qualitative study of persons with SMI and their caregivers on marriage reported that caregivers found it difficult to get marital alliance for their patients due to ongoing symptoms. Often patients experienced rejection from prospective partners, and that caused distress.[22] A qualitative study among persons living with psychosis and their experiences in a romantic relationship revealed the concerns among participants in forming and maintaining romantic relationships due to their illness.[26] In a qualitative study from South Korea on the marriage of couples with schizophrenia, participants expressed that marriage is a feeling of being accepted and ‘becoming’ like others. According to the couples, marriage implies that they are normal like any other people.[27] The concept of viewing marriage as a step toward feeling normal is also found in a study on persons with psychosis and romantic relationship.[28] Another study reported that marriage would increase their self-esteem and satisfaction of life and prevent loneliness.[29] Most of the caregivers are filled with apprehension as who will take care of the patients in the future. To most of them, marriage is a solution to ensure that their patients are taken care.[24,30]

Sexual dysfunction and SMI

A qualitative study on sexual dysfunction reported persons with SMI have difficulty in initiating and maintaining sexual and intimate relationships due to their chronic illness and the side effects of anti-psychotic medications.[31] Sexual dysfunctions such as erectile dysfunction, lack of desire, ability to reach orgasm, and satisfaction from orgasm were commonly reported among this population.[32] Numerous studies between healthy and control groups reported that the rate of sexual dysfunction was quite high in persons with SMI and among gender, women were found to have a high rate in sexual dysfunction.[32,33,34,35] A study on 607 persons with schizophrenia reported 69.9% had sexual dysfunction. 60% of males and 80% of females reported dysfunction.[36] Sexual dysfunction is a significant predictor of marital dissatisfaction and poor quality of marital life.[10,35,36,37]

Marriage rates

The marital rates among persons with SMI, as cited in Table 2, in Asian countries are high compared to Western countries.[38] A 10-year follow-up study of 76 persons with the first onset of schizophrenia in South India reported that 70% of the individuals were married.[39] A cross-sectional study with a sample of 101 patients with schizophrenia reported 69.3% as the rate of marriage.[40] Similarly, a study from China has also revealed a high rate of marriage with 59.12% of the persons with mental illness being married, while 33% are never married.[41] However, a study from Sweden, which consists of 1750 males and 1506 females in the age group of 16–64 who were diagnosed with schizophrenia and discharged from the hospital, has reported only 27% of the marriage rate.[42] Likewise, a study among 235 patients with schizophrenia in Sweden reported a marital rate of 16%.[43] Another study compared the rate of marriage between rural and urban areas. A community-based study was conducted to find the marital outcome in rural and urban areas of China. A sample of 393 persons with psychosis residing in the community was interviewed. The study reported the overall marital status of the person with psychosis was 60.6%. Respondents residing in urban areas were less likely to get married as compared to those in rural areas. The marriage rate in rural areas was found to be 71.3%, whilst in urban areas, it was 55%.[44]

Table 2.

Rate of marriage

Author	Year	Sample size	Rates of marriage%	Country
Thara and Srinivasan	1997	76	70	India
Salokangas et al.	2001	3,256	27	Finland
Olsson et al.	2016	235	16	Sweden
Deshmukh et al.	2015	101	69.3	India
Li et al.	2015	817	59.1	China
Yang et al.	2015	393	60	China
Ran et al.	2016	510	72.4	China

Gender difference

Most studies on persons with SMI have found that the majority of the females are married as compared to the males, and it was corroborated by a study, conducted among patients with schizophrenia during their post-hospitalization. While 19% of the females were married, only 8% of the males were married in this study.[42] Most women (77.5%) are married within 5 years of the starting of the illness.[45] The low rate of marriage among males could be of two reasons: first, men are the breadwinners in the family, and their employment status, unemployed, underemployed, and poor occupational functioning, can affect their chance of marriage. Another major reason is the poor outcome and course of illness in the male.[39]

Divorce rates

A study from San Diego on people with schizophrenia revealed about 59% of the persons were married at one point in their life. Out of those persons, only 13% are currently continuing relationship and 46% are divorced/separated.[23] A retrospective case-control study in India among persons with schizophrenia revealed that 42.5% of married persons with schizophrenia were divorced and about 70% of them were divorced within 2 years of their marriage.[45]

Social disadvantages and marriage

Studies among persons with SMI from India revealed that being employed leads to a better prognosis and better chances for the marital alliance.[3,40] Respondents in a study expressed that a feeling of being stigmatised makes them feel less confident for intimate relationships. A few respondents also expressed that they were being rejected by their partners/or being treated differently after disclosing their illness.[46] Similarly, a study was conducted to examine which mental illness (severe or common mental disorders) individuals would avoid entering into a romantic relationship. The study revealed that individuals would avoid having a romantic relationship if the other partner is diagnosed with SMIs such as schizophrenia or bipolar disorder.[47] Furthermore, a study from an Asian country conducted among the general population also found that 70% were not willing to enter into a relationship with a partner who has a mental illness.[48] Another qualitative study on stigma and mental illness also revealed that persons with SMI had difficulty in finding alliances for marriage. Due to their illness, they had to settle for someone who was less desirable. For instance, respondents had to marry someone who was already married or someone with other terminal illnesses.[49]

A study on schizophrenia reported only 20% of the respondents disclosed their SMI before marriage to a prospective partner. Out of the 20%, 37% gave detailed information about their mental illness, and the others disclosed it as problems in sleep, anxiety, and/or headache.[45] Another qualitative study revealed that persons with schizophrenia concealed their mental illness and sometimes would disguise their mental illness with other medical illnesses for fear of rejection.[50]

Many studies have also found that the early onset of illness would reduce the chance of getting married.[23,40,44,51] A 14-year-follow-up study reported that variables such as gender, being female; duration of illness, a shorter duration; and educational status, low, increase the probability of marriage.[52] Similarly, other studies also found that females were more likely to get married than males.[39,44]

Marriage before the onset of illness has been found to reduce the chances of divorce and separation. Patients with catatonic symptoms had a poor chance of getting married compared to the diagnosis of paranoid and acute undifferentiated syndromes.[39] Having children is a protective factor that prevents separation. About 72.2% of the respondents who had children did not separate. However, respondents who do not have children are three times more likely to be separated.[25] A study reported that remission is one factor that leads to promoting marital satisfaction.[53] Disability is one of the main factors that lead to a poor marital outcome. A study from China found that the divorce and widowed groups had a higher Social Disability Screening Schedule (SDSS) score than the married group (9.15 ± 5.19 versus 6.81 ± 5.57).[41]

Influence of marriage on mental illness

Many studies have examined the effect of marriage on persons with SMI, and these studies have shown results on both positive and negative effects of marriage on persons with SMI. For example, studies on persons with schizophrenia have found that married persons have a high quality of life as compared to the divorced/separated and the single.[23] A better support system and the presence of a caregiver in married persons with SMI help them to face challenges. Hence, it reduces the chance of homelessness and social isolation.[52] Better social functioning is found in married persons rather than in single or separated persons with SMI.[41,52]

Few studies reported that marriage would affect persons with SMI and relapses were likely to occur more often in married persons with SMI (70%) as compared to the unmarried (57%).[45,54] Most patients with SMI have poor adherence to medication or stopped their medication after marriage. Studies also observed poor marital adjustment, especially in patients with bipolar affective disorders and schizophrenia.[55,56] This could also be due to their negative symptoms and poor functioning.[55]

Framework for facilitating marriage-associated decisions

As noted in the review, high rates of marriage, divorce and disability, gender issues, caregiver concerns, disclosure, and other key influencing variables such as employment and income and the pattern or treatment seeking indicate the need for a framework [Figure 1] for addressing challenges during pre- and post-marriage life without affecting the course of illness and outcome of treatment.

Figure 1.

Framework for facilitating marriage-associated decisions in persons with SMI

To mitigate the impact of stigma, disability, unemployment, and disclosure-related issues, psycho-social interventions such as psychoeducation, guided disclosure, supported employment/education, supported relationship, and premarital counseling can help to a great extent. These interventions would ensure treatment adherence, reduce divorce rates and relapse, better marital adjustment, and enhance social support. A Jewish study has illustrated the benefits of the active therapeutic alliance between patients, therapists, family members, and allied support systems would reduce the challenges involved in marriage-associated decisions.[57]

Discussion

Numerous studies have highlighted the impact of marriage on mental illness as marriage is a protective factor in enhancing social support, quality of life, and social functioning.[44,45,52,58,59,60] Also, there are few studies that revealed contrary findings to the above results and reported that marriage had an effect on persons with SMI in relapse, poor adherence to medication, and poor marital adjustment.[11,19,54] The need to be accepted like others or be treated as normal has been expressed by persons with SMI. Marriage would mean that an individual is capable of taking up responsibilities (family, financial, and social) and fulfilling them as expected by society. In addition to this, in Asian countries like India, unmarried people are stigmatised.[6,27,44] The perspectives of families on the marriage of persons with mental illness are to enhance social support.[13,30] With the change in the family structure from joint to nuclear family, family dynamics associated with caregiving have become a challenge in community-based rehabilitation.[61] Both individuals and families think having an empathetic listener as a partner might reduce mental stress. Due to this belief, most family members get their patients married with the belief that they will get better or cured.[24,25,26]

SMI starts during the early stage of adulthood. This gradually affects their social life such as education, employment, and building romantic relationships. As such, by the time these patients recovered, they would have crossed their marriageable age.[45,62,63] Compromised social functioning, especially deficits in social skills and skills in managing activities of daily living, affects their prospects of marriage. This leads to unemployment, which reduces their chance of being considered for marriage.[3,39,40] Working with patients in improving their functioning and helping them through supported employment and vocational rehabilitation are done so that they become independent and self-reliant.[64]

A few researchers have studied the phenomenon of disclosure. While family physicians and mental health clinicians suggest the need to disclose SMI status to the prospective partners, studies have shown that patients and families hesitate to disclose considering their lived experience of being rejected and failing to get into alliances after disclosing their mental illness.[12,25] Guided disclosure, which is facilitated by mental health professionals, will assist individuals with SMI and their families to prepare themselves on “What, How, and When” to disclose.[57,65,66] In the clinical setting, it is observed that most patients stopped their medications because they have concealed their illness before marriage.[13,25] It is important to provide psychoeducation to the family members and the patients on the importance of continuing medication after marriage. The importance of consulting mental health professionals while planning a family can be emphasised during the process of help.[57,66]

Just as premarital counseling is essential for young adults, it is also very important for persons with SMI. Premarital counseling should be provided to patients focusing on the importance of communication skills, decision and problem-solving skills, skills to handle difficulties in intimacy,[67,68,69] parenting skills, and so on.[70,71] It is observed that individuals with SMI have difficulty in relating, developing, and maintaining relationships, which often are the main causes of breakups. Through supported relationships, persons with SMI can form, build, and maintain relationships.[70,71]

Limitations of this narrative review

1. Due to the paucity of studies on the rates of marriage among people living with SMI, the rates of marriage have been taken from studies on marriage and related variables.

2. Mentioned retrospective studies might have not adequately controlled bias in recalling the traumatic experience of separation and divorce.

Conclusion

Marriage-related guidance should be planned and tailored made according to the needs of persons with SMI for promoting marital satisfaction, social support, and social network and for reducing the risk for relapse through adherence to medication and rehabilitation plans at different levels of primary medical care. High rates of separation or divorces unnecessarily would increase the discrimination against people living with SMI. Hence, planned and supported relationships can reduce the care burden and can enhance the well-being of persons with SMI.

Financial support and sponsorship

We thank the University Grant Commission for supporting the first author financially in pursuing the Ph.D. and this work has been carried out as part of her Ph.D. research.

Conflicts of interest

There are no conflicts of interest.