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 RESEARCH ARTICLE

The relationship of marital status and clinical characteristics in middle-aged and older patients with schizophrenia and depressive symptoms

Maren Nyer, MEd

University of Virginia, Department of Human Services, The Curry School of Education, Charlottesville, VA, USA

John Kasckow, MD, PhD

VA Pittsburgh Healthcare System, Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA

Ian Fellows, MS

Department of Psychiatry, Division of Geriatric Psychiatry (116A-1), University of California, San Diego, San Diego, CA, USA

Edith C. Lawrence, PhD

University of Virginia, Department of Human Services, The Curry School of Education, Charlottesville, VA, USA

Shah Golshan, PhD

Department of Psychiatry, Division of Geriatric Psychiatry (116A-1), University of California, San Diego, San Diego, CA, USA

Ellen Solorzano, MSW

Department of Psychiatry, Division of Geriatric Psychiatry (116A-1), University of California, San Diego, San Diego, CA, USA

Sidney Zisook, MD

Department of Psychiatry, Division of Geriatric Psychiatry (116A-1), University of California, San Diego, VA San Diego Healthcare System, San Diego, CA, USA

BACKGROUND: This study examines the relationship of marital status to depression, positive and negative symptoms, quality of life, and suicidal ideation among 211 patients with schizophrenia-spectrum disorders and subsyndromal depressive symptoms. We hypothesized that single participants would have more severe symptomatology than married and cohabitating participants.

METHODS: Outpatients, age 40 or older, were diagnosed with schizophrenia or schizoaffective disorders using the MINI Structured Clinical Interview for DSM-IV Axis 1 Disorders. Participants exhibited a score of >8 on the Hamilton Rating Scale for Depression but did not meet criteria for a major depressive episode.

RESULTS: Participants who were married or cohabitating had a later age of onset of first psychotic episode or hospitalization than those who were single (age, 29.35 vs 24.21). Married participants rated their quality of life higher than those who were single (mean Quality of Life Scale scores, 72.28 vs 53.87) and had less suicidal ideation than those who were divorced, widowed, or separated (7.4% vs 29.2%).

CONCLUSIONS: In middle-aged and older individuals with schizophrenia or schizoaffective disorder and depressive symptoms, marriage appeared to enhance quality of life and protect against suicidal ideation. Efforts that focus on providing additional support for those who are experiencing divorce or separation could prove to be lifesaving for these individuals.

KEYWORDS: marriage, quality of life, suicide, subsyndromal depression, marital status, divorce

ANNALS OF CLINICAL PSYCHIATRY 2010;22(3):172–179

  BACKGROUND

Studies have found marital status to be an important correlate of well-being, quality of life, onset of major depression, and persistence of depressive symptoms.1-4 Far less is known about marriage in persons with severe mental illness. A case in point is how little is known about marriage in patients with schizophrenia, a chronic and severe mental illness generally associated with substantial impairments across multiple domains of life, including intimacy and social adjustment. What little is known suggests that individuals with schizophrenia—especially men—are less likely than others to ever get married,5-10 that being single might actually increase the risk for developing schizophrenia,5,6,8,11,12 and that being single may itself be a risk for poor outcomes in persons with schizophrenia.9,13,14

Single marital status in patients with schizophrenia has been linked to various clinical characteristics, such as hospitalization,15 suicidality,16 quality of life,17 depression,9 differing symptom profiles,9,10 prognosis,13,14,18,19 violence,20 and social disability.21 Taken together, these studies suggest that marital status plays a particularly important role in the impact, course, and prognosis of schizophrenia. Marriage has been shown to affect males and females differently in this population. Single male patients with schizophrenia report more symptoms and lower quality of life than single female patients.10,17,22

The importance of marriage or being single for patients with schizophrenia may be magnified in subgroups of patients with other risk factors for isolation and poor outcomes, such as patients with schizophrenia who also experience clinically significant depressive symptoms.23 One form of depressive symptoms, subsyndromal depression (SSD), is a common and clinically important syndrome. SSD consists of depressive symptoms that are too mild in severity to meet criteria for major depression and too brief in duration to meet criteria for dysthymic disorder.24 To date, there have been no studies examining marriage as a moderating variable in symptomatology for patients with schizophrenia and SSD. Moreover, little is known about the impact of divorce or widowhood on patients with schizophrenia. The present study is one of the first to examine clinical factors associated with marriage, divorce, and widowhood in patients with schizophrenia and schizoaffective disorder who are at particularly high risk for poor outcomes by virtue of also having SSD.

The primary aim of this investigation was to examine the relationship between marital status and key clinical characteristics (depression, positive and negative symptoms, quality of life, and suicidality) among patients with schizophrenia spectrum disorders. We hypothesized that single patients would have a more severe symptom profile across each of these domains than would married or cohabitating participants.

  METHODS

All participants signed written informed consent forms after an initial screening and before baseline information was obtained. Patients were recruited for a trial sponsored by the National Institute of Mental Health to study the effectiveness of citalopram vs placebo as an augmenting agent in the treatment of patients with schizophrenia/schizoaffective disorder and subsyndromal depressive symptoms. Participants were outpatients at either of 2 sites: (1) the University of California, San Diego/VA San Diego Healthcare System (VASDHS), or (2) the University of Cincinnati/Cincinnati VA Medical Center. The study was approved by the University of California and University of Cincinnati Human Subjects Review Committees.

Recruited over a period of approximately 3 years, participants underwent assessment and diagnosis of schizophrenia or schizoaffective disorder, which was verified by the Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-I).25 For inclusion in the study, participants also needed to have at least 2 of the 9 items required to meet criteria for major depression, and a baseline score of at least 8 on the 17-item Hamilton Rating Scale for Depression (HAMD).26 There were 2 raters, and inter-rater reliability between the 2 sites was established to a minimum of .70 reliability on all measures before data collection began, as previously reported.27 Other requirements for participation were: (1) age >40; (2) outpatient status; (3) adequate decisional capacity for informed consent, as determined by posttest questions and the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR28); and (4) having a care-giver. Patients were excluded if they had (1) a dementing disorder; (2) major depression or mania within the past 2 months; (3) active substance abuse/dependence; (4) mental retardation; (5) head injury with unconsciousness lasting more than 30 minutes, or less than 30 minutes if loss of consciousness was associated with significant cognitive impairment; and (6) seizure disorder if associated with significant cognitive impairment.

During the same time that the SCID-I was administered, study location, gender, ethnicity, diagnosis, living situation, educational level, age, and age of onset were documented.

Scales used to assess psychopathology and quality of life included the following: the Calgary Depression Rating Scale (CDRS),29 the Positive and Negative Syndrome Scale (PANSS),30 the Beck Scale for Suicidal Ideation (BSS),31 and the Heinrichs Quality of Life Scale (QLS).32 The QLS is a clinician-rated scale used to assess social functioning, interpersonal relationships, and intrapsychic well-being in studies of schizophrenia.

To test the primary hypotheses in this study, marital status data was collapsed into 3 categories: married/ cohabitating, divorced/widowed/separated, and single, and bivariate analyses were run. To investigate site differences, continuous data were analyzed using t tests and categorical data were analyzed using chi-square tests. Due to large site effects, continuous outcome variables were analyzed using analysis of covariance, adjusting for site. Categorical outcome variables were analyzed using Mantel-Haenszel tests, stratifying on site. Small sample Monte Carlo Mantel-Haenszel tests were used where marginal cell counts were low. Appropriate transformations were employed to approximate normality of the distributions or homogeneity of the variance, or both. All tests were 2-tailed, and the statistical significance for all tests was set at P < .05.

  RESULTS

The ages of the total sample were as follows: 70% were under age 55, 18.7% were age 55 through 60, 5.4% were age 61 through 65, and 5.9% were over age 65. Although only 13% of the total group was currently married or cohabitating, another 46% had been previously married. Thus, taken together, 59% of the sample had at one point been married. Most participants were male (79%) and the group’s mean age was 52 + 7.03 years. The majority of participants (59%) were diagnosed with schizophrenia and the remaining with schizoaffective disorder. Participants were evenly split between the 2 study sites (San Diego, 51.9 %; Cincinnati, 48.1%).

Analyses to determine if there were any differences in the demographic and diagnostic characteristics of the 2 sites revealed significant differences for patients’ age, living situation, gender, diagnosis, ethnicity, and marital status. The average age for participants from the San Diego site was slightly but significantly younger than the Cincinnati site (50.91 + 6.12 years vs 54.29 + 7.55 years; F[1,208] = 12.78; P = .001). The San Diego site also had significantly more females (n = 32) than Cincinnati (n = 12; χ2[1] = 9.66; P = .002) and enrolled significantly more single participants (n = 54 vs 31) but fewer divorced, widowed, and separated (n = 44 vs 54) or married/cohabitating (n = 12 vs 16) participants (χ2[2] = 7.45; P = .024).

TABLE 1 displays the sociodemographic and diagnostic information of the sample by marital group for all categorical data, and TABLE 2 presents findings for all continuous data. The only significant differences between marital status groups were for living situation and age of onset. The divorced/widowed/separated group was most likely to be living alone, the single group to be living in an assisted living facility, and the married/cohabitating to be living with someone (Monte Carlo Mantel-Haenszel, M2[6] = 28.23; P < .001). TABLE 2 shows that the single group had the earliest age of illness onset (F[2,179] = 7.28; P = .001).

As shown in TABLE 3, marital status groups also were significantly different on the measure of quality of life (F[2,160] = 5.10; P = .007), with married/cohabitating participants having significantly higher QLS scores than either singles (72.28 vs 53.87; P < .001) or divorced/widowed/separated participants (72.28 vs 62.40; P = .046). The divorced/widowed/separated group had higher QLS scores than the single group (62.40 vs 53.87; P = .018) but lower than the married/cohabitating group. Additionally, suicidal ideation was significantly related to marital status (Monte Carlo Mantel-Haenszel, M2[2] = 6.24; P = .047). Married and cohabitating participants had lower levels of suicidal ideation than divorced/widowed/separated participants (7.4% of the married/cohabitating group endorsed suicidal ideation vs 29.2% of the divorced/widowed/separated group; P = .022). There were no significant differences in suicidal ideation between the single group and either of the other groups. No significant differences based on marital status were found for depressive symptoms (F[2,205] = 0.40; P = .671), positive symptoms (F[2,206] = 1.24; P = .293), or negative symptoms (F[2,205] = 1.13; P = .324). The means for depressive symptoms of each of the marital status groups were married/cohabitating (7.07 ± 3.34), divorced/widowed/separated (6.81 ± 3.60), and single (6.59 ± 2.54).

We investigated the interaction effects of gender, site, and age of onset to discover if there existed any significant moderation of our findings. None of the interaction effects of site or gender were significant. There was a significant age of onset by marital status interaction effect (F[2,174] = 4.26; P = .016) with regard to depressive symptoms, but the main effect of marital status remained nonsignificant. The large number of interaction effects tested makes this finding difficult to interpret. More study is necessary to determine if this is a result of multiple testing.


TABLE 1

Demographic and clinical categorical variables for the 3 marital groups (N = 211)

Marital status group
  Married/Cohabitating
(n = 28)
Divorced/Widowed/
Separated (n = 98)
Single (n = 85)
Variables % No. % No. % No.
Study locationa
San Diego 42.9 12 44.9 44 63.5 54
Cincinnati 57.1 16 55.1 54 36.5 31
Gender
Male 71.4 20 79.6 78 81.2 69
Female 28.6 8 20.4 20 18.8 16
Ethnicity
Caucasian 60.7 17 55.1 54 54.1 46
African American 32.1 9 31.6 31 36.5 31
Hispanic 3.6 1 8.2 8 5.9 5
Other 3.6 1 5.1 5 3.5 3
Diagnosis
Schizophrenia 53.6 15 54.1 53 68.2 58
Schizoaffective disorder 46.4 13 45.9 45 31.8 27
Living situationb
Alone 10.7 3 40.8 40 24.7 21
With someone 64.3 18 22.4 22 21.2 18
Board and care 21.4 6 29.6 29 45.9 39
Other 3.6 1 7.1 7 8.2 7
aP < .05.
bP < .001.

TABLE 2

Sociodemographic continuous variables for the 3 marital groups (N = 211)

Variable Marital status group
Married/Cohabitating
(n = 28)
Divorced/Widowed/
Separated (n = 98)
Single (n = 85)
No. of patients Mean SD No. of patients Mean SD No. of patients Mean SD
Years of education 28 12.57 2.39 96 11.79 2.40 85 11.98 1.98
Age 28 54.10 7.26 98 53.30 7.21 85 50.88 6.20
Age of onseta 23 29.35 11.32 83 30.11 10.51 77 24.21 8.90
aP = .001.

TABLE 3

CLINICAL CHARACTERISTICS AS A FUNCTION OF MARITAL GROUPS (N = 211)

Variable Marital status group F or M2a
Married/Cohabitating
(n = 28)
Divorced/Widowed/
Separated (n = 98)
single (n = 85)
No. of patients Mean or % SD No. of patients Mean or % SD No. of patients Mean or % SD
Positive Symptoms 28 13.86 4.39 98 15.56 5.49 84 16.20 5.46 1.24
Negative symptoms 28 14.75 5.28 98 15.57 4.78 83 16.31 5.51 1.13
Quality of lifeb 25 72.28 23.26 70 62.40 23.44 69 53.87 19.70 5.10
Depression 28 7.04 3.34 96 6.81 3.60 85 6.59 2.54 0.40
Suicidal ideationc 27 7.4%   96 29.2%   80 20%   6.24
aMantel-Haenszel tests.
bP < .01.
cP < .05.

CONCLUSIONS

This study examined the relationship between marital status and other demographic and key clinical characteristics among a group of middle-aged and older patients with schizophrenia and subsyndromal depressive symptoms (SSDs). Although this study utilized a sample of convenience, patients with schizophrenia and clinically meaningful depressive symptoms comprise a significant proportion of patients with schizophrenia. Our main findings were that quality of life and suicidal ideation were significantly related to marital status for this population. Those who were married had a higher quality of life and were less likely to have current suicidal ideation, whereas the divorced/widowed/ separated group had the greatest amount of suicidal ideation.

Consistent with the expectations of the study, quality of life was significantly higher in the marital/cohabitating group compared with the single group. The divorced/ widowed/separated group had mean QLS scores that were intermediate to those of the married and single individuals. This finding is consistent with previous research indicating that quality of life is lower for individuals with schizophrenia who are single.17 It is also consistent with the studies by Caron and colleagues (2005) that found that attachment (a sense of emotional closeness and security) emerged as a predictor of quality of life over a 6-month period in 143 patients with schizophrenia or schizoaffective disorder.33

The finding that married individuals in this study reported less suicidal ideation than unmarried individuals also was consistent with previous studies.34,35 Additionally, it is not surprising that divorced/widowed/separated individuals were identified as being at the greatest risk for suicidal ideation, given the literature indicating that those who endure a marital loss are at heightened risk for suicide. For instance, in the National Longitudinal Mortality Study, of 471,922 men and women, divorced individuals were twice as likely to commit suicide compared with their married counterparts.36

Contrary to the study’s hypotheses, no association was found between positive and negative symptoms or depression and marital status. Previous research has found that auditory hallucinations9 and total symptom scores10 were related to marital status in patients with schizophrenia; however, no association between either positive or negative symptoms of schizophrenia and marital status was found in this study. Perhaps even more surprising was the lack of relationship between marital status and symptoms of depression, as previous research has highlighted the importance of marital status with regard to well-being and depression, especially for men.37,38 However, the study’s selection bias (enrolling participants experiencing a narrow range of depressive symptoms) may have precluded our ability to find relationships between depressive symptoms and marital status.

It has been well established that patients with schizophrenia are less likely to marry than the general population,5,10,39,40 and this held true for this sample of patients with schizophrenia spectrum disorders as well. Comparing the results from this study with the US Census 2000 report on marital status in the general population age 15 and greater, a larger percentage of the study population had never been married (40.3% vs 27.1%, respectively).41 Only 12.8% of the participants were currently married. Consistent with other findings for patients with schizophrenia,6,22,42-44 females had higher rates of marriage (18.2% of females and 11.4% of males were married). On the other hand, a similar percentage of males and females had never married (36.4% of females; 41.3% of males). However, given the low representation of female participants in this study, these gender findings must be viewed cautiously.

In contrast to previous research that found that marriage in individuals with schizophrenia affects males and females differently, this study found no such gender association between marital status and outcome. Results from several previous studies have suggested that the gender of patients with schizophrenia has a direct effect on quality of life and an interactive effect with marital status; singles, and especially males, report the lowest quality of life.17,22 Additionally, there is some evidence to suggest a relationship between marital status and differing symptomatology in schizophrenia based on gender. In a study of 882 psychiatric patients with schizophrenia (521 male and 361 female), Walker10 found that formerly married men were the most symptomatic, and currently married men the least symptomatic. In contrast, married women had a higher rate of symptoms than the never-married or formerly married women.10 Of the many reasons that no association between gender and marriage was found in this study, the most likely has to do with sample size limitations; too few female participants may have been enrolled, resulting in a decrease in the statistical power needed to identify gender differences. Of course, it is also possible that gender effects do not exist in this older population with schizophrenia spectrum disorders and SSDs for the variables examined. More research is needed to answer this important question.

This study offers several important clinical implications. First, it may be reassuring for individuals with schizophrenia and schizoaffective disorder and their families to know that many individuals with these disorders do marry, even though the rates are low. Focused work on helping these patients improve their socialization skills, especially in intimate relationships, may be fruitful. Early intervention is especially important for promoting and supporting socialization in this population, which is underscored by the findings that those who marry appear to have a better quality of life and are less suicidal. Furthermore, efforts focused on helping individuals with schizophrenia or schizoaffective disorder maintains supportive marriages may prove beneficial. This is likely to include both general supports for the spouse as well as specific relationship enhancement strategies for the individuals with schizophrenia or schizoaffective disorder. Finally, those who do divorce may be an especially high-risk group for suicide. These individuals may need additional support and monitoring from family and professionals during this stressful transition.

This study has several strengths. Be only midlife and older adults were included in the sample, data on marriage are provided on a group of individuals with schizophrenia spectrum disorders largely overlooked in previous studies. Additionally, the use of 2 different sites was important with regard to maintaining diversity and increasing generalizability. However, the results of this study must be interpreted in the context of several limitations. First, the results of this study may not be generalizable to younger individuals with schizophrenia or those without depressive symptoms. Second, the current study takes into account only patients’ current marital status, and previous research has shown quality of the marital relationship45-47 and number and type of marital loss48 affect outcomes. Third, the predominance of male participants, especially at one of the sites, prevented careful examination of potential interactions of gender and marital status. Finally, this study was cross-sectional. Longitudinal follow-up would provide important information about the stability of our findings over time. In the coming decades, older adults will comprise an increasingly greater proportion of patients with schizophrenia, despite that fact that considerably less is known about this age group.49 As such, this study provides important information about the clinical characteristics of this understudied population. Further understanding of the degree to which marital status—serving, perhaps, as a proxy for relationship skills—is a protective factor for serious depression among individuals with schizophrenia and schizoaffective disorder is an important focus for future research.

ACKNOWLEDGEMENTS: Supported by MH 063931(SZ), MH6398 (JWK), the VISN 4 and VISN 22 MIRECC, and the University of California, San Diego Center for Community-based Research in Older People with Psychoses. In addition J.W.K. was supported by a VISN 4 CPPF grant. We also wish to thank the Cincinnati VA Medical Center and the University of Cincinnati College of Medicine for all of their support.

DISCLOSURES: Drs. Nyer, Kasckow, Lawrence, Golshan, Mr. Fellows, and Ms. Solorzano report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products. Dr. Zisook receives grant/research support from Pamlab, the National Institute of Mental Health, and the American Foundation for Suicide Prevention.

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CORRESPONDENCE: Maren Nyer, MEd, University of Virginia, Department of Human Services, The Curry School of Education, 405 Emmet Street, Charlottesville, VA 22903 USA E-MAIL: mbn4k@virginia.edu