Dyadic adjustment and marital communication of persons with depression

One of the most important relationships between a man and a woman is marriage. Marriage is a social union as well as a legal contract between people that creates kinship. It is a primary institution of society. Marriage involves an emotional and legal commitment that is quite important in any adult life and even Conclusion: There is need to involve the spouse in the treatment process, and couple-based interventions will help for better marital adjustment and communication with depression patients compared to the healthy controls.


INTRODUCTION
Depressive disorders are one of the major leading causes of disability due to their high prevalence rates. ey will cost a huge burden financially as well due to lack of productivity. [1] Depression is one of the common mental disorders, and persons with depression have a higher risk of suicide rate than the general population. Risk factors of depression are manifold, but family and marital factors have been recognised as essential reasons. In 2010, depression was estimated as the second most common cause of years lived with disability (YLD) worldwide. [2] Marriage is one of the basic social institutions in human society. It produces family and fulfils human society's needs in an organised way, which is the distinct feature from animal society. A healthy marital relationship must have following characteristics: a) positively oriented healthy communication between married couples, b) presence of reciprocal as well as complementary relationship, c) emotionality in relationship or presence of emotional attachment between couples, and d) mutual sense of responsibility. [3] e systemic transactional model (STM) explains that rather than the individualistic view of stress and coping, it is more of partners' mutual interdependent experiences. During interactions between the couples, the dyad acts as the medium of sharing feelings, negotiating opinions, and coping with stressors. [4,5] e general consensus suggests that marriage has potential protective qualities against psychological problems including depression. [6,7] However, some past observations suggested that the psychological benefits of marriage largely depend on the interpersonal processes operating in the marital dyads. [8][9][10] Globally, depressive disorders are one of the top three leading causes of YLD in 2017 for both genders. [11] Numerous studies had shown that psychiatric disorder has significant negative impacts on almost all aspects of marital life. [12][13][14][15] Not only marital life, perhaps, but the psychiatric disorder also has a negative impact on a person and his/her all spheres. Psychiatric disorders limit one's performance and abilities in every sphere of life. Some research indicates that marital problems and psychological disorders reciprocally influence one another. [16] Nevertheless, it is equally true that there is no simple explanation for the association between the poor quality of marriage and depression. Both poor marriage and depression form part of the complex system of interactions represented in the bi-directional relationship between marriage and depression. [17,18] In Indian society, marriage is considered one of the most important institutions

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that has a significant role in the interplay of social norms and values. Marriage is a social bond and meets the intimate needs of human beings which guide the path for procreation and maintenance of the human race. Empirical evidence showed that men and women in satisfying marriages appear to be at lower risk for a psychiatric disorder than other segments of the population. [19][20][21] Several past empirical studies showed that in marital dyads with one partner with depression have some distinctive characteristics, such as paucity of verbal and nonverbal positivity, asymmetry in interaction patterns between couples, presence of a high degree of passivity/ withdrawn relationships between partners, frequent occurrences of negative statements between the couples (e.g. complaints, negative self-statements), and negative reciprocity between them. [22,23] Couples with a depressed partner were found to be negative and less congenial in their marital interactions, and depressive symptoms also predict the weakening of the couple's marital adjustment and satisfaction. [22,24,25] METHODS AND MATERIALS e present study aimed to compare the pattern of dyadic adjustment and marital communication between married individuals with depression and married healthy controls.
is was a cross-sectional study. Purposive sampling was used to collect the data from the outpatient department and psychosocial unit of the Central Institute of Psychiatry (CIP), Kanke, Ranchi, Jharkhand, India. is study was conducted with 60 samples, 30 married individuals with depression as study group and control group with 30 samples matched with the age, sex, duration of the marriage, and family income with the study group. Objectives of the study were to compare dyadic adjustment and marital communication among persons with depression and healthy controls, and to look at the difference between males and females suffering from depression. Inclusion criteria were persons with depression diagnosed according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10),[26] married for at least two years living with the spouse in the age range of 20-50 years with a minimum of fi h class education. Healthy controls were taken a er screening with the General Health Questionnaire (GHQ)-12;[27] persons who scored less than or equal to three were considered as healthy controls. Exclusion criteria were the presence of comorbid psychiatric, physical, or neurological problems. A er obtaining permission from the institutional review board of CIP, consent was obtained from the respondents, data was collected, and all ethical considerations were taken care of in the process of data collection.

Sociodemographic datasheet
Sociodemographic datasheet was prepared by the researcher to collect the basic sociodemographic details of the respondents.

General health questionnaire (GHQ)-12
GHQ-12[27] is a screening device for identifying minor mental health issues in the general population. It consists of 12 items and scored on a four-point Likert-type scale (from zero to three). e score was used to generate a total ranging from zero to 36. e positive items were corrected from zero (always) to three (never), and the negative ones from three (always) to zero (never). High scores indicate worse health. Internal consistency of this tool is excellent. A high degree of internal consistency is found for all the 12 items with Cronbach's alpha value of 0.37-0.79, while total score was 0.79.

Dyadic adjustment scale (DAS)
e Dyadic Adjustment Scale (DAS) [28] is a 32-item selfreported scale. It has been used in many studies to measure marital adjustment and satisfaction. It has four subscales: dyadic satisfaction, dyadic cohesion, dyadic consensus, and affectional expression. Scores range from zero to 151 on the total scale; a higher score indicates better adjustment. e tool consistently discriminates between distressed and nondistressed couples, and cut off scores of 97 and 100 have been used. Internal reliability estimates of 0.96 were found for DAS; Cronbach's alpha for this sample was 0.93.

Marital communication inventory (MCI)
e Marital Communication Inventory (MCI) [29] is a selfreport measure of marital communication that assesses processes like spouse's ability to express themselves and their style of expressions. It is a 46-item inventory, arranged on a fourpoint rating scale with options of usually, sometimes, seldom, and never. e tool yields a single total score. Scores range from zero to 138. Higher scores indicate better communication. e spilt-half reliability was 0.93. e inventory could also reliably discriminate between individuals with good and poor marital communication.
e tool has been widely used in marital research, evaluation of marital counselling, and family life education programmes. It has also been widely used to assess communication and therapy change in Indian couples. [30] Table 1 shows the comparison of scores in different domains and aggregate of DAS between depressive patients and healthy controls. Very significant differences (p<0.001) were observed between these two groups in both domain specific and aggregate scores of DAS. Table 2 shows the marital communication between the study and control group. Very significant difference (p<0.001) was observed between these two groups in the scores of MCI. Table 3 shows the comparison of dyadic adjustment and marital communication of males and females of depression group.

RESULTS
ere was no difference found in the domains of dyadic consensus, dyadic satisfaction, dyadic cohesion, affectional expression, marital communication, comparison between males and females.

DISCUSSION
e aim of the present study was to compare the pattern of dyadic adjustment and marital communication between married individuals with depression and married healthy controls. A er fulfilling the inclusion and exclusion criteria, the current study recruited 30 married persons with depression and 30 married healthy controls. e study group was recruited from outpatient department and psychosocial unit of CIP and healthy control group was taken from the hospital surroundings. e mean age of the study group of depressed patients is 35.33±6.94 years and control group is 35.83±4.69 years, consisted of 30 married healthy controls matched with the samples of the study group on sociodemographic parameters (e.g. age, sex, duration of the marriage, and monthly income). In India, the proportion of disability was estimated to be 67% to 70% among major depressive disorder. [31] Disability can affect marital relationships; the current dyadic adjustment scores and marital communication were found to be below cut-off scores among persons with depression.
Comparison of the dyadic adjustment of the depressed patients and the healthy controls on various domains of DAS, [28] i.e. dyadic consensus, dyadic satisfaction, dyadic cohesion, and affectional expression was made. Very significant differences (p<0.001) were seen between patients' group and healthy control group in all domains of DAS as well as the total score of DAS. is finding is consistent with numerous studies done in the past in relation to dyadic communication and adjustment of depressed patients. [14,32,33] In the present study, individuals with depression showed problems (low scores in all areas of DAS in comparison to healthy controls) in dyadic adjustment because of their illness, which might cause marital problems in them. Empirical evidence had shown in the past that marital problems and depression are known to be among the most frequent problems for which adults seek treatment in a mental health facility. [34,35] Being depressed is o en proved to be an antagonistic factor for marital life and it may cause significant distress to spouses of the depressed people. [36,37] is way present study has been in consonance with previous studies mentioned earlier.
In Asian countries, one of the most prominent aspects of couple's relationship is marital communication. [38,39] In the present study, marital communication has also been found to be problematic in depressed patients as depressed patients had scored significantly lower than healthy controls on MCI. Past studies showed that poor marital quality (characterised by shallow and insipid communications between spouses, lower presence of emotionality in communicational styles and contents, and overall faultiness in spousal communication) might lead to depression and depression may lead to poor marital quality, and it is probable that, when both are present, they reinforce each other. So, this way present study is also in consonance with previous studies that communication pattern as well as resources in married depressed people, is problematic because of inadequacy and inaccuracy. [37,40] at is why in the present study, married depressed people scored significantly lower than healthy controls. e quality of interpersonal relationship between the couple is also important while handling married depressive patients; these issues should not be neglected for holistic care. Longitudinal studies have shown that couple problems and depressive

Limitations
1. e present study was conducted with small sample size and purposive sampling design le scope for potential selection bias in the study. 2.
e healthy controls' sociodemographic parameters varied from the study group as the patient group approaching for treatment had a diverse demographic structure while healthy controls were the subjects of the hospital surroundings only.

Conclusion
In the current study, the dyadic adjustment and marital communication were found to be low as reported by persons with depression compared to healthy control, which indicates the need for couple-based psychosocial interventions for the married persons with depressive disorders. If depressive symptoms act as risk factors in marital relationship, couple-based interventions will address depressive symptoms as well couple relationship issues. Couple-based indigenous psychosocial interventions are needed with this population.