The inconsistent findings from previous research on the relationship between one spouse’s alcohol abuse and the other spouse’s mental health indicate that the relationship is more complex than previously assumed. This study seconds this interpretation, as the results suggest that alcohol consumption was related to less spousal mental distress, whereas alcohol-related problems were either unrelated to spousal mental distress or related to higher levels of spousal distress. Bivariate analyses of the association between alcohol consumption and spousal mental distress were not sufficient to produce this result, whereas a slightly protective effect of alcohol consumption appeared when the acknowledged problems associated with alcohol abuse - in terms of CAGE scores - were adjusted for.
Alcohol-related problems, measured by CAGE, were in general related to an increase in spousal mental distress, although the specific type of problem that significantly predicted the outcome varied according to which variables were entered into the model. The strongest effects were found in model 4, where the effects of CAGE were adjusted for demography and alcohol consumption. The results are in accordance with results reported by Tempier et al. [3] who found a small increase in spousal mental distress associated with index persons with a minimum of two positive CAGE responses. In our study, both female and male spouses of persons who had felt bad or guilty due to excessive drinking had overall significantly higher mental distress than other spouses. Having felt bad or guilty due to excessive drinking involves a certain degree of realization that the drinking is causing problems either for oneself or for others, and as such may be indicative of long-term -or serious drinking problems. Also, male spouses of female index persons who had been criticized for excessive drinking had significantly higher scores on mental distress. Most likely, one of the persons having criticized the alcohol consumption is the spouse him/herself. A lack of cultural acceptance for a high consumption of alcohol among women may cause male spouses to criticize female spouses’ alcohol consumption more readily. However, the graver social stigma of female alcohol abuse may also cause male spouses to evade criticizing their spouses’ consumption. Thus, the item “Criticized” may in fact reflect a very high consumption, and possibly be highly suggestive of alcohol abuse among female index persons.
Including the variables in model 5 may represent an over-adjustment of the effects of the predictor variables, but is informative as to the magnitude of the additional variables’ joint mediating and/or confounding effects on the effects of index person alcohol consumption and problems. The effects of the CAGE items decreased for both male and female index persons when adding spousal alcohol variables and index person mental distress in model 5, indicating partial mediation or confounding by at least some of these additional variables. The decrease may be particularly due to a relatively strong effect (as judged by the standardized beta values) of the index persons’ mental distress, which seems to “take over” the effect of the worry expressed by the CAGE items. We find it likely that the observed mental distress mediates, rather than confounds, the effects of the CAGE items, implying that the estimates in model 5 are somewhat over-adjusted. On the other hand, the estimates in model 4 may be slightly under-adjusted, suggesting that the realistic values of the estimates are somewhere between those from model 4 and those from model 5.
The estimated effects of each of the CAGE items must be conceived as fractions of the total effect of CAGE, most of them down-adjusted because of inter–item correlations. However, the fact that the CAGE items behaved rather differently in their relationship with spousal mental distress after adjusting for alcohol consumption justifies the usage of each item as a single predictor. Using the CAGE items in the traditional manner – by using a cut off at two positive CAGE responses – would disguise this difference in directionality of the CAGE items, giving a less informative portrait of the relationship between our alcohol variables and spousal mental distress.
Spouses of index persons having felt the need to “Cut down” had significantly less mental distress compared with spouses of index persons who had not felt such a need (model 5). Also, the “Eye-opener” item of female index persons tended to be associated with less mental distress, although not significantly so. The other CAGE items seemed to be related to spousal mental distress, although at levels varying from non-significant to significant, and only significantly in model 4.
The results for alcohol consumption from model 4 indicate that there also may be constructive factors associated with drinking alcohol, after adjusting for alcohol-related problems. Our data were not based on diagnosis, and therefore we cannot be absolutely sure that the individuals categorized as high and very high consumers in fact have a problematic relationship to alcohol. By categorizing only the top 5% in a high and very high consumption group, most of the persons in these groups are probably abusers, as the 12-month prevalence rate of alcohol use disorders in Norway has been observed to be higher (16.4% for men and 6.0% for women) [19]. However, there will also most likely be high and very high consumers in our study who do not qualify for an alcohol abuse diagnosis, and consequently we cannot state positively that our consumption measure is indicative of alcohol abuse as such. Rather, our results indicate that altogether a high consumption is weakly related to good spousal mental health. This interpretation may be seconded by results from the Schuckit et al. [5] study. Although not statistically significant, Schuckit and colleagues found a tendency for spouses of alcohol abusers to have fewer psychiatric symptoms than spouses of non-abusers. A high consumption of alcohol may be related to other third factors not measured in this study. For instance, a high consumption of alcohol may involve more social activities, and being socially active may be protective against mental distress [18]. Also, drinking large quantities of alcohol may be related to a tendency to enjoy oneself - of being a bon vivant - which possibly may be constructive for the spouse.
Concordance for high alcohol consumption has previously been found to indicate high marital satisfaction [9], which in turn may cause less mental distress [11]. The significant interaction effects indicated that concordance for high alcohol consumption was related to significantly less mental distress and discordance for alcohol consumption to increased mental distress. Female index persons’ alcohol consumption showed a stronger negative (protective) relationship with mental distress among male spouses with high and very high alcohol consumption than among spouses with a low/normal consumption. Similar results were found for male index persons having felt the need to cut down on drinking and female spouses having been criticized for drinking. Female spousal mental distress tended to be more increased by the male index person having been criticized in spouses who had not had an “Eye-opener” than in spouses having had an “Eye-opener”, although this trend did not reach significance after a Bonferroni correction. These results may indicate that spousal discordant drinking patterns may increase the risk of experiencing mental distress, whereas spousal concordant drinking patterns may to a certain extent protect against mental distress, which may or may not be a function of marital satisfaction.
Previous research has suggested that the relationship between alcohol abuse and spousal mental distress may be dependent upon educational level [5]. Higher education is related to higher alcohol consumption, but also to lower frequency of binge drinking [20]. Mental disorders are more prevalent among individuals with low socioeconomic status [21]. We found no significant interaction effects suggesting a moderator effect of educational level.
Our results on alcohol consumption are in contrast to the results of the study by Maes et al. [12], who found significant cross-assortment between alcohol abuse in one partner and anxiety or depression in the other. Such cross-assortment implies a correlation between trait A in spouse 1 and trait B in spouse 2 after the correlation due to assortment for other correlated variables has been partialled out [12]. Our results on alcohol-related problems are consistent with those of Maes et al. Different methods may explain the partial discrepancy. The Maes et al. study was based on lifetime diagnoses obtained by structured interview, whereas our study examined current self-reported consumption, lifetime alcohol problems, and symptoms of anxiety and depression assessed by questionnaire. The study by Dawson et al. [4], who also found a higher risk of anxiety and depression among female spouses of male alcohol abusers, identified spouses of alcohol abusers by asking the respondents to indicate whether or not their spouses had an alcohol use disorder. Only a small fraction of their sample reported having husbands with alcohol use disorders, incongruent with the prevalence numbers of alcohol use disorders in the United States. This may imply that their results only apply for spouses of the most seriously afflicted alcohol abusers, which may be why such a high risk of spousal anxiety and depression was found. An even more important reason for the large effect size reported by Dawson et al. may have been a misclassification of the alcohol cases correlated by the outcome measure. That is, depressed persons may be more inclined to characterize their partners as alcohol abusers than are mentally healthy persons.
The sizes of the effects of a high and very high consumption on spousal mental distress in our study were quite small and probably would not have been detected as significant in a sample much smaller than ours. Despite the small effects, the tendency regarding positive aspects of a high consumption was clear, challenging the notion that a high alcohol consumption is exclusively related to negative aspects for the spouses. Due to our study’s large sample and precise estimates, this finding adds to the existing literature by showing that once the variation associated with problems related to drinking is accounted for, alcohol consumption seems either directly or indirectly to be related to good spousal mental health.
Methodological considerations
The existing literature on the relationship between one spouses’ alcohol abuse and the other spouses’ mental distress has for the most part only investigated the relationship between male alcohol abusers and female spouses. Also, several of the previous studies have been based on samples of limited generalizability. The present study is based on data from both male and female spouses, from a large sample, representative of the Norwegian adult population, implying a high generalizability of our results.
However, there are methodological limitations to our study. The response rate for the individuals having returned both Q1 and Q2 (59.5%) may have caused a selection bias. However, a recent attrition study of the HUNT 2 sample showed that high alcohol consumption in a previous HUNT study only predicted non-participation in HUNT 2 moderately well (OR= 1.27 for the top 3% consumption) [22]. Also, even highly selective non-participation only seems to moderately influence associations between variables [23], giving reason to believe that our estimates have not been severely affected by non-participation.
The lack of diagnostic measures rendered us incapable of positively identifying alcohol abusers among the index persons. As shown by the mean values of the high and very high consumption groups, the consumption reported may not be indicative of alcohol use disorders. However, alcohol consumption is usually underreported in population studies [24], making it feasible to assume that the actual consumption is considerably higher than reported. The degree to which underreporting leads to misclassifications depends upon whether or not the underreporting is systematic - that is, whether the amount of under-reporting correlates highly with the real consumption, such that most people report, say, half their real consumption - or non-systematic. The distribution of the consumption in our sample corresponds well with distributions normally observed in alcohol consumption research, in which approximately 2/3 of the population reports drinking less than the average consumption and 15% reports drinking more than twice that of the average [25]. This suggests that the underreporting is systematic, and that the high and very high consumption groups in fact primarily include high and very high consumers – who for the large part will be individuals with alcohol use disorders. By choosing strict criteria for what is considered high and very high consumption, there is a much higher probability of misclassifying a real case as a non-case than of misclassifying a non-case as a case. To avoid substantial attenuation of the results, keeping the case groups relatively free from false positives is much more important than is avoiding some pollution of the large non-case group by (a relative low fraction of) false negatives. Therefore, the choice of strict criteria defining the top five percentile as high and very high consumers with potential alcohol problems is methodologically sound.
Alcohol consumption was measured as current consumption, whereas alcohol-related problems were measured as lifetime problems. The outcome, mental distress, was also measured as current distress. Current disorders are more predictive of co-occurring problems in the spouse [1], which may have deflated the observed association between alcohol-related problems and spousal mental distress. Furthermore, individuals abstaining from alcohol were asked to skip the CAGE, which may have caused previous alcohol abusers to skip this measure given that they were abstaining at the time of the survey. It was not possible to separate steady heavy drinkers from binge drinkers in this data material. Previous research has found that spouses of steady heavy drinkers experience less mental distress than spouses of binge drinkers – although the total alcohol consumption of steady heavy drinkers in general is higher than that of binge drinkers [6]. Being able to distinguish effects of steady heavy drinking from effects of binge drinking on spousal distress would have added information to our results.
The mental distress index was composed of two separate mental health measures, the HADS and the CMD, which has not previously been used in a combined version, and of which only the first has previously been validated. However, we still judged the face validity of the combined index to be better than that of the HADS alone, because the HADS depression items seem not to include negative emotionality. The correlation between the HADS scores and the scores from the combined index was 0.96 for men and 0.97 for women, so clearly the content of the HADS was not radically changed after the inclusion of the CMD items. Also, the internal consistency of the measure increased after including the CMD. Accordingly, even if our measure was not strictly validated, we must assume that the validity was as least as good as for the HADS instrument.
Our design is not suited to decide about the causal direction between alcohol abuse and spousal mental distress. Although not evidence-based, we would judge a causal direction from alcohol abuse in one of the spouses to mental distress in the other as more plausible than the reversed causal pathway, but there are probably also people who drink to drown problems related to their spouse’s’ poor mental health.
Finally, and related to the problem of unknown causality, our results could be confounded by effects of assortative mating, primarily for alcohol consumption, for which there is a strong spouse correlation. The association between alcohol abuse in spouse A and mental health in spouse B could partly reflect assortative mating for alcohol abuse together with a relationship between own alcohol abuse and own mental health. However, recent results based on HUNT data suggest that most of the observed spouse similarity for alcohol consumption reflects convergence during the spouses’ life together rather than assortative mating. Only a minor part of the spouse similarity seems to have been present at the time the spouses started to see each other [26]. Also, the association between own alcohol abuse and mental health is moderate (Table 1), implying that an important confounding by assortative mating is unlikely.
