Drug and Alcohol Dependence 138 (2014) 124–129
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Interpersonal violence against wives by substance dependent men Nanjayya B. Subodh ∗ , Sandeep Grover, Manpreet Grewal, Seema Grewal, Debashish Basu, Surendra K. Mattoo PGIMER, Department of Psychiatry, Nehru Hospital, PGIMER, Chandigarh 160012, India
a r t i c l e
i n f o
Article history: Received 1 October 2013 Received in revised form 13 January 2014 Accepted 11 February 2014 Available online 23 February 2014 Keywords: Alcohol Opioids Violence Intimate partner violence Dependence
a b s t r a c t Background: Indian research on intimate partner violence (IPV) with substance use covers only alcohol, and very few studies have reported on IPV with other substances. The study aims to assess IPV against wives by substance dependent men. Methods: The study sample was recruited by convenient sampling from men (and their wives) seeking treatment at a de-addiction centre in North India between October, 2011 and February, 2012. The consenting wives self-administered the violence questionnaire. Results: 267 wives were recruited into the study. The prevalence rates for IPV were: 55% for the whole sample, 63.19% for alcohol dependence and 42.33% for opioid dependence. IPV was associated with higher age of husband, lower education or unemployment of either spouse, lower income of family and nuclear family structure. Conclusions: Present research confirms that IPV against wives is highly prevalent among substance dependent men, more with alcohol dependence as compared to opioid dependence. Addressing IPV should be an integral part of substance abuse management. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Intimate partner violence (IPV) is understood as any behaviour within an intimate relationship that causes any harm (physical or psychological or sexual) to the partner or spouse. It includes acts of physical aggression (slapping, hitting, kicking or beating), psychological abuse (intimidation, constant belittling or humiliation), forced sexual intercourse, or any other controlling behaviour (isolating a person from family and friends, monitoring their movements and restricting access to information or assistance; Klostermann, 2006; Johnson, 2006; Saltzman et al., 2002). Traditionally considered as a private family matter, IPV remained hidden from the public view for long. However, the changing times and values have now made it a public health issue that requires the attention of both the treatment community and the criminal justice system. There is a large body of research from the West linking substance use and abuse with domestic violence. Substance abusers, particularly alcohol abusers, frequently indulge in partner violence both during intoxication and withdrawal phase (Poulose and Srinivasan, 2009). Severity of domestic violence increases with alcohol use
∗ Corresponding author. Tel.: +91 1722756818. E-mail address: [email protected] (N.B. Subodh). http://dx.doi.org/10.1016/j.drugalcdep.2014.02.017 0376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.
(Johnson, 2001; Kantor and Straus, 1987). About half of the partnered men who sought treatment for the substance abuse reported indulging in partner violence in the past year (Chermack et al., 2000; Fals-Stewart and Kennedy, 2005) and being 11 times more likely to abuse their partner on a day when they took alcohol (FalsStewart, 2003). In India, substance use is more prevalent in men. The largest community based study showed nearly one in every four adult men using one or more substances other than tobacco (Ray, 2004). Over the years alcohol and other substance use disorders have increased in clinical population (Murthy et al., 2010; Basu et al., 2012). The most commonly used substances in north India are alcohol and various opioids (Basu et al., 2012; Ray and Chopra, 2012; Chavan et al., 2007; Varma et al., 1980). The Indian research on IPV is sparse. The International clinical epidemiologists network (INCLEN) report on domestic violence suggested that the husband’s drunkenness was a significant risk factor for domestic violence (Ahuja et al., 2000). Others showed that compared to the general population alcohol users indulged in IPV more frequently (Ahuja et al., 2000; Kumar et al., 2005). IPV has been reported to be associated with problematic alcoholic users in one third to half of cases in a community-based study (Gururaj et al., 2006) and in 20–60% in two other studies (Kumar et al., 2005; Babu and Kar, 2009). Thus, while there is some research on IPV and alcohol use, there is no data on IPV and other commonly abused
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substances like opioids. More importantly, none of the existing research specifically assessed the wives of men abusing other substances like opioids. In India, men seeking treatment for their substance dependence are usually accompanied by their wives. This provides a unique opportunity to assess IPV experience directly from such wives. In view of the lack of Indian data on IPV for different substances of abuse and from the victims themselves, the present research aimed to study the prevalence, socio-demographic correlates and different types of IPV experienced by the wives of those seeking treatment for alcohol or opioids dependence. 2. Methods 2.1. Setting The study was conducted at the drug de-addiction and treatment centre (DDTC) at the post graduate institute of medical education and research (PGIMER), Chandigarh. DDTC PGIMER caters to 20 inpatients and yearly average of 1500–1800 new outpatients. Thus, most of our patients are managed as outpatients. Almost all the patients are accompanied by their family members who are involved in patient care and treatment. Almost all (99.5%) of our patients are male and around two third of them(62.5–76.8%) are married (Basu et al., 2012). Participants for this study were recruited from both the inpatient and outpatient settings. To be included in the study, the patients were required to: be older than 18 years of age, fulfill the diagnostic criteria for either alcohol or opioid dependence as per the international classification of diseases, 10th revision (ICD-10), and been living with their wife for at least 1 year. Patients with comorbid severe mental disorders like psychotic, affective and obsessive compulsive disorders were excluded. The wives were required to be able to read hindi, punjabi or english. Wives who had psychotic disorders, mental retardation, dementia and organic brain disorders were excluded. This was assessed by a psychiatrist based on a semi-structured interview. Those couples who were already in the legal process of mutual divorce were excluded. Participants were recruited by convenient sampling during the intake period of October, 2011–February, 2012. The sample consisted of 267 patients and their spouses. 2.2. Instrument for assessment of intimate partner violence A modified version of the domestic violence questionnaire (DVQ) by Morgan et al. (2010) was used to assess the IPV. DVQ has 21 items, covering the 3 broad dimensions of IPV: physical violence, threatening behaviour and controlling behaviour (Grover et al., 2013). One item each was added to the questionnaire to assess violence during pregnancy and general level of fearfulness from patients in wives. All the items are answered as ‘yes’ or ‘no’. To facilitate self administration the questionnaire was translated and back translated from english into hindi and punjabi by bilingual experts (Menon et al., 2012). 2.3. Ethical issues The study was funded by the institute research fund and was approved by the ethics review board of the institute. All the patients and their spouses were recruited after obtaining a written informed consent. 2.4. Procedure During the intake period all the inpatients and outpatients attending DDTC were approached and the aim of the study was explained. Those patients and wives who provided written informed consent were evaluated for inclusion and exclusion criteria. Socio-demographic and clinical profile of the consenting patients was recorded. Wives fulfilling the study criteria were invited to complete the modified DVQ in their preferred language. Privacy was ensured for the wives while completing the questionnaire. Further, the scale was administered after ensuring confidentiality of the information provided by the wives and they were informed that the information would not be shared with their spouses. 2.5. Statistical analysis Analysis was done by using SPSS-14 (statistical package for the social sciences, 2005, Chicago, IL, USA). Frequencies and percentages were computed for discontinuous socio-demographic and clinical variables and each item of DVQ. Mean and standard deviation with range for continuous variables were calculated. Chisquare test, t-test, ANOVA and Fisher exact test were used for comparisons as per the requirement. Correlations among socio-demographic, clinical and IPV variables were carried out using Pearson’s product moment correlation and Spearman’s rank correlation.
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3. Results 3.1. Sample During the study period (October, 2011–February, 2012), 613 new patients were evaluated at the DDTC, of whom 380 were currently married. Of the 380 patients, 267 participated in the study along with their wives. The reasons for exclusion of 113 patients were: 20 cases were dependent on tobacco only, 55 cases had psychiatric comorbidity, 14 refused to give consent and 24 had both opioid and alcohol dependence. Of the 267 patients, 61.1% (N = 163) were dependent on alcohol and 38.9% (N = 104) were dependent on opioids. In the alcohol group comorbid nicotine dependence was more prevalent (151 out of 163; 92.63%) compared to the opioid dependence group (90 out of 104; 86.53%). None of the patients reported harmful use or dependence on other substances than mentioned above.
3.2. Socio-demographic profile (Table 1) The mean age of the patients was 38.46 ± 9.27 years with a range of 19–66 years and that of the wives was 35.13 ± SD − 9.01 years with a range of 19–63 years . Three fourths of the patients and their wives were studied upto matric and the mean number of years of education of wives was slightly less than that of the patients. About three-fifth of the patients were doing some kind of skilled work, one-fifth were professionals and another one-fifth were unemployed. A majority (87.6%) of the wives were homemakers. Slightly more than half of the couples belonged to non-nuclear families and three-fifths were residing in urban locality. In three-fourths of the cases, monthly family income was less than rupees 19,575. The average monthly income was three times more than average monthly income of the Indian family (Government of India, 2013). Compared to opioid dependent patients and their wives, alcohol dependent patients and their wives were older. Compared to the opioid dependent group, the alcohol dependent group had more families with income of ≥rupees 19,575 and were living independently from their adult parents. Wives of the substance dependent patients were not using any substances or psychotropic medications or suffering from any known psychiatric diagnosis. Substance dependent men were more educated compared to their wives (r = 0.127, p = 0.038).
3.3. Prevalence and forms of intimate partner violence (IPV) (Table 2) Lifetime experience of IPV among wives averaged 55.1%, being higher in alcohol dependence than in opioid dependence group (63.19% vs. 42.31) . For the whole group, among the different types of violence, the threatening behaviour was much less common with mean of 0.70 ± 01.01, compared to controlling behaviour with mean of 1.75 ± 01.97 and physical violence with mean of 1.63 ± 02.41 behaviours. The prevalence of different types of violence ranged 2.2–34.5% for physical, 15.7–28.8% for threatening and 1.97–46.4% for controlling behaviours. Overall, 56.2% wives experienced at least one type of violence. Among those who experienced IPV (40% of the total sample; 70% of those who experienced IPV) reported experiencing violent behaviour in the range of 1–8 and only a minority of the spouses/partners reported experiencing ≥9 violent behaviours Table 3. Physical violence in the last 12 months was reported by 18.7% wives. Feeling afraid of their partners was reported by 21.3% wives, while 9.4% reported experiencing violence during pregnancy.
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Table 1 Socio-demographic profile of the patients and the wives.
Profile of patients Age in years – Education Upto matric Beyond matric Education in years – Occupation Unemployed Skilled Professional – Family income Upto 19,575 More than equal to 19,575 – Family typea Nuclear Non-nuclear – Locality Urban Rural – Profile of wives Age in years – Education Upto matric Beyond matric Education in years – Occupation Homemakers Skilled Professional
Whole group (N = 267) Mean ± SD/N (%)
Alcohol dependence (N = 163) Mean ± SD/N (%)
Opioid dependence (N = 104) Mean ± SD/N (%)
Alcohol vs. opioid dependence Chi-square value/ t-test
38.46 ± 9.27
41.07 ± 09.33
34.37 ± 07.58
6.147 (p = 0.001)
204 (76.4) 63 (23.6) 10.45 ± 4.04
124 (76.07) 39 (23.93) 10.16 ± 4.21
80 (76.92) 24 (23.08) 10.89 ± 3.74
0.025 (0.873)
52 (19.5) 165 (61.8) 50 (18.7)
30 (18.40) 98 (60.12) 35 (21.47)
22 (21.15) 67 (64.42) 15 (14.42)
2.121 (0.346)
199 (74.5) 68 (25.5)
113 (69.33) 50 (30.67)
86 (82.69) 18 (17.31)
5.977 (p = 0.014)
120 (44.9) 147 (55.1)
84 (51.53) 79 (48.47)
36 (34.62) 68 (65.38)
7.344 (p = 0.007)
159 (59.6) 108 (40.4)
104 (63.80) 59 (36.20)
55 (52.88) 49 (47.12)
3.143 (p = 0.076)
35.13 ± 9.01
37.52 ± 09.27
31.38 ± 07.15
5.746 (p = 0.001)
207 (77.5) 60 (22.5) 9.53 ± 04.86
128 (78.53) 35 (21.47) 09.13 ± 04.99
79 (75.96) 25 (24.04) 10.15 ± 04.60)
0.240 (0.624)
234 (87.6) 18 (06.7) 15 (05.6)
146 (89.57) 10 (06.13) 07 (04.29)
88 (84.62) 8 (07.69) 8 (07.69)
1.711 (0.425)
1.451 (p = 0.148)
1.686 (p = 0.093)
a Nucelar family setup means in which a couple is living with/without their children and non-nuclear family set-up means where the couple is living with their parents/married or unmarried siblings.
3.4. Comparison of IPV between alcohol and opioids Comparatively, the alcohol group reported higher mean number of physical violence (1.97 ± 2.59 vs. 1.10 ± 2.00, p = 0.004), whereas the opioids group reported higher mean number of controlling behaviours (1.20 ± 1.72 vs. 0.86 ± 1.93, p = 0.021). Different types of specific violent behaviours, like being grabbed or shoved (40.49% vs. 25.00%, p = 0.009), punched on the body/arms/legs (34.36% vs. 15.38%, p = 0.001), punched in the face (36.81% vs. 23.08%, p = 0.018), attempt to burn (03.68% vs. 00.00%, p = 0.048), criticism (49.69% vs. 30.77%, p = 0.002) and locked in the house (10.43% vs. 00.96%, p = 0.003) were reported more by the alcohol group. 3.5. Socio-demographic factors associated with partner violence Patients with reported IPV were older (mean ± SD: 39.57 ± 9.03 vs. 37.08 ± 9.4, p = 0.028) than those whose wives did not report IPV. Patients who were matric completers more frequently indulged in shouting and screaming (52.4% vs. 39.3%, p = −0.03) and kept the partner short of money (26.9% vs. 15.6%, p = −0.02) than those wives who did not complete matric education. Overall, patients indulging in partner violence were less educated (mean ± SD: 9.97 ± 4.31 vs. 11.01 ± 3.61, p = 0.037), and the number of years of education was significantly less for those who indulged in shouting and screaming (mean ± SD: 9.87 ± 4.18 vs. 10.94 ± 3.86, p = 0.030) compared to
those who were more educated. Those with family income of upto rupees 19,575 more frequently kept the partner short of money (25.6% vs. 10.3%, p = 0.008), and their partners were afraid of them (24.62% vs. 11.76%, p = 0.02) than those who were earning more than rupees 19,575. Patients staying in nuclear family more frequently indulged in any form of partner violence (62.5% vs. 49%, p = 0.027), and indulged in violent behaviours like grabbing and shoving (43.33% vs. 27.2%, p = 0.006), punching on body/arms/legs (33.33% vs. 21.76%, p = 0.034), punching on the face (40.83% vs. 23.8%, p = 0.003), kicking the partner to the floor (16.66% vs. 6.8%, p = 0.011), punching, kicking or throwing things at the partner (32.5% vs. 19.04%, p = 0.012), and criticizing their partner (50% vs. 36%, p = 0.022) compared to those who were not living in a nuclear family. The age of the patients had a positive correlation with the mean of threatening behaviours (r = 0.127, p = 0.038) and total number of violent behaviours (r = 0.131, p = 0.032). Similarly, education of the patients had significant correlations with violent behaviours in the form of total number of controlling behaviours (r = 0.121; p = 0.048) and overall total number of violent behaviours (r = 0.126; p = 0.04). Patients staying in nuclear family set up more frequently indulged in physical violence (mean ± SD: 2.07 ± 2.51 vs. 1.26 ± 2.26, p = 0.001), threatening behaviour (Mean ± SD: 0.82 ± 1.05 vs. 0.59 ± 0.96, p = 0.039), controlling behaviours (mean ± SD: 1.79 ± 1.96 vs. 1.32 ± 1.81, p = 0.032) and overall
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Table 2 IPV profile of the study sample. Whole Group (N = 267)
Do you think you have ever experienced partner violence? – Physical violence Grabbed or shoved you Punched you on body/arms/legs Punched you in the face Forced you to have sex Physically violent to you in other way Kicked you on the floor Choked or held hand over your mouth Used weapon or object to hurt you Tried to strangle you Tried to burn you Tried to drown you Mean number of physical violence Physical violence in the past 12 months – Threatening behaviour by partner Punched, kicked or threw things Threatened you with fist, hand or foot Threatened to kill you Mean number of threatening behaviour – Controlling behaviour by partner Shouted, screamed or swore at you Criticized you Checked up on your movements Restricted your social life Tried to control you in any other way not physical violence Kept you short of money Locked you in the house Mean number of controlling behaviour Mean number of overall violence Have you ever felt afraid of your partner? Faced violence during pregnancy
Opioid dependence group (N = 104)
Alcohol vs. opioid groups (p value)
Mean ± SD/ N (%)
Alcohol dependence group (N = 163) Mean ± SD/ N (%)
Mean ± SD/ N (%)
Chi-square value/ t-test
147 (55.1)
103 (63.19)
44 (42.31)
11.18 (0.001)
92 (34.50) 72 (27.00) 84 (31.50) 41 (15.40) 57 (21.30) 30(11.20) 13 (04.90) 20 (07.50) 11 (04.10) 06 (02.20) 09 (03.40) 1.63 ± 2.41 50 (18.7)
66 (40.49) 56 (34.36) 60 (36.81) 29 (17.79) 41 (25.15) 23 (14.11) 11 (06.75) 14 (08.59) 08 (04.91) 06 (03.68) 07 (04.29) 1.97 ± 2.59 35 (21.47)
26 (25.0) 16 (15.38) 24 (23.08) 12 (11.54) 16 (15.38) 07(06.73) 02 (01.92) 06 (05.77) 03 (02.88) 00 (00.00) 02 (01.98) 1.10 ± 2.00 15 (14.42)
6.74 (0.009) 11.60 (0.001) 5.55 (0.018) 1.91 (0.167) 3.60 (0.057) 3.46 (0.063) 3.19 (0.074) 0.72 (0.393) 0.65 (0.417) 3.91 (0.048) 1.09 (0.295) 2.93 (0.004) 2.07 (0.150)
67 (25.1) 77 (28.8) 42 (15.7) 0.70 ± 1.01
46 (28.22) 53 (32.52) 30 (18.40) 0.79 ± 1.05
21 (20.19) 24 (23.08) 12 (11.54) 0.55 ± 0.94
2.17 (0.140) 2.75 (0.097) 2.25 (0.133) 1.92 (0.055)
124 (46.4) 113 (42.3) 38 (14.2) 39 (14.6) 20 (07.5)
82 (50.31) 81 (49.69) 27 (16.56) 29 (17.79) 15 (09.21)
42 (40.38) 32(30.77) 11 (10.58) 10 (09.62) 05 (04.81)
2.51 (0.113) 9.31 (0.002) 1.86(0.172) 3.40 (0.065) 1.77 (0.183)
58 (21.7) 18 (06.7) 1.75 ± 1.97 3.86 ± 4.85 57 (21.3) 25 (09.4)
34 (20.86) 17 (10.43) 0.86 ± 1.93 4.51 ± 5.11 41 (25.15) 17 (10.43)
24 (23.08) 01 (0.96) 1.20 ± 1.72 2.85 ± 4.23 16 (15.38) 08 (07.69)
0.18 (0.668) 9.05 (0.003) 2.32 (0.021) 2.76 (0.006) 3.60 (0.057) 0.56 (0.454)
total number of violent behaviours (mean ± SD: 4.69 ± 5.02 vs. 3.18 ± 4.60, p = 0.004) more than those patients who were living in a non nuclear set up. Wives who were less educated more frequently faced physical violence (r = 0.131, p = 0.032), threatening behaviour (r = 0.130; p = 0.033), controlling behaviour (r = 0.154; p = 0.012) and higher overall total number of violent behaviours (r = 0.164; p = 0.007) than those wives who were more educated. 4. Discussion The present study aimed to assess the IPV experienced by the spouses/partners of those dependent on alcohol or opioids. The IPV
reported by 55% of wives in our study is very similar to that reported in other studies from India conducted in de-addiction clinic settings and in the general population (Kumar et al., 2005; Chandra et al., 2009; WHO, 2005). Studies from the West also suggest that while 25–50% of substance dependent patients own up indulging in IPV, 50% of the women reporting partner-IPV attribute it to the partner’s substance abuse/dependence (Bennett and Bland, 2013). The prevalence rate of IPV in our study is also within the 18–70% range of spousal IPV reported from different parts of India; although these studies did not focus specifically on the wives of substance abusers (Ray and Chopra, 2012; Ahuja et al., 2000; Kumar et al., 2005; Chandra et al., 2009; World Health Organization, 2005; Sinha et al., 2012; Jejeebhoy, 1998; IIPS and Macro International, 2007;
Table 3 Correlation between socio-demographic profile and domestic violence questionnaire. Age (p)a Physical violence Threatening behaviour Mean number of threatening behaviour Controlling behaviour Mean number of controlling behaviour Mean number of overall violence p = client; s = spouse a Spearman rank correlation. b Mann Whitney U test. * p ≤ 0.05. ** p ≤ 0.001.
Education (p)a
Education (s)a
Family setupb
−0.131 −0.130*
6871** 7694*
−0.154*
7545*
−0.164*
7109*
*
0.127*
0.131*
0.121* 0.126*
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Verma and Collumbien, 2003; Jeyaseelan et al., 2007; Varma et al., 2007). Existing Indian research on spousal IPV is not specifically focused on drug dependence. However, there is the general suggestion that alcohol use is associated with higher prevalence of IPV (Ahuja et al., 2000; Chandra et al., 2009; World Health Organization, 2005). Because a majority of our patients come from the states of Punjab and Haryana, the interpretation of our findings require an understanding of the IPV in the general population in India in general and in our catchment area in particular. For these 2 states the national family health survey-3 reported prevalence of any one type of spousal violence experienced by women ranging 26.7–28%, compared to the national average of 39.7%. The prevalence of spousal IPV in our study at 63.2% for alcohol dependence and 42.3 for opioid dependence clearly indicates that prevalence of IPV is significantly higher in wives of alcohol or opioid dependent men. The implication of these findings is that clinical evaluation of alcohol and opioid dependent patients should also focus on the marital unit and psychological morbidity in the spouses. There is additional evidence suggesting IPV victims showing higher psychiatric morbidity (Chandra et al., 2009; Varma et al., 2008; Scheffer and Renck, 2008), poor social support, and a higher level of perceived burden and expressed emotions, all of which have been shown to be associated with relapse of substance abuse (Poulose and Srinivasan, 2009; Mattoo and Singh, 2009). Thus, the physicians or psychiatrists managing the substance abusers should routinely evaluate for and address spousal IPV; this would, in turn, improve the substance dependence treatment outcome. Our finding of higher spousal IPV in alcohol dependent compared to opioid dependent subjects must be interpreted in light of the fact that alcohol dependent patients were older. Future research should evaluate this association in detail using matched control groups. In terms of different types of IPV, the present study reflects that the patients with substance dependence indulge in controlling behaviours more frequently than other forms of partner violence. Further, when one compares the prevalence of different types of controlling behaviours seen in the present study, i.e., 6.7–46.4% with that reported in studies from general population, i.e., NFHS3 which reported the prevalence of controlling behaviour to be 5.5–16.4%, it can be concluded that this kind of behaviour is much more common in patients with substance dependence. It can be hypothesized that this higher prevalence of controlling behaviours could be due to the direct consequence of substance dependence (e. g., delusions of infidelity due to alcohol dependence, financial constraints due to substance dependence, or substance intoxication or withdrawal state). Our findings that IPV is more frequently associated with higher age of male, lower education of both partners and lower family income, are in accordance to the existing literature (Babu and Kar, 2009; Varma et al., 2007; Jewkes et al., 2002; White and Chen, 2002). Our study had many limitations. It was conducted in a tertiary care drug de-addiction clinic population; hence, the findings cannot be extrapolated to the general population. Because the study was limited to the wives of treatment seeking substance dependent patients, the findings do not necessarily represent the partner violence experience for substances of abuse other than alcohol and opioids and of those living in the community. The study questionnaire used to assess IPV in the study was not validated. There is also the possibility of reporting bias with potential for underestimation, particularly given that the husbands were also aware of and consented for the study. The present study did not evaluate variables like spousal distress and psychological morbidity using structured diagnostic instrument and impact of IPV on the dyadic adjustment between the couple. We also did not evaluate the relationship of
IPV with different patient variables like severity of substance abuse, and the personality profile (trait/disorder) of the patients and their spouses. Future research can overcome these limitations. Role of funding agency The funding for this study was provided by PGI research fund; the PGI research fund had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. Contributors Authors Subodh BN and Sandeep Grover designed the study and wrote the protocol. Authors Manpreet Grewal and seema Grewal collected the research data, literature search and helped in entering the data. Authors Subodh BN, Debashiish Basu and Surendra Mattoo managed the literature searches and summaries of previous related work . Authors Sandeep Grover and Subodh BN undertook the statistical analysis, and author Subodh BN wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript. Conflict of interest There are no actual or potential conflicts of interest including any financial, personal or other relationships with other people or organizations within three (3) years of beginning the work submitted that could inappropriately influence, or be perceived to influence, their work. Acknowledgement Dr. Preeti P and Dr. Sunil G for helping in data collections. References Ahuja, R.C., Bangdiwala, S., Bhambal, S.S., Jain, D., Jeyaseelan, L., Kumar, S., Lakshman, M., Mitra, M.K., Nair, M.K.C., Pillai, R., Pandey, R.M., Peedicayal, A., Sadowski, L., Suresh, S., Upadhyaya, A.K., 2000. Domestic Violence in India: A Summary Report of a Multi Site Household Survey. International Clinical Epidemiologists Network (INCLEN), International Centre for Research on Women, Washington DC, www.icrw.org/docs/DomesticViolence3.pdf (accessed 02.04.13). Babu, V.B., Kar, S.K., 2009. Domestic violence against women in eastern India: a population-based study on prevalence and related issues. BMC Public Health 9, 129. Basu, D., Aggarwal, M., Das, P.P., Mattoo, S.K., Kulhara, P., Varma, V.K., 2012. Changing pattern of substance abuse in patients attending a de-addiction centre in north India (1978–2008). Indian J. Med. Res. 135, 830–836. Bennett, L., Bland, P., 2013. Substance Abuse and Intimate Partner Violence. VAWnet, a project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence, Harrisburg, PA, http://www.vawnet.org (retrieved 13.04.13). Chandra, Satyanarayana, V.A., Carey, M.P., 2009. Women reporting intimate partner violence in India: associations with PTSD and depressive symptoms. Arch. Womens Ment. Health, 203–209. Chavan, B.S., Arun, P., Bhargava, R., Singh, G.P., 2007. Prevalence of alcohol and drug dependence in rural and slum population of Chandigarh: a community survey. Indian J. Psychiatry 49, 44–48. Chermack, S.T., Fuller, B.E., Blow, F.C., 2000. Predictors of expressed partner and nonpartner violence among patients in substance abuse treatment. Drug Alcohol Depend. 58, 43–54. Fals-Stewart, W., 2003. The occurrence of partner physical aggression on days of alcohol consumption: a longitudinal diary study. J. Consult. Clin. Psychol. 71, 41–52. Fals-Stewart, W., Kennedy, C., 2005. Addressing intimate partner violence in substance-abuse treatment. J. Subst. Abuse Treat. 29, 5–17. Government of India , First Revised Estimates of National Income, Consumption Expenditure, Saving and Capital Formation 2011–12 2013; http://mospi.nic.in/Mospi New/upload/nad press release 31jan13.pdf (accessed 27.11.13). Grover, S., Ghosh, A., Avasthi, A., Kate, N., Sharma, S., Kulhara, P., 2013. Intimate partner violence (IPV) among female psychiatric outpatients-a study from India. Ind. J. Soc. Psychiatry. 29 (1–2), 19–28.
N.B. Subodh et al. / Drug and Alcohol Dependence 138 (2014) 124–129 Gururaj, G., Benegal, V., Girish, N., Chandra, V., Pandav, R., 2006. Alcohol Control Series 2: Public Health Problems Caused by Harmful Use of Alcohol – Gaining Less or Losing More? World health Organisation, Regional Office for South East Asia, New Delhi. International Institute for Population Sciences (IIPS), Macro International, 2007. National Family Health Survey (NFHS-3), 2005–06. International Institute for Population Sciences (IIPS) and Macro International, Mumbai. Jejeebhoy, S.L., 1998. Wife-beating in rural India: a husband’s right? Econ. Polit. Weekly 33, 855–862. Jewkes, R., Levin, J., Penn-Kekana, L., 2002. Risk factors for domestic violence: findings from a South African cross-sectional study. Soc. Sci. Med. 55, 1603–1617. Jeyaseelan, L., Kumar, S., Neelakantan, N., Peedicayil, A., Pillai, R., Duvvury, N., 2007. Physical spousal violence against women in India: some risk factors. J. Biosoc. Sci. 39, 657–670. Johnson, H., 2001. Contrasting views of the role of alcohol in cases of wife assault. J. Interpers. Violence 16, 54–72. Johnson, M.P., 2006. Violence and abuse in personal relationships: conflict, terror, and resistance in intimate partnerships. In: Vangelisti, A.L., Perlman, D. (Eds.), The Cambridge Handbook of Personal Relationships. Cambridge University Press, New York, pp. 557–578. Kantor, G., Straus, M.A., 1987. The drunken bum theory of wife beating. Soc. Probl. 34, 213–230. Klostermann, C.K., 2006. Substance abuse and intimate partner violence: treatment considerations. Subst. Abuse Treat. Prev. Pol. 1, 24. Kumar, S., Jeyaseelan, L., Suresh, S., Ahuja, R.C., 2005. Domestic violence and its mental health correlates in Indian women. Br. J. Psychiatry 187, 62–67. Mattoo, S.K., Singh, S.M., 2009. High risk behaviors and alcohol dependence. Indian J. Med. Res. 129, 354–356. Menon, B., Cherkil, S., Aswathy, S., Unnikrishnan, A.G., Rajani, G., 2012. The process and challenges in the translation of world health organization quality of Life (WHOQOL-BREF) to a regional language; Malayalam. Indian J. Psychol. Med. 34, 149–152. Morgan, J.F., Zolese, G., McNulty, J., Gebhardt, S., 2010. Domestic violence among female psychiatric patients: cross-sectional survey. Psychiatrist 34, 461–464.
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Murthy, P., Manjunatha, N., Subodh, B.N., Chnad, P.K., Benegal, V., 2010. Substance use and addiction research in India. Indian J. Psychiatry 52, S189–S199. Poulose, B., Srinivasan, K., 2009. High risk behaviours following alcohol use in alcohol dependent men. Indian J. Med. Res. 129, 376–381. Ray R., 2004. The Extent, Pattern and Trends Of Drug Abuse In India, National Survey. WHO, Ministry Of Social Justice and Empowerment, Government Of India and United Nations Office On Drugs and Crime Regional Office For South Asia. Ray, R., Chopra, A., 2012. Monitoring of substance abuse in India-Initiatives and experiences. Indian J. Med. Res. 135, 806–808. Saltzman, L.E., Fanslow, J.L., McMahon, P.M., Shelley, G.A., 2002. Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 1.0., Centers for Disease Control and Prevention. National Center for Injury Prevention and Control, Atlanta. Scheffer, L.M., Renck, B., 2008. ‘It is still so deep-seated, the fear’: psychological stress reactions as consequences of intimate partner violence. J. Psychiatr. Ment. Health Nurs. 15, 219–228. Sinha, A., Mallik, S., Sanyal, D., Dasgupta, S., Pal, D., Mukherjee, A., 2012. Domestic violence among ever married women of reproductive age group on slum area of Kolkata. Indian J. Public Health 56, 31–36. Varma, D., Chandra, P.S., Thomas, T., Carey, M.P., 2007. Intimate partner violence and sexual coercion among pregnant women in India: relationship with depression and post-traumatic stress disorder. J. Affect Disord. 102, 227–235. Varma, V.K., Singh, A., Singh, S., Malhotra, A.K., 1980. Extent and pattern of alcohol use in North India. Indian J. Psychiatry 22, 331–337. Verma, R.K., Collumbien, M., 2003. Wife beating and the link with poor sexual health and risk behaviour among men in urban slums in India. J. Comp. Fam. Stud. 34, 61–74. White, H.R., Chen, P.H., 2002. Problem drinking and intimate partner violence. J. Stud. Alcohol 63, 205–214. World Health Organization, 2005. Intimate Partner Violence, World Health Organization Regional Office for South-East Asia.
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Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Interpersonal violence against wives by substance dependent men Nanjayya B. Subodh ∗ , Sandeep Grover, Manpreet Grewal, Seema Grewal, Debashish Basu, Surendra K. Mattoo PGIMER, Department of Psychiatry, Nehru Hospital, PGIMER, Chandigarh 160012, India
a r t i c l e
i n f o
Article history: Received 1 October 2013 Received in revised form 13 January 2014 Accepted 11 February 2014 Available online 23 February 2014 Keywords: Alcohol Opioids Violence Intimate partner violence Dependence
a b s t r a c t Background: Indian research on intimate partner violence (IPV) with substance use covers only alcohol, and very few studies have reported on IPV with other substances. The study aims to assess IPV against wives by substance dependent men. Methods: The study sample was recruited by convenient sampling from men (and their wives) seeking treatment at a de-addiction centre in North India between October, 2011 and February, 2012. The consenting wives self-administered the violence questionnaire. Results: 267 wives were recruited into the study. The prevalence rates for IPV were: 55% for the whole sample, 63.19% for alcohol dependence and 42.33% for opioid dependence. IPV was associated with higher age of husband, lower education or unemployment of either spouse, lower income of family and nuclear family structure. Conclusions: Present research confirms that IPV against wives is highly prevalent among substance dependent men, more with alcohol dependence as compared to opioid dependence. Addressing IPV should be an integral part of substance abuse management. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Intimate partner violence (IPV) is understood as any behaviour within an intimate relationship that causes any harm (physical or psychological or sexual) to the partner or spouse. It includes acts of physical aggression (slapping, hitting, kicking or beating), psychological abuse (intimidation, constant belittling or humiliation), forced sexual intercourse, or any other controlling behaviour (isolating a person from family and friends, monitoring their movements and restricting access to information or assistance; Klostermann, 2006; Johnson, 2006; Saltzman et al., 2002). Traditionally considered as a private family matter, IPV remained hidden from the public view for long. However, the changing times and values have now made it a public health issue that requires the attention of both the treatment community and the criminal justice system. There is a large body of research from the West linking substance use and abuse with domestic violence. Substance abusers, particularly alcohol abusers, frequently indulge in partner violence both during intoxication and withdrawal phase (Poulose and Srinivasan, 2009). Severity of domestic violence increases with alcohol use
∗ Corresponding author. Tel.: +91 1722756818. E-mail address: [email protected] (N.B. Subodh). http://dx.doi.org/10.1016/j.drugalcdep.2014.02.017 0376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.
(Johnson, 2001; Kantor and Straus, 1987). About half of the partnered men who sought treatment for the substance abuse reported indulging in partner violence in the past year (Chermack et al., 2000; Fals-Stewart and Kennedy, 2005) and being 11 times more likely to abuse their partner on a day when they took alcohol (FalsStewart, 2003). In India, substance use is more prevalent in men. The largest community based study showed nearly one in every four adult men using one or more substances other than tobacco (Ray, 2004). Over the years alcohol and other substance use disorders have increased in clinical population (Murthy et al., 2010; Basu et al., 2012). The most commonly used substances in north India are alcohol and various opioids (Basu et al., 2012; Ray and Chopra, 2012; Chavan et al., 2007; Varma et al., 1980). The Indian research on IPV is sparse. The International clinical epidemiologists network (INCLEN) report on domestic violence suggested that the husband’s drunkenness was a significant risk factor for domestic violence (Ahuja et al., 2000). Others showed that compared to the general population alcohol users indulged in IPV more frequently (Ahuja et al., 2000; Kumar et al., 2005). IPV has been reported to be associated with problematic alcoholic users in one third to half of cases in a community-based study (Gururaj et al., 2006) and in 20–60% in two other studies (Kumar et al., 2005; Babu and Kar, 2009). Thus, while there is some research on IPV and alcohol use, there is no data on IPV and other commonly abused
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substances like opioids. More importantly, none of the existing research specifically assessed the wives of men abusing other substances like opioids. In India, men seeking treatment for their substance dependence are usually accompanied by their wives. This provides a unique opportunity to assess IPV experience directly from such wives. In view of the lack of Indian data on IPV for different substances of abuse and from the victims themselves, the present research aimed to study the prevalence, socio-demographic correlates and different types of IPV experienced by the wives of those seeking treatment for alcohol or opioids dependence. 2. Methods 2.1. Setting The study was conducted at the drug de-addiction and treatment centre (DDTC) at the post graduate institute of medical education and research (PGIMER), Chandigarh. DDTC PGIMER caters to 20 inpatients and yearly average of 1500–1800 new outpatients. Thus, most of our patients are managed as outpatients. Almost all the patients are accompanied by their family members who are involved in patient care and treatment. Almost all (99.5%) of our patients are male and around two third of them(62.5–76.8%) are married (Basu et al., 2012). Participants for this study were recruited from both the inpatient and outpatient settings. To be included in the study, the patients were required to: be older than 18 years of age, fulfill the diagnostic criteria for either alcohol or opioid dependence as per the international classification of diseases, 10th revision (ICD-10), and been living with their wife for at least 1 year. Patients with comorbid severe mental disorders like psychotic, affective and obsessive compulsive disorders were excluded. The wives were required to be able to read hindi, punjabi or english. Wives who had psychotic disorders, mental retardation, dementia and organic brain disorders were excluded. This was assessed by a psychiatrist based on a semi-structured interview. Those couples who were already in the legal process of mutual divorce were excluded. Participants were recruited by convenient sampling during the intake period of October, 2011–February, 2012. The sample consisted of 267 patients and their spouses. 2.2. Instrument for assessment of intimate partner violence A modified version of the domestic violence questionnaire (DVQ) by Morgan et al. (2010) was used to assess the IPV. DVQ has 21 items, covering the 3 broad dimensions of IPV: physical violence, threatening behaviour and controlling behaviour (Grover et al., 2013). One item each was added to the questionnaire to assess violence during pregnancy and general level of fearfulness from patients in wives. All the items are answered as ‘yes’ or ‘no’. To facilitate self administration the questionnaire was translated and back translated from english into hindi and punjabi by bilingual experts (Menon et al., 2012). 2.3. Ethical issues The study was funded by the institute research fund and was approved by the ethics review board of the institute. All the patients and their spouses were recruited after obtaining a written informed consent. 2.4. Procedure During the intake period all the inpatients and outpatients attending DDTC were approached and the aim of the study was explained. Those patients and wives who provided written informed consent were evaluated for inclusion and exclusion criteria. Socio-demographic and clinical profile of the consenting patients was recorded. Wives fulfilling the study criteria were invited to complete the modified DVQ in their preferred language. Privacy was ensured for the wives while completing the questionnaire. Further, the scale was administered after ensuring confidentiality of the information provided by the wives and they were informed that the information would not be shared with their spouses. 2.5. Statistical analysis Analysis was done by using SPSS-14 (statistical package for the social sciences, 2005, Chicago, IL, USA). Frequencies and percentages were computed for discontinuous socio-demographic and clinical variables and each item of DVQ. Mean and standard deviation with range for continuous variables were calculated. Chisquare test, t-test, ANOVA and Fisher exact test were used for comparisons as per the requirement. Correlations among socio-demographic, clinical and IPV variables were carried out using Pearson’s product moment correlation and Spearman’s rank correlation.
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3. Results 3.1. Sample During the study period (October, 2011–February, 2012), 613 new patients were evaluated at the DDTC, of whom 380 were currently married. Of the 380 patients, 267 participated in the study along with their wives. The reasons for exclusion of 113 patients were: 20 cases were dependent on tobacco only, 55 cases had psychiatric comorbidity, 14 refused to give consent and 24 had both opioid and alcohol dependence. Of the 267 patients, 61.1% (N = 163) were dependent on alcohol and 38.9% (N = 104) were dependent on opioids. In the alcohol group comorbid nicotine dependence was more prevalent (151 out of 163; 92.63%) compared to the opioid dependence group (90 out of 104; 86.53%). None of the patients reported harmful use or dependence on other substances than mentioned above.
3.2. Socio-demographic profile (Table 1) The mean age of the patients was 38.46 ± 9.27 years with a range of 19–66 years and that of the wives was 35.13 ± SD − 9.01 years with a range of 19–63 years . Three fourths of the patients and their wives were studied upto matric and the mean number of years of education of wives was slightly less than that of the patients. About three-fifth of the patients were doing some kind of skilled work, one-fifth were professionals and another one-fifth were unemployed. A majority (87.6%) of the wives were homemakers. Slightly more than half of the couples belonged to non-nuclear families and three-fifths were residing in urban locality. In three-fourths of the cases, monthly family income was less than rupees 19,575. The average monthly income was three times more than average monthly income of the Indian family (Government of India, 2013). Compared to opioid dependent patients and their wives, alcohol dependent patients and their wives were older. Compared to the opioid dependent group, the alcohol dependent group had more families with income of ≥rupees 19,575 and were living independently from their adult parents. Wives of the substance dependent patients were not using any substances or psychotropic medications or suffering from any known psychiatric diagnosis. Substance dependent men were more educated compared to their wives (r = 0.127, p = 0.038).
3.3. Prevalence and forms of intimate partner violence (IPV) (Table 2) Lifetime experience of IPV among wives averaged 55.1%, being higher in alcohol dependence than in opioid dependence group (63.19% vs. 42.31) . For the whole group, among the different types of violence, the threatening behaviour was much less common with mean of 0.70 ± 01.01, compared to controlling behaviour with mean of 1.75 ± 01.97 and physical violence with mean of 1.63 ± 02.41 behaviours. The prevalence of different types of violence ranged 2.2–34.5% for physical, 15.7–28.8% for threatening and 1.97–46.4% for controlling behaviours. Overall, 56.2% wives experienced at least one type of violence. Among those who experienced IPV (40% of the total sample; 70% of those who experienced IPV) reported experiencing violent behaviour in the range of 1–8 and only a minority of the spouses/partners reported experiencing ≥9 violent behaviours Table 3. Physical violence in the last 12 months was reported by 18.7% wives. Feeling afraid of their partners was reported by 21.3% wives, while 9.4% reported experiencing violence during pregnancy.
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Table 1 Socio-demographic profile of the patients and the wives.
Profile of patients Age in years – Education Upto matric Beyond matric Education in years – Occupation Unemployed Skilled Professional – Family income Upto 19,575 More than equal to 19,575 – Family typea Nuclear Non-nuclear – Locality Urban Rural – Profile of wives Age in years – Education Upto matric Beyond matric Education in years – Occupation Homemakers Skilled Professional
Whole group (N = 267) Mean ± SD/N (%)
Alcohol dependence (N = 163) Mean ± SD/N (%)
Opioid dependence (N = 104) Mean ± SD/N (%)
Alcohol vs. opioid dependence Chi-square value/ t-test
38.46 ± 9.27
41.07 ± 09.33
34.37 ± 07.58
6.147 (p = 0.001)
204 (76.4) 63 (23.6) 10.45 ± 4.04
124 (76.07) 39 (23.93) 10.16 ± 4.21
80 (76.92) 24 (23.08) 10.89 ± 3.74
0.025 (0.873)
52 (19.5) 165 (61.8) 50 (18.7)
30 (18.40) 98 (60.12) 35 (21.47)
22 (21.15) 67 (64.42) 15 (14.42)
2.121 (0.346)
199 (74.5) 68 (25.5)
113 (69.33) 50 (30.67)
86 (82.69) 18 (17.31)
5.977 (p = 0.014)
120 (44.9) 147 (55.1)
84 (51.53) 79 (48.47)
36 (34.62) 68 (65.38)
7.344 (p = 0.007)
159 (59.6) 108 (40.4)
104 (63.80) 59 (36.20)
55 (52.88) 49 (47.12)
3.143 (p = 0.076)
35.13 ± 9.01
37.52 ± 09.27
31.38 ± 07.15
5.746 (p = 0.001)
207 (77.5) 60 (22.5) 9.53 ± 04.86
128 (78.53) 35 (21.47) 09.13 ± 04.99
79 (75.96) 25 (24.04) 10.15 ± 04.60)
0.240 (0.624)
234 (87.6) 18 (06.7) 15 (05.6)
146 (89.57) 10 (06.13) 07 (04.29)
88 (84.62) 8 (07.69) 8 (07.69)
1.711 (0.425)
1.451 (p = 0.148)
1.686 (p = 0.093)
a Nucelar family setup means in which a couple is living with/without their children and non-nuclear family set-up means where the couple is living with their parents/married or unmarried siblings.
3.4. Comparison of IPV between alcohol and opioids Comparatively, the alcohol group reported higher mean number of physical violence (1.97 ± 2.59 vs. 1.10 ± 2.00, p = 0.004), whereas the opioids group reported higher mean number of controlling behaviours (1.20 ± 1.72 vs. 0.86 ± 1.93, p = 0.021). Different types of specific violent behaviours, like being grabbed or shoved (40.49% vs. 25.00%, p = 0.009), punched on the body/arms/legs (34.36% vs. 15.38%, p = 0.001), punched in the face (36.81% vs. 23.08%, p = 0.018), attempt to burn (03.68% vs. 00.00%, p = 0.048), criticism (49.69% vs. 30.77%, p = 0.002) and locked in the house (10.43% vs. 00.96%, p = 0.003) were reported more by the alcohol group. 3.5. Socio-demographic factors associated with partner violence Patients with reported IPV were older (mean ± SD: 39.57 ± 9.03 vs. 37.08 ± 9.4, p = 0.028) than those whose wives did not report IPV. Patients who were matric completers more frequently indulged in shouting and screaming (52.4% vs. 39.3%, p = −0.03) and kept the partner short of money (26.9% vs. 15.6%, p = −0.02) than those wives who did not complete matric education. Overall, patients indulging in partner violence were less educated (mean ± SD: 9.97 ± 4.31 vs. 11.01 ± 3.61, p = 0.037), and the number of years of education was significantly less for those who indulged in shouting and screaming (mean ± SD: 9.87 ± 4.18 vs. 10.94 ± 3.86, p = 0.030) compared to
those who were more educated. Those with family income of upto rupees 19,575 more frequently kept the partner short of money (25.6% vs. 10.3%, p = 0.008), and their partners were afraid of them (24.62% vs. 11.76%, p = 0.02) than those who were earning more than rupees 19,575. Patients staying in nuclear family more frequently indulged in any form of partner violence (62.5% vs. 49%, p = 0.027), and indulged in violent behaviours like grabbing and shoving (43.33% vs. 27.2%, p = 0.006), punching on body/arms/legs (33.33% vs. 21.76%, p = 0.034), punching on the face (40.83% vs. 23.8%, p = 0.003), kicking the partner to the floor (16.66% vs. 6.8%, p = 0.011), punching, kicking or throwing things at the partner (32.5% vs. 19.04%, p = 0.012), and criticizing their partner (50% vs. 36%, p = 0.022) compared to those who were not living in a nuclear family. The age of the patients had a positive correlation with the mean of threatening behaviours (r = 0.127, p = 0.038) and total number of violent behaviours (r = 0.131, p = 0.032). Similarly, education of the patients had significant correlations with violent behaviours in the form of total number of controlling behaviours (r = 0.121; p = 0.048) and overall total number of violent behaviours (r = 0.126; p = 0.04). Patients staying in nuclear family set up more frequently indulged in physical violence (mean ± SD: 2.07 ± 2.51 vs. 1.26 ± 2.26, p = 0.001), threatening behaviour (Mean ± SD: 0.82 ± 1.05 vs. 0.59 ± 0.96, p = 0.039), controlling behaviours (mean ± SD: 1.79 ± 1.96 vs. 1.32 ± 1.81, p = 0.032) and overall
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Table 2 IPV profile of the study sample. Whole Group (N = 267)
Do you think you have ever experienced partner violence? – Physical violence Grabbed or shoved you Punched you on body/arms/legs Punched you in the face Forced you to have sex Physically violent to you in other way Kicked you on the floor Choked or held hand over your mouth Used weapon or object to hurt you Tried to strangle you Tried to burn you Tried to drown you Mean number of physical violence Physical violence in the past 12 months – Threatening behaviour by partner Punched, kicked or threw things Threatened you with fist, hand or foot Threatened to kill you Mean number of threatening behaviour – Controlling behaviour by partner Shouted, screamed or swore at you Criticized you Checked up on your movements Restricted your social life Tried to control you in any other way not physical violence Kept you short of money Locked you in the house Mean number of controlling behaviour Mean number of overall violence Have you ever felt afraid of your partner? Faced violence during pregnancy
Opioid dependence group (N = 104)
Alcohol vs. opioid groups (p value)
Mean ± SD/ N (%)
Alcohol dependence group (N = 163) Mean ± SD/ N (%)
Mean ± SD/ N (%)
Chi-square value/ t-test
147 (55.1)
103 (63.19)
44 (42.31)
11.18 (0.001)
92 (34.50) 72 (27.00) 84 (31.50) 41 (15.40) 57 (21.30) 30(11.20) 13 (04.90) 20 (07.50) 11 (04.10) 06 (02.20) 09 (03.40) 1.63 ± 2.41 50 (18.7)
66 (40.49) 56 (34.36) 60 (36.81) 29 (17.79) 41 (25.15) 23 (14.11) 11 (06.75) 14 (08.59) 08 (04.91) 06 (03.68) 07 (04.29) 1.97 ± 2.59 35 (21.47)
26 (25.0) 16 (15.38) 24 (23.08) 12 (11.54) 16 (15.38) 07(06.73) 02 (01.92) 06 (05.77) 03 (02.88) 00 (00.00) 02 (01.98) 1.10 ± 2.00 15 (14.42)
6.74 (0.009) 11.60 (0.001) 5.55 (0.018) 1.91 (0.167) 3.60 (0.057) 3.46 (0.063) 3.19 (0.074) 0.72 (0.393) 0.65 (0.417) 3.91 (0.048) 1.09 (0.295) 2.93 (0.004) 2.07 (0.150)
67 (25.1) 77 (28.8) 42 (15.7) 0.70 ± 1.01
46 (28.22) 53 (32.52) 30 (18.40) 0.79 ± 1.05
21 (20.19) 24 (23.08) 12 (11.54) 0.55 ± 0.94
2.17 (0.140) 2.75 (0.097) 2.25 (0.133) 1.92 (0.055)
124 (46.4) 113 (42.3) 38 (14.2) 39 (14.6) 20 (07.5)
82 (50.31) 81 (49.69) 27 (16.56) 29 (17.79) 15 (09.21)
42 (40.38) 32(30.77) 11 (10.58) 10 (09.62) 05 (04.81)
2.51 (0.113) 9.31 (0.002) 1.86(0.172) 3.40 (0.065) 1.77 (0.183)
58 (21.7) 18 (06.7) 1.75 ± 1.97 3.86 ± 4.85 57 (21.3) 25 (09.4)
34 (20.86) 17 (10.43) 0.86 ± 1.93 4.51 ± 5.11 41 (25.15) 17 (10.43)
24 (23.08) 01 (0.96) 1.20 ± 1.72 2.85 ± 4.23 16 (15.38) 08 (07.69)
0.18 (0.668) 9.05 (0.003) 2.32 (0.021) 2.76 (0.006) 3.60 (0.057) 0.56 (0.454)
total number of violent behaviours (mean ± SD: 4.69 ± 5.02 vs. 3.18 ± 4.60, p = 0.004) more than those patients who were living in a non nuclear set up. Wives who were less educated more frequently faced physical violence (r = 0.131, p = 0.032), threatening behaviour (r = 0.130; p = 0.033), controlling behaviour (r = 0.154; p = 0.012) and higher overall total number of violent behaviours (r = 0.164; p = 0.007) than those wives who were more educated. 4. Discussion The present study aimed to assess the IPV experienced by the spouses/partners of those dependent on alcohol or opioids. The IPV
reported by 55% of wives in our study is very similar to that reported in other studies from India conducted in de-addiction clinic settings and in the general population (Kumar et al., 2005; Chandra et al., 2009; WHO, 2005). Studies from the West also suggest that while 25–50% of substance dependent patients own up indulging in IPV, 50% of the women reporting partner-IPV attribute it to the partner’s substance abuse/dependence (Bennett and Bland, 2013). The prevalence rate of IPV in our study is also within the 18–70% range of spousal IPV reported from different parts of India; although these studies did not focus specifically on the wives of substance abusers (Ray and Chopra, 2012; Ahuja et al., 2000; Kumar et al., 2005; Chandra et al., 2009; World Health Organization, 2005; Sinha et al., 2012; Jejeebhoy, 1998; IIPS and Macro International, 2007;
Table 3 Correlation between socio-demographic profile and domestic violence questionnaire. Age (p)a Physical violence Threatening behaviour Mean number of threatening behaviour Controlling behaviour Mean number of controlling behaviour Mean number of overall violence p = client; s = spouse a Spearman rank correlation. b Mann Whitney U test. * p ≤ 0.05. ** p ≤ 0.001.
Education (p)a
Education (s)a
Family setupb
−0.131 −0.130*
6871** 7694*
−0.154*
7545*
−0.164*
7109*
*
0.127*
0.131*
0.121* 0.126*
128
N.B. Subodh et al. / Drug and Alcohol Dependence 138 (2014) 124–129
Verma and Collumbien, 2003; Jeyaseelan et al., 2007; Varma et al., 2007). Existing Indian research on spousal IPV is not specifically focused on drug dependence. However, there is the general suggestion that alcohol use is associated with higher prevalence of IPV (Ahuja et al., 2000; Chandra et al., 2009; World Health Organization, 2005). Because a majority of our patients come from the states of Punjab and Haryana, the interpretation of our findings require an understanding of the IPV in the general population in India in general and in our catchment area in particular. For these 2 states the national family health survey-3 reported prevalence of any one type of spousal violence experienced by women ranging 26.7–28%, compared to the national average of 39.7%. The prevalence of spousal IPV in our study at 63.2% for alcohol dependence and 42.3 for opioid dependence clearly indicates that prevalence of IPV is significantly higher in wives of alcohol or opioid dependent men. The implication of these findings is that clinical evaluation of alcohol and opioid dependent patients should also focus on the marital unit and psychological morbidity in the spouses. There is additional evidence suggesting IPV victims showing higher psychiatric morbidity (Chandra et al., 2009; Varma et al., 2008; Scheffer and Renck, 2008), poor social support, and a higher level of perceived burden and expressed emotions, all of which have been shown to be associated with relapse of substance abuse (Poulose and Srinivasan, 2009; Mattoo and Singh, 2009). Thus, the physicians or psychiatrists managing the substance abusers should routinely evaluate for and address spousal IPV; this would, in turn, improve the substance dependence treatment outcome. Our finding of higher spousal IPV in alcohol dependent compared to opioid dependent subjects must be interpreted in light of the fact that alcohol dependent patients were older. Future research should evaluate this association in detail using matched control groups. In terms of different types of IPV, the present study reflects that the patients with substance dependence indulge in controlling behaviours more frequently than other forms of partner violence. Further, when one compares the prevalence of different types of controlling behaviours seen in the present study, i.e., 6.7–46.4% with that reported in studies from general population, i.e., NFHS3 which reported the prevalence of controlling behaviour to be 5.5–16.4%, it can be concluded that this kind of behaviour is much more common in patients with substance dependence. It can be hypothesized that this higher prevalence of controlling behaviours could be due to the direct consequence of substance dependence (e. g., delusions of infidelity due to alcohol dependence, financial constraints due to substance dependence, or substance intoxication or withdrawal state). Our findings that IPV is more frequently associated with higher age of male, lower education of both partners and lower family income, are in accordance to the existing literature (Babu and Kar, 2009; Varma et al., 2007; Jewkes et al., 2002; White and Chen, 2002). Our study had many limitations. It was conducted in a tertiary care drug de-addiction clinic population; hence, the findings cannot be extrapolated to the general population. Because the study was limited to the wives of treatment seeking substance dependent patients, the findings do not necessarily represent the partner violence experience for substances of abuse other than alcohol and opioids and of those living in the community. The study questionnaire used to assess IPV in the study was not validated. There is also the possibility of reporting bias with potential for underestimation, particularly given that the husbands were also aware of and consented for the study. The present study did not evaluate variables like spousal distress and psychological morbidity using structured diagnostic instrument and impact of IPV on the dyadic adjustment between the couple. We also did not evaluate the relationship of
IPV with different patient variables like severity of substance abuse, and the personality profile (trait/disorder) of the patients and their spouses. Future research can overcome these limitations. Role of funding agency The funding for this study was provided by PGI research fund; the PGI research fund had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. Contributors Authors Subodh BN and Sandeep Grover designed the study and wrote the protocol. Authors Manpreet Grewal and seema Grewal collected the research data, literature search and helped in entering the data. Authors Subodh BN, Debashiish Basu and Surendra Mattoo managed the literature searches and summaries of previous related work . Authors Sandeep Grover and Subodh BN undertook the statistical analysis, and author Subodh BN wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript. Conflict of interest There are no actual or potential conflicts of interest including any financial, personal or other relationships with other people or organizations within three (3) years of beginning the work submitted that could inappropriately influence, or be perceived to influence, their work. Acknowledgement Dr. Preeti P and Dr. Sunil G for helping in data collections. References Ahuja, R.C., Bangdiwala, S., Bhambal, S.S., Jain, D., Jeyaseelan, L., Kumar, S., Lakshman, M., Mitra, M.K., Nair, M.K.C., Pillai, R., Pandey, R.M., Peedicayal, A., Sadowski, L., Suresh, S., Upadhyaya, A.K., 2000. Domestic Violence in India: A Summary Report of a Multi Site Household Survey. International Clinical Epidemiologists Network (INCLEN), International Centre for Research on Women, Washington DC, www.icrw.org/docs/DomesticViolence3.pdf (accessed 02.04.13). Babu, V.B., Kar, S.K., 2009. Domestic violence against women in eastern India: a population-based study on prevalence and related issues. BMC Public Health 9, 129. Basu, D., Aggarwal, M., Das, P.P., Mattoo, S.K., Kulhara, P., Varma, V.K., 2012. Changing pattern of substance abuse in patients attending a de-addiction centre in north India (1978–2008). Indian J. Med. Res. 135, 830–836. Bennett, L., Bland, P., 2013. Substance Abuse and Intimate Partner Violence. VAWnet, a project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence, Harrisburg, PA, http://www.vawnet.org (retrieved 13.04.13). Chandra, Satyanarayana, V.A., Carey, M.P., 2009. Women reporting intimate partner violence in India: associations with PTSD and depressive symptoms. Arch. Womens Ment. Health, 203–209. Chavan, B.S., Arun, P., Bhargava, R., Singh, G.P., 2007. Prevalence of alcohol and drug dependence in rural and slum population of Chandigarh: a community survey. Indian J. Psychiatry 49, 44–48. Chermack, S.T., Fuller, B.E., Blow, F.C., 2000. Predictors of expressed partner and nonpartner violence among patients in substance abuse treatment. Drug Alcohol Depend. 58, 43–54. Fals-Stewart, W., 2003. The occurrence of partner physical aggression on days of alcohol consumption: a longitudinal diary study. J. Consult. Clin. Psychol. 71, 41–52. Fals-Stewart, W., Kennedy, C., 2005. Addressing intimate partner violence in substance-abuse treatment. J. Subst. Abuse Treat. 29, 5–17. Government of India , First Revised Estimates of National Income, Consumption Expenditure, Saving and Capital Formation 2011–12 2013; http://mospi.nic.in/Mospi New/upload/nad press release 31jan13.pdf (accessed 27.11.13). Grover, S., Ghosh, A., Avasthi, A., Kate, N., Sharma, S., Kulhara, P., 2013. Intimate partner violence (IPV) among female psychiatric outpatients-a study from India. Ind. J. Soc. Psychiatry. 29 (1–2), 19–28.
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