Close relationships such as marriage are increasingly recognized as important to health and functioning in RA and other chronic pain conditions. 19
Research, however, has not examined how both marital status and marital adjustment are related to various domains of functioning in RA. In this study, we compared the health status of people with RA as a function of both marital status—that is, married or unmarried—and of level of marital adjustment. We differentiated the married patients into those with distressed or non-distressed marriages to determine the role of marital adjustment on RA health status. In general, we found that although marital status is related to RA health status, the level of adjustment in the marriage is more important to consider than simply whether or not one is married.
Our first hypothesis, that is, that marital adjustment would be associated with better health status, was generally supported. Among married participants, better marital adjustment was associated with less psychological disability and marginally less affective pain after controlling for age, gender, race, education, and disease severity. Thus, married people with RA who have low levels of marital adjustment may be at risk for psychological disability and higher pain relative to those who have high levels of marital adjustment.
Findings from analyses comparing three groups based on marital status and level of marital adjustment generally supported initial hypotheses; non-distressed married participants tended to have better health than both distress married and unmarried participants. On both affective pain and psychological disability, unmarried participants had worse functioning, but only when compared with married participants who were in non-distressed marriages. In contrast, unmarried participants were similar to participants in distressed marriages on all measures. Although effects on some measures (i.e., sensory pain, physical disability), were attenuated when controlling for confounds, these findings suggest strongly that being married may have benefit for health status when considered in the context of a well-adjusted, or at least not distressed, marriage. 34
Research has traditionally noted that being married confers benefits for one’s mental and physical health because it provides steady and reliable companionship, emotional intimacy, sexual partnership, and a buffer against ongoing stress. 8,16
Among those with RA, poorer quality of the marital relationship has been linked to higher pain 6,40
and psychological distress. 7,35,38
Conversely, patients with RA who experience positive interpersonal relationships report less pain and psychological distress. 11
Consistent with prior findings, this study suggests that that the association between marital status and health status depends on the quality of the marriage; only being in a well adjusted marriage is linked with better health status, whereas being in a distressed or low adjustment marriage is similar to being unmarried.
One of the most interesting findings of the current study was that of the strong link between marital adjustment and health status variables tapping into affective functioning (i.e., affective pain and psychological disability). These findings are consistent with prior studies showing that higher marital quality is associated with better mental health in RA 7,35,38
and that current marital status is strongly associated with depression. 19
That marital quality was related most strongly to psychological disability and affective pain, a construct that assesses pain unpleasantness or emotional qualities of patients’ pain, suggests that the marital relationship may play a particularly strong role in influencing patients’ suffering
; that is, the affective or emotional experience of distress associated with their pain. 15
Having a high quality marital relationship may make the disease more emotionally tolerable and thereby reduce the affective components of patients’ pain and disability. Conversely, poor marital adjustment or being unmarried may increase stress 8
or hamper adaptive coping, as well as influence whether patients engage in maladaptive health behaviors or avoid positive health behaviors—including appropriate medical care—all of which could lead to worse pain and suffering.
This study has several limitations. First, the cross-sectional nature of this study precludes determining the direction of these effects. For instance, although it is possible that marital adjustment has an impact on health status, the opposite causal direction is also possible. Having worse pain and mental health can make it difficult for individuals to enter into and remain in a marriage, and may contribute to poor marital adjustment. A bidirectional relationship between marital distress and functioning is most likely. 3,13
Second, this study did not include non-married individuals in close, committed partnered relationships in the “married group,” and did not assess same sex relationships, and future research should do this. Third, this study did not examine gender differences in how marital status or marital quality might be related to health status. The relatively small number of men, particularly unmarried men, in this sample precluded such analyses. There are a number of studies showing that simply being married may be more protective of health for men than women. 5,16
Yet, marital quality, rather than just marital status, may be more important to women, 17
and women have been found to have greater physiological reactivity to marital stress than do men. 26
Still other studies have found no gender differences in health benefits of marriage. 37,42
Thus, this complicated picture of the role of gender, marital status, marital quality and health needs further study.
Longitudinal studies could clarify how marital status and marital adjustment affect disease and health status. Research might examine the effects of shifts in marital status (i.e., marriage, separation and divorce, widowhood, and remarriage) as well as changes in marital adjustment on RA severity and functioning. One interesting idea would be to track RA status prior to and following loss of a relationship. Recently, Hughes and Waite 19
found that marital disruption was related to a greater number of chronic conditions, reduced mobility, poorer physical health, and worse depression in a large population sample, with particular evidence for the long-term, cumulative effects of marital disruption on chronic conditions and mobility limitations. Because that study did not focus on patients with chronic pain or RA, it is difficult to know whether these findings would be similar for RA patients. Although those authors did not find that the cause of marital dissolution (i.e., widowhood, divorce) was a key factor in predicting health, it is possible that the nature of a marriage’s dissolution might be differentially related to health status when considering patients with chronic conditions such as RA; for such patients, leaving a poor marriage through divorce might provide health benefits, whereas losing a good marriage due to the death of a spouse could be damaging to health. It would also be valuable to know whether relationship-enhancing psychosocial interventions would lead not only to improvements in marital adjustment but also in pain and disability. Finally, it may also be useful to examine whether smaller fluctuations in marital adjustment stemming from events such as positive or negative interactions would also influence RA severity and functioning.
A key implication of the current study is that simply using marital status as an indicator of the presence of social support may be inadequate; clinicians need to consider the level of adjustment or distress in the relationship. We hope that studies such as the current one will lead to the development of novel psychosocial treatments that adequately address relationship issues for RA patients and their partners. Recently, several studies have shown the potential for spouse-assisted and couples’ interventions to improve disease management and outcomes (e.g., pain, psychological distress) in arthritis populations. 22,23,24,29
Yet such interventions do not directly target the relationship quality. Based on the current findings, we propose that psychosocial interventions in RA might be improved by including modules that target the marital relationship directly by, for example, providing training in effective communication and behavioral and cognitive skills taken from couples’ therapy (e.g., joint engagement in enjoyable activities). Such interventions might be of particular benefit to RA patients in troubled marriages. We predict that such interventions will not only improve marital adjustment but also improve health and functioning in RA.