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Article Excerpt
BEING MARRIED TO OR LIVING WITH an alcoholic or a problem drinker increases the likelihood of a wide range of physical and mental health problems. Correlates of partner alcohol problems, heavy drinking, or both include psychological abuse (Rosenbaum and O'Leary, 1981); depressive symptomatology (Finney et al., 1983; Homish et al., 2005; Maes et al. 1998; Moos et al., 1990); excess levels of physical health problems and current illness (Okazaki et al., 1994); general relationship problems including high levels of conflict, stress, psychological distress, and sexual dysfunction (Arias and Pape, 1999; Gomberg, 1987; Kogan and Jackson, 1965; McCrady et al., 1998; O'Farrell et al., 1997; Zweben, 1986); and an increased probability of separation or divorce (DeMaris, 2000, 2001; Nace, 1982; Ramisetty-Mikler and Caetano, 2005). In some studies, these outcomes appear to be at least partially mediated through an excess risk of alcohol-related intimate partner violence (IPV) (e.g., see Coker et al., 2002; Diaz et al., 2002; Golding, 1999; Hem et al., 2006; Kahler et al., 2003; Koss et al., 1991; Liebschutz et al., 1997; Orford et al., 2001; Ramisetty-Mikler and Caetano, 2005; Testa and Leonard, 2001), an issue that has been the focus of much of the recent research on partner alcohol problems.
In studies of individuals or couples receiving treatment for alcohol problems, other substance problems, or both, the pretreatment prevalence of IPV has been in the range of approximately 50%-65% (Chase et al., 2003; Chermack et al., 2000; Murphy and O'Farrell, 1994). Data from treatment samples indicate that male-to-female violence increases on drinking days (Fals-Stewart et al., 2003; Fals-Stewart, 2003), alcohol use increases the likelihood that conflicts will be of a violent nature (Murphy et al., 2005), and the likelihood of male-perpetrated IPV is positively correlated with the severity of men's alcohol problems (Murphy et al., 2001; Parrott et al., 2003). Likewise, in general population studies, where the past-year prevalence of male-perpetrated IPV has been estimated to be in the range of 10% to 20% (Caetano et al., 2005; Coker et al., 2000; Schafer et al., 1998; Straus and Gelles, 1995), male-perpetrated IPV has been linked to alcohol problems (Caetano et al., 2005; Cunradi et al., 2002; Peek-Asa et al., 2005), in-the-event drinking (Thompson and Kingree, 2006), and both volume of alcohol consumption and heavy episodic drinking (O'Leary and Schumacher, 2003).
Case-control studies of emergency-department/traumacenter patients (Kyriacou et al., 1998; Lipsky et al., 2005; Weinsheimer et al., 2005) and victims of criminal IPV (Martin and Bachman, 1997; Walton-Moss et al., 2005) provide additional evidence that male-partner alcohol misuse and heavy drinking are strong predictors of injuries related to male-perpetrated IPV. Unfortunately, the nature of these designs--in which controls are drawn from the same population as cases, whether they be emergency-department patients or victims of assault or homicide--precludes estimation of the association between partner alcohol problems and the likelihood of injury, victimization, or emergency-department attendance per se.
One would expect that the excess risks of IPV, health problems, and psychological distress associated with partner alcohol problems would be reflected in increased injuries and increased health care utilization among women married to or living with alcoholics. Although existing data on pretreatment health insurance claims of alcoholics and their families are generally supportive of this hypothesis with respect to overall health care utilization (see reviews in Holder and Cunningham, 1992; Holder et al., 1992), the results with respect to injuries have been more equivocal, showing apparent differences in some but not all age groups of women (Holder, 1989). There are no recent studies documenting rates of health care utilization and/or injuries associated with partner alcohol problems in nationally representative samples.
In assessing the association of male-partner drinking problems and adverse outcomes in women, it is crucial to consider the possible role of the women's own drinking. There is evidence of assortative mating with respect to maladaptive pattems of alcohol use (Leonard and Das Eiden, 1999; Sehuckit et al., 2002), whereby being married to an alcoholic or problem drinker increases a woman's own likelihood of drinking heavily or having an alcohol-use disorder (AUD). Although some studies have failed to find an association between women's drinking in the event and their risk of victimization (Brecklin and Ullman, 2002; Scott et al., 1999; Thompson and Kingree, 2006), there is an extensive literature that does link women's own AUDs, as well as heavy drinking and drug-use disorders (DUDs), with an increased risk of IPV and other forms of violent victimization (see reviews in Kantor and Asdigian, 1997; Miller, 1996; see also Cunradi et al., 2002; Lown and Vega, 2001; Parks and Fals-Stewart, 2004). Thus, the association between partner alcohol problems and women's physical and mental health problems would likely be overestimated without appropriate control for women's own substance use, substance-use disorders, and psychiatric disorders.
Most of the general population studies that have examined the role of partner drinking problems on women have focused narrowly on IPV as an outcome. Few have collected data that either explored a broader range of physical and mental health outcomes or that permitted adjustment for the women's own substance use or substance-use disorders. This study addresses this gap in the literature by examining, in a large, nationally representative sample of U.S. women, the association between partner alcohol problems and outcomes that include not only criminal victimization of any type but also injuries, health care utilization, mood and anxiety disorders, self-perceived health, level of stress, and quality of life. The associations between these outcomes and partner alcohol problems are compared with the associations of the outcomes with the women's own AUDs and are additionally controlled for the women's DUDs and tobacco use.
Method
Sample
This analysis is based on data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a national comorbidity study conducted by the National Institute on Alcohol Abuse and Alcoholism. The NESARC sample represents the civilian, noninstitutionalized adult population of the United States, including the District of Columbia, Alaska, and Hawaii (Grant et al., 2003b). The sample, which included persons living in households, military personnel living off base, and persons residing in selected group quarters, oversampled blacks, Hispanics, and young adults 18-24 years of age. One adult 18 years of age or older was randomly selected for interview from each sample household. The overall response rate was 81% (N = 43,093). Data were collected in personal interviews. All potential NESARC respondents were informed in writing about the nature of the survey, the statistical uses of the survey data, the voluntary aspect of their participation, and the federal laws that rigorously provide for the confidentiality of identifiable survey information. Those respondents consenting to participate after receiving this information were interviewed. The research protocol, including informed consent procedures, received full ethical review and approval from the U.S. Census Bureau and the U.S. Office of Management and Budget. This analysis is based on 11,683 women 18 years of age and older who were either legally married or living with someone as if married (cohabiting) at the time of the NESARC interview.
Measures
Physical and mental health indicators. Victimization was ascertained by means of a single question that asked respondents how often in the past year they were personally the victim of a crime or attempted crime ("such as if a stranger or someone you knew beat you up, mugged you or attacked you, hit you with something, took something from you by force or threat of force, or forced you to have sex with them"), excluding robberies that occurred when the respondent was not present. This measure did not distinguish crimes related to IPV from other forms of victimization. From the reported number of incidents of victimization, two dichotomous outcomes were created, one reflecting any victimization and the other reflecting multiple incidents of victimization. Respondents also were asked about the...
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