Theme 1: Concealment, stigma and disclosure of illness.

There was a consistent lack of prior disclosure regarding one spouse’s SMI/psychiatric diagnosis. Many participants either discovered the condition immediately after marriage: “I found out on the second day of marriage… it should have been told to me before.” (C1-18) or only recognized its severity during a critical episode: “I only realized it was a ‘saya’ [spiritual possession] turned into a psychiatric issue after eight years.” (C1-9). Spouse-participants who had not been informed about the mental illness of their prospective partner, prior to the marriage overall considered this as a form of deception (C4-6). They reported being “shocked” (C4-8), “angry” (C4-9) when they first found out about the illness, often made evident when it manifested itself in violent behavior. A wife stated that “I should have picked it up because I always felt the hints were there. He used to get angry, beat himself up. Strange as it is, I never picked it up.” (C4-9) Partners also recounted that when they told their family members about the illness, “they were angry, and the explanation we got from their side [in-laws], was rubbish, about why we were kept in the dark. That we didn’t ask, so they didn’t think of informing us.” (C4-9) On the other hand, one spouse-participant (husband) considered that this was part of “..’kismet’ (fate) that he would get married to someone with a mental illness.” (C4-4)

Patient-participants admitted that their families deliberately withheld information, fearing the proposal would be rejected or the marriage would not proceed otherwise. For one spouse-participant (C1-16), his wife’s parents “didn’t want her in-laws to know she had bipolar… she seemed fine at the time of the wedding.” Participants described stigma around mental health as a primary motive for concealing the information. This pervasive withholding of information often undermined a sense of trust once symptoms surfaced.

When questioned whether they would marry the individual if they possessed prior knowledge about the illness, majority of the spouse-participants replied in the negative, because: “Why would anyone want their life to get ruined?” (C4-4) and “Why would I have put my life in such great difficulty? (C4-8). According to another, “even if you do get married, you shouldn’t start a family or have a kid.” (C4-8). One husband, facing multiple issues in the marriage due to his wife’s illness was indecisive, “maybe, I am not sure. If you have any doubt, then you shouldn’t marry.” (C4-1) On the other hand, another husband stated, “I would have married her because I am used to dealing with tough situations in life.” (C4-7)

Even when disclosure occurred prior to marriage, interviews with both spouse-participants and patient-participants revealed that the quality of marriage was still negatively affected, regardless of the type of marriage (love or arranged). In arranged marriages, families often used the term ‘depression’ to inform the prospective family about the illness, “My sister-in-law before marriage told me that he has depression. But I didn’t know the extent of the ‘depression.’ I thought that sure, he may be depressed just like everyone is, living in Pakistan.” (C3-1) Another spouse-participant expressed that since she was quite young at the time of engagement to her now-husband, she could not understand the gravity and the problems that she would experience later on in her marriage. Eventually, “the more I talked to him, I got interested in him. I was madly in love with him. I said to myself, so what if he has the illness? We will see. God is there to take care of me.” (C3-2) Inadequate understanding of the illness therefore led to marriage strain when spouses started living with their partners who had mental illness.

Knowing the spouse beforehand with a prior emotional bond did not serve as a protective factor in all marriages as evident in the case of C5-1, whose wife divorced him after 13 years of marriage. He shared, “She took it as long as she could. And then she could not bear it anymore and then she left.” When questioned as to why she eventually left, he further shared, “Not anything specific but a lot of incidents. Sporadic incidents. They kept happening. I started showing manic symptoms. My aggression increased, and her patience decreased. And that is a lethal combination. Between theory and reality, things are very different. She [the wife] knew the theory of it and when reality hit, she couldn’t handle it.” (C5-1) This was evident in the case of a female patient-participant who believed she did not treat her husband well due to her illness and expressed, “I do owe him an apology. I do take the blame for the marriage ending. There is a lot of guilt in me and sadness in me that probably I did not behave the way I was meant to behave.” (C5-3).

This theme is well-supported: concealing a diagnosis appears to be the prevailing cultural norm, mentioned in over half the transcripts across diverse diagnoses, and it also reinforces that SMI threatens marital stability.

Theme 2: Family dynamics and influence of in-laws.

The role of in-laws and extended family emerged as a crucial factor. Two sub-themes illustrate contrasting experiences of either support or blame.

In some cases, extended families provided robust emotional and financial support, thus facilitating marital stability. In C1-4, a spouse-participant stated, “I live in a joint-family, my father-in-law is very nice… they handle most expenses and help with children.” According to another wife, “I have ample amount of support. From my family, as well as my in-laws” (C1-2). For one spouse-participant, whose husband was hospitalized for many weeks, believed that the support of her in-laws had made it easier to deal with the illness, “Everyone is behind me. No one has left me alone at this hour. Whenever we need anyone from the family, they immediately come to our help” (C1-13). This participant shared that she did not have to worry about household chores, or even taking care of her children when her husband was hospitalized, because the in-laws were doing that, and she had to “simply be there for my husband” (C1-13) Therefore, she reported that she did not feel any “Bojh” [burden]” or any kind of “worry.” For many wives, their relationship with their in-laws also improved once their husbands were diagnosed with the mental illness, “my mother-in-law helps now after the illness. She takes care of the cooking and everything else.” (C1-20) In cases where wives were suffering from a mental illness, it was often her parents who stepped in to cover the cost of the treatment and extended moral support by taking care of the children (C1-1).

Conversely, many participants described in-law conflict marked by hostility and accusations. In one case, for instance, the wife, while facing physical abuse from her spouse with SMI, also struggled with difficulties in relationship with her in-laws, “His brothers do not help us at all… in fact they blame me for his schizophrenia.” (C1-7) In fact many a times, spouse-participants stated that they were advised to divorce their mentally ill spouses by their parents, particularly mothers, “when we first found about the illness, she [mother] said leave him, he will not get any better” (C1-4). Parental concern stemmed from the ill spouse’s impaired daily functioning, “You cannot continue like this. He won’t take care of the child. He’s sleepy, doesn’t go to office regularly, how will you deal with it?” (C4-9) Families also suggested divorce because “he was creating a lot of issues so my mother, my older sister and they all said that “leave him, leave him.” I used to speak ill of my husband and that was my foolishness.” (C5-3)

While some parents did not directly mention divorce, they appeared to question the decision of spouse-participants, “My parents said to me that all responsibilities are on you. What do you want? What should we do now? But I told them that I do not want to leave her. I have hope that she will get better.” (C4-4) However, as time progressed, family members also seemed to advise the healthy partners to stay in the marriage, because “the illness was out of his control” (C1-2) and that attempts should be made “to make her better.” (C3-6)

We have moderate–high confidence that in-law relationships matter: nearly all participants noted extended family involvement, with effects ranging from supportive to negative. Pressures are gendered; daughters-in-law consistently reported higher (real and perceived) in-law demands.

Theme 3: Daily burden and caregiving.

Regardless of the diagnosis, spouses often described intense caregiving demands. Two sub-themes emerged: (a) role reversal and (b) exhaustion/ burnout.

Nearly all the spouses in this study believed that due to the SMI of their spouse, they had to take additional responsibilities. For those who were married to someone with a more severe manifestation of the illness, majority of the tasks fell upon them which included tasks that are traditionally considered to be of the other spouse. For husbands, for example, while fulfilling the role of a breadwinner, they also had to take responsibilities of managing the house, and child-rearing, which they considered to be the domain of women.

Child-rearing, in particular, became the responsibility of the husband in case the wife was ill, “I have brought up the children, I have bathed them, I have done everything” (C1-16). Other tasks included “making breakfast” (C1-1) and “giving them feeders” (C1-19). Husbands also believed that the essential tasks of parenting such as teaching children the difference between right and wrong, and providing moral direction in life was an additional task they had taken upon themselves due to the vacuum provided by their wives. While some considered it their responsibility “to support their wives” (C1-1) others also considered it to be ‘a problem” (C1-16) and found it “annoying” when they had to do “double work.” (C1-19) Husbands also believed that they had taken up those responsibilities which “no one else would have taken” (C4-3).

Such responsibilities often fell upon the husbands, in the case of intact marriages, because of the specific manifestation of the illness, for instance, in the case of one partner with a mental illness, homicidal intent towards the child became evident. The physician had then advised the husband to “keep the child away from her” and “to take up responsibility of the child.” (C4-4). This also became pronounced because lack of support from other family members compounded the number of responsibilities that had to be undertaken by spouse-participant.

For healthy wives in the union, earning for the family became a responsibility although this was less evident, compared to men taking up the responsibilities of child-rearing. One spouse-participant for example, recounted that her husband was unable to “take care of the credit card bills, so I have to take care of it.” (C1-2). For one of the wives, coming home after a long day at work, and then cooking and looking after the child posed difficulties for her (C4-6). Wives also believed that because of their husband’s illness, they had to take up responsibilities such as “running to the bank and submitting children’s school fees,” (C4-8) something that they considered the responsibility of the father.

Many caregivers expressed anger, resentment, or depression arising from continuous strain. In C1-17 the wife said, “I do vent out… I yell at him. But it falls on deaf ears… I have to keep going for our son.” Sleep disruption, health problems (e.g., hormone imbalances, weight loss) were also common. Spouse-participants also reported “I had to go for counseling, because it was getting very difficult for me to cope up especially with my son.” (C1-2) This was also because “I feel I am forgetting things and my memory is getting weaker.” (C1-2) When questioned directly about their feelings due to the mental illness of their partner, spouse-participants reported feeling “sad,” “crying all the time, because of the sadness” (C1-9), “feeling depressed and anxious” (C1-9), “feeling hopeless” (C4-4) and “stressed out” (C1-2, C1-10). For one spouse-participant whose husband had displayed violent behavior, she reported feeling fearful all the time (C1-7). Others also believed that they had grown more “sensitive” due to their partner’s illness, “thinking about one thing constantly” and “often getting angry at very little things.” (C3-2) Amidst all the difficulties that spouse-participants were experiencing due to the mental illness of their partners, majority of them saw a “bleak future” (C1-2) especially because they did not know whether “he will get better.” (C1-4)

On the basis of repeated detailed accounts, we have high confidence for burnout, role strain and role reversal across our interviews with different psychiatric conditions.

Theme 4: Cultural & religious norms around marriage and divorce.

Our study revealed that one of the important reasons for intact marriages was the negative attitude towards divorce in the Pakistani society, common among both male and female participants, but more so for latter. They referred to strong cultural or religious disapproval of divorce. Even amid severe stress, couples felt pressured to stay married.

For a large number of spouse-participants, husbands and wives alike, divorce was not considered an option, since “it is bad, I don’t believe in it” (C1-8) and a “wrong act” (C4-7). In fact, the aversion to divorce for many participants was such that “separation should not even be thought about” (C4-7, C1-18) and that every attempt should be made to “compromise” (C4-2) and “for the couple to be patient with each other and work it out.” (C1-1) Interviewees also highlighted that problems are present in every marriage, and that “One should strive to make the marriage work. Small things should not be blown out of proportion.” (C1-13)

While a few participants agreed that religion provided a recourse to divorce, keeping the marriage intact was still believed to be a priority because “Allah has thought of something for you, that’s why you are married. Yes, He has provided the option for divorce, but even then one should not think about it.” (C1-17). One spouse-participant also expressed that since divorce was so “painful” he did not consider it to be lawful within religion. On the other hand, a patient-participant who was divorced expressed, “When religion allows it, why not?” She had initially considered divorce to be “taboo, and that it was better to die rather than to take divorce.” (C2-2)

Other spouse-participants also expressed the concept of “till death do us apart” and believed that they were meant to remain with their partner until one of them died (C1-18). Many others also considered the relationship between a husband and wife to be of utmost importance therefore, “divorce is an extremely wrong act. You can ruin someone’s life this way. What is there in life? For men, it is still easy to survive after divorce, but for a woman, it is not.” (C1-18) Another one expressed that while he may seek separation from his wife, “she can live with her parents, and I can live on my own” but “I will never ever give divorce.” (C4-5)

A few participants highlighted that divorce should be undertaken only in certain circumstances, such as in the case of infidelity, “I would have only considered divorce if she had illicit relations with any other man. This is not the case.” (C4-3) One spouse-participant also expressed that constant physical abuse may also lay the grounds for divorce, “Well if there is a lot of beating, then a person should seek divorce.” (C1-7) It is interesting to note that for this particular participant, physical abuse was present in the early years of the marriage, but she chose to stay back in the marriage.

Despite the general negative attitude towards divorce, especially amongst those in intact marriages, a few spouse-participants shared that they had thought of divorce intermittently, “When I am desperate, and I feel like I cannot carry on, I think of divorce, even after 14 years of relationship” (C1-20). They reported thinking about this frequently “whenever we have a fight” (C1-2) and threatening their spouse that “I am going to leave” (C1-6), when the patient is hospitalized “I often feel like running away. To be honest, I am more relaxed when he is not at home” (C1-5). This also happened in instances when the patient was particularly violent, “I feel like just going through with it [divorce] when she is acting this way.” (C4-2)

During times of violence exhibited by the mentally ill partners, spouses shared that they had left them for certain periods, “I did run away once, but my child told me to come back” (C1-9). One spouse-participant recounted an instance where he had gotten into a fight with his wife, and “I broke a glass because I was so angry, and then I told her parents to take her away.” However, when his anger subsided, he went and “brought her back” (C4-4). Another wife shared how her husband had hit her multiple times, after “which I left him. Then someone told me about this doctor, and take him for treatment, so I went back.” (C4-8) Thoughts regarding divorce also surfaced for spouses when they were feeling exhausted, “There are times when I am very tired taking care of her, and then I think to myself, maybe I should end it, I am being honest here, but then I think no, let’s fight this.” (C4-4)

Our participants also highlighted that patients also considered divorce as an option and it was not only a recourse for healthy partners. Due to the violent behavior of her husband and in-laws, one patient-participant chose to seek separation, because “I cannot find love for him in my heart anymore.” (C6-2)

A handful of spouse-participants also expressed that while they wanted to leave their spouse, they felt trapped because “He says he does not have anyone, even his brothers don’t help him” (C1-7) and “if I leave him, his family will not help him. He will be sent to a mental asylum” (C4-8) It appears as if they stayed in the marriage out of a sense of responsibility since there was no one else to take care of the patient, “If I don’t support him, then he will be completely lost.” (C1-7) Despite being unhappy in the marriage, she did not consider leaving her husband, suffering from schizophrenia, characterized by violent behavior, to be an option because “How will I be at peace if I leave him [in this condition] when there is no one to take care of him?” (C1-7) Her dilemma was further highlighted by the fact that she shared her feelings of fear of sharing a bedroom with him, tracing it back to how he had tried to strangle her while she was sleeping, and that staying married to him was not bringing her peace, “I have a fire burning inside me. I am so afraid. How can I let go off this fear?” (C1-7) Another spouse-participant also shared how his wife’s parents were unable to take care of her, and therefore, he did not think he “could leave her in this state. She will get worse there. They didn’t get her the right treatment before [marriage]. How will they take care of her now?” (C4-8)

Some participants stated that their families insisted that “in our family, divorce is not an option” (C1-18). Another participant (C1-13) fought until the very end, stating, “Never… I am sure there are people more tolerant, so we should not divorce.” In rarer cases, second marriage (allowed in Islam) was suggested as a coping mechanism or alternative to divorce (C1-2), where the husband took a second wife due to first wife’s illness; C1-18 “I told her if I find a good girl, I might marry again… no wrongdoing in it.”

Our confidence in this theme is moderate because, while cultural norms appeared influential across interviewees cutting across class and socioeconomic status, the degree to which participants adhered to or resisted these norms differed based on individual beliefs and family expectations.

Theme 5: Emotional and physical violence.

A subset of participants, mainly wives (both patient-participants and spouse-participants), experienced emotional abuse and, at times physical violence or intimidation from the spouse.

Husbands often used emotional abuse as a tactic particularly when they had discovered existence of mental illness after the marriage. According to one divorced patient-participant, “He used to say bad stuff about my parents. He would say, ‘you have given me your crazy daughter.’ There was a lot of emotional torture. He never hit me though.” (C2-5). One spouse-participant reported hitting his wife during her manic phases, “I get angry with her. Sometimes I raise my hand at her [in frustration]. I feel bad afterwards and then try to make amends once my anger has cooled down.” (C3-6). Some participants recounted non-physical intimidation: locked rooms, taking away phones, or threatening a second marriage (multiple marriages are allowed in Islam for men) to manipulate. For example, in C1-20, a spouse-participant reported that her husband had “threatened to lock me in the room” while she was pregnant.

Spouse-participants particularly wives reported both emotional and physical violence during the active stages of the disease. One reported, “His [ill husband]’s attitude changed a lot. There was a lot of swearing, a lot of cursing. To the extent that our children got disturbed.” (C1-4) Others, mainly women, however reported experiencing physical violence in varying degrees of intensity. Another one shared, “Sometimes he has even mishandled me. But not too hard that I was hurt.” (C1-2). Yet another spouse-participant recounted that throughout the duration of her marriage to her husband diagnosed with bipolar disorder, there were several instances of violence directed towards her. One particular incident with dangerous levels of violence was in a particularly acute manic state, where her husband beat her with a belt and it escalated to the point that he tried to strangle her. She reported feeling “shattered” (C1-7) to the point that she kept crying for hours until finally she settled. Despite the real threat of violence and contemplation of divorce several times, she chose not to leave due to lack of support at her natal home.

We have moderate level of confidence here. While the data on emotional and physical violence is strong in those interviews where it appears, it is not consistent across all cases.

Theme 6: Love, duty, and children.

For majority of spouse-participants, both male and female, the presence of children appeared to be a strong motivator in keeping the marriage together. In the case of intact marriages, thirty-three couples had children, whereas only two did not. In contrast, six out of ten patient-participants separated or divorced did not have any children.

When spouse-participants were asked the reasons for staying in the marriage despite the multiple difficulties that they faced in their marriage, responses such as “because of kids” (C1-3),“and one has to think about kids” (C3-5), and “it is important for children to have both mother and father living together” (C1-4) surfaced consistently. One stated that divorce should not be considered as an option, “if there are children involved” especially by “women.” However, she believed that in case there were no children, then divorce could be a possibility (C4-8).

In instances where the quality of marriage was severely impacted due to the mental illness of their spouse, participants believed that this should not be “taken out on the children” (C4-5) due to the belief that “children suffer in case of divorce” and for the sake of the children, “compromises should be made in a marriage.” (C1-9) Spouse-participants reported that they were trying to “survive” in the marriage because of children (C1-16). One wife recounted the instance of when she had “left and went to my mother’s place” but “came back after six months because I realized I had to continue. I have a 1.5 year old daughter” despite repeated physical abuse. (C1-20)

Male spouses believed that even though their wives were suffering from mental illness, they were still “someone’s daughter” particularly pronounced for those who also had daughters themselves (C3-5, C4-2). While many healthy husbands did not consider themselves close to their wives, they still viewed them “the mother of their children.” (C1-16, C4-4) This was equally true in the case of healthy wives who believed, “I can’t take my daughters away from their father. I am nobody to do that, and I would never want it like that. What if my daughters ask me when they grow up, why did you leave him, he wasn’t well, it wasn’t his fault.” (C1-20) One healthy husband, in particular, reported that he had to stay back in the marriage because of the children since “I don’t have anyone else in the house to look after the children. No one will give love to my children. At least she [wife] will still give some love to them [since she is their mother].” (C1-16).

Participants who were now divorced, and had children believed that the divorce had affected their children adversely, because they believed that “the mental health of the children suffer.” (C2-5) One female patient-participant suffering from schizophrenia with one son recounted during the interview that she regrets that her husband divorced her because “he [pointing to her child] is suffering” since “when he goes to his father to meet him, he feels it. What will he think about his father when he grows up?” (C2-5)

A few spouse-participants also demonstrated some form of emotional attachment and a personal bond with their partners irrespective of the type of marriage (love or arranged), “I am attached to my husband” (C1-17). Wives in particular described a self-sacrificial or altruistic perspective: “He’s not normal, but that is acceptable to me” (C1-16). One husband stated, “I have suffered a lot because of her illness, and people have made fun of me, and no one has supported me. But I think about how she had supported when I was sick, and how she used to take care of me. Now when she is sick, I have to take care of her.” (C1-16) Another husband reported how prior to the onset of the illness, his wife had supported him financially since she was a tailor “who used to take care of her own expenses initially [in order to help me out].” (C1-1) Another spouse-participant shared that when she was pregnant with their first child, her husband had taken care of her a lot, and after the mental illness became “troublesome,” she thought of leaving him, leading her to feel extremely “guilty” (C1-2).

In the absence of emotional attachment between the spouses, some spouse-participants perceived their decision to stay back in the marriage as a compromise they had made, stating, “A relationship has been established. What can I do now?” (C4-2) Others also conveyed a sense of resignation when they believed that this is how “they will pass the rest of their days” (C4-1). Another one after expressing his frustration in dealing with his wife stated that his attempt was to be patient, and leave his life up to God (C4-3).

We have high confidence in this theme: love, moral obligation, and especially children’s futures recur in nearly all interviews that led to continued marriage. The data are rich, coherent, and transferable across BDP, schizophrenia, and OCD; dependability is shown by repeated reports of secrecy, caregiver burden, and in-law conflict.

Overall, we retain high confidence in the core themes: concealment, daily burden, cultural norms, and the centrality of children, but only moderate confidence about polygamy’s prevalence and abuse intensity, which appear in limited subsets. Overall, the findings can be organized into push–pull dynamics in the context of marriage as shown in the table below (Table 3).

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Table 3. Push and Pull factors.

https://doi.org/10.1371/journal.pgph.0005652.t003

Across interviews, participants moved between these push-pull tensions, resulting in either a decision to remain in the marriage (often citing love, duty, or children) or a breakdown (when aggression and abuse, considerable stress, or stigma overshadowed any possible resolution).

In sum, the results reveal a complex interplay of social, cultural, and emotional factors guiding how spouses navigate marriage under the stress of mental illness. On the “push” side, undisclosed or poorly managed psychiatric conditions, critical in-law environments, role reversal, caregiver’s burden and violence/aggression commonly pushed marriages toward separation. Conversely, “pull” factors like cultural aversion to divorce, presence of emotional bond, the presence of children, and supportive extended families often helped sustain marriages despite significant challenges. These findings underscore the necessity of disclosure prior to marriage, family-wide support, open communication which can help stigma reduction and prevent the cycle of hiding information and marital dissatisfaction frequently noted in the interviews.