Patients with schizophrenia and their finances : what they earn and own

Lack of financial resources clearly constitutes a barrier to the establishment and fulfilment of personal goals essential to the recovery of the schizophrenic patient. In Geneva, Switzerland, the disability pensions paid to patients with severe mental disorders are undoubtedly quite comfortable compared to the situation in other settings. It is therefore crucial to investigate how patients on welfare manage their money, to assess (1) whether it ensures a decent living, and (2) whether they are able to invest it in worthwhile, goal-oriented domains. The results are intended to show how to furnish optimum assistance to these patients, who may present residual symptoms which not only impair their ability to manage their income but also lower their motivation to pursue projects of long-term benefit [1]. The literature on money management and psychosis is scant [2], most research investigating the relationships between drug use and disability payments with contradictory findings [3, 4]. The goal of this study is to investigate what level of disability pension schizophrenic patients receive, whether their pensions allow them to live in decent conditions, what they own and how they spend their money. The study also aims to assess how the absence or presence of a guardian and patient housing conditions influence these parameters.

Lack of financial resources clearly constitutes a barrier to the establishment and fulfilment of personal goals essential to the recovery of the schizophrenic patient.In Geneva, Switzerland, the disability pensions paid to patients with severe mental disorders are undoubtedly quite comfortable compared to the situation in other settings.It is therefore crucial to investigate how patients on welfare manage their money, to assess (1) whether it ensures a decent living, and (2) whether they are able to invest it in worthwhile, goal-oriented domains.The results are intended to show how to furnish optimum assistance to these patients, who may present residual symptoms which not only impair their ability to manage their income but also lower their motivation to pursue projects of long-term benefit [1].The literature on money management and psychosis is scant [2], most research investigating the relationships between drug use and disability payments with contradictory findings [3,4].The goal of this study is to investigate what level of disability pension schizophrenic patients receive, whether their pensions allow them to live in decent conditions, what they own and how they spend their money.The study also aims to assess how the absence or presence of a guardian and patient housing conditions influence these parameters.

Method
Fifty-seven patients (mean age 43) meeting the ICD-10 [5] criteria for diagnosis of schizophrenia were included.Data were gathered on patients' incomes and expenses, in cooperation with their payee if any.Patients were then seen in their own homes, and their possessions inventoried on the basis of a structured questionnaire we had developed.Housing was rated as "comfortable" if they owned more than the minimum, "basic" if all essential equipment was present (i.e.heating, stove, refrigerator, etc.), and "poor" if any of these items was missing.Likewise, the status of furniture and other household objects was described as "luxurious" if they exceeded basic needs, "standard" if all customary items were present (e.g.television, CD player, etc.) and "poor" if these items were missing.Additionally, their leisure activities were listed and open-ended questions used to investigate patients' level of satisfaction with their financial situation and leisure activities.

Results
Patients living in subsidised accommodation were more likely to present the features of a more severe disorder, i.e. an assigned payee, an association of antipsychotic medications, and more symptoms as measured by the PANSS [6].42% of patients were assigned a payee.These patients were more likely to be living in subsidised housing (79% vs 33%, p <0.001) and to be evaluated as "severely ill" by the CGI scale (88% vs 58%, p <0.04).
The median total income was 4125 Swiss francs (CHF) (i.e.US$ 3590) per month, with patients in subsidised housing receiving more (median CHF 5390) than patients living alone (median CHF 3000) or with families (median CHF 1750).These differences are due to the fact that the Canton of Geneva bases pensions on patient housing costs.Federal disability insurance provides around CHF 1400 per month.In addition, the Canton of Geneva provides a supplement which varies according to patients' housing needs.Patients living in subsidised housing may receive up to CHF 200 per day to pay for it.If a patient lives in a flat, this fund will provide up to CHF 1100 per month.This arrangement is logically reflected in our results, since in the three housing situations patients' spending money appears to be roughly the same (i.e.CHF 300-500 per month).
Patients assigned to payees received more (median CHF 5352 vs CHF 2998), due to the fact that most of these patients live in subsidised housing and are thus allocated larger funds to pay for it.
Four patients received less than CHF 800 per month, since they were not yet in receipt of disability pension or any other financial support.Most of them were young people living with their parents.
30% of the patients were not satisfied with their income and 84% would have liked to earn more.When asked what they would buy with it, it appears that most of them were satisfied in terms of basic needs (i.e.food, clothes, living conditions, etc.).They also considered that they had enough money to allow them to smoke.81% of patients wanted more money primarily for leisure activities.Interestingly, there was only a tendency to associate satisfaction and global income (rho 024, p <0.08), a finding suggesting that some patients may not be fully aware of the amounts they receive.
Housing was evaluated during a visit to patients' homes.The living conditions were evaluated as poor in four cases, all of them patients living alone.Tw o patients lived in almost empty apartments, reflecting severe negative symptoms involving flat affect and a lack of motivation to invest in their homes.The other two patients primarily presented positive symptoms and stockpiled furniture and various objects collected on the street, with detrimental consequences for their living conditions.The inventory of furniture and objects was qualified as poor in around one out of four cases.All subsidised housing was considered to provide at least standard comfort.

Discussion
In the US patients receive smaller disability incomes, i.e. a total of less than US$ 1000 [2,3].The spending money left over after basic needs have been covered is usually less than US$ 100 per month, much less than in Geneva (see [7] for more details).In Brazil, patients with schizophrenia receive an average total income of US$ 208 per month, meaning that about two-thirds have insufficient funds for an enjoyable life [8].In Canada, total disability income for chronic mental disorders was CAN$ 852 (US$ 730) per month in 2007.This amount includes all expenses borne by patients, except treatment costs and insurance.In Belgium, disability income was 500 Euros in 2003, i.e.US$ 660.In France, this income was 620 Euros (US$ 815), which also covered all expenses.
The data in the present study were collected from patients who were regularly followed by our outpatient clinics -and who agreed to be interviewed.Thus, some individuals may not receive psychiatric care or social and financial help.Bearing this limitation in mind, it appears that the situation in Geneva, featuring quite a generous and comprehensive system, psychiatric care, social and financial assistance and payee assignment, allows patients to meet their financial and housing needs.These patients may of course receive more money than those with psychiatric disability in other settings.Nevertheless, this "real life" situation may provide some incentive to increase resources in other areas which may benefit from such measures.