This study aimed to examine differences in unmet financial needs between people with psychotic disorders, parents, siblings, and controls. Additionally, we aimed to examine whether family clustering contributes to unmet financial needs, and to what extent demographic, economic, psychiatric, functional, and cognitive characteristics and substance use predict unmet financial needs in people with psychosis.

In line with our hypothesis, people with psychotic disorders showed significantly higher levels of unmet financial needs compared to parents, siblings, and controls. Almost one-quarter of people with psychosis reported unmet financial needs, compared to only 7.9% of controls, 4.1% of parents, and 8.4% of siblings. These findings are consistent with previous studies showing that people with psychosis have problems in objective financial functioning [4,5,6,7,8,9,10,11,12,13] and subjective financial functioning [16,17]. Particularly, the current findings align with our previous study, in which one-quarter of people with psychotic disorders reported financial dissatisfaction [18]. This percentage was three to four times higher than proportions of financial dissatisfaction in the general population [20]. In our previous study, people with psychosis had relatively long illness durations (mean > 13 years [18]) whereas in the current study, people’s illness duration was generally short (mean < 5 years), indicating that relatively high levels of financial dissatisfaction/unmet financial needs occur in people with psychosis in all phases of their illness. Knowingly, based on these findings, the causal direction could not be determined. On the one hand, research indicates that psychosis is a risk factor for financial problems [4,5]. On the other hand, negative financial conditions (e.g., low income or poverty) are recognized as risk factors for a worsening of mental health generally [71], and the development and maintenance of psychosis specifically [72]. Simultaneously, negative financial conditions are linked to higher stigma [73] and less social engagement [74] in people with severe mental illness. Irrespective of the direction of the relationship, these findings highlight that not having enough money to meet one’s financial needs is an important stressor for healthcare professionals working with people with psychosis to be aware of. Unfortunately, the discrepancy between unmet financial needs as indicated by people with psychosis and as perceived by clinicians or researchers indicates that this stressor is often overlooked.

Contrary to our expectations, parents and siblings did not significantly differ from controls regarding unmet financial needs. Furthermore, our results suggest a negligible effect of family clustering on meeting financial needs. This outcome is noteworthy, considering that previous studies consistently demonstrated a high financial burden on caregivers of people with psychosis [26,27,28,29,30,31,32,33,34,35,36]. In our study, family members were not necessarily caregivers. Yet, their involvement in their relative’s lives was implicit. It is important to note that an indirect familial effect could not be ruled out and warrants further exploration in future studies. The covariates contributing to the diminished familial clustering (i.e., ethnicity, educational level, and living situation) are often shared among family members, suggesting that some shared family-level factors can still play a role. However, these variables can also be influenced by other—individual—factors unrelated to family dynamics. For instance, a person might live with an intimate partner, or educational level can differ from that of family members due to the impact of psychotic symptoms. Thus, our results suggest that the individual characteristics or the condition itself, rather than SES-O or other shared familial factors, are key for unmet financial needs in people with psychotic disorders [73,75].

Indeed, individual characteristics that predicted higher levels of unmet financial needs in people with psychotic disorders in the exploratory analysis included demographic (i.e., region of assessment, not being married/not living together), economic (i.e., having another source of income as compared to earning wages), psychiatric (i.e., more positive symptoms), and functional characteristics (i.e., lower global functioning) and substance use (i.e., more tobacco and cannabis use). However, only tobacco and cannabis use remained significant predictors of unmet financial needs in the confirmatory analyses. Again, these findings are consistent with our previous study, in which cannabis and other substance users were significantly more often financially dissatisfied than nonusers, whereas other factors played a more marginal role. One possible explanation is the high expenditure associated with substance use in people with psychosis [15]. Additionally, substance use can complicate people’s financial management [76]. Together, our findings suggest that substance use, most consistently cannabis use, is an important factor to consider when people report low subjective evaluations of their financial situation. Furthermore, relatively high levels of unmet financial needs seem to occur in a heterogeneous group of people with psychosis, independent of demographic, economic, psychiatric, and functional characteristics. Unmet financial needs also appear to be independent of cognition, despite/contrasting with other studies reporting cognition affects other domains of subjective functioning in this group [42,43].

One possible mechanism behind relatively high levels of unmet financial needs in this group is that having a psychotic disorder leads to reduced educational and vocational opportunities, resulting in lower current SES (e.g., [22]). However, surprisingly, while in the current study, people with psychotic disorders indeed had lower educational levels, lower income levels, and higher proportions of illness invalidity benefits than the other groups, these factors did not consistently predict unmet financial needs. This finding suggests that the subjective evaluation of having enough money to meet one’s needs appears distinct from someone’s objective current SES. While this is counterintuitive, it is consistent with previous findings in the general population [77,78]. One possible explanation is that people with psychotic disorders can have substantial healthcare costs [36,79,80], which influences their disposable but not their gross income, which was measured in the present study. Additionally, other allocations of income, such as spending money on substance use [15], could create financial strain, without influencing gross income levels. Lastly, limited research suggests diminished financial competence in people with psychosis [13]. Financial competence (encompassing financial knowledge and financial judgment) is positively associated with subjective financial evaluations in the general population (e.g., [81]). Lower financial competence might lead to higher levels of unmet financial needs, irrespective of actual income levels. Thus, future studies are encouraged to include more detailed objective financial indicators (i.e., net income, disposable income, allocation of income, financial competence) as potential predictors of meeting financial needs in people with psychotic disorders.

A strength of the naturalistic nature of the current cohort study is that results can be generalized to people with psychosis in clinical practice. Furthermore, the study uniquely includes the subjective evaluations of family members, thereby expanding the limited scientific literature on the topic with evaluations of other important stakeholders. Some limitations need to be addressed when interpreting the results. Most importantly, unmet financial needs were assessed with one item from the WHOQOL-BREF [44]. To provide further insight in the association between psychosis and financial needs, future studies are recommended to use more detailed questions regarding having enough money to meet specific needs (e.g., nutrition, housing, leisure activities). In addition, we encourage including more detailed questionnaires related to this construct (e.g., assessing satisfaction with income and savings, financial stress). Secondly, we were unable to account for some potential confounders, which might affect financial outcomes. For example, research suggests that comorbid psychiatric conditions, such as anxiety or depression, are common among people with psychosis [82], while these conditions can also influence financial outcomes [83]. Thus, it is important to include information on comorbidities in future studies. Thirdly, it is essential to evaluate the results of this study in its social and economic context, as policies concerning social determinants of health, such as finances, and (the legality of) substance use vary across countries. Fourthly, we included data from participant’s first assessments, due to the large quantities of missing data in the subsequent waves (e.g., parents were not included in the follow-up assessments). This may limit generalizability. However, regarding group comparisons on unmet financial needs, data from the second and third assessments seem to correspond with our results. In these, the proportions of people with psychosis who cannot meet their financial needs are three to seven times higher than those of their siblings and controls (Supplementary Table S2). Lastly, a selection bias might be present. Participants who are willing and able to participate in lengthy studies may differ from participants in smaller studies or those who refuse or are ineligible to participate. Also, differences between family members and people with psychosis might be overestimated, if family members who are unable or unwilling to participate have some shared characteristics with their affected relative. Unfortunately, information on response rates was lacking.

These limitations notwithstanding, we conclude that one-fourth of people with psychotic disorders report unmet financial needs. This percentage is considerably higher than in siblings, parents, and controls. The negligible family effect on unmet financial needs highlights the distinctive challenge for people with psychosis. Lastly, cannabis and tobacco use consistently predict higher levels of unmet financial needs. Unmet financial needs appear to be relatively independent of demographic, economic, psychiatric, functional, and cognitive characteristics. Overall, our results suggest that relatively high levels of unmet financial needs occur in a heterogeneous group of people with psychosis.

Unmet financial needs can have detrimental consequences on mental health, stigmatization, leisure time activities and social engagement. It is recognized that professionals should routinely consider financial issues in their contact with patients (for a review see [84]) including people with psychosis [15,85]. Despite the growing availability of interventions such as financial therapy, which integrates mental health and financial health [86,87], mental healthcare professionals often do not address these issues [88]. This is perhaps due to insufficient knowledge about social determinants of health, such as finances, and existing interventions. Other likely barriers include short consultation times or a focus on symptomatic recovery (e.g., symptom severity, side effects [85,89]). However, recognizing unmet financial needs as a crucial stressor, especially among people using substances, is a pivotal first step toward timely addressing their negative consequences for people with psychosis.