There was a wage tendency that the group with ongoing experience of institutional contact to a higher degree was divorced, had no children at home, and had longer contact with psychiatric care—eventually indicating more SMHP compared to the institutional recovery group. Other background variables did not differ between the two service outcome groups.
In general, receiving a psychosis diagnosis tends to be connected to a lesser presence on the labour market and consequently to a fall in one’s income level.
Income and social welfare
In Sweden, this drop is counteracted through the public social security system. However, most of those general insurances are connected to one’s prior presence on the labour market. For persons that have not entered this market, the only possible source of public financial support is the social services. Confirming the findings of Falk et al. [
28], the different forms of support developed by the welfare state seem to reduce, but not fully compensate for, the economic consequences of the illness, even for a person who has previously participated in the labour market.
Over the 10 years of the follow-up, we can notice how the gap between the income from persons with a first psychosis diagnosis and the general population increased by over 30%. At the tenth year, the general population’s income was twice the income of the follow-up group, thus, reaching the relative poverty level. SMHP seemed to cause relative poverty, even in welfare states. This might partly be due to an ongoing deterioration of the different social security systems, entailing a lower level of remuneration and/or a shorter time a person might be eligible have to receive payments. Even the criteria to get access to different types of remuneration have also made stricter [
29].
Recovery, work, and income
Since persons with a first-time psychosis diagnosis follow different institutional recovery paths, we chose to compare two groups with opposite institutional recovery processes. The first group consisted of persons without any contact either with psychiatric or social services during the follow-up period’s last five years (institutional recovery). The second group consisted of persons who had received institutional and community-based psychiatric and/or social care during the same period (ongoing experiences of institutionalisation).
Not surprisingly, the incomes for the two groups differed. The income of the first group was 50,000 SEK (about 5000 euros) a year (about 30%) higher compared to the second group at year 10.
Even the sources of income differed between the groups. Three times more people from the second group had a disability pension, and five times more received financial social support. On the other hand, in the first group, nearly, 2.5 times more people had a salary compared with the group with ongoing experiences of institutionalisation.
Institutional recovery was often connected to a return to the labour market, but not returning to the income level of the general population. Already, at year 1, when the persons in the follow-up received their FTPD, we noticed a gap of around 100 000 SEK (about 10,000 euros), compared to the general population. This might, at least partly, be due to a period of illness prior to the diagnosis. Another possible explanation could be that, generally, persons with SMHP are more frequent in lower social status groups [
18].
The persistence and even widening of an income gap, even after a return to the labour market might be explained in different ways. Probably, not all persons with an institutional recovery worked full time and they might not have been able to get well-paid jobs. As working is often connected to expenses for travelling, food, and clothes, the result of working might be a deteriorated financial situation [
8,
30].
Work on the regular labour market is often proposed as the main road out of poverty for persons with SMHP [
31,
32]. Different initiatives have been taken to sustain this option, ranging from a reduction of taxes to “stimulate” people outside the labour market to start working, to the introduction of evidence-based interventions such as Individual Placement and Support to help persons with SMHP in their efforts to find work and maintain it [
33].
Part-time, low-paid work with low-level expectations and no control over the work conditions might lead to mental health risks both for persons with or without mental health problems. The risk for ill health for people working and living under such conditions might be higher than for persons on unemployment benefits [
8,
34].
Accepting the definition of relative poverty as below 60% of the general population’s median income, the median income of the follow-up participants was below this level at the time they received their psychosis diagnosis, compared to the median income of the inhabitants in the Stockholm region. Ten years later, they were clearly below that level.
Placing our findings in a contemporary context, we saw that, in the middle of the 1990s, the economic situation of persons with SMHP was inferior compared to the general population in Sweden and even compared to persons with other forms of disabilities. This knowledge led to a focus on normalisation of the living conditions of persons with SMHP in connection to the closing of mental hospitals. Despite this, the data we have presented show growing differences between persons with SMHP and the general population.
Poverty and recovery
The continuous financial strain connected to SMHP poses some core problems, both to our understanding of SMHP, “illnesses”, and “disorders” and to the elaboration of adequate interventions to ease the pain connected to them.
There is a growing body of knowledge about the confusion existing between, on one hand, the behaviours and suffering that are often considered to be symptoms of “severe mental illness”, and on the other hand, what could be considered as fully understandable and normal reactions to oppressive living conditions and experiences [
35].
Mood & Jonsson [
36] studied how a period of relative poverty affected people from the general population and showed a reduction of their social networks and activities. This type of reduction is often interpreted as a tendency towards passivity and isolation, which are considered symptoms of mental illness when it comes to people diagnosed with SMHP [
37]. On the other hand, the persons themselves connected their isolation and “passivity” to the living conditions. Poverty made it difficult to go to the usual places for social intercourse, such as coffee houses and restaurants, but also made it hard to visit friends and relatives and to invite them to one’s home to maintain a reciprocal situation. Consequences of prolonged poverty could be a deteriorated physical health status, old, worn out clothes and other factors preventing one taking part in social situations [
20,
21,
38].
Studies of supported socialisation, where persons with SMHP received a certain amount of extra money, show that their social networks tended to increase. Their quality of life and sense of self improved. Symptoms such as depression and anxiety decreased [
22,
23,
25,
39]. In addition, the users themselves have pointed to financial strain as one of their main problems [
40,
41].
In this context, it is noteworthy that there seems to be a serious lack of interest, except in policy documents, both from most of the professional mental health community and policy makers, in directly improving the financial situation for persons with SMHP [
42].
In an editorial in World Psychiatry, Priebe [
43] declared that there was no need for more research about prevention of mental illness. He claimed that we already knew enough and pointed to some interventions on a structural level to prevent mental ill health in the community. One of the changes he put forward was a decrease of income inequality. The results from several studies, the knowledge-based user claims are present. Is it time for changes?