There is limited research regarding the role of poverty on the clinical outcomes of schizophrenia. A study by Fond et al sought to better understand the role poverty played in the characterization and symptoms of schizophrenia, as well as patient functioning and quality of life.1  

Research

This was a cross-sectional observational study involving patients referred between January 2015 and December 2018 to 10 Schizophrenia Expert Centers in France.1  

To be included in the study, patients must have had a Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis of schizophrenia or schizoaffective disorder, and no hospitalizations or alterations in treatment during the previous 8 weeks. Patients with psychiatric comorbidities other than major depression, anxiety disorders, eating disorders, and substance use disorders, were excluded. To enroll in the study, patients needed to be proficient in French.1  

Diagnosis of schizophrenia or schizoaffective disorder was validated by 2 psychiatrists from the Schizophrenia Expert Centers Network, using the Structured Clinical Interview for DSM-5 (SCID-5).1  

A variety of data was collected for this study (Table 1).

Table 1. Variables collected

Category

Measures

Sociodemographic

  • Poverty level

    • As defined by the National Institute of Statistics in France

  • Age

  • Sex

  • Education level

Clinical

  • Clinical Global Impression Scale (CGI)

  • Psychotic symptomology

    • Positive and Negative Syndrome Scale (PANSS) total score and positive and negative factors

  • Current depressive symptoms

  • Insight into illness

    • Birchwood Insight Scale (BIS) total score

  • Lifetime history of planned suicide

    • Interview on Suicidal Feelings (ISF)

  • Current functioning

    • Personal and Social Performance Scale (PSP)

  • Sociality variables

    • Relationship status

    • Living arrangements

    • Parenthood

  • Treatments

    • Use of second-generation antipsychotics

    • Cognitive-behavioral therapy within the last 12 months

    • Antipsychotic daily dose

    • Medication Adherence Report Scale (MARS)

Physical health

  • Self-reported weekly physical activity as defined by the World Health Organization (WHO)

  • History of hypertension and coronary heart disease

  • Body mass index (BMI) and abdominal circumference

  • Routine blood work

Caregiver-reported outcomes

  • Evaluation of Cognitive Processes involved in Disability in  Schizophrenia (ECPDS) scale

Patient-reported outcomes

  • Self-reported quality of life

  • Schizophrenia Quality of Life Questionnaire (S-QoL)

  • Self-reported aggressiveness

 

Multivariate models were created for each variable that was shown to have a significant association with poverty. All models were adjusted for age, sex, education level, poverty, and PANSS total score.1  

Key Findings

A total of 916 patients were included in this study with 739 patients categorized into the poverty group. Poverty was associated with more severe psychiatric symptoms and aggressive behavior, but not depressive symptoms.1

Poverty was also associated with increased metabolic disturbances (eg, hypertension and high LDL cholesterol).1  

While poverty was associated with a lower education level, unemployment, reduced social engagement, and single or child-free status, patients in the poverty group reported higher self-esteem levels compared to wealthier patients. Poverty was not associated with substance use disorders, reduced treatment adherence, decreased access to psychotherapy, lower insight into illness, decreased social functioning, heightened depression, or a lower quality of life.1

Limitations  

The socioeconomic variables included in this study were collected at time of enrollment and did not include patients’ early history. Data on a patient’s early socioeconomic history, such as parental income throughout childhood and the current financial status of a patient’s caregivers, were not collected. Poverty was measured at enrollment of this study and treated as a circumstance preceding enrollment, not allowing researchers to study the trajectory of poverty over time. The lifetime symptomology of the patients was not collected, as this is difficult to capture retrospectively.1

Impact 

Studies have shown that income is related to health, with lower income linked to worse health outcomes.2 These results show that poverty can have a negative impact on schizophrenia outcomes, even in countries like France where healthcare is accessible to all. Determining how to better provide care for these patients is essential. In countries like the United States where healthcare is not as accessible, patients in poverty may face even worse outcomes than described in this study. Providers can be aware of this socioeconomic factor and ensure that they take extra time with patients with socioeconomic disadvantages.1  

Future studies looking at the lifetime impact of socioeconomics in schizophrenia patients are needed. Factors such as parental income when growing up, number of siblings, presence of a monoparental household, and financial status of caregivers will be important to understand the role socioeconomics plays throughout the lifetime of a schizophrenia patient.1 Income-related factors such as these may increase the risk of developing schizophrenia, with studies showing that parental income and income mobility throughout childhood may be linked to schizophrenia.2,3 If we can better understand the risk factors for developing schizophrenia, we can determine what to do on a population level to help mitigate the risk of this debilitating disease.3 For the United States specifically, learning when to provide income support to patients already diagnosed with schizophrenia will also be critical.4

References:

  1. Fond GB, Yon DK, Tran B, et al. Poverty and inequality in real-world schizophrenia: a national study. Front Public Health. 2023;11:1182441. doi:10.3389/fpubh.2023.1182441
  2. Schneider M, Müller CP, Knies AK. Low income and schizophrenia risk: a narrative review. Behav Brain Res. 2022;435:114047. doi:10.1016/j.bbr.2022.114047
  3. Hakulinen C, Webb RT, Pedersen CB, Agerbo E, Mok PLH. Association between parental income during childhood and risk of schizophrenia later in life. JAMA Psychiatry. 2020;77(1):17-24. doi:10.1001/jamapsychiatry.2019.2299
  4. Zipursky RB. Why are the outcomes in patients with schizophrenia so poor? J Clin Psychiatry. 2014;75(Suppl 2):20-24. doi:10.4088/JCP.13065su1.05