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The Relationship between Bipolar Disorder and Financial Difficulties: A Qualitative Exploration of Client's Views

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This paper uses a qualitative methodology to explore how those with a diagnosis of Bipolar Disorder view their mental health as related to their finances. Themes identified were guilt around impulse spending, comfort spending and avoidant coping with finances.
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This is a pre-publication version of the following article: Richardson, T., Jansen, M., Turton,
W. & Bell, L. The Relationship Between Bipolar Disorder and Financial Difficulties: A
Qualitative Examination of Patient‟s Views. Clinical Psychology Forum, In Press.
The Relationship between Bipolar Disorder and Financial Difficulties:
A Qualitative Exploration of Client’s Views
Thomas Richardson, Principal Clinical Psychologist (Research Lead) a,b*
Megan Jansen Assistant Research Psychologist a,b
Wendy Turton, Professional Lead Waiting List Initiative c
Lorraine Bell, Consultant Clinical Psychologist a,b
a Mental Health Recovery Team North, Solent NHS Trust, St. Mary‟s Community Health
Campus, Milton Road, Portsmouth, PO3 6AD, U.K.
b School of Psychology, University of Southampton, Southampton, SO17 1BJ, U.K.
c Psychology and Psychological Therapy, Devon Partnership NHS Trust, Exeter, EX2 5FY
* Corresponding Author: Dr Thomas Richardson, Email thr1g10@soton.ac.uk, phone
004478767461662, fax: 023 9268 0267
Summary
This paper uses a qualitative methodology to explore how those with a diagnosis of Bipolar
Disorder view their mental health as related to their finances. Themes identified were guilt
around impulse spending, comfort spending and avoidant coping with finances.
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Introduction
A diagnosis of Bipolar Affective Disorder (BAD) is characterised by episodes of
depression and elevated mood (or mania) and is applied to 2-3% of the population
(Merikangas et al., 2011). Impulsive spending is also listed as a possible symptom in the
diagnostic criteria for a manic episode (American Psychiatric Association, 2013). During a
manic phase individuals have been shown to be at „high risk‟ for behaving impulsively with
increased risk of disruptive behaviours such as unrestrained spending, sexual indiscretions
and embarking on grand schemes (Muhtadie et al , 2014). Jones et al. (2015) found that
approximately 1 in 10 of those with BAD were at risk of developing a gambling problem.
Cheema, MacQueen, and Hassel (2015) found that those with BAD are poorer at managing
their finances, possibly related to increased impulsivity.
Richardson, Elliott, and Roberts (2013) conducted a systematic review and meta-analysis
and found that those with depression were more than twice as likely to be in debt. When
examined qualitatively (Barnes et al., 2016) found that economic hardships in combination
with other vulnerabilities “acted as the final straw to trigger self-harm”. A number of studies
have also identified that financial difficulties in particular overspending are a significant
source of stress for caregivers of those with a diagnosis of BAD (Beentjes, Goossens &
Poslawsky, 2012). However there are no previous studies on the impact of debt on mental
health in clients with BAD specifically (Richardson et al., 2013).
The present study therefore aimed to conduct a preliminary exploration of the relationship
between financial difficulties and mental health in those living with BAD using a qualitative
methodology.
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Method
Procedures
This qualitative study formed part of a larger quantitative study examining correlates
of debt in BAD. Participants with a diagnosis of BAD within a National Health Service
(NHS) secondary care mental health service were invited to take part by their clinician.
Participants were asked the following „Yes/No‟ questions: “In your opinion, have
your mental health problems made your debt or financial difficulties worse?” (84.3% n=59
responded „Yes‟) and In your opinion, have your debt or financial difficulties made your
mental health problems worse?” (71.4% n=50 responded „Yes‟). Forty four participants who
commented further on these questions were included in the qualitative analysis.
Six participants from this larger study were selected and invited to take part in a focus
group. Participants were selected at random; however twenty participants refused to take part
due to childcare difficulties, feeling uncomfortable in a group setting and work commitments.
The following questions were posed: Do you think debt and financial difficulties have an
impact on your mental health personally?, Do you think your mental health problems can
make your debt and financial difficulties worse? and Why do you think this might be?” The
discussion lasted 75 minutes.
Ethical approach was granted by the University Of Southampton School Of
Psychology Ethics Committee as well as the local NHS research ethics committee. Informed
written consent was obtained from all participants.
Participant Characteristics
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Participants were 68.2% (n=30) female, ages ranged from 25 to 69 with mean of 49.
Ethnicity was 77.3% (n=34) white British and,36.4% (n=16) i were employed. Co-morbid
psychiatric diagnoses were present in 34.1% (n=15) vof participants.
Qualitative analysis
Thematic Analysis (Braun & Clarke, 2006) was conducted. The focus group
recording and responses from the written questions were analysed together. Two reviewers
did an initial thematic analysis separately with no prior assumption of themes. Themes were
identified if quotes fitted from five or more participants. Reviewers then met to compare
initial themes and finalise themes.
Results
Seven main themes were identified, with a further three subthemes. Illustrative quotes and the
number of participants whose responses fitted into these themes are described below.
1. Over-spending
Over-spending when hypo(manic) emerged as a broad theme with impulsive shopping and
excessive generosity as sub-themes.
1a. Impulse Shopping (n=44)
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“Impulsive purchases… will spend all that I have when I am manic or hypo-manic.
Will spend on grand schemes.
When I am manic, I am extremely impulsive, and I can spend hours (mostly during
the night when I can’t sleep) shopping online.”
Participants reported that they exhibit spontaneous and impulsive spending habits
during (hypo)manic episodes, for example bulk buying and spending money on unnecessary
items. Participants reported „maxing out‟ credit cards and overdrafts and pawning jewellery
in order to have more dispensable income to then spend impulsively. This resulted in
“spending thousands of pounds on items,” and building up large debts of up to£12,000.
1b. Excessive Generosity (n=6)
I became high and gave away all my savings to charity 4 years ago.
When my mood is elevated, I feel the need to shower my wife and kids with gifts,
irrespective of finances.
Participants described during a (hypo)manic episode, being over-generous towards
others, with some giving all their savings to a charity, or buying gifts excessively for their
family and friends.
2. Anxiety/Depression (n=29)
The constant stress of financial pressure worsens my anxiety”
The realisation of debt can trigger a depressive bout.
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Participants reported that debt and financial difficulties exacerbated depression and
anxiety. Participants reported stress about being able to pay off debt and meet living
expenses. Others criticised themselves for „economic inactivity‟ and linked this to depression.
Some participants reported having extreme anxieties surrounding possible bankruptcy and
home repossession. Participants linked these to feeling hopeless and unable to deal with their
financial situation.
2a. Suicidality (n=7)
The very reason I tried to commit suicide 3 years ago.
Increased spend, anxiety which leads to suicidal attempts/ideation to resolve it all.
Participants described having suicidal ideation resulting from what they saw as a
hopeless financial situation. At the extreme end, participants have felt so hopeless financially
that they have made attempts to end their life or ended up in hospital.
3. Regret/Guilt (n=10)
“When I am on a low that’s when it hits me how much I've spent on a high you don't
think about it
Then to lows, I would be concerned and worried about financial situation 'What
have I done!?'
Participants described feelings of guilt and regret upon releasing the extent to which they had
overspent when (hypo)manic, and this appeared to be linked to feeling low in mood.
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4. Poor Planning/Avoidant Coping (n=27)
When I am depressed, I don’t open my mail and bills and get left unpaid. I avoid any
social contact at this time so telephone banking and going into a branch is out of the
question.
When I get letters for debt, I don’t always open them or ignore them until the situation
gets worse
Participants reported leaving post and bills unopened to avoid dealing with their
financial situation, especially when low. Some also spoke about not being able to think
rationally or remember their purchases when depressed and subsequently making poor
financial decisions.
5. Vicious Cycle (n=8)
Catch 22. Stressed about money. You buy more and it goes round in circles.”
“It’s a vicious cycle. I realise I’m spending and putting my family in financial stress
and leads to larger depression. This is then leads to comfort spending again.”
Participants reported a bi-directional relationship whereby over-spending when
(hypo)manic led to depression when the extent of financial difficulties was realised. A way of
coping was then to comfort spend which then led to a vicious cycle or „downward spiral‟.
6. Impact on Employment (n=24)
I am dependent on benefits so I face constant pressure to economise.
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After my last breakdown, I had to take a lot of time off work and lost my job. Mental
illness makes it difficult to earn money. Therefore meaning I am trapped.”
Participants described that having a diagnosis of BAD introduced difficulties in
maintaining employment. As a result, participants reported having to take on lesser role or a
part-time position with a reduced income or stop work altogether and rely on benefits which
introduced additional pressure to economise.
7. Comfort Spending (n=6)“If I am depressed I reward myself I can go out on food and
alcohol.”
During down periods, I essentially comfort spend.
During low periods, participants reported that they were inclined to buy items to self-
soothe and comfort themselves. Some said they bought items with the aim to cheer
themselves up or try and make themselves feel better, with some even saying that when they
were low about financial difficulties they bought items to cheer themselves up, thus this also
linking to the vicious cycle theme described above This appears qualitatively different to the
impulsive spending experienced during a (hypo)manic episode as it served a different
function.
The present study aimed to examine the relationship between financial difficulties and
mental health in those living with BAD using qualitative methods. This is the first time this
relationship has been examined in this population. The emerging themes support the
impulsive spending diagnostic criteria for bipolar disorder (APA, 2013). Overspending was
the strongest theme that emerged with all participants identifying with this. , which links with
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previous literature that overspending is reported as a source of stress in caregivers of those
with BAD (Beentjes, Goossens & Poslawsky, 2012). Participants reported that shopping
impulsively and excessive financial generosity towards others were key behaviours when
elated followed by a feeling of guilt and regret upon realisation of the resulting financial
situation. Guilt is a common characteristic of depression (APA, 2013). Similarly, the theme
of avoidant coping and poor planning emerged, which has also been shown as an important
psychosocial concept in depression (Ottenbreit & Dobson, 2004).
Participants reported experiencing feelings of anxiety and depression as a
consequence of their poor financial management and/or situation, linking to previous research
demonstrating a relationship between debt and depression (Richardson et al., 2013). In
addition, participants reported suicidal thoughts, in line with Barnes et al. (2016) who found
that economic hardship contributes to self-harm. Participants reported that they comfort
spend to try and make themselves feel better when depressed. Interventions which try to
reduce depression and anxiety in BAD may therefore reduce comfort spending and improve
financial capability. The impact of employment theme links to previous research suggests
that the majority of those with BAD are unemployed (Bowden, 2005).
A vicious cycle with mental health impacting those financial difficulties and this then
looping back to affect their mental health also emerged from the Thematic Analysis. This is
outlined in Figure 1. Over-spending whilst (hypo)manic via impulsive shopping or excessive
generosity appears to lead to regret and guilt when mood begins to stabilise and individuals
contemplate their financial situation. This then fuels anxiety and depression, and poor
planning and avoidant coping around finances when depressed can worsen financial
difficulties potentially leading to suicidality. Many then end up comfort spending to try and
ease negative affect, however the positive impact of this is short-lived and there is a potential
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vicious cycle back to depression when individuals start to regret or feel guilty about their
over-spending again.
***Insert Figure 1 here***
Limitations
One of the limitations is the lack of ethnic diversity within the sample. There may
have been a selection bias in the focus group as many people refused to take part. In addition
the larger quantitative study was advertised as on „Mood and Money‟ so participants may be
more likely to see finances and mental health as related than those who declined to take part.
Conclusion
The findings highlight that financial difficulties may be a particular issue for those
with a diagnosis of BAD; further research to explore this relationship is needed. A number of
possible psychological mechanisms were identified; including impulsivity during high
moods, and self-critical thoughts and avoidant coping behaviours during low moods, and
suggestions are made as to how these might be related over time. Psychological interventions
could be utilised to help address these variables and thus possibly reduce the impact of poor
mental health on finances and vice versa in those with a diagnosis of BAD. These findings
have also highlighted the possibility of financial or social intervention to reduce impulsive
spending when manic, for example having a „guardian‟ to look after credit cards.
Acknowledgments
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Thank you to the participants and staff who helped with recruitment. This research
was supported by a Research Capability Fund grant from the National Institute for Health
Research via Solent NHS Trust.
Word count
2,491 (including table)
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Figure 1: A diagrammatic timeline of the proposed themes in line with mood changes
... A recent longitudinal study also showed that debts increased the risk of developing a common mental health problem over the course of a year, but those with existing mental health problems were also more at risk of being unable to pay back debts over the course of the year (9). Qualitative research with those with Bipolar Disorder has similarly identified a theme of a "Vicious Cycle" between money and mental health problems (10). ...
... Research with Bipolar disorder has also shown the role of psychological factors, such as cognitions around achievement, dependency, and poorer mindfulness increasing compulsive spending over item (41). As well as our knowledge regarding the impact of financial difficulties on mental health, given the research suggesting a possible vicious cycle (6,7,9,10), the intervention also aimed to work on factors which might lead to poor mental health impacting finances such as addressing poor financial coping and avoidance around finances which have been reported by individuals with Bipolar Disorder (10). Space from Money Worries thus aimed to tackle financial difficulties and poor mental health in an integrative fashion. ...
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... For many, it is the desired part of a dopamine loop and a distraction from negative feelings (17). While these purchasing habits may have temporary and fleeting positive outcomes for the individual, they can create increased feelings of regret, guilt, and even suicidality in the long-term (7). Not only can they affect personal finances, but can also become a stressor in relationships and other parts of their life. ...
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Diagnostic and statistical manual of mental disorders (DSM-5)
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5): American Psychiatric Association.