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Chris Fitch is a research fellow at the Royal College of Psychiatrists’ Research and Training Unit (CRTU). He is a sociologist with an interest in finance and mental health, and the challenges of living with a mental health problem in the community. Robert Chaplin is a research fellow at the CRTU and a consultant in general adult psychiatry for Oxfordshire Mental Healthcare NHS Trust. He has interests in audit, the therapeutic alliance and mental capacity. Colin Trend is project manager at Money Advice Plymouth, and provides advice and guidance to people in debt, including those with mental health problems. Sharon Collard is a research fellow at the Personal Finance Research Centre at the University of Bristol. She has research interests in the use of credit and other financial services by low-income consumers, and is a member of the Department for Trade and Industry advisory group on over-indebtedness.
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Abstract |
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 Top Abstract What is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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Clearly, when it can be repaid or managed, debt is not inherently problematic. Furthermore, many individuals with mental health problems have the skills and capacity to manage their finances. However, concerns have been voiced by professionals and carers about the negative impact that debt problems can have on patients’ mental health, about mental health problems acting as pathways into debt and about irresponsible practice experienced by people with mental health problems from an expanding UK financial services industry (Edwards, 2003). These concerns have been framed within a wider debate on UK personal debt, which now totals £1.25 trillion (Credit Action, 2006).
Despite this, patient debt is rarely discussed in the psychiatric literature. This may reflect a belief that ‘debt’ is better addressed by social workers and nursing staff. However, although psychiatrists should not be expected to become proxy ‘debt advisors’, they do arguably have a role to play in:
Research suggests, however, that health professionals are not engaging with patient debt because they feel insufficiently knowledgeable and confident (Sharpe & Bostock, 2002). This could mean that a debt crisis is not identified or managed, that mental health could be subsequently worsened and that an even larger set of future problems may build up for the individual, their carers and the professionals supporting them.
In this article we therefore aim to improve psychiatrists’ knowledge and confidence in dealing with patients’ debt. Throughout we provide recommendations on the practical actions that psychiatrists can take to avert patient debt crises. These are described in more detail in the leaflet Final Demand: Debt and Mental Health (Fitch, 2006a). An outline of the terminology we use appears in Box 1
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| Box 1 Debt analysis and terminology Debt Debt is defined as having outstanding money to repay. Someone is therefore ‘in debt’ if they have a personal bank loan, owe money on credit cards, have a mortgage, or are unable to settle a domestic or utility bill. Problem debt If people fall behind with payments, bills or other commitments they have a problem debt. There is no monetary point at which ‘debt’ becomes ‘problem debt’. The UK organisation Citizens Advice has suggested that the transition into problem debt may occur when the individual is unable to meet repayment and other commitments without reducing other expenditure below normal minimum levels. Others have suggested that falling behind on a third month of payments might indicate the emergence of a problem debt. Problem debt can also be understood as a process – understanding the steps and mechanisms through which a manageable debt becomes a problem debt can help professionals act before a full-blown crisis occurs. Priority debts These are debts with the most serious consequences for non-payment, such as the loss of an essential service (e.g. disconnection of domestic utilities) or court action that could lead to the loss of liberty. Priority debts need to be paid back before all other debts.
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What is debt? |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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This viewpoint is not, however, shared by financial organisations, which make an important distinction between ‘debt’ and ‘problem debt’. First, they observe that most credit use is non-problematic: government surveys indicate that 95% of UK adults – the same proportion as a decade ago – say that their debt is not a ‘heavy burden’ (Department for Trade and Industry, 2005). Second, they note that the proportion of those with problem debt is minor: in the same surveys only 4% of adults report outstanding consumer debts or domestic arrears of more than 3 months. Third, they contend that the benefits of debt – access to cash when needed, the convenience of credit cards and a means of spreading expenditure over time – outweigh any disadvantages.
Social commentators are more sceptical. They observe that problem debt is socially patterned, affecting some social groups more than others. First, they note that, although government surveys indicate that only 4% of UK respondents report outstanding debts or arrears, this rises to 64% among people with annual incomes lower than £9500 (Department for Trade and Industry, 2005). Second, among those in debt, there is an overrepresentation of individuals experiencing ‘significant life events’ in the past year, disabled people and their carers (Department for Trade and Industry, 2004) and people with mental health problems (Office for National Statistics, 2002a). Third, these groups are also more likely to have arrears on ‘priority debts’ (such as domestic bills), which have the most severe legal consequences. They may also borrow from high-cost home credit or door-step lenders, with annual percentage rates (APRs) ranging from 100% to 400% or more (Collard & Kempson, 2005). As with other forms of inequality, problem debt may therefore affect the most vulnerable.
Health analysts also contend that debt has a meaning for individual health and social well-being, as well as for financial status. Reflecting established literature on poverty as a determinant and consequence of poor physical and mental health (for a review see Murali & Oyebode, 2004), analysts point to a similar relationship between debt and health. Furthermore, it has been argued that debt may be a factor in social isolation, feelings of insecurity and shame, self-harm and suicidal ideation. Debt can therefore be understood in financial, health and social terms.
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What is the extent of debt? |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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A handful of studies have also been undertaken on the prevalence of debt among people who self-harm. Hatcher (1994), for example, found that 37% of 147 patients assessed after an act of self-poisoning were in debt. Critically, more than three-quarters of those in debt had not sought help. Taylor (1994) undertook a comparative study of the finances of 53 accident and emergency patients who had harmed themselves and those of 53 patients from a fracture clinic. Almost three times as many in the self-harm sample reported ‘significant worries with debt that you cannot repay’ than in the control group (37 v. 13%). Only a quarter of those with debts had sought help or advice. Finally, surveys conducted with service users and specialist advice agencies provide insight into debt among people with mental health problems. In a review of this literature, Davis (2003) reports that a third or more of those surveyed had debt problems.
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What impact can debt have? |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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Anxiety and stress
Drentea & Lavrakas (2000) found that among 1000 US survey participants, self-reported anxiety increased with the ratio of credit card debt to personal income. Nettleton & Burrows (1998), using British Household Panel Survey data, report that the onset of mortgage debt had a negative impact on mental health and, among male participants, resulted in increased rates of general practitioner (GP) consultation because of stress. Research undertaken with 374 individuals seeking debt advice from a UK consumer advice service found that 62% reported that their debt problems had led to stress, anxiety or depression, and over a quarter of the total reported seeking GP treatment for this (Edwards, 2003). Brown et al(2005) reported that heads of household who have outstanding non-mortgage debt are significantly less likely to report complete psychological well-being, whereas (in contrast to Nettleton & Burrows’ findings) no such association was found with mortgage debt.
Depression
Reading & Reynolds (2001) reported an association between debt and the development of postnatal depression in longitudinal research with 271 UK families. Although they were unable to conclude that debt caused the depression, debt was the strongest socio-economic predictor of depression. Research has also been conducted on financial strain (which differs from debt) and depression. Chi & Chou (1999) in a longitudinal study of 554 elderly people in Hong Kong found that financial strain predicted increased depressive symptoms at 3-year follow-up (controlling for demographic, support and physical health variables). However, after a 3-year prospective community study of older individuals in the USA, Mendes de Leon et al(1994) contended that financial problems were predictive of depression only in men, an effect modified by good physical health and social support.
Self-harm and suicidal ideation
In a community study of over 4000 Finnish participants, Hintikka et al(1998) found that difficulties in repaying debts during the previous 12 months (student loans, bank loans, credit cards, loans from friends/family) was an independent predictor of suicidal ideation. Furthermore, participants who had experienced repayment difficulties had marked mental symptoms more often than those who had not. A number of studies on debt have been conducted with people who self-harm. Bancroft et al(1976) assessed patients who had taken overdoses and found those who stated that they had wished to die were more likely to have financial problems. In an uncontrolled study, Hatcher (1994) reported that people who were in debt were more likely to harm themselves, with greater suicidal intent, and would report more depression and hopelessness after the act. Meanwhile, Taylor (1994) found that patients who self-harmed were more likely to be in debt than a control group of fracture clinic patients.
Social consequences
The impact of debt on individuals’ social relationships can be implicated in isolation and social exclusion, and in strain placed on existing relationships. Material deprivation is also associated with debt. Drentea & Lavrakas (2000) have contended that individuals in debt will have less resources to spend on ‘quality’ goods (particularly those related to health and healthcare), as they attempt to make cutbacks to retain financial stability. Individuals who do make their debt repayments may be stretching themselves, with consequences for their health and social well-being. Finally, feelings of shame, social embarrassment and a sense of personal failure or other negative internalised identities associated with their debt may make individuals unwilling to disclose or discuss their financial situation (Hayes, 2000).
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Why do people get into problem debt? |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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The influence of income
The most obvious explanation for problem debt is a lack of money, which may result in individuals borrowing money or delaying the payment of domestic bills. Lack of money may be the result of already living on a low income, but it can also arise from unexpected changes in income (such as job changes, redundancy or relationship breakdown). It follows that people with mental health problems are susceptible to debt: UK mental health service users often live on lower than average incomes; over 75% are reliant on welfare benefits (Office for National Statistics, 2002b); unemployment rates are as high as 76% (Office for National Statistics, 2003). Furthermore, disruptions in benefit payments are often reported by individuals with mental health problems. Problem debt can also have an impact on carers, who may take on debts accrued by the person they care for, or incur debts because of the constraints that providing care can place on employment.
Mental health problems
Debt is triggered not only by income – specific mental health factors can also affect an individual’s financial situation. These factors include the onset of mental illness, greater spending as a result of a condition (e.g. mania and spending sprees) and communication difficulties when an individual with a mental illness withdraws and does not acknowledge the problem. A small number of studies have considered the biological correlates of debt (Grossi et al, 2001; Spinella et al, 2004), and some have described disorders such as ‘compulsive shopping disorder’, where debt is the salient feature of an impulse control failure (Black, 2001; Aboujaoude et al, 2003). Other studies have taken a social perspective, and have contended that individuals may borrow money because of their unhappiness at being perceived and living as ‘mental patients’ – consequently attempting to purchase material goods and the apparently desirable lifestyle and identity marketed alongside them (Fitch, 2006b).
Socio-demographic characteristics
People in their 20s and 30s are more likely to have debt problems: Bank of England research has reported that 37% of those who found debt a ‘heavy burden’ were between 25 and 34 years of age (Tudela & Young, 2003). This may be due to life-cycle types of debt such as student loans, as well as to the greater likelihood in young adulthood of factors such as having children, setting up a new home and more liberal attitudes towards credit (Kempson, 2002). In addition, tenants are more likely than homeowners to report debt problems; single-parent families are more susceptible to debt than other family types; and women are overrepresented on most debt indicators (Department for Trade and Industry, 2005).
Availability of credit
The wider availability of credit in the UK during the past two decades has also played a role. It is due to two factors: the deregulation of financial markets in the 1980s; and the mid-1990s entry of US lenders into the market, which resulted in intensified competition, new initiatives, aggressive marketing and the targeting of new customer groups (including those on low incomes).
Although the voluntary Banking Code Standards Board (which sets standards for UK banking practice) stipulates that lenders should assess customers’ ability to repay before extending credit to them, only two of the following four criteria have to be taken into account: an income and expenditure budget, an assessment based on previous knowledge of the customer (account history), a credit score, or an external credit reference check. Health information does not form part of the credit application (unless someone with mental health problems voluntarily adds information to their credit reference file). Furthermore, in Britain it is illegal to deny credit to an individual on the basis that they have a mental health problem, unless evidence exists that the person does not have the capacity to understand the credit agreement (Disability Discrimination Act 2005; Mental Capacity Act 2005; Adults with Incapacity (Scotland) Act 2000).
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How does ‘debt’ become ‘problem debt’? |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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). Critically, intervention is possible at each stage.
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Juggling finances
When missed payments occur, individuals often juggle their finances – paying the creditor who is applying the greatest pressure, or going without/cutting back on basic items (e.g. food or heating). Unfortunately, some people pay consumer credit bills, not realising that utility or rent arrears can have more serious legal consequences. Patients may also take out further loans.
Creditor pressure
Pressure from creditors can often build – unpaid creditors will make contact at this stage, with varying levels of understanding. Creditors may also transfer or sell on unpaid debts to debt collection agencies, whose demands are likely to be more intimidating and anxiety-provoking. The combined pressure of debt and creditor demands can generate enormous stress. If the patient is not already in touch with an external debt advisor, the psychiatrist should help to arrange this now.
Financial breakdown
One consequence of such pressure is that people often become overwhelmed and try to ignore what is happening. This can result in personal and financial breakdown, and it is at this point that the individual’s mental health can be most affected. In seeking to address any such decline in mental health, psychiatrists have an opportunity to raise the issue of problem debt with patients. However, patients may not volunteer information about their debt, either not wishing to acknowledge it, or believing it might be seen as further proof of illness or failure to cope.
Unrealistic arrangements
Where creditors do make contact, individuals can make unrealistic repayment arrangements – because the creditor does not understand their position, or because the individual just wants the creditor off their back. All negotiations should be through an external debt advisor (if this option has been taken). However, some creditors also contact the individual directly, which can lead to a situation where one repayment figure is agreed with the advisor, then an often higher one is set with the patient.
Legal proceedings
Frequently, the individual will fail to keep to these unrealistic promises, and legal proceedings will begin. Depending on the type of debt, this can result in a court setting a repayment schedule (Griffiths Commission on Personal Debt, 2005). If this is not met, enforcement orders can be applied – these include sending in bailiffs, direct deductions from income and bankruptcy orders. For other types of debt, repossession, eviction, disconnection of service and (very rarely) imprisonment can be instigated. Finally, total loss can occur – this can be financial (creditors continuing to chase unpaid debts) or, in extreme cases, debt-related suicides (Arehart-Treichel, 2005).
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How should psychiatrists respond? |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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Collaborative working already offers a solution to this problem – but its aims and operation may need to be re-evaluated. Community mental health team (CMHT) staff in the UK are well versed in arranging for patients to see debt advisors in external agencies (typically in the voluntary sector), where debt counselling and management are provided (Box 2). Some of these generic advice outlets (such as Citizens Advice and Money Advice Plymouth) employ or provide advisors trained in mental health awareness, while a handful of agencies also provide support to clients currently on psychiatric wards.
| Box 2 Resources for people in debt Guidelines, resources and links on debt and mental health http://www.nationaldebtline.co.uk Free specialist advice and help in the UK http://www.citizensadvice.org.uk Information on the nearest UK advice bureaux
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However, there may be an understandable belief among some CMHT members that such external agencies offer a ‘magic bullet’, allowing them effectively to hand over the whole problem for the debt advice agency to resolve. In practice, this is unlikely to work. Psychiatrists should therefore encourage CMHT staff to initiate action prior to referral, to attend debt advice meetings to facilitate the patient–advisor relationship, and to have enough of a grasp on the overall process to proactively support the patient and advisor throughout. The CMHT role is integral, rather than peripheral.
During such work, psychiatrists and the CMHT can gain a clearer understanding of the debt advice process, allowing them to develop their own confidence and skills, and also better equiping them to answer ‘what will happen?’ questions from patients. It will also be advantageous if the CMHT are aware of what creditors can offer if asked. For example, the Royal Bank of Scotland has its own specialist mental health advisors and also allows customers with mental health problems to ‘flag’ accounts so that these can be monitored for unusual spending patterns. A similar flag may be placed on any UK individual’s credit reference files (held by a credit reference agency), indicating that the individual does not want further loans.
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Assessing mental capacity to make financial decisions |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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Due to come into force in England and Wales in April 2007, the Mental Capacity Act 2005 (http://www.dca.gov.uk/menincap/legis.htm) will cover matters of capacity relating to financial decisions, as well as health and welfare. A detailed description of the Act is beyond this article (for a full review see Jones, 2005). This new legislation will involve the formal adoption of functional tests of capacity that refer to specific decision-making processes. This contrasts with assessments of capacity based on status (e.g. diagnosis) or outcome (e.g. the type of decision made). However, although it is current best practice to use a functional approach, Suto et al(2002) found that in capacity assessments conducted by psychiatrists of people with a range of mental health problems, 74% involved a status approach.
One possible reason for this is the lack of any standardised measure or procedure for assessing a patient’s mental capacity to make financial decisions. This is in stark contrast to the wide range of instruments designed to measure decision-making capacity regarding treatment. Below we present three guides to such capacity assessment.
Assessment models
One framework for the assessment of mental capacity to make financial decisions is provided by the British Medical Association & Law Society (Box 3). This is a dynamic model that accounts for the individual’s history, the prognosis of their illness and changes in their financial situation. Other strengths are the highlighting of consequences for the patient (and others) of poor financial decision-making. However, it does not provide a clear operational framework for how to assess the basic skills required in budgeting.
| Box 3 Checklist to guide assessment of mental capacity to manage property or affairs Evaluate the extent of the person’s property and affairs, including an examination of:
Personal information, which might include
The person’s vulnerability:
(Adapted from British Medical Association & Law Society (2004), with permission of BMJ Books)
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Arguing that mental capacity to make financial decisions is possibly the best predictor of whether an individual will be able to function independently in the community, Marson et al(2006) have developed a model that emphasises the assessment of financial skills. This is outlined in Box 4. The clinician is required to assess, for example, the patient’s ability to calculate the value of coins, purchase items, use a chequebook, pay bills and budget on a weekly basis. The assessment requires tasks involving knowledge, calculations and the use of reasoning. Less emphasis is placed on the broader context of financial decision-making.
| Box 4 Assessing the financial decision-making capacity of people with severe mental illnesses Individuals are assessed on their ability to carry out the tasks listed in the following five domains Basic money skills
Cash transactions
Understanding chequebooks
Bill payment
Budgeting
By informal questioning the assessor also asks the individual about:
The assessor can then judge the individual’s overall financial capacity, in terms of:
(Adapted from Marson et al, 2006. With permission from Oxford University Press)
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The two assessment frameworks have in common the need to be aware of the individual’s current financial arrangements and both serve as a guide in making a decision based on overall clinical judgement.
Vignettes about situations requiring financial decisions are used in a model to assess the mental capacity of people with intellectual disabilities (Suto et al, 2005). These vignettes include, for example, making decisions when buying items in a supermarket, deciding whether to go to work and paying for car repairs. For each vignette, capacity is assessed across four domains: understanding, appreciation, reasoning and communication. Using the instrument Suto et al found that 40% of people with an intellectual disability (mean IQ = 61) obtained full scores on at least one question; understanding was the most problematic area of capacity; and measured capacity declined as the required decision became more complex. Consequently, although people with intellectual disabilities performed less well than a comparison group with normal intellectual ability, many were able to make some financial decisions.
It may be beneficial to combine the three approaches described above with detailed enquiry into the specific financial skills necessary for the person’s life (including the history, consequences and likelihood of change in these skills, and the exploration of common hypothetical situations where decisions are necessary), as well as the individual’s mental capacity to understand, retain and deliberate on this information, and to take and express a decision.
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Conclusions |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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The challenges of patient debt for psychiatrists are likely to become more apparent over the coming years. First, it is probable that existing levels of debt across UK society will continue to increase well above inflation or earnings, and that the burden of debt will be carried by socially vulnerable groups. Second, with the implementation in England and Wales of the Mental Capacity Act in 2007, discussions about ‘financial capacity’ (and the role of the psychiatrist in assessing it) are likely to intensify as unanticipated scenarios arise. Third, new guidance specifically focused on dealing with people with mental health problems who are in debt will also be delivered to the UK financial services industry in 2007. Formulated by a working group of the credit industry, debt advice agencies and mental health organisations, this will contain recommendations on best practice and liaison with medical professionals, carers and people with mental health problems.
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Declaration of interest |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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MCQs |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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MCQ answers
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References |
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TopAbstractWhat is debt?What is the extent...What impact can debt...Why do people get...How does 'debt' become...How should psychiatrists...Assessing mental capacity to...ConclusionsDeclaration of interestMCQsReferences |
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Arehart-Treichel, J. (2005) Suicide risk may increase when debts pile up. Psychiatric News, 40(5), 28.
Bancroft, J. H., Skrimshire, A. M. & Simkin, S. (1976) The reasons people give for taking overdoses. British Journal of Psychiatry, 128, 538–548.
BBC (2003) ‘The debt trap: help from Breakfast’. Retrieved 11th December, 2006 from http://news.bbc.co.uk/1/hi/programmes/breakfast/3103318.stm
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Chi, I. & Chou, K. (1999) Financial strain and depressive symptoms among Hong Kong Chinese elderly: a longitudinal study. Journal of Gerontological Social Work, 32, 41–60.[CrossRef]
Collard, S. & Kempson, E. (2005) Affordable Credit, The Way Forward. Policy Press.
Credit Action (2006) ‘Debt statistics’. Retrieved 9th December, 2006 from http://www.creditaction.org.uk/debtstats.htm
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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