Discussion

Our study provides insights into the relationship and employment dynamics of individuals with affective and psychotic disorders compared with healthy controls. We addressed the research question whether, being diagnosed with an affective or psychotic disorder, an individual's relationship and employment status change compared with those of a healthy control. Furthermore, we investigated whether differences were affected by the diagnostic group or the functional level measured by the GAF score.

Regarding relationship dynamics, we can answer our first research question as follows: our results indicate that people in the clinical group had a significantly higher hazard of losing partners and jobs than the healthy control group. The impact was more pronounced among people in the psychotic group than among those in the affective group. Our results align with existing research indicating that conditions such as schizophrenia and bipolar disorder can hinder social interactions and contribute to social withdrawal.^{Reference Dziwota, Stepulak, Włoszczak-Szubzda and Olajossy23,Reference Pascual-Sanchez, Jenaro and Montes24} Symptoms such as mania, paranoia, risky sexual behaviour and medication-related sexual dysfunction can further exacerbate difficulties in maintaining relationships.^{Reference Kopeykina, Kim, Khatun, Boland, Haeri and Cohen25–Reference Montejo, Montejo and Navarro-Cremades28} Noteworthy is that the hazard of losing a partner was higher in the clinical group, which may indicate that pre-existing relationships in particular are at risk and shorter than those in controls, a hypothesis that is supported by the high divorce rates of individuals with mental disorders.^{Reference Grover, Nehra and Thakur4,Reference Idstad, Torvik, Borren, Rognmo, Røysamb and Tambs29} Thus, the results emphasise the need for interventions that stabilise pre-existing relationships. Involving partners in therapy and educating family members can play a crucial role in fostering relationship stability and is recommended by treatment guidelines.^{Reference Gaebel, Hasan and Falkai30,Reference Pfennig, Bschor, Baghai, Bräunig, Brieger and Falkai31} Additionally, interventions such as social skills training and cognitive remediation therapy (CRT) can equip individuals with tools to improve their relational capabilities and communication.^{Reference Rajji, Mamo, Holden, Granholm and Mulsant32–Reference Bellani, Ricciardi, Rossetti, Zovetti, Perlini and Brambilla34} Our findings suggest that individuals with psychotic and affective spectrum disorders, and especially the group with psychotic disorders, may also encounter challenges in initiating new relationships when compared with their healthy counterparts, which answers our second research question. However, it should be noted that this effect appears to be less pronounced than the hazard of relationship dissolution. A possible explanation is that the initial attraction to someone and the process of searching for a partner may not substantially differ between patients and healthy individuals. Furthermore, many people are hesitant to divulge their psychiatric history to potential partners and often prefer a staged disclosure.^{Reference Seeman35} Nevertheless, this cautious approach could inadvertently contribute to the brevity of relationships and the higher frequency of breakups. Yet it is important to note that not every relationship breakup should be viewed negatively, e.g. leaving an abusive relationship can be a positive personal development.

Addressing our third research question, our findings suggest a correlation between lower GAF scores and a heightened hazard of relationship and employment loss. Notably, participants in the psychotic group exhibited lower functional levels than those in the affective group, which may potentially explain the former group's increased vulnerability to these challenges. Relationships may be particularly vulnerable in individuals with severely debilitating disorders or during periods of high symptom burden. Higher levels of functioning, which are usually associated with fewer symptoms, may reduce the hazard of losing a partner; however, global functioning and relationship stability are mutually dependent. This finding also emphasiszes the potential benefits of providing effective treatment and minimising adverse treatment effects to enhance people's functional outcome and hence their relationship and job stability.

In terms of employment and answering research questions one to three for this area, our study similarly revealed an increased hazard of job loss among people with affective and psychotic spectrum disorders, although the effect was partially conditioned by the functional level. Importantly, this association persisted after controlling for GAF scores. Notably, participants with psychotic disorders had greater difficulty in finding new employment than healthy controls, whereas this impairment was not evident in the affective disorder group. This effect might partially depend on higher cognitive deficits in participants with psychotic disorders.^{Reference Keefe36} Another possible reason for this might be that biogenetic explanations and illness labels, particularly for schizophrenia, may inadvertently reinforce public perceptions of dangerousness, unpredictability and desire for social distance, potentially leading employers and colleagues to harbour increased fear and stigma towards these individuals in the workplace.^{Reference Read, Haslam, Sayce and Davies37,Reference Haslam and Kvaale38} The findings underscore the significance of initiatives to support job retention and assist people in finding employment, particularly individuals with psychotic disorders. Effective symptom management and tailored interventions, e.g. individual placement support (IPS), CRT or computer-based cognitive training programs can aid in enhancing employment prospects.^{Reference de Winter, Couwenbergh, van Weeghel, Sanches, Michon and Bond39,Reference Christensen, Wallstrøm, Stenager, Bojesen, Gluud and Nordentoft40} In a comprehensive analysis of 28 randomised controlled trials involving approximately 6500 participants, it was observed that 55% of people engaged in IPS initiatives successfully obtained employment within the general labour market, compared with 25% in predominantly prevocational training procedures.^{Reference Bond, Drake and Becker41} Besides the success rates, IPS is assumed to be cost-efficient.^{Reference Nischk, Herwig, Senner and Rockstroh42,Reference Drake, Bond, Goldman, Hogan and Karakus43} Research on the effects of psychopharmacological treatment on employment remains scarce. There is evidence that antipsychotic medication adherence in combination with cognitive remediation can improve cognitive deficits and work/school functioning in early schizophrenia, particularly when combined with supported employment,^{Reference Nuechterlein, Ventura, Subotnik, Gretchen-Doorly, Turner and Casaus44} yet there is a critical lack of randomised controlled trials on the direct effects of psychopharmacological treatment on work productivity. Moreover, the potential adverse effects of antipsychotic medications, such as sedation,^{Reference Miller45} may negatively impact work productivity, highlighting the need for more comprehensive research that considers both the beneficial and detrimental effects of these treatments on employment and functional outcomes.

A key aspect to consider in our discussion is the impact of stigma in the workplace. Our findings reveal that functional level alone does not fully account for the heightened hazard of job loss among individuals with affective and psychotic disorders. Even with normal functional levels, the hazard of job loss persists. This might be an effect caused by stigmatisation. Stigmatisation is known to be a particularly pronounced phenomenon among people with schizophrenia.^{Reference Valery and Prouteau46} Both anticipated and experienced discrimination limit opportunities for individuals with mental disorders and are critical factors influencing employment outcomes,^{Reference Farrelly, Clement, Gabbidon, Jeffery, Dockery and Lassman47} underscoring the imperative for comprehensive efforts to combat stigma in work environments. Encouraging direct interactions between individuals with and without mental illness can foster destigmatisation and cultivate a healthier workplace culture.^{Reference Thornicroft, Sunkel, Alikhon Aliev, Baker, Brohan and El Chammay48}

Additionally, it is important to mention that the heightened vulnerability in facing the risk of job and relationship loss surpasses the challenges of seeking new employment or partners. This underscores the critical importance within the treatment process to prioritise the stabilisation of both romantic and occupational relationships, since each instance of separation, job displacement but also re-marriage belongs to major life events and can significantly impact the stability of one's mental health.^{Reference Horesh and Iancu49}

Besides the valuable insights gained from this study and its notable strengths, such as the substantial sample size and well-balanced diagnostic groups, certain limitations warrant consideration. The participants’ functioning and its implications for employment and relationship status were assessed with the GAF scale, but the GAF scale itself encompasses both employment and social relationship status. This overlap could potentially reinforce the observed impacts attributed to the GAF score. Nevertheless, it is crucial to acknowledge that beyond employment and relationship status, the GAF score is influenced by a multitude of factors, including concentration ability, insomnia, anger, communication skills and various symptoms. Notably, factors such as job loss and relationship separations may be influenced not only by reduced functioning, but also by external factors such as stigma. Additionally, the absence of a standardised questionnaire for GAF introduces subjectivity, leading to potential variability in how different interviewers perceive and prioritise the various dimensions of GAF, potentially resulting in divergent ratings. As a further limitation, it is important to highlight that this study did not account for medication effects, so any potential positive or negative impacts of specific medications on employment, relationships or overall functioning remain unexplored. An absence of information regarding the reasons behind participants’ job losses or relationship changes is also a limitation. Access to such insights could offer a deeper understanding and serve as a basis for targeted support strategies. Another limitation is the notable dropout rate 12 and 18 months after enrolment. Although efforts were made to incorporate all available data into the statistical analyses, the substantial dropout rate must be acknowledged as a potential source of bias. The reasons for dropout are diverse and speculative, ranging from participants achieving remission or recovery and consequently discontinuing participation, to exacerbated disorders impeding their adherence to appointments, and these varying circumstances could have introduced both positive and negative biases in hazard estimates within this study. A significant proportion of the dropouts were out-patients (76.8% at 12 months and 73.1% at 18 months), a group that presents challenges in tracking their status and ensuring their continued participation. Moreover, it is well documented that dropout rates tend to rise over the course of longitudinal studies. This phenomenon is especially pronounced in cases where participants do not anticipate tangible advantages stemming from their participation.

In conclusion, our study demonstrates the elevated hazard of relationship and employment disruptions among individuals diagnosed with affective and psychotic disorders. The specific disorder and functional level play roles in mediating these challenges. Given the well-established negative consequences of unemployment and relationship instability on mental health outcomes, our findings highlight the urgency of developing strategies to support functional improvement and empower individuals to attain their goals. Further research in this area will be pivotal in enhancing the quality of life and recovery rates for individuals grappling with these disorders.