Functional Disability and Loneliness Among Clinically Stable Individuals with Schizophrenia: A Cross-sectional Study

Abstract

Background

Functional disability and loneliness frequently persist among clinically stable individuals with schizophrenia, thereby impeding recovery and restricting social participation.

Purpose

This study assessed functional disability and loneliness in clinically stable individuals with schizophrenia and to examine their associations with socio-demographic variables and employment status.

Methods

A descriptive cross-sectional study was conducted with 50 clinically stable individuals with schizophrenia, aged 18 to 60 years. Data were collected using socio-demographic schedule, the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), and the UCLA Loneliness Scale.

Results

The mean loneliness and WHODAS scores were 43.16 ± 11.96 and 74.28 ± 14.65, respectively. No significant differences were observed by gender or domicile. Participants from joint families showed higher disability in self-care (p = .005), household activities (p = .041), and participation (p = .007). Duration of unemployment was positively correlated with disability (r = 0.311–0.517, p < .05), whereas employment duration was negatively correlated with disability in interpersonal, work, and participation domains.

Conclusion

Unemployment and joint family dynamics are associated with increased disability, underscoring the importance of vocational rehabilitation and family-focused psychosocial interventions.

Keywords

Schizophrenia functional disability loneliness employment duration family type

Introduction

India’s national mental health survey reported a prevalence of schizophrenia spectrum disorders at 1.41% and a current prevalence of 0.42%.¹ There is a significant treatment gap for schizophrenia in India, with 72% of current cases not receiving treatment, which rises to 83.3% in urban non-metro areas. Factors contributing to this gap include stigma, superstition, poverty, poor accessibility to healthcare facilities and social issues such as marriage prospects for female patients.²

Psychosocial functioning in schizophrenia refers to impairments in social relationships, daily activities, work and self-care. A meta-analysis of 36 studies found moderate-to-strong negative correlations between social functioning and overall psychopathology, positive symptoms, negative symptoms, disorganised symptoms and depressive symptoms.³ Another study reported that most of the functionality issues stem from negative symptoms and suggested social dysfunction as a core disorder manifestation.⁴ Schizophrenia is a major mental disorder causing disability in patients. A Bangalore-based hospital study reported that 23.8% of patients with first-episode schizophrenia met the criteria for certifiable disability after 2 years of follow-up.⁵ Functionality and disability in schizophrenia are inversely related. A recent study identified cognitive deficits, disease severity, low insight and neurocognition as key predictors linking reduced functionality to increased disability. Higher education, income and cognitive insight correlate with better functionality.⁶ The available literature highlights that severe schizophrenia increases the risk of disability and limits participation in social functioning.

Need for the Study

Many studies reported that even when active symptoms are subsided, individuals with schizophrenia frequently experience persistent difficulties in daily functioning and ongoing loneliness. These challenges impede recovery and hinder independent living within the community. Loneliness remains prevalent among people with schizophrenia, including those who are clinically stable and is associated with depression, diminished quality of life, stigma and hopelessness.^7–9 Despite symptomatic improvement following treatment, many individuals continue to withdraw socially, resulting in isolation and poorer health outcomes.^{9, 10} Similarly, functional disability frequently persists even after symptomatic improvement. Studies using the WHO Disability Assessment Schedule (WHODAS) indicate that challenges in social participation and employment often remain. Employment is correlated with improved quality of life and greater self-esteem.^11–13 However, in India, few studies have investigated both loneliness and functional disability concurrently in clinically stable individuals with schizophrenia. This gap restricts understanding of recovery processes and complicates the development of effective psychosocial and vocational interventions.

Methods

A descriptive cross-sectional design was employed to compare loneliness and functional disability across gender, residence and family structure. The study further investigated the association between employment duration, unemployment and functional disability within WHODAS domains among individuals with schizophrenia. Data were collected from June 2023 to June 2024.

Sampling Procedure

Individuals diagnosed with schizophrenia who attended the outpatient department at NIMHANS for follow-up during the study period were considered for inclusion. Qualified psychiatrists established the diagnosis of schizophrenia using standard clinical evaluations and case record reviews. The clinical schizophrenia subtype reported in this study was derived from patient medical records.

The sample size was set at 50 based on feasibility considerations. For correlation analysis, the estimated sample size was 47, calculated using a correlation coefficient of 0.40, a Type I error rate of 0.05 and a Type II error rate of 0.20. Participants were selected using purposive sampling according to predefined inclusion and exclusion criteria. Purposive sampling was employed because the study aimed to recruit clinically stable individuals with schizophrenia, a defined subgroup not adequately represented through random sampling in a routine outpatient setting. This method ensured the inclusion of participants who met specific clinical and functional criteria relevant to the study objectives. Eligible participants were identified during routine outpatient follow-up visits and screened according to the inclusion and exclusion criteria. Individuals who met these criteria were approached consecutively and invited to participate in the study.

A total of 90 individuals were approached, of whom 60 met the inclusion criteria. Ten individuals declined participation, resulting in a final sample of 50 participants. Inclusion criteria consisted of a diagnosis of schizophrenia according to ICD-11, illness duration of at least 1 year, age between 18 and 60 years, and both genders. Clinical stability was defined as a clinical global impression-severity (CGI-S) score of 3 or less, indicating mildly ill status or better, and the absence of any recent acute exacerbation requiring hospitalisation. This criterion ensured that all participants were in a stable phase of illness. Exclusion criteria comprised comorbid psychiatric or neurological conditions, which were identified through clinical evaluation by the treating psychiatrist, review of case records and corroborative information from patients and caregivers. Additional exclusion criteria included the inability to provide informed consent and age greater than 60 years. These measures ensured that all participants were clinically stable and capable of providing informed consent.

Tools

The socio-demographic data sheet gathered information on age, gender, marital status, domicile, religion, education and employment status. Additional details regarding job type, employment duration and number of days worked in the past month were also recorded.

The clinical global impressions (CGI) Severity Scale is a 7-point, clinician-rated instrument (1 = normal, 7 = most extremely ill) widely utilised to assess overall illness severity, where higher scores reflect greater impairment. This scale demonstrates acceptable internal consistency and reliability in psychiatric populations, including applications specific to schizophrenia, and is appropriate for brief clinical assessments.¹⁴

WHODAS 2.0: The instrument is a 36-item measure assessing functioning and disability. Each item is rated on a 5-point scale from 0 (none) to 4 (extreme/cannot do), with higher raw scores reflecting greater disability. The total score is typically converted to a 0–100 scale, where 100 represents full disability (WHO, 2010; filled-in scoring algorithms are available from WHO). The validation study has demonstrated strong internal consistency, with a Cronbach’s α of 0.92.¹⁵

University of California, Los Angeles (UCLA) Loneliness Scale: The UCLA Loneliness Scale utilises a 4-point response format, with options from 1 (never) to 4 (always). The total score is calculated by summing responses to all 20 items. Four positively worded items require reverse scoring. Higher total scores indicate greater loneliness. The scale exhibits strong reliability, as demonstrated by studies reporting high internal consistency, with Cronbach’s α typically ranging from 0.89 to 0.94.¹⁶

Data Collection Procedure

The lead researcher collected data after participants were familiarised with the study instruments. Eligible participants were identified, and the study’s purpose and procedures were explained to both participants and their caregivers. Written informed consent was obtained. Interviews were conducted in a private conference room to ensure confidentiality. The researcher verified participant understanding, addressed questions and collected the required information. Each interview lasted between 30 and 40 min.

Statistical Analysis

Data were entered into Microsoft Excel and analysed using SPSS version 26. Descriptive statistics, including mean and standard deviation, were used to summarise the data. Normality was assessed using the Shapiro–Wilk and Kolmogorov–Smirnov tests. As the data were normally distributed, independent-samples t-tests were conducted to compare loneliness and functional disability by gender, domicile and family type. Pearson correlation analysis assessed the relationship between employment duration and WHODAS disability scores. A p value of .05 or less was considered statistically significant.

Results

Of the 50 participants, 27 (54.0%) were male, and 23 (46.0%) were female. Nearly half were married (24; 48.0%), and 21 (42.0%) were unmarried. The majority had completed secondary education (27; 54.0%), and 12 (24.0%) were graduates. Most participants were from rural areas (30; 60.0%). A large proportion were unemployed (32; 64.0%), and 18 (36.0%) were employed. Among the employed, 16 (88.89%) worked in the private sector. Regarding working hours, 3 (6.0%) worked 1–4 h per day, and 15 (83.0%) worked 5–10 h per day. Permanent employment was reported by 10 (55.56%) and temporary employment by 8 (44.44%). Previous vocational history was reported by 22 (44.0%), while 28 (56.0%) had no prior vocational experience (Table 1).

Half of the respondents were diagnosed with paranoid schizophrenia (86.0%). Treatment-resistant schizophrenia and undifferentiated schizophrenia were each reported by 6.0% of respondents, and catatonic schizophrenia by 2.0%. Most respondents had been ill for more than 10 years (40.0%) and 28.0% for 5–10 years. The majority did not report a family history of mental illness (72.0%). Most respondents did not report suicidal ideas, depression or prominent negative symptoms (94.0%) (Table 2).

With regard to overall mean scores, the mean CGI-S score among participants was 1.94 ± 0.73, indicating clinical stability. The mean loneliness score was 43.16 ± 11.96, while the mean overall WHODAS score was 74.28 ± 14.65.

Table 3 shows the inter-domain comparison of mean values for gender, domicile and family type. There was no significant or borderline difference in loneliness or disability domains between males and females, or between rural and urban respondents. Participants from joint families had higher mean disability scores in self-care (joint: 7.50, nuclear: 5.64, p = .005), household activities (joint: 11.14, nuclear: 9.50, p = .041) and participation in society (joint: 19.64, nuclear: 16.72, p = .007) compared to those from nuclear families. Borderline differences were found in getting along with people (joint: 11.21, nuclear: 9.86, p = .098) and work-related disability (joint: 10.79, nuclear: 9.00, p = .063), with higher scores among joint family participants. Overall, only the family type showed significant differences across domains (Table 3).

Table 4 presents the association between employment duration and WHODAS disability dimensions. Participants with longer unemployment duration had higher disability scores in all WHODAS domains. Moderate positive correlations were found for communication and getting around. Stronger positive correlations were observed for self-care, getting along, household activities, work and participation in society. In contrast, longer employment duration was associated with lower disability in getting along, work and participation in society. Overall, longer duration of unemployment was associated with increased disability, while sustained employment was linked to reduced disability in social and work domains (Table 4).

Discussion

This study evaluated functionality and loneliness among individuals with schizophrenia and compared these outcomes across selected demographic variables. The following sections present the discussion of these findings.

Socio-demographic and Occupational Characteristics of Participants

The socio-demographic and occupational characteristics of participants in this study reflect trends observed in schizophrenia populations in India, where rural residence, limited educational attainment and high unemployment are prevalent. Over half of the participants were male, and nearly half were married, consistent with findings from a Tamil Nadu-based study on the employability of individuals with mental illness.¹⁷ The majority rural origin (60%) reflects India’s schizophrenia burden, concentrated in rural agricultural settings with limited mental health infrastructure, as evidenced by South Indian studies showing comparable rural predominance.¹⁸

The study showed that over half of the participants had secondary education (54%), which exceeds illiteracy rates in some Indian cohorts but underscores barriers to higher attainment, as evidenced by a 64% unemployment rate. This finding may be attributed to the onset and severity of illness, which cause disruptions in education and employment. However, contrasting findings were reported by an Indian study on employability in people with severe mental illness, which found that more mentally ill people in rural areas are self-employed and employers, implying substantial family involvement in caring for patients.¹⁹ Further, the study reported that the majority of participants held permanent private-sector employment with no vocational training. Possible reasons include migration to cities, participants’ education (PUC and Graduation), regular follow-up, adherence to medication and strong social support²⁰ likely to increase the employability among patients.

Loneliness and Functionality

It was found that there are no statistically notable gender differences in loneliness or functionality domains among the study population, in contrast to several Western studies that often show better social outcomes for females. From a psychosocial perspective, several Indian cultural and family factors may explain why both genders experience similar levels of loneliness and functionality. In Western contexts, people with schizophrenia often live alone or in assisted facilities, causing greater loneliness, particularly among males who customarily depend on broader social networks. However, in the Indian setting, extended family support, shared household responsibilities and assistance with self-care and other activities may lead to comparable levels of loneliness and functionality in both genders.²¹ However, men face stigma related to occupation. Since the male identity in India is heavily tied to being a ‘provider’, the inability to work leads to profound shame and social withdrawal, which might be the reason for increased loneliness. The lack of difference in the communication and getting along domains may be attributed to cultural norms of passivity and obedience.²²

There was no significant difference in loneliness and functionality between urban and rural participants with schizophrenia. This may be because rural areas now face socio-economic stress and weaker social support similar to those in urban areas.²³ In both settings, a large treatment gap leads to similar clinical outcomes due to a lack of specialised care.²⁴ Most families in both groups provide care for patients, including assistance with daily activities and household chores, resulting in similar functionality issues.¹

Higher disability was observed in joint families. This may be due to overcare and task compensation, in which family members perform daily chores for the patient, leading to learned helplessness. Social shielding to reduce community stigma also limited patients’ social participation. In contrast, nuclear families required more individual agency. Joint families may mask and worsen functional decline through collective role substitution.^24–26

It was found that the extended unemployment duration was positively associated with higher WHODAS disability scores across all domains (r = 0.311–0.517, all p < .05). Participants with longer unemployment periods showed greater impairments in communication, mobility, self-care, social relations, household tasks, work and participation in society. Extended joblessness was also linked to increased mental impairment, social exclusion, skill loss, dependency and stigma, which affected daily functioning.^{27, 28} In contrast, longer employment duration was negatively associated with disability, especially in the interpersonal (r = −0.289, p = .042), work (r = −0.319, p = .024), as well as societal domains (r = −0.333, p = .001). The current findings are consistent with previous studies showing that sustained employment improves social performance, quality of life and recovery. Employment supported role fulfilment and self-efficacy and reduced isolation, although effects in other domains were not significant, possibly due to the small number of employed participants.^{29, 30}

Implication

The study observed lower functionality in clinically stable individuals with schizophrenia. These findings indicate that mental health professionals should facilitate participation in vocational rehabilitation and prioritise collaboration with community-based care providers. This approach includes training lay health workers to provide psychosocial support in conjunction with facility-based care to reduce disability. Furthermore, implementing family skill-building programmes is essential for training joint family members in problem-solving and limit-setting strategies to address learned helplessness. Psychoeducational content tailored for joint families should be developed to address increased disability in self-care and household activities by mitigating overprotection and managing expressed emotions. These approaches align with multidisciplinary psychosocial care practices, including those commonly employed in psychiatric social work.

Strengths, Limitations and Future Research Directions

Strengths

This study linked employment duration with WHODAS domains in stable Indian schizophrenia patients. Joint family overprotection was found to be a unique factor increasing disability, which is not often reported in previous studies. The use of WHODAS 2.0 and UCLA tools, and the NIMHANS setting, supported the validity of the findings.

Limitations

The small purposive sample (n = 50) limits generalizability, and the cross-sectional design does not allow for conclusions about causality. Important confounding factors such as symptom severity (beyond CGI), neurocognition, insight and medication adherence were not measured, which may have affected the observed relationship between employment and disability. The study also did not include rural-specific controls, so differences in infrastructure were not considered. Future research should use larger and more diverse samples and longitudinal designs. Studies should adjust for cognition, symptoms and insight using multivariate models, and test interventions focused on family type and vocational programmes in the Indian joint family context.

Table 1.

Socio-demographic and Occupational Profile of Participants.

Variables	Categories	Frequency (n)	%
Gender	Male	27	54.00
Gender	Female	23	46.00
Marital status	Married	24	48.00
	Unmarried	21	42.00
	Other	5	10.00
Education	No formal education/primary	11	22.00
	Secondary education	27	54.00
	Graduation	12	24.00
Domicile	Rural	30	60.00
Domicile	Urban	20	40.00
Occupation	Employed	18	36.00
Occupation	Unemployed	32	64.00
Employment sector (n = 18)	Other	2	11.11
Employment sector (n = 18)	Private	16	88.89
Daily working hours (n = 18)	1–4 h	3	16.67
Daily working hours (n = 18)	5–10 h	15	83.33
Status of job (n = 18)	Permanent	10	55.56
Status of job (n = 18)	Temporary	8	44.44
Previous vocational history	Yes	22	44.00
Previous vocational history	No	28	56.00

Source: Author’s work (Primary data collected and analysed by the authors).

Note: This table presents original data generated from the present study. No material has been reproduced or adapted from previously published sources; therefore, no permissions were required.

Table 2.

Clinical Profile of the Respondents.

Variables	Categories	Frequency (n = 50)	%
Diagnosis	Catatonic schizophrenia	1	2.00
	Paranoid schizophrenia	18	86.00
	Treatment-resistant schizophrenia	3	6.00
	Undifferentiated schizophrenia	3	6.00
Duration of illness	<5 years	16	32.00
	5–10 years	14	28.00
	>10 years	20	40.00
Family history of mental illness	Present	14	28.00
Family history of mental illness	Absent	36	72.00
Suicidal ideas/depression/negative symptoms	Yes	3	6.00
Suicidal ideas/depression/negative symptoms	No	47	94.00

Table 3.

Comparison of Loneliness and Disability Domains Across Gender, Domicile and Family Type.

Variable	Gender	Mean ± SD	t, p Value	Domicile	Mean ± SD	t, p Value	Family Type	Mean ± SD	t, p Value
Loneliness	Male (n = 27)	44.48 ± 12.25	t = 0.844, p = .403	Rural (n = 30)	45.00 ± 12.17	t = 1.343, p = .186	Nuclear (n = 36)	41.69 ± 11.48	t = −1.403, p = .167
Loneliness	Female (n = 23)	41.61 ± 11.69	t = 0.844, p = .403	Urban (n = 20)	40.40 ± 11.39	t = 1.343, p = .186	Joint (n = 14)	46.93 ± 12.78	t = −1.403, p = .167
Communication	Male	13.85 ± 2.90	t = 0.235, p = .815	Rural	13.90 ± 3.04	t = 0.405, p = .687	Nuclear	13.64 ± 3.15	t = −0.459, p = .648
Communication	Female	13.65 ± 3.11	t = 0.235, p = .815	Urban	13.55 ± 2.91	t = 0.405, p = .687	Joint	14.07 ± 2.50	t = −0.459, p = .648
Getting around	Male	6.89 ± 2.42	t = −0.725, p = .472	Rural	7.33 ± 2.72	t = 0.757, p = .453	Nuclear	7.14 ± 2.44	t = 0.087, p = .931
Getting around	Female	7.39 ± 2.46	t = −0.725, p = .472	Urban	6.80 ± 1.94	t = 0.757, p = .453	Joint	7.07 ± 2.50	t = 0.087, p = .931
Self-care	Male	6.26 ± 1.89	t = 0.349, p = .729	Rural	6.10 ± 2.19	t = −0.238, p = .813	Nuclear	5.64 ± 1.87	t = −2.941, p = .005
Self-care	Female	6.04 ± 2.48	t = 0.349, p = .729	Urban	6.25 ± 2.17	t = −0.238, p = .813	Joint	7.50 ± 2.35	t = −2.941, p = .005
Getting along with people	Male	10.60 ± 2.59	t = 1.043, p = .302	Rural	10.43 ± 2.58	t = 0.642, p = .524	Nuclear	9.86 ± 2.52	t = −1.689, p = .098
Getting along with people	Female	9.83 ± 2.59	t = 1.043, p = .302	Urban	9.95 ± 2.65	t = 0.642, p = .524	Joint	11.21 ± 2.61	t = −1.689, p = .098
Household activities	Male	10.22 ± 2.44	t = 0.778, p = .440	Rural	10.20 ± 2.38	t = 0.805, p = .425	Nuclear	9.50 ± 2.65	t = −2.098, p = .041
Household activities	Female	9.65 ± 2.74	t = 0.778, p = .440	Urban	9.60 ± 2.85	t = 0.805, p = .425	Joint	11.14 ± 1.99	t = −2.098, p = .041
Work	Male	10.04 ± 3.44	t = 1.360, p = .180	Rural	9.53 ± 2.94	t = 0.094, p = .926	Nuclear	9.00 ± 3.11	t = −1.907, p = .063
Work	Female	8.87 ± 2.46	t = 1.360, p = .180	Urban	9.45 ± 3.28	t = 0.094, p = .926	Joint	10.79 ± 2.58	t = −1.907, p = .063
Participation in society	Male	18.22 ± 3.27	t = 1.510, p = .138	Rural	17.46 ± 3.45	t = −0.179, p = .858	Nuclear	16.72 ± 3.55	t = −2.827, p = .007
Participation in society	Female	16.74 ± 3.67	t = 1.510, p = .138	Urban	17.65 ± 3.67	t = −0.179, p = .858	Joint	19.64 ± 2.41	t = −2.827, p = .007

Table 4.

Association between Duration of Employment Status and WHODAS Disability Dimensions.

WHODAS Dimensions	Duration of Unemployment (r)	p Value	Duration of Employment (r)	p Value
Communication	0.311	.028	−0.166	.249
Getting around	0.325	.021	−0.062	.67
Self-care	0.404	.004	−0.099	.493
Getting along	0.415	.003	−0.289	.042
Household activities	0.469	.001	−0.217	.131
Work	0.517	.001	−0.319	.024
Participation in society	0.452	.001	−0.333	.018

Conclusion

This study reported that prolonged unemployment increased functional disability in all WHODAS domains among stable schizophrenia patients. A longer employment duration was associated with better social, work and community functioning. Overprotection in joint families increased disability, while nuclear families showed more independence. These results highlight the need for targeted vocational rehabilitation and family psychoeducation in India to support recovery and reduce loneliness.

Footnotes

Acknowledgement

The authors thank all the participants of this study.

Authors’ Contribution

SS—Conceptualisation, data collection, data analysis and manuscript drafting. PK—Methodological guidance, statistical supervision and manuscript review and editing. SA—Study design supervision, critical revision and final approval of manuscript. ES—Academic supervision, interpretation of findings and manuscript review.

Data Availability Statement

No additional data is available for sharing.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ICMJE Statement

The manuscript complies with ICMJE guidelines.

Statement of Ethics

The study was approved by the Institutional Ethics Committee of the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India (Approval No: N.NIMH/DO/IEC (BEH.sc.DIV) 2024). The study was conducted in accordance with institutional and national ethical standards and the Declaration of Helsinki.

ORCID iDs

Pradeep Kumar PC

Sojan Antony

E. Sinu

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