Prevalence of loneliness and its correlates among patients with schizophrenia

Abstract

Background:

There are limited data on loneliness and its correlates in patients with schizophrenia.

Objective:

To evaluate prevalence and correlates of loneliness in patients with schizophrenia, currently in clinical remission.

Methodology:

A total of 160 patients of schizophrenia in clinical remission were assessed on UCLA Loneliness Scale, Positive and Negative syndrome scale, Calgary Depression Scale for Schizophrenia (CDSS), Internalized Stigma of Mental Illness Scale, Rosenberg Self-esteem Scale, Brief COPE, Beck’s Hopelessness Scale, Brief Dyadic Scale of Expressed Emotions, and Self-report Quality of Life Measure.

Results:

The mean age of the study sample was 34.99 (SD = 9.13) years. The prevalence of loneliness in the study sample was 80%, with mean total UCLA-loneliness scale score of 30.04 (16.9).Compared to participants without loneliness, those with loneliness had had higher CDSS score, had poor quality of life, lower self-esteem, experienced higher level of stigma, more often used maladaptive coping strategies such as self-blaming and reported a higher level of hopelessness. In the correlation analysis, higher level of loneliness was associated higher severity of depression, higher level of stigma (except for stigma resistance) and discrimination, poorer quality of life, lower self-esteem, perception of a higher level of expressed emotions, higher use of maladaptive coping in the domains of behavioral disengagement, and self-blaming, and a higher level of hopelessness. In regression analysis, the maximum variance of loneliness was explained by quality of life score (29%), followed by hopelessness score (8.8%) and discrimination score (2%).

Conclusion:

There is a high prevalence of loneliness in patients with schizophrenia, and there is a need to routinely evaluate the patients of schizophrenia for loneliness and address the same.

Keywords

Schizophrenia loneliness correlates

Introduction

Schizophrenia is a chronic mental disorder, that is associated with significant stigma, and these patients face a lot of discrimination, expressed emotions, and abuse at the hand of their family members and others (Kudo et al., 2002; Mueser & McGurk, 2004). It is noted that better insight into the illness among patients with schizophrenia is associated with hopelessness, depression, suicidal tendencies, decreased self-esteem, and low quality of life (Hasson-Ohayon et al., 2009). All these factors lead to isolation of patients with schizophrenia, and many of them suffer from significant loneliness (Kudo et al., 2002). These factors negatively impact the wellbeing and functioning of patients with schizophrenia (Robinson et al., 2016).

Loneliness is universal, and everybody is touched by it to some degree. The effect of loneliness on a person’s life and health is very much under-estimated by today’s society. According to one of the definition, loneliness is defined as ‘the negative emotional response to a discrepancy between the desired and achieved quality of one’s social network’ (Baumeister & Leary, 1995).

Very few studies have evaluated loneliness in patients with schizophrenia. These studies suggest that patients with schizophrenia feel more lonely as compared to healthy controls (Neeleman & Power, 1994). Most of the patients report feeling lonely or not satisfied with their social network. Their social network is limited to family and health care providers’ only (Schwartz & Gronemann, 2009).

Preliminary data on correlates of loneliness among patients with schizophrenia suggest that a higher level of loneliness is associated with low resilience, lower happiness, lower level of satisfaction with life and mental wellbeing, high depression, a higher level of perceived stress, anxiety, and lower level of current social position (Eglit et al., 2018). It is also suggested that low self-esteem is associated with higher level of loneliness (Ludwig et al., 2020; Świtaj et al., 2015). An experience of discrimination has been demonstrated to increase the level of loneliness both directly and indirectly. The indirect effect of discrimination on loneliness is mediated bylow self-esteem (Shioda et al., 2016; Świtaj et al., 2015). Loneliness has also been reported to be associated with a higher prevalence of depression, and substance use disorders among patients with schizophrenia (Trémeau et al., 2016). Other correlates of higher level of loneliness noted in one or more studies include younger age of onset, higher severity of positive symptom, a higher number of hospitalizations, and poor quality of life (Chrostek et al., 2016; Eglit et al., 2018; Yildirim & Budak, 2020). Some studies suggest that loneliness mediates the association between internalized stigma and psychiatric hospitalization (Prince et al., 2018). Data supports the association of loneliness with suicide attempts and depressive symptoms (Beutel et al., 2017; Grover et al., 2018; Lasgaard et al., 2011; McClelland et al., 2020; Teo et al., 2018). Other factors that have been shown to be associated with loneliness in patients with schizophrenia in cross-sectional studies include higher age, female sex, poor quality of social contacts, low competence, low socioeconomic status, and presence of chronic medical conditions (Killeen, 1998; Solmi et al., 2020). However, it can still be said that there is limited data on prevalence of loneliness among patients with schizophrenia and its correlates.

Traditionally, it is considered that in India, the family is closely involved in the care of patients with schizophrenia. Accordingly, closer involvement of family in patients with schizophrenia can possibly influence the perception of loneliness. Based on this, it can be hypothesized that patients with schizophrenia will experience a lower level of loneliness in the Indian context. In this background, the present study aims to evaluate the prevalence and correlates of loneliness in patients with schizophrenia, currently in clinical remission.

Methodology

A cross-sectional study design was employed. The study sample was recruited from the patient population attending the outpatient services of a tertiary care center. The Ethics Committee of the institute approved the study, and all the participants were recruited after obtaining written informed consent. The study sample was recruited during the time period of Oct 2019 to March 2020.

The study included 160 patients with schizophrenia. To be included in the study, the study participants were required to be diagnosed with schizophrenia as per diagnostic and statistical manual, fifth revision (DSM-5) criteria (confirmed by using MINI 7.0.2 version (Sheehan et al., 1998), in clinical remission (as defined by Andreasen et al., 2005), aged between 18 and 65 years, able to read Hindi, and/or English. Patients who were not in clinical remission, those with comorbid organic brain syndrome, intellectual disability, current comorbid substance dependence (other than tobacco dependence) were excluded.

The study participants were assessed on University of California Los Angeles Loneliness Scale (UCLA-LS; Russell, 1996), Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987), Calgary Depression Scale for Schizophrenia (CDSS; Addington et al., 1990), Self-report Quality of Life Measure for people with Schizophrenia (SQLS; Wilkinson et al., 2000), Rosenberg Self-esteem Scale (Rosenberg, 1965), The Internalized Stigma of Mental Illness (ISMI) Scale (Ritsher et al., 2003), Brief COPE (Carver, 1997), and Brief Dyadic Scale of Expressed Emotions (BDSEE; Medina-Pradas et al., 2011).

University of California Los Angeles Loneliness Scale (UCLA-LS)

It is a 20-item scale designed to measure one’s subjective feelings of loneliness as well as feelings of social isolation (Russell, 1996). The items of the scale reflect one’s dissatisfaction with social relationships. Each item is rated on a 4-point scale, with higher scores indicating more loneliness. The three-items of the scale (lack of companionship, left out in life, and isolated from others) have been used to assess the prevalence of loneliness across many studies and response for any of these three items in the form of ‘sometimes/often’, that is, ⩾2 is considered as indicative of the presence of loneliness. The scale has been shown to have good internal consistency (coefficient ranging from .89 to .94), test-retest reliability (r = .73), and adequate convergent and construct validity. The Hindi translated version of the scale was used in this study.

Positive and Negative Syndrome Scale (PANSS)

PANSS is one of the standard tools for assessing the clinical outcome among patients with schizophrenia. It has three subscales – positive, negative, and general psychopathology. Based on a semi-structured clinical interview and other informational sources, pertaining to the previous 1 week, each item is rated on a 7-point scale. Alpha coefficient varies from .73 to .83 (p < .001) for each of the subscales, indicating high inter-rater reliability and homogeneity among items (Kay et al., 1987).

Calgary Depression Scale for Schizophrenia (CDSS)

This scale was specifically developed to assess the level of depression in schizophrenia (Addington et al., 1990). It distinguishes depressive symptoms from positive, negative and extrapyramidal symptoms in patients with schizophrenia. Rating is done on the basis of an observer scale on the basis of a semi-structured, goal directed interview, with a time axis of 2 weeks, unless otherwise specified. The scale has nine items, each of which is rated on a 4-point scale of 0 to 3. A score above 6 has 82% specificity and 85% sensitivity for predicting the presence of a major depressive episode.

Self-report quality of life measure for people with schizophrenia (SQLS)

It is a 30-item self-reported quality of life questionnaire in people with schizophrenia, that can be completed in 5 to 10 minutes (Wilkinson et al., 2000).The items of the scale are divided into three subscales: ‘psychosocial’, ‘motivation and energy’ and ‘symptoms and side effects’. The scale has internal reliability of .83 to .92 (Isjanovski et al., 2016).

Rosenberg Self-Esteem Scale

It is a unidimensional 10-item scale that measures global self-worth by measuring both positive and negative feelings about the self (Rosenberg, 1965). Each item is responded on a 4-point Likert scale with some of the items being reverse coded and a higher score indicating higher self-esteem. The internal consistency for the scale is .77, and the minimum coefficient of reproducibility is at least .9. Test-retest reliability for the 2-week interval is reported to be .85, and the test-retest reliability at the 7-month interval is .63.

The Internalized Stigma of Mental Illness (ISMI) Scale

This 29-item scale measures the subjective experiences of self-stigma. Each question is rated on a 4-point Likert scale, with a higher score indicating higher level of internalized stigma. The various items of ISMI are categorized into five subscales – alienation, perceived discrimination, stereotype endorsement, stigma resistance, and social withdrawal. The internal consistency of the scale is .90, and the test-retest reliability coefficient is .92 (Ritsher et al., 2003). This scale has been validated in Hindi (Singh et al., 2016) and in the present study, Hindi version was used.

Brief Coping Orientation to Problems Experienced (COPE)

This is a 28-item self-rated scale to assess different adaptive and maladaptive coping methods, which were adapted from a longer COPE scale for easier use (Carver, 1997). Different aspects of coping strategies assessed include self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. These coping mechanisms are further categorized into three groups: emotion-focused coping, problem-focused coping, and dysfunctional coping. The scale has good test-retest validity, and regression analysis has shown both good concurrent and convergent validity (Carver, 1997). Intra-class correlation coefficient has been shown to range from .05 to 1.00 (Yusoff et al., 2010).

Brief Dyadic Scale of Expressed Emotions (BDSEE)

It is 14 items self-rating questionnaire that measures the three leading indices of expressed emotions (EEs), that is, ‘perceived criticism’ (four items), ‘perceived emotional over involvement’ (six items), and ‘perceived warmth’ (four items; Medina-Pradas et al., 2011). Each item of this self-report measure is scored on a 10-point Likert scale, with higher scores representing a more negative affectionate quality of the dyadic relationship. It has an excellent internal consistency of .82 to .92.

Beck’s Hopelessness Scale (BHS)

This scale consists of 20 items, each rated as ‘True’ or ‘False’ (Beck et al., 1974). The total BHS score is a sum of item responses and can range from 0 to 20 such that higher scores reflect higher levels of hopelessness. Scores of 4 to 8 indicate mild hopelessness, scores from 9 to 14 indicate moderate level of hopelessness, and scores greater than 14 are suggestive of severe hopelessness. The various items are divided into three aspects of hopelessness: feelings about the future, loss of motivation, and expectations. The scale has good internal consistency, with alpha coefficient of .93.

Statistical Analysis

Data were analyzed by using the SPSS-14 version. Descriptive analysis involved computing mean and standard deviation and range for continuous variables and frequency and percentages for categorical variables. Correlation analysis was used to assess the association of loneliness with other variables. Comparisons were made by using the unpaired t-test and Chi-square test. In view of multiple comparisons and correlations, a p-value of .001 (44 comparisons and correlations: .05/44 = .0011) was considered as significant. Linear regression analysis was carried out to evaluate the correlates of loneliness. Based on the data of linear regression, a path involving various correlates of loneliness was constructed.

Results

The study included 160 patients with a mean age of 34.99 (SD = 9.13) years. The number of males outnumbered females. The majority of the study participants were currently single (unmarried/divorced/widowed), unemployed, from nuclear families, urban background, Hindu by religion, and lower or lower-middle socioeconomic status (Table 1).

Table 1.

Sociodemographic profile of the study sample.

Variables	Total sample (n = 160)
	M (SD)/frequency (%)
Age in years	34.99 (9.13) [median = 34; range = 19–60]
Gender
Male	95 (59.4%)
Female	65 (40.6%)
Marital status
Married/remarried	60 (37.5%)
Unmarried/divorced/widowed	100 (62.5%)
Education in years	13.22 (3.49) [median = 13; Range = 0–20.5]
Occupation of patient
Employed	60 (37.5%)
Unemployed	100 (62.5%)
Occupation of the head of the family
Employed	123 (76.9%)
Unemployed	37 (23.1%)
Family type
Nuclear	98 (61.3%)
Extended/Joint	62 (38.8%)
Locality
Urban	112 (70%)
Rural	48 (30%)
Kuppuswamy socioeconomic status
Lower/upper lower/lower middle (3–15)	111 (69.4%)
Upper middle class/upper (16–29)	49 (30.6%)
Religion
Hindu	109 (68.1%)
Non-Hindu (Sikh/Muslim/Christian)	51 (31.9%)

Clinical profile of the study sample

The mean age of onset of the study sample was 22.15 (SD = 5.95) years, and the mean duration of illness was 12.83 (SD = 7.61) years. The study participants were on treatment for a mean duration of 11.69 (SD = 7.8) years at the time of assessment. Patients were on the current antipsychotic medication for 7.04 (SD = 4.73) years. The mean positive and negative syndrome scale (PANSS) score for the study sample was 41.99 (SD = 10.02), with a mean negative symptom subscale score slightly more than the positive symptoms subscale score. The mean general psychopathology subscale score was 22.14 (SD = 5.13), depression subscale score was 7.36 (SD = 2.35), and prosocial subscale was 9.33 (SD = 2.91). The PANSS insight subscale score was 2 (SD = 1.49). The mean CDSS score was 4.54 (SD = 5.21), with one-fourth (25%) of the participants having current depression as per the CDSS.

Prevalence of loneliness

In terms of loneliness, 80% of participants fulfilled the criteria of loneliness, and the mean total score of UCLA-loneliness scale was 30.04 (SD = 16.90).

Correlates of loneliness

Compared to participants without loneliness, those with loneliness had higher CDSS score, had poor quality of life in the psychosocial domain and total quality of life, lower self-esteem, higher scores in all the domains of ISMI scale except for stigma resistance, more often used maladaptive coping strategies such as self-blaming, and total maladaptive coping mechanisms and reported a higher level of hopelessness (Table 2).

Table 2.

Details of correlates of loneliness.

Variables	Total sample, n = 160 M (SD)/frequency (%)	Loneliness absent	Loneliness present	T-test value (p value)/χ²value (p-value)	Pearson correlation coefficient
Calgary Depression Scale for Schizophrenia (CDSS)
Total score	4.54 (5.21)	1.78 (3.27)	5.22 (5.37)	U = 1,018 (<.001)***	0.409 (<.001)***
Depression as per the CDSS	40 (25%)	3 (9.4%)	37 (28.9%)	χ² = 4.21 (.040)	−4.187 (<.001)***
The everyday discrimination scale
Total score	10.74 (10.27)	6.40 (10.09)	11.82 (10.05)	t = −2.721 (.007)	0.397 (<.001)***
Self-report quality of life measure for people with schizophrenia (SQLS)
Psychosocial subscale	23.86 (9.58)	14.50 (6.12)	26.19 (8.84)	t = −7.061 (<.001)***	0.609 (<.001)***
Symptom and side effects subscale	8.02 (4.07)	6.31 (3.81)	8.45 (4.03)	t = −2.715 (.007)	0.288 (<.001)***
Total score	45.07 (13.98)	32.65 (8.96)	48.17 (13.28)	t = −6.254 (<.001)***	0.542 (<0.001)***
Internalized Stigma of Mental Illness Scale (ISMIS)
Stereotype endorsement subscale	15.43 (5.01)	11.65 (4.21)	16.37 (4.74)	t = −5.137 (<.001)***	0.405 (<.001)***
Alienation subscale	14.61 (5.15)	10.93 (4.71)	15.53 (4.85)	t = −4.814 (<.001)***	0.504 (<.001)***
Perceived discrimination subscale	11.18 (3.59)	8.87 (3.64)	11.75 (3.35)	t = −4.271 (<.001)***	0.469 (<.001)***
Social withdrawal subscale	13.49 (4.63)	10.43 (4.72)	14.25 (4.30)	t = −4.405 (<0.001)***	0.425 (<.001)***
ISMIS total score	66.76 (16.75)	54.00 (16.33)	69.95 (15.32)	t = −5.198 (<.001)***	0.510 (<.001)***
ISMIS total score without stigma resistance	54.7 (16.83)	41.90 (16.22)	57.92 (15.45)	t = −5.192 (<.001)***	0.405 (<.001)***
Brief Dyadic Scale of Expressed Emotions – Expanded Patient Version (BDSEE)
Perceived criticism subscale	18.94 (9.50)	15.18 (9.70)	19.88 (9.26)	t = −2.541 (.012)	0.395 (<.001)***
Perceived emotional over-involvement	29.52 (11.14)	24.53 (12.59)	30.76 (10.42)	t = −2.897 (.004)	0.324 (<.001)***
Perceived warmth	25.56 (9.35)	28.34 (9.83)	24.85 (9.13)	t = 1.901 (.059)	−0.279 (<.001)***
BDSEE total score	74.02 (16.65)	68.06 (16.27)	75.50 (16.47)	t = −2.292 (.023)	0.286 (<.001)***
Rosenberg Self-Esteem Scale (Rosenberg SES)
Total score	16.43 (6.29)	20.34 (5.99)	15.45 (5.99)	t = 4.126 (<.001)***	−0.471 (<.001)***
Maladaptive coping
Behavioral disengagement	4.24 (1.59)	3.46 (1.62)	4.43 (1.53)	t = −3.155 (.002)	0.356 (<.001)***
Self-blaming	4.34 (1.87)	3.18 (1.40)	4.63 (1.86)	t = −4.092 (<.001)***	0.401 (<.001)***
Total coping score
Total adaptive coping score	39.49 (8.88)	39.50 (9.61)	39.49 (8.73)	t = 0.004 (.996)	0.349 (<.001)***
Beck’s Hopelessness Scale (BHS)
BHS total score	9.99 (4.76)	6.28 (3.90)	10.91 (4.50)	t = −5.336 (<.001)***	0.522 (<.001)***

Note. # = Yate’s continuity correction, U = Mann Whitney test.

***

p < .0001.

When the correlation analysis was carried out, higher loneliness was associated higher CDSS depression score, experienced higher level of discrimination, had poorer quality of life in all the domains except for motivational and energy subscale, had lower self-esteem, perceived higher level of stigma except for the stigma resistance subscale, had perception of a higher level of expressed emotions in all the domains, more often used maladaptive coping in the domains of behavioral disengagement, and self-blaming, and adaptive coping mechanisms, and a higher level of hopelessness (Table 2).

All the variables which had a significant correlation with the mean loneliness score were entered in the linear regression analysis by using the stepwise method. Among the various variables, the maximum variance of loneliness was explained by quality of life total score (29%), followed by a hopelessness score (8.8%) and a discrimination score (2%).

Path analysis

Further, to understand the impact of other variables on loneliness, multiple regression analyses were carried out to understand the impact of correlations of other variables with each other and loneliness. Based on this, an attempt was made to draw a path for the direct or indirect contribution of different variables on the total loneliness score. It was seen that besides the three variables which directly explained the variance of loneliness, stigma emerged as the most important variable, which operated indirectly on the loneliness through the quality of life, by explaining 39.5% of the variance of quality of life. Further, the stigma explained 21.5% of the variance of the discrimination scale and 28.6% of variance of hopelessness. These findings suggest that although stigma does not appear to impact loneliness directly, it has a significant impact on all the three variables that explain the variance of loneliness (Figure 1).

Figure 1.

Path analysis of loneliness.

Discussion

The present study aimed to evaluate the prevalence and correlates of loneliness in patients with schizophrenia in clinical remission. In the present study, the prevalence of loneliness was 80%, with the mean total UCLA loneliness scale score 30.04 (16.90). This prevalence finding of loneliness is similar to the large Australian National Survey of psychosis, which included 1,825 patients and reported loneliness in the past 12 months in 80.1% of the participants (Stain et al., 2012). This prevalence figure is also significantly higher than that reported for the general population from India (Peltzer & Pengpid, 2019) but similar to the prevalence reported for elderly patients with depression from India (Grover et al., 2018). Many other studies have evaluated loneliness in patients with psychotic disorders by using different measures, varying from a single item assessment to a more detailed assessment. A metanalysis of 13 studies, which assessed loneliness in patients with various psychotic disorders, suggests that there is a significant moderate level association between psychosis and loneliness, with an effect size of 0.32 (confidence interval: [0.2, 0.44]; Michalska da Rocha et al., 2018). Some of the authors have postulated that the association of psychosis and loneliness is like a self-preserving cycle and suggested that loneliness plays a maintaining role in the continuation of psychotic symptoms. Others have suggested that loneliness may play a role in the onset of psychotic illnesses and suggest that loneliness may also be seen in persons prone to psychosis, those who have schizotypy, or are in at-risk mental states. Based on this, it is suggested that the association of loneliness and psychosis occurs at various levels (Michalska da Rocha et al., 2018). The high prevalence of loneliness in patients with schizophrenia as noted in the present study, calls for urgent attention and the need for its assessment and management.

This high prevalence of loneliness in patients with schizophrenia suggests this needs attention, as loneliness is known to be independently associated with multiple of adverse physical health and psychological health outcomes. Multiple studies involving participants with general population suggest that loneliness is associated with physical health consequences like headache, sleep disturbances, fatigue, poor immune functioning, adverse cardiovascular outcomes, and diabetes mellitus (Hawkley, 2022; Hawkley & Cacioppo, 2010; Michalska da Rocha et al., 2018). In terms of psychological consequences, loneliness has also been shown to increase the risk of depression, suicidal attempt and completed suicide, depression, poor well-being, and higher risk of substance use (Hawkley, 2022; Hawkley & Cacioppo, 2010; Michalska da Rocha et al., 2018). This high level of prevalence suggests that there is a need to develop appropriate intervention strategies to address the same.

It has been postulated that loneliness can contribute to the onset of psychosis or maintenance of psychosis. In terms of maintenance of psychosis, it is suggested that there is a self-preserving cycle of loneliness and psychosis, with loneliness contributing to the maintenance of psychosis (Gayer-Anderson & Morgan, 2013). In terms of onset of psychosis, it is suggested that loneliness may be related to subclinical manifestation of psychosis (Van Os et al., 2000; Yung et al., 2003). Hence, it can be said that, it is important to evaluate the concept of loneliness in patients with psychosis in detail to understand the inter-relationship.

In terms of factors associated with loneliness, the present study shows that compared to participants without loneliness, those with loneliness have higher depression score, poor quality of life, especially in the psychosocial domain, lower self-esteem, higher stigma except for stigma resistance, more often use maladaptive coping strategies such as self-blaming, and have a higher level of hopelessness. In the correlation analysis higher loneliness was associated higher level of depression, higher level of stigma in all domains except for the stigma resistance subscale, higher level of discrimination, poorer quality of life, lower self-esteem, perception of a higher level of expressed emotions in all the domains, higher use of maladaptive coping in the domains of behavioral disengagement, and self-blaming, and higher use of adaptive coping mechanisms, and a higher level of hopelessness. Accordingly, it can be said that findings of the present study are in concurrence with previous studies that have reported association of higher level of loneliness with depression (Eglit et al., 2018; Trémeau et al., 2016), internalized stigma, low self-esteem (Ludwig et al., 2020; Świtaj et al., 2015), higher level of discrimination (Shioda et al., 2016; Świtaj et al., 2015), and poor quality of life (Chrostek et al., 2016; Yildirim & Budak, 2020). Pooled data also support the longitudinal association between loneliness and depressive symptoms (Beutel et al., 2017; Lasgaard et al., 2011; McClelland et al., 2020; Teo et al., 2018; Grover et al., 2018). These findings must be understood as association, rather than by causality model, suggesting that some of these negative outcomes may be contributing to development of loneliness and vice-versa, with loneliness contributing to some of these negative outcomes. Additionally, the present study suggests that higher use of maladaptive coping and hopelessness are also associated with higher level of loneliness. In the regression analysis, among all the correlates, poor quality of life (29%), hopelessness (8.8%), and discrimination (2%) emerged as significant predictors of loneliness. These findings suggest that clinicians managing patients with schizophrenia should routinely enquire about the hopelessness and discrimination, and address the same, to reduce loneliness and its impact on the quality of life.

The existing literature also suggests the association of loneliness with a higher prevalence of substance use disorders (Trémeau et al., 2016), younger age of onset, higher severity of positive symptoms (Eglit et al., 2018), and higher number of hospitalizations (Chrostek et al., 2016). The findings of the present study do not support the same. This could be due to the fact that we controlled for multiple comparisons and correlates, which could have led to non-consideration of correlates of lower strength.

In the present study, the impact of the different variables on loneliness was evaluated by carrying out a path analysis. From this analysis, it was seen that although internalized stigma directly does not influence loneliness, but it has significant impact on all the three variables, which directly influence loneliness. Previous studies that have attempted to evaluate the prevalence and correlates of loneliness among patients with schizophrenia have not looked at the pathways explaining the association of different variables. Hence, it is not possible to compare these findings of the present study with the existing literature.

It is not possible to draw a cause-and-effect relationship from a cross-sectional study. However, considering that this is an exploratory study, the path analysis possibly suggests that internalized stigma is an important component which determines loneliness directly or indirectly. The internalized stigma makes the person feel that they are different from others and resultantly feel hopeless and discriminated. The stigma also directly influences the quality of life. These three variables together lead to development of loneliness.

According to one of the cognitive models of psychosis, poor self-concept and self-esteem influence the maladaptive cognitions about self and others (Garety et al., 2001). Hence, it can be said that internalized stigma may be a reflection of maladaptive cognitions about self and the discrimination may be a maladaptive cognition about others. Further it can be said that stigma leads to hopelessness and low self-esteem. It is also possible that once loneliness sets-in, it contributes further to the hopelessness and other negative consequences. Based on this analysis, it can be said that addressing the internalized stigma is the most important variable to reduce loneliness in patients with schizophrenia. Accordingly, various psychotherapeutic and psychoeducational interventions should be designed for patients with schizophrenia should give due importance to internalized experienced by patients with schizophrenia.

The following limitations must be kept in mind while interpreting the results of this study. The study included patients attending a General Hospital Psychiatry Unit. So, the results cannot be generalized to other patient populations. The study involved a cross-section assessment of the participants selected by convenient sampling. Further, we did not assess the personality of the study participants in details. It is well known that certain personality traits may make people more prone to loneliness.

Conclusion

To conclude, the present study suggests that loneliness is highly prevalent in patients with schizophrenia, currently in clinical remission. This finding suggests that there is a need to routinely evaluate the patients with schizophrenia for loneliness and address the same. Further, the present study suggests that sociodemographic and clinical variables except for depression do not significantly impact loneliness. Among the various psychosocial variables, quality of life, hopelessness, and discrimination faced by the patients significantly impact the experience of loneliness. Although internalized stigma directly does not impact the experience of loneliness but it has a significant impact on the variables which directly influence loneliness. Based on these findings, it can be said that psychoeducation and psychotherapeutic interventions focusing on addressing stigma, discrimination, and hopelessness should be designed to reduce loneliness.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Swapnajeet Sahoo

Sandeep Grover

References

Addington

Schissel

(1990). A depression rating scale for schizophrenics. Schizophrenia Research, 3, 247–251. https://doi.org/10.1016/0920-9964(90)90005-r

Andreasen

N. C.

Carpenter

W. T.

Kane

J. M.

Lasser

R. A.

Marder

S. R.

Weinberger

D. R.

(2005). Remission in Schizophrenia: Proposed criteria and rationale for consensus. American Journal of Psychiatry, 162, 441–449. https://doi.org/10.1176/appi.ajp.162.3.441

Baumeister

R. F.

Leary

M. R.

(1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117, 497–529. https://doi.org/10.1037/0033-2909.117.3.497

Beck

A. T.

Weissman

Lester

Trexler

(1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42, 861–865. https://doi.org/10.1037/h0037562

Beutel

M. E.

Klein

E. M.

Brähler

Reiner

Jünger

Michal

Wiltink

Wild

P. S.

Münzel

Lackner

K. J.

Tibubos

A. N.

(2017). Loneliness in the general population: Prevalence, determinants and relations to mental health. BMC Psychiatry, 17, 97. https://doi.org/10.1186/s12888-017-1262-x

Carver

C. S.

(1997). You want to measure coping but your protocol’ too long: Consider the brief cope. International Journal of Behavioral Medicine, 4, 92. https://doi.org/10.1207/s15327558ijbm0401_6

Chrostek

Grygiel

Anczewska

Wciórka

Świtaj

(2016). The intensity and correlates of the feelings of loneliness in people with psychosis. Comprehensive Psychiatry, 70, 190–199. https://doi.org/10.1016/j.comppsych.2016.07.015

Eglit

G. M. L.

Palmer

B. W.

Martin

A. S.

Jeste

D. V.

(2018). Loneliness in schizophrenia: Construct clarification, measurement, and clinical relevance. PLOS ONE, 13, e0194021. https://doi.org/10.1371/journal.pone.0194021

Garety

P. A.

Kuipers

Fowler

Freeman

Bebbington

P. E.

(2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31, 189–195.

10.

Gayer-Anderson

Morgan

(2013). Social networks, support and early psychosis: A systematic review. Epidemiology and Psychiatric Sciences, 22: 131–146.

11.

Grover

Avasthi

Sahoo

Lakdawala

Dan

Nebhinani

Dutt

Tiwari

Gania

A. M.

Subramanyam

A. A.

Kedare

Suthar

(2018). Relationship of loneliness and social connectedness with depression in elderly: A multicentric study under the aegis of Indian Association for Geriatric Mental Health. Journal of Geriatric Mental Health, 5, 99–106. https://doi.org/10.4103/jgmh.jgmh_26_18

12.

Hasson-Ohayon

Kravetz

Meir

Rozencwaig

(2009). Insight into severe mental illness, hope, and quality of life of persons with schizophrenia and schizoaffective disorders. Psychiatry Research, 167, 231–238. https://doi.org/10.1016/j.psychres.2008.04.019

13.

Hawkley

L. C.

(2022). Loneliness and health. Nature Reviews Disease Primers, 8, 22.

14.

Hawkley

L. C.

Cacioppo

J. T.

(2010). Loneliness matters: A theoretical and empirical review of consequences and mechanisms. Annals of Behavioral Medicine, 40(2), 218–227.

15.

Isjanovski

Naumovska

Bonevski

Novotni

(2016). Validation of the schizophrenia quality of life scale revision 4 (SQLS-R4) among patients with schizophrenia. Open Access Macedonian Journal of Medical Sciences, 4, 65–69. https://doi.org/10.3889/oamjms.2016.015

16.

Kay

S. R.

Fiszbein

Opler

L. A.

(1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13, 261–276. https://doi.org/10.1093/schbul/13.2.261

17.

Killeen

(1998). Loneliness: An epidemic in modern society. Journal of Advanced Nursing, 28, 762–770. https://doi.org/10.1046/j.1365-2648.1998.00703.x

18.

Kudo

Mori

Gomibuchi

(2002). Loneliness as expressed by schizophrenic patients in the early remission phase. Nagoya Journal of Medical Science, 65, 115–126.

19.

Lasgaard

Goossens

Elklit

(2011). Loneliness, depressive symptomatology, and suicide ideation in adolescence: Cross-sectional and longitudinal analyses. Journal of Abnormal Child Psychology, 39, 137–150. https://doi.org/10.1007/s10802-010-9442-x

20.

Ludwig

K. A.

Nye

L. N.

Simmons

G. L.

Jarskog

L. F.

Pinkham

A. E.

Harvey

P. D.

Penn

D. L.

(2020). Correlates of loneliness among persons with psychotic disorders. Social Psychiatry and Psychiatric Epidemiology, 55, 549–559. https://doi.org/10.1007/s00127-019-01789-5

21.

McClelland

Evans

J. J.

Nowland

Ferguson

O’Connor

R. C.

(2020). Loneliness as a predictor of suicidal ideation and behaviour: A systematic review and meta-analysis of prospective studies. Journal of Affective Disorders, 274, 880–896. https://doi.org/10.1016/j.jad.2020.05.004

22.

Medina-Pradas

Navarro

J. B.

López

S. R.

Grau

Obiols

J. E.

(2011). Further development of a scale of perceived expressed emotion and its evaluation in a sample of patients with eating disorders. Psychiatry Research, 190, 291–296. https://doi.org/10.1016/j.psychres.2011.06.011

23.

Michalska da Rocha

Rhodes

Vasilopoulou

Hutton

(2018). Loneliness in psychosis: A meta-analytical review. Schizophrenia Bulletin, 44, 114–125. https://doi.org/10.1093/schbul/sbx036

24.

Mueser

K. T.

McGurk

S. R.

(2004). Schizophrenia. Lancet, 363, 2063–2072. https://doi.org/10.1016/S0140-6736(04)16458-1

25.

Neeleman

Power

M. J.

(1994). Social support and depression in three groups of psychiatric patients and a group of medical controls. Social Psychiatry and Psychiatric Epidemiology, 29, 46–51. https://doi.org/10.1007/bf00796448

26.

Peltzer

Pengpid

(2019). Loneliness correlates and associations with health variables in the general population in Indonesia. International Journal of Mental Health Systems, 13, 24. https://doi.org/10.1186/s13033-019-0281-z

27.

Prince

J. D.

Oyo

Mora

Wyka

Schonebaum

A. D.

(2018). Loneliness among persons with severe mental illness. The Journal of Nervous and Mental Disease, 206, 136–141. https://doi.org/10.1097/NMD.0000000000000768

28.

Ritsher

J. B.

Otilingam

P. G.

Grajales

(2003). Internalized stigma of mental illness: Psychometric properties of a new measure. Psychiatry Research, 121, 31–49. https://doi.org/10.1016/j.psychres.2003.08.008

29.

Robinson

Kissane

D. W.

Brooker

Burney

(2016). A review of the construct of demoralization: History, definitions, and future directions for palliative care. American Journal of Hospice and Palliative Medicine, 33, 93–101. https://doi.org/10.1177/1049909114553461

30.

Rosenberg

(1965). Society and the adolescent self-image. University Press.

31.

Russell

D. W.

(1996). UCLA Loneliness Scale (Version 3): Reliability, validity, and factor structure. Journal of Personality Assessment, 66, 20–40. https://doi.org/10.1207/s15327752jpa6601_2

32.

Schwartz

Gronemann

O. C.

(2009). The contribution of self-efficacy, social support and participation in the community to predicting loneliness among persons with schizophrenia living in supported residences. Israel Journal of Psychiatry and Related Sciences, 46, 120–129.

33.

Sheehan

D. V.

Lecrubier

Sheehan

K. H.

Amorim

Janavs

Weiller

Hergueta

Baker

Dunbar

G. C.

(1998). The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59, 22–33.

34.

Shioda

Tadaka

Okochi

(2016). Loneliness and related factors among people with schizophrenia in Japan: A cross-sectional study. Journal of Psychiatric and Mental Health Nursing, 23, 399–408. https://doi.org/10.1111/jpm.12318

35.

Singh

Grover

Mattoo

S. K.

(2016). Validation of Hindi version of internalized stigma of mental illness scale. Indian Journal of Social Psychiatry 32(2), 104–14. https://doi.org/10.4103/0971-9962.181089

36.

Solmi

Veronese

Galvano

Favaro

Ostinelli

E.G.

Noventa

Favaretto

Tudor

Finessi

Shin

J. I.

Smith

Koyanagi

Cester

Bolzetta

Cotroneo

Maggi

Demurtas

De Leo

Trabucchi

(2020). Factors associated with loneliness: An umbrella review of observational studies. Journal of Affective Disorders, 271, 131–138. https://doi.org/10.1016/j.jad.2020.03.075

37.

Stain

H. J.

Galletly

C. A.

Clark

Wilson

Killen

E. A.

Anthes

Campbell

L. E.

Hanlon

M.-C.

Harvey

(2012). Understanding the social costs of psychosis: The experience of adults affected by psychosis identified within the second Australian National Survey of Psychosis. Australian & New Zealand Journal of Psychiatry, 46, 879–889. https://doi.org/10.1177/0004867412449060

38.

Świtaj

Grygiel

Anczewska

Wciórka

(2015). Experiences of discrimination and the feelings of loneliness in people with psychotic disorders: The mediating effects of self-esteem and support seeking. Comprehensive Psychiatry, 59, 73–79. https://doi.org/10.1016/j.comppsych.2015.02.016

39.

Teo

A. R.

Marsh

H. E.

Forsberg

C. W.

Nicolaidis

Chen

J. I.

Newsom

Saha

Dobscha

S. K.

(2018). Loneliness is closely associated with depression outcomes and suicidal ideation among military veterans in primary care. Journal of Affective Disorders, 230, 42–49. https://doi.org/10.1016/j.jad.2018.01.003

40.

Trémeau

Antonius

Malaspina

Goff

D. C.

Javitt

D. C.

(2016). Loneliness in schizophrenia and its possible correlates. An exploratory study. Psychiatry Research, 246, 211–217. https://doi.org/10.1016/j.psychres.2016.09.043

41.

Van Os

Hanssen

Bijl

R. V.

Ravelli

(2000). Strauss (1969) revisited: A psychosis continuum in the general population? Schizophrenia Research, 45, 11–20.

42.

Wilkinson

Hesdon

Wild

Cookson

Farina

Sharma

Fitzpatrick

Jenkinson

(2000). Self-report quality of life measure for people with schizophrenia: The SQLS. The British Journal of Psychiatry, 177, 42–46. https://doi.org/10.1192/bjp.177.1.42

43.

Yildirim

Budak

F. K.

(2020). The relationship between internalized stigma and loneliness in patients with schizophrenia. Perspectives in Psychiatric Care, 56, 168–174. https://doi.org/10.1111/ppc.12399

44.

Yung

A. R.

Phillips

L. J.

Yuen

H. P.

Francey

S. M.

McFarlane

C. A.

Hallgren

McGorry

P. D.

(2003). Psychosis prediction: 12-month follow up of a high-risk (“prodromal”) group. Schizophrenia Research, 60, 21–32.

45.

Yusoff

Low

W. Y.

Yip

C. H.

(2010). Reliability and validity of the Brief COPE Scale (English version) among women with breast cancer undergoing treatment of adjuvant chemotherapy: A Malaysian study. Medical Journal of Malaysia, 65, 41–44. https://doi.org/PMID:21265247