Common Challenges for People Living With Schizophrenia

Understanding the Roots: The Genetic and Environmental Etiology of Schizophrenia 

Epidemiologic studies suggest that schizophrenia is highly heritable, with genetic factors accounting for up to 80% of the risk, yet the genetics of the disease remains poorly understood.^1,2 In addition to genetic predisposition,^1,2 a range of environmental and psychosocial risk factors contribute to schizophrenia susceptibility.^1,3,4 These include prenatal exposures such as pregnancy complications and advanced paternal age,^3,4 childhood trauma or abuse,¹ substance use (particularly cannabis),¹ and social or environmental stressors.¹  

In individuals who go on to develop schizophrenia, these shared stressors give rise to early symptoms that resemble psychological responses to the same stressors in the general population—anxiety and depression, social withdrawal, and cognitive, motor, and social impairments.³ In addition, the negative symptoms of schizophrenia may worsen symptoms such as social withdrawal and flattened affect.⁵ 

People may think that the greatest challenge for people living with schizophrenia is managing the positive symptoms, such as delusions and hallucinations; however, many patients achieve adequate control of psychosis with oral antipsychotic treatment.⁶  

Difficulties Maintaining Relationships and Independence 

Despite significant advancements in psychosis management, patients with schizophrenia may find it challenging to maintain stable, long-term relationships. In a study that enrolled 3445 veterans with schizophrenia, 80% of the veterans had either been married and divorced or had never married at all.⁷ 

Independence and self-sufficiency required for everyday life remain elusive for most persons with schizophrenia, as research suggests that 70-90% have difficulty maintaining an independent residence and remaining employed.^8,9 A study of 234 patients with schizophrenia spectrum disorders found that only 22% were presently employed. In contrast, 29% had never been employed, and 49% had been employed but were unemployed for more than a year.⁸ A 20-year follow-up to the Suffolk County Mental Health Project found that only 40 of 146 (27.4%) persons with schizophrenia were living independently, and 36 (24.7%) were employed, highlighting the long-term challenges faced by individuals beyond the period of early acute care.⁹ The impacts of relationship status and self-sufficiency in patients with schizophrenia are profound, as being single and unemployed are known risk factors for suicidality in this population.¹⁰  

Factors Contributing to Ongoing Challenges  

These issues persist even in patients whose positive symptoms are controlled, due in part to negative and cognitive symptoms.¹¹ Functional outcomes are further influenced by many other external factors, including cognition,^11,12 stigma,¹³ and lack of support.¹⁴ Employment may be hindered by ethnic disparities,⁸ but may be aided by access to rehabilitation services.¹⁵ Social cognition, the ability to interpret and respond to social cues, has been found to mediate the link between cognitive deficits and functional outcomes, and limited metacognition may explain poor functional status, despite preserved cognitive function.¹² 

Beyond Positive Symptoms: Additional Ways to Address These Challenges 

To address ongoing challenges, long-term solutions must look beyond simply managing the positive symptoms of schizophrenia, which should include interventions that target diverse aspects of cognition, social skills, and global functioning. Effective strategies include various multidisciplinary interventions, such as psychoeducation, psychosocial interventions, family interventions, social skills training, employment and housing support, and community-based rehabilitation.¹⁵  

References: 

1. Davis J, Eyre H, Jacka FN, et al. A review of vulnerability and risks for schizophrenia: beyond the two-hit hypothesis. Neurosci Biobehav Rev. 2016;65:185-194. doi:10.1016/j.neubiorev.2016.03.017 
2. Merikangas AK, Shelly M, Knighton A, Kotler N, Tanenbaum N, Almasy L. What genes are differentially expressed in individuals with schizophrenia? A systematic review. Mol Psychiatry. 2022;27:1373–1383. https://doi.org/10.1038/s41380-021-01420-7 
3. Howes OD, Murray RM. Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet. 2014;383:1677-1687. doi:10.1016/S0140-6736(13)62036-X 
4. Khachadourian V, Zaks N, Lin E, Reichenberg A, Janecka M. Advanced paternal age and risk of schizophrenia in offspring - review of epidemiological findings and potential mechanisms. Schizophr Res. 2021;233:72-79. doi:10.1016/j.schres.2021.06.016 
5. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association; 2022. Accessed April 21, 2025. doi:10.1176/appi.books.9780890425787.  
6. Buckley PF, Harvey PD, Bowie CR, Loebel A. The relationship between symptomatic remission and neuropsychological improvement in schizophrenia patients switched to treatment with ziprasidone. Schizophr Res. 2007;94(1-3):99-106. doi:10.1016/j.schres.2006.12.032 
7. Harvey PD, Siever LJ, Huang GD, et al. The genetics of functional disability in schizophrenia and bipolar illness: methods and initial results for VA cooperative study #572. Am J Med Genet B Neuropsychiatr Genet. 2014;165:381-389. doi:10.1002/ajmg.b.32242 
8. Fundora C, Cruz M, Barone K, et al. Lifetime employment in schizophrenia: correlates of developing long-term unemployment after being employed before. Cogn Neuropsychiatry. 2021;26:95-106. doi:10.1080/13546805.2020.1865896  
9. Strassnig M, Kotov R, Fochtmann L, Kalin M, Bromet EJ, Harvey PD. Associations of independent living and labor force participation with impairment indicators in schizophrenia and bipolar disorder at 20-year follow-up. Schizophr Res. 2018;197:150-155. doi:10.1016/j.schres.2018.02.009 
10. Sher L, Kahn RS. Suicide in schizophrenia: an educational overview. Medicina (Kaunas). 2019;55(7):361. doi:10.3390/medicina55070361 
11. Leung WW, Bowie CR, Harvey PD. Functional implications of neuropsychological normality and symptom remission in older outpatients diagnosed with schizophrenia: A cross-sectional study. J Int Neuropsychol Soc. 2008;14:479-488. doi:10.1017/S1355617708080600 
12. Harvey PD, Strassnig MT, Silberstein J. Prediction of disability in schizophrenia: Symptoms, cognition, and self-assessment. J Exp Psychopathol. 2019;10(3). doi:10.1177/2043808719865693 
13. Çapar M, Kavak F. Effect of internalized stigma on functional recovery in patients with schizophrenia. Perspect Psychiatr Care. 2019;55(1):103-111. doi:10.1111/ppc.12309 
14. DeTore NR, Ventura J, Subotnik KL, Nuechterlein KH. Family burden predicts functional outcome in the early course of schizophrenia beyond psychiatric symptoms and baseline functioning. Schizophr Res. 2018;202:328-332. doi:10.1016/j.schres.2018.06.068 
15. Chiappini S, Di Carlo F, Mosca A, et al. Efficacy of psychosocial and psychological interventions in addition to drug therapy to improve global functioning of inpatients with schizophrenia spectrum and mood disorders: a real-world observational study. Neuropsychiatr Dis Treat. 2023;19:1887-1897. doi:10.2147/NDT.S418627 

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