J. Psychosoc. Rehabil. Ment.

Health
https://doi.org/10.1007/s40737-020-00211-7

ORIGINAL ARTICLE

Relationship Between Quality of Life and Social Support

Among Patients with Schizophrenia and Bipolar Disorder:
A Cross-Sectional Study
Sayujya Prabhakaran . Padmavathi Nagarajan . Natarajan Varadharajan .
Vikas Menon

Received: 14 September 2020 / Accepted: 16 November 2020

Ó Springer Nature India Private Limited 2021

Abstract Many studies have demonstrated that
quality of life (QoL) is poor among individuals
suffering from severe mental illness like bipolar
disorder (BD) and Schizophrenia due to various
factors like residual symptoms, side effects of med-
ication, and lack of social support. This study aims to
explore the relationship between QoL and perceived
social support among patients with schizophrenia and
BD in remission and to identify the factors associated
with QoL. A cross-sectional, descriptive study was
carried out in a Psychiatry outpatient department of a
tertiary care hospital. Patients diagnosed with BPAD
and Schizophrenia as per International Classification
Disorders-10 diagnostic criteria were recruited for the
S. Prabhakaran
JIPMER, Puducherry, India
e-mail: sayujyacp@gmail.com
P. Nagarajan (&)
Department of Psychiatric Nursing, College of Nursing,
Jawaharlal Institute of Post Graduate Medical Education
and Research (JIPMER), Puducherry, India
e-mail: padmavathi2002@gmail.com
N. Varadharajan
Department of Psychiatry, JIPMER, Puducherry, India
e-mail: natarajanv1158@gmail.com
V. Menon
Department of Psychiatry, Jawaharlal Institute of Post
Graduate Medical Education and Research (JIPMER),
Puducherry, India
e-mail: drvmenon@gmail.com
study. The WHO Quality of Life BREF Scale was used
to assess quality of life and the Multidimensional
Scale of Perceived Social Support was used to assess
social support. The mean age of Schizophrenia and the
BD group was 35.86 years (± 11.40) and 38.34 years
(± 11.10). In the quality of life domain, patients with
schizophrenia had significantly high environmental
health as compared to the bipolar group. More than
one-half of patients with Schizophrenia and three-fifth
of patients with BD perceived high support. The
perceived support was found to be more from the
family followed by friends and significant others.
There was a significant positive correlation between
social support and quality of life in patients with
Schizophrenia only. Hence, psychosocial interven-
tions aimed at improving social support needs to
promoted in routine patient care
Keywords Quality of life (QoL)
Social support

WHO quality of life BREF scale
Introduction
Individuals suffering from severe mental illness (SMI)
like bipolar disorder (BD), Schizophrenia despite
having attained clinical remission often tend to have
a poor quality of life (QoL) due to various factors like
residual symptoms, side effects of medication, and
social support [6, 7, 11, 14, 19, 20]. Social support is

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an important psychosocial factor and has a bidirec-
tional relationship in both BD and schizophrenia. It
has been conceptualized in two ways- the qualitative
or structural aspect (which deals with social network
size and frequency of social interactions) and quali-
tative or functional (which deals with the quality of
social relationships like perceived emotional or instru-
mental support), both of them influence QoL [38]. It
acts as a buffer/ protective agent by mitigating the
adverse consequences by enhancing the individuals
coping against acute or chronic stressors as well
promoting well-being, self-esteem and boosts morale,
[9] thereby preventing relapse due to enhanced
treatment adherence and functionality due to better
assistance from family and friends [24, 38, 41]. Both
these groups of patients with schizophrenia and BD
have been found to have poor social support when
compared to the general population [5, 12, 13, 29].
Among patients with schizophrenia, social support
is one of the factors that determine symptom severity
[27], recovery and health outcomes [10], and medica-
tion adherence in patients with schizophrenia [33].
They suffer from social network contraction [12, 28]
owing to the deficit in their social cognition [31] and
persistent residual symptoms which can lead to stress
in the family due to lack of social support [36].
Similarly, in patients with BD, poor social support
predicts poorer treatment outcomes [8], more depres-
sive relapses [8, 22, 38, 42], poor response to lithium,
[25] and disruption of the biological rhythms [2, 15]
leading to a vicious cycle of relapse and hampering
their social relationship even further ultimately QoL
[16]. One study, where patients suffering from severe
mental illness (Schizophrenia and affective disorders)
where assessed for the association between occupa-
tional status and QoL, which revealed that social
support mediated the relationship between them [35].
Research suggests that despite having a good social
circle (structural aspect) patients’ subjective percep-
tion of social support is considered more important
[4, 23, 39, 40]. Although various studies have assessed
social support in these groups of patients, the majority
of them had a small sample size and evaluated them in
acute phases/ symptomatic patients of BD and
Schizophrenia. There is a paucity of studies from the
Indian subcontinent exploring such a relationship
especially in remitted patients of BD and schizophre-
nia, as symptomatic patients would perceive lower
social support and bias the results. Also, findings from
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J. Psychosoc. Rehabil. Ment. Health
the West do not apply to our country entirely due to
cultural differences. Hence, we attempted to explore
the relationship between QoL and perceived social
support among remitted patients with schizophrenia
and BD and to determine which component of
perceived support was associated with QoL.
Methodology
Study setting and design
It was a cross-sectional study conducted in the
psychiatry outpatient department (OPD) of a tertiary
care multi-specialty hospital in South India after
approval from the Institutional Ethics Committee.
Study Sample
Study participants were selected by purposive sam-
pling. Those patients diagnosed with Bipolar disorder
(BD) and Schizophrenia as per international classifi-
cation disorders-10 (ICD-10) diagnostic criteria were
included for study. Additionally, patients of either sex,
aged between 18–65, and those who attained remis-
sion i.e., as confirmed by the scores indicated by the
Positive and Negative Symptom Scale (mild on all
symptoms), Hamilton Depression Rating Scale/
Young Mania Rating Scale (B 7) were recruited
[18, 45]. Those patients who are in the acute phase
of illness or with acute medical conditions and those
who cannot read Tamil or English were excluded.
Estimation of sample size was done using Open Epi
software version 3.01. With an expected proportion of
80% of patients have impaired quality of life from a
population size of 313 with 5% precision and a design
effect of 1.0; the required sample size was 138 [1]. A
total of 140 patients were recruited, n = 72 with
schizophrenia and n = 68 with BD after they gave
their informed consent. The data collection period was
6 weeks from September 1st, 2017 to October 5th,
2017.
Instruments
The consented subjects were assessed with semi-
structured socio-demographic proforma, WHO quality
of life BREF (WHO-QOL) [37] Scale for subjective
quality of life, Multidimensional Scale of Perceived
J. Psychosoc. Rehabil. Ment. Health

Table 1 Socio-demographic profile of patients with Bipolar disorder and Schizophrenia

Socio demographic details Bipolar disorder (n = 68) Schizophrenia (n = 72)
Frequency (%) Frequency (%)
Mean (SD)[range] Mean (SD) [range]

Age 35.87 (11.41) [16–61] 38.35 (11.10) [18–60]

Sex
Male 37 (55.4) 46 (63.9)
Female 31 (45.6) 26 (36.1)
Religion
Hindu 65 (95.6) 65 (90.3)
Others 3 (4.4) 7 (9.7)
Educational status
Above matric 8 (11.8) 10 (13.9)
Below matric 60 (88.2) 62 (86.1)
Locality
Urban 21 (30.9) 20 (27.8)
Rural 47 (69.1) 52 (72.2)
Socioeconomic status
Lower 14 (20.6) 25 (34.7)
Middle 47 (69.1) 45 (62.5)
Upper 7 (10.3) 2 (2.8)
Per capita income# 6114.71 (15,336.62) [100–120000] 2737.50 (3016.88) [200–15000]
Occupation
Unemployed 32 (47) 43 (59.7)
Employed 36 (53) 29 (40.3)
Family type
Nuclear 57 (83.8) 61 (84.7)
Joint/Extended 11 (16.2) 11 (15.3)
Marital status
Currently single 27 (39.7) 35 (48.6)
Currently married 41 (60.3) 37 (51.4)
#
Duration of marital life (in years) 11.29 (12.61) [0–45] 10.67 (12.59) [0–45]
#
Mann Whitney test

Social Support (MSPSS) for perceived social support,
and Global Assessment of Functioning for the level of
functioning of the individual [46], APA [3]. The
MSPSS tool was translated into the Tamil version by
following the standard process recommended for
translation and validation of a scale. [43] World
Health Organization Quality of Life-Bref Version
(WHO-QOL Bref) is the most commonly used instru-
ment for assessing QoL. It contains 26 questions by
which the following domains of health namely phys-
ical, environment, psychological and social health is
measured. The GAF scale is a clinician-administered
scale to rate an individual’s overall level of
functioning on a scale ranging from 0 (inadequate
information) to 100 (superior functioning). The period
of assessment is usually the past month but can be
extended to the past year.
The MSPSS is the most extensively used scale to
assess perceived social support and it has 12 items.
Response items are rated on a Likert scale ranging
from very strongly disagree (= 1) to very strongly
agree (= 7). It measures social support perceived by an
individual from friends, family, and significant other.
Total scores range from 12 to 84. The total score is
divided by 12 and categorized as low (1–2.9), medium
(3–5), or high social support (5.1–7). All scales have

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demonstrated to have adequate validity and inter-rater
reliability.
Data analysis
Statistical analysis was carried out by using statistical
package for social science (SPSS) version 18. The
nominal and ordinal variables were expressed as
frequency and percentage. The continuous variables
were expressed as mean and standard deviation. t-test
and Chi-square test were used for comparing normally
distributed data. Mann–Whitney test was used for data
with non-normal distributions. Correlations were
studied by using Pearson’s or Spearman’s correlation
coefficient. Multiple regression analysis was carried
out by using QoL domain scores as the dependent
variable and different perceived scores as the inde-
pendent variable.
Results
Both groups did not differ significantly in their socio-
demographic profile. The mean age of Schizophrenia
and the BD group was 35.87 years (SD ± 11.41) and
38.38 years (SD ± 11.10). More than one-half of
patients in both the groups were males. (n = 37, 55%;
n = 46, 64%) The majority of the patients in both
groups belonged to the Hindu religion and had
educational status below matriculation. More than
two-third of the patients were from rural backgrounds
belonging to middle socioeconomic status. Nearly half
and three- fifth of patients in the Schizophrenia and
BD group were unemployed. The majority (about
84%) of them belonged to a nuclear family type.
(Table 1).
In QoL domains, patients with schizophrenia had
significantly better environmental health as compared
to the bipolar group (t = 2.10, p = 0.04). More than
one-half of patients with Schizophrenia and three-fifth
of patients with BD perceived high support. The
perceived support was found to be more from the
family (t = 2.02, p = 0.04) followed by friends
(t = 2.49, p = 0.01) and significant others
(t = 1.08, p = 0.28). Overall, patients suffering from
Schizophrenia had significantly better total support
when compared to BD patients, especially from family
and friends (t = 2.16, p = 0.03). (Table 2).
As shown in Tables 3 and 4, there was no significant
association between age and income with social

Table 2 Comparison of Quality of life, functioning and social support of patients with bipolar disorder and schizophrenia (n = 140)
Functioning and social support Bipolar disorder (n = 68) Schizophrenia(n = 72) t-test/chi-square
Frequency (%) Frequency (%)
Mean (SD) [range] Mean (SD) [range]

Functioning
WHO-QOL BREF
Physical health 57.90 (15.37) [13–100] 55.74 (18.11) [0–100] 0.76 (0.45)
Psychological health 53.35 (17.09) [6–94] 55.88 (18.49) [0–94] 0.84 (0.40)
Environmental health 53.62 (22.98) [0–100] 45.24 (24.16) [0–100] 2.10 (0.04)*
Social health 58.3 5(19.58) [13–88] 59.00 (19.24) [0–100] 0.20 (0.84)
GAF 69.26 (10.21) [51–95] 68.89 (8.95) [50–95] 0.23 (0.82)
MSPSS
Family subscale 5.49 (1.15) [2.25–7] 5.04 (1.47) [1–7] 2.02 (0.04)*
Friends subscale 5.15 (1.34) [1.50–7] 4.52 (1.65) [1–7] 2.49 (0.01)*
Significant others subscale 5.21(1.31) [1–7] 4.97 (1.36) [1–7] 1.08 (0.28)
Total score 63.68 (13.24) [24–84] 58.40 (15.48) [17–84] 2.16 (0.03)*
Categories
Low support 4(5.6) 2(2.9) 0.90(0.64)
Medium support 29(40.3) 25(36.7)
High support 39(54.1) 41(60.4)
*p value \ 0.05

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J. Psychosoc. Rehabil. Ment. Health

Table 3 Association of sociodemographic variables and quality of life in patients with perceived social support among patients with
Schizophrenia (N = 72)
Variables Significant other subscale Family subscale Friends subscale Total score

Age - 0.011 (0.925) 0.079 (0.510) 0.224 (0.058) 0.124 (0.299)

#
Income 0.116 (0.332) - 0.021 (0.861) - 0.117 (0.328) - 0.030 (0.804)
Duration of marital life - 0.093 (0.437) - 0.085 (0.476) 0.014 (0.906) - 0.047 (0.698)
Physical health 0.433** (\ 0.001) 0.384** (0.001) 0.247* (0.036) 0.408** (\ 0.001)
Psychological health 0.360** (0.002) 0.376** (0.001) 0.260* (0.027) 0.389** (0.001)
Environmental health 0.465** (\ 0.001) 0.291* (0.013) 0.320* (0.006) 0.422** (\ 0.001)
Social health 0.539** (\ 0.001) 0.576* (0.006) 0.353** (0.002) 0.567** (\ 0.001)
*p value \ 0.05; **p value \ 0.005
#
Spearman’s Rho

Table 4 Association of sociodemographic variables and quality of life in patients with Bipolar disorder (N = 68)
Variables Significant other subscale Family subscale Friends subscale Total score

Age - 0.006 (0.961) - 0.040 (0.744) - 0.009 (0.940) - 0.031 (0.803)

Income# 0.017 (0.889) - 0.156 (0.204) - 0.218 (0.074) - 0.110 (0.372)
Duration of marital life - 0.137 (0.264) - 0.024 (0.847) - 0.026 (0.831) - 0.091 (0.459)
Physical health 0.239 (0.050) 0.124 (0.315) 0.061 (0.621) 0.175 (0.153)
Psychological health 0.067 (0.588) 0.017 (0.891) 0.051 (0.681) 0.042 (0.734)
Environmental health 0.168 (0.171) 0.209 (0.087) 0.247* (0.043) 0.213 (0.080)
Social health 0.196 (0.110) 0.185 (0.132) 0.076 (0.539) 0.179 (0.145)
*p value \ 0.05
#
Spearman’s rho

support (Pearson’s correlation coefficient = -0.01 to
0.22, p[ 0.05,Spearman’s rho = --0.12 to 0.12,
p [ 0.05). However, social support was positively
associated with QoL in patients with Schizophrenia
(Pearson’s correlation coefficient = 0.25 to 0.57,
p \ 0.05). Higher social support levels in all 3
subscale scores of the MSPSS scale were associated
with a higher score in all four domains of QoL.
However, there was no similar significant association
observed in the bipolar patient group except that a
higher score of friends subscale was associated with
higher scores on environmental health (Pearson’s
correlation coefficient = 0.25, p = 0.04).
In the schizophrenia group, by univariate analyses,
the perceived support from family, friends, and
significant others were found to have significant
associations with various domain scores of QoL. To
ascertain the relative contribution of these variables to
QoL scores, multiple regression analyses were done
with the individual QoL domain scores (namely the
Physical, environmental, psychological, and social
health scores) as the dependent variable and perceived
support scores as the independent variables (Enter
method).
Perceived social support from family members,
friends, and significant others together explained 36%
of the variance in the social health domain of QoL
(adjusted R2 = 0.333, F (3.68) = 2.794, p \ 0.001),
25% of environmental health (adjusted R2 = 0.215, F
(3.68) = 7.471, p \ 0.001), 20% of physical health
(adjusted R2 = 0.162, F (3.68) = 5.562 p = 0.002) and
16% of psychological health (adjusted R2 = 0.121, F
(3,68) = 4.268, p = 0.008). Social health was signif-
icantly predicted by family support. Support from
significant others significantly predicted physical and
environmental health (b = 4.35, p = 0.04; b = 9.41,
p \ 0.01). (Tables 5 and 6).

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Table 5 Predictors of QoL after multiple regression analysis among perceived support
MSPSS Physical health Psychological health Environmental health Social health
B (p value) 95% CI B 95% CI B (p value) 95% CI B (p value) 95% CI
(p value)

Family support 1.66(0.45) - 2.79, 2.71(0.24) - 1.82, - 3.59 - 9.18, 5.08(0.02)* 0.97, 9.18
3.12 7.24 (0.21) 2.00
Friends support 0.17(0.91) - 2.67, 0.55(0.72) - 2.54, 2.96 (0.13) - 0.86, 0.08(0.05) - 2.72,
5.99 3.64 6.77 2.88
Significant others 4.35(0.04)* 0.10, 8.60 2.44(0.28) - 2.01, 9.41 3.92, 14.90 3.55(0.08) - 0.48,
support 6.88 (\ 0.01)* 7.58
B, Beta Coefficeient
*p value \ 0.05

Table 6 Contribution of variable independent variables to different domains of QoL

Variables entered Family, friends and significant others R R2 Adjusted R2 F change p value

Physical health 0.444 0.197 0.162 5.562 0.002

Psychological health 0.398 0.158 0.121 4.268 0.008
Environmental health 0.498 0.248 0.215 7.471 \ 0.001
Social health 0.601 0.361 0.333 12.794 \ 0.001

Discussion social support from family followed by others. Our

The main finding of the study is that high social
support was observed in both patient groups suffering
from schizophrenia and BD who were in remission.
Also, QoL in patients suffering from schizophrenia
was highly significant, when they had good social
support when compared to BD patients.
Our findings are congruent to a cross-sectional
study done in patients with schizophrenia receiving
community psychiatric service (n = 160), which
found that all 4 domains of QoL correlated signif-
icantly with social support in terms of total scores,
support from friends followed by family and not from
significant others, which correlated only with the QoL
on social health [32]. Another study, a similar
correlation with all domains of social support and
QoL was observed [17]. Maximum social support was
perceived from family followed by significant others
or friends in both schizophrenia and BD patients and
our study revealed similar results [17, 32]. One study
attempted to study the association between suicidal
behavior and social support in patients with remitted
BD where one group with a history of suicidal attempt
and another without, both these groups had more
results in line with this study [23]. Only one study
reported perceived support to be more from friends
followed by family, significant others, however, it was
undertaken in unremitting patients and hence, there
would be high expressed emotions due to active
symptoms among patients [36]. Also, the overall
social support among previous studies was mostly
poor (21–72%) which is much contrast to our findings
were less than 5% had poor social support [30, 32, 34].
This might be due to a variety of reasons- Firstly, our
study was done in patients who were in remission
compared to other studies which were done in
symptomatic patients. Secondly, almost three-fourth
of the patients in other studies were unemployed and
single when compared to our study where only half of
our sample were unemployed. And lastly, developing
countries like India have good family support which
leads to improved outcomes in schizophrenia as its
well documented by earlier studies like the Interna-
tional Pilot Study on Schizophrenia (IPSS), the
Determinants of Outcome of Severe Mental Disorders
(DOSMeD), and the International Study of
Schizophrenia (ISoS) [25]. Few studies from the West
found social support to be poor in patients with

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J. Psychosoc. Rehabil. Ment. Health
remitted BD than healthy controls, which contrasts
with our results where only 2% were categorized as
having lower social support. It was not significant
when compared to patients with schizophrenia. How-
ever, our study agrees concerning Indian data where
patients BD had high social support [7]. This again
might be due to the fact only clinically stable remitted
patients ([ 3 months) were included in the study from
a tertiary care hospital which might be over
representative.
The same study also found that family and friends
support was a significant predictor of better QOL
across all domains, with family support being a
stronger predictor in Physical, Psychological, and
Environmental domains while friends support with
better in the social health domain of QOL [32]. The
other study found support from friends and significant
others predicted overall QoL and psychological,
social, and environmental and the physical domain
of QoL was predicted by family [17]. In our study,
among schizophrenia patients, only family support
predicted social health and support from significant
others predicted physical and environmental health.
Support from family, friends, and significant others
explained 36% of the variance in the social health
domain of QoL. An earlier Indian study found that
patient’s age was positively correlated with social
support but we did not find such an association [34].
Our present study has certain limitations. Being a
cross-sectional study, a causal relationship could not
be ascertained. Second, we did not include healthy
control for comparison. Third, the details regarding
residual symptoms, medications were not collected
and it is well known that they do impair the quality of
life of schizophrenic and BD patients could have
confounded the results [44]. Lastly, this was an
exploratory study and hence no correction was done
for multiple comparisons. Future studies must recruit
sample through random sampling technique and
employ longitudinal follow up study designs to
capture the interaction between social support and
QoL in a better light.
Conclusion
This study reveals statistically significant social sup-
port among remitted patients with schizophrenia and
BD in the Indian context. Social support in patients
with schizophrenia is positively associated with QoL.
Especially perceived support from family was associ-
ated with social health and support from significant
others with physical and environmental health hence,
it emphasizes a need to promote psychosocial inter-
ventions involving social support especially tailored
for the patients in Indian settings to enhance their QoL
further.
Authors Contribution SP: concepts, design, definition of
intellectual content, literature search, clinical studies, data
acquisition, data analysis, statistical analysis, manuscript
preparation, manuscript editing, manuscript review; PD:
concepts, design, definition of intellectual content, literature
search, clinical studies, data acquisition, data analysis, statistical
analysis, manuscript preparation, manuscript editing,
manuscript review, guarantor; NV: concepts, design, definition
of intellectual content, literature search, data analysis, statistical
analysis, manuscript preparation, manuscript editing,
manuscript review; VM: concepts, design, definition of
intellectual content, literature search, data analysis, statistical
analysis, manuscript preparation, manuscript editing,
manuscript review.
Funding Funding was not received from any source for
conducting this study.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no
conflict of interest.
Data Availability and Material (Data Transparency) Dei-
dentified individual participant data will not be made available.
Ethical Approval Obtained from Institute Ethics Committee,
JIPMER vide JIP/IEC/2017/0025.
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