Published on in Vol 21, No 6 (2019): June

Preprints (earlier versions) of this paper are available at, first published .
Social Media and Social Functioning in Psychosis: A Systematic Review

Social Media and Social Functioning in Psychosis: A Systematic Review

Social Media and Social Functioning in Psychosis: A Systematic Review


1Department of Social Studies, Faculty of Social Sciences, University of Stavanger, Stavanger, Norway

2Network for Clinical Research in Psychosis, Stavanger University Hospital, Stavanger, Norway

3Norsk Lærer Akademi, University College, Bergen, Norway

4School of Medicine, Yale University, New Haven, CT, United States

5Institution for Social and Policy Studies, Yale University, New Haven, CT, United States

6Network for Medical Sciences, Faculty of Health, University of Stavanger, Stavanger, Norway

7Norwegian Centre for Mental Disorders Research, Faculty of Medicine, University of Oslo, Oslo, Norway

8School of Social and Health Sciences, Leeds Trinity University, Leeds, United Kingdom

9Department of Psychosocial Science, University of Bergen, Bergen, Norway

Corresponding Author:

Jone Bjornestad, MSc, PhD

Department of Social Studies

Faculty of Social Sciences

University of Stavanger

PO Box 8600 Forus

Stavanger, 4036


Phone: 47 97141599


Background: Individuals with psychosis are heavy consumers of social media. It is unknown to what degree measures of social functioning include measures of online social activity.

Objective: To examine the inclusion of social media activity in measures of social functioning in psychosis and ultrahigh risk (UHR) for psychosis.

Methods: Two independent authors conducted a search using the following electronic databases: Epistemonikos, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE, Embase, and PsycINFO. The included articles were required to meet all of the following criteria: (1) an empirical study published in the English language in a peer-reviewed journal; (2) the study included a measure of objective or subjective offline (ie, non-Web-mediated contact) and/or online social functioning (ie, Web-mediated contact); (3) the social functioning measure had to be used in samples meeting criteria (ie, Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases) for a psychotic disorder or UHR for psychosis; and (4) the study was published between January 2004 and February 2019. Facebook was launched as the first large-scale social media platform in 2004 and, therefore, it is highly improbable that studies conducted prior to 2004 would have included measures of social media activity.

Results: The electronic search resulted in 11,844 distinct articles. Full-text evaluation was conducted on 719 articles, of which 597 articles met inclusion criteria. A total of 58 social functioning measures were identified. With some exceptions, reports on reliability and validity were scarce, and only one measure integrated social media social activity.

Conclusions: The ecological validity of social functioning measures is challenged by the lack of assessment of social media activity, as it fails to reflect an important aspect of the current social reality of persons with psychosis. Measures should be revised to include social media activity and thus avoid the clinical consequences of inadequate assessment of social functioning.

Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42017058514;

J Med Internet Res 2019;21(6):e13957



Social functioning impairment is a core dimension of psychotic disorders [1]. Thus, measures of social functioning are crucial for clinical assessment, prognosis, and outcome. Research indicates high engagement with social media platforms and associated social interaction in subjects with psychosis and those at ultrahigh risk (UHR) for psychosis states, including friendship formation and overcoming barriers associated with having severe psychiatric symptoms [2-5]. Social media activity should therefore be included as part of social functioning measures.

In an Australian national survey, more than one-third of adults with psychosis rated social functioning issues as their greatest challenge for the future [6]. Long-term deficits in social functioning have been linked to negative symptoms, such as social withdrawal, apathy, and avolition [7,8], as well as impaired social cognitive capacities, including capacity for mentalization and theory of mind [5,9]. Similar findings have been found for UHR populations; when compared to healthy controls, they show both higher levels of baseline social decline and lower levels of quality of life [10-14]. Conversely, good social functioning has been identified as a robust predictor of recovery [15-18].

Empirical research on social functioning largely originates from standardized questionnaires based on two dimensions [19]. The objective dimension encompasses the ability to meet social roles, such as employability and being a spouse, a family member, or a friend, combined with socioeconomic measures, such as finances and housing [20]. These measures are easily quantifiable and can thus be replicated [20]. The subjective dimension comprises self-reported measures of social roles and measures of satisfaction with family life, recreational activities, and life as a whole [20]. Ratings on both objective and subjective measures are found to correlate with prognosis, course development, and outcome [21].

Since the advent of Facebook in 2004, social media is exponentially more often involved in establishing and maintaining social networks [22-24]. Globally, there are approximately 2.6 billion registered social media profiles and the number is expected to grow by an additional 400 million over the next three years [25]. In 2015, in the United States, more than 75% of people used social media compared to 7% a decade ago, and 92% of adolescents went online daily [26]. Nonetheless, the conceptualization of social media participation as a dimension of social functioning is underdeveloped. At face value, when compared with offline contact, social media platforms represent radically evolving platform structures and a more asynchronistic kind of communication. These are technology-mediated tools that enable individuals to share, exchange, and create ideas, images, and information through online communities and networks [27-29].

Despite having fewer or less-frequent social contacts outside social media, individuals with psychosis or those at UHR for psychosis are heavy consumers of social media when compared to peers of the same age [30-34]. The Internet has become an influential source of mental health information for people with psychosis [28] and, thus, social media and digital devices have been utilized to support mental health care [32-35] and destigmatization campaigns [36]. Particularly for the youngest age group with psychosis and those at UHR for psychosis, there has already been social media-based interventions developed that are targeted on psychological, functional, and social recovery [37,38].

Science and technology studies aim at offering a comprehensive understanding of the interaction between science, technology, and society [39]. According to this framework, technologies may fundamentally alter societal dynamics, influencing communication. Moreover, post-normal science (PNS) is a perspective emphasizing the value of direct stakeholder involvement in practices where facts are uncertain and stakes are high [40], as they arguably are in psychosis. If measures of social functioning in psychosis do not embody the fundamental changes caused by technological innovations and do not consult target groups directly, they run the risk of low ecological validity.

The main objective of this study was to examine whether measures of social functioning in psychosis and UHR for psychosis include the assessment of social behavior on social media. It also compared the validity and reliability of reported measures of social functioning.

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [41] to ensure comprehensive and transparent reporting of methods and results. The protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) in March 2017 (registration number: CRD42017058514).

Search Strategy

Two independent authors (JB and WTVH) conducted a search using the following electronic databases: Epistemonikos, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, and PsycINFO. The search terms used were as follows: (“psychosis” or “psychoses” or “psychotic*” or “schizo*”) AND (“social*” or “psychosocial*” or “communit*” or “peer*” or “famil*” or “friend*”). Specific search terms were added to capture social media activity (eg, the Medical Subject Headings [MeSH] term “social media”; see Multimedia Appendix 1 for model search). The search queries were reviewed by an information scientist and were limited to title, abstract, keywords, and subject headings. In addition, a manual literature search was performed using reference lists of reviews and meta-analyses. In cases of doubt, the full-text paper was read to determine eligibility. Papers published between January 2004 and February 2019 were included. The last search was conducted on February 15, 2019.

Eligibility Criteria

The included articles were required to meet all of the following criteria:

  1. Empirical study published in the English language in a peer-reviewed journal.
  2. The study included a measure of objective or subjective offline (ie, non-Web-mediated contact) and/or online social functioning (ie, Web-mediated contact).
  3. The social functioning measure had to be used in samples meeting criteria (ie, Diagnostic and Statistical Manual of Mental Disorders [DSM] or International Classification of Diseases [ICD]) for a psychotic disorder or UHR for psychosis.
  4. The study was published between January 2004 and February 2019. Facebook was launched as the first large-scale social media platform in 2004 and, therefore, it is highly improbable that studies conducted prior to 2004 would have included measures of social media activity.

Exclusion Criteria

Articles were excluded if the only functioning assessed by the measure was one of the following:

  1. Premorbid functioning measures.
  2. Global functioning measure.
  3. Performance-based skills assessment.
  4. Studies exclusively dealing with social relationships, including social functioning, between study participants and professionals.

Data Collection

All potential studies were exported into a reference citation manager, EndNote (Clarivate Analytics), before removing duplicates. Two independent reviewers (JB and WTVH) separately performed the screening of titles and abstracts, full-text analysis, and selection of social functioning measures. Disagreements were resolved through discussion until consensus was reached. A third reviewer (SP) was available to resolve disagreements. Finally, the list of included and excluded measures was sent to an independent auditor (HJS) for critical evaluation. The kappa coefficient was used to assess the level of agreement of the two independent reviewers for the selection of included and excluded measures.

Analytic Methods and Data Extraction Procedure

A narrative descriptive synthesis was performed for the included articles. The data extraction procedure was performed in two steps. First, subjective and objective measures of social functioning across different social domains (ie, work, community functioning, socioeconomic status, etc) for both offline and online engagements were identified. Second, the content, quality, and psychometric properties, with a particular focus on whether measures assessed social media activities and interactions, were examined and assessed, including validity and reliability statistics of the measures. Since the selection of screened and included articles was extensive, validation literature was sourced directly from the reviewed articles. In addition, a manual search was performed for each individual measure to identify further validation literature.

Search Results

The electronic search returned 12,437 articles. After duplicates were removed, there were 11,844 articles, of which 671 were reviews or meta-analyses: 178 articles from the Cochrane Database of Systematic Reviews and 493 from Epistemonikos. A hand search of reference lists of reviews and meta-analyses returned a further 82 articles. Full-text evaluation was conducted for 719 articles, of which 597 met the inclusion criteria and were included for the final synthesis. From the 597 articles, 58 measures were identified: 41 (71%) social functioning and 17 (29%) quality-of-life measures that included assessment of social functioning. Interrater reliability (ie, agreement between independent reviewers) for inclusion of measures was high (k=.83). Details of the search results are summarized in Figure 1.

Figure 1. Flow diagram of the reviewing process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
View this figure

Frequently Used Social Functioning Measures

Details of the included 58 measures of social functioning are summarized in Tables 1 and 2. The three most frequently used measures were the Social Functioning Scale (78 references), the Quality-of-Life Scale (67 references), and the World Health Organization Quality of Life Brief Version (WHOQOL-BREF) (57 references). Several measures (eg, the Social Adjustment Scale II and the Global Functioning-Social Scale) had been used to address social functioning in UHR populations. Although developed for young people, none of these measures were exclusively used in UHR populations.

Table 1. Included social functioning measures (N=41).
MeasureAuthor, year, number of scale citationsaDescriptionValidation samplesValidityReliabilitybSocial media (Yes or No)
Assessment of Communication and Interaction SkillsForsyth et al, 1999, 1Observer-rated
20 items, 4-point Likert response format
Three domains: physicality, information exchange, and relations
Gathers data on skill as it is exhibited during performance in an occupational form and/or within a social group context
Psychosis and general psychiatryGood internal and construct validity [43,44]
Good discriminant validity [43,44]
Good interrater reliability [43,44]No
Behavior and Symptom Identification ScaleEisen et al, 1999, 1Self-report
32 items, 4-point Likert response format
Five domains: relationship (self and others), daily living and role performance, depression and anxiety, impulsive and addictive behavior, and psychosis
Psychosis, inpatients and outpatientsQuestionable internal and construct validity; poor for psychosis [45]
Good discriminant validity; unacceptable for psychosis [45]
Good sensitivity to change [45]
Good interrater reliability [45]No
Client’s Assessment of Strengths, Interests and GoalsWallace et al, 2001, 2Self-report and informant-report
102 items, 5-point Likert response format
Six domains: current social and independent living skills, medication compliance and side effects, quality of life, quality of treatment, symptoms, and performance of unacceptable community behaviors
Psychosis and general psychiatryQuestionable concurrent validity
Good discriminant validity [46]
Good test-retest reliability
Questionable interrater reliability
Good internal consistency [46]
Community Adjustment FormStein & Test, 1980, 7Observer-rated semistructured interview
140 items, 10-item scale
17 domains (eg, living situation, work and social functioning, family involvement, and medication use)
Also includes an observer-rated, 10-item scale of prosocial behaviors
PsychosisNo data availableExcellent interrater reliability [47]No
Disability Assessment Schedule—IIWHOc, 2010, 31Observer-rated
12, 36, or 97 items; scoring based on all available information (eg, patient´s written records or data from informants)
Six domains: understanding and communicating, getting around, self-care, getting along with others, household and work activities, and participation in society
Several versions: DASd, DAS-II-sve, SDSSf, and WHO-DASg
General psychiatryModerate concurrent validity [48]Good internal consistency [48]
Excellent test-retest reliability [48]
First Episode Social Functioning ScaleLecomte et al, 2014, 5Self-report
34 items, 4-point Likert response format
Eight domains: independent living skills, interacting with people in different contexts, social activities, intimacy, friendships, family relations, work, and school
Perceived ability and actual behavior rated for each item
PsychosisGood convergent validity [42]
Good discriminant validity [42]
Good sensitivity to change [42]Yes
Functional Assessment Short TestRosa et al, 2007, 1Self-report
24 items, 4-point Likert response format
Six domains: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time
Bipolar disorderGood concurrent validity
Questionable discriminant validity [49]
Good test-retest reliability [49]
High internal consistency [49]
Functional Remission of General SchizophreniaLlorca et al, 2009, 5Observer-rated
19 items, 5-point Likert response format
Six domains: daily life, activities, relationships, quality of adaptation, health, and treatment
SchizophreniaGood concurrent validity [50]Good internal consistency [50]No
Global Assessment of Relational FunctioningDausch BM et al, 1996, 1Observer-rated
20 domains of relationship functioning, 100-point scale (81-100 indicates satisfying functioning)
Bipolar disorderGood concurrent validity
Good discriminant validity [51]
Good-to-high interrater reliability [51]
Good internal consistency [51]
Global Functioning—SocialCornblatt B et al, 2007, 22 (5 UHRh)Observer-rated
Seven probe questions, 10-point Likert response format
Assesses levels of social contact and friendships outside of the family
PsychosisGood construct validity [52]Good interrater reliability [52]No
Groningen Social Disability ScheduleWiersma, 1988, 8Observer-rated semistructured interview
5-point Likert response format
Eight domains: self-care, relationship with the family, relationship with a partner, friendship, parental role, citizenship, leisure activities, and work and occupation
General psychiatryPoor-to-excellent sensitivity to change [53]
Good discriminant validity [54]
Good interrater reliability
Questionable test-retest reliability [53]
Health of the Nation Outcome ScaleWing et al, 1998, 8Observer-rated
12 items, 4-point Likert response format
Aggression, self-harm, drug and alcohol use, cognitive problems, physical illness and disability, hallucinations and delusions, depression, other symptoms, social relationships, activities of daily living, residential environment, and day-time activity
General psychiatryGood concurrent validity [55]
Good discriminant validity [55]
Poor-to-good interrater reliability [55]
Poor-to-acceptable test-retest reliability [55]
Index of Social CompetenceMcConkey R & Walsh J, 1982, 1Observer-rated
15 items of ability
Six domains: community skills, self-care skills, communication skills, time, money, and additional handicaps
General psychiatryNo data availableGood interrater reliability [56]No
Inventory of Interpersonal ProblemsHorowitz et al, 1988, 1Self-report
32 items, 4-point Likert response format
Nine domains: domineering or controlling, vindictive or self-centered, sociable, intimate, submissive, responsible, nonassertive, self-sacrificing, and intrusive
Community: nonclinicalNo data availableAcceptable-to-good test-retest reliability [57]
Good internal consistency [57]
Interview Schedule for Social InteractionHenderson S et al, 1980, 2Observer-rated
53 items, individual summary scores for each domain
Four domains: availability of close relationships, adequacy of above, availability of friendships, and adequacy of above
General populationGood face validity [58]Acceptable test-retest reliability [58]
Acceptable internal consistency [58]
Life Skills ProfileParker et al, 1991, 14Observer-rated
39 items, 4-point Likert response format
Five domains: ability for self-care, turbulent behavior (reverse scored), sociability, communication, and responsibility
Psychosis, inpatients and outpatientsQuestionable construct validity [59]Good interrater reliability [59]
Good test-retest reliability [59]
Multnomah Community Ability ScaleBarker et al, 1994, 12Observer-rated
17 items, 5-point Likert response format
Four domains: assessment of interference with functioning, adjustment to living, social competence, and behavioral problems
General psychiatry, chronic patientsNo data availableGood interrater reliability [60]
Good test-retest reliability [60]
Personal and Social PerformanceMorosini et al, 2000, 55Observer-rated
Single-item, 100-point response format (score determined by domain score range)
Four domains (6-point response format per domain): socially useful activities, personal and social relationships, self-care, disturbing and aggressive behaviors
PsychosisGood construct validity [61]Good interrater reliability [61]
Excellent test-retest reliability [61]
Provision of Social Relations ScaleTurner et al, 1983, 2Self-report
15 items that measure social relationships with family and friends, 5-point Likert response format
Schizophrenia, bipolar disorder, and healthy controlsNo data availableGood test-retest reliability [62]No
Psychosocial Functioning ScaleValencia et al, 1989, 1Self-report
35 items, 5-point Likert response format
Five domains: occupational, social, money management, marital, and familial
General psychiatryGood construct validityGood internal consistency [63]No
Recovery Assessment ScaleCorrigan et al, 1999, 2Self-report
41 items, 5-point agreement scale
Four domains: doing things I value, looking forward, mastering my illness, and connecting and belonging
General psychiatry, chronic patientsGood concurrent validity [64]Good test-retest reliability [64]No
Rehabilitation Evaluation Hall and BakerBaker R & Hall JN, 1988, 1Observer-rated
22 items, 9-point Likert response format
Two domains: deviant behavior and general behavior
General Behavior subscale (only subscale relevant for the cited study):
15 items
Five domains: social activity, speech disturbance, speech skills, self-care skills, and community skills
General psychiatryGood criterion validity [65]
Good discriminant validity [65]
Good interrater reliability [65]No
Role Functioning ScaleGoodman et al, 1993, 7Observer-rated
Four items, 7-point Likert response format
Four domains: work, independent living and self-care, immediate social network relationships, and extended social network relationships
Psychosis and depressionGood discriminant validity [66]Poor-to-good interrater reliability [66]
Good test-retest reliability [66]
Good internal consistency [66]
Schizophrenia Social Functioning IndexPadmavathi R, 1995, 2Observer-rated
17 items, 5-point Likert response format
Four domains: self-concern, occupational role, role in family, and other social roles
Each section has several subsections covering different areas of social functioning
Schizophrenia and relativesGood concurrent validity [67]Good interrater reliability [67]
Good test-retest reliability [67]
Acceptable internal consistency [67]
Self Evaluation and Social Support—Schizophrenia versionHumphreys et al, 2001, 1Observer-rated
Five domains: social and recreational, occupational, relationships, parenting, and homemaking
Questions in these sections involve both perceived competence and commitment in each possible role, and responses are used in an overall rating; also, sections covering self-evaluation of personal attributes and self-acceptance
PsychosisNo data availableAcceptable-to-good interrater reliability [68]
Poor test-retest reliability [68]
Short Form Health Survey—36Ware & Donald, 1992, 12Observer-rated or self-report
36 items, 100-point response format
Eight domains: physical functioning, role limitations due to physical health problems, bodily pain, general health perceptions, vitality, social functioning, role limitation due to emotional problems, and general mental health
PsychosisModerate discriminant validity [69]Good test-retest reliability [69]No
Social Adaptation Self-Evaluation ScaleBosc M et al, 1997, 4Self-report
21 items, 4-point Likert response format
Four domains: social, familial, occupational, and environmental functioning
Major depressionAcceptable sensitivity to change [70]Poor test-retest reliability [70]
Good internal consistency [70,71]
Social Adaptive Functioning EvaluationHarvey et al, 1997, 1Observer-rated
17 items, 5-point Likert response format
Three domains: impulse control, instrumental and self-care, and social functions
SchizophreniaGood convergent validity [72]
Good discriminant validity [72]
Good interrater reliability [72]
Good test-retest reliability [72]
Social Adjustment Inventory for Children and AdolescentsGammon et al, 1987, 1 (UHR)Observer-rated interview
Multiple domains: functioning in school, spare time activities, and interactions with peers and family
Children and adolescents of parents with and without major depressionQuestionable-to-poor convergent validity [73]Poor interrater reliability [71,73]
Good-to-poor internal consistency [73]
Social Adjustment Scale IIPaykel et al, 1971, 27 (1 UHR)Observer-rated semistructured interview
52 items, 5-point Likert response format
Eight domains: work, domestic relationship, parental role, relationship with external family, social and leisure activities, sexual activity, romantic involvement, and personal well-being
Self-report version [74]
DepressionPoor-to-acceptable convergent validity [74]No data availableNo
Social Behaviour ScaleWykes & Sturt, 1986, 16Observer-rated
21 items, 5-point Likert response format
Six domains: occupation, behavioral problems, personal self-care, leisure activities, performance and expectations, and communication skills
General psychiatryGood discriminant validity [75]
Good concurrent validity [75]
Good interrater reliability [76]
Good interinformant reliability [76]
Good test-retest reliability [76]
Social Functioning QuestionnaireTyrer et al, 2004, 1Self-report
Eight-item assessment of perceived social functioning, score 0-24
Developed from the Social Functioning Scale
Psychiatric outpatient (nonpsychotic)No data availableGood interrater reliability [77]
Good test-retest reliability [77]
Good internal consistency [77]
Social Functioning ScaleBirchwood et al, 1990, 78Self-report or observer-report
79 items, 4-point Likert response format
Seven domains: social engagement, interpersonal behavior, prosocial activities, recreation, independence-competence, independence-performance, and employment and occupation
PsychosisGood construct validity [78]
Good discriminant validity [78]
Good convergent validity [78]
Good interrater reliability [78]No
Social Integration SurveyKawata AK & Revicki DA, 2008, 1Self-report or informant-report
62 items, 4-6-point Likert response format
Five domains: social perception, work interactions, social skills, social cognition, and daily living skills or self-care
SchizophreniaGood discriminant validity [79]Good internal consistency [79]
Poor interrater reliability [79]
Social and Occupational Functioning Assessment ScaleAmerican Psychiatric Association, 1994, 35Observer- or self-report
Single-item, 100-point response form
General psychiatryAcceptable sensitivity to change [80]No data availableNo
Social Occupational Functioning ScaleSaraswat N, 2006, 2Observer-rated
15 items, 5-point Likert response format
Three domains: adaptive living skills, social appropriateness, and interpersonal skills
SchizophreniaAcceptable concurrent validity [81]
Acceptable criterion validity (positive and negative symptom total score) [81]
Acceptable discriminant validity [81]
High internal consistency [81]
Good test-retest [81]
Social Role Functioning TestMcPheeters H, 1984, 1Observer-rated
28 items, 7-point Likert response format
Three domains: work productivity, independent living, and social network relationships (immediate and extended)
General psychiatryNo data availableGood internal consistency [82]No
Specific Levels of FunctioningSchneider & Struening, 1983, 19Observer-rated
43 items, 5-point Likert response format
Six dimensions: physical functioning, personal care skills, interpersonal relationships, social acceptability, activities, and work skills
Psychosis and general psychiatryNo data availableExcellent internal consistency [83]
Excellent interrater reliability [83]
Strauss Carpenter Level of FunctioningStrauss & Carpenter, 1977, 10Observer-rated
Four items, 5-point Likert response format
Four domains: symptomatology, work, social contacts, and function
Not statedNo data availableNo data availableNo
Strauss Carpenter Outcome ScaleStrauss & Carpenter, 1972, 7Observer-rated
Four items, 49-point Likert response format
Four domains: social activities, work, independent living, and hospitalization
SchizophreniaNo data availableNo data availableNo
Time Budget MeasureJolley et al, 2006, 1Observer-rated
Diary-based measure (28 time blocks for the week), score range 0-112
PsychosisAcceptable convergent validity [84]Good interrater reliability [85]
Good test-retest reliability [85]

aNumber of citations the scale has gotten throughout the years, which indicates the scale popularity and impact.

bReliability: 1 (perfect reliability), ≥.9 (excellent reliability), ≥.8<.9 (good reliability), ≥.7<.8 (acceptable reliability), ≥.6<.7 (questionable reliability), ≥.5<.6 (poor reliability), <.5 (unacceptable reliability), 0 (no reliability).

cWHO: World Health Organization.

dDAS: Disability Assessment Schedule.

eDAS-II-sv: Disability Assessment Schedule—II: Schizophrenia Version

fSDSS: Social Disability Screening Schedule.

gWHO-DAS: World Health Organization Disability Assessment Schedule

hUHR: ultrahigh risk.

Table 2. Included quality-of-life measures (N=17).
MeasureAuthor, year, number of scale citationsaDescriptionValidation samplesValidityReliabilitybSocial media (Yes or No)
Assessment of Quality of LifeHawthorne et al, 1999, 2Self-report
47 items, 4-point Likert response format
Five domains: illness, independent living, social relationships, physical senses, and psychological well-being
Clinical and community sampleGood discriminant validity [86]Good internal consistency [86]No
Health Related Quality of LifeNelson et al, 1987, 3Self-report
5-point Likert response format
Nine global questions, each illustrated with drawings to measure the following domains: physical fitness, pain, feelings and emotions, daily activities, social activities, change in health, overall health, social support, and overall quality of life.
Mainly chronic illnessesGood face validity [87]Good test-retest reliability [88]
Good interrater reliability [88]
Lancashire Quality of Life ProfileOliver, 1991, 3Observer-rated
100 items, 7-point Likert response format
10 domains: living situation, leisure and social participation, health, finances, family relations, safety, positive esteem, negative esteem, framework, and fulfilment
General psychiatryModerate-to-good concurrent validity [89]Moderate-to-good internal consistency [89]
Good test-retest reliability [89]
Manchester Short Assessment of Quality of LifePriebe et al, 1989, 23Observer-rated clinical interview
25 items, 7-point Likert response format
12 domains with three subscales: these include stable personal patient details, personal details that may change over time (eg, education), and questions that must be asked at each assessment, including both objective and subjective items concerning quality of life and social life
Psychosis and studentsGood concurrent validity [90]Good internal consistency [91]No
Modular System for Quality of LifePukrop R et al, 2000, 3Self-report
47 items, 7-point Likert response format
Seven domains: physical health; vitality; and psychosocial, affective, material, spare time, and general quality of life
Schizophrenia and general populationPoor discriminant validity [92]Good internal consistency [92]
Good test-retest reliability [92]
Sickness Impact ProfilePollard et al, 1976, 1Self-report
48 items (short version), individual category scores
Four domains: sleep and rest, home management, contact with family and friends, and leisure activities
Psychiatric samples and somatic samplesHigh internal consistency [93]
Good concurrent validity [94]
High test-retest reliability [93]
High interrater reliability [93]
Quality of Life Enjoyment and Satisfaction Questionnaire—Short FormEndicott et al, 1993, 8Observer-rated
59 items, 5-point Likert response format
Five domains: general activities, physical activities, emotional functioning, recreational activities, and social relationships
Psychosis and depressionPoor-to-moderate discriminant validity [95]Good internal consistency [96]
Moderate test-retest reliability [96,97]
Quality of Life IndexFerrans CE & Powers MJ, 1985, 1Self-report
32 items, 6-point Likert response format
Four domains: health and functioning, social and economic, psychological and spiritual, and family
Schizophrenia and healthy controlsGood convergent validity [98]Excellent internal consistency [98]No
Quality of Life InterviewLehman, 1983, 29Observer-rated semistructured interview
143 items (brief versions: 33 or 78 items)
Eight domains: accommodation, family, social relations, leisure, safety, finances, physical health, and mental health
Psychosis and general psychiatryGood construct validity [99]Good-to-acceptable internal consistency [99]
Poor-to-good test-retest reliability [99]
Quality of Life Inventory—74Frisch MB, 1992, 2Self-report
17 items, 4-point Likert response format
General psychiatry, undergraduates, and forensicGood convergent validity [100]
Good construct validity [100]
Good test-retest reliability [100]
Good internal consistency [100]
Quality of Life ScaleHeinrichs et al, 1984, 67Observer-rated semistructured interview
21 items, 7-point Likert response format
Four domains: intrapsychic foundations, interpersonal relations, instrumental role, and common objects and activities
Psychosis and general psychiatryPoor-to-good convergent validity [101]Excellent interrater reliability [101]No
Quality of Well-BeingKaplan et al, 1978, 2Observer-rated
Preference weight for each domain
Three domains: mobility, physical activity, and social activity
Chronic somatic illnessGood discriminant validity [102,103]
Good convergent validity [102,103]
No data availableNo
Satisfaction With Life ScaleTest et al, 2005, 6Self-report
18 items, 5-point Likert response format
Four domains: living situation, work, social relationships, and self and present life
Schizophrenia and general psychiatryGood construct validity [104]
Good concurrent validity [104]
Good internal consistency [104]No
Schizophrenia Quality of Life—18Boyer et al, 2010, 1Self-report
41 items, index scores from 0 to 100
Eight domains: psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy, and sentimental life
SchizophreniaGood-to-unacceptable concurrent validity; great scale variability [105]Good-to-acceptable internal consistency [105]
Good-to-acceptable test-retest reliability [105]
Schizophrenia Quality of Life ScaleWilkinson et al, 2000, 10Self-report
30 items, 5-point Likert response format
Three domains: psychosocial, motivation and energy, and symptoms and side effects
SchizophreniaGood construct validity [106]Good internal consistency [106]
Good test-retest [106]
Wisconsin Quality of Life IndexBecker, 1993, 4Self-report
113 items, 5-point Likert response format
Nine domains: general life satisfaction, activities and occupations, psychological well-being, physical health, social relations and support, economics, activities of daily living, symptoms, and goal attainment
Schizophrenia and general psychiatryGood convergent validity [107]Good-to-acceptable internal consistency [107]
Good test-retest reliability [107]
WHOQOL-BREFcWHO Quality of Life Group, 1998, 57Self-report
268 items, 5-point Likert response format
Four domains: physical, psychological, social, and environmental
Psychosis and general psychiatryPoor-to-moderate construct validity [108]Good internal consistency [108]No

aNumber of citations the scale has gotten throughout the years, which indicates the scale popularity and impact.

bReliability: 1 (perfect reliability), ≥.9 (excellent reliability), ≥.8<.9 (good reliability), ≥.7<.8 (acceptable reliability), ≥.6<.7 (questionable reliability), ≥.5<.6 (poor reliability), <.5 (unacceptable reliability), 0 (no reliability).

cWHOQOL-BREF: World Health Organization Quality of Life Brief Version.

Structure and Administration of Measures

A total of 35 out of 58 measures (60%) were primarily observer-rated, while 23 (40%) were primarily self-reported. The completion time ranged from 10 minutes (ie, Social Functioning Questionnaire) to 60 minutes (ie, Social Adjustment Scale). Most of the social functioning and quality-of-life measures used a Likert response format (40/58, 69%). Most measures assessed behaviors, not perceived ability, related to physical forms of social functioning, such as face-to-face or telephone contact with friends and family. There was great variability in how comprehensive measures reported on social functioning characteristics, ranging from the First Episode Social Functioning Scale (FESFS) with nine subscales to those who reported a few items (eg, part of a single subscale) of social functioning. Also, quality-of-life measures typically concentrated more on subjective evaluations of general life domains and were thus less focused on social functioning. The FESFS was the only measure to include an assessment of social activity on social medial; this is evaluated in a separate section below.

Psychometric Properties of the Measures

Out of all 58 included measures; 32 (55%) had previously been validated in patients with psychosis, 16 (28%) in a general psychiatric or clinical and community sample, 2 (3%) in a sample of patients with bipolar disorder, 2 (3%) in a sample of patients with depression, 2 (3%) in a sample of patients with somatic illness, 2 (3%) in a nonclinical sample, 1 (2%) in a sample of adolescents of parents with and without major depression, and 1 (2%) did not record any sample information. More data were available for reliability (53/58, 91%) than for validity (47/58, 81%). In general, lack of information prevented a comprehensive evaluation of the psychometric properties of most measure instruments. Theoretical foundation and construct validity was particularly poorly reported. When psychometric properties were reported, measures showed overall good validity and reliability regarding offline social functioning. The Social Functioning Scale, the Groningen Social Disability Schedule, and the Health of the Nation Outcomes Scale are examples of measure instruments with comprehensive reporting of this type of social functioning.

Measure Assessing Social Activity on Social Media

The FESFS was developed in 2014 [42] by the authors listing activities based on their experience with people with early psychosis and on reviews of existing measures of social functioning [40]. The FESFS is designed to measure social functioning in young people in the early stages of psychosis and was the only measure instrument identified in this review as addressing social activity on social media. The scale can be administered as observer-rated or self-report, with each item rating behavior—focus on frequency—and perceived individual ability. The FESFS comprises 34 items distributed on nine subscales assessing various domains of social functioning. The item language was intentionally constructed to fit the target group (eg, “hanging out with buddies” and “chatting on the net”). Two items, respectively from the items Friends and activities and Living skills, address social media activity explicitly: “I am really good in solo activities such as going to the gym, going to the movies, chatting on the net, taking lessons (music, painting, etc)” and “I am comfortable using the phone, Internet, or email to communicate.” The scale is cited five times, of which three of the cited articles include the measure developers as authors.

Scale validation was based on the self-report version. The validation sample included 203 people, with an average age of 24.5 years, diagnosed with a schizophrenia spectrum psychotic disorder, and with an average of 12.7 years of education. The nine factors showed good internal consistency, ranging from .63 to .80. Good convergent and discriminant validity, as well as good sensitivity to change, were also demonstrated. Three subscales had an inverse correlation with negative symptoms.

Measures Should Include Contemporary Social Reality

Due to technological innovation and rapid alterations in the norms of social media usage, any instrument designed to measure social functioning, including social media activity, should encapsulate contemporary trends. The main finding of this review was that current measures of social functioning almost exclusively comprise offline social activity, with the sole exception of the FESFS, as discussed in a separate section below. This limitation is likely to reflect the time of development of currently used measures, as most were developed before the launch of the Internet in 1992, and only eight measures were developed or revised after the advent of Facebook in 2006. Many of these scales have good psychometric properties, which may be a good starting point if they were revised to include measures of social media activity. It is notable that the first measures developed were based on chronic inpatients (eg, the Interview Schedule for Social Interaction). However, there is now an emphasis on early intervention to target quality of life and younger early-stage patients, as opposed to chronic inpatients [109], and current measures fail to capture an important aspect of the current social context.

It is worth discussing whether the two most widely used categories of measures—social functioning and quality of life—are expedient. For instance, a number of the measures within these categories address social participation, while others address the more narrowly defined concept of social skills. In practice, then, choosing a measure from either category for evaluative purposes could potentially influence interpretations of findings.

Further, regarding validity, while the original psychometric assessment of some measures show good reliability and validity, they may lack ecological validity. For example, leaving out assessment of social media activity may lead to low scores on social functioning among young people with psychosis and, thus, increase the likelihood of false positives. Moreover, the core negative symptom of social withdrawal [8] may manifest differently in a social media context compared to an offline context. There is also a risk of social media addiction, negative social comparison, cyberbullying, as well as it being used to exclude real-life contacts [27,110], with potential negative consequences on illness course, outcome, and quality of life. Online social functioning measures should aim to be sensitive to these types of matters. Also, they should track symptom levels [2], change in social participation, and support that unfolds online [3]. In this regard, a survey found that adults with schizophrenia were as likely as adults without mental illness to form social relationships online, despite having fewer offline relationships, lower income, and less Internet access [4]. Compensating for symptoms that people with psychosis themselves experience that interfere with socializing in face-to-face encounters [111] may be a fruitful remedy for some of the obstacles associated with the enhanced levels of toxic loneliness and stigma associated with psychosis populations [5]. This type of information would also be important for treatment timing and tailoring.

Social Media Assessment

The FESFS represents an attempt to address contemporary forms of social functioning, including online activity. Additionally, the scale assesses both behavior and ability, which make a more nuanced assessment possible. However, the scale has fundamental limitations. The validation sample has an average age of 24.5 years, which is relatively high when aiming at early psychosis and UHR of psychosis. The subscales related to work and education are not satisfactorily validated, as only a small part of the validation sample was working or studying. Test-retest reliability for the scale has not been conducted and neither factorial structure nor construct validity has been confirmed. In addition, only the self-report version has been validated. Furthermore, the scale has only been cross-validated across context to a very limited extent [112]—as opposed to, for example, the Personal and Social Performance or the Psychosocial Functioning Scale—which implies uncertainty regarding robustness and usability. Further, the authors do not articulate a theoretical foundation for the scale, and scale content is derived from the scale authors’ own listing of experience-based domains of social functioning.

Science and technology studies is a highly influential theoretical framework analyzing the entanglements of science, technology, and society [39]. A basic premise in science and technology studies is that technological innovation affects society and human behavior in fundamental ways. Specific technologies, such as social media, do not merely add to the possibilities of communication, but changes the nature of communication processes. Consequently, attempts to include technology-mediated communication processes should start from the premise that these probably do not reflect nontechnological communication. Compared with face-to-face contact, social media represents radically evolving platform structures and a more asynchronistic form of communication. However, it is unclear whether social media platforms require extra social flexibility or if they are adaptable to facilitate communication for persons who may have limitations in face-to-face social skills, such as the limitations typically found for individuals with active psychosis. It has been suggested that individuals with mental health problems may use social media to seek support. When compared to face-to-face interaction, social media allows more time for reflection before acting [113].

The FESFS “chatting on the net” item is defined as a solo activity and yet this may not reflect the experience of social media by individuals. Social media includes virtual communities allowing users to create a public profile, interact with real-life and virtual friends, and make new acquaintances. Social media engagements often seem to be a fundamental social activity [114]. Also, the FESFS defines using the Internet or email communication as a living skill. However, it is difficult to equate these technological skills as being representative of social activity or functioning. While the FESFS has been the first measure to attempt to capture social media activity, the measure requires significant further development for validity of measurement of contemporary social media engagements.

Future Research: Need for a Radical Change

The use of social media as a dimension of social functioning in psychosis is a complex issue and the knowledge base is limited. It is possible to explore social media behavior based on the most reliable and valid dimensions of currently available offline social functioning measures, such as the Social Functioning Scale. This scale provided the most comprehensive reporting of traditional psychometric properties for offline social functioning, including construct validity. With this scale, social skills or social behavior were registered as present or absent, thus removing the need for an evaluative decision. This could be a feasible starting point to track online social behavior. Some degree of social skill transfer between online and offline activities seems plausible. Additionally, it might be important to understand the relationship between more traditional measures of social skills and social media usage. In this regard, purely scientist-driven approaches have clear limitations. For example, the likely age gap between researchers and the target group of early psychosis, particularly the UHR segment, risks a lack of understanding of the social context. Therefore, a collaborative approach with the target group as codevelopers of the measure could remedy this shortcoming. The general omission of user involvement, which is highly prioritized and valued in most contemporary health care systems, is a major challenge to the validity of these measures [115]. We therefore propose a theoretical framework in which service users are involved, so as to explore social media as part of social functioning of young people with psychosis.

PNS was developed for interpreting and applying scientific results at the science-policy interface. PNS was tailored for situations where “facts [are] uncertain, values [are] in dispute, stakes [are] high, and decisions [are] urgent” [40]. The research field of social functioning in psychosis includes multiple theoretical perspectives, such as physiological, biological, evolutionary, social, and cultural perspectives. The complex nature of social functioning makes it difficult to indicate causality [1]. There are conflicts of interest causing tension between groups, such as the psychopharmaceutical industry, governments, professional associations, and user organizations [116-118]. The stakes are arguably high as social functioning impairment is regarded as a core symptom of serious mental illness, namely psychosis [119]. The PNS remedy is to communicate uncertainty, assess quality, and justify practice by including extended peer communities. In practical terms, the PNS framework ensures the inclusion of social components perceived as important by the target group. This will presumably lead to inclusion of new facets of social functioning that have been omitted by previous measures, and the risk of implementing outdated or ecologically invalid models is lowered.

Future reviews should take social media use or online activity into consideration when also evaluating social functioning measures in general patient populations. When developing and validating social functioning measures, researchers today should include social media activity: content, frequency, quality, and effects, both positive and negative.

Strengths and Limitations

The strengths of the study are evident in the study protocol being publicly available (ie, PROSPERO) before conducting the review, thus ensuring transparency, and the review was conducted according to PRISMA guidelines [41]. In addition, the inclusion of studies was determined by two independent raters and showed high interrater reliability.

The main purpose of this review was to assess to what degree social functioning measures included assessments of any online social activity. Hence, we applied broad inclusion criteria to avoid ignoring any potential measures. A side effect of this strategy was the inclusion of some measures that were not tailored to specifically target social functioning in general or psychosis specifically.

The conclusions drawn in this review may have been influenced by several of the included studies not reporting relevant psychometric properties. Although only one of the identified instruments specifically assessed social media activity, it cannot be ruled out that respondents may answer generic questions about social functioning with social media activity in mind. Another limitation is that each individual study was not assessed for key sources of biases (eg, sample characteristics). However, in line with previous research [20], it seems warranted to conclude that some studies were based on small samples and that most instruments were constructed and tested within Anglo-American cultures. Grey literature was not included. This will typically raise the risk of reporting bias, implying that the included studies represent selective research dissemination [120]. However, it should be emphasized that the aim was to identify instruments with a high level of use within the field and that the search was conducted in several literature databases. The included studies did use samples with somewhat different characteristics (eg, sex, age, and level of symptomatology), which may violate the transitivity assumption and, thus, questions direct comparisons across included studies.


A special thanks to the staff at the Medical Library of Stavanger University Hospital for assistance with the literature search.

Authors' Contributions

JB conceptualized and performed the current analyses and wrote the first draft. WTVH, HJS, SP had a special role in data collection, extraction, and analysis. SP also had a special role in ensuring that the chosen approach, PRISMA, was performed according to the guidelines. All authors were involved in study design, provided scientific oversight throughout the project, provided detailed comments about the paper across several drafts, and edited the paper.

Conflicts of Interest

None declared.

Multimedia Appendix 1

Model search for replication.

DOCX File, 15KB

  1. van Os J, Kenis G, Rutten BP. The environment and schizophrenia. Nature 2010 Nov 11;468(7321):203-212. [CrossRef] [Medline]
  2. Birnbaum M, Rizvi A, Choudhury MD, Ernala S, Cecchi G, Kane J. Identifying psychotic symptoms and predicting relapse trough social media. Schizophr Bull 2018 Apr 01;44(Suppl 1):S100. [CrossRef]
  3. Gowen K, Deschaine M, Gruttadara D, Markey D. Young adults with mental health conditions and social networking websites: Seeking tools to build community. Psychiatr Rehabil J 2012;35(3):245-250. [CrossRef] [Medline]
  4. Spinzy Y, Nitzan U, Becker G, Bloch Y, Fennig S. Does the Internet offer social opportunities for individuals with schizophrenia? A cross-sectional pilot study. Psychiatry Res 2012 Jul 30;198(2):319-320. [CrossRef] [Medline]
  5. Highton-Williamson E, Priebe S, Giacco D. Online social networking in people with psychosis: A systematic review. Int J Soc Psychiatry 2015 Feb 01;61(1):92-101. [CrossRef] [Medline]
  6. Stain H, Galletly C, Clark S, Wilson J, Killen EA, Anthes L, et al. Understanding the social costs of psychosis: The experience of adults affected by psychosis identified within the second Australian National Survey of Psychosis. Aust N Z J Psychiatry 2012 Sep;46(9):879-889. [CrossRef] [Medline]
  7. Kirkpatrick B, Fenton W, Carpenter W, Marder S. The NIMH-MATRICS consensus statement on negative symptoms. Schizophr Bull 2006 Apr;32(2):214-219 [FREE Full text] [CrossRef] [Medline]
  8. Marder S, Galderisi S. The current conceptualization of negative symptoms in schizophrenia. World Psychiatry 2017 Feb;16(1):14-24. [CrossRef]
  9. MacBeth A, Gumley A. Premorbid adjustment, symptom development and quality of life in first episode psychosis: A systematic review and critical reappraisal. Acta Psychiatr Scand 2008 Feb;117(2):85-99. [CrossRef] [Medline]
  10. Zipursky RB. Why are the outcomes in patients with schizophrenia so poor? J Clin Psychiatry 2014;75(Suppl 2):20-24. [CrossRef]
  11. Fusar-Poli P, Borgwardt S, Bechdolf A, Addington J, Riecher-Rössler A, Schultze-Lutter F, et al. The psychosis high-risk state: A comprehensive state-of-the-art review. JAMA Psychiatry 2013 Jan;70(1):107-120 [FREE Full text] [CrossRef] [Medline]
  12. Fusar-Poli P, Rocchetti M, Sardella A, Avila A, Brandizzi M, Caverzasi E, et al. Disorder, not just state of risk: Meta-analysis of functioning and quality of life in people at high risk of psychosis. Br J Psychiatry 2015 Sep 2;207(3):198-206. [CrossRef] [Medline]
  13. Fusar-Poli P, Smieskova R, Kempton M, Ho B, Andreasen N, Borgwardt S. Progressive brain changes in schizophrenia related to antipsychotic treatment? A meta-analysis of longitudinal MRI studies. Neurosci Biobehav Rev 2013 Sep;37(8):1680-1691 [FREE Full text] [CrossRef] [Medline]
  14. Bjornestad J, Hegelstad WTV, Joa I, Davidson L, Larsen TK, Melle I, et al. "With a little help from my friends": Social predictors of clinical recovery in first-episode psychosis. Psychiatry Res 2017 Dec;255:209-214. [CrossRef] [Medline]
  15. Turner D, McGlanaghy E, Cuijpers P, van der Gaag M, Karyotaki E, MacBeth A. A meta-analysis of social skills training and related interventions for psychosis. Schizophr Bull 2018 Dec 06;44(3):475-491 [FREE Full text] [CrossRef] [Medline]
  16. Lally J, Ajnakina O, Stubbs B, Cullinane M, Murphy KC, Gaughran F, et al. Remission and recovery from first-episode psychosis in adults: Systematic review and meta-analysis of long-term outcome studies. Br J Psychiatry 2017 Dec;211(6):350-358. [CrossRef] [Medline]
  17. Thompson KN, McGorry PD, Harrigan SM. Recovery style and outcome in first-episode psychosis. Schizophr Res 2003 Jul;62(1-2):31-36 [FREE Full text] [CrossRef]
  18. Burns T, Patrick D. Social functioning as an outcome measure in schizophrenia studies. Acta Psychiatr Scand 2007 Dec;116(6):403-418 [FREE Full text] [CrossRef] [Medline]
  19. Mueser KT, Tarrier N. Handbook Of Social Functioning In Schizophrenia. Boston, MA: Allyn & Bacon; 1998.
  20. Priebe S. Social outcomes in schizophrenia. Br J Psychiatry 2018 Jan 02;191(S50):s15-s20. [CrossRef]
  21. Duggan M. Pew Research Centre. Washington, DC: Pew Internet & American Life Project; 2015 Aug 19. Mobile messaging and social media 2015   URL: [accessed 2019-06-23]
  22. Valmaggia L. The use of virtual reality in psychosis research and treatment. World Psychiatry 2017 Oct;16(3):246-247 [FREE Full text] [CrossRef] [Medline]
  23. Villani M, Kovess-Masfety V. How do people experiencing schizophrenia spectrum disorders or other psychotic disorders use the Internet to get information on their mental health? Literature review and recommendations. JMIR Ment Health 2017 Jan 03;4(1):e1 [FREE Full text] [CrossRef] [Medline]
  24. Statista. 2018 Nov 29. Number of social media users worldwide from 2010 to 2021 (in billions)   URL: [accessed 2019-06-23]
  25. Perrin A. Pew Research Center. Washington, DC: Pew Internet & American Life Project; 2015 Oct 08. Social media usage: 2005-2015   URL: [accessed 2019-06-23]
  26. Lenhart A, Duggan M, Perrin A, Stepler R, Rainie L, Parker K. Pew Research Center. Washington, DC: Pew Internet & American Life Project; 2015 Apr 09. Teens, social media, & technology overview 2015: Smartphones facilitate shifts in communication landscape for teens   URL: [accessed 2019-06-23]
  27. Kaplan A, Haenlein M. Users of the world, unite! The challenges and opportunities of Social Media. Bus Horiz 2010 Jan;53(1):59-68. [CrossRef]
  28. Torous J, Keshavan M. The role of social media in schizophrenia: Evaluating risks, benefits, and potential. Curr Opin Psychiatry 2016 May;29(3):190-195. [CrossRef] [Medline]
  29. Alvarez-Jimenez M, Alcazar-Corcoles M, González-Blanch C, Bendall S, McGorry P, Gleeson J. Online, social media and mobile technologies for psychosis treatment: A systematic review on novel user-led interventions. Schizophr Res 2014 Jun;156(1):96-106. [CrossRef] [Medline]
  30. Firth J, Torous J. Smartphone apps for schizophrenia: A systematic review. JMIR Mhealth Uhealth 2015 Nov 06;3(4):e102 [FREE Full text] [CrossRef] [Medline]
  31. Naslund J, Aschbrenner K, McHugo G, Unützer J, Marsch L, Bartels S. Exploring opportunities to support mental health care using social media: A survey of social media users with mental illness. Early Interv Psychiatry 2019 Jun;13(3):405-413. [CrossRef] [Medline]
  32. Batra S, Baker R, Wang T, Forma F, DiBiasi F, Peters-Strickland T. Digital health technology for use in patients with serious mental illness: A systematic review of the literature. Med Devices (Auckl) 2017;10:237-251 [FREE Full text] [CrossRef] [Medline]
  33. Kumar D, Tully L, Iosif A, Zakskorn LN, Nye KE, Zia A, et al. A mobile health platform for clinical monitoring in early psychosis: Implementation in community-based outpatient early psychosis care. JMIR Ment Health 2018 Feb 27;5(1):e15 [FREE Full text] [CrossRef] [Medline]
  34. Naslund J, Aschbrenner K, Marsch L, McHugo G, Bartels S. Facebook for supporting a lifestyle intervention for people with major depressive disorder, bipolar disorder, and schizophrenia: An exploratory study. Psychiatr Q 2018 Dec;89(1):81-94 [FREE Full text] [CrossRef] [Medline]
  35. Mueller N, Panch T, Macias C, Cohen B, Ongur D, Baker J. Using smartphone apps to promote psychiatric rehabilitation in a peer-led community support program: Pilot study. JMIR Ment Health 2018 Aug 15;5(3):e10092 [FREE Full text] [CrossRef] [Medline]
  36. Ladea M, Bran M, Marcel Claudiu S. Online destigmatization of schizophrenia: A Romanian experience. Eur Psychiatry 2016 Mar;33:S276. [CrossRef]
  37. Alverez M, Thomas N. Innovations in technology-based treatments and management for psychosis: Moderated online social therapy (Horyzons) and self-management and recovery technology. In: Proceedings of the Royal Australian and New Zealand College of Psychiatrists Congress (RANZCP 2017). 2017 Presented at: The Royal Australian and New Zealand College of Psychiatrists Congress (RANZCP 2017); April 30-May 4, 2017; Adelaide, Australia.
  38. Alvarez-Jimenez M, Gleeson J, Bendall S, Rice S, D’Alfonso S, Eleftheriadis D, et al. Momentum: A novel online social media, mindfulness, and strengths-based intervention to promote functional recovery in ultra high-risk (UHR) patients. Schizophr Bull 2017 Mar;43(Suppl 1):S206-S207. [CrossRef]
  39. Jasanoff S. The Ethics of Invention: Technology and the Human Future. New York, NY: WW Norton & Company; 2016.
  40. Funtowicz SO, Ravetz JR. Science for the post-normal age. Futures 1993 Sep;25(7):739-755. [CrossRef]
  41. Hutton B, Salanti G, Caldwell D, Chaimani A, Schmid CH, Cameron C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: Checklist and explanations. Ann Intern Med 2015 Jun 02;162(11):777-784. [CrossRef] [Medline]
  42. Lecomte T, Corbière M, Ehmann T, Addington J, Abdel-Baki A, Macewan B. Development and preliminary validation of the First Episode Social Functioning Scale for early psychosis. Psychiatry Res 2014 May 30;216(3):412-417. [CrossRef] [Medline]
  43. Forsyth K, Lai J, Kielhofner G. The Assessment of Communication and Interaction Skills (ACIS): Measurement properties. Br J Occup Ther 2016 Nov 05;62(2):69-74. [CrossRef]
  44. Hsu W, Pan AW, Chen TJ. A psychometric study of the Chinese version of the assessment of communication and interaction skills. Occup Ther Health Care 2008;22(2-3):177-185. [CrossRef] [Medline]
  45. Eisen S, Wilcox M, Leff H, Schaefer E, Culhane M. Assessing behavioral health outcomes in outpatient programs: Reliability and validity of the BASIS-32. J Behav Health Serv Res 1999 Feb;26(1):5-17. [CrossRef]
  46. Wallace C, Lecomte T, Wilde J, Liberman R. CASIG: A consumer-centered assessment for planning individualized treatment and evaluating program outcomes. Schizophr Res 2001 May;50(1-2):105-119. [CrossRef]
  47. Brekke JS, Levin S, Wolkon GH, Sobel E, Slade E. Psychosocial functioning and subjective experience in schizophrenia. Schizophr Bull 1993 Jan 01;19(3):599-608. [CrossRef] [Medline]
  48. Üstün T, Kostanjsek N, Chatterji S, editors. Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). Geneva, Switzerland: World Health Organization; 2010.
  49. Rosa A, Sánchez-Moreno J, Martínez-Aran A, Salamero M, Torrent C, Reinares M, et al. Validity and reliability of the Functioning Assessment Short Test (FAST) in bipolar disorder. Clin Pract Epidemiol Ment Health 2007 Jun 07;3:5 [FREE Full text] [CrossRef] [Medline]
  50. Llorca P, Lançon C, Lancrenon S, Bayle FJ, Caci H, Rouillon F, et al. The "Functional Remission of General Schizophrenia" (FROGS) scale: Development and validation of a new questionnaire. Schizophr Res 2009 Sep;113(2-3):218-225. [CrossRef] [Medline]
  51. Dausch BM, Miklowitz DJ, Richards JA. Global Assessment of Relational Functioning Scale (GARF): II. Reliability and validity in a sample of families of bipolar patients. Fam Process 1996 Jun;35(2):175-189. [CrossRef]
  52. Cornblatt B, Auther A, Niendam T, Smith CW, Zinberg J, Bearden CE, et al. Preliminary findings for two new measures of social and role functioning in the prodromal phase of schizophrenia. Schizophr Bull 2007 May;33(3):688-702 [FREE Full text] [CrossRef] [Medline]
  53. Schützwohl M, Jarosz-Nowak J, Briscoe J, Szajowski K, Kallert T. Inter-rater reliability of the Brief Psychiatric Rating Scale and the Groningen Social Disabilities Schedule in a European multi-site randomized controlled trial on the effectiveness of acute psychiatric day hospitals. Int J Methods Psychiatr Res 2006 Nov;12(4):197-207. [CrossRef]
  54. Van der Does AJ, Linszen DH, Dingemans PM, Nugter MA, Scholte WF. A dimensional and categorical approach to the symptomatology of recent-onset schizophrenia. J Nerv Ment Dis 1993 Dec;181(12):744-749. [Medline]
  55. Orrell M, Yard P, Handysides J, Schapira R. Validity and reliability of the Health of the Nation Outcome Scales in psychiatric patients in the community. Br J Psychiatry 1999 May;174:409-412. [Medline]
  56. McConkey R, Walsh J. An index of social competence for use in determining the service needs of mentally handicapped adults. J Ment Defic Res 1982 Mar;26(Pt 1):47-61. [Medline]
  57. Horowitz L, Rosenberg S, Baer B, Ureño G, Villaseñor VS. Inventory of interpersonal problems: Psychometric properties and clinical applications. J Consult Clin Psychol 1988 Dec;56(6):885-892. [Medline]
  58. Henderson S, Duncan-Jones P, Byrne D, Scott R. Measuring social relationships. The Interview Schedule for Social Interaction. Psychol Med 1980 Nov;10(4):723-734. [Medline]
  59. Parker G, Rosen A, Emdur N, Hadzi-Pavlov D. The Life Skills Profile: Psychometric properties of a measure assessing function and disability in schizophrenia. Acta Psychiatr Scand 1991 Feb;83(2):145-152. [CrossRef]
  60. Barker S, Barron N, McFarland B, Bigelow D. A community ability scale for chronically mentally Ill consumers: Part I. Reliability and validity. Community Ment Health J 1994 Aug;30(4):363-383. [CrossRef]
  61. Patrick D, Burns T, Morosini P, Rothman M, Gagnon DD, Wild D, et al. Reliability, validity and ability to detect change of the clinician-rated Personal and Social Performance scale in patients with acute symptoms of schizophrenia. Curr Med Res Opin 2009 Jan 07;25(2):325-338. [CrossRef]
  62. Huprich SK, Sanford K, Smith M. Psychometric evaluation of the depressive personality disorder inventory. J Pers Disord 2002 Jun;16(3):255-269. [Medline]
  63. Valencia M, Rojas E, González C, Ramos L, Villatoro J. Evaluation of social functioning in patients at a health center [Article in Spanish]. Salud Publica Mex 1989;31(5):674-687. [Medline]
  64. Corrigan P, Giffort D, Rashid F, Leary M, Okeke I. Recovery as a psychological construct. Community Ment Health J 1999 Jun;35(3):231-239. [Medline]
  65. Foreman EI, Baker R. A validity study of a new rating scale for psychiatric patients. Acta Psychiatr Scand 1986 Jan;73(1):101-108. [CrossRef]
  66. Goodman S, Sewell D, Cooley E, Leavitt N. Assessing levels of adaptive functioning: The Role Functioning Scale. Community Ment Health J 1993 Apr;29(2):119-131. [Medline]
  67. Padmavathi R, Thara R, Srinivasan L, Kumar S. Scarf social functioning index. Indian J Psychiatry 1995 Oct;37(4):161-164 [FREE Full text] [Medline]
  68. Barrowclough C, Tarrier N, Humphreys L, Ward J, Gregg L, Andrews B. Self-esteem in schizophrenia: Relationships between self-evaluation, family attitudes, and symptomatology. J Abnorm Psychol 2003 Feb;112(1):92-99. [Medline]
  69. Russo J, Trujillo C, Wingerson D, Decker K, Ries R, Wetzler H, et al. The MOS 36-Item Short Form Health Survey: Reliability, validity, and preliminary findings in schizophrenic outpatients. Med Care 1998 May;36(5):752-756. [Medline]
  70. Bosc M, Dubini A, Polin V. Development and validation of a social functioning scale, the Social Adaptation Self-evaluation Scale. Eur Neuropsychopharmacol 1997 Apr;7 Suppl 1:S57-S70; discussion S71. [Medline]
  71. Bech P, Lunde M, Undén M. Social Adaptation Self-evaluation Scale (SASS): Psychometric analysis as outcome measure in the treatment of patients with major depression in the remission phase. Int J Psychiatry Clin Pract 2002;6(3):141-146. [CrossRef] [Medline]
  72. Harvey P, Davidson M, Mueser K, Parrella M, White L, Powchik P. Social-Adaptive Functioning Evaluation (SAFE): A rating scale for geriatric psychiatric patients. Schizophr Bull 1997;23(1):131-145. [CrossRef] [Medline]
  73. John K, Gammon D, Prusoff B, Warner V. The Social Adjustment Inventory for Children and Adolescents (SAICA): Testing of a new semistructured interview. J Am Acad Child Adolesc Psychiatry 1987 Nov;26(6):898-911. [Medline]
  74. Weissman MM. Assessment of social adjustment by patient self-report. Arch Gen Psychiatry 1976 Sep 01;33(9):1111. [CrossRef]
  75. Wykes T, Wing J. A ward in a house: Accommodation for "new" long-stay patients. Acta Psychiatr Scand 1982 May;65(5):315-330. [Medline]
  76. Wykes T, Sturt E. The measurement of social behaviour in psychiatric patients: An assessment of the reliability and validity of the SBS schedule. Br J Psychiatry 1986 Jan;148:1-11. [Medline]
  77. Tyrer P, Nur U, Crawford M, Karlsen S, McLean C, Rao B, et al. The Social Functioning Questionnaire: A rapid and robust measure of perceived functioning. Int J Soc Psychiatry 2005 Sep;51(3):265-275. [Medline]
  78. Birchwood M, Smith J, Cochrane R, Wetton S, Copestake S. The Social Functioning Scale. The development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients. Br J Psychiatry 1990 Dec;157:853-859. [Medline]
  79. Kawata A, Revicki DA. Reliability and validity of the social integration survey (SIS) in patients with schizophrenia. Qual Life Res 2008 Feb;17(1):123-135. [CrossRef] [Medline]
  80. Roy-Byrne P, Dagadakis C, Unutzer J, Ries R. Evidence for limited validity of the revised global assessment of functioning scale. Psychiatr Serv 1996 Aug;47(8):864-866. [CrossRef] [Medline]
  81. Saraswat N, Rao K, Subbakrishna D, Gangadhar B. The Social Occupational Functioning Scale (SOFS): A brief measure of functional status in persons with schizophrenia. Schizophr Res 2006 Jan 31;81(2-3):301-309. [CrossRef] [Medline]
  82. McPheeters H. Statewide mental health outcome evaluation: A perspective of two southern states. Community Ment Health J 1984;20(1):44-55. [Medline]
  83. Schneider L, Struening E. SLOF: A behavioral rating scale for assessing the mentally ill. Soc Work Res Abstr 1983;19(3):9-21. [Medline]
  84. Jolley S, Garety P, Ellett L, Kuipers E, Freeman D, Bebbington PE, et al. A validation of a new measure of activity in psychosis. Schizophr Res 2006 Jul;85(1-3):288-295. [CrossRef] [Medline]
  85. Jolley S, Garety P, Dunn G, White J, Aitken M, Challacombe F, et al. A pilot validation study of a new measure of activity in psychosis. Soc Psychiatry Psychiatr Epidemiol 2005 Nov;40(11):905-911. [CrossRef] [Medline]
  86. Hawthorne G. Assessing utility where short measures are required: Development of the short Assessment of Quality of Life-8 (AQoL-8) instrument. Value Health 2009 Sep;12(6):948-957 [FREE Full text] [CrossRef] [Medline]
  87. Lam C, van Weel C, Lauder IJ. Can the Dartmouth COOP/WONCA charts be used to assess the functional status of Chinese patients? Fam Pract 1994 Mar;11(1):85-94. [CrossRef] [Medline]
  88. Nelson E, Wasson J, Kirk J, Keller A, Clark D, Dietrich A, et al. Assessment of function in routine clinical practice: Description of the COOP Chart method and preliminary findings. J Chronic Dis 1987;40 Suppl 1:55S-69S. [Medline]
  89. van Nieuwenhuizen C, Schene A, Koeter M, Huxley P. The Lancashire Quality of Life Profile: Modification and psychometric evaluation. Soc Psychiatry Psychiatr Epidemiol 2001 Jan;36(1):36-44. [Medline]
  90. Priebe S, Huxley P, Knight S, Evans S. Application and results of the Manchester Short Assessment of Quality of Life (MANSA). Int J Soc Psychiatry 1999;45(1):7-12. [CrossRef] [Medline]
  91. Björkman T, Svensson B. Quality of life in people with severe mental illness. Reliability and validity of the Manchester Short Assessment of Quality of Life (MANSA). Nord J Psychiatry 2005;59(4):302-306. [CrossRef] [Medline]
  92. Pukrop R, Möller HJ, Steinmeyer E. Quality of life in psychiatry: A systematic contribution to construct validation and the development of the integrative assessment tool "modular system for quality of life". Eur Arch Psychiatry Clin Neurosci 2000;250(3):120-132. [Medline]
  93. Bergner M, Bobbitt R, Carter W, Gilson B. The Sickness Impact Profile: Development and final revision of a health status measure. Med Care 1981 Aug;19(8):787-805. [Medline]
  94. Gerety M, Cornell J, Mulrow C, Tuley M, Hazuda HP, Lichtenstein M, et al. The Sickness Impact Profile for nursing homes (SIP-NH). J Gerontol 1994 Jan;49(1):M2-M8. [Medline]
  95. Endicott J, Nee J, Harrison W, Blumenthal R. Quality of Life Enjoyment and Satisfaction Questionnaire: A new measure. Psychopharmacol Bull 1993;29(2):321-326. [Medline]
  96. Ritsner MS, Awad AG, editors. Quality of Life Impairment in Schizophrenia, Mood and Anxiety Disorders: New Perspectives on Research and Treatment. Dordrecht, the Netherlands: Springer; 2007.
  97. Swan A, Watson H, Nathan P. Quality of life in depression: An important outcome measure in an outpatient cognitive-behavioural therapy group programme? Clin Psychol Psychother 2009;16(6):485-496. [CrossRef] [Medline]
  98. Ferrans CE, Powers MJ. Psychometric assessment of the quality of life index. Res Nurs Health 1992 Feb;15(1):29-38. [CrossRef]
  99. Lehman A. Measures of quality of life among persons with severe and persistent mental disorders. Soc Psychiatry Psychiatr Epidemiol 1996 Mar;31(2):78-88. [Medline]
  100. Frisch MB, Cornell J, Villanueva M, Retzlaff PJ. Clinical validation of the Quality of Life Inventory. A measure of life satisfaction for use in treatment planning and outcome assessment. Psychol Assess 1992;4(1):92-101. [CrossRef]
  101. Heinrichs DW, Hanlon TE, Carpenter WT. The Quality of Life Scale: An instrument for rating the schizophrenic deficit syndrome. Schizophr Bull 1984 Jan 01;10(3):388-398. [CrossRef] [Medline]
  102. Kaplan R, Atkins C, Timms R. Validity of a quality of well-being scale as an outcome measure in chronic obstructive pulmonary disease. J Chronic Dis 1984;37(2):85-95. [Medline]
  103. Kaplan RM, Anderson JP, Ganiats TG. The Quality of Well-being Scale: Rationale for a single quality of life index. In: Walker SR, Rosser RM, editors. Quality of Life Assessment: Key Issues in the 1990s. Dordrecht, the Netherlands: Springer; 1993:65-94.
  104. Test M, Greenberg J, Long J, Brekke J, Burke S. Construct validity of a measure of subjective satisfaction with life of adults with serious mental illness. Psychiatr Serv 2005 Mar;56(3):292-300. [CrossRef] [Medline]
  105. Boyer L, Simeoni M, Loundou A, D'Amato T, Reine G, Lancon C, et al. The development of the S-QoL 18: A shortened quality of life questionnaire for patients with schizophrenia. Schizophr Res 2010 Aug;121(1-3):241-250. [CrossRef] [Medline]
  106. Wilkinson G, Hesdon B, Wild D, Cookson R, Farina C, Sharma V, et al. Self-report quality of life measure for people with schizophrenia: The SQLS. Br J Psychiatry 2000 Jul;177:42-46. [Medline]
  107. Becker M, Diamond R, Sainfort F. A new patient focused index for measuring quality of life in persons with severe and persistent mental illness. Qual Life Res 1993 Aug;2(4):239-251. [Medline]
  108. World Health Organization. The World Health Organization Quality of Life assessment (WHOQOL): Position paper from the World Health Organization. Soc Sci Med 1995 Nov;41(10):1403-1409. [Medline]
  109. Fusar-Poli P, McGorry P, Kane J. Improving outcomes of first-episode psychosis: An overview. World Psychiatry 2017 Oct;16(3):251-265 [FREE Full text] [CrossRef] [Medline]
  110. Andreassen CS, Pallesen S. Social network site addiction: An overview. Curr Pharm Des 2014;20(25):4053-4061. [Medline]
  111. Dickerson F, Sommerville J, Origoni AE, Ringel NB, Parente F. Outpatients with schizophrenia and bipolar I disorder: Do they differ in their cognitive and social functioning? Psychiatry Res 2001 May 10;102(1):21-27. [Medline]
  112. Wang Y, Yeh YH, Tsang SM, Liu WH, Shi HS, Li Z, et al. Social functioning in Chinese college students with and without schizotypal personality traits: An exploratory study of the Chinese version of the First Episode Social Functioning Scale. PLoS One 2013;8(5):e61115 [FREE Full text] [CrossRef] [Medline]
  113. Andreassen C, Torsheim T, Brunborg G, Pallesen S. Development of a Facebook Addiction Scale. Psychol Rep 2012 Apr;110(2):501-517. [CrossRef] [Medline]
  114. Kuss D, Griffiths M. Online social networking and addiction: A review of the psychological literature. Int J Environ Res Public Health 2011 Dec;8(9):3528-3552 [FREE Full text] [CrossRef] [Medline]
  115. Wykes T. Great expectations for participatory research: What have we achieved in the last ten years? World Psychiatry 2014 Feb;13(1):24-27 [FREE Full text] [CrossRef] [Medline]
  116. Davidson L, Schmutte T, Dinzeo T, Andres-Hyman R. Remission and recovery in schizophrenia: Practitioner and patient perspectives. Schizophr Bull 2008 Jan;34(1):5-8 [FREE Full text] [CrossRef] [Medline]
  117. Slade M, Leamy M, Bacon F, Janosik M, Le Boutillier C, Williams J, et al. International differences in understanding recovery: Systematic review. Epidemiol Psychiatr Sci 2012 Dec;21(4):353-364. [CrossRef] [Medline]
  118. Sohler N, Adams B, Barnes D, Cohen G, Prins S, Schwartz S. Weighing the evidence for harm from long-term treatment with antipsychotic medications: A systematic review. Am J Orthopsychiatry 2016;86(5):477-485 [FREE Full text] [CrossRef] [Medline]
  119. Evensen S, Wisløff T, Lystad J, Bull H, Ueland T, Falkum E. Prevalence, employment rate, and cost of schizophrenia in a high-income welfare society: A population-based study using comprehensive health and welfare registers. Schizophr Bull 2016 Mar;42(2):476-483 [FREE Full text] [CrossRef] [Medline]
  120. Kirkham J, Altman D, Williamson P. Bias due to changes in specified outcomes during the systematic review process. PLoS One 2010 Mar 22;5(3):e9810 [FREE Full text] [CrossRef] [Medline]

DARE: Database of Abstracts of Reviews of Effects
DAS: Disability Assessment Schedule
DAS-II-sv: Disability Assessment Schedule—II: Schizophrenia Version
DSM: Diagnostic and Statistical Manual of Mental Disorders
FESFS: First Episode Social Functioning Scale
ICD: International Classification of Diseases
MeSH: Medical Subject Headings
PNS: post-normal science
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
PROSPERO: International Prospective Register of Systematic Reviews
SDSS: Social Disability Screening Schedule
UHR: ultrahigh risk
WHO: World Health Organization
WHO-DAS: World Health Organization Disability Assessment Schedule
WHOQOL-BREF: World Health Organization Quality of Life Brief Version

Edited by G Eysenbach; submitted 08.03.19; peer-reviewed by O Ness, F Dark, G Snethen; comments to author 03.04.19; revised version received 06.05.19; accepted 10.05.19; published 28.06.19


©Jone Bjornestad, Wenche Ten Velden Hegelstad, Henrik Berg, Larry Davidson, Inge Joa, Jan Olav Johannessen, Ingrid Melle, Helen J Stain, Ståle Pallesen. Originally published in the Journal of Medical Internet Research (, 28.06.2019.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.