{'fraction_non_alphanumeric': 0.031833476281586066, 'fraction_numerical': 0.016032196344923137, 'mean_word_length': 5.290724216642457, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Stuck Inside

Abstract Social distancing policies enacted during the COVID-19 pandemic altered our social interactions. People with schizophrenia, who already exhibit social deficits, may have been disproportionally impacted. In this pilot study, we a) compared prepandemic social functioning to functioning during the pandemic in people with schizophrenia (n = 21) who had data at both time points; and b) examined if patterns of decline in schizophrenia differed from healthy controls (n = 21) across a series of repeated-measures analyses of variance. We observed larger declines in social functioning in schizophrenia (η2 = 0.07, medium effect size) during the pandemic compared with the control group. Between-group declines did not extend to other domains, suggesting that declines are specific to social functioning. Our findings signal that treatments focusing on reconnecting people with schizophrenia to their social networks should be prioritized. Future studies should continue tracking social functioning after the pandemic to illustrate patterns of recovery.

I n response to the COVID-19 pandemic, widespread social distancing policies were enacted across the world. These policies altered how we interacted with friends, family, and acquaintances-eliminating some of these interactions entirely. This sea change in how we interacted with others likely had profound effects on social functioning. People with schizophrenia, who already exhibit deficits in social functioning Green et al., 2015), may have been disproportionally impacted. Because social distancing restricted many interactions to online encounters, the smaller social networks and lower rates of Internet access in schizophrenia (Degnan et al., 2018;Young et al., 2020) made connecting with others difficult. When social networks are disrupted in schizophrenia, an array of negative outcomes occur (e.g., increased psychotic symptoms, less focus on mental and physical health; Degnan et al., 2018; see Zhand and Joober, 2021). Thus, it is important to understand how social functioning in schizophrenia changed during the pandemic: was it in step with the declines experienced by healthy adults or did those with schizophrenia have steeper drops in functioning?
To answer this question, it is necessary to accurately assess individual responses during the pandemic. This requires baseline measurements of social functioning. Without a baseline, it is difficult to estimate how a person's social functioning differs from their typical course of behavior. To examine if a specific deficit in social functioning exists-rather than a general decline across all areas-it is also important to analyze how other domains were affected during the pandemic. Symptoms, role functioning, and quality of life are good candidates for evaluation; all are negatively impacted in schizophrenia and each has the potential to be affected by the COVID-19 pandemic (Kozloff et al., 2020;Strauss et al., 2022;Zhand and Joober, 2021). To address these issues, we a) recruited people who had participated in studies before the pandemic (i.e., before the first reported statewide case of  and b) compared their prepandemic data on functioning and symptoms measures to data collected during the COVID-19 pandemic.
To date, few studies have assessed how functioning or symptom domains have changed in schizophrenia during the pandemic. In terms of social activity, two studies found that in-person interactions decreased and communication using digital devices increased in schizophrenia when comparing prepandemic to pandemic activity (Jagesar et al., 2021;Valeri et al., 2021). Mixed results have been observed regarding symptoms (Haddad et al., 2022;Pinkham et al., 2021;Strauss et al., 2022). Pinkham et al. (2021) found that symptoms remained relatively stable while well-being actually increased during the early stages of the pandemic. Strauss et al. (2022) focused on how negative symptoms changed during the pandemic and observed increased severity of both experiential and behavioral symptoms. Although little information exists on changes in role functioning or quality of life, it is likely that increased unemployment rates and social distancing restrictions would be associated with decreases in these constructs as the pandemic continued. There is also evidence that other types of symptoms (e.g., depression), use of maladaptive coping strategies, and loneliness have all increased in schizophrenia as social distancing has remained in place (Rosa-Alcázar et al., 2021;Tso and Park, 2020;Valeri et al., 2021).
The COVID-19 pandemic also raises important issues about the intersection between health and social behavior. People with schizophrenia have higher rates of comorbid health conditions (e.g., diabetes, obesity) that place them at greater risk for mortality if COVID-19 infection occurs (see Barcella et al., 2021;Barlati et al., 2021;Kozloff et al., 2020;Maguire and Looi, 2020). A study by Tzur Bitan et al. (2021) found that those with schizophrenia were less likely to be diagnosed with COVID-19; when diagnosed, however, they exhibited more severe cases and were three times more likely to die from infection. Thus, schizophrenia populations may be more likely to receive intensive social distancing and quarantining recommendations than the general public. This may leave two unfavorable options: 1) isolate for a longer period and risk further disconnection from social networks; or 2) break protocol-either by choice or necessity-and face increased risk of developing COVID-19 with severe complications. Observing how those with schizophrenia respond to social distancing policies-and how psychological, health, and socioeconomic variables are related to their responses-is critical for understanding how these options are weighed.

Study Objectives and Hypotheses
This pilot study had three aims. First, we examined if social functioning declined in schizophrenia during the pandemic and, if so, how these declines compared with those seen in healthy adults. We hypothesized that social functioning would decline in both groups when prepandemic and pandemic scores were compared but that declines would be more severe in schizophrenia. Second, we tested whether symptoms, role functioning, and quality of life changed in schizophrenia during the pandemic compared with controls. Again, we expected to find changes in both groups, with the schizophrenia group exhibiting more significant changes. A goal of this aim was to observe whether changes in those with schizophrenia during the pandemic were specific to social functioning or represented a more global decline across different domains. Third, we identified if psychological (loneliness, resilient coping, optimism toward the future), health (medical conditions linked to worse COVID-19 outcomes), or socioeconomic factors (lack of access to Internet/smartphone) were associated with changes in social functioning during the pandemic. Our expectation was that these constructs would be linked to social declines in both groups. By evaluating these hypotheses, this study has potential to illustrate how social behavior changed in response to the COVID-19 pandemic and to identify constructs that are associated with these changes. This is important for determining the level of vulnerability experienced by those with schizophrenia. It may also allow us to identify treatment targets in schizophrenia that should be prioritized as the pandemic subsides.

Participants
Given our focus on testing people with prepandemic data, all participants were recruited from study registries (see Minor et al., 2022). To be included, those in the schizophrenia group had to a) have a schizophrenia-spectrum disorder diagnosis (e.g., schizophrenia, schizoaffective disorder) listed in their medical record and supported using the Mini International Neuropsychiatric Interview (Sheehan et al., 1998); b) have prepandemic data before March 6, 2020 (i.e., date of first reported COVID-19 case statewide); c) be 18-65 years old; d) exhibit English fluency; e) have no change in outpatient status or medications in the month before testing; f ) demonstrate no current substance dependence; and g) have no documented intellectual disability. The healthy control group met similar inclusion criteria with one exception: they could not have a current affective, substance use, or psychotic disorder or have a history of psychosis at baseline or follow-up testing.
In total, prepandemic and pandemic data were collected for 42 people (schizophrenia = 21, control = 21). Prepandemic data were collected in person for all participants. Pandemic data were collected primarily using online video programs and/or over the phone (there were also in person procedures for a minority of participants). Figure 1 provides more information on study contacts and rates of participation from those with baseline data. Regarding when pandemic data were collected, the majority (schizophrenia = 11, control = 11) of assessments occurred when businesses in the state were allowed to operate but at ≤50% capacity and only with social distancing guidelines in place (May 20, 2020 to September 22, 2020). Twelve people were assessed (schizophrenia = 5, control = 7) when businesses were allowed to operate at full capacity but before the administration of the first approved vaccine in the state (September 23, 2020 to December 12, 2020). The remaining 8 participants were assessed (schizophrenia = 5, control = 3) when vaccines were available in the state, but those in the participant's age group were ineligible to receive them (December 13, 2020 to February 27, 2021).

Social Functioning
Three instruments were used to capture social functioning: 1) the Global Functioning: Social Scale (GF: Social; Auther et al., 2006); 2) the Interpersonal Relations subscale from the Heinrichs Quality of Life Scale (Heinrichs et al., 1984); and 3) a social activities measure designed specifically for this study. The GF: Social and QLS-IR are clinician-rated measures that have demonstrated good psychometric properties (Cornblatt et al., 2007;Gupta et al., 2000) and have been used previously with schizophrenia samples Fulford et al., 2020;Minor et al., 2016;Minor et al., 2022). They were administered at both time points (prepandemic, pandemic). The GF: Social assesses functioning in romantic and social relationships as compared with one's peers using a 10-point scale. The QLS-IR uses a 7-point scale and consists of eight items (e.g., active acquaintances, social network sociosexual relations). Increasing scores signify better social functioning on both measures.
The measure created for this study was administered at the pandemic time point and assessed social activities across different modalities. Social activities were separated into how interactions occurred (e.g., in person, online using video, texting). Participants estimated how often and the amount of time they spent interacting with others before and during the pandemic. Questions were separated into prepandemic and pandemic categories and administered in an interview format by study personnel (see Table 1 for specific questions).

Symptoms
The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) is an interview-rated scale consisting of 30 items across five factors (positive, negative, disorganized, hostility, depression; see Bell et al., 1994;Minor and Lysaker, 2014;Minor et al., 2015a). All items use a 7-point scale, with higher scores signifying greater severity. In past studies, the PANSS has shown good internal consistency (Kay et al., 1987), interrater reliability (Lysaker et al., 2013), and predictive validity (Bell et al., 1992). Here, it was administered at prepandemic and pandemic assessments. Postpandemic PANSS assessments were typically conducted over the phone or by using online video programs. Some symptom variables could not be collected (negative domain: blunted affect, motor retardation, preoccupation; disorganized domain: tension and mannerisms and posturing) when phone-based assessments were the only modality used. In these instances, scores from other items in that symptom category were extrapolated (e.g., "tension" was the mean of other disorganized variables at the pandemic time point).

Role Functioning
The Global Functioning: Role Scale (GF: Role; Cornblatt et al., 2007) is a clinician-rated scale that was given at prepandemic and pandemic time points. Interviewers selected participants' primary role from three choices (school, work, homemaker). Ratings used a 10-point scale and were based on how well the participant performed in their role compared with their peers. The GF: Role has exhibited strong psychometric properties and been used in past studies with schizophrenia samples (Cornblatt et al., 2007;Minor et al., 2015b).

Quality of Life
The QLS-IR (Heinrichs et al., 1984) consists of three subscales in addition to the QLS-IR. The Instrumental Role subscale assesses work and school functioning across four items. The Intrapsychic Foundations subscale measures factors such as motivation and sense of purpose using seven items. The Common Objects and Activities has two items that assess one's access to common objects and activities. All items were administered at prepandemic and pandemic assessments and are rated on a 7-point scale, with increasing scores indicating greater quality of life.
Psychological, Health, and Socioeconomic Constructs samples (Kamenov et al., 2016;Mote et al., 2019;Palmer et al., 2018). For health and socioeconomic variables, questions were designed specifically for this study. Health questions focused on whether participants had been diagnosed with a condition that would place them at higher risk for severe COVID-19 infection if they had been exposed to or developed COVID-19. Socioeconomic questions centered on whether participants had a prolonged period during the pandemic without access to the Internet or a smartphone. Specific questions designed for this study were administered by study personnel in an interview format and are included in Table 2.

Statistical Analysis
Analyses occurred in four parts. First, independent t-tests and chi-square analyses compared demographic and clinical data in schizophrenia and control groups. Second, a series of repeated-measures analyses of variance (ANOVAs) were run with time (prepandemic, pandemic) and group (schizophrenia, control) as independent variables and social functioning as the dependent variable (DV). Partial eta-square values were used to assess the magnitude of time by group interactions. Paired samples t-tests were implemented to capture change from prepandemic to pandemic time points within each group. Third, a series of repeated-measures ANOVAs were also conducted using symptoms, role functioning, and quality of life as DVs. Finally, partial Pearson's correlations were analyzed for each group to determine if psychological, health, or socioeconomic constructs were associated with social functioning during the pandemic while controlling for prepandemic social functioning. For all analyses, an alpha level of 0.05 was used to determine significance.

Demographic, Clinical, and Health Variables During the Pandemic
Regarding demographic data, groups did not significantly differ in age, sex, or race (see Table 3 and Fig. 1). Significant differences in education and marital status were observed, with the schizophrenia group being less likely to progress beyond high school or have been married. Household data indicated no significant group differences in the number of overall people/ children in the household, the number of days between prepandemic and pandemic assessments, or the number of days that participants were assessed following the first reported statewide COVID-19 case. Table 3 also lists psychological, health, and socioeconomic variables. Regarding psychological variables, the schizophrenia group reported greater loneliness, less resilient coping, and less optimism toward the future. Regarding health variables, significant group differences were found for obesity, diabetes, and the presence of one/multiple health conditions that could lead to severe COVID-19 infection. In each instance, the schizophrenia group was more likely to report having a condition. The control group was significantly more likely to report experiencing COVID-19 symptoms, to have been tested for COVID-19, and to have received a positive COVID-19 diagnosis. No significant group differences were found for subjective health ratings, cardiovascular conditions or chronic lung disease, whether participants were currently socially distancing, or if there was a period during the pandemic when participants were without access to the Internet/smartphone. On the study-specific social activity measure, time by group interactions were only observed for time spent interacting with others outside of one's residence. Healthy controls had a sharper decrease in this category compared with those with schizophrenia. Paired samples t-tests indicated that those with schizophrenia had significant changes from prepandemic to pandemic assessments in the frequency they interacted with others online using video (increase), t(20) = −2.65, p = 0.008, the frequency they interacted with mental health professionals (decrease), t(20) = 1.92, p = 0.035, and the number of minutes they interacted with others outside of their residence (decrease), t(20) = 1.82, p = 0.043. Significant changes in controls were observed for the frequency they interacted with others online (increase), t(20) = −2.35, p = 0.015, the frequency (increase), t(20) = −4.51, p = 0.000, and the amount of time they interacted How often did you interact with friends or family members online? How often did you interact with friends or family members online using video? How often did you text with friends or family members on the phone? How often did you talk with friends or family members on the phone? How often did you visit a mental health professional? Questions assessing estimated hours of interactions per week with friends and family Before March 2020…/since March 2020…

Social Functioning Before and During the Pandemic
How long (in minutes) would you estimate that you interacted with people outside of your household in person during a typical week? How long (in minutes) would you estimate that you interacted with friends and family online during a typical week? How long (in minutes) would you estimate that you interacted with friends and family online using video during a typical week? How long (in minutes) would you estimate that you texted with friends and family on the phone during a typical week? How long (in minutes) would you estimate that you talked with friends and family on the phone during a typical week? How long (in minutes) would you estimate that you spent visiting a mental health professional during a typical week? a Scale: 1 = never, 2 = once or twice per month, 3 = once per week, 4 = more than once per week, 5 = daily, 6 = multiple times per day.

Symptoms, Role Functioning, and Quality of Life Before and During the Pandemic
Repeated-measures ANOVAs did not reveal significant time by group interactions for overall symptoms, any symptom domain, role functioning, or two of three quality of life domains (excluding the QLS-IR; see Table 5). An interaction was observed for Intrapsychic Foundations, with the schizophrenia group exhibiting a sharper decline during the pandemic.

Relationships Between Social Functioning With Psychological, Health, and Socioeconomic Variables
Partial correlations between social functioning during the pandemic and psychological, health, and socioeconomic variables were run while controlling for prepandemic social functioning (Table 6). For the schizophrenia group, GF: Social was inversely associated with loneliness and positively associated with optimism toward the future. In the control group, both social functioning measures were inversely related to loneliness and having a period during the pandemic without  Scale: 1 = never, 2 = once or twice per month, 3 = once per week, 4 = more than once per week, 5 = daily, 6 = multiple times per day.
the Internet or a smartphone. No significant associations were observed for resilient coping or health condition variables in either group.

DISCUSSION
In this pilot study, we assessed how social functioning changed in schizophrenia during the COVID-19 pandemic and identified psychological, health, and socioeconomic constructs that might help explain lower functioning. Four main findings were observed. First, those with schizophrenia showed larger drops in social functioning than healthy adults during the pandemic. Although both groups exhibited declines, our data suggest that the pandemic had a more deleterious social impact in schizophrenia-where social deficits already existed before the pandemic. Second, in-person social activity decreased for both groups, with healthy adults showing larger declines. Declines were partially offset by a boost in time spent communicating via digital devices, although increases were more likely to be found in healthy adults. Third, role functioning and at least one quality of life domain significantly declined for both groups. Symptoms remained relatively stable across time points; disorganized symptoms in schizophrenia were the only domain that increased. Finally, loneliness was identified as a variable linked to social functioning during the pandemic-while controlling for prepandemic functioning-across groups; optimism toward the future was also inversely related to pandemic social functioning in schizophrenia.
The key finding in this study was that the schizophrenia group had a more severe drop in social functioning. The declines found here indicate that those with schizophrenia experienced increased disconnection from their social networks during the pandemic; this is troubling given the importance of social connections to mental health (Bellack et al., 2007;Degnan et al., 2018;Harvey et al., 2007). As many medical and mental health appointments shifted online during the pandemic, there is also evidence that those with schizophrenia had reduced contact with their medical care teams. Dickerson et al. (2022), as well as data here, showed that those with schizophrenia were more likely to miss medical appointments than controls and attended appointments less frequently than before the pandemic. Although preliminary, this raises concerns about access to care and whether a subgroup with schizophrenia had very few social interactions throughout the pandemic. At minimum, it seems that the already limited social support systems available to those with schizophrenia have been reduced significantly compared with before the pandemic.
The larger declines experienced in schizophrenia seem to be specific to social functioning. When observed, declines in other domains  did not differ according to group status. This has important potential implications for treatment as the pandemic ends. Given the limited resources available in community mental health, findings from this study suggest that interventions focused on improving social connections should be prioritized. This will be challenging because of the widespread need following the pandemic (e.g., see Fares-Otero et al., 2021;Hamada and Fan, 2020). However, if these findings hold true-and replication needs to occur given the limited sample-social functioning in schizophrenia should be a focal point. One point of promise is that past studies have shown that, although social deficits are observed, people with schizophrenia desire social affiliation at similar levels to healthy adults and often list increasing social contacts as a treatment goal (Blanchard et al., 2015;Shumway et al., 2003). This could point to motivation to engage in socially based treatments. Implementing digital or telehealth interventions and providing access to devices may be one way to increase focus more rapidly given the increased implementation of these interventions-and increased acceptance of digital devices-during the pandemic (see Sanchez-Guarnido et al., 2021;Torous and Keshavan, 2020). A potential explanation for the steeper social functioning declines in schizophrenia centers on how social activity occurred during the pandemic. First, the control group reported a greater drop for in-person social activity than those with schizophrenia. To contextualize this finding, however, the control group went from having over 30 hours of weekly in-person activity to just under 15 hours, whereas those with schizophrenia went from just over 11 hours to approximately 6 hours. Thus, the large baseline group differences may signal why the less severe decline in schizophrenia may still hold important implications for global social functioning (i.e., they had less room to decline and still maintain social connections). Second, controls were more likely to report increased use of digital devices during the pandemic. Although those with schizophrenia also exhibited increased use of these devices, their largest increase in reported minutes was with texting. Those in the control group were more likely to report increased frequency of using digital means that more closely approximated in-person interactions. This is important because interactions that more closely approximate in-person conversations may be more substantive; substantive conversations are linked with increased well-being (Mehl et al., 2010) and may foster closer social connections (Rabin, 2010).
Given the observed declines in social and role functioning, it was somewhat surprising that symptoms remained relatively stable in schizophrenia. Overall symptoms were similar to prepandemic levels, and four of five symptom domains did not significantly increase. This supports findings from Pinkham et al. (2021), who also reported that symptoms did not change early in the pandemic. We did not replicate findings from Strauss et al. (2022), who observed an increase in negative symptoms during the pandemic. One reason may be that Strauss et al. (2022) implemented a measure designed specifically to assess negative symptoms, whereas we used a broader measure given our focus on a wider range of symptoms. Disorganized symptoms were the lone domain that increased. This increase may be a result of the greater isolation experienced during the pandemic; de Sousa et al. (2015Sousa et al. ( , 2018 have shown that disorganization tends to rise when those with schizophrenia are more isolated. This study had limited success identifying possible correlates for social functioning during the pandemic. Across groups, loneliness showed the most consistent associations with pandemic social functioning, even when controlling for prepandemic functioning. Loneliness has been identified as a major problem for people with serious mental illness during the COVID-19 pandemic, with approximately a third of these individuals reporting high levels of loneliness (Heron et al., 2022). This and findings from our study are not particularly surprising, but they do illustrate how the relationship between loneliness and lower social functioning during the pandemic contributed to one another across schizophrenia and control groups. Optimism toward the future was also associated with pandemic social functioning for one of two measures in schizophrenia.
This could point to the importance of hope as a way to maintain social functioning under adverse conditions. The health and socioeconomic variables examined here did not show strong links with social functioning in schizophrenia-despite the higher rates of medical conditions conferring increased COVID-19 risk.
The inclusion of participants with prepandemic data and the number of domains tested serve as study strengths. The small sample size is a central limitation. Groups were well-matched, but the low number reduces power to draw inferences. Replication from other studies is needed. A second limitation is that in-person assessments were conducted for prepandemic measures, whereas a mix of online and phone-based assessments was primarily administered during the pandemic. This was necessary due to health and safety protocols. Although other studies have implemented phone-based protocols to deliver psychological assessments (Ainsworth et al., 2013;Eisner et al., 2019), this may have resulted in some unintended differences across time points here. A third limitation is that the activity measure created for this study could only be administered retrospectively, which limits the inferences that can be drawn about how specific types of interactions changed during the pandemic. Potential response bias is a fourth limitation. Although we reached out to all eligible individuals, only approximately 40% per group participated (see Fig. 1 for more information). It could be that those who could not be contacted or declined participation may have responded differently during the pandemic (e.g., contact changed due to no longer being able to pay phone bill, declined participation due to increased symptoms). These limitations should be considered when interpreting findings.

CONCLUSIONS
In sum, we found that people with schizophrenia demonstrated sharp declines in social functioning during the COVID-19 pandemic. When compared with healthy adults, the steeper declines in schizophrenia seem specific to social functioning-as declines in symptoms, role functioning, and quality of life did not differ based on group status. This signals that reconnecting people with schizophrenia to their social networks should be prioritized. Implementing creative methods of connecting people with social support (e.g., digital or telehealth interventions and programs; see Sanchez-Guarnido et al., 2021;Torous and Keshavan, 2020) is critical for increasing social connections. Regarding correlates of social functioning during the pandemic, loneliness seemed to be the most promising indicator when controlling for prepandemic functioning. Future studies should replicate study findings in larger samples and compare how social functioning responds in healthy adult and schizophrenia groups as the pandemic subsides.