A Meta-Analysis and Systematic Review on Creativity in Schizophrenia: Toward an Ecological Understanding Integrating Clinical and Philosophical Perspectives

Paola Pennisi^1*Federica Longo^2*Sara Alfia Nicotra²Mohammad Ali Salehienjad³Carmelo Mario Vicario²Alessandra Maria Falzone²

• ¹Department of Adult and Childhood Human Pathology “Gaetano Barresi”, Universita degli Studi di Messina, Messina, Italy
• ²Department of Cognitive Sciences, Psychology, Education, and Cultural Studies, Università degli Studi di Messina, Universita degli Studi di Messina, Messina, Italy
• ³Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Medical Faculty, Aachen, Germany

Background: The presumed link between schizophrenia and creativity has long captured the collective imagination, but empirical data paint a more complex picture: while some patients produce extraordinary artistic works, quantitative studies consistently report lower creativity scores in individuals with schizophrenia compared to healthy controls. This contrasts with phenomenological accounts and clinical observations that highlight the expressive power of language and art in conveying the altered subjective experience of schizophrenia. Objective: This study aimed to update the existing evidence on creativity in schizophrenia through a systematic review and meta-analyses, and to assess whether a more fine-grained, ecologically valid approach might offer new insights. Methods: A systematic search of major databases yielded 4,043 studies after duplicate removal. Following PRISMA guidelines and strict inclusion criteria, 15 studies were included in the final qualitative synthesis and 13 in the quantitative meta-analyses. Creativity was analyzed both globally and across four subcomponents: elaboration, flexibility, fluency, and originality. Only tasks explicitly designed to elicit creative production were included. Results: All five meta-analyses showed statistically significant deficits in patients with schizophrenia compared to controls. The strongest effects emerged for overall creativity (d = –0.79), fluency (d = – 0.83), and originality (d = –0.61). Moderator analyses revealed that age was the only significant variable: older patients showed larger deficits, particularly in fluency and flexibility. Other demographic and methodological factors did not account for variability in outcomes. Discussion: These findings confirm and extend prior work, suggesting that creativity is broadly impaired in schizophrenia. However, the consistent directionality of the results also raises critical questions about the ecological validity of standardized tests. Phenomenological and qualitative perspectives point to the importance of subjectivity and lived experience—dimensions often diminished by clinical treatments aimed at restoring shared reality. We call for the development of subjectivity-sensitive assessment tools capable of capturing this complexity. Conclusion: Creativity in schizophrenia remains a multidimensional phenomenon that cannot be fully understood through normative psychometric measures alone. Future research should adopt interdisciplinary approaches and develop novel tools for ecological assessment that are more sensitive to the creative potential of individuals with schizophrenia. Systematic review registration: https://www.crd.york.ac.uk/prospero/, PROSPERO [CRD42024629254].