Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis

Trajectories of suicidal behavior and their clinical correlates in the early phases of schizophrenia spectrum disorders

BACKGROUND

Many risk factors for suicidal behavior (SB) in schizophrenia spectrum disorders (SSD) are present before the onset of psychosis or are associated with specific phases of illness. We aim to investigate the trajectories of SB from before the onset of psychosis until the first start of treatment in patients with first-episode psychosis (FEP).

METHOD

A total of 252 patients with first-episode SSD were recruited, out of which 224 had complete SB data. They participated in clinical interviews and self-report questionnaires during their first treatment. We assessed SB in three time periods: Before the onset of psychosis, during untreated psychosis, and at treatment start (study baseline). We used K-mean cluster analyses to identify trajectories of SB over these periods.

RESULTS

Four trajectories of SB were identified: persistent low/no SB (n = 114, 51 % of 224), increasing mild/moderate SB (n = 54, 24 %), severe SB during untreated psychosis (n = 25, 11 %), severe persistent SB (n = 31, 14 %). With "persistent low/no SB" as a reference group, all other groups had significantly more depressive symptoms at baseline. The duration of untreated psychosis was significantly longer in the group with "severe SB during untreated psychosis". Clinical insight subscale scores differed between the trajectory groups. Also, the "severe persistent SB" group reported more emotional abuse and total childhood trauma than the "increasing mild/moderate SB" group.

CONCLUSION

Our findings suggest the presence of different pathways to SB in FEP. More knowledge about these pathways can support the development of tailored preventive strategies in this patient group.

Mapping Insight Dimensions and Symptom Dynamics in Schizophrenia: A Data-Driven Network Approach: Cartographie des dimensions d'insight et de la dynamique symptomatique dans la schizophrénie: une approche par réseau fondée sur les données

ObjectivesPatients with schizophrenia spectrum disorders (SSD) present with cognitive, behavioral, and emotional difficulties. Affected individuals often exhibit poor insight into aspects of their illness, such as awareness of the illness itself or the need for treatment, which can hinder treatment adherence and complicate clinical outcomes. This study aimed to investigate the relationships between clinical symptoms and dimensions of insight in SSD using a network approach, which captures direct and indirect relationships among variables. We hypothesized that illness awareness would correlate negatively with positive symptoms and positively with depressive symptoms, and that positive symptoms would have the strongest influence on the network.MethodsData were collected from 142 individuals diagnosed with SSD. Insight was measured using the Birchwood Insight Scale (IS) across three dimensions: illness awareness, symptom re-labelling, and awareness of the need for treatment. Symptoms were evaluated using the Scale for the Assessment of Positive Symptoms, the Scale for the Assessment of Negative Symptoms, the Calgary Depression Scale and the Hamilton Anxiety Scale. Network analysis was employed to explore interconnections (edges) between variables (nodes) and identify influential variables through centrality measures (strength, betweenness, closeness).ResultsA significant positive connection was found between illness awareness and depressive symptoms. Anxiety and depressive symptoms were identified as the most central and influential variables within the network. Treatment awareness showed greater centrality than illness awareness, indicating this dimension's potential importance in influencing symptom dynamics in a clinical profile.ConclusionsAnalyzing a more extensive network that includes treatment adherence and cognitive domains affected in SSD could enhance and validate the understanding of the cascading effects of symptoms and insight dimensions, allowing for more tailored treatments.Plain Language Summary TitleInterconnections between levels of awareness and clinical symptoms in schizophrenia and related disorders.

The Psychosocial Impact of Insight Paradox and Internalized Stigma in Chronic Psychotic Disorders

Stigma and discrimination remain significant challenges to the quality of life and social integration of individuals with chronic mental disorders, particularly schizophrenia, one of the most stigmatized conditions. The paradox of insight, in which greater awareness of illness correlates with poorer psychosocial outcomes in the presence of high internalized stigma, provides a critical framework for understanding these challenges. This study examined the moderation between insight and internalized stigma and its influence on psychosocial outcomes in 83 male participants diagnosed with psychotic spectrum disorders. Using K-means clustering, three distinct profiles emerged: (1) good insight and minimal stigma, (2) poor insight and mild stigma, and (3) good insight and severe stigma. These profiles showed significant differences in depression, quality of life, and global functioning. Findings confirmed that internalized stigma moderates the relationship between insight and psychosocial well-being, exacerbating the negative influence of insight on quality of life and psychological health when stigma levels are high. The results emphasize the need for psychoeducational interventions to normalize experiences of psychosis, family and community engagement to reduce stigma, and cognitive-behavioral therapies to address stigma-related beliefs. These strategies are essential for improving psychosocial well-being and supporting recovery in this population.

Persons at risk for psychosis overestimate social functioning compared to persons with major depressive disorder and community controls

Poor insight is common in persons with psychosis, but treatment can improve insight. Individuals with psychosis who exhibit better insight have better social functioning, reduced negative symptoms, and paradoxically worse depression. There is limited research investigating insight among persons at clinical high risk for psychosis (CHR). Understanding the relationship between insight, social functioning, negative symptoms, and depression might inform treatment. We focused on introspective bias (IB), the overestimation or underestimation of social functioning. Persons with CHR (N = 36), Major Depressive Disorder (MDD; N = 164), and community controls (N = 60) were recruited from the Multisite Assessment of Psychosis-risk Study and completed clinical interviews and self-report instruments. The estimation type was operationalized by whether a person was above or below the standardized mean difference between self-reported and interviewer-rated social functioning. We hypothesized that 1) persons at CHR would have less depressive symptom severity than those with MDD diagnoses, but more depressive symptom severity than control participants accounting for IB within diagnostic groups, 2) CHR and MDD participants would endorse higher levels of negative symptoms, viewed transdiagnostically (e.g., anhedonia, avolition), than controls but not each other, 3) overestimators would endorse higher levels of negative symptoms and depression than underestimators, 4) CHR participants would have the greatest proportions of overestimators, MDD would have the greatest proportion of underestimators, and control participants would have equal proportions of under- and overestimators. Those at CHR had more overestimators, overestimators overall had worse depression and negative symptoms, and diagnostic group membership did not impact the effects of IB on symptoms. This study suggests that IB has clinically relevant correlates but is not a primary treatment target for persons at CHR.

Protocol for evaluation of iTEST, a novel blended intervention to enhance introspective accuracy in psychotic disorders

Poor introspective accuracy (IA), defined as inaccurate judgments of one's abilities and performance, is a strong and independent predictor of functional impairment in people with psychotic disorders. However, there are currently no treatments that directly target IA in this population as a primary outcome. We describe a protocol for a clinical trial to test a newly developed blended digital intervention, Improving Thinking through Everyday SelfAssessment Training (iTEST), aimed at improving IA in people with psychotic disorders to improve functional outcomes. iTEST involves daily training consisting of feedback on IA in mobile cognitive tests, coupled with individual coaching that applies improved IA to participant-identified recovery goals. Following the NIMH experimental therapeutics paradigm, the first step in the evaluation of iTEST is an open trial in 60 individuals with psychotic disorders to assess 1) feasibility and acceptability, and 2) whether the intervention leads to clinically significant improvement in an objective target: IA on trained tasks along with transfer to an untrained task-based measure of IA. After programming of the mobile intervention and the creation of treatment manuals, enrollment for an open trial started in November 2023 and will be completed by April 2025. If effective, iTEST could be integrated with cognitive training and other rehabilitative interventions to boost the impact on functional outcomes. Trial registration: ClinicalTrials.gov NCT05899348.

Is too much insight bad for you?

Insight in psychosis is associated with reduced psychotic symptom severity, less coercive treatment and better functioning. Controversially, it has been suggested that insight may lead to depression, higher suicide risk and worse self-perceived quality of life. Future clinical trials are warranted to address this 'insight paradox', particularly the direction of causality.

Predictors of clinical insight in first-episode psychosis: Different patterns in men and women

BACKGROUND

We aimed to explore gender-related differences in the associations of insight impairment with clinical symptoms, metacognition, and social cognition in psychosis.

METHODS

Regression analysis of several clinical insight dimensions was conducted on the data from 116 men and 56 women with first-episode psychosis. Various clinical symptoms and measures of metacognition and social cognition were entered as predictors.

RESULTS

In both men and women, delusions emerged as a strong predictor of all insight dimensions, and verbal hallucinations as a strong predictor of symptom relabelling. In men, certain negative symptoms as well as self-certainty, lack of self-reflectiveness, impaired theory of mind, attributional biases, and a jumping-to-conclusions bias were additional predictors of poor insight, while good insight was associated with depression, anxiety, avolition, blunted affect, and impaired emotional recognition. In women, poor insight was associated with a self-serving/externalising bias, impaired emotional recognition, and attention disorders.

CONCLUSIONS

Poor insight in first-episode psychosis is strongly linked to deficits in metacognition and social cognition, with marked differences between men and women with respect to the specific skills involved in the impairment. Meanwhile, good insight is linked to a variety of affective manifestations in men. These findings suggest new avenues for more targeted cognitive interventions to improve clinical insight in psychosis.

Factors influencing the level of insight and treatment attitude: a cross-sectional study of 141 elderly patients of major depression in Guangzhou, China

Objective

To explore the insight, treatment attitude, and related influencing factors of hospitalized elderly patients suffering from major depression.

Methods

A total of 141 hospitalized elderly patients with depression were selected as the research objects. Insight was evaluated by the total score of the Insight and Treatment Attitude questionnaire (ITAQ). The data collected included sociodemographic characteristics, psychiatric symptoms, delirium status, social functioning, social support, suicide risk, and cognitive function.

Results

The sample included 74.5% of female patients, and the mean age was 67.53 (sd=7.19) years. The influencing factors of inpatients with depression included alcohol consumption, length of hospitalization, admission types, and the main caregivers (P<0.05). The various factors were further analyzed by linear regression, revealing that the insight and treatment attitude of elderly depressed hospitalized patients were mainly related to the Mini-Mental State Examination (MMSE) (β= 0.225, 95% CI 0.055-0.395, P=0.01), dependent on a caregiver (β=-5.810, 95% CI -8.086~-3.535, P<0.001), the type of admission (involuntary admission) (β=-3.365, 95% CI -5.448~-1.283, P=0.002), Functional Activities Questionnaire (FAQ) (β=-0.156, 95% CI -0.303~-0.010, P=0.037), and length of stay (≤28 days) (β=2.272, 95% CI 0.055~-4.489, P=0.045).

Conclusion

The level of insight was affected by cognitive function, involuntary admission, dependent on a caregiver, social function and length of stay. Future studies should focus on cognitive function recovery, observation of admission mode, and self-care ability in elderly patients with depression.

Demoralization in Schizophrenia: A Pathway to Suicidal Ideation?

INTRODUCTION

Individuals with schizophrenia are at increased risk for suicide, and the Demoralization Hypothesis states that non-delusional awareness of one's social, cognitive, or occupational deterioration elicits depression and hopelessness. Both depression and hopelessness are established risk factors for suicide and are features of schizophrenia. The present study investigated whether insight into one's schizophrenia yields suicidal ideation, specifically by way of thwarted belongingness and perceived burdensomeness, which are constructs related to demoralization and measured by the Interpersonal Needs Questionnaire (INQ).

METHODS

Three separate models explored the mediating role of INQ scores on suicidal ideation in 99 participants with schizophrenia. With suicidal ideation entered as the dependent variable and INQ scores entered as the mediator, the first model included insight as the independent variable, the second included cognitive functioning, and the third included cognitive deterioration post-illness-onset.

RESULTS

Consistent with our hypothesis, INQ scores related to suicidal ideation (B = .03, SE = .01, p < .001). However, neither insight, cognitive functioning, nor cognitive deterioration predicted INQ scores or suicidal ideation. Additionally, INQ scores did not mediate relationships with suicidal, ideation.

CONCLUSION

Although INQ scores led to increased suicidal ideation, neither insight into illness, current cognitive functioning, nor shift in functioning led to increased INQ scores. Implications are discussed, and future directions are proposed.

Functioning, clinical severity, education and sex moderate the inverse relationship between insight and quality of life in patients with schizophrenia

BACKGROUND

In schizophrenia, insight, the recognition that one has a medical illness that requires treatment, has long been related to deteriorated quality of life, a phenomenon that has been described as the "insight paradox". Here, we aimed to determine whether certain socio-demographic and clinical characteristics strengthen or weaken this negative relationship.

METHODS

We used data from the French network of rehabilitation centers REHABase (N = 769). We explored mean differences in quality-of-life scores between patients with good insight vs. poor insight. We also explored modifying effects of socio-demographic and clinical characteristics (sex, education, age, functioning, clinical severity, duration of illness).

RESULTS

Patients with good insight had a decreased quality-of-life total score. Similar effects were found for the following sub-dimensions of quality of life: autonomy, physical and psychological well-being, and self-esteem. The negative effect of insight on quality of life was attenuated for people who had >12 years of education and for people with a higher level of functioning. By contrast, the negative effect of insight on quality of life was accentuated in people with greater clinical severity. Functioning and clinical severity showed similar modifying effects for other quality-of-life dimensions: autonomy, physical and psychological well-being, and self-esteem. Finally, males demonstrated an increased negative association between insight and self-esteem.

CONCLUSIONS

The relationship between insight and quality of life is moderated by socio-demographic and clinical circumstances. Future inquiries may utilize our findings by integrating socio-demographic and clinical factors in treatment programs designs to conjointly improve insight and quality of life.

The role of insight, social rank, mindfulness and self-compassion in depression following first episode psychosis

Gaining awareness of psychosis (i.e., insight) is linked to depression, particularly in the post-acute phase of psychosis. Informed by social rank theory, we examined whether the insight-depression relationship is explained by reduced social rank related to psychosis and whether self-compassion (including uncompassionate self-responding [UCS] and compassionate self-responding [CSR]) and mindfulness buffered the relationship between social rank and depression in individuals with first episode psychosis during the post-acute phase. Participants were 145 young people (Mage  = 20.81; female = 66) with first episode psychosis approaching discharge from an early psychosis intervention centre. Questionnaires and interviews assessed insight, depressive symptoms, perceived social rank, self-compassion, mindfulness and illness severity. Results showed that insight was not significantly associated to depression and thus no mediation analysis was conducted. However, lower perceived social rank was related to higher depression, and this relationship was moderated by self-compassion and, more specifically, UCS. Mindfulness was related to depression but had no moderating effect on social rank and depression. Results supported previous findings that depressive symptoms are common during the post-acute phase. The role of insight in depression for this sample is unclear and may be less important during the post-acute phase than previously considered. Supporting social rank theory, the results suggest that low perceived social rank contributes to depression, and reducing UCS may ameliorate this effect. UCS, social rank and possibly mindfulness may be valuable intervention targets for depression intervention and prevention efforts in the recovery of psychosis.

Patterns and correlates of insight among patients with schizophrenia in China：A network perspective

OBJECTIVE

To explore the patterns and correlates of insight among patients with schizophrenia in a large Chinese population.

METHOD

A multi-center cross-sectional study was conducted in Guangdong province, China. Patients with schizophrenia were included. Basic socio-demographic and clinical characteristics were collected in this study. Univariate analyses, multivariate logistic regression, and network analysis were conducted.

RESULTS

A total of 6090 participants (58.8% were male, and 41.2% were female) met the study criteria and completed all the assessments. 63.5% (n = 3869) patients with schizophrenia had impaired insight. Fewer drug sides effect, higher psychological and environment domains scores in quality of life have a positive significant impact on insight in patients with schizophrenia. Younger age, higher BPRS scores have a negative significant impact on insight in patients with schizophrenia. The node ITAQ 8 (strength=1.17) was the most central node within the ITAQ network, while node ITAQ 3 was the least central node (strength=0.69). The edge ITAQ 1-ITAQ 2 was the thickest and most saturated edge in network model.

CONCLUSIONS

Considering patterns and correlation of insight, it is necessary to ensure adherence to medications and engagement with mental health services for patients with schizophrenia, which could also improve their quality of life. Taking medication actively is more central to identify ITAQ and might be the potential targets for future interventions.

Insight in schizophrenia is associated with psychoeducation and social support: Testing a new more comprehensive insight tool in Turkish schizophrenia patients

Insight is a continuous and multidimensional phenomenon, including awareness of having an illness, the presence of symptoms and accurate symptom attribution, the need for treatment, and the consequences of treatment. Good insight into illness is associated with better adherence to treatment, better cognitive, psychosocial, and vocational functioning along with less symptom severity, decreased relapses, and hospitalizations. Several tools are used for insight evaluation. We recruited 90 patients diagnosed with schizophrenia and analyzed the forms of 58 patients. The patients completed the VAGUS-SR (self-rated), Beck Cognitive Insight Scale, Knowledge About Schizophrenia Questionnaire, and Multidimensional Scale of Perceived Social Support (MSPSS). Clinicians performed a mental status examination and completed the Positive and Negative Syndrome Scale, Schedule for the Assessment of Insight, VAGUS-CR (clinician-rated), Calgary Depression Scale for Schizophrenia, and Clinical Global Impressions. We found that the level of insight evaluated using the VAGUS forms increased with knowledge regarding schizophrenia. Upon investigating the relationship between perceived social support and insight, we identified a relationship between VAGUS-CR and only significant other subscales of MSPSS, and between one of the VAGUS-SR scale sub-dimensions and significant other and total scores of MSPSS. Our findings also suggest that the VAGUS-SR and VAGUS-CR scales can be used to evaluate insight in Turkish populations. The positive relationship between perceived social support and insight emphasizes the importance of increasing social support through interventions aimed at improving insight. Our data also highlighted the value of psychoeducational studies in this patient group. Considering the multidimensional effects of insight on patients with schizophrenia, it would be beneficial to use scales such as VAGUS, which allow the insights of individuals to be evaluated in detail by both the clinician and the patient.

Role of Clinical Insight at First Month in Predicting Relapse at the Year in First Episode of Psychosis (FEP) Patients

INTRODUCTION

Clinical insight constitutes a useful marker of the progress and outcome of the First Episode of Psychosis (FEP), and lack of insight has been associated with more severe psychopathology, treatment non-adherence, and rehospitalization/relapse. In this study, we aimed to further investigate the possible role of insight as a predictor of relapse, its relation to diagnosis, and other parameters of positive psychotic symptomatology (delusions, hallucinations, and suspiciousness).

METHODS

The Athens FEP study employed a prospective, longitudinal cohort design in which consecutive newly diagnosed patients with psychosis were interviewed and asked to voluntarily participate after completing informed consent. A total of 88/225 patients were examined at three different time points (baseline, month, and year). Their scores in the relevant items of the Positive and Negative Syndrome Scale (PANSS) were compared (G12 for insight, P1 for delusions, P3 for hallucinations, and P6 for suspiciousness), and they were further associated to diagnosis and the outcome at the end of the year (remission/relapse).

RESULTS

In total, 22/88 patients with relapse at the year had greater scores in G12 for both the month and the year, and this finding was corroborated after adjusting the statistical analysis for demographics, diagnosis, social environment, and depression via multiple logistic regression analysis. Moreover, delusions and suspiciousness were significantly higher in patients diagnosed with non-affective psychosis compared to those diagnosed with affective psychosis (p < 0.001) at the first month.

CONCLUSIONS

Lack of insight at the first month may serve as a predictor of relapse at the year.

Development and validation of the Schedule for the Assessment of Insight in Alcohol Dependence (SAI-AD): Dimensions and correlates of insight in alcohol use disorder

INTRODUCTION

The objectives of this study were to develop a multidimensional, clinician-rated scale that assess impaired insight into illness in patients with alcohol use disorder (AUD) and to examine its reliability, validity and internal structure. Moreover, we investigated the relationships of overall insight and its dimensions with demographic and clinical characteristics in AUD.

METHODS

We developed the Schedule for the Assessment of Insight in Alcohol Dependence (SAI-AD), based on scales that has already been used in psychosis and other mental disorders. Sixty-four patients with AUD were assessed with SAI-AD. Hierarchical cluster analysis and multidimensional scaling were used to identify insight components and assess their inter-relationships.

RESULTS

The SAI-AD demonstrated good convergent validity (r = -0.73, p < 0.001) and internal consistency (Cronbach's alpha = 0.72). Inter-rater and test-retest reliabilities were high (intra-class correlations 0.90 and 0.88, respectively). Three subscales of SAI-AD were identified which measure major insight components: awareness of illness, recognition of symptoms and need for treatment, and treatment engagement. Higher levels of depression, anxiety and AUD symptom severity were associated with overall insight impairment but not with recognition of symptoms and need for treatment, or with treatment engagement. Illness duration was specifically and positively associated with the treatment engagement component of insight.

CONCLUSIONS

Insight is a multidimensional construct in AUD and its major components appear to be associated with different clinical aspects of the disorder. The SAI-AD is a valid and reliable tool for the assessment of insight in AUD patients.

Mediation Effects of Social Cognition on the Relationship between Neurocognition and Social Functioning in Major Depressive Disorder and Schizophrenia Spectrum Disorders

BACKGROUND

In schizophrenia spectrum disorders (SSD), social cognition mediates the relationship between neurocognition and social functioning. Although people with major depressive disorder (MDD) also exhibit cognitive impairments, which are often prolonged, little is known about the role of social cognition in MDD.

METHODS

Using data obtained through an internet survey, 210 patients with SSD or MDD were selected using propensity score matching based on their demographics and illness duration. Social cognition, neurocognition, and social functioning were evaluated using the Self-Assessment of Social Cognition Impairments, Perceived Deficits Questionnaire, and Social Functioning Scale, respectively. The mediation effects of social cognition on the relationship between neurocognition and social functioning were examined in each group. Invariances of the mediation model across the two groups were then analyzed.

RESULTS

The SSD and MDD groups had mean ages of 44.49 and 45.35 years, contained 42.0% and 42.8% women, and had mean illness durations of 10.76 and 10.45 years, respectively. In both groups, social cognition had significant mediation effects. Configural, measurement, and structural invariances across the groups were established.

CONCLUSION

The role of social cognition in patients with MDD was similar to that in SSD. Social cognition could be a common endophenotype for various psychiatric disorders.

Auditory Hallucinations, Depressive Symptoms, and Current Suicidal Ideation or Behavior Among Patients with Acute-episode Schizophrenia

Suicide risk and auditory hallucinations are common in schizophrenia, but less is known about its associations. This cross-sectional study aimed to determine whether the presence and severity of auditory hallucinations were associated with current suicidal ideation or behavior (CSIB) among patients with schizophrenia. We interviewed 299 individuals with schizophrenia and acute symptoms and reviewed their medical records. Measurement included the Psychotic Symptom Rating Scale (PSYRATS-AH), the Calgary Depression Scale for Schizophrenia (CDSS), and the Positive and Negative Syndrome Scale. Logistic regression and path analysis were used. The CSIB prevalence was higher among patients with current auditory hallucination than those without (19.5% vs. 8.6%, crude odds ratio = 2.58, p = .009). Lifetime auditory hallucination experience (adjusted odds ratio [AOR] = 3.81; 95% CI: 1.45-10.05) or current auditory hallucination experience (AOR = 3.22; 95% CI: 1.25-8.28) can elevate the likelihood of CSIB while controlling for depressive symptoms and lifetime suicide-attempt history. Among those with auditory hallucinations, the emotional score of the PSYRATS-AH was positively associated with the CDSS score and there was a small indirect effect of the CDSS score on the association between the emotional domain score and CSIB (bias-corrected 95% CI, 0.02-0.20). In conclusion, the presence of auditory hallucinations was strongly associated with CSIB, independent of depressive symptoms and lifetime suicide attempts. Suicide risk assessment should consider auditory hallucination experience and patients' appraisal of its emotional characteristics. Future cohort studies are necessary to provide more conclusive evidence for the mediating pathways between auditory hallucinations and CSIB.HIGHLIGHTSThe presence of auditory hallucinations was associated with current suicidality.Auditory hallucinations' emotional severity was related to depressive symptoms.The severity of auditory hallucination was not directly associated with suicidality.

Two-year cohort-up study of clozapine prescription in Chinese patients with schizophrenia treated in rural primary care

Few studies have examined the clozapine in cohort studies of Chinese patients with schizophrenia in rural primary care. The objective of this two-year cohort study was to describe the usage of clozapine and investigate and identify the demographic, clinical correlations and risk variables which affect the use of clozapine in patients with schizophrenia. A random cluster sampling technique was used, and participants were collected from China National Psychiatric Management System (CNPMS). The variables for clozapine use in individuals with schizophrenia who had undergone a two-year follow-up were determined using the generalized estimating equation (GEE). In this study, 742 patients with schizophrenia were invited, and 491 completed the two-year follow-up study. Being married, more years of education, more waist circumference, using mood stabilizer, using anticholinergic, higher ITAQ (Insight and Treatment Attitude Questionnaire) scores were more significantly related to the use of clozapine. Older age of onset, using second-generation antipsychotics (SGAs) except clozapine predicted a lower prevalence of using clozapine. The usage of clozapine was very common in patients with schizophrenia treated by primary care physicians, and was influenced by a variety of factors, including price of drugs, clinical factors, health regulations, and the characteristics of treatment environment. Further examination of the rationale and appropriateness of clozapine in primary care in China is necessary.

Preserved electrophysiological markers of confidence in schizophrenia spectrum disorder

A large number of behavioral studies suggest that confidence judgments are impaired in schizophrenia, motivating the search for neural correlates of an underlying metacognitive impairment. Electrophysiological studies suggest that a specific evoked response potential reflecting performance monitoring, namely the error-related negativity (ERN), is blunted in schizophrenia compared to healthy controls. However, attention has recently been drawn to a potential confound in the study of metacognition, namely that lower task-performance in schizophrenia compared to healthy controls involves a decreased index of metacognitive performance (where metacognitive performance is construed as the ability to calibrate one's confidence relative to response correctness), independently of metacognitive abilities among patients. Here, we assessed how this confound might also apply to ERN-blunting in schizophrenia. We used an adaptive staircase procedure to titrate task-performance on a motion discrimination task in which participants (N = 14 patients and 19 controls) had to report their confidence after each trial while we recorded high density EEG. Interestingly, not only metaperceptual abilities were preserved among patients at the behavioral level, but contrary to our hypothesis, we also found no electrophysiological evidence for altered EEG markers of performance monitoring. These results bring additional evidence suggesting an unaltered ability to monitor perceptual performance on a trial by trial basis in schizophrenia.

Interactions between mood and paranoid symptoms affect suicidality in first-episode affective psychoses

BACKGROUND

Suicide prevention is a major challenge in the treatment of first-episode affective psychoses. The literature reports that combinations of manic, depressive and paranoid symptoms, which may interact, are associated with an increased risk of suicide. The present study investigated whether interactions between manic, depressive and paranoid symptoms affected suicidality in first-episode affective psychoses.

METHODS

We prospectively studied 380 first-episode psychosis patients enrolled in an early intervention programme and diagnosed with affective or non-affective psychoses. We compared intensity and presence of suicidal thoughts and occurrence of suicide attempts over a three-year follow-up period and investigated the impact of interactions between manic, depressive and paranoid symptoms on level of suicidality.

RESULTS

At 12 months follow-up, we observed a higher level of suicidal thoughts and higher occurrence of suicide attempts among the affective psychoses patients compared to non-affective psychoses patients. Combined presence of either depressive and paranoid symptoms, or manic and paranoid symptoms, was significantly associated with increased suicidal thoughts. However, the combination of depressive and manic symptoms showed a significant negative association with suicidal thoughts.

CONCLUSIONS

This study suggests that paranoid symptoms combined with either manic or depressive symptoms are associated with an increased risk of suicide in first-episode affective psychoses. Detailed assessment of these dimensions is therefore warranted in first-episode affective patients and integrated treatment should be adapted to increased suicidal risk, even if patients do not display full-blown depressive or manic syndromes.

Clinical insight in first episode psychosis: the role of metacognition

BACKGROUND

Poor clinical insight has been commonly reported in those with First Episode Psychosis (FEP) and thought to be influenced by a range of factors, including neurocognition and symptoms. Clinical insight may be compromised as a result of alterations in higher-level reflective processes, such as metacognitive ability and cognitive insight.

AIMS

To explore whether metacognitive ability and cognitive insight are associated with clinical insight while controlling for IQ, depression, and symptoms in FEP.

METHODS

60 individuals with FEP completed measures for clinical insight, metacognitive ability, cognitive insight, positive and negative symptoms, depression, and IQ.

RESULTS

Higher levels of metacognitive ability were associated with better clinical insight, even when controlling for IQ, depression, positive and negative symptoms, and medication. Integration subscale of metacognitive ability was most strongly associated with clinical insight. Cognitive insight was associated with clinical insight when controlling for covariates. However, when including metacognitive ability and cognitive insight in the predictive model, only metacognitive ability was significantly related to clinical insight.

DISCUSSION

Metacognitive ability, specifically the ability to describe one's evolving mental state to provide a coherent narrative, was significantly related to clinical insight, independent of covariates, and may be a potentially important target for intervention in FEP.

A pilot 1-year follow-up randomised controlled trial comparing metacognitive training to psychoeducation in schizophrenia: effects on insight

Poor insight in schizophrenia spectrum disorders (SSD) is linked with negative outcomes. This single-centre, assessor-blind, parallel-group 1-year follow-up randomised controlled trial (RCT) tested whether metacognitive training (MCT) (compared to psychoeducation) may improve insight and outcomes in outpatients with SSD assessed: at baseline (T0); after treatment (T1) and at 1-year follow-up (T2). Insight (primary outcome) was measured with (i) the Schedule for Assessment of Insight-Expanded version- (SAI-E), including illness recognition (IR), symptom relabelling (SR), treatment compliance (TC) and total insight scores (TIS); and (ii) the Beck Cognitive Insight Scale (BCIS). Between-group comparisons were nonsignificant, while within the MCT group (but not within controls) there was a significant medium effect size for improved TIS at T2 (d = 0.67, P = 0.02). Secondary outcomes included cognitive measures: Jumping to Conclusions (JTC), Theory of Mind (ToM), plus symptom severity and functioning. Compared to psychoeducation, MCT improved the PANSS excitement (d = 1.21, P = 0.01) and depressed (d = 0.76, P = 0.05) factors at T2; and a JTC task both at T1 (P = 0.016) and at T2 (P = 0.031). Participants in this RCT receiving MCT showed improved insight at 1-year follow-up, which was associated with better mood and reduced JTC cognitive bias. In this pilot study, no significant benefits on insight of MCT over psychoeducation were detected, which may have been due to insufficient power.

Correlates of poor insight: A comparative fMRI and sMRI study in obsessive-compulsive disorder and schizo-obsessive disorder

BACKGROUND

Despite the several researches on the correlates of insight in psychosis, less is known regarding the specificity of disease diagnosis on the relationship between insight and the correlates. The current study sought to explore the effects of insight and disease diagnosis on those in patients with obsessive-compulsive disorder (OCD) and patients with schizo-obsessive disorder (SOD).

METHODS

We evaluated clinical symptoms and neurocognitions among 111 patients (including 41 OCD with good insight, 40 OCD with poor insight, 14 SOD with good insight and 16 SOD with poor insight. Gray matter volume and spontaneous neural activity were also examined by analyzing the voxel-based morphometry and amplitude of low frequency fluctuation (ALFF), respectively.

RESULTS

Interactive effects of insight and diagnosis was found on working memory and the gray matter volume in right superior and middle temporal gyrus. Main effect of insight was found on working and visual memory, compulsion and obsession, and ALFF in right middle and superior occipital cortex. Main effect of diagnosis was found on severity of compulsion, relative verbal IQ, executive function, verbal and visual memory, working memory and ALFF in precuneus, medial superior frontal gyrus, anterior cingulate and paracingulate gyri, and inferior parietal, postcentral gyrus, paracentral lobule.

CONCLUSIONS

As a common feature in mental disorders, insight has its own special influence on neurocognition and possible structural/functional alterations in brain, and the influence is partly dependent of disease diagnosis.

A Randomized Controlled Trial of the Effects of Early Intervention Services On Insight in First Episode Psychosis

BACKGROUND AND HYPOTHESIS

Impaired insight into one's illness is common in first episode psychosis (FEP), is associated with worse symptoms and functioning, and predicts a worse course of illness. Despite its importance, little research has examined the effects of early intervention services (EIS) on insight.

DESIGNS

This paper evaluated the impact of EIS (NAVIGATE) on insight compared to usual community care (CC) in a large cluster randomized controlled trial. Assessments were conducted at baseline and every 6 months for 2 years.

RESULTS

A multilevel regression model including all time points showed a significant time by treatment group interaction (P < .001), reflecting greater improvement in insight for NAVIGATE than CC participants. Impaired insight was related to less severe depression but worse other symptoms and functioning at baseline for the total sample. At 6 months, the same pattern was found within each group except insight was no longer associated with depression among NAVIGATE participants. Impaired insight was more strongly associated with worse interpersonal relationships at 6 months in NAVIGATE than in CC, and changes in insight from baseline to 6 months were more strongly correlated with changes in relationships in NAVIGATE than CC.

CONCLUSIONS

The NAVIGATE program improved insight significantly more than CC. Although greater awareness of illness has frequently been found to be associated with higher depression in schizophrenia, these findings suggest EIS programs can improve insight without worsening depression in FEP. The increased association between insight and social relationships in NAVIGATE suggests these 2 outcomes may synergistically interact to improve each other in treatment.

The differential associations of positive and negative symptoms with suicidality

BACKGROUND

Suicide is one of the leading causes of death in people with schizophrenia. Identifying risk factors for suicide in schizophrenia is therefore an important clinical and research priority.

METHOD

A cross-sectional secondary analysis was conducted on the DNA Polymorphisms in Mental Illness Study (DPIM) data. Suicidality data was extracted, and the number of positive and negative symptoms were established for a total of 1494 participants. Logistic and negative binomial regression analyses were conducted to assess for associations between positive or negative symptoms and suicidal ideation, attempt, or number of attempts, whilst adjusting for potential confounders.

RESULTS

Negative symptoms were associated with a reduction in the risk of suicidal ideation (odds ratio [OR]: 0.83; 95 % CI: 0.75-0.91) and suicide attempt (OR: 0.79; 95 % CI: 0.71-0.88) after adjusting for age and sex. Positive symptoms were associated with an increased risk of suicidal ideation (OR: 1.06; 95 % CI: 1.03-1.09), suicide attempt (OR: 1.04; 95 % CI: 1.00-1.07) and number of suicide attempts (incidence rate ratio [IRR]: 1.05; 95 % CI: 1.01-1.08). Further adjusting for depressive symptoms slightly increased the magnitude of associations with negative symptoms but attenuated associations between positive symptoms and suicidality to the null.

CONCLUSIONS

Negative symptoms are associated with a reduced risk of suicidality, whilst positive symptoms are associated with an increased risk of suicidality. Depressive symptoms may confound or mediate these associations.

Association between obsession, compulsion, depression and insight in obsessive-compulsive disorder: a meta-analysis

BACKGROUND

Previous studies examining potential relationships of impaired insight with severity obsessive-compulsive (O-C) symptoms and depressive symptoms in patients diagnosed with obsessive-compulsive disorder (OCD) have produced mixed results. Here, we examined differences in these clinical characteristics and their changes after treatment in adult patients with OCD who have poor insight (OCD-PI) versus in those who have good insight (OCD-GI).

METHODS

Fifty-nine full-text articles were screened for eligibility with 20 studies ultimately being included in the present meta-analysis.

RESULTS

The OCD-PI and OCD-GI groups differed from each other with respect to O-C symptom (p < 0.001, g > 0.7) and depressive symptom (p < 0.001, g = 0.614) severity. Significant and moderate correlations were observed between insight and treatment outcomes (O-C symptoms, r = 0.33; depressive symptoms, r = 0.47). Exploratory meta-regression showed that methodological factors influenced the magnitudes of inter-group O-C symptom differences.

CONCLUSIONS

The current meta-analysis indicates that poorer insight is associated with more severe O-C and depression, and less improvement of symptoms in patients with OCD. Insight impairment may be a critical and core OCD-related deficit.

Clinical insight in first-episode psychosis: Clinical, neurocognitive and metacognitive predictors

OBJECTIVE

Poor insight is a major problem in psychosis, being detrimental for treatment compliance and recovery. Previous studies have identified various correlates of insight impairment, mostly in chronic samples. The current study aimed to determine clinical, neurocognitive, metacognitive, and socio-cognitive predictors of insight in first-episode psychosis.

METHODS

Regression analyses of different insight dimensions were conducted in 190 patients with first-episode psychosis. Measures of clinical symptoms, neurocognition, metacognition, social cognition, and 'jumping to conclusions' bias were entered as predictors.

RESULTS

Delusions, disorganisation, and certain negative symptoms were associated with unawareness in various domains, while depression was associated with greater awareness of illness. Deficit in theory of mind and self-reflective processes, as well as a 'jumping to conclusions' bias, contributed to poor insight. Several neuropsychological scores also contributed to this but their contribution was no longer observed in regression analyses that included all the previously identified clinical and cognitive predictors. A measure of perseverative errors was still associated with unawareness and misattribution of symptoms.

CONCLUSION

In models that account for 28 % to 50 % of the variance, poor insight in first-episode psychosis is mainly associated with delusions and certain negative symptoms. At the cognitive level it does not appear to result from neuropsychological impairment but rather from altered reasoning bias and dysfunction in metacognitive processes. Therapeutic strategies specifically directed at these mechanisms could help improve the evolution of insight in first episode psychosis.

Impaired insight in schizophrenia: impact on patient-reported and physician-reported outcome measures in a randomized controlled trial

BACKGROUND

Impaired insight poses a challenge in the treatment of patients with schizophrenia because of its potential to jeopardize therapeutic engagement and medication adherence. This study explored how insight impairment, graded from none to extreme, is related to patient-reported mental health status, depression, and neurocognition in schizophrenia.

METHODS

In a post hoc analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study (NCT00014001), insight was measured using the Positive and Negative Syndrome Scale (PANSS) Item G12 (lack of insight). Additional assessments for this analysis included the 12-Item Short-Form Health Survey (SF-12) Mental Component Summary (MCS), physician- and patient-reported Clinical Global Impression-Severity (CGI-S), MATRICS Consensus Cognitive Battery, and Calgary Depression Scale for Schizophrenia. Relationships between patient-reported outcomes and PANSS total and Item G12 ratings were evaluated.

RESULTS

Among 1431 CATIE study participants in this analysis, increasingly impaired insight at baseline was significantly associated with better patient-reported quality of life (QoL), lower baseline depression, and greater divergence between physician- and patient-reported illness severity. Patients with more severely impaired insight reported milder illness compared with physician reports, particularly those with moderate-severe to extreme impairment (PANSS Item G12 rating ≥ 5), approximately 10% (138/1431) of CATIE participants. For the 90% of patients with PANSS Item G12 ratings < 5, patient-reported QoL decreased with increasing symptoms. SF-12 MCS scores were linearly related to baseline PANSS total score only in patients with PANSS total score < 90 (moderately ill or better), and better symptom scores were associated with higher QoL. No significant relationship between insight and neurocognition was observed.

CONCLUSIONS

In the small subgroup (10%) of CATIE study patients with schizophrenia and PANSS Item G12 ratings ≥5, moderate-severe-severe/extreme insight impairment was associated with significantly more positive perception of QoL and illness severity by the patient versus the treating physician. This was not observed in the remaining 90% of patients with normal to moderately impaired insight, suggesting that poor insight as a threat to the validity of self-report is uncommon.

Clinical and psychological correlates of insight dimensions in patients with early psychosis

AIM

To investigate correlates of insight dimensions in Chinese adult patients with early psychosis.

METHODS

Insight dimensions including awareness of mental disorder (AMD), illness consequences (AIC) and medication effect (AME) were measured. A wide array of variables encompassing demographics, premorbid adjustment, onset profiles, symptomatology, treatment characteristics and psychological factors were comprehensively assessed.

RESULTS

Of 130 participants, 53.1%, 47.7% and 56.2% were categorized with good AMD, AIC and AME, respectively. Good AMD was associated with female gender, fewer positive and disorganization symptoms, more severe depression and greater self-stigma. Good AIC was related to female gender, more severe depression and greater self-stigma. Younger age of onset, fewer positive symptoms and greater service satisfaction associated with good AME.

CONCLUSIONS

Poor insight is prevalent in early psychosis. Differential relationships of insight dimensions with other illness variables underscore the importance of multidimensional approach in insight evaluation, and suggest potential treatment target for insight enhancement.

An Update on Clinical Insight, Cognitive Insight, and Introspective Accuracy in Schizophrenia-Spectrum Disorders: Symptoms, Cognition, and Treatment

INTRODUCTION

Poor insight, or unawareness of morbid changes in cognition, emotional states, or behavior, is commonly observed among people with schizophrenia. Poor insight represents a persistent barrier to wellness because it interferes with treatment and self-direction. Paradoxically, good insight may also be a barrier to health when awareness of these changes leads to depression or self-stigma.

AREAS COVERED

This paper builds upon this previous work by exploring these issues in schizophrenia separately as they have appeared in published research over the last three years in three different kinds of insight: clinical, cognition, and introspective accuracy. Specifically, studies are reviewed that address: the adverse effects of poor insight, the paradoxical effects of good insight, correlates with other forms of cognition, and emerging treatments.

EXPERT OPINION

The evidence continues to offer a nuanced picture of the complex effects of good insight in schizophrenia. Incremental improvements were also found in the development of novel integrative treatment approaches. This work also highlights the intricacy of the concept of insight, the need for further exploration of the effects of culture, and conceptual work that distinguishes the points of convergence and divergence of these forms of insight.

Clinical insight and cognitive functioning as mediators in the relationships between symptoms of psychosis, depression, and suicide ideation in first-episode psychosis

First-episode psychosis (FEP) is a particularly high-risk period for suicide. Literature suggests poor cognitive functioning may serve as a protective factor, while investigations of clinical insight reveal a complex relationship with suicide outcomes. This study examined the mediating role of cognition and clinical insight in the relationships between positive and negative symptoms, depression, and subsequent suicide ideation among individuals in FEP. Data were obtained from the Recovery After an Initial Schizophrenia Episode project. Participants (n = 404) included adolescents and adults in FEP between the ages of 15 and 40. Measurement utilized the Calgary Depression Rating Scale, Positive and Negative Syndrome Scale, and Brief Assessment of Cognition in Schizophrenia. Structural equation modeling was used to examine the mediation model. The likelihood of experiencing suicide ideation was significantly decreased when working memory was stronger (b = -0.034, SE = 0.02, OR = 0.967, p < .05), and significantly increased when clinical insight was stronger (b = 0.191, SE = 0.08, OR = 1.21, p < .01), positive symptoms were greater (b = 0.422, SE = 0.20, OR = 1.52, p < .05) and depressive symptoms were greater (b = 0.545, SE = 0.15, OR = 1.70, p < .001). Clinical insight and working memory functioned as mediators in the relationships between depression, positive symptoms, negative symptoms, and suicide ideation. Findings suggest it is essential that clinicians have awareness of insight being a risk factor for suicide ideation and balance therapeutic efforts to strengthen clinical insight and cognition in psychosocial treatments with suicide risk assessment and prevention methods.

Effectiveness of mobile applications for patients with severe mental illness: A meta-analysis of randomized controlled trials

BACKGROUND

A systematic review and meta-analysis was conducted to evaluate the effectiveness of mobile applications used by patients diagnosed with mental disorders.

METHODS

An electronic literature search in five databases including PubMed, Embase, the Cochrane Library, CINAHL, and PsychInfo was conducted. The keywords used were "mental disorder," "mental illness," "mobile phone," "smartphone," "mHealth," "application," and "app". The search was restricted to randomized controlled trials (RCTs) written in English and Korean.

RESULTS

Fourteen RCTs, involving 1307 patients diagnosed with depression, schizophrenia, and bipolar disorder were included in the analysis. The included studies were published between 2012 and 2020 and used mobile applications. The risk of bias tool was used to assess methodological quality and the overall risk of bias of the included studies was moderate. The pooled data favored mobile application interventions in reducing the disease-related symptoms of depression (standardized mean difference [SMD] = -0.255, 95% CI: -0.370 to -0.141), mania symptoms (SMD = -0.279, 95% CI: -0.456 to -0.102), and positive (SMD = -0.205, 95% CI: -0.388 to -0.022) and negative psychotic symptoms (SMD = -0.406, 95% CI: -0.791 to -0.020). In subgroup analysis, the incorporation of feedback, notification, and data tracking features in the mobile application intervention produced better outcomes.

CONCLUSION

This review provided evidence that mobile applications could well-assist patients diagnosed with mental disorders. Greater benefits could be achieved by well-designed interventions incorporating strategies with thoughtful consideration of the disease characteristics. Mobile applications present the potential to be effective supplements to clinical treatment.

Video self-confrontation as a therapeutic tool in schizophrenia: A randomized parallel-arm single-blind trial

BACKGROUND

Lack of insight is a barrier to treating psychosis. Preliminary studies have suggested that showing people videos of their psychotic behaviour may improve personal insight. This clinical trial aimed to assess the effect of video self-confrontation.

METHODS

Inpatients between 18 and 65 years old with schizophrenia or schizoaffective disorder were filmed upon admission to two psychiatric hospitals while experiencing acute psychosis. After stabilization, individuals were randomized 1:1 to the "self-video" group where they watched their own video or to the "no video" control group. The primary outcome was the Scale to assess Unawareness of Mental Disorder (SUMD) at 48 h by a blinded assessor. Secondary objectives included psychotic and depressive symptoms, medication adherence and functioning using the Functional Remission of General Schizophrenia. Patients were followed up for four months.

RESULTS

60 participants were randomized and the level of insight did not differ between groups at 48 h (p = 0.98). There was no impact on SUMD subscores or the other insight questionnaires at any timepoint, nor on psychopathology or medication adherence. At one month, the level of functioning of those in the "self-video" group (n = 23) was higher (61.8 vs 53.5, p = 0.02), especially concerning "Treatment" and "Daily life". No adverse effects were reported. After video self-confrontation, people expressed more positive than negative emotions and were less lost to follow-up.

CONCLUSION

Video self-confrontation did not change levels of insight, but may have a therapeutic impact nonetheless, by improving levels of self-care and adherence to care, indicating that this innovative therapeutic tool requires further study.

TRIAL REGISTRATION NUMBER

NCT02664129.

Validation of the Psychological Insight Scale: A new scale to assess psychological insight following a psychedelic experience

INTRODUCTION

As their name suggests, 'psychedelic' (mind-revealing) compounds are thought to catalyse processes of psychological insight; however, few satisfactory scales exist to sample this. This study sought to develop a new scale to measure psychological insight after a psychedelic experience: the Psychological Insight Scale (PIS).

METHODS

The PIS is a six- to seven-item questionnaire that enquires about psychological insight after a psychedelic experience (PIS-6) and accompanied behavioural changes (PIS item 7). In total, 886 participants took part in a study in which the PIS and other questionnaires were completed in a prospective fashion in relation to a planned psychedelic experience. For validation purposes, data from 279 participants were analysed from a non-specific 'global psychedelic survey' study.

RESULTS

Principal components analysis of PIS scores revealed a principal component explaining 73.57% of the variance, which displayed high internal consistency at multiple timepoints throughout the study (average Cronbach's α = 0.94). Criterion validity was confirmed using the global psychedelic survey study, and convergent validity was confirmed via the Therapeutic-Realizations Scale. Furthermore, PIS scores significantly mediated the relationship between emotional breakthrough and long-term well-being.

CONCLUSION

The PIS is complementary to current subjective measures used in psychedelic studies, most of which are completed in relation to the acute experience. Insight - as measured by the PIS - was found to be a key mediator of long-term psychological outcomes following a psychedelic experience. Future research may investigate how insight varies throughout a psychedelic process, its underlying neurobiology and how it impacts behaviour and mental health.

Maintaining social capital in offenders with schizophrenia spectrum disorder-An explorative analysis of influential factors

The importance of "social capital" in offender rehabilitation has been well established: Stable family and community relationships offer practical assistance in the resettlement process after being released from custody and can serve as motivation for building a new sense of self off the criminal past, thus reducing the risk of re-offending. This also applies to offenders with severe mental disorders. The aim of this study was to identify factors that promote or hinder the establishment or maintenance of social relationships upon release from a court-ordered inpatient treatment using a modern statistical method-machine learning (ML)-on a dataset of 369 offenders with schizophrenia spectrum disorder (SSD). With an AUC of 0.73, support vector machines (SVM) outperformed all the other ML algorithms. The following factors were identified as most important for the outcome in respect of a successful re-integration into society: Social integration and living situation prior to the hospitalization, a low risk of re-offending at time of discharge from the institution, insight in the wrongfulness of the offense as well as into the underlying psychiatric illness and need for treatment, addressing future perspectives in psychotherapy, the improvement of antisocial behavior during treatment as well as a detention period of less than 1 year emerged as the most predictive out of over 500 variables in distinguishing patients who had a social network after discharge from those who did not. Surprisingly, neither severity and type of offense nor severity of the psychiatric illness proved to affect whether the patient had social contacts upon discharge or not. The fact that the majority of determinants which promote the maintenance of social contacts can be influenced by therapeutic interventions emphasizes the importance of the rehabilitative approach in forensic-psychiatric therapy.

Insight Into Illness and Psychological Defense Attitudes in People With Chronic Schizophrenia Using Markova's Insight Scale

ABSTRACT

Insight into illness is a multidimensional phenomenon, and various assessments are available. We focused on Markova's Insight Scale (IS) and investigated the relationship between insight, psychological defenses, and neurocognition in 38 patients with schizophrenia. Results showed that insight was significantly correlated with an immature defense style. Moreover, IS was significantly predicted by immature defense style after adjusting for clinical variables. Although insight is often assumed to be multidetermined with potential contributions from factors such as cognitive function and psychological defensive mechanisms, our results indicated that better insight assessed with the IS is more likely to reflect immature defenses. This may also be reflected in our result that a higher insight score correlated with earlier onset of illness. The insight score may reflect the immature psychological defensive attitudes of schizophrenia and may lead such patients to wish to comply with the views of clinicians.

Comorbid major depression in first-episode drug-naïve patients with schizophrenia: Analysis of the Depression in Schizophrenia in China (DISC) study

BACKGROUND

Depression is very common in patients with schizophrenia, but few studies have investigated the diagnosed major depressive episode (MDE) in first episode and drug naive (FEDN) schizophrenia. To our best knowledge, this is the first large sample study to examine the prevalence, clinical correlates and associated factors of diagnosed MDE in FEDN schizophrenia, as well as the relationship between depressive symptoms and psychopathological symptoms in these schizophrenia patients.

METHODS

A total of 996 FEDN schizophrenia patients were recruited. The 17-item Hamilton Depression Rating Scale (HAMD17) and Positive and Negative Syndrome Scale (PANSS) were used to assess the severity of depression and psychopathology, respectively.

RESULTS

Our results demonstrated that MDE coexisted in nearly half (49.30%) of FEDN schizophrenia patients. Male gender, smoking, PANSS general psychopathology and early age of onset were associated with MDE in patients with FEDN schizophrenia (all p<0.05). In schizophrenia patients with MDE, oridinal logistic regression showed that men (OR=6.65, 95%CI: 4.12-10.45, p<0.001) and smoking (OR=1.94, 95%CI: 1.25-3.01, p=0.003) were positively associated with severity category of depression (all p<0.05), while multivariate regression showed that HAMD17 total score was significantly associated with the PANSS general psychopathology (B=0.06, t=2.72, p=0.007) and total scores (B=0.04, t=2.57, p=0.01).

CONCLUSION

Our study shows that the prevalence of comorbid MDE is high in FEDN schizophrenia patients. Some demographic and clinical variables are associated with the severity of depression in these schizophrenia patients.

Are Demoralization and Insight Involved in Suicide Risk? An Observational Study on Psychiatric Inpatients

INTRODUCTION

Several features contribute to determining suicide risk. This study was designed with the aim of evaluating whether insight into illness and demoralization are involved in suicide risk (active suicidal ideation or behavior).

METHODS

For this purpose, in a sample of 100 adult psychiatric inpatients, we used the Columbia Suicide Severity Rating Scale to assess suicide risk, the Demoralization Scale for demoralization symptoms, and the Insight Scale to assess illness insight. We also investigated several demographic and clinical features, including gender, age, duration of untreated illness, previous suicide attempts, and nonsuicidal self-injurious behavior.

RESULTS

The results demonstrated that patients with higher scores on the insight-high dimension had 1.35 greater odds of having a higher suicide risk, and those with lifetime suicide attempts had 7.45 greater odds of having a higher suicide risk. Among the various clinical factors, the study indicated that only nonsuicidal self-harm behaviors in the last 3 months was a risk factor for suicide risk.

CONCLUSIONS

The results indicated that greater illness insight is involved in suicide risk regardless of demoralization.

The course and concomitants of depression in first-episode schizophrenia spectrum disorders: A 24-month longitudinal study

Depressive symptoms are common in schizophrenia and have been associated with both favourable and unfavourable outcomes. We studied the longitudinal course of depressive symptoms and explored their temporal relationships with other manifestations of the illness and its treatment. This longitudinal cohort study included 126 antipsychotic naïve or only briefly treated patients with first-episode schizophrenia spectrum disorders treated with a long-acting antipsychotic over 24 months. Depressive symptoms were assessed at three monthly intervals using the Calgary Depression Scale for Schizophrenia and changes over time were assessed using linear mixed-effect models for continuous repeated measures. Depressive symptoms were most prominent at baseline with highly significant reductions during the first three months of treatment and maintenance of improvement thereafter. Most improvement occurred with antipsychotic treatment alone, with few patients requiring additional antidepressants. We also found that depressive symptoms were associated with positive symptoms, better insight and poorer quality of life, but not with negative symptoms, extrapyramidal symptoms, substance use or cumulative antipsychotic dose.There were few differences between patients who met criteria for depression during the acute phase of treatment and those in the post-acute phase.

The relationship between demoralization and depressive symptoms among patients from the general hospital: network and exploratory graph analysis

INTRODUCTION

Depression and demoralization are highly prevalent among individuals with physical illnesses but their relationship is still unclear.

OBJECTIVE

To examine the relationship between clinical features of depression and demoralization with the network approach to psychopathology.

METHODS

Participants were recruited from the medical wards of a University Hospital in Italy. The Demoralization Scale (DS) was used to assess demoralization, while the Patient Health Questionnaire-9 (PHQ-9) to assess depressive symptoms. The structure of the depression-demoralization symptom network was examined and complemented by the analysis of topological overlap and Exploratory Graph Analysis (EGA) to identify the most relevant groupings (communities) of symptoms and their connections. The stability of network models was estimated with bootstrap procedures and results were compared with factor analysis.

RESULTS

Life feeling pointless, low mood/discouragement, hopelessness and feeling trapped were among the most central features of the network. EGA identified four communities: (1) Neurovegetative Depression, (2) Loss of purpose, (3) Frustrated Isolation and (4) Low mood and morale. Loss of purpose and low mood/morale were largely connected with other communities through anhedonia, hopelessness and items related to isolation and lack of emotional control. Results from EGA displayed good stability and were comparable to those from factor analysis.

LIMITATIONS

Cross-sectional design; sample heterogeneity CONCLUSIONS: Among general hospital inpatients, features of depression and demoralization are independent, with the exception of low mood and self-reproach. The identification of symptom groupings around entrapment and helplessness may provide a basis for a dimensional characterization of depressed/demoralized patients, with possible implications for treatment.

Exploring the relationship of insight with psychopathology and gender in individuals with schizophrenia spectrum disorders with structural equation modelling

To model the influence of psychopathology on insight deficits in schizophrenia spectrum patients with a gender-stratified analysis. Five hundred sixteen patients (65.1% men) with schizophrenia spectrum disorders were evaluated in four centres of the metropolitan area of Barcelona (Catalonia). Psychopathological assessment was performed using different PANSS factors. Insight and its three main dimensions were assessed by means of the Scale of Unawareness of Mental Disorder: awareness of the disease (SUMD-1), of the effect of medication (SUMD-2) and of the social consequences of the disease (SUMD-3). Structural equation models (SEMs) were used to fix the model in the total sample and by gender. Additional analyses included age, duration of illness (DOI) and education status (ES). There were no significant differences between men and women in the three main dimensions of insight. The SEMs in the total sample showed a modest fitting capacity. Fitting improved after a gender-stratified analysis (particularly in women). In men, positive and excited symptoms were associated with poorer insight in all SUMD dimensions, whereas depressive symptoms were associated with better insight. ES in men was also associated with better SUMD-2 or SUMD-3. In contrast, in women, symptoms did not have a negative effect on SUMD-1 or SUMD-2. However, positive symptoms were associated with a poorer SUMD-3, whereas depressive symptoms were associated with better SUMD-3. Moreover, education level was also associated with a better SUMD-3. A gender approach improved the comprehension of the model, supporting the relevance of gender analysis in the study of insight.

Development and validation of the schedule for the assessment of insight in eating disorders (SAI-ED)

This study examined the reliability, validity and internal structure of the newly developed, interview-based Schedule for the Assessment of Insight in Eating Disorders (SAI-ED) and the relationships of insight with demographic and clinical characteristics in EDs. Ninety-four female patients - 44 with anorexia nervosa (AN) and 50 with bulimia nervosa (BN) - were assessed with SAI-ED. The Brown Assessment of Beliefs Scale was used to evaluate convergent validity of SAI-ED. Hierarchical cluster analysis and multidimensional scaling were used to identify insight components and assess their inter-relationships. The final 8-item SAI-ED demonstrated good psychometric properties. Inter-rater and test-retest reliabilities were high. Three subscales of SAI-ED were identified which measure major insight components: awareness of illness, awareness of symptoms, and treatment engagement. Patients with AN had significant lower score on SAI-ED than patients with BN. Impaired insight was associated with: (a) lower current and lowest lifetime BMI and more severe dietary restrain in AN, (b) illness duration, severity of overall ED symptoms, body-related concerns and obsessionality in BN. Insight is a multidimensional construct in EDs associated with different clinical aspects in AN and BN. The SAI-ED is a valid and reliable tool for the assessment of insight in EDs patients.

The insight paradox in schizophrenia: A meta-analysis of the relationship between clinical insight and quality of life

Poor clinical insight affects people with schizophrenia and has been cited as a chief cause of poor outcomes. As such, clinical insight is often a target of intervention; however, increases in insight have shown associations with decreased quality of life in a phenomenon known as the "insight paradox." Understanding the relationship between insight and quality of life is important as clients often feel hopeless when quality of life decreases. This meta-analysis sought to clarify relationships between clinical insight, its subdomains, and quality of life in schizophrenia. Further, we explored the role of two moderators (quality of life measurement type, symptom severity) on the insight-quality of life relationship. Studies were identified according to PRISMA guidelines through a focused literature search extending to March 1, 2019. Correlations between clinical insight, its subdomains, and quality of life were extracted and used to calculate overall mean weighted effect sizes using a random-effects model. In support of the insight paradox, overall clinical insight was inversely related to quality of life. Symptom severity moderated the relationship between clinical insight and quality of life, such that greater symptom severity weakened the inverse relationship between overall insight and quality of life. Regarding subdomains of clinical insight, awareness of illness was inversely associated with quality of life; however, other subdomains failed to reach significance. Our findings support the notion that increased insight is associated with lower quality of life and highlight the need for further exploration of the role of meaning-making processes on this relationship.

Insight and psychosis: the next 30 years

Academic interest in the concept of insight in psychosis has increased markedly over the past 30 years, prompting this selective appraisal of the current state of the art. Considerable progress has been made in terms of measurement and confirming a number of clinical associations. More recently, the relationship between insight and involuntary treatment has been scrutinised more closely alongside the link between decision-making capacity and insight. Advances in the clinical and cognitive neurosciences have influenced conceptual development, particularly the field of 'metacognition'. New therapies, including those that are psychologically and neurophysiologically based, are being tested as ways to enhance insight.

Prevalence of comorbid depression in schizophrenia: A meta-analysis of observational studies

INTRODUCTION

Comorbid depressive symptoms (depression thereafter) often occur in schizophrenia and are associated with negative outcomes. This meta-analysis estimated the prevalence of comorbid depression and its associated factors in schizophrenia.

METHODS

Both international (PubMed, EMBASE, PsycINFO, and Web of Science) and Chinese (WANFANG and CNKI) databases were systematically searched. Studies with data on the prevalence of comorbid depression in schizophrenia measured with the Calgary Depression Scale for Schizophrenia (CDSS) were included. Random-effects models were used in all analyses.

RESULTS

Fifty-three studies covering 9,879 patients were included. The pooled prevalence of comorbid depression was 28.6% (95%CI: 25.3%-32.2%). Subgroup analyses revealed that studies examining inpatients, being published in Chinese language, or those with lower CDSS cut-od values reported higher depression rates. Meta-regression analyses indicated that the rate of depression was positively associated with publication year, proportion of males, mean age, and severity of psychotic symptoms, and negatively associated with illness duration and study quality.

CONCLUSION

Comorbid depression is common in schizophrenia. Due to its negative impact on patients' quality of life and prognosis, regular screening and effective treatment for comorbid depression should be implemented in patients with schizophrenia.

Painful insight vs. usable insight in schizophrenia. Do they have different influences on suicidal behavior?

BACKGROUND

Suicidal behavior is highly prevalent in schizophrenia. Among the risk factors, insight has been little studied and has yielded contradictory results. In addition, it has been studied neglecting relevant psychological aspects, such as beliefs about illness and coping styles.

METHOD

We assessed 133 outpatients diagnosed with schizophrenia according to ICD-10 criteria. Evaluation included sociodemographic, general clinical, psychopathological, psychological and suicidal behavior variables.

RESULTS

Neither insight nor insight coupled with negative beliefs and/or coping styles were associated with suicidal behavior. Nevertheless, insight coupled with negative beliefs and/or coping styles was associated with greater hopelessness and depression, internalized stigma, worse control over illness and greater global severity as compared to insight coupled with positive beliefs and coping styles. Suicide attempt and suicidal ideation groups showed greater depression and hopelessness, worse global beliefs and worse control over illness, higher socio-economic level, and greater number of previous psychiatric admissions compared to the non-suicidal group.

CONCLUSIONS

Insight coupled with negative beliefs and/or coping style was not associated with suicidal behavior. Nevertheless, it was associated with greater depression and hopelessness, both of which are firmly established risk factors for suicide in schizophrenia. Prospective studies with long-term follow-up and large samples are needed to clarify this issue. Clinicians should assess these psychological features associated with insight, both in patients with insight and in those with poor insight when promoting it.

The association between insight and depressive symptoms in schizophrenia: Undirected and Bayesian network analyses

Background.

Greater levels of insight may be linked with depressive symptoms among patients with schizophrenia, however, it would be useful to characterize this association at symptom-level, in order to inform research on interventions.

Methods.

Data on depressive symptoms (Calgary Depression Scale for Schizophrenia) and insight (G12 item from the Positive and Negative Syndrome Scale) were obtained from 921 community-dwelling, clinically-stable individuals with a DSM-IV diagnosis of schizophrenia, recruited in a nationwide multicenter study. Network analysis was used to explore the most relevant connections between insight and depressive symptoms, including potential confounders in the model (neurocognitive and social-cognitive functioning, positive, negative and disorganization symptoms, extrapyramidal symptoms, hostility, internalized stigma, and perceived discrimination). Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association between insight and depression.

Results.

After adjusting for confounders, better levels of insight were associated with greater self-depreciation, pathological guilt, morning depression and suicidal ideation. No difference in global network structure was detected for socioeconomic status, service engagement or illness severity. The DAG confirmed the presence of an association between greater insight and self-depreciation, suggesting the more probable causal direction was from insight to depressive symptoms.

Conclusions.

In schizophrenia, better levels of insight may cause self-depreciation and, possibly, other depressive symptoms. Person-centered and narrative psychotherapeutic approaches may be particularly fit to improve patient insight without dampening self-esteem.

Better insight seems associated with depressive symptoms in schizophrenia.

Network analyses were used to explore this association in a large sample.

Insight was associated with self-depreciation, guilt, and suicidal ideation.

Although cross-sectional, data suggest causal direction from insight to depression.