Much ado about everything: A literature review of insight in first episode psychosis and schizophrenia

Perspective of patients with first-episode psychosis, their relatives, and mental health professionals on the design and usability of an app in clinical practice

AIM

Therapeutic non-compliance remains the main difficulty for people with psychotic disorders, standing around 50% in people with schizophrenia. Lack of treatment adherence, either partial or total, to medication has economic and clinical consequences. E-health technologies may be a promising therapeutic tool to improve adherence, with the subsequent reduction in clinical and economic burden. Our aims were to know the preferences on how technologies in mental health treatment should be for use in clinical practice, and to learn about the opinion and preferences on the use of technologies in mental health treatment from the perspectives of patients with FEP, their relatives, and mental health professionals.

METHODS

Forty-one patients with a diagnosis of first-episode psychosis (FEP), 18 relatives and 49 mental health professionals were included in the study. They completed an online survey related to the use, availability and user-skill of online platforms and apps created by a group of experts in psychosis and in the use of technologies. Data were summarized in frequencies, percentages, and means, and Chi-square tests were used to calculate differences between-groups.

RESULTS

An app directed to people with psychosis would be well received by users if it contains psychoeducational material, offers reminders for scheduled visits and treatment and allows online consultations.

CONCLUSIONS

Co-creating an app with users, their families and mental health professionals allows incorporating their preferences to increase its use, improve outpatient care and creating an app that is viable in clinical practice.

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.

Cognitive insight in individuals at ultra-high risk for psychosis compared to patients with first-episode psychosis and non-psychotic help-seeking youths

BACKGROUND

Defective insight is a hallmark of schizophrenia. Less is known about insight in emerging psychosis. In this study a widely used measure of cognitive insight, the Beck Cognitive Insight Scale (BCIS), has been applied to a sample including patients with first-episode psychosis (FEP), at ultra-high risk (UHR) for psychosis, and help-seeking youths without psychotic symptoms.

METHODS

The Comprehensive Assessment of At-Risk Mental State (CAARMS) interview was used to classify patients. Enrolled patients were assessed with the General Health Questionnaire-12 (GHQ-12), the Prodromal Questionnaire-16 (PQ-16), the Social and Occupational Functioning Assessment Scale (SOFAS), and the BCIS.

RESULTS

The sample included 212 participants (58%) with non-psychotic mental distress, 131 participants (36%) were UHR, and 22 (6%) were with FEP. Males and females were in equal proportion, mean age was 19.2 ± 2.6 years old (range: 15-25 years). Reliability (Cronbach's alpha) was good for clinical scales (>0.7) and acceptable (around 0.6) for the two BCIS subscales. The self-certainty subscale of the BCIS was more reproducible in factor analysis than the self-reflectiveness scale. Youths devoid of psychotic symptoms scored lower than UHR and FEP participants on the GHQ-12 and the PQ-16 and had better psychosocial functioning as measured by the SOFAS. Levels of cognitive insight did not differ between groups.

CONCLUSION

People in the early stages of psychosis may be still accessible to self-reflectiveness and more hesitant about the certainty of their beliefs than patients at more advanced stages of the illness, as those with fully displayed schizophrenia.

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.

Dynamics between insight and medication adherence in first-episode psychosis: Study of 3-year trajectories

Background

While specialized early intervention programs represent the gold standard in terms of optimal management of first-episode psychosis (FEP), poor medication adherence remains a predominant unmet need in the treatment of psychosis. In this regard, an interaction between insight and adherence in FEP patients has been hypothesized but has been challenged by multiple pitfalls.

Methods

Latent profile analysis and trajectory modeling techniques were used to evaluate insight and adherence of 331 FEP patients engaged at the beginning, middle, and end of a 3-year specialized early psychosis program. A Bayesian model comparison approach was used to compare scores of clinical, functional, and socioeconomic outcomes at the end point of the study.

Results

Nearly one-third of the patients maintain a high level of insight and adherence during the entire program. At the end of the 3-year follow-up, more than three-quarters of patients are considered adherent to their medication. Patients with low levels of insight and adherence at the beginning of the program improve first in terms of adherence and then of insight. Furthermore, patients with high levels of insight and adherence are most likely to reach functional recovery and to experience an increase in environmental quality of life.

Conclusions

Latent FEP subpopulations can be identified based on insight and adherence. Medication adherence was the first variable to improve, but a gain in insight possibly plays a role in the reinforcement of adherence.

Predictors of diagnostic stability in brief psychotic disorders: Findings from a 3-year longitudinal study

INTRODUCTION

Brief psychotic disorder (BPD) is a relatively uncommon and underexplored psychotic condition. Even though BPD has been related to a more favorable outcome than other schizophrenia spectrum disorders (SSD), current knowledge of its predictive factors remains scant. This study aimed to examine its prevalence and find early predictors of BPD diagnostic stability.

METHODS

SSD diagnosis following Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria was explored in a large epidemiological cohort (n = 569) of non-affective first-episode psychosis (FEP) patients enrolled in a three-year longitudinal intervention program (PAFIP). Premorbid, sociodemographic, and clinical information was collected to characterize BPD patients and determine factors predictive of diagnostic stability. Multivariate analysis included predictors selected from clinical knowledge and also those that had achieved marginal significance (p ≤ 0.1) in univariate analysis.

RESULTS

A total of 59 patients enrolled in the PAFIP program (10.4% of the whole cohort) met DSM-IV criteria for BPD, of whom 40 completed the three-year follow-up. The temporal stability of BPD in our sample was as high as 40% (n = 16). Transition from BPD to schizophrenia occurred in 37% (n = 15) of patients. Fewer hallucinations at baseline and better insight independently significantly predicted BPD diagnostic stability over time.

CONCLUSION

Our findings confirm that BPD is a clinical condition with moderate-to-low temporal stability and demonstrate that approximately two-thirds of FEP individuals experiencing BPD will develop a long-lasting psychotic disorder during follow-up, mainly schizophrenia.

Accuracy of self-reported adherence and therapeutic drug monitoring in a psychiatric emergency ward

The aims of the study were: (1) the evaluation of the agreement between therapeutic drug monitoring (TDM) and a self-assessment of adherence to psychopharmacological treatments; (2) the identification of predictors of TDM results.Adherence in patients admitted into a psychiatric emergency service (PES) for a relapse of a schizophrenia spectrum disorder (SSD) or a bipolar disorder (BD; DSM-5) was assessed both directly with TDM and indirectly with a self-reported measure (Medication Adherence Report Scale -MARS- 10 items). The agreement between TDM and MARS was evaluated. Fifty-seven patients with SSD and 76 people with BD participated in the study. TDM was in range in about 50% of the global sample. No evidence of an association between MARS total scores and TDM results was found. Sensitivity, specificity, positive and negative predictive values of almost all MARS total scores were near to 50%. Smoking was strongly associated with a reduction of TDM results within the reference range. In the BD group, female sex was a predictor of TDM in range. In this clinical setting, self-assessment of adherence is neither reliable nor predictive. Furthermore, smoking is a strong predictor of poor adherence to psychopharmacological therapy.

Dynamic Interplay Between Insight and Persistent Negative Symptoms in First Episode of Psychosis: A Longitudinal Study

Persistent negative symptoms (PNS) are an important factor of first episode of psychosis (FEP) that present early on in the course of illness and have a major impact on long-term functional outcome. Lack of clinical insight is consistently associated with negative symptoms during the course of schizophrenia, yet only a few studies have explored its evolution in FEP. We sought to explore clinical insight change over a 24-month time period in relation to PNS in a large sample of FEP patients. Clinical insight was assessed in 515 FEP patients using the Scale to assess Unawareness of Mental Disorder. Data on awareness of illness, belief in response to medication, and belief in need for medication were analyzed. Patients were divided into 3 groups based on the presence of negative symptoms: idiopathic (PNS; n = 135), secondary (sPNS; n = 98), or absence (non-PNS; n = 282). Secondary PNS were those with PNS but also had clinically relevant levels of positive, depressive, or extrapyramidal symptoms. Our results revealed that insight improved during the first 2 months for all groups. Patients with PNS and sPNS displayed poorer insight across the 24-month period compared to the non-PNS group, but these 2 groups did not significantly differ. This large longitudinal study supported the strong relationship known to exist between poor insight and negative symptoms early in the course of the disorder and probes into potential factors that transcend the distinction between idiopathic and secondary negative symptoms.

Cognitive insight in individuals with an at-risk mental state for psychosis: A meta-analysis

AIM

To compare cognitive insight abilities measured with the Beck Cognitive Insight Scale (BCIS) between individuals with an at-risk mental state (ARMS) and healthy controls.

METHOD

Review and meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A search for articles investigating cognitive insight in ARMS in the MEDLINE and ScienceDirect databases revealed five studies including 303 ARMS and 376 controls. Regarding BCIS subscales, ARMS individuals displayed significant higher scores for self-certainty than controls with a small-to-moderate effect size (ESg = 0.45 [0.23;0.67], P < .005), whereas no significant difference was observed for self-reflectiveness (ESg = -0.56 [-0.18;1.29], P = .14). No significant differences were observed between ARMS and controls for overall cognitive insight abilities as indexed by the BCIS composite score (ESg = -0.24 [-0.43;0.91], P = .45).

CONCLUSIONS

Self-certainty abnormalities seem to predate the expression of full-blown psychotic episode and to be higher in ARMS than in healthy controls. By contrast, ARMS did not display abnormal self-reflectiveness and overall cognitive insight abilities.

Insight, personality, and symptoms among individuals with psychosis: Cross-sectional and longitudinal relationships

BACKGROUND

Reports on the relationship between clinical insight and psychotic symptoms have shown inconsistent results, and the association between clinical insight and personality has rarely been addressed. The aim of this study was to examine whether personality is correlated cross-sectionally with insight level, and longitudinally with change in insight, beyond symptoms.

METHODS

Participants were a sub-sample of the Dutch Genetic Risk and Outcome of Psychosis (GROUP) project. Two hundred and eleven participants diagnosed with non-affective psychotic disorders took part in the cross-sectional part of the study, of whom 136 took part in the three-year follow-up assessment. They were administered with self-report Birchwood insight scale and NEO-Five Factor Inventory, and clinicians assessed them according to PANSS and CDS symptoms scales.

RESULTS

Cross-sectional analysis showed baseline self-report insight was positively related to neuroticism and agreeableness and negatively related to extraversion. Longitudinal analysis showed change in level of self-reported insight was predicted by baseline-insight and change in symptoms of disorganization. Personality factors did not predict insight change (as measured either by self-report or by clinician assessment).

DISCUSSION

The cross-sectional findings showed self-report insight (as opposed to clinician-rated) is associated with personality traits, suggesting negative affect is related to higher level of insight and that having insight may be influenced by the wish to comply with views of professionals, or a tendency to cover up problems. The longitudinal findings imply that not personality but change in severity of symptoms of disorganization, and possibly other variables, predicts change in insight.

A study in first-episode psychosis patients: does angiotensin I-converting enzyme (ACE) activity associated with genotype predict symptoms severity reductions after treatment with the atypical antipsychotic risperidone?

BACKGROUND

Our previous studies showed increased angiotensin I-converting enzyme (ACE) activity in chronic schizophrenia (SCZ) patients compared to healthy control (HC) volunteers, and the relevance of combining ACE genotype and activity for predicting SCZ was suggested.

METHODS

ACE activity was measured in plasma of ACE insertion/deletion (I/D) genotyped HC volunteers (N = 53) and antipsychotic-naïve first-episode psychosis (FEP) patients (N = 45), assessed at baseline (FEB-B) and also after 2-months (FEP-2M) of treatment with the atypical antipsychotic risperidone.

RESULTS

ACE activity measurements showed significant differences among HC, FEP-B and FEP-2M groups (F = 5.356, df = 2, p = 0.005), as well as between HC and FEP-2M (post-hoc Tukey's multiple comparisons test, p = 0.004). No correlation was observed for ACE activity increases and symptom severity reductions in FEP as assessed by total PANSS (r = -0.131, p = 0.434). FEP subgrouped by ACE I/D genotype showed significant ACE activity increases, mainly in the DD genotype subgroup. No correlation between ACE activity and age was observed in FEP or HC groups separately (r = 0.210, p = 0.392), but ACE activity levels differences observed between these groups were influenced by age.

CONCLUSIONS

The importance of measuring the ACE activity in blood plasma, associated to ACE I/D genotyping to support the follow-up of FEP patients did not show correlation with general symptoms amelioration in the present study. However, new insights into the influence of age and I/D genotype for ACE activity changes in FEP individuals upon treatment was demonstrated.

Moderating role of cannabis use between insight and depression in early psychosis

BACKGROUND

A high level of insight in first episode psychosis (FEP) is positively correlated to important prognostic factors such as medication adherence and functional outcome but is associated with increased depression level and suicidal behavior.

AIMS

This is the first study questioning the potential moderating role of cannabis use in the relationship between insight and depression one year after a FEP.

METHOD

In this prospective observational study, we enrolled 214 FEP patients who had provided informed consent and been referred to a specialized early psychosis program and followed for 36 months. A series of multivariate regression models were used. Baseline insight, medication adherence and cannabis use (level of use on a continuum) were entered as independent variables, while the PANSS (positive and negative), the MADRS and the SOFAS scores after one year were alternately selected as the dependent variable.

RESULTS

We found a three-way interaction term between cannabis use, insight and medication adherence on depression level one year after the entry into the program. A high level of insight was significantly associated with higher MADRS scores in patients with high cannabis use, while depression decreased in high-insight patients with low cannabis use.

CONCLUSIONS

Cannabis use continuation during the year following a first episode psychosis may play a significant role in the development or the maintenance of post-psychotic depression in patients who present with high level of insight and adherence to medication, stressing the need for specific therapeutic strategies in this subgroup of patients.

Violent behaviour in early psychosis patients: Can we identify clinical risk profiles?

AIMS

The objective of this study is to explore, within a sample of early psychosis patients (EPP), if subgroups regarding rate of violent behaviour (VB) against others can be identified on the basis of dynamic risk factors (treatment modifiable characteristics).

METHODS

In a sample of 265 EPP, treated at the Treatment and Early Intervention in Psychosis Program in Lausanne, we conducted a latent-class analysis on the basis of the main dynamic VB risk factors (substance use disorder [SUD], positive symptoms, insight, and impulsivity). VB were restricted to "serious violence" and were assessed through patients self-report, interview with relatives or forensic services and with a standardized instrument.

RESULTS

The analysis confirmed the heterogeneity of the sample regarding rate of VB. Patients could be stratified within 4 subgroups, 3 of which were at increased risk of VB. The two groups with the highest rates of VB displayed specific clinical profiles. The first one was characterized by high levels of impulsivity, hostility, positive symptoms and SUD, and the second, by low level of insight and low social functioning. These patterns suggest that significant difficulties in social interaction may contribute to the emergence of aggressive reactions against others.

CONCLUSIONS

Identification of EPP at increased risk of VB seems possible on the basis of dynamic risk factors. If confirmed prospectively, this could pave the way to the development of preventive strategies and specific interventions.

Measuring empathy in schizophrenia: The Empathic Accuracy Task and its correlation with other empathy measures

INTRODUCTION

Empathy is an interpersonal process impaired in schizophrenia. Past studies have mainly used questionnaires or performance-based tasks with static cues to measure cognitive and affective empathy. We used the Empathic Accuracy Task (EAT) designed to capture dynamic aspects of empathy by using videoclips in which perceivers continuously judge emotionally charged stories. We compared individuals with schizophrenia with a healthy comparison group and assessed correlations among EAT and three other commonly used empathy measures.

METHOD

Patients (n = 92) and a healthy comparison group (n = 42) matched for age, gender and education completed the EAT, the Interpersonal Reactivity Index, Questionnaire of Cognitive and Affective Empathy and Faux Pas. Differences between groups were analyzed and correlations were calculated between empathy measurement instruments.

RESULTS

The groups differed in EAT performance, with the comparison group outperforming patients. A moderating effect was found for emotional expressivity of the target: while both patients and the comparison group scored low when judging targets with low expressivity, the comparison group performed better than patients with more expressive targets. Though there were also group differences on the empathy questionnaires, EAT performance did not correlate with questionnaire scores.

CONCLUSIONS

Individuals with schizophrenia benefit less from the emotional expressivity of other people than the comparison group, which contributes to their impaired empathic accuracy. The lack of correlation between the EAT and the questionnaires suggests a distinction between self-report empathy and actual empathy performance. To explore empathic difficulties in real life, it is important to use instruments that take the interpersonal perspective into account.

[Insight and Violent Behavior in a Cohort of Early Psychosis Patients]

OBJECTIVES:

An important proportion of patients with first episode psychosis behave in a violent, hetero-aggressive manner. This study aims to explore the association between insight and violent behavior (VB), and insight evolution in the follow-up period.

METHOD:

The study was carried out with a prospective cohort of 265 patients recruited from the early treatment and intervention for psychotic disorders program, and followed for a 3-year period. Insight assessing is based on a 3-item scale and the insight item in Positive and Negative Syndrome Scale (PANSS). VBs were evaluated by case managers, information from forensic services and through a record of VBs noted during hospitalization. Univariate and multivariate logistic regression analyses, t-tests and correlations were conducted.

RESULTS:

The significant effect of insight as a factor associated with VBs that was found in univariate analyses disappears after controlling for the effect of positive symptoms, substance addiction diagnosis, impulsivity and treatment compliance.

CONCLUSION:

If patient insight in their illness develops positively during treatment, our results suggest that the risk of VBs occurring is not influenced by insight level. On the other hand, it is significantly linked to substance abuse and impulsivity, which might implicate focusing on these 2 dimensions in preventive strategies. Insight impact on VB should be further explored in more focused prospective analyses.