Insight into illness and its relationship to illness severity, cognition and estimated antipsychotic dopamine receptor occupancy in schizophrenia: An antipsychotic dose reduction study

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.

Risk factors for readmission in schizophrenia treated with combined psychoeducation and standard therapy

Background

We conducted a historical cohort study of patients with schizophrenia to identify more robust risk factors at discharge that contribute to readmission within a year.

Methods and Findings

The subjects underwent brief psychoeducation during hospitalization. Multivariate analysis was conducted using factors selected in the univariate analysis. Using logistic regression analysis, the number of hospital admissions (P = .01) and Schedule for Assessment of Insight Japanese version score (P = .04) were identified as risk factors for readmission, with odds ratios of 0.70 and 1.18, respectively.

Conclusions

These results suggest that improvement in insight and early intervention may lead to a more stable community life.

We conducted a historical cohort study of patients with schizophrenia to identify more robust risk factors at discharge that contribute to readmission within a year. The number of hospital admissions and Schedule for Assessment of Insight Japanese version score were identified as risk factors for readmission.

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.

Association between cognition and suicidal ideation in patients with major depressive disorder: A longitudinal study

BACKGROUND

Suicidal ideation (SI) is common in patients with major depressive disorder (MDD) and often related to cognitive deficits. Limited longitudinal study has shown that cognitive improvement is associated with reduced SI. However, the comparatively study in Chinese depressed patients is still absent. The objective of this study was to explore the specific cognitive deficits in Chinese MDD with SI and investigate the relationship between changes in cognition and change in SI across antidepressant treatment.

METHODS

Three hundred and five patients with MDD received four weeks of antidepressant treatment. The 17-item Hamilton Depression Rating Scale (HAMD-17) and four domains of the MATRICS Consensus Cognitive Battery (MCCB), including speed of processing, working memory, visual learning and verbal learning were measured at baseline and four-week follow-up.

RESULTS

One hundred and thirty patients (42.6%) expressed suicidal ideation. Suicidal patients performed worse on verbal learning than non-suicidal patients. Change in speed of processing domain was negatively associated with change in suicidal scores over time. Logistic regression analysis showed that reduction of SI was associated with improvement of speed of processing.

LIMITATION

The major limitation was that there was no healthy control group in the current study, which might limit the interpretation of cognitive deficits in depressed patients with SI.

CONCLUSIONS

Our findings suggest that suicidal patients performed worse on verbal learning which can potentially serve as a cognitive biomarker of suicide risk in MDD. Moreover, reduced suicidal ideation was associated with improved speed of processing.

The effects of illness severity, cognition, and estimated antipsychotic dopamine receptor occupancy on insight into the illness in schizophrenia: An analysis of clinical antipsychotic trials of intervention effectiveness (CATIE) data

BACKGROUND

The relationship between dopamine D₂ receptor (D₂R) occupancy and impaired illness awareness (IIA) remains unclear. While IIA is associated with illness severity and cognitive dysfunction, antipsychotic medication, the principal treatment for schizophrenia, indirectly improves IIA, but may simultaneously contribute to cognitive dysfunction at supratherapeutic doses.

AIM AND METHODS

We investigated the influence of estimated D₂R (Est.D₂R) occupancy by antipsychotics on the relationships between IIA and illness severity, and IIA and cognition. IIA was assessed in 373 adult patients with schizophrenia (18-62 years) using data from CATIE. IIA was measured using the Positive and Negative Syndrome Scale (PANSS) item G12. D₂R occupancy levels were estimated from plasma concentrations for risperidone, olanzapine, and ziprasidone. Correlation, regression, and path analyses were performed to examine IIA's relationship to illness severity, cognition, and Est.D₂R.

RESULTS

Illness severity was predictive of IIA. However, premorbid IQ, cognition, and Est.D₂R did not predict IIA, and Est.D₂R did not serve either a moderating or mediating role in both regression and path analyses.

CONCLUSIONS

Consistent with previous literature, our results suggest that IIA is a function of illness severity in adult patients with schizophrenia. Future studies should explore whether D₂R occupancy mediates the relationships between IIA and illness severity, and IIA and cognitive dysfunction, in late-life schizophrenia (i.e. ≥60 years) given the effects of aging on cognition, IIA, and antipsychotic sensitivity.

The Multiple Dimensions of Insight in Schizophrenia-Spectrum Disorders

The concept of insight is used to indicate the propensity of patients with schizophrenia and other severe mental disorders to recognize their illness and engage in treatment. Thus, insight may have notable consequences for the ill individual: Those who lack insight are at higher risk of nonadherence to treatments, negative clinical outcomes, and worse community functioning. Although insight is an intuitive concept, its essence remains difficult to capture. However, many rating scales are available to aid assessment, both for clinical and research purposes. Insight cannot be reduced to a symptom, a psychological mechanism, or a neuropsychological function. It is likely to have dynamic relationships with all these dimensions and with responses to personal events and contextual factors. In particular, social consequences of mental illness and explanatory models that are alternative to the medical model may fundamentally shape insight and treatment choice. Moreover, the cultural or individual stigmatization of mental illness may turn the acquisition of insight into a painful event and increase the risk of depression. Clinicians need to carefully evaluate and promote insight through a personalized approach to aid patient process of care and personal growth.

The relationship between dopamine receptor blockade and cognitive performance in schizophrenia: a [11C]-raclopride PET study with aripiprazole

Aripiprazole's effects on cognitive function in patients with schizophrenia are unclear because of the difficulty in disentangling specific effects on cognitive function from secondary effects due to the improvement in other schizophrenic symptoms. One approach to address this is to use an intermediate biomarker to investigate the relationship between the drug's effect on the brain and change in cognitive function. This study aims to investigate aripiprazole's effect on working memory by determining the correlation between dopamine D2/3 (D2/3) receptor occupancy and working memory of patients with schizophrenia. Seven patients with schizophrenia participated in the study. Serial positron emission tomography (PET) scans with [¹¹C]raclopride were conducted at 2, 26, and 74 h after the administration of aripiprazole. The subjects performed the N-back task just after finishing the [¹¹C]raclopride PET scan. The mean (±SD) D2/3 receptor occupancies were 66.9 ± 6.7% at 2 h, 65.0 ± 8.6% at 26, and 57.7 ± 11.2% at 74 h after administering aripiprazole. Compared with performance on the zero-back condition, performance in memory-loaded conditions (one-, two-, and three-back conditions) was significantly related to D2/3 receptor occupancy by aripiprazole (error rate: ß = -2.236, t = -6.631, df = 53.947, and p = 0.001; reaction time: ß = -9.567, t = -2.808, df = 29.967, and p = 0.009). Although the sample size was relatively small, these results suggest that aripiprazole as a dopamine-partial agonist could improve cognitive function in patients with schizophrenia.

Comparison of insight and clinical variables in homeless and non-homeless psychiatric inpatients in China

There are no published data on insight in homeless patients with psychiatric disorders in China. This study examined insight in homeless and non-homeless Chinese psychiatric inpatients in relation to demographic and clinical variables. A total of 278 homeless and 222 non-homeless inpatients matched in age and gender were included in the study. Demographic and clinical characteristics were collected based on a review of medical charts and a clinical interview with standardized instruments. Insight was evaluated with the Insight and Treatment Attitudes Questionnaire. Altogether 20.5% of homeless inpatients and 43.7% of the non-homeless controls had good insight. Compared with homeless inpatients with impaired insight, homeless inpatients with good insight had higher physical quality of life, longer duration of illness and less severe positive and negative symptoms. Impaired insight appeared more common in homeless psychiatric inpatients in China. Further studies should address the need for effective therapeutic interventions that promote homeless patients' insight.