Changes in insight among patients with bipolar I disorder: a 2-year prospective study

Efficacy of Transcranial Direct Current Stimulation to Improve Insight in Patients With Schizophrenia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND AND HYPOTHESIS

Impaired insight into the illness and its consequences is associated with poor outcomes in schizophrenia. While transcranial direct current stimulation (tDCS) may represent a potentially effective treatment strategy to relieve various symptoms of schizophrenia, its impact on insight remains unclear. To investigate whether tDCS would modulate insight in patients with schizophrenia, we undertook a meta-analysis based on results from previous RCTs that investigated the clinical efficacy of tDCS. We hypothesize that repeated sessions of tDCS will be associated with insight improvement among patients.

STUDY DESIGN

PubMed and ScienceDirect databases were systematically searched to identify RCTs that delivered at least 10 tDCS sessions in patients with schizophrenia. The primary outcome was the change in insight score, assessed by the Positive and Negative Syndrome Scale (PANSS) item G12 following active tDCS sessions as opposed to sham stimulation. Effect sizes were calculated for all studies and pooled using a random-effects model. Meta-regression and subgroup analyses were conducted.

STUDY RESULTS

Thirteen studies (587 patients with schizophrenia) were included. A significant pooled effect size (g) of -0.46 (95% CI [-0.78; -0.14]) in favor of active tDCS was observed. Age and G12 score at baseline were identified as significant moderators, while change in total PANSS score was not significant.

CONCLUSIONS

Ten sessions of active tDCS with either frontotemporoparietal or bifrontal montage may improve insight into the illness in patients with schizophrenia. The effect of this treatment could contribute to the beneficial outcomes observed in patients following stimulation.

A comparative study evaluating insight in different phase of illness among patients with bipolar disorder by using multiple scales

AIM

This cross-sectional study aimed to evaluate insight and its correlates among patients with bipolar disorder (BD).

METHODOLOGY

180 patients with BD were evaluated on Scale to Assess Unawareness of Mental Disorders (SUMD), Insight scale for affective disorders (ISAD), Mood Disorders Insight Scale (MDIS), and Beck Cognitive Insight Scale (BCIS).

RESULTS

About half of the patients were in clinical remission (N = 94; 52.2%), one-fifth (N = 37; 20.55%) were in the phase of mania and one-fourth (N = 49; 27.2%) were in a depression. There was no significant difference in the level of insight between those in clinical remission and those in depression except for one of the domains of BCIS. Patients with mania had poorer insight compared to those in remission and depression. In terms of association of insight as assessed by different scales, in the whole sample and all the three subgroups, SUMD current and past scores had a significant positive correlation with the ISAD total score. In the whole sample, among patients currently in remission and those currently in depression, ISAD total score had significant negative correlation with MDIS total score. Poorer insight as assessed on SUMD (current and past), ISAD and MDIS was associated with poorer medication adherence.

CONCLUSION

The present study demonstrates that patients with mania have poor insight when compared to the patients in clinical remission and depression. The present study also demonstrates that the assessment of clinical insight is not affected much by the type of scale used.

The Patient Health Questionnaire-9 vs. the Hamilton Rating Scale for Depression in Assessing Major Depressive Disorder

Background: The Hamilton Rating Scale for Depression (HAMD-17) has been used for several decades to assess the severity of depression. Multiple studies have documented defects in this scale and deemed it unsuitable for clinical evaluation. The HAMD-6, which is the abbreviated version of HAMD-17, has been shown to be effective in assessing the core symptoms of depression with greater sensitivity than HAMD-17. And the Patient Health Questionnaire-9 (PHQ-9) is suggested as an effective alternative to the HAMD-17 because of its simplicity and ease-of-use. Methods: Research was completed involving 1,741 participants having major depressive disorder. Cronbach's alpha, intraclass correlation coefficient (ICC) and weighted Kappa analysis was used to determine the reliability of the scales. Pearson correlation analysis and factor analysis were used to analyze validity. Item response theory (IRT) was used to analyze psychological characteristics of items in both the HAMD-17 and PHQ-9. Results: Reliability analysis showed that the Cronbach's alpha of the HAMD-17, HAMD-6 and PHQ-9 were 0.829, 0.764, and 0.893 respectively, and the ICC of the three scales ranged from 0.606 to 0.744. The Kappa score of the consistency of depression severity assessment was 0.248. Validity analysis showed that the PHQ-9 was a single factor structure, and the total score of the scale was strongly correlated with the HAMD-17 (r = 0.724, P < 0.001). The IRT analysis showed that the discrimination parameters of the PHQ-9 were higher than that of the HAMD-17 in all dimensions. The HAMD-6 had the lowest measurement accuracy in distinguishing the severity of depression, while the PHQ-9 had the highest measurement accuracy. Conclusion: Results showed that the PHQ-9 was satisfactory in terms of reliability, validity and distinguishing the severity of depression. It is a simple, rapid, effective and reliable tool which can be used as an alternative to the HAMD-17 to assess the severity of depression.

Insight in substance use disorder: A systematic review of the literature

Insight refers to a person's understanding of themselves and the world around them. Recent literature has explored people's insight into their substance use disorder (SUD) and how this is linked to treatment adherence, abstinence rates, and comorbid mental health symptoms. The aim of this systematic review was to synthesise and critically examine the existing literature on insight in SUD. Five academic databases (Medline, PsychINFO, SCOPUS, CINAHL, Web of Science) were searched for key terms related to insight and substance use. Included studies were on humans aged 18 years or over with SUD that examined the relationship between substance use and insight using a quantifiable measure of insight. Of 10,067 identified papers, 20 met the inclusion criteria, employing 13 different measures of insight. The most commonly used measure was the Hanil Alcohol Insight Scale (HAIS) which was the only measure designed for a substance use population and was specific to alcohol use. Based on a pooled sample from five studies (n = 585), 57% of participants had poor insight, 36% had fair insight, and 7% had good insight on the HAIS. Better insight was generally related to negative consequences from substance use, better treatment adherence and maintaining abstinence. Insight appears to be an important factor to consider within SUD. Exploring the most appropriate way to measure insight and assess its role in SUD has implications for intervention design, and engaging and maintaining people with SUD in treatment.

The Relation Between Empathy and Insight in Psychiatric Disorders: Phenomenological, Etiological, and Neuro-Functional Mechanisms

Lack of insight, i.e., unawareness of one's mental illness, is frequently encountered in psychiatric conditions. Insight is the capacity to recognize (psychical insight) and accept one's mental illness (emotional insight). Insight growth necessitates developing an objective perspective on one's subjective pathological experiences. Therefore, insight has been posited to require undamaged self-reflexion and cognitive perspective-taking capacities. These enable patients to look objectively at themselves from the imagined perspective of someone else. Preserved theory-of-mind performances have been reported to positively impact insight in psychosis. However, some patients with schizophrenia or obsessive-compulsive disorders, although recognizing their mental disease, are still not convinced of this and do not accept it. Hence, perspective-taking explains psychical insight (recognition) but not emotional insight (acceptance). Here, we propose a new conceptual model. We hypothesize that insight growth relies upon the association of intact self-reflexion and empathic capacities. Empathy (feeling into someone else) integrates heterocentered visuo-spatial perspective (feeling into), embodiment, affective (feeling into) and cognitive processes, leading to internally experience the other's thought. We posit that this subjective experience enables to better understand the other's thought about oneself and to affectively adhere to this. We propose that the process of objectification, resulting from empathic heterocentered, embodiment, and cognitive processes, generates an objective viewpoint on oneself. It enables to recognize one's mental illness and positively impacts psychical insight. The process of subjectification, resulting from empathic affective processes, enables to accept one's illness and positively impacts emotional insight. That is, affectively experiencing the thought of another person about oneself reinforces the adhesion of the emotional system to the objective recognition of the disease. Applying our model to different psychiatric disorders, we predict that the negative effect of impaired self-reflexion and empathic capacities on insight is a transnosographic state and that endophenotypical differences modulate this common state, determining a psychiatric disease as specific.

Validity of the Birchwood insight scale in patients with schizophrenia spectrum- and bipolar disorders

The aim of this study is to investigate the validity of the Norwegian version of the Insight Scale (IS) in large and representative samples of patients with schizophrenia spectrum disorders, bipolar I disorder and bipolar II disorder. A total of 997 participants were included (schizophrenia spectrum disorders: 557; bipolar I disorder: 282; bipolar II disorder: 138). Confirmatory factor analysis was conducted to investigate the construct validity and bivariate correlational analysis was applied to investigate convergent validity. Confirmatory factor analyses indicated a reasonable model fit to the original three-factor subscale structure of the IS in all three diagnostic groups. The IS total score and its subscales correlated significantly with both the insight items in the Young Mania Rating Scale and the Positive and Negative Syndrome Scale in both schizophrenia spectrum disorders and bipolar I disorder. In the bipolar II disorder group, however, the IS subscales correlated poorly with both the observer-rated measures. Our study supports the construct validity of the IS in both schizophrenia spectrum disorder- and bipolar disorder populations. The study also demonstrates that patients' self-reports of insight correspond to observer-based single item ratings of insight in bipolar I disorder and schizophrenia spectrum disorders.

The Association of Insight and Change in Insight with Clinical Symptoms in Depressed Inpatients

BACKGROUND

Lack of insight has been extensively studied and was found to be adversely correlated with impaired treatment compliance and worse long term clinical outcomes among patients with schizophrenia, while not much is known about this phenonmenon in patients with severe depression.

AIM

To explore the correlates of insight and its relation to symptom changes among the most seriously ill patients with affective disorders, those who require hospitalization.

METHODS

Patients hospitalized in a large psychiatric hospital in south China with either major depressive disorder (MDD)(N=55) or bipolar depression (BD) (N=85) based on ICD-10 diagnostic criteria were assessed with the Insight and Treatment Attitudes Questionnaire (ITAQ) one week after admission and at the time of discharge. Clinical symptoms were measured at the same time with the Hamilton Rating Scale for Depression (HAMD-17) and the Depression subscale of the Symptom Check list-90 (SCL-90). Length of stay (LOS), duration of illness, duration of untreated mood disorder, number of previous episodes of depression and previous admissions for depression were documented during interviews with patients and their families and from a review of medical records. Bivariate correlations and multiple regression analysis were used to examine the relationship of sociodemographic characteristics, clinical symptomatology and clinical history, to insight at the time of admission. The relationships between change in clinical symptoms and change in insight from admission to discharge were also examined.

RESULTS

Stepwise multiple regression models suggested that any previous admissions for depression and higher anxiety factor scores on the HAMD-17 are significant independent predictors of insight accounting for 22.9% of the variance. Multiple regression analysis residual change scores (change scores adjusted for baseline values) on the ITAQ showed that improved insight over average stays of 51 days were inversely related to the residual psychomotor retardation factor on the HAMD-17 accounting for 9.1% of the variance.

CONCLUSIONS

More severe anxiety symptoms and previous hospitalization for depression were associated with greater insight into illness at admission. Reduction of motor retardation symptoms during treatment was associated with greater improvement in insight to the time of discharge. The patients who are sicker at admission and who show more improvement in psychomotor retardation show the greatest insight.

Clinical correlates of loss of insight in bipolar depression

INTRODUCTION

Affective state may influence insight, especially regarding mania. Nevertheless, studies have so far suggested that depression seems not to significantly impair insight. To the best of our knowledge, this study pioneers the evaluation of how insight variations in bipolar depression correlate with clinical variables.

METHOD

A group of 165 bipolar patients, 52 of whom had depressive episodes according to DSM-5 criteria, were followed during a year. All patients underwent clinical assessment, and insight was evaluated through the Insight Scale for Affective Disorders (ISAD). Repeated-measures ANOVA was calculated comparing scores on the four ISAD factors (insight into symptoms, the condition itself, self-esteem and social relationships) in order to investigate differences in insight according to different objects. Correlational analysis explored which clinical symptoms were linked to reduced insight.

RESULTS

Worse total insight correlated with suicide attempt/ideation and fewer subsyndromal manic symptoms such as mood elevation, increased energy and sexual interest. Worse self-esteem insight was associated with not only suicide ideation/attempt but also with activity reduction and psychomotor retardation. Worse symptom insight also correlated with psychomotor retardation. Better insight into having an affective disorder was associated with more intense hypochondria symptoms. Finally, worse insight into having an illness was associated with psychotic episodes.

CONCLUSION

Our study found that symptoms other than psychosis - suicide ideation, psychomotor retardation and reduction of activity and work - correlate with insight impairment in bipolar depression.

The influence of current mood state, number of previous affective episodes and predominant polarity on insight in bipolar disorder

BACKGROUND

Although many studies have explored the effect of current affective episodes on insight into bipolar disorder, the potential interaction between current mood state and previous affective episodes has not been consistently investigated.

OBJECTIVE

To explore the influence of dominant polarity, number of previous affective episodes and current affective state on insight in bipolar disorder patients in euthymia or mania.

METHODS

A total of 101 patients with bipolar disorder were recruited for the study, including 58 patients in euthymia (30 with no defined predominant polarity and 28 with manic predominant polarity) and 43 in mania (26 with no defined predominant polarity and 17 with manic predominant polarity). Patients underwent a clinical assessment and insight was evaluated through the Insight Scale for Affective Disorders.

RESULTS

Bipolar disorder patients in mania had worse insight than those in euthymia, with no effect of dominant polarity. In addition, positive psychotic symptoms showed a significant effect on insight and its inclusion as a covariate eliminated differences related to mood state. Finally, the number of previous manic or depressive episodes did not correlate with insight level.

CONCLUSIONS

Mania is a predictor of loss of insight into bipolar disorder. However, it is possible that its contribution is linked to the more frequent presence of psychotic symptoms in this state. Dominant polarity and number/type of previous affective episodes have a limited impact on insight.

The metabolic basis of cognitive insight in psychosis: A positron emission tomography study

The purpose of this study was to investigate the relationship between cognitive insight and cerebral metabolism in patients suffering from psychosis. The Beck Cognitive Insight Scale (BCIS) was administered to 63 patients with psychosis undergoing Positron Emission Tomography investigation. The sample was divided into two groups considering the BCIS score. Data were analyzed using Statistical Parametric Mapping.

RESULTS

patients with low insight, compared to those with high insight, showed decreased metabolism in the right fusiform gyrus, left precuneus, superior temporal gyrus and insula bilaterally, as well as increased metabolism in the left orbito-frontal gyrus (all p<0.005). Our results suggest that reduced posterior (occipito-temporo-insulo-parietal) and increased anterior (orbitofrontal) cerebral metabolism may sustain low cognitive insight in psychosis.

Highs and lows, ups and downs: Meteorology and mood in bipolar disorder

Seasonal variation of manic and depressive symptoms is a controversial topic in bipolar disorder research. Several studies report seasonal patterns of hospital admissions for depression and mania and variation in symptoms that appear to follow a seasonal pattern, whereas others fail to report such patterns. Differences in research methodologies, data analysis strategies, and temporal resolution of data may partly explain the variation in findings between studies. The current study adds a novel perspective to the literature by investigating specific meteorological factors such as atmospheric pressure, hours of sunshine, relative humidity, and daily maximum and minimum temperatures as more proximal predictors of self-reported daily mood change in people diagnosed with bipolar disorder. The results showed that daily maximum temperature was the only meteorological variable to predict clinically-relevant mood change, with increases in temperature associated with greater odds of a transition into manic mood states. The mediating effects of sleep and activity were also investigated and suggest at least partial influence on the prospective relationship between maximum temperature and mood. Limitations include the small sample size and the fact that the number and valence of social interactions and exposure to natural light were not investigated as potentially important mediators of relationships between meteorological factors and mood. The current data make an important contribution to the literature, serving to clarify the specific meteorological factors that influence mood change in bipolar disorder. From a clinical perspective, greater understanding of seasonal patterns of symptoms in bipolar disorder will help mood episode prophylaxis in vulnerable individuals.

The correlation between plasma brain-derived neurotrophic factor and cognitive function in bipolar disorder is modulated by the BDNF Val66Met polymorphism

We explored the effect of the Brain-derived neurotrophic factor (BDNF) Val66Met polymorphism (rs6265) on correlation between changes in plasma BDNF levels with cognitive function and quality of life (QoL) after 12 weeks of treatment in bipolar disorder (BD). Symptom severity and plasma BDNF levels were assessed upon recruitment and during weeks 1, 2, 4, 8 and 12. QoL, the Wisconsin Card Sorting Test (WCST), and the Conners’ Continuous Performance Test (CPT) were assessed at baseline and endpoint. The BDNF Val66Met polymorphism was genotyped. Changes in cognitive function and QoL over 12 weeks were reduced using factor analysis for the evaluation of their correlations with changes in plasma BDNF. Five hundred forty-one BD patients were recruited and 65.6% of them completed the 12-week follow-up. Changes in plasma BDNF levels with factor 1 (WCST) were significantly negatively correlated (r = −0.25, p = 0.00037). After stratification of BD subtypes and BDNF genotypes, this correlation was significant only in BP-I and the Val/Met genotype (r = −0.54, p = 0.008). We concluded that changes in plasma BDNF levels significantly correlated with changes in WCST scores in BD and is moderated by the BDNF Val66Met polymorphism and the subtype of BD.

Insight in bipolar mania: evaluation of its heterogeneity and correlation with clinical symptoms

BACKGROUND

Studies on insight in bipolar mania are not numerous and usually consider insight as a unitary construct.

OBJECTIVE

Evaluate how different facets of insight are affected in bipolar mania and investigate correlations between insight for each specific object in bipolar disorder and manic symptomatology.

METHOD

A group of 165 bipolar patients were followed during a year, with 51 patients having manic episodes according to DSM-IV-TR criteria. Patients underwent a clinical assessment and insight was evaluated through the Insight Scale for Affective Disorders.

RESULTS

The study found that insight regarding symptoms is worse than insight of having bipolar disorder, social relationships and self esteem. Moreover, poor global insight (total ISAD) correlates with more severe changes in mood, speech and thought structure, with worse insight about symptoms correlating with the same alterations and also with more severe symptoms of agitation/energy.

LIMITATIONS

Although a large sample of bipolar patients was followed up, the final sample composed of patients with at least one manic episode was relatively smaller. Moreover, the fact that the study was performed in a university hospital may have led to selection biases.

CONCLUSION

Results suggest that patients with BD are reasonably capable of identifying that their condition implies consequences but have more impaired awareness of their energy and activity levels. A lower level of insight specifically about symptoms correlates with more severe symptoms of agitation/energy, which suggests a psychomotor nucleus able to impair insight in mania.

Does Insight Affect the Efficacy of Antipsychotics in Acute Mania?: An Individual Patient Data Regression Meta-Analysis

Patients having an acute manic episode of bipolar disorder often lack insight into their condition. Because little is known about the possible effect of insight on treatment efficacy, we examined whether insight at the start of treatment affects the efficacy of antipsychotic treatment in patients with acute mania. We used individual patient data from 7 randomized, double-blind, placebo-controlled registration studies of 4 antipsychotics in patients with acute mania (N = 1904). Insight was measured with item 11 of the Young Mania Rating Scale (YMRS) at baseline and study endpoint 3 weeks later. Treatment outcome was defined by (a) mean change score, (b) response defined as 50% or more improvement on YMRS, and (c) remission defined as YMRS score less than 8 at study endpoint. We used multilevel mixed effect linear (or logistic) regression analyses of individual patient data to assess the interaction between baseline insight and treatment outcomes. At treatment initiation, 1207 (63.5%) patients had impaired or no insight into their condition. Level of insight significantly modified the efficacy of treatment by mean change score (P = 0.039), response rate (P = 0.033), and remission rate (P = 0.043), with greater improvement in patients with more impaired insight. We therefore recommend that patients experiencing acute mania should be treated immediately and not be delayed until patients regain insight.

Daily electronic self-monitoring in bipolar disorder using smartphones - the MONARCA I trial: a randomized, placebo-controlled, single-blind, parallel group trial

BACKGROUND

The number of studies on electronic self-monitoring in affective disorder and other psychiatric disorders is increasing and indicates high patient acceptance and adherence. Nevertheless, the effect of electronic self-monitoring in patients with bipolar disorder has never been investigated in a randomized controlled trial (RCT). The objective of this trial was to investigate in a RCT whether the use of daily electronic self-monitoring using smartphones reduces depressive and manic symptoms in patients with bipolar disorder.

METHOD

A total of 78 patients with bipolar disorder according to ICD-10 criteria, aged 18-60 years, and with 17-item Hamilton Depression Rating Scale (HAMD-17) and Young Mania Rating Scale (YMRS) scores ≤17 were randomized to the use of a smartphone for daily self-monitoring including a clinical feedback loop (the intervention group) or to the use of a smartphone for normal communicative purposes (the control group) for 6 months. The primary outcomes were differences in depressive and manic symptoms measured using HAMD-17 and YMRS, respectively, between the intervention and control groups.

RESULTS

Intention-to-treat analyses using linear mixed models showed no significant effects of daily self-monitoring using smartphones on depressive as well as manic symptoms. There was a tendency towards more sustained depressive symptoms in the intervention group (B = 2.02, 95% confidence interval -0.13 to 4.17, p = 0.066). Sub-group analysis among patients without mixed symptoms and patients with presence of depressive and manic symptoms showed significantly more depressive symptoms and fewer manic symptoms during the trial period in the intervention group.

CONCLUSIONS

These results highlight that electronic self-monitoring, although intuitive and appealing, needs critical consideration and further clarification before it is implemented as a clinical tool.

Insight Across the Different Mood States of Bipolar Disorder

In bipolar disorder, levels of insight vary as a function of the mood state and appear to influence pharmacology compliance, quality of life, the presence of suicidal ideations, and aggressive behavior. To establish a comparison among different mood states in bipolar with regard to level of insight. Forty-eight patients were evaluated in different affective states (i.e., euthymia, mania, depression, and mixed state). Identifying information, sociodemographic data, and clinical records were recorded. The following scales were applied: Hamilton Depression Scale, Young Mania Rating Scale, Positive and Negative Syndrome Scale positive symptoms subscale, and Global Assessment of Functioning and Clinical Global Impressions Scale for use in bipolar disorder. Insight was evaluated using items 11 and 17 of the Young Mania Rating Scale and Hamilton Depression Scale, respectively. Insight in bipolar disorder was found to be more compromised during manic phases and mixed episodes than during periods of depression or euthymia. The factors associated with lower levels of insight were the following: shorter illness duration, older age, and greater severity in mania; the female gender and older age in depression; and shorter illness duration and more severe depressive symptoms in mixed episodes. In the same individual, levels of insight vary as a function of the affective state over the course of bipolar disorder and appear to be influenced by several clinical variables.

The impact of insight in a first-episode mania with psychosis population on outcome at 18 months

BACKGROUND

To explore whether poor initial insight during a first episode of mania with psychotic features was predictive of poor psychosocial and clinical outcomes at 18 months.

METHODS

Secondary analysis was performed on data collected during an 8-week RCT comparing the efficacy of olanzapine versus chlorpromazine as an adjunct to lithium, and at 18-month follow-up. 74 participants were divided into three groups (no insight, partial insight, and full insight) according to the insight item from the Young Mania Rating Scale (YMRS). Differences between these three groups were examined at baseline and at 18 months on measures of symptoms (YMRS, HAMD-21, and CGI-S), and social and occupational functioning (SOFAS). Baseline differences between the three groups were determined using general linear models and chi-squared analyses. Group differences from baseline to 18-month follow-up were determined using repeated measures general linear models.

RESULTS

At baseline there were significant differences between the three insight groups in terms of mania and functioning, but at 18 months all groups had improved significantly in terms of psychopathology, mania, depression and social and occupational functioning. There were no significant differences between the three groups at study completion with respect to these domains.

LIMITATIONS

The study was limited by the lack of availability of a more detailed rating scale for insight, and it did not account for the duration of untreated psychosis (DUI).

CONCLUSIONS

Poor initial insight during a first episode of mania with psychotic features does not predict poor clinical and psychosocial outcome at 18 months.

Cognitive performance and quality of life early in the course of bipolar disorder

BACKGROUND

Several studies have reported cognitive functioning as a significant predictor of quality of life (QoL) in patients with established bipolar disorder (BD), in addition to mood symptoms. However, it is unclear whether cognitive functioning predicts QoL early in the course of illness. The purpose of this study was therefore to evaluate the relationship between mood and neuropsychological variables and self-reported QoL early in the course of BD.

METHODS

Patients with BD-I (n=54) completed a neuropsychological battery and clinical assessment within 3 months of resolution of their first manic episode. QoL was assessed 6 months later using the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). Cognitive predictors of QoL were assessed through Pearson correlations and hierarchical multiple regression.

RESULTS

After accounting for mood rating scores at the time of cognitive testing (ΔR²=.27, p<.001), measures of sustained attention (ΔR²=.08, p<.05), verbal memory (ΔR²=.09, p<.01), working memory (ΔR²=.06, p<.05), and executive functioning (ΔR²=.08, p<.05) each predicted QoL when entered independently in separate regression models. When entered simultaneously, the cognitive domains explained 15% (R(2)=.42, p<.05) of the variance in QoL beyond mood.

LIMITATIONS

Some aspects of QoL that are particularly important in BD may be missing as a result of using the Q-LES-Q, because the measure was not specifically developed to assess QoL in BD.

CONCLUSIONS

In addition to mood symptoms, poorer cognitive functioning is a significant predictor of reduced QoL early in the course of BD. Recently diagnosed patients with BD may benefit from early cognitive-enhancing interventions to maintain or restore their QoL.

O insight no transtorno bipolar: uma revisão sistemática

Objetivos Realizar uma revisão sistemática para compreender que fatores estão relacionados a uma maior ou menor consciência de morbidade no transtorno bipolar (TB), como o insight varia em função do estado afetivo e estabelecer uma comparação com outros transtornos mentais. Métodos Realizou-se uma revisão sistemática da literatura científica sobre o insight em pacientes com TB. Foram buscados estudos clínicos originais sobre o tema nas bases de dados Medline, ISI e SciELO. Os termos de busca empregados foram: “insight” OR “awareness” AND “bipolar” OR “mania” OR “manic”. Resultados Foram selecionados 55 artigos. O insight no TB parece ser mais prejudicado do que na depressão unipolar, porém menos do que na esquizofrenia. Com relação ao TB, um menor nível de insight está relacionado à presença de sintomas psicóticos e de alterações cognitivas. Além disso, um comprometimento do insight está associado a uma menor adesão ao tratamento. Por outro lado, uma maior preservação do insight pode estar associada a maior ideação suicida. Finalmente, a fase maníaca cursa com um nível inferior de insight quando comparada à fase depressiva ou de eutimia. Conclusão No TB, o insight está significativamente prejudicado, especialmente na mania. Diversos fatores clínicos parecem influenciar o nível de insight.

The diagnosis and treatment of bipolar disorder: decision-making in primary care

Bipolar disorder is a chronic episodic illness, characterized by recurrent episodes of manic or depressive symptoms. Patients with bipolar disorder frequently present first to primary care, but the diversity of the potential symptoms and a low index of suspicion among physicians can lead to misdiagnosis in many patients. Frequently, co-occurring psychiatric and medical conditions further complicate the differential diagnosis. A thorough diagnostic evaluation at clinical interview, combined with supportive case-finding tools, is essential to reach an accurate diagnosis. When treating bipolar patients, the primary care physician has an integral role in coordinating the multidisciplinary network. Pharmacologic treatment underpins both short- and long-term management of bipolar disorder. Maintenance treatment to prevent relapse is frequently founded on the same pharmacologic approaches that were effective in treating the acute symptoms. Regardless of the treatment approach that is selected, monitoring over the long term is essential to ensure continued symptom relief, functioning, safety, adherence, and general medical health. This article describes key decision-making steps in the management of bipolar disorder from the primary care perspective: from initial clinical suspicion to confirmation of the diagnosis to decision-making in acute and longer-term management and the importance of patient monitoring.

Exploring the recovery concept in bipolar disorder: a decision tree analysis of psychosocial correlates of recovery stages

OBJECTIVES

The recovery movement has generated interest in the concept of personal recovery, but little attention has been paid to it in relation to bipolar disorder (BD). The aim of this study was to examine personal recovery in BD using a staged model, exploring whether different stages are associated with different psychosocial and clinical profiles.

METHODS

Adults with BD in remission (n = 75) were recruited from an outpatient psychiatric clinic in Hong Kong. Their average age was 45 years, with 11% and 45% working part time and full time, respectively. The data included stages of recovery, sociodemographic characteristics, clinical information, and perceptions of the importance of recovery factors and the resilience-engendering features of health services. Decision tree analysis was used to identify the predictors of stages of recovery, and receiver operating characteristic curves were employed to detect the rates of correct classification within the staged model.

RESULTS

'Respect, hope, and self-directed empowerment', older age, binge drinking history, early first diagnosis, and 'meaningful role' were all associated with being in a later stage of personal recovery. The first two variables demonstrated better classification accuracy than the last three. Using these variables, the classification accuracy of Stages 2-4 was adequate.

CONCLUSIONS

There are associations between the stage of recovery and psychosocial variables among individuals with BD in remission. Interventions that promote 'respect, hope, and self-directed empowerment' have the potential to facilitate personal recovery from BD.

The reliability of self-assessment of affective state in different phases of bipolar disorder

Some studies have indicated that the capacity of self-assessment of affective state is more compromised during mania than during depression. In the present study, we investigated whether the reliability of self-assessment in bipolar disorder varies as a function of actual affective state (i.e., euthymia, mania, or depression). Sixty-five patients with a diagnosis of type I and type II bipolar disorder were evaluated with regard to the occurrence of an affective syndrome using the Clinical Global Impressions Scale for use in bipolar illness, the Positive and Negative Syndrome Scale, and the Global Assessment of Functioning scale. In parallel, we applied the Analog Visual Mood Scale, a self-assessment tool to evaluate mood changes. The same individual prospectively completed the self-assessment scale in different affective states. During depression, the patients' evaluation was significantly different from when they were in manic or euthymic mood states. However, when in mania, the patients evaluated their mood state similarly to when they were euthymic. The bipolar patients in mania but not in depression did not reliably evaluate themselves with regard to their affective state.

Genotype variant associated with add-on memantine in bipolar II disorder

Memantine is a non-competitive N-methyl-d-asparate (NMDA) receptor antagonist with a mood-stabilizing effect. We investigated whether using valproic acid (VPA) plus add-on memantine to treat bipolar II disorder (BP-II) is more effective than using VPA alone (VPA + Pbo). We also evaluated, in BP-II patients, the association between the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism with treatment response to VPA + add-on memantine and to VPA + Pbo. In this randomized, double-blind, controlled 12 wk study, BP-II patients undergoing regular VPA treatments were randomly assigned to a group: VPA + Memantine (5 mg/day) (n = 115) or VPA + Pbo (n = 117). The Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) were used to evaluate clinical response during week 0, 1, 2, 4, 8 and 12. The genotypes of the BDNF Val66Met polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis. To adjust within-subject dependence over repeated assessments, multiple linear regression with generalized estimating equation methods was used to analyze the effects of the BDNF Val66Met polymorphism on the clinical performance of memantine. Both groups showed significantly decreased YMRS and HDRS scores after 12 wk of treatment; the differences between groups were non-significant. When stratified by the BDNF Val66Met genotypes, significantly greater decreases in HDRS scores were found in the VPA + memantine group in patients with the Val Met genotype (p = 0.004). We conclude that the BDNF Val66Met polymorphism influenced responses to add-on memantine by decreasing depressive symptoms in patients with BP-II.

Differences and similarities between functional and personal recovery in an Asian population: a cluster analytic approach

This study gathers empirical data to test whether two forms of recovery are related: (1) the traditional outcome-based notion of recovery from a mental illness, which is called "functional recovery," and (2) the more recent, consumer-based concept of recovery in mental illness, which is called "personal recovery." A total of 150 Chinese outpatients were recruited, 75 with bipolar disorder and 75 with schizophrenia, as determined by structured clinical interview. Participants were reported to be in clinical remission for at least the previous 6 months by treating psychiatrists. Personal recovery was measured with the Stages of Recovery Scale, and functional recovery was measured with residential and employment status. In addition to clinical and demographic data, self-report measures included functioning (confirmed through chart review) and a survey of the participant's assessment of the importance of various elements of recovery. Personal recovery was significantly correlated with functional recovery; small effect size suggested that the two domains are far from identical. The strength of this correlation was stronger for participants with schizophrenia than for those with bipolar disorder. A cluster analysis also suggested that residential and employment statuses, along with personal recovery scores, were useful in differentiating participants. Patients were more likely to reach better recovery outcomes if they were female, married, had higher family income, and perceived social roles as less important to their recovery. Consistent with the consumer literature, personal recovery is related but still distinct from functional recovery. Personal recovery has more to do with life circumstances than with functioning status alone.

A prospective study of the trajectories of clinical insight, affective symptoms, and cognitive ability in bipolar disorder

BACKGROUND

Clinical insight in bipolar disorder is associated with treatment adherence and psychosocial outcome. The short-term dynamics of clinical insight in relationship to symptoms and cognitive abilities are unknown.

METHODS

In a prospective observational study, a total of 106 outpatients with bipolar disorder I or II were assessed at baseline, 6 weeks, 12 weeks, and 26 weeks. Participants were administered a comprehensive neuropsychological battery, clinical ratings of manic and depressive symptom severity, and self-reported clinical insight. Lagged correlations and linear mixed-effects models were used to determine the temporal associations between symptoms and insight, as well as the moderating influence of global cognitive abilities.

RESULTS

At baseline, insight was modestly correlated with severity of manic symptoms, but not with depressive symptoms or cognitive abilities. Insight and depressive symptoms fluctuated to approximately the same extent over time. Both lagged correlations and mixed effects models with lagged effects indicated that the severity of manic symptoms predicted worse insight at later assessments, whereas the converse was not significant. There were no direct or moderating influences of global cognitive abilities.

LIMITATIONS

Our sample size was modest, and included relatively psychiatrically stable outpatients, followed for a six month period. Our results may not generalize to acutely symptomatic patients followed over a longer period.

CONCLUSIONS

Clinical insight varies substantially over time within patients with bipolar disorder. Impaired insight in bipolar disorder is more likely to follow than to precede manic symptoms.

Mood self-assessment in bipolar disorder: a comparison between patients in mania, depression, and euthymia

BACKGROUND: Some studies indicate that mood self-assessment is more severely impaired in patients with bipolar disorder in a manic episode than in depression. OBJECTIVES: To investigate variations in mood self-assessment in relation to current affective state in a group of individuals with bipolar disorder. METHODS: A total of 165 patients with a diagnosis of bipolar disorder type I or type II had their affective state assessed using the Clinical Global Impressions Scale for use in bipolar illness (CGI-BP), the Positive and Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF). In addition, participants completed a self-report visual analog mood scale (VAMS). Patients were divided into three groups (euthymia, mania, and depression) and compared with regard to VAMS results. RESULTS: Manic patients rated their mood similarly to patients in euthymia in 14 out of 16 items in the VAMS. By contrast, depressed patients rated only two items similarly to euthymic patients. CONCLUSION: Patients with bipolar disorder in mania, but not those in depression, poorly evaluate their affective state, reinforcing the occurrence of insight impairment in the manic syndrome.

Development of the insight scale for affective disorders (ISAD): modification from the scale to assess unawareness of mental disorder

BACKGROUND

Research on insight in patients with mood disorders has grown in recent years. Several instruments to assess insight have been used, but most of them have been specifically designed for psychosis and may not appear relevant to mood disorders. The aim of the present study is to develop a short, multidimensional, reliable and valid scale to measure insight in patients with mood disorders, based on the Amador's Scale to Assess Unawareness of Mental Disorders (SUMD).

METHOD

A Delphi method was used to facilitate expert participation and ensure face and content validity. The SUMD structure and items were used as a reference in the scale development. A new scale with 17 items was obtained. Internal consistency, test-retest and inter-rater reliability and validity were studied in a sample of 76 outpatients with a DSM-IV diagnosis of major depression or bipolar disorder (type I or II).

RESULTS

Internal consistency of the general items was moderate, and high for the symptoms awareness subscale. Scores on ISAD correlated with other measures of insight and with some clinical measures, thus supporting its validity.

LIMITATIONS

The majority of the sample came from community services. Future studies should use inpatients or patients with severe symptoms to broaden the range of responses. Moreover, the rating of insight and other measures by the same clinician might introduce a methodological bias.

CONCLUSION

The ISAD, with a multidimensional approach, appears as a short, reliable and valid measure of insight in mood disorders. Expert consensus ensures its face and content validity.

Hopelessness and suicidal risk in bipolar disorder. A study in clinically nonsyndromal patients

OBJECTIVE

Attempted suicide and death due to suicide are not uncommon among patients with bipolar disorder. Although some risk factors for suicidality in bipolar patients have been identified, little is known about hopelessness and other possible trait or diathesis-related factors. Consequently, the objective of this study was to investigate variables associated with suicidal risk in clinically nonsyndromal bipolar patients.

METHODS

A sample of 102 outpatients with a diagnosis of bipolar disorder according to International Classification of Diseases, 10th Revision criteria during nonsyndromal stage were evaluated. On the basis of suicidal history, patients were divided into suicide attempt, suicidal ideation, and nonsuicidal groups. Sociodemographic, clinical, and psychopathological variables were assessed.

RESULTS

As compared with the nonsuicidal group, female sex, combined psychopharmacologic treatment, and hopelessness were independently associated with suicide attempt. Hopelessness and insight into having a mental disorder were independently associated with history of suicidal ideation.

CONCLUSIONS

Patients with bipolar disorder and suicidal history are characterized by the presence of hopelessness, which probably confers greater vulnerability for suicidal behavior in the presence of stress factors. This identification of the risk profile for suicidal behavior in nonsyndromal bipolar patients adds complementary information to risk factors established for suicidality during acute phases of the disease, allows for differentiated preventive and treatment approaches of patients at risk, and suggests psychotherapy as an advisable intervention in this group of patients.

Neurobiological correlates of illness progression in the recurrent affective disorders

Some clinical aspects of affective illness progression, such as episode-, stress-, and substance-induced sensitization, have been well documented in the literature, but others have received less attention. These include cognitive deficits, treatment-refractoriness, and neurobiological correlates of illness progression, which are the primary focus of this paper. We review the evidence that cognitive dysfunction, treatment resistance, medical comorbidities, and neurobiological abnormalities increase as a function of the number of prior episodes or duration of illness in the recurrent unipolar and bipolar disorders. Substantial evidence supports the view that cognitive dysfunction and vulnerability to a diagnosis of dementia in old age increases as a function of number of prior mood episodes as does non-response to many therapeutic interventions as well as naturalistic treatment. Neurobiological abnormalities that correlate with the number of mood episodes or duration of illness include: anatomical, functional, and biochemical deficits in the prefrontal cortex and hippocampus, as well as amygdala hyperactivity and cortisol hyper-secretion. Some neurotrophic factors and inflammatory markers may also change with greater illness burden. Causality cannot be inferred from these correlative relationships. Nonetheless, given the potentially grave consequences of episode recurrence and progression for morbidity and treatment non-responsiveness, it is clinically wise to assume episodes are causing some of the progressive cognitive and neurobiological abnormalities. As such, earlier and more sustained long-term prophylaxis to attempt to reduce these adverse outcomes is indicated.

The association between insight and symptoms in bipolar inpatients: An Italian prospective study

Objective

To evaluate potential differences in insight among bipolar manic, mixed and bipolar depressed inpatients and assess the role of clinical and demographic characteristics as possible predictors.

Method

One hundred and twenty consecutive inpatients divided into three diagnostic groups were studied on admission (T0), at discharge (T1) and at 18weeks after hospitalization (T2). The Young Mania Rating Scale (YMRS), the Hamilton Rating Scale for Depression (HAMD) and the Scale to Assess Unawareness of Mental Disorder (SUMD) were used.

Results

Patients with mixed mania showed highest scores on the SUMD than patients with mania or bipolar depression. It was found a significant relationship between improvements in mania and in the insight. The level of insight at baseline was the only predictor of awareness in social consequences, moreover clinical and demographic characteristics were predictors of insight into mental illness. For what concerns insight about therapy benefits it was influenced by level of mania at baseline.

Conclusion

The three general dimensions of insight revealed significant differences among the three groups. Regression models suggest that insight is a multidimensional concept in which some aspects are state-related, associated with psychopathology, whereas others are trait-like qualities, not directly associated with symptoms and predicted only by level at baseline.

Comparison of insight among schizophrenia and bipolar disorder patients in remission of affective and positive symptoms: Analysis and critique

Background

Schizophrenia and bipolar disorder are associated with impairments in insight, leading to a poorer clinical outcome and functioning. Earlier studies comparing the two disorders on the basis of insight included inpatients or patients who were clinically symptomatic. The current study therefore assessed patients in remission of affective symptoms and positive symptoms of schizophrenia.

Methods

Schizophrenia and bipolar disorder patients (n = 32, n = 34; respectively) underwent clinical and functional evaluations. Insight was assessed using the Scale to assess Unawareness of Mental Disorder (SUMD) and the Positive and Negative Syndrome Scale (PANSS). Attention was assessed using a continuous performance task (CANTAB's Rapid Visual Information Processing).

Results

Schizophrenia patients displayed poorer insight into having a mental disorder and into the social consequences thereof compared to the bipolar disorder patients. They were also less aware of their anhedonia-asociality. Age, however, was significantly correlated with insight and differences in insight between the patient groups became nonsignificant when age was used as a covariate in the statistical analyses. Age was not a moderating variable of the relationship between diagnosis and insight.

Conclusions

Significant differences in insight held by the two patient groups might be related to age disparities between patient groups. Earlier studies did not adequately address these age differences, their cause and their potential effects on findings. These issues are explored with regard to the findings of the current study, as well as earlier studies, emphasizing the need for further research of the relationship between age and insight.

Insight in bipolar disorder: relationship to episode subtypes and symptom dimensions

BACKGROUND

The study of insight in bipolar disorder has received limited attention, despite its potential impact on treatment compliance and prognosis. In the current study we compare insight levels during different phases of bipolar disorder, and consider its relationship to symptoms dimensions and epidemiologic variables.

METHODS

Insight ratings obtained from 156 bipolar subjects in any phase of bipolar disorder were compared. A regression analysis was also conducted to identify symptom dimensions predictive of insight levels.

RESULTS

Greater impairments in insight were observed during pure manic episodes than during mixed or depressed episodes, or during euthymia. Depressive symptoms were associated with better insight. Improvements in insight with treatment were neither complete nor universal. Lack of insight was unrelated to age, years of illness, age of first psychiatric illness, or lifetime number of hospitalizations.

CONCLUSIONS

Although psychosis may be associated with impaired insight, other variables also impact on degree of impaired insight. Specifically, depressed mood appears to be associated with preservation of insight. That relationship may transcend strict syndromal diagnosis.

A population-based analysis of distinguishers of bipolar disorder from major depressive disorder

BACKGROUND

Many people with bipolar disorder (BD) in the community are misdiagnosed with major depressive disorder (MDD). A probabilistic model has been proposed to assist in the identification of BD among patients with depressive symptoms, however there are limited population-based data on the key distinguishers of BD from MDD. The objective of this study was to identify distinguishers of BD from MDD in a population-based sample.

METHODS

Population-based data were extracted from the Canadian Community Health Survey: Mental Health and Well-Being. Sociodemographic variables, clinical variables, and depressive symptomatology were compared between subjects with BD (N=467) and MDD (N=4145). Logistic regression analysis was used to identify significant correlates of BD, and areas under the receiver operating characteristic curves (AUCs) were determined for each model.

RESULTS

BD and MDD subjects differed across a number of characteristics. Clinical variables significantly associated with BD included greater number of lifetime depressive episodes, earlier age of first depressive episode, lifetime anxiety disorder, problematic substance use, and lifetime suicide attempt. Symptoms significantly more common during a major depressive episode among BD subjects included agitation, suicidal ideation, anxious symptoms, and irritability. AUCs for these models ranged from 0.72 to 0.81.

LIMITATIONS

Data were not available for all potential distinguishers; subgroups of BD could not be determined; cross-sectional data.

CONCLUSIONS

These population-based results reinforce the effort to establish a generalizable probabilistic model that incorporates clinical and symptom variables in order to assist clinicians in the diagnostic assessment of BD.

[French adaptation and validation of the scale to assess unawareness of mental disorder]

OBJECTIVES

To validate the French version of the Scale to Assess Unawareness of Mental Disorder (SUMD) in patients with schizophrenia.

METHOD

One hundred patients with schizophrenic disorders were included. Our statistical analyses evaluated interrater reliability, theoretical validity, and convergent or divergent validity. Finally, an exploratory factor analysis was conducted.

RESULTS

The results revealed good psychometric properties for the French version of the SUMD. Both interrater reliability (ICC ranged from 0.68 to 1.00) and internal consistency (Cronbach 0.70) were satisfactory. Criterion validity was confirmed by high correlation values between SUMD scores and scores on the Positive and Negative Syndrome Scale G12 item evaluating insight. Moreover, as hypothesized, there were few associations between SUMD scores and clinical variables. Finally, Principal Component Analyses confirmed the hypothesis of 2 distinct insight dimensions (consciousness and attribution) for both present and past aspects.

CONCLUSIONS

This French version of the SUMD is a reliable and valid measure of insight in schizophrenia. The clinical relevance of its measure and the development of psychosocial interventions to improve insight into illness in patients with schizophrenia are discussed.

Temperamentsxgenes in bipolar I and bipolar II disorder patients

We found the main effects of harm avoidance temperament in predicting bipolar I and II, but the interaction between novelty seeking and Ser9Gly polymorphisms of dopamine D3 receptor gene was demonstrated in bipolar-I patients only. This study provided evidence that differences existed between BP-I and BPII in gene and temperament interactions.

Poorer sustained attention in bipolar I than bipolar II disorder

BACKGROUND

Nearly all information processing during cognitive processing takes place during periods of sustained attention. Sustained attention deficit is among the most commonly reported impairments in bipolar disorder (BP). The majority of previous studies have only focused on bipolar I disorder (BP I), owing to underdiagnosis or misdiagnosis of bipolar II disorder (BP II). With the refinement of the bipolar spectrum paradigm, the goal of this study was to compare the sustained attention of interepisode patients with BP I to those with BP II.

METHODS

In all, 51 interepisode BP patients (22 with BP I and 29 with BP II) and 20 healthy controls participated in this study. The severity of psychiatric symptoms was assessed by the 17-item Hamilton Depression Rating Scale and the Young Mania Rating Scale. All participants undertook Conners' Continuous Performance Test II (CPT-II) to evaluate sustained attention.

RESULTS

After controlling for the severity of symptoms, age and years of education, BP I patients had a significantly longer reaction times (F(2,68) = 7.648, P = 0.001), worse detectability (d') values (F(2,68) = 6.313, P = 0.003) and more commission errors (F(2,68) = 6.182, P = 0.004) than BP II patients and healthy controls. BP II patients and controls scored significantly higher than BP I patients for d' (F = 6.313, P = 0.003). No significant difference was found among the three groups in omission errors and no significant correlations were observed between CPT-II performance and clinical characteristics in the three groups.

CONCLUSIONS

These findings suggested that impairments in sustained attention might be more representative of BP I than BP II after controlling for the severity of symptoms, age, years of education and reaction time on the attentional test. A longitudinal follow-up study design with a larger sample size might be needed to provide more information on chronological sustained attention deficit in BP patients, and to illustrate clearer differentiations between the three groups.

Relationship between psychosocial adjustment and executive function in patients with bipolar disorder and schizophrenia in remission: the mediating and moderating effects of insight

OBJECTIVES

The aims of this study were to examine the relationships between executive function and psychosocial adjustment, and the mediating and moderating effects of insight on the association between executive function and psychosocial adjustment in patients with bipolar disorder and schizophrenia in clinical remission.

METHODS

The level of psychosocial adjustment was assessed in 96 subjects with bipolar disorder and 96 subjects with schizophrenia who were in remitted state. The association between executive function and psychosocial adjustment and the mediating and moderating effects of insight were examined by multiple regression analysis models and the Goodman test.

RESULTS

The results indicated that executive function had direct effect on psychosocial adjustment in both subjects with bipolar disorder and schizophrenia. However, the mediating effect of insight on the association between executive function and psychosocial adjustment was only found in subjects with schizophrenia, but not in subjects with bipolar disorder. No moderating effect of insight on the association between executive function and psychosocial adjustment was found in subjects with schizophrenia or bipolar disorder.

CONCLUSIONS

The results of this study indicated that executive function has an important role in psychosocial adjustment in both patients with bipolar disorder and schizophrenia. Meanwhile, insight has a different role in the association between executive function and psychosocial adjustment between patients with bipolar disorder and schizophrenia.

Predictive value of self-stigma, insight, and perceived adverse effects of medication for the clinical outcomes in patients with depressive disorders

The aims of this prospective study were to examine the predictive values of self-stigma, insight, and perceived adverse effects of medication for remission of depressive symptoms, suicidal risk, and medication adherence in patients with depressive disorders over a 1-year follow-up period. One hundred seventy-four participants who were in a state of obvious depression underwent an index interview to determine their degree of self-stigma, insight, and perceived adverse effects of medication. One year later, they were reassessed to determine the severity of their depressive symptoms, suicidal risk, and the level of the medication adherence, and their associations with the 3 possible predictors at the index interview were examined. The results of this study indicated that perceiving more severe adverse effects of medication at the index interview increased the risks of the nonremission of depressive symptoms, occurrence of suicidal ideation or attempt, and medication nonadherence in patients with depressive disorders in the 1-year period. However, the degrees of self-stigma and insight did not predict the severity of depressive symptoms, suicidal risk, or the level of the medication adherence. Based on the results of this study, we suggest that it is important for clinicians to prevent the occurrence of and to help patients manage the adverse effects of medication. We also suggest that further prospective studies are needed to examine the predictive values of self-stigma and insight for clinical outcomes and medication adherence.

Only half of bipolar I and II patients report prodromal symptoms

BACKGROUND

Learning to detect prodromal symptoms is a key element of psychosocial treatment of bipolar disorder (BD). However, previous studies have described only prodromes of manic and depressive phases of BD I patients, while information on prodromes in BD II, or other phases is lacking.

METHODS

The Jorvi Bipolar Study included 191 in- and outpatients with DSM-IV BD (90 BD I, 101 BD II) in any acute phase of illness at baseline. The prevalence, type and duration of preceding prodromes were investigated using open-ended questions. The effects of type I or II disorder, index phase, socio-demographic factors, comorbidity, illness history and other correlates on report and duration of prodromes were investigated.

RESULTS

Prodromes were reported by 45.0% of BD I and 50.0% of BD II patients. The first prodromal symptom was usually mood congruent, but sometimes non-specific for mood or a symptom of anxiety; the median duration was 30.5 days. No differences between BD I and II, or between patients who did and those who did not report prodromes were found. Only Axis I comorbidity associated with longer prodromes, but not independently after adjusting for age, gender and type of phase.

LIMITATIONS

The study was cross-sectional. Reporting prodromes depends on patients' insight which was likely affected by a sub-acute phase at time of interview.

CONCLUSIONS

Only half of ordinary, secondary care bipolar patients are able to report prodromes. The chronic and fluctuating course of illness, and sometimes short time interval to full episode may limit the potentials of prodrome-based interventions.

Insight, quality of life and cognitive functioning in euthymic patients with bipolar disorder

INTRODUCTION

The relationship between insight, quality of life and cognition in bipolar disorder has not been clearly established.

METHOD

A neuropsychological battery assessing attention, mental control, perceptual-motor skills, executive functions, verbal fluency, abstraction and visuo-spatial attention was administered to 70 remitted bipolar patients and 50 healthy controls. Insight was assessed using the Scale to Assess Unawareness of Mental Disorder; Quality of Life was assessed using the Portuguese version of the WHO Quality of Life Assessment--Abbreviated version (WHOQOL-BREF-PT).

RESULTS

No differences in QoL and cognitive performance were observed between bipolar patients with 'impaired' and 'preserved' insight. Insight was found to be correlated with poorer psychological and environmental QoL. A multiple regression model showed that depressive symptoms were significant predictors of physical, psychological and environmental QoL.

CONCLUSION

The present study adds to the notion that depressive symptoms, even of low intensity, are strong predictors of QoL. The present study suggests that the impact of insight on self-reported QoL may be subtle during remission and may be more substantially affected in the presence of manic symptoms.

Quality of life and its association with insight, adverse effects of medication and use of atypical antipsychotics in patients with bipolar disorder and schizophrenia in remission

OBJECTIVE

The present study aimed: (i) to compare the level of quality of life (QOL) among subjects with bipolar disorder (BD) and schizophrenia who were in remission and healthy control subjects and (ii) to examine the association of QOL with insight, adverse effects of medication and use of atypical antipsychotics among subjects with BD and schizophrenia who were in remission by controlling other confounding factors.

METHODS

The QOL on the four domains of the World Health Organization Questionnaire on Quality of Life: Short Form - Taiwan version (WHOQOL-BREF) were compared between 96 subjects with BD in remission, 96 subjects with schizophrenia in remission and 106 healthy control subjects. The association between the four QOL domains and subjects' insight, adverse effects of medication and use of atypical antipsychotics were examined using multiple regression analyses in the subjects with BD and schizophrenia in remission.

RESULTS

The results demonstrated that the subjects with BD in remission had similarly poor levels of QOL in all four domains as those subjects with schizophrenia in remission, and both subjects with BD and schizophrenia had poorer QOL than those in the control group. For both subjects with BD and schizophrenia in remission, insight was negatively associated with QOL on the physical domain, and adverse effects of medication were negatively associated with QOL on the physical and environment domains. Use of atypical antipsychotics was not associated with QOL, but subjects with BD receiving olanzapine perceived better psychological QOL than those receiving risperidone and better psychological and social relationship QOL than those receiving no atypical antipsychotic.

CONCLUSIONS

The results of the present study indicate that subjects with BD are dissatisfied with their QOL, even when they are in a remitted state. Clinicians must consider the negative influences of insight and adverse effects of medication on QOL of patients with BD and schizophrenia in remission.

Relationship between insight and neurocognition in patients with bipolar I disorder in remission

The aim of this study was to examine the relationships between insight and neurocognition in a population of patients with bipolar I disorder who were in a remitted state. Using the Schedule of Assessment of Insight (SAI) and its expanded version, we evaluated 96 patients with bipolar I disorder in remission to determine their level of insight. We also evaluated their neurocognitive function included in the domains of executive function, attention, and memory. The associations between insight and neurocognitive function were examined by using the stepwise multiple regression analysis to control the confounding effects of sociodemographic and clinical factors. The results indicated that by controlling the confounding effects of other factors, executive function was positively associated with the SAI dimensions of awareness of illness and relabeling of phenomena, and the total expanded version of the SAI in remitted bipolar patients. The results of this study indicated that the relationships vary between different dimensions of insight and domains of neurocognitive function in remitted bipolar patients.

Suicidality and its association with insight and neurocognition in taiwanese patients with bipolar I disorder in remission

The aims of this study were to examine the relationships between suicidality, insight, and neurocognition in patients with bipolar I disorder who were in a remitted state. Using the Violence and Suicide Assessment Scale, we evaluated 96 patients with bipolar I disorder in remission to determine their suicidal ideations and attempts over the previous year. We also evaluated their level of insight by using the Schedule of Assessment of Insight (SAI) and its expanded version (SAI-E), as well as their neurocognitive function by a series of neurocognitive function tests. Insight and neurocognitive functions of bipolar subjects who had and who had no suicidal ideations or attempts over the previous year were compared. The results indicated that the remitted bipolar subjects who had suicidal ideations or attempts over the previous year had higher insight scores on all 3 SAI dimensions and on the SAI-E compared with those who had no suicidal ideations or attempts. However, no difference in any neurocognitive function was found between the 2 groups of remitted bipolar subjects. The results of this study suggest clinicians need to be particularly alert to the potential for suicide in bipolar patients with a high level of insight.

Unawareness of illness in neuropsychiatric disorders: phenomenological certainty versus etiopathogenic vagueness

Awareness of illness is a form of self-knowledge concerning information about the pathological state, its functional consequence, and the way it affects the patient and his interaction with the environment. Unawareness of illness has raised much interest for its consequences on compliance with treatment, prognosis, and the patient's quality of life. This review highlights the great complexity of this phenomenon both at phenomenological and etiopathogenic levels in stroke, traumatic brain injury, psychosis, dementias, and mood disorders. In particular, the clinical expression is characterized by failure to acknowledge being ill, misattribution of symptoms, and noncompliance with treatment. Unawareness of illness may also be linked with characteristics that are peculiar to each individual disturbance, such as symptom duration and cognitive impairment. Despite a long-lasting interest in the clinical characteristics of unawareness, only recently has the focus of research investigated pathogenic mechanisms, with sometimes controversial results. The vast majority of studies have pointed out a remarkable involvement of the right hemisphere. Specifically, functional and structural changes of the dorso-lateral prefrontal cortex and some other frontal areas have often been found to be associated with awareness deficit, as well as parieto-temporal areas and the thalamus, although to a lesser extent. These data indicate the present difficulty of localizing a specific cerebral area involved in unawareness and suggest the existence of possible brain circuits responsible for awareness. In conclusion, phenomenological manifestations of poor awareness are well outlined in their complexity, whereas neuroanatomic and neuropsychological findings are still too vague and sparse and need further, greater efforts to be clarified.