Predictors of insight in first-episode schizophrenia: a 5-year cohort study from India

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.

Beliefs About the Causes of Psychosis Among Persons With Psychosis and Mental Health Professionals: A Scoping Review

OBJECTIVE

The beliefs that people with psychosis hold about causes of their illness (causal beliefs) can affect their choice to adhere to treatment and engage in mental health services. However, less is known about causal beliefs of mental health professionals (MHPs) and their impact on treatment adherence and service engagement. This review explored literature focusing on MHPs' causal beliefs and mapped the degree of concordance between their causal beliefs and those of people with psychosis.

METHODS

A systematic literature search of PubMed, Embase, Scopus, PsycINFO, and Applied Social Sciences Index Abstracts and a gray-literature search of PsyArXiv and MedNar yielded 11,821 eligible references. The first author reviewed all titles and abstracts, and the coauthors reviewed 10% (N=1,200).

RESULTS

Forty-two articles were included. Most articles indicated that MHPs tend to endorse biogenetic beliefs (9 of 15 articles assessing MHPs' beliefs, 60%), whereas people with psychosis tend to endorse psychosocial beliefs (16 of 31 articles, 52%) and other nonbiogenetic beliefs (in 8 of 31 articles, 26%). Most studies did not compare causal beliefs of people with psychosis and their treating MHP. Studies varied in design, setting, and measures.

CONCLUSIONS

MHPs and people with psychosis often hold complex views composed of different types of causal beliefs. However, a gap in causal beliefs between these groups appears to exist, which may affect the therapeutic relationship and pose barriers to treatment adherence. Future studies should address this gap by developing interventions that facilitate open communication about causal beliefs to promote treatment alliance and shared decision making.

Insight in psychosis: A critical review of the contemporary confusion

This commentary highlights the context, complexity, conflicting claims and the contemporary confusion related to insight in people with psychosis. Traditional psychiatric precepts suggests that good insight is inversely related to the severity of psychotic symptoms and directly related to depression scores, better clinical outcome, and treatment adherence. However, recent studies have recognised that insight does not predict outcomes, changes over time, and is dependent on the trajectory of the individual's illness and the social and cultural context arguing that "insight" is an explanatory model and a coping strategy. Methodological issues related to the assessment of insight, the limitations of psychiatric classification and complex interaction between biology and the environment make simplistic explanations of the concept of insight less than useful. The paper argues that the biomedical model should be presented without dismissing or devaluing patient beliefs and explanations. Psychiatry needs to embrace the complexity of mental illness and value diverse attempts at restoring homeostasis.

Machine learning for predicting psychotic relapse at 2 years in schizophrenia in the national FACE-SZ cohort

BACKGROUND

Predicting psychotic relapse is one of the major challenges in the daily care of schizophrenia.

OBJECTIVES

To determine the predictors of psychotic relapse and follow-up withdrawal in a non-selected national sample of stabilized community-dwelling SZ subjects with a machine learning approach.

METHODS

Participants were consecutively included in the network of the FondaMental Expert Centers for Schizophrenia and received a thorough clinical and cognitive assessment, including recording of current treatment. Relapse was defined by at least one acute psychotic episode of at least 7 days, reported by the patient, her/his relatives or by the treating psychiatrist, within the 2-year follow-up. A classification and regression tree (CART) was used to construct a predictive decision tree of relapse and follow-up withdrawal.

RESULTS

Overall, 549 patients were evaluated in the expert centers at baseline and 315 (57.4%) (mean age = 32.6 years, 24% female gender) were followed-up at 2 years. On the 315 patients who received a visit at 2 years, 125(39.7%) patients had experienced psychotic relapse at least once within the 2 years of follow-up. High anger (Buss&Perry subscore), high physical aggressiveness (Buss&Perry scale subscore), high lifetime number of hospitalization in psychiatry, low education level, and high positive symptomatology at baseline (PANSS positive subscore) were found to be the best predictors of relapse at 2 years, with a percentage of correct prediction of 63.8%, sensitivity 71.0% and specificity 44.8%. High PANSS excited score, illness duration <2 years, low Buss&Perry hostility score, high CTQ score, low premorbid IQ and low medication adherence (BARS) score were found to be the best predictors of follow-up withdrawal with a percentage of correct prediction of 52.4%, sensitivity 62%, specificity 38.7%.

CONCLUSION

Machine learning can help constructing predictive score. In the present sample, aggressiveness appears to be a good early warning sign of psychotic relapse and follow-up withdrawal and should be systematically assessed in SZ subjects. The other above-mentioned clinical variables may help clinicians to improve the prediction of psychotic relapse at 2 years.

Instrumental Activities of Daily Living Dysfunction among People with Schizophrenia

BACKGROUND

Life skills are the basic skills that are needed to live independently and that support meaningful, productive roles. The negative symptoms and cognitive dysfunction seen in schizophrenia may lead to deterioration in the life skills of the patient. The assessment of current life skills of the patient and subsequent intervention becomes necessary for comprehensive rehabilitation of people with mental illness. This study attempted to assess the instrumental activities of daily living among people with schizophrenia in India.

METHODS

One hundred consecutive patients with schizophrenia, between 18 and 60 years, who presented to a tertiary psychiatric facility were assessed using (i) Lawton instrumental activities of daily living scale (LIADL), (ii) positive and negative symptom scale (PANSS), (iii) pro forma for sociodemographic and clinical characteristics.

RESULTS

The majority of the patients were male, young adults, married, with secondary school education, middle socioeconomic status, from nuclear families, unemployed and were diagnosed to have paranoid schizophrenia. The reported IADL dysfunction included difficulties in handling medications (86%), preparing food (85%), shopping (78%), handling finances (61%), doing laundry (52%), housekeeping (47%), using public transport (32%), and using telephones (5%). The dysfunction documented differs from that reported in the west. Total PANSS score (P = 0.015) and its general psychopathology subscale (P = 0.005) correlated inversely with the total LIADL score; PANSS scores and sociodemographic variables were associated with some subscales of LIADL.

CONCLUSIONS

IADL dysfunction, common in people with schizophrenia, demands detailed assessment, and tailored training to ensure optimum functioning.

Remission and recovery from first-episode psychosis in adults: systematic review and meta-analysis of long-term outcome studies

BackgroundRemission and recovery rates for people with first-episode psychosis (FEP) remain uncertain.AimsTo assess pooled prevalence rates of remission and recovery in FEP and to investigate potential moderators.MethodWe conducted a systematic review and meta-analysis to assess pooled prevalence rates of remission and recovery in FEP in longitudinal studies with more than 1 year of follow-up data, and conducted meta-regression analyses to investigate potential moderators.ResultsSeventy-nine studies were included representing 19072 patients with FEP. The pooled rate of remission among 12301 individuals with FEP was 58% (60 studies, mean follow-up 5.5 years). Higher remission rates were moderated by studies from more recent years. The pooled prevalence of recovery among 9642 individuals with FEP was 38% (35 studies, mean follow-up 7.2 years). Recovery rates were higher in North America than in other regions.ConclusionsRemission and recovery rates in FEP may be more favourable than previously thought. We observed stability of recovery rates after the first 2 years, suggesting that a progressive deteriorating course of illness is not typical. Although remission rates have improved over time recovery rates have not, raising questions about the effectiveness of services in achieving improved recovery.

Perspectives about mental health, illness, and recovery

PURPOSE OF REVIEW

Patient and physician perspectives about mental health, illness, and recovery, which affect different aspects of help seeking and healthcare, needs to be understood and theorized.

RECENT FINDINGS

People seem to simultaneously hold multiple and contradictory illness beliefs and seek help from diverse sources of cure and healing. Explanatory models elicited at baseline do not predict outcomes of illness, change over time, and are dependent on the interaction between the trajectory of individual's illness and the sociocultural milieu. Illness narratives contextualize the patient, describe the patient's reality and his/her ways of coping, and attempt to make sense of illness experiences, control them, and improve quality of life. On the other hand, diversity of beliefs among psychiatrists, family physicians, and public health specialists is dependent on their disciplinary perspectives. Nevertheless, the variability within psychiatric syndromes and the inability to predict individual trajectories of illness support cultural beliefs about uncertainties of life. These are identified by cultures through idioms and metaphors and labeled as luck, chance, karma, fate, punishment by God, evil spirits, black magic, disease and so on.

SUMMARY

There is a need for a broad-based approach to mental health, which allows individuals to make sense of their contexts and find meaning in life.

Insight in psychosis: Standards, science, ethics and value judgment

BACKGROUND

The clinical assessment of insight solely employs biomedical perspectives and criteria to the complete exclusion of context and culture and to the disregard of values and value judgments.

AIM

The aim of this discussion article is to examine recent research from India on insight and explanatory models in psychosis and re-examine the framework of assessment, diagnosis and management of insight and explanatory models.

METHODS

Recent research from India on insight in psychosis and explanatory models is reviewed.

RESULTS

Recent research, which has used longitudinal data and adjusted for pretreatment variables, suggests that insight and explanatory models of illness at baseline do not predict course, outcome and treatment response in schizophrenia, which seem to be dependent on the severity and quality of the psychosis. It supports the view that people with psychosis simultaneously hold multiple and contradictory explanatory models of illness, which change over time and with the trajectory of the illness. It suggests that insight, like all explanatory models, is a narrative of the person's reality and a coping strategy to handle with the varied impact of the illness.

CONCLUSION

This article argues that the assessment of insight necessarily involves value entailments, commitments and consequences. It supports a need for a broad-based approach to assess awareness, attribution and action related to mental illness and to acknowledge the role of values and value judgment in the evaluation of insight in psychosis.

World Health Organization disability assessment schedule 2.0: An international systematic review

PURPOSE

This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument.

METHOD

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on "whodas" using the ProQuest, PubMed, and Google Scholar electronic databases.

RESULTS

We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry).

CONCLUSIONS

The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single "minimal clinically important .difference" score for the WHODAS 2.0 has not yet been established.

Insight in Psychosis: An Indicator of Severity of Psychosis, an Explanatory Model of Illness, and a Coping Strategy

Recent studies related to insight, explanatory models (EMs) of illness and their relationship to outcome of psychosis are reviewed. The traditional argument that insight predicts outcome in psychosis is not supported by recent longitudinal data, which has been analyzed using multivariable statistics that adjust for severity and quality of illness. While all cognition will have a neurobiological representation, if "insight" is related to the primary psychotic process, then insight cannot be seen as an independent predictor of outcome but a part of the progression of illness. The evidence suggests insight, like all EMs, is belief which interacts with the trajectory of the person's illness and the local culture to produce a unique understanding of the illness for the particular individual and his/her family.