Insight, psychopathology, explanatory models and outcome of schizophrenia in India: a prospective 5-year cohort study

A qualitative enquiry on the impact of mental illness stigma on caregiving role and experiences in Singapore

Introduction

Given that mental illness stigma is a common occurrence amongst people with mental illness and caregivers (CGs) can be a potential victim of stigma themselves, there is a need to examine caregivers' perspective on the phenomenon. This study is part of a larger study which aims to qualitatively examine the concept of mental illness stigma amongst different stakeholders in Singapore.

Methods

Focus group discussions (FGDs) were conducted amongst 21 informal caregivers to explore the experience of stigma encountered by them and their care recipients, and how it may implicate their caregiving experience. Both inductive and deductive thematic analyses were employed to analyze the data.

Results

Three overarching themes of stigma encounters that may have implication on caregiving experience were identified: 1) Stigma within the family; 2) Structural stigma; and 3) Stigma by association. Experience of stigma within family (e.g., social exclusion and lack of understanding) limits the caregiving supports available to CGs. CGs also took up a mediating role between their care recipients and other family who may hold stigmatizing views. Witnessing their care recipients being subjected to structural disadvantages (e.g., employment, school, and mandatory conscription) can induce emotional stresses amongst CGs and motivate them to protest and seek redress on their behalf. Furthermore, encounters of stigma themselves (e.g., being judged or blamed for their loved one's condition) also led to feelings of guilt and self-blame amongst the CGs.

Discussion

These findings can aid the formulation of interventions in informing CGs on what to expect on their caregiving journey and supporting them in dealing with issues relating to stigma and highlight the importance of anti-stigma efforts in organizational settings such as schools, corporations, and government agencies.

Prevalence, correlates and explanatory models of cognitive deficits in patients with schizophrenia-A cross sectional study

Background

Schizophrenia may cause significant impairment in social and economic aspects of a patient's life. Current evidence suggests that cognitive deficits may affect the functioning of a person with schizophrenia more than positive or negative symptoms. There is a lack of literature on explanatory models of cognitive deficits in schizophrenia that can influence help-seeking behavior.

Objectives

This study aimed to estimate the prevalence of cognitive deficits and assess their relationship with socio-demographic and clinical characteristics among patients with schizophrenia. We also planned to explore the explanatory models of cognitive deficits in these patients.

Methods

Consecutive outpatients with schizophrenia who met eligibility criteria were recruited after obtaining informed consent. The Addenbrooke's Cognitive Examination Tamil version (ACE III) and Observable Social Cognition - A Rating Scale (OSCARS) and Positive and Negative Symptom Scale (PANSS) were used to assess cognitive functioning and symptom profile, respectively. Beliefs about illness were recorded using the modified Short Explanatory Model Interview (SEMI). Socio-demographic and treatment-related details were collected with a structured proforma. Statistical analysis was done using SPSS for Windows (version 16.0.1).

Results

One hundred and forty patients participated in the study. The prevalence of cognitive deficits was 75.7% using ACE-III scores, 19.3% on OSCARS, and 40% based on subjective reports. Though the majority (81.4%) of patients reported a medical explanatory model for cognitive impairment, a significant number of them (70.7%) also held non-medical models simultaneously.

Conclusion

Cognitive deficits are prevalent in the majority of patients with schizophrenia. Poor test performance on cognitive testing was observed in those with a significant family history. Multiple contradictory explanatory models for the causation of cognitive deficits were reported.

Causal Beliefs About and Perceptions of Illness in Persons Experiencing Schizophrenia and in Close Relatives of Such Individuals: An Exploratory Study

BACKGROUND

The cause to which persons experiencing schizophrenia attribute their illness influences emotional and adjustment variables. This is also true for close relatives (CRs), who are important players in the affected individual's environment and whose mood can influence the person's day-to-day life or treatment adherence. Recent literature has highlighted a need to further explore the impact of causal beliefs on different aspects of recovery as well as on stigma.

AIMS

The objective of this study was to explore causal beliefs about the illness and their relationship to other illness perceptions and stigma among persons experiencing schizophrenia and their CRs.

METHODS

Twenty French individuals experiencing schizophrenia and 27 CRs of individuals with schizophrenia answered the Brief Illness Perception Questionnaire, which investigates probable causes of an illness and other illness perceptions, and the Stigma Scale. A semi-structured interview was used to collect information about diagnosis, treatment, and access to psychoeducation.

RESULTS

The individuals with schizophrenia identified fewer causal attributions than the CRs. They were more likely to endorse psychosocial stress and family environment as probable causes, while CRs mostly favored genetic explanations. We found significant relationships between causal attributions and most negative perceptions of the illness, including components of stigma, in both samples. Among CRs, having received family psychoeducation was strongly correlated with viewing substance abuse as a probable cause.

CONCLUSIONS

Relationships between causal beliefs about illness and perceptions of illness both in individuals experiencing schizophrenia and in CRs of such individuals should be explored further with harmonized and detailed tools. Assessing causal beliefs about schizophrenia as a framework for psychiatric clinical practice could prove useful for all those involved in the recovery process.

Rates of treatment-resistant schizophrenia from first-episode cohorts: systematic review and meta-analysis

BACKGROUND

Treatment-resistant schizophrenia (TRS) is associated with high levels of functional impairment, healthcare usage and societal costs. Cross-sectional studies may overestimate TRS rates because of selection bias.

AIMS

We aimed to quantify TRS rates by using first-episode cohorts to improve resource allocation and clozapine access.

METHOD

We undertook a systematic review of TRS rates among people with first-episode psychosis and schizophrenia, with a minimum follow-up of 8 weeks. We searched PubMed, PsycINFO, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews, and meta-analysed TRS rates from included studies.

RESULTS

Twelve studies were included, totalling 11 958 participants; six studies were of high quality. The rate of TRS was 22.8% (95% CI 19.1-27.0%, P < 0.001) among all first-episode cohorts and 24.4% (95% CI 19.5-30.0%, P < 0.001) among first-episode schizophrenia cohorts. Subgroup sensitivity analyses by location of recruitment, TRS definition, study quality, time of data collection and retrospective versus prospective data collection did not lead to statistically significant differences in heterogeneity. In a meta-regression, duration of follow-up and percentage drop-out did not significantly affect the overall TRS rate. Men were 1.57 times more likely to develop TRS than women (95% CI 1.11-2.21, P = 0.010).

CONCLUSIONS

Almost a quarter of people with first-episode psychosis or schizophrenia will develop TRS in the early stages of treatment. When including people with schizophrenia who relapse despite initial response and continuous treatment, rates of TRS may be as high as a third. These high rates of TRS highlight the need for improved access to clozapine and psychosocial supports.

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.

Schizophrenia outcomes in the 21st century: A systematic review

OBJECTIVE

We report a review of outcomes in schizophrenia in the twenty-first century, replicating and extending work undertaken by the late Richard Warner in his seminal book, "Recovery from Schizophrenia: Psychiatry and Political Economy" (1985;2004).

METHOD

Warner's methods were followed as closely as possible. Only observational/naturalistic studies were included. Six scientific databases were searched from 2000 to 2020. 6,640 records were retrieved. 47 met inclusion criteria.

RESULTS

Overall, complete recovery is higher in this study than in Warner's (37.75% cf 20.4%), especially for first episode psychosis (FEP) (57.1% cf 20.7%). Clinical recovery, annualized remission rate (ARR), and employment outcomes were significantly superior for first episode psychosis compared with multiple episode psychosis (MEP). ARR shows a trend toward reduction over time, from 2.2 before the financial crash of 2008 to 1.6 after (t = 1.85 df 40 p = .07). The decline is statistically significant for the MEP group (t = 2.32 df18 p = .03). There were no differences in outcome by region, sample characteristics, outcome measures used, or quality of studies. Heterogeneity of clinical outcome measures across the literature makes evidence synthesis difficult. Weak and inconsistent reporting of functional and employment outcomes mean that findings lack meaning with respect to lived experience.

CONCLUSION

Future research strategies should aim to reduce heterogeneity in clinical outcome measures and to increase the emphasis on capture and reporting of more sophisticated measures of social and functional outcome. Outcome domains should be disaggregated rather than conflated into unitary recovery constructs.

Rating Opportunity for Long-Acting Injectable Antipsychotic Initiation Index (ROLIN)

Background: Schizophrenia is a severe psychiatric condition with devastating consequences for the individual's functionality and leading to severe disability. Lack of insight and non-adherence to treatment remain the most important factors in the progression of the disease to chronicity. Despite their proven effectiveness in preventing relapses, reducing morbidity and mortality, long-acting injectable antipsychotics (LAIs) are still underused. One of the causes invoked is the lack of guidelines or protocols for initiating LAIs. Objective: The aim of this article is to present Rating Opportunity for Long-Acting Injectable Antipsychotic Initiation Index (ROLIN), a clinician-rated index that rates the important factors of the disorder across seven items: age, duration of illness, relapses, antipsychotic treatment response, family support, antipsychotic existing formulation and adherence. Method: A retrospective study in which all patients with schizophrenia discharged on oral antipsychotics without LAIs treatment lifetime were evaluated with ROLIN for opportunity for LAIs initiation. Results: Of 225 consecutive patients, 126 patients (56%) had a strong indication for initiating LAI (score between 25 and 35). Kolmogorov-Smirnov test was used for checking the normal distribution of values (95% CI for the mean = 9.5781 to 20.4219; 95% CI for the median = 6.5920 to 24.8161; SD = 9.7907; Coefficient of Skewness = 0.0743; Coefficient of Kurtosis = -1.1377). Conclusion: This paper proposed an instrument designed to improve treatment in schizophrenia using a simple conceptual model which integrates important predictors of good or poor outcomes.

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.

Explanatory models of mental illness among family caregivers of persons in psychiatric rehabilitation services: A pilot study

BACKGROUND

Understanding the explanatory models of family caregivers is particularly important in interdependent contexts like India, where they often play a significant role in the help-seeking behaviours, treatment decision-making and long-term care of those diagnosed with mental illness.

AIMS

This study was planned to explore the diversity of explanatory models among family caregivers at a centre for recovery-oriented rehabilitation services in South India.

METHODS

The sample for this study included 60 family caregivers of patients referred to Psychiatric Rehabilitation Services within a tertiary-care hospital for mental health and neurosciences. Bart's Explanatory Model Inventory, including a semi-structured interview and a checklist, assessed the family caregivers' explanatory model of distress on five domains: identity, cause, timeline, consequences and control/cure/treatment.

RESULTS

The results indicated the coexistence of multiple causal explanatory models including psychosocial, supernatural, situational and behavioural contributors. While 36.7% of the caregivers displayed two explanatory models, 33.3% of the caregivers held three explanatory models and 16.6% of the caregivers endorsed four explanatory models. Caregivers shared their concerns about varied consequences of mental illness but less than half of them were aware of the name of the psychiatric disorder. While they accessed various forms of treatments and adjunctive supports such as prayer, medication was the most frequently used treatment method.

CONCLUSIONS

The findings have implications for collaborative goal setting in recovery-oriented services for persons with mental illness and their families.

[The concept of narrative insight in schizophrenia: A systematic review]

AIM

The aim of this systematic revue of literature is to examine articles dealing with the narrative insight (patient's explanatory models of his difficulties) in patients suffering from schizophrenia. In addition to the theoretical interest of this work, it would make it possible to better adjust the clinical practices concerning the stories of patients about their disorders.

METHOD

A study was conducted using the databases ScienceDirect, Medline, PsychInfo and PubPsych using the key words "narrative insight", "cultural insight", "subjective insight", "narrative awareness", "mental illness", and "psychiatric disorder". This search by keywords led to eighty-six results; abstracts of all the articles were consulted. Then the authors selected and studied all articles corresponding to inclusion criteria and compared their results and reached agreement by consensus in case of difference. The theme of the study was to focus on the concept of narrative insight or any other close concept mentioning an explanatory model of mental and/or psychiatric disorders, moving away from the biomedical model. Nine articles were selected based on the inclusion criteria (articles published in peer reviewed journals, where the both the resume and article are accessible; articles dealing with narrative insight of people suffering from schizophrenia).

RESULTS

The authors of these articles agree that awareness of mental illness, insight, is a narrative act in which people give a personal meaning to their disorder. The most popular biomedical model used has many limitations and is the subject of many controversies. Results of the conducted study suggest considering narrative insight as adaptive strategies to mental illnesses. Indeed the process of narrative insight essentially consists in the patient adapting his life story to his conceptions and his values. To tell the story of one's own troubles with one's own values and beliefs gives meaning that helps protect identity and give back hope. This concept is considered to be dynamic and multidimensional. In addition, studies highlight its positive effects including the simultaneous presence of several models, which would have a greater favorable impact on the prognosis than the medical explanation alone.

CONCLUSION

It seems necessary to take into account the concept of narrative insight in order to evaluate insight of patients suffering from mental illness. This implies that the evaluation methods of insight as well as the clinical practice must evolve to adapt to the culture and subculture of the patient. This could have beneficial effects on the well-being of patients, therapeutic relations, access to treatment as well as psychiatric research, as well as limit controversies around this topic. It would be interesting to confirm this new conception of insight and the therapeutic relations by carrying out new studies as well as by starting to take it into account in patient care.

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.

Sexual Dysfunction among Men in Rural Tamil Nadu: Nature, Prevalence, Clinical Features, and Explanatory Models

BACKGROUND AND AIM

There is a dearth of community data on nature, prevalence, clinical features, and explanatory models related to sexual dysfunction among men, particularly from rural India. This study attempted to examine different aspects of male sexual dysfunction and misconceptions in the community.

MATERIALS AND METHODS

Villages in Kaniyambadi Block, Vellore district were stratified, and four were randomly selected. Men living in these villages were recruited for the study. The following instruments were administered: (i) International Index of Erectile Function, (ii) Chinese Index of Premature Ejaculation (iii) Short Explanatory Model Interview, and (iv) Revised Clinical Interview Schedule. The data were analyzed using standard bivariate and multivariate statistics.

RESULTS

A total of 211 men were recruited. The majority were middle-aged (mean 40.73 years), literate (84.8%), married, and with children (72%), from nuclear families (99.6%), followed the Hindu religion (87.7%), reported satisfaction with their marriage (51.2%), had a single sexual partner (99.5%), and practised contraception (88.2%). A minority reported erectile dysfunction (29.9%), premature ejaculation (19.4%), and depression/anxiety (30.8%). Erectile dysfunction was associated with single marital status (P < 0.001), premature ejaculation (P < 0.001), worry about nocturnal emission and loss of semen (P < 0.02), and punishment by God as causal beliefs (P < 0.001). Premature ejaculation was associated with diabetes mellitus (P < 0.05), alcohol use (P < 0.05), anxiety and depression (P < 0.01), guilt about masturbation (P < 0.001), and belief that nocturnal emission is causal (P < 0.001) and erectile dysfunction (P < 0.05).

CONCLUSION

Sexual misconception and dysfunction in men are significant problems in rural communities in India. They mandate the need for sex education in schools and the empowerment of physicians in primary and secondary care to manage such problems.

Quality of Life and Explanatory Models of Illness in Patients with Schizophrenia

BACKGROUND

Patients with schizophrenia hold a variety of explanatory models of illness that influence different aspects of their life including their understanding of the disease, ability to cope and sense of well-being.

AIM

To study the association of explanatory models and quality of life in patients with schizophrenia.

MATERIALS AND METHODS

One hundred and thirty consecutive patients with schizophrenia attending a psychiatric outpatient clinic were recruited in the study and administered the Positive and Negative Symptom Scale (PANSS), the modified Short Explanatory Model Interview (SEMI) and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) Scale to assess severity of psychosis, explanatory models of illness, and quality of life. Sociodemographic and clinical details of patients were also recorded. Standard bivariate and multivariable statistics were employed.

RESULTS

Higher quality of life scores were associated with better socioeconomic conditions and lower scores on negative and general psychopathology subscales of PANSS. Quality-of-life scores were significantly higher in patients who did not perceive their illness to have negative effects on the different domains of their functioning.

CONCLUSION

Explanatory models of illness are associated with perceived quality of life in patients with schizophrenia. There is a need to focus on attitudes, perceptions and functioning, rather than symptom reduction alone, to enhance the quality of life in schizophrenia.

Unraveling the insight paradox: One-year longitudinal study on the relationships between insight, self-stigma, and life satisfaction among people with schizophrenia spectrum disorders

The promotion of insight among people with schizophrenia spectrum disorders has posed a dilemma to service providers as higher insight has been linked to positive clinical outcomes but negative psychological outcomes. The negative meaning that people attached to the illness (self-stigma content) and the recurrence of such stigmatizing thoughts (self-stigma process) may explain why increased insight is associated with negative outcomes. The present study examined how the presence of high self-stigma content and self-stigma process may contribute to the negative association between insight and life satisfaction. A total of 181 people with schizophrenia spectrum disorders were assessed at baseline. 130 and 110 participants were retained and completed questionnaire at 6-month and 1-year follow-up, respectively. Results showed that baseline insight was associated with lower life satisfaction at 6-month when self-stigma process or self-stigma content was high. Furthermore, baseline insight was predictive of better life satisfaction at 1-year follow-up when self-stigma process was low. Findings suggested that the detrimental effects of insight can be a result from both the presence of cognitive content and habitual process of self-stigma. Future insight promotion interventions should also address self-stigma content and process among people with schizophrenia spectrum disorders so as to maximize the beneficial effects of insight.

Angry characters and frightened souls: Patients and family explanatory models of bipolar disorder in Taiwan

Bipolar disorder (BD) affects a significant proportion of Taiwanese individuals (Weissman et al., 1996; Yang, Yeh, & Hwu, 2012). Psychotropic medications are typically the mainstay of treatment for BD, and there is an abundance of international research on biological etiology and medication options. However, there is comparatively little research on psychosocial aspects of BD, including how it is understood and managed within families. As culture provides the context in which psychiatric disease is managed, there is a need to identify distinct Chinese psychosocial perspectives that might shed light on intervention options. This research explored how Taiwanese patients and family members comprehend and cope with BD. A sample of 42 participants, including 20 Taiwanese patients diagnosed with Bipolar Disorder-I (BD-I) for at least 4 years, and 22 family members, participated in separate interviews on explanatory models of illness. Qualitative thematic analysis focused on features that were distinct from those in current Western research literature. Five themes were identified that represented Taiwanese conceptualizations of BD, notions of etiology, views regarding treatment, and the difficulties in managing the disorder. Participants used Chinese language terms and descriptions of BD that reflected greater concerns about irritability, anger, and family conflict than about other symptoms, and participants also emphasized characterological trait descriptions of the condition. Their responses reflected their acceptance of lifelong family responsibility for caretaking, clashing beliefs regarding biomedical versus traditional Chinese medical and spiritual models of etiology and cure, profound concerns about the effects of psychiatric medication on the liver and kidney systems, and a focus on stress rather than genetic or biological models of etiology.

Psychosis: clinical insight and beliefs in immigrants in their first episode

AIM

Lack of insight into illness is frequent in psychotic disorders and seen as part of their primary pathology. The recognition of symptoms as psychotic, and beliefs about treatment alternatives, is also influenced by socio-cultural factors. Here we examined clinical insight into illness and beliefs about psychosis in immigrants in their first episode of psychosis compared with a reference group.

METHODS

A total of 277 first-episode psychosis participants were recruited to this cross-sectional study; 40 first- and 40 second-generation immigrants from Europe, Americas and Oceania (n = 37), Asia including Turkey (n = 28) or Africa (n = 15). The Birchwood Insight Scale was used to measure clinical insight and 'The Attitudes and Beliefs about Mental Health Problems' schizophrenia version to assess socio-cultural beliefs.

RESULTS

Immigrants did not differ from the reference sample in clinical insight. After controlling for education level, first-generation immigrants were less likely to recognize psychotic symptoms (odds ratio (OR) 2.9; Wald = 8.977, degrees of freedom (d.f.) 1, P = 0.003) and viewed hospitalization (OR 5.2; Wald = 20.388, d.f. 1, P = 0.001) and treatment by a psychiatrist (OR 4.9; Wald = 6.609, d.f. 1, P = 0.01)) as less beneficial than the reference group. Immigrants from Asia held more alternative explanations (OR 0.3; Wald = 6.567, d.f. 1, P = 0.010). There were significantly stronger associations between clinical insight and socio-cultural beliefs in the reference group.

CONCLUSIONS

Socio-cultural beliefs about psychosis in immigrants in first-episode psychosis call for more tailored information to this group, and emphasize the importance of treatment interventions involving both a cultural and personal perspective of insight.

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.

Cross-cultural psychometric assessment of the VAGUS insight into psychosis scale - Spanish version

Impaired insight into illness, a core feature of schizophrenia with negative clinical implications, is a multidimensional phenomenon existing on a continuum. However, the degree to which illness perception in distinct cultures influences the appraisal of insight into illness in schizophrenia remains unclear. As such, we aimed to determine if the psychometric properties of the VAGUS insight into psychosis scale (www.vagusonline.com), which was originally assessed in English speaking Canadians, were similar in a sample of Latino Mexican Spanish speaking patients with schizophrenia. To accomplish this, the VAGUS - Self-Report (SR) version was translated from English to Spanish and psychometrically evaluated in 95 participants. The Spanish version of the VAGUS-SR was internally consistent (ᾳ = 0.713), and demonstrated good convergent and discriminant validity with the subscales of the Positive and Negative Syndrome Scale. Factor analysis identified two components of insight, congruent with two of the components of the English version of the VAGUS-SR. In conclusion, the VAGUS-SR is a brief, novel, and valid measure of insight into illness in schizophrenia, which demonstrated similar psychometric properties in two culturally and linguistically distinct samples with schizophrenia. Future studies should assess whether the VAGUS demonstrates similar psychometric properties in non-Western cultures.

Comparison of clinician-rated and self-report insight in Korean patients with schizophrenia using VAGUS insight scale

This study was aimed to explore self-report auditory verbal hallucinations to provide unique and valuable information in addition to clinician-rated assessment in patients with schizophrenia. The VAGUS (http://www.vagusonline.com) is a recently developed insight scale that includes both clinician-rated (CR) and self-report (SR) versions. Insight measures obtained by the two versions of the VAGUS from the clinicians and the patients, respectively, in forty-one patients diagnosed with schizophrenia by DSM-IV-TR criteria were compared. Correlation coefficients for inter-scale convergence and 3-D biplots for multivariate relationship were derived from the subscales of the VAGUS. For external validation, correlation analyses with abridged version of Scale to Assess Unawareness in Mental Disorder (SUMD-A) and PANSS G12 item were conducted. Total scores of VAGUS-CR and -SR were 5.2 ± 2.6 and 4.9 ± 2.2, respectively. There was a strong correlation between them along with moderate pairwise correlations among the subscales. The 3-D biplots demonstrated that most subscales were clustered as a single factor apart from self-report Symptom Attribution separated as an independent factor. The VAGUS-CR, not -SR correlated significantly with the SUMD-A and PANSS G12. The utility of the VAGUS in reaching more overall understanding of the elusive phenomenon of insight in patients with schizophrenia is discussed.

Explanatory Models of Illness, Help Seeking Behaviours and Related Factors in Patients with Schizophrenia: A Comparative Study from Two Different Provinces of Turkey

This study aims to identify the help seeking behaviours of patients from two geographically distinct provinces of Turkey. A questionnaire about sociodemographic characteristics and help seeking ways was applied to 49 schizophrenia patients from Van, 99 from Ankara. The ratio of patients seeking psychiatric help at the beginning of their illness was 76% in Ankara, the capital city, in contrast to 54% in Van (p = 0.01). Twenty-two percent of patients from Ankara and 69% from Van reported that non-psychiatric help seeking was the choice of their families (p < 0.001). Thirty-five percent of all patients sought religious support when their symptoms started. Patients with lower education levels sought more religious help (p = 0.002). Help seeking behaviours show regional variations. Religious help seeking behaviour is a major way of dealing with the illness. Psychoeducation is a crucial need both for patients and families.

Religiosity among patients with schizophrenia: An exploratory study

AIM

This study aimed to compare the religiosity and religious coping of patients with schizophrenia with a healthy control group and to assess the correlation between the level of religiosity and religious coping with residual psychopathology, level of functioning, and quality of life (QOL).

METHODOLOGY

Patients of schizophrenia were assessed on religiousness measure scale, duke religion index (DUREL), brief religious coping scale (RCOPE), positive and negative symptom scale, and World Health Organization QOL-BREF version.

RESULTS

Of the 100 patients of schizophrenia, 99% reported that they believed in God. About 60% of patients attended religious places either once a week or more and 56% of patients indulged in private religious activity at least once a day. Two-third of the participants had high intrinsic religiosity score. The mean score of positive religious coping (PRC) subscale was 14.56 and that for negative religious coping (NRC) subscale was 8.31. No significant difference was noted in the various domains of religious measure scale, DUREL, and PRC between patients with schizophrenia and healthy controls. However, compared to healthy controls, patients more often used NRC. Various aspects of religiosity (except for negative RCOPE score) correlated negatively with residual psychopathology and positively with functioning and QOL.

CONCLUSION

Findings of this study suggest that high proportions of patients with schizophrenia are religious and this is similar to healthy controls in the community. Higher level of religiosity and more frequent use of religious coping are associated with lower level of psychopathology and better QOL.

How people from Chinese backgrounds make sense of and respond to the experiences of mental distress: Thematic analysis

RATIONALE FOR THE STUDY

Many Chinese people do not contact mental health services when they first develop mental health problems. It is therefore important to find out reasons for low uptake of services so that strategies can be identified to promote early intervention. WHAT IS ALREADY KNOWN ABOUT THE TOPIC?: Most Chinese people only come into contact with mental health services during crisis situations. Language difference, lack of knowledge of mainstream services and stigma attached to mental health problems are barriers to access and utilize mental health services. WHAT THE STUDY ADDS TO THE INTERNATIONAL EVIDENCE?: Chinese people apply both Western medication and traditional healing to manage distress caused by mental health problems. Because of the extreme stigma associated with mental health problems, Chinese people are reluctant to accept support from their own cultural groups outside their family. Family plays a major role in caring for relatives with mental health problems. Families are prepared to travel across the world in search of folk healing if not available in Western societies. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is important to recognize the different approaches to understanding and managing mental health problems among Chinese people, otherwise they will be dissuaded from engaging with mental health services if their beliefs are disregarded and invalidated. Services that involve Chinese speaking mental health workers can address the issue of language differences and sensitive mental health issues within the Chinese community.

ABSTRACT

Introduction Late presentation and low utilization of mental health services are common among Chinese populations. An understanding of their journey towards mental health care helps to identify timely and appropriate intervention. Aim We aimed to examine how Chinese populations make sense of the experiences of mental distress, and how this understanding influences their pathways to mental health care. Method We undertook in-depth interviews with fourteen people with mental health problems (MHPs) and sixteen family members. Thematic analysis was used to analyse data. Results/Discussions Different conceptualization of mental distress and the stigma attached to MHPs explained why most participants accessed services at crisis points. Because of mental illness stigma, they were reluctant to seek help outside of the family. Participants used a pragmatic pluralistic approach to incorporate ritual healing and Western interventions to manage mental distress as they travelled further on the pathway journey. Families play a key role in the journey and are prepared to visit different parts of the world to seek traditional healers. Implications for practice Mental health nurses need to adopt a transcultural working approach to address mental health issues so that family will get the support needed to continue their caring role.

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.

Insight and white matter fractional anisotropy in first-episode schizophrenia

Impaired insight is a hallmark feature of schizophrenia. Structural studies implicate predominantly prefrontal, cingulate, cuneus/precuneus, and inferior temporal brain regions. The cortical midline structures (CMS) are also implicated in functional studies primarily through self-reflective processing tasks. However, few studies have explored the relationship between white matter tracts and insight in schizophrenia, and none in first-episode schizophrenia (FES). Here, we examined for fractional anisotropy (FA) differences in 89 minimally treated FES patients and 98 matched controls, and identified those FA differences associated with impaired clinical insight in patients. We found widespread FA reduction in FES patients compared to controls. Poorer insight in patients was predicted by lower FA values in a number of white matter tracts with a predilection for tracts associated with cortical midline structures (fronto-occipital, cingulate, cingulate hippocampus, uncinate, anterior corona radiata), and more severe depressive symptoms. The association between FA abnormalities and insight was most robust for the awareness of symptoms and illness awareness domains. Our study implicates a network of tracts involved in impaired insight in schizophrenia with a predilection for the CMS. This study is a first step in delineating the white matter tracts involved in insight impairment in schizophrenia prior to chronicity.

Explanatory model of psychosis: impact on perception of self-stigma by patients in three sub-saharan African cities

BACKGROUND

Most cultures in sub-Saharan Africa subscribe to the belief that the root cause of psychosis is supernatural. Individuals in the community who hold a religiomagical explanatory model of causation have been shown to exhibit more stigmatizing attitudes towards people with psychosis. Self-stigma among individuals with psychosis is less frequently studied.

METHOD

We used a mixed-method approach, consisting of key informant's interviews to elicit information on explanatory models of causation of psychosis and questionnaire assessment of internalized stigma with an adapted version of the Scale for Internalized Stigma of Mental Illness. Twenty-four, 31, and 30 subjects with recent experience of utilizing the service of traditional or faith healers for severe mental disorders in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya), respectively, were interviewed.

RESULTS

About 44 % (42.1 %) of the Nigerian respondents had a high (severe) level of self-stigma with the respective proportions among Ghanaian and Kenyan respondents being 20.7 and 37.5 %. Compared with 4 out of a total of 12 respondents (33.3 %) who reported low self-stigma reported supernatural attribution, 14 out of 20 respondents (70 %) with the highest level of self-stigma reported supernatural attribution across the three sites. When low scorers ascribed supernatural causation, it was often with a religious focus.

CONCLUSION

There is a greater tendency for persons with high levels of self-stigma than those with low levels to ascribe supernatural attribution to their experience of a severe mental health condition.

Determining the effectiveness of the third person interview in the level of insight psychotic patients

The goal of this study was to determine the effectiveness of the third person interview in increasing the level of insight and cooperation in psychotic patients. We used a quasi-experimental posttest design with an alternative method group. A number of 40 individuals with a definite diagnosis of psychosis were selected using a simple random sampling, and were put randomly in an experimental group (third person interview) and an alternative control group (clinical interview). The results indicated that using the third person interview, the insight level of the psychotic patients increased in all dimensions of insight, except awareness of flat or blunted affect and awareness of unsociability. The results of the independent t-test samples showed no significant difference in cooperation between the two groups of psychotic patients. It seems that the ability to consider one's mental viewpoint from other's, is dependent on the relative ability of psychotic patients to represent other's mental states (theory of mind). But, psychotic patients have severe impairment in the ability to represent their own mental states, resulting in an impairment in the recognition of their mental disorder, psychotic symptoms, the need for therapy, and social consequences of their mental disorder.

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.

On the border of deep spirituality and psychosis… A case study

This article is a case study of a 28-year-old patient diagnosed with F23. The report is preceded by an extensive literature review describing the situation of the mentally ill, in which psychiatry intermingles with spirituality and the sacrum.

The aim of the study was to investigate the relationship between religion/spirituality and schizophrenia as well as to draw attention to the complex problem of differential diagnosis of religious and spiritual problems. When is psychiatric treatment enough and when is intervention of a priest really essential?

The authors discuss the problem of mental disorders in connection with religion and spirituality in the clinical context. The article shows that it is very important that the processes of diagnosis and treatment take into account the patients’ individual traits, beliefs, values and spirituality.

Effects of antipsychotics on insight in schizophrenia: results from independent samples of first-episode and acutely relapsed patients

We aimed to investigate whether antipsychotics differentially impact insight and whether these effects appear because of improvement in psychopathological manifestation in 132 first-episode schizophrenia patients and 201 acutely relapsed schizophrenic patients, who were followed up for 12 weeks. Olanzapine and risperidone were administered to first-episode schizophrenia patients, whereas acutely relapsed schizophrenic patients were treated with olanzapine, perazine and ziprasidone. The Positive And Negative Syndrome Scale (PANSS) was used to assess psychopathology. Insight was assessed using the G12 item of PANSS. Unadjusted mixed-model regression analysis indicated a significant improvement in the PANSS G12 item score in both groups. There were no significant differences between distinct treatment subgroups of patients in terms of improvement in the PANSS G12 item score. After adjustment for the trajectories of changes in symptom dimensions, a decrease in the PANSS G12 item score was because of an improvement in positive, negative and excitement symptoms. A decrease in the PANSS G12 item score was also related to an increase in the severity of depressive symptomatology. Our results indicate that antipsychotics exert similar effects on insight in acute psychosis. These effects are likely because of an improvement in psychopathological manifestation. The improvement in insight might be related to the development of depressive symptoms.

The Role of Insight in Moderating the Association Between Depressive Symptoms in People With Schizophrenia and Stigma Among Their Nearest Relatives: A Pilot Study

BACKGROUND

There is evidence of a positive association between insight and depression among patients with schizophrenia. Self-stigma was shown to play a mediating role in this association. We attempted to broaden this concept by investigating insight as a potential moderator of the association between depressive symptoms amongst people with schizophrenia and stigmatizing views towards people with mental disorders in their close social environment.

METHOD

In the initial sample of 120 pairs, data were gathered from 96 patients with a diagnosis of "paranoid schizophrenia" and 96 of their nearest relatives (80% response rate). In this cross-sectional study data were collected by clinical interview using the following questionnaires: "The Scale to Assess Unawareness of Mental Disorder," "Calgary Depression Scale for Schizophrenia," and "Brief Psychiatric Rating Scale." The stigmatizing views of patients' nearest relatives towards people with mental disorders were assessed with the "Mental Health in Public Conscience" scale.

RESULTS

Among patients with schizophrenia depressive symptom severity was positively associated with the intensity of nearest relatives' stigmatizing beliefs ("Nonbiological vision of mental illness," τ = 0.24; P < .001). The association was moderated by the level of patients' awareness of presence of mental disorder while controlling for age, sex, duration of illness and psychopathological symptoms.

CONCLUSIONS

The results support the hypothesis that the positive association between patients' depression and their nearest relatives' stigmatizing views is moderated by patients' insight. Directions for further research and practical implications are discussed.

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.

Clinical predictors of therapeutic response to antipsychotics in schizophrenia

The search for clinical outcome predictors for schizophrenia is as old as the field of psychiatry. However, despite a wealth of large, longitudinal studies into prognostic factors, only very few clinically useful outcome predictors have been identified. The goal of future treatment is to either affect modifiable risk factors, or use nonmodifiable factors to parse patients into therapeutically meaningful subgroups. Most clinical outcome predictors are nonspecific and/or nonmodifiable. Nonmodifiable predictors for poor odds of remission include male sex, younger age at disease onset, poor premorbid adjustment, and severe baseline psychopathology. Modifiable risk factors for poor therapeutic outcomes that clinicians can act upon include longer duration of untreated illness, nonadherence to antipsychotics, comorbidities (especially substance-use disorders), lack of early antipsychotic response, and lack of improvement with non-clozapine antipsychotics, predicting clozapine response. It is hoped that this limited capacity for prediction will improve as pathophysiological understanding increases and/or new treatments for specific aspects of schizophrenia become available.

[Deactualization and orthostrophy. Phenomenological psychopathology of receding delusions]

In this article we develop a phenomenological psychopathology of receding delusions in persons with a diagnosis of schizophrenia. Drawing on Klaus Conrad's (1905-1961) descriptions of beginning schizophrenia and an in-depth single case study, we develop descriptions of the process of receding delusions as opposed to ongoing delusions in the manner of a double-orientation to reality. We distinguish two stages in this process of social recovery and term these stages deactualization and orthostrophy. We argue that delusional convictions lose importance and persuasive power if they are no longer supported by corresponding value apprehensions or perceptions and perception-like experiences (i.e. hallucinations). Consequently, we propose that the process of receding delusions proceeds in layers comparable to a regression of the process of upcoming delusions. Lastly we discuss both stages of receding delusions (deactualization and orthostrophy) and ongoing delusions (double-orientation to reality) as possible continuous manners of social recovery concerning delusional psychosis (diagnosis of schizophrenia) and argue for specific interventions according to these different continuous manners.

The impact of insight on social functioning in patients with schizophrenia

BACKGROUND

It is still unclear whether insight has a direct association with social functioning in schizophrenia, independent of its association with symptoms.

AIM

This study aimed to investigate the relationship of insight and its dimensions with social functioning in schizophrenia.

METHODS

A total of 170 outpatients with schizophrenia were included in this study. All patients were evaluated with the Scale to Assess Unawareness of Mental Disorder (SUMD), Positive and Negative Syndrome Scale (PANSS) and Personal and Social Performance Scale (PSP). Patients with impaired insight and patients with unimpaired insight were compared for PSP score through independent samples t test. Pearson's correlation analysis was used to determine the correlations between study variables. Multiple stepwise linear regression analysis was used in order to determine the variables that predict social performance.

RESULTS

The PSP score of patients with impaired insight was significantly lower than that of patients with unimpaired insight. There were significant correlations between insight dimensions and PSP score. PANSS negative scale score, awareness of achieved effects of medication and awareness of anhedonia/asociality were significant predictors of social performance.

CONCLUSION

Insight has a significant impact on social functioning in schizophrenia, and some, but not all, insight dimensions have direct impact on social performance, independent of their association with symptoms.

Course and outcome of schizophrenia in asian countries: review of research in the past three decades

Considerable variation has been observed in the course and outcome of schizophrenia. With regard to epidemiology of schizophrenia, papers from different Asian countries have reported findings which are in contrast with literature from the western countries. In this background we undertook a narrative review of literature regarding course and outcome of schizophrenia in Asian countries. We conducted Medline search for English-language papers on long-term course and outcome of schizophrenia conducted in Asia in the past 3 decades. We also reviewed data pertaining to Asian countries from the World Health Organization's International Study of Schizophrenia (ISoS). In addition to ISoS, we retrieved 14 reports from 9 Asian countries. While ISoS used comparable methodology across the countries, non-ISoS studies differed substantially in their aims, sampling, follow-up rates and assessment tools used for studying the course and outcome. Overall, the percentage of patients who experienced clinical and functional outcome in the Asian countries were largely comparable to those in the western studies. We observed significant variations in the long-term outcome and mortality in schizophrenia even among the Asian countries. In conclusion, there is substantial variation in the long-term course and outcome and mortality across different Asian countries. The reason for this remains unexplored. Cross-national studies exploring biological and cultural explanations for this variation may provide clues, which may have heuristic, translational and public-health significance.

Clinical predictors of therapeutic response to antipsychotics in schizophrenia

The search for clinical outcome predictors for schizophrenia is as old as the field of psychiatry. However, despite a wealth of large, longitudinal studies into prognostic factors, only very few clinically useful outcome predictors have been identified. The goal of future treatment is to either affect modifiable risk factors, or use nonmodifiable factors to parse patients into therapeutically meaningful subgroups. Most clinical outcome predictors are nonspecific and/or nonmodifiable. Nonmodifiable predictors for poor odds of remission include male sex, younger age at disease onset, poor premorbid adjustment, and severe baseline psychopathology. Modifiable risk factors for poor therapeutic outcomes that clinicians can act upon include longer duration of untreated illness, nonadherence to antipsychotics, comorbidities (especially substance-use disorders), lack of early antipsychotic response, and lack of improvement with non-clozapine antipsychotics, predicting clozapine response. It is hoped that this limited capacity for prediction will improve as pathophysiological understanding increases and/or new treatments for specific aspects of schizophrenia become available.

The effects of aging on insight into illness in schizophrenia: a review

OBJECTIVES

Impaired insight into illness is a prevalent feature of schizophrenia, which negatively influences treatment adherence and clinical outcomes. Little is known about the effects of aging on insight impairment. We aimed to review the available research literature on the effects of aging on insight into illness in schizophrenia, in relation to positive, negative, and cognitive symptoms. Ultimately, we propose a trajectory of insight in schizophrenia across the lifespan.

METHOD

A systematic Medline® literature search was conducted, searching for English language studies describing the relationship of insight into illness in schizophrenia with aging.

RESULTS

We identified 62 studies. Insight impairment is associated with illness severity, premorbid intellectual function (i.e. IQ), executive function, and memory. Insight impairment improves modestly during midlife, worsening again in late life. It tends to fluctuate with each episode of psychosis, likely in relation to worsening positive symptoms that improve with antipsychotic treatment. The relationship between insight impairment and cognitive dysfunction appears to attenuate with age, while the relationship with lower premorbid intellectual function is preserved. The association between impaired insight and negative symptoms is unclear.

CONCLUSIONS

The available literature suggests that the course of insight impairment follows a U-shaped curve, where insight impairment is severe during the first episode of psychosis, modestly improves over midlife, and declines again in late life. Future studies are required to investigate the trajectory of insight into illness and its core domains across the lifespan from prodromal phase to late life.

Insight in psychosis: an independent predictor of outcome or an explanatory model of illness?

While the traditional view within psychiatry is that insight is independent of psychopathology and predicts the course and outcome of psychosis, recent data from India argues that insight is secondary to interaction between progression of illness on one hand and local culture and social environment on the other. The findings suggest that "insight" is an explanatory model (EM) and may reflect attempts at coping with the devastating effects of mental disorders. Most societies are pluralistic and offer multiple, divergent and contradictory explanations for illnesses. These belief systems interact with the trajectory of the person's illness to produce a unique personal understanding, often based on a set of complex and contradictory EMs. Like all EMs, insight provides meaning to explain and overcome challenges including disabling symptoms, persistent deficits, impaired social relations and difficult livelihood issues. The persistence of distress, impairment, disability and handicap, despite regular and optimal treatment, call for explanations, which go beyond the simplistic concept of disease. People tend to choose EMs, which are non-stigmatizing and which seem to help explain and rationalize their individual concerns. The frequent presence of multiple and often contradictory EMs, held simultaneously, suggest that they are pragmatic responses at coping. The results advocate a non-judgmental approach and broad based assessment of EMs of illness and their comparison with culturally appropriate beliefs, attributions and actions. The biomedical model of illness should be presented without dismissing patient beliefs or belittling local cultural explanations for illness. Clinical practice demands a negotiation of shared model of care and treatment plan between patient and physician perspectives. The diversity of patients, problems, beliefs and cultures mandates the need to educate, match, negotiate and integrate psychiatric and psychological frameworks and interventions. It calls for multifaceted and nuanced understanding of "insight" and explanatory models of illness.

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

BACKGROUND AND AIMS

There is a dearth of data on the predictors of insight in schizophrenia. This study attempted to assess the predictors of insight in a cohort of first-episode schizophrenia followed up over 5 years.

METHODS

Patients diagnosed to have Diagnostic and statistical manual of mental disorders (4th ed.; DSM-IV) schizophrenia (n = 131) were assessed prospectively for insight, psychopathology and explanatory models of illness over a 5-year period using standard instruments. Multiple linear regression and generalized estimating equations (GEE) were employed to assess predictors of insight.

RESULTS

We could follow up 95 (72.5%) patients, 5 years after recruitment. A total of 65 of these patients interviewed at 60 months (68.4%) achieved remission. Cross-sectional evaluations suggest a relationship between insight, psychosis rating and explanatory models of illness with good insight and medical models associated with good outcome. However, baseline and early illness data do not predict insight scores at 5 years. Serial longitudinal assessment of insight is negatively associated with Brief Psychiatric Rating Scale (BPRS) scores and positively associated with the number of nonmedical explanatory models of illness held by patients.

CONCLUSION

These findings argue that insight and explanatory models of illness are secondary to psychopathology, course and outcome. They are dependent on the trajectory of the person's illness, are not independent of the condition and call for multifaceted understanding of the issues.

Is living with psychosis demoralizing? Insight, self-stigma, and clinical outcome among people with schizophrenia across 1 year

Lack of insight is a major target in the treatment of schizophrenia. However, insight may have undesirable effects on self-concept and motivation that can hinder recovery. This study aimed to examine the link between insight, self-stigma, and demoralization as predictors of symptoms and functioning. Insight, self-stigma, depressive and psychotic symptoms, and functioning were assessed among 133 outpatients with schizophrenia at baseline and 12 months later. The data were analyzed by hierarchical multiple linear regressions. More insight at baseline and an increase in self-stigma over 12 months predicted more demoralization at follow-up. Insight at baseline was not associated with any outcome variable, but self-stigma at baseline was related to poorer functioning and more positive symptoms at follow-up. More demoralization at baseline predicted poorer functioning 12 months later. Demoralization did not mediate the relationship between self-stigma at baseline and functioning after 1 year. Given the decisive role of self-stigma regarding recovery from schizophrenia, dysfunctional beliefs related to illness and the self should be addressed in treatment. Different psychotherapeutical approaches are discussed.

Predictors of disability: a 5-year cohort study of first-episode schizophrenia

BACKGROUND

There is a dearth of information about the predictors of disability in schizophrenia from low and middle-income countries. This study attempted to investigate the impact of socio-demographic and clinical variables on disability in a cohort of first episode schizophrenia.

METHOD

Patients diagnosed to have DSM IV schizophrenia (n=131) were assessed prospectively for psychopathology, functioning, insight and explanatory models of illness at baseline, 6, 12 and 60 months using standard instruments. Disability was assessed at 5 years. Multiple linear regression was employed to adjust for common confounders.

RESULTS

We could follow-up 95 (72.5%) patients. Sixty-five of these patients (68.4%) achieved remission. Disability scores at 5 years were associated negatively with episodic nature of illness at baseline, functional assessments at 6 and 12 months and return to pre-morbid level function. Disability correlated positively with psychopathology at 6 and 12 months and time spent in psychotic episodes. It was also associated with psychopathology, remission, insight and patient perspectives at the 5th year cross-sectional evaluation. While employment status at recruitment was not associated with disability, it was associated with unemployment at follow-up.

CONCLUSIONS

Disability at 5 years was associated with illness variables - episodic nature of illness at baseline, psychopathology and functioning, duration in psychotic episode and return to pre-morbid function. Patient perspectives about their illness (insight and patient explanatory models) were only associated cross-sectionally at 60 months but not earlier and are more suggestive of a coping response rather than being predictive of outcome. The relationship between unemployment and disability suggests that they are products of the same disease process.

Religion, spirituality, and schizophrenia: a review

Religion and spirituality exert a significant role in the lives of many individuals, including people with schizophrenia. However, the contribution of religion and spirituality to various domains (psychopathology, explanatory models, treatment seeking, treatment adherence, outcome, etc.) has not received much attention. In this article, we review the exiting data with regards to the relationship of religion, spirituality, and various domains in patients with schizophrenia. Available evidence suggests that for some patients, religion instills hope, purpose, and meaning in their lives, whereas for others, it induces spiritual despair. Patients with schizophrenia also exhibit religious delusions and hallucinations. Further, there is some evidence to suggest that religion influences the level of psychopathology. Religion and religious practices also influence social integration, risk of suicide attempts, and substance use. Religion and spirituality also serves as an effective method of coping with the illness. Religion also influences the treatment compliance and outcome in patients with schizophrenia.