Insight and recovery in schizophrenic patients

Relationships between cognitive performance, clinical insight and regional brain volumes in schizophrenia

Impairments in cognitive performance are common in schizophrenia, and these contribute to poor awareness of symptoms and treatment (‘clinical insight’), which is an important predictor of functional outcome. Although relationships between cognitive impairment and reductions in regional brain volumes in patients are relatively well characterised, less is known about the brain structural correlates of clinical insight. To address this gap, we aimed to explore brain structural correlates of cognitive performance and clinical insight in the same sample. 108 patients with schizophrenia (SZH) and 94 age and gender-matched controls (CON) (from the Northwestern University Schizophrenia Data and Software Tool (NUSDAST) database) were included. SZH had smaller grey matter volume across most fronto-temporal regions and significantly poorer performance on all cognitive domains. Multiple regression showed that higher positive symptoms and poorer attention were significant predictors of insight in SZH; however, no significant correlations were seen between clinical insight and regional brain volumes. In contrast, symptomology did not contribute to cognitive performance, but robust positive relationships were found between regional grey matter volumes in fronto-temporal regions and cognitive performance (particularly executive function). Many of these appeared to be unique to SZH as they were not observed in CON. Findings suggest that while there exists a tight link between cognitive functioning and neuropathological processes affecting gross brain anatomy in SZH, this is not the case for clinical insight. Instead, clinical insight levels seem to be influenced by symptomology, attentional performance and other subject-specific variables.

Is clinical insight a determinant factor of subjective recovery in persons living with schizophrenia or schizoaffective disorders?

Good clinical insight is predictive of clinical recovery in schizophrenia (i.e. symptomatic remission and functional improvement). However, the recent subjective recovery paradigm (i.e. the self-identity reconstruction process with and beyond psychosis) questioned the relevance of seeking patients' awareness of their medically-defined illness. This study aimed to assess the relationship between clinical insight and subjective recovery in individuals with psychotic disorders. Sixty-seven outpatients diagnosed with schizophrenia or schizoaffective disorder were assessed for clinical insight using the Scale to assess Unawareness of Mental Disorder (SUMD) and for self-rated subjective recovery using the Recovery Assessment Scale (RAS). Among all dimensions of insight, only the unawareness of current symptoms was significantly associated with RAS total score, with illness duration as the only moderating factor. On the final regression model, unawareness of current symptoms was confirmed as the strongest of six factors explaining all together 44% of the subjective recovery variance, whereas clinical insight taken as an independent multidimensional construct did not significantly participate in explaining subjective recovery. Our study highlights the weak and only partial implication of clinical insight in subjective recovery, and invites clinicians to consider the patients' meaning making process of morbid experiences in order to build a self-directed and medically-supported recovery.

The Mental Health of Patients With Psychotic Disorder From a Positive, Multidimensional and Recovery Perspective

Positive mental health (PMH) and mental illness are distinct, yet interrelated, constructs. However, this relationship has yet to be adequately established. We aimed to evaluate the level of PMH and its relationship with sociodemographic and clinical determinants as well as to explore the relationship between PMH and the positive constructs of recovery, subjective wellbeing (SWB), insight and functioning in patients with psychotic disorder. A multicenter, descriptive, cross-sectional and correlational study with a sample of 347 patients with psychotic disorder was conducted. The following assessment instruments were used: Positive Mental Health Questionnaire, Maryland Assessment of Recovery in Serious Mental Illness scale, Insight Scale, Personal Wellbeing Index-Adult version (PWI-A), Overall Life Satisfaction (OLS) and Global Assessment of Functioning scale. The mean global level of PMH was 116.16 (range of 39–156, SD = 19.39). Significant differences were found in PMH in relation to sociodemographic (sex, civil status and employment situation) and clinical variables (family history of mental disorders, number of prescribed antipsychotics, treatment with anxiolytics, treatment with antidepressants and suicide attempts). PMH was significantly and positively correlated with recovery (r = 0.760), SWB (PWI-A: r = 0.728 and OLS: r = 0.602) and functioning (r = 0.243), and negatively with insight (r = −0.335). These results can lead to a major change in mental health care. If actions are taken to increase PMH, then recovery, SWB and functioning will also increase. At the same time, interventions should be carried out to boost insight, since increasing PMH could decrease insight, all resulting in better quality of life for patients with psychotic disorder.

The relationship between functional recovery and quality of life in patients affected by schizophrenia and treated at a community mental health center in Turkey

PURPOSE

The study was conducted to determine the levels of functional recovery and quality of life (QOL) among a group of patients suffering from schizophrenia treated at a Community Mental Health Center (CMHC) and to evaluate the relationship between these two treatment outcomes.

DESIGN AND METHODS

This observational study was implemented among 132 patients affected by schizophrenia treated at a CMHC in Turkey.

FINDINGS

A statistically significant positive correlation was found between the general and subscale mean scores of the functional remission of general schizophrenia scale and the mean score of all domains of the World Health Organization QOL (r = 0.63-0.33; P < .001).

PRACTICE IMPLICATIONS

QOL increases as the functional recovery levels increase. Nursing practices should be planned to improve functional recovery levels of patients.

Validation of a four items version of the Functional Remission of General Schizophrenia scale (the mini-FROGS) to capture the functional benefits of clinical remission

Objectives

We previously developed the Functional Remission Of General Schizophrenia (FROGS) scale demonstrating first, reliable assessment in a cross-sectional study and second, good time-stability. The purpose of the present analysis was to propose a shorter version (mini-FROGS), more compatible with the limited time available in a psychiatric visit, focusing on the functional domains that have higher likelihood of being improved with higher and/or longer symptomatic remission in different cultural backgrounds.

Methods

We used multiple regressions to find the most informative items explaining increased length of symptomatic remission, using prospective data from a national observational multicenter survey. Then, the mini-FROGS was used in different European countries to test its between-center reliability, compared to other scales.

Results

Four domains were retained as capturing the maximum of symptomatic remission, namely (1) travel and communication, (2) management of illness and treatment, (3) self-esteem and sense of independence and (4) respect of biological rhythms. First, the mini-FROG was evaluated in 443 French patients with clinical remission and 22 without, and 12/18 months later in 140 patients still in clinical remission and 23 in relapse. In Europe, 295 schizophrenia patients were assessed with the mini-FROGS and other scales devoted to functional remission, allowing comparisons. The mini-FROGS showed good correlations with other scales in different countries and demonstrated good psychometric properties.

Conclusion

These results give evidence that a 4 items-only version of the FROGS scale may be useful to assess important aspects of functional remission, tightly linked to the length of clinical remission.

Rate of and time to symptomatic remission in first-episode psychosis in Northern Malawi: A STROBE-compliant article

Although longer duration of untreated psychosis (DUP) is associated with poor response to antipsychotic treatment, it remains unclear whether it independently influences time to symptomatic remission in first-episode psychosis (FEP). This study examined rate of symptomatic remission, and explored if DUP, premorbid functioning, global functioning, insight and socio-demographic characteristics were independently associated with time to symptomatic remission in FEP.This prospective study enrolled 126 FEP patients (aged 18-65) between June 2009 and September 2012. Subjects were followed-up monthly over 18 months after they had received antipsychotic medication. Remission in positive and negative symptoms was defined as in the Remission in Schizophrenia Working Group (RSWG) criteria. Subjects were defined as "in symptomatic remission" if they remitted in both negative and positive symptoms. At baseline, the following explanatory variables were measured: socio-demographic characteristics; DUP as short (≤5 months) and long (>5 months); premorbid functioning as deteriorating, stable poor, and stable good according to Cannon-Spoor Premorbid Adjustment Scale; global functioning as "worst (1-10) to serious (41-50)" and "moderate (51-60) to superior (91-100)," according to the Global Assessment of Functioning Scale; and insight as poor (≤8) and good (≥9) according to the Insight Scale (Birchwood). Univariate and multivariable analyses were used to generate results.Out of 126 subjects, 98 (78%) completed follow-up, of which 70 (71.4%) achieved symptomatic remission within mean duration of 8.05 (4.54) months. Besides, having long DUP and separated/divorced/widowed (adjusted hazard ratio [aHR] = 0.07, 95%CI = [0.01, 0.46]), long DUP and poor insight (aHR = 0.18, 95%CI = [0.04, 0.89]), poor insight and separated/divorced/widowed (aHR = 0.09, 95%CI = [0.01, 0.70]), deteriorating premorbid functioning (aHR = 0.47, 95%CI = [0.23, 0.97]), family history of psychiatric disorders (aHR = 0.52, 95%CI = (0.30, 0.93]), and being male (aHR = 0.47, 95%CI = [0.24, 0.92]) delayed symptomatic remission.These results propose that psychological interventions and social support for mental health problems are warranted and may enhance better response to antipsychotic medications among separated/divorced/widowed patients with long DUP or poor insight, and poor insight patients with long DUP. Deteriorating premorbid functioning, family history of psychiatric disorders and being male continue being important risk factors for poor odds of remission.

Insight in schizophrenia spectrum disorders: relationship with behavior, mood and perceived quality of life, underlying causes and emerging treatments

Poor insight in schizophrenia is prevalent across cultures and phases of illness. In this review, we examine the recent research on the relationship of insight with behavior, mood and perceived quality of life, on its complex roots, and on the effects of existing and emerging treatments. This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function, while good insight predicts a higher frequency of depression and demoralization, especially when coupled with stigma and social disadvantage. This research also suggests that poor insight may arise in response to biological, experiential, neuropsychological, social-cognitive, metacognitive and socio-political factors. Studies of the effects of existing and developing treatments indicate that they may influence insight. In the context of earlier research and historical models, these findings support an integrative model of poor insight. This model suggests that insight requires the integration of information about changes in internal states, external circumstances, others' perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes. One implication is that treatments should, beyond providing education, seek to assist persons with schizophrenia to integrate the broad range of complex and potentially deeply painful experiences which are associated with mental illness into their own personally meaningful, coherent and adaptive picture.

Insight and recovery and the stigma of mental illness - analysis of the phenomenon of insight in schizophrenia and its correlations with the processes of stigma and self-stigma

Does better insight associated with the process of recovery mean a stronger sense of mental illness stigma? This article presents the relationship between a multidimensional construct, which is the insight and the phenomena of stigma and self-stigma of patients diagnosed with schizophrenia. It is well known that the term insight contains: a sense of illness, the patient's attitude to its symptoms, explanation of the causes of the illness, attitude to the rationale of treatment and awareness of the risk of relapse. On the other hand, self-stigma occurs when the patient internalizes and refers to himself/herselfnegative and stigmatizing social attitudes, conditioned by the presence of conventionalbeliefs, strengthened by the media, and this weakens the process of recovery.

How much does good insight strengthen the patient on the way to fuller social functioning, and how much does it imprint stigma of mental illness and weaken its positionin society? The authors of the paper are discussing the subject of insight and stigma from the patient's perspective, over the patient’s attitude towards the diagnosis of schizophrenia, the process of recovery and the aspect of hope - important in recovery. These study of construct insight shows that the relationship insight-recovery-stigma is a multi-dimensional plane, dependent on various factors, that needs constant deepening and complementing with further research.

Recovery and serious mental illness: a review of current clinical and research paradigms and future directions

INTRODUCTION

Recovery from serious mental illness has historically not been considered a likely or even possible outcome. However, a range of evidence suggests the courses of SMI are heterogeneous with recovery being the most likely outcome. One barrier to studying recovery in SMI is that recovery has been operationalized in divergent and seemingly incompatible ways: as an objective outcome versus a subjective process. Areas covered: This paper offers a review of recovery as a subjective process and recovery as an objective outcome; contrasts methodologies utilized by each approach to assess recovery; reports rates and correlates of recovery; and explores the relationship between objective and subjective forms of recovery. Expert commentary: There are two commonalities of approaching recovery as a subjective process and an objective outcome: (i) the need to make meaning out of one's experiences to engage in either type of recovery and (ii) there exist many threats to engaging in meaning making that may impact the likelihood of moving toward recovery. We offer four clinical implications that stem from these two commonalities within a divided approach to the concept of recovery from SMI.

The impact of second generation antipsychotics on insight in schizophrenia: Results from 14 randomized, placebo controlled trials

Despite the negative impact of lack of insight on the prognosis, general functioning and treatment adherence, the effect of antipsychotic medication on insight has been investigated only in small samples and uncontrolled studies. In this study we examine whether previously reported effects of antipsychotics on insight from uncontrolled studies can be confirmed in a database including 14 randomized, double-blind, placebo-controlled trials. The database contained placebo-controlled RCTs of five second-generation antipsychotics (SGAs: olanzapine, paliperidone, quetiapine, risperidone and sertindole) and included a total of 4243 patients with schizophrenia. Insight was assessed with item G12 of the Positive and Negative Syndrome Scale (PANSS) at baseline and at six weeks. Overall, SGA treatment resulted in a significantly larger improvement in insight than placebo (0.43 points versus 0.15 points; Hedge׳s g 0.23; p<0.001). However this difference in improvement in insight was largely explained by improvement in other symptoms. In the initial analysis, one of the compounds was significantly less effective in improving insight than the other SGAs, but this difference no longer persisted when improvement in other symptoms was taken into account. The effect of SGAs on improvement in insight was not moderated by geographic region, illness duration or drop-out. The present study showed that SGA treatment of patients with schizophrenia is associated with improved insight, but that this improvement is associated with SGA induced improvements in other symptoms, though the causal relationship may not be established.