The “Insight Paradox” in Schizophrenia: Magnitude, Moderators and Mediators of the Association Between Insight and Depression

Abstract

The so-called "insight paradox" posits that among patients with schizophrenia higher levels of insight are associated with increased levels of depression. Although different studies examined this issue, only few took in account potential confounders or factors that could influence this association. In a sample of clinically stable patients with schizophrenia, insight and depression were evaluated using the Scale to assess Unawareness of Mental Disorder and the Calgary Depression Scale for Schizophrenia. Other rating scales were used to assess the severity of psychotic symptoms, extrapyramidal symptoms, hopelessness, internalized stigma, self-esteem, and service engagement. Regression models were used to estimate the magnitude of the association between insight and depression while accounting for the role of confounders. Putative psychological and sociodemographic factors that could act as mediators and moderators were examined using the PROCESS macro. By accounting for the role of confounding factors, the strength of the association between insight into symptoms and depression increased from 13% to 25% explained covariance. Patients with lower socioeconomic status (F = 8.5, P = .04), more severe illness (F = 4.8, P = .03) and lower levels of service engagement (F = 4.7, P = .03) displayed the strongest association between insight and depression. Lastly, hopelessness, internalized stigma and perceived discrimination acted as significant mediators. The relationship between insight and depression should be considered a well established phenomenon among patients with schizophrenia: it seems stronger than previously reported especially among patients with lower socioeconomic status, severe illness and poor engagement with services. These findings may have relevant implications for the promotion of insight among patients with schizophrenia.

The dynamic relationship between insight and suicidal behavior in first episode psychosis patients over 3-year follow-up

“…Suicide prevention strategies, particularly in early psychosis, should therefore focus on ensuring medication compliance. In other words, there seems to be a time-effect of insight on suicidality in FEP patients, which may be conceptually part of the so-called "insight paradox" in addition to depression (Belvederi Murri et al, 2016, Mintz et al, 2003. The role of previous suicide attempts and depression together with poor premorbid adjuntment in the increased risk of suicide attempts was also replicated by our study (Massons et al, 2017).…”

“…prior to first presentation) (Lopez-Morinigo et al, 2014), depressive symptoms and negative beliefs about psychosis (Barrett et al, 2010), may confound/mediate such an association, which has been replicated by a recent cross-sectional study of patients with psychotic disorders (Massons et al, 2017). Hence there is evidence that insight may be associated with both good and poor outcomes (Belvederi Murri et al, 2016, Mintz et al, 2003, the so-called "insight paradox". Belvederi and colleagues (Belvederi Murri et al, 2016) remarked that the association between insight and higher levels of depression and potentially suicidal behavior could be explained by potential confounders, such as the severity of psychotic symptoms, extrapyramidal symptoms, hopelessness, internalized stigma, self-esteem, socio-economic status and service engagement.…”

“…Hence there is evidence that insight may be associated with both good and poor outcomes (Belvederi Murri et al, 2016, Mintz et al, 2003, the so-called "insight paradox". Belvederi and colleagues (Belvederi Murri et al, 2016) remarked that the association between insight and higher levels of depression and potentially suicidal behavior could be explained by potential confounders, such as the severity of psychotic symptoms, extrapyramidal symptoms, hopelessness, internalized stigma, self-esteem, socio-economic status and service engagement. It has also been suggested that the effect of insight on suicidal behaviour can go in opposite directions at different time-points, with insight at baseline increasing the risk and insight at follow-up decreasing it (Barrett et al, 2015).…”

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

“…Replicating earlier research 75 , several groups have found that the link between insight and depression was mediated by self-stigma [82][83][84] . Others have suggested that, beyond stigma, a generally negative appraisal of one's future 85 and tendency to ruminate 79 influence the effects of insight on mood.…”

Insight is a useful construct in clinical assessments if used wisely

“…Although academics are predisposed to question if not dispute relevant evidence and facts, they can be reassured that a number of systematic reviews and meta-analyses based on dozens of studies and many thousands of participants have been conducted and it is possible to say with confidence that—at least as applied to psychosis—(a) insight is related to psychopathology (worse psychopathology, worse insight3) but to an extent that does not render the measurement of insight redundant; (b) there is a reliable association between mood and insight (lower mood, better insight) for various postulated reasons4; (c) insight is related to IQ (lower IQ, worse insight) but again the proportion of variance explained by IQ is small suggesting this is only one of several associated factors 5. There is also a consensus that insight is a powerful predictor of adherence to treatment6 (even when items related to compliance are omitted from the insight measure in question) and an emerging view that some medium and longer-term outcomes are predicted by insight—over and above adherence to treatment 7.…”