Insight into schizophrenia: the effects of cognitive behavioural therapy on the components of insight and association with sociodemographics—data on a previously published randomised controlled trial
Introduction
The validity of the concept of insight in schizophrenia is widely questioned, as no consensus exists with regard to its definition and relationship to outcome and prognosis (Kemp and David, 1997, Beck-Sandler, 1998). Some studies have shown measures of insight to be correlated with the course of the illness (Amador et al., 1993), rates of rehospitalisation and compliance with treatment (McEvoy et al., 1989b); while others have related improved insight to increased suicidal risk (Amador et al., 1996). Medical anthropologists have criticised the concept of insight for failing to recognise that people can have various culturally shaped frameworks to explain their illnesses, all possibly valid. From this point of view, the concept of insight is “Eurocentric and essentially arrogant” (Perkins and Moodley, 1993).
David (1990) has argued that insight is composed of three overlapping components. These include insight into adherence with treatment, awareness of illness and correct re-labelling of psychotic experiences. The importance of neuroleptic treatment in schizophrenia is well accepted and prognosis of illness is shown to be associated with compliance with it (Green, 1998). Estimates of the incidence of noncompliance in psychosis vary between 10% and 80% (Babiker, 1986). Compliance is a complex phenomenon affected by social, cultural and demographic factors and beliefs about health and sickness.
However, insight into presence of illness can also lead to the development of depression in patients suffering psychotic symptoms (Iqbal et al., 2000). The context is provided by the patient's appraisal of psychosis which embodies loss, humiliation, entrapment and their consequent ‘down ranking’ of themselves (Birchwood and Iqbal, 1998). Therefore, there may be a relationship between the various constructs of insight in schizophrenia, but the relationship may not be a linear one. Similarly, all the constructs of insight may not influence outcome and prognosis in schizophrenia equally.
Recent studies have shown cognitive behavioural therapy (CBT) to be of benefit in the treatment of positive symptoms (Tarrier et al., 1998) and negative symptoms (Sensky et al., 2000) of schizophrenia. Compliance has been cost-effectively (Knapp and Healey, 1998) improved by a brief CBT intervention in patients with schizophrenia (Kemp et al., 1996). The insight study (Turkington et al., 2002) reported a statistically significant improvement in overall insight and symptoms of depression at post-therapy assessment with a brief insight-oriented CBT intervention delivered by trained nurses to patients with schizophrenia in the community.
Section snippets
Objectives
The key objectives of this sub-analysis from the initial study (Turkington et al., 2002) are:
- (1)
To determine 1-year outcome measures of total insight, psychopathology and depression.
- (2)
To determine whether there is a difference in the degree of change in the three components of insight (compliance, recognition of illness and ability to re-label mental disturbances as pathological) with therapy.
- (3)
To determine if an improvement in the components of insight following therapy led to depression.
- (4)
To determine
Method
This has been fully described in the first publication by this research group (Turkington et al., 2002) and so relevant details only are given here.
Baseline characteristics
There were no statistically significant baseline differences between the groups when measured for severity of illness, previous admissions and medication doses (Turkington et al., 2002). Baseline characteristics of participants and scores of outcome measures are shown in Table 1, Table 2 , respectively. (Table 1, Table 2).
Dropouts
A total of 422 patients entered the study of which 353 were assessed at 5 months. The total number of patients who received the CBT intervention was 225 (32 dropouts). The
Discussion
This study suggests that a brief insight-focused Cognitive Behaviour Therapy (CBT) program, delivered by trained nurses, leads to significant improvement in two out of the three components of insight in the short term, with a sustained influence on total insight and insight into compliance in the long term compared with the TAU group. Component 2 of insight (the patient's awareness of their illness) did not show a statistically significant difference between the two groups. This might indicate
Acknowledgement
Pfizer funded the insight study. The authors acknowledge the advice of the Insight into Schizophrenia Research Group in the preparation of this manuscript.
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