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

https://doi.org/10.1016/j.schres.2004.07.003Get rights and content

Abstract

Insight in schizophrenia is an evolving concept with widespread use in clinical practice. Results are presented from a multicentre randomised trial in which patients with schizophrenia and carers received a short insight-focused Cognitive Behaviour Therapy (CBT) intervention from trained nurses in the community. The CBT group demonstrated significantly greater improvement in insight into compliance with treatment and the ability to re-label their psychotic symptoms as pathological compared with the control group at post-therapy assessment. Those participants who demonstrated improved insight into having a mental illness tended to become depressed. At the end of therapy and at 1-year follow-up, there was a statistically significantly increased dropout rate in African-Caribbean and Black African participants. The Black Caribbean group showed a significantly smaller change in insight compared to the white group. At 1-year follow-up, the result on total insight and compliance was durable. The change in insight in the Black African group was significantly lower compared to the white group. The study emphasizes the role of a short insight-focused CBT intervention in improving patients' insight into compliance and its implications. The results confirm previous findings of difficulties in engaging patients of Afro-Caribbean origin and their poor response to psychological therapies as currently delivered.

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.

References (36)

  • X. Amador et al.

    Assessment of insight in psychosis

    American Journal of Psychiatry

    (1993)
  • X.F. Amador et al.

    Suicidal behaviour in schizophrenia and its relationship with awareness of illness

    American Journal of Psychiatry

    (1996)
  • M. Åsberg et al.

    A comprehensive psychopathological rating scale

    Acta Psychiatrica Scandinavica

    (1978)
  • I.E. Babiker

    Non-compliance in schizophrenia

    Psychiatric Developments

    (1986)
  • A. Beck-Sandler

    Is insight into psychosis meaningful

    Journal of Mental Health

    (1998)
  • D. Bhugra et al.

    Incidence and outcome of schizophrenia in Whites, Afrocaribbeans and Asians in London

    Psychological Medicine

    (1997)
  • M.J. Birchwood et al.

    Depression and suicidal thinking in psychosis: a cognitive approach

  • S. Byford et al.

    Factors that influence the cost of caring for patients with severe psychotic illness. Report from the UK 700 trial

    British Journal of Psychiatry

    (2001)
  • A.S. David

    Insight and psychosis

    British Journal of Psychiatry

    (1990)
  • A. David et al.

    Perspectives on depressive realism: Implications for cognitive theory of depression

    Behaviour Research and Therapy

    (1995)
  • P.A. Garety et al.

    Cognitive behavioural therapy for drug resistant psychosis

    British Journal of Medical Psychology

    (1994)
  • L. Gordis et al.

    The inaccuracy in using interviews to estimate patient reliability in taking medications at home

    Medical Care

    (1969)
  • J.H. Green

    Frequent rehospitalisation and non-compliance with treatment

    Hospital and Community Psychiatry

    (1998)
  • Z. Iqbal et al.

    Cognitive approach to depression and suicidal thinking in psychosis 2. Testing the validity of the social ranking model

    British Journal of Psychiatry

    (2000)
  • S. Johnson et al.

    Insight and psychosis: a social perspective

    Psychological Medicine

    (1995)
  • R. Kemp et al.
  • R. Kemp et al.

    Compliance therapy in psychotic patients: a randomised controlled trial

    British Medical Journal

    (1996)
  • M. Knapp et al.

    Economic evaluation of psychological treatments for schizophrenia

  • Cited by (123)

    • Targeting relapse prevention and positive symptom in first-episode schizophrenia using brief cognitive behavioral therapy: A pilot randomized controlled study

      2019, Psychiatry Research
      Citation Excerpt :

      Part of patients’ acceptance of their illness and self-knowledge is recognising the importance of treatment, which is associated with subsequent improved adherence to medication (Bedford and David, 2014; Wang et al., 2003) and reduced relapse rates and hospital readmissions (Kemp et al., 1996). A number of previous studies have demonstrated that CBT can improve insight in first episode psychosis patients (Jackson et al., 1998; Wang et al., 2003), potentially via psychoeducation or behavioural experiments (Rathod et al., 2005). Interestingly, in the present study we found that both groups had high SAI scores at 1 year with significant improvements in insight over time.

    • Psychotherapy for schizophrenia and bipolar disorder

      2019, Global Mental Health and Psychotherapy: Adapting Psychotherapy for Low- and Middle-Income Countries
    • Cognitive Behavioural Therapies for Psychosis

      2019, A Clinical Introduction to Psychosis: Foundations for Clinical Psychologists and Neuropsychologists
    View all citing articles on Scopus
    View full text