Insight in Individuals With First-episode Psychosis: Correlates With Symptoms, Neurocognition and Psychosocial Functioning Over Acute and Stable Phases

Abstract

Background: Poor insight is prevalent in individuals with first-episode psychosis (FEP) and is associated with unfavorable outcomes. Despite distinctions in insight characteristics between FEP and established schizophrenia, further research at this early stage is needed. This research investigates the relationship between insight and psychotic and depressive symptoms in acute and stable phases of FEP, as well as the association between insight, neuropsychological performance, and social functioning in the stable phase. Moreover, we explore how changes in insight correlate with symptom evolution between the two phases. 

Methods: Ninety individuals with FEP were assessed at the acute and/or stable phases of the illness. Insight was assessed using the Scale to Assess Unawareness of Mental Disorder (SUMD) across three dimensions: insight into having a mental disorder (IMD), insight into the effects of medication (IEM), and insight into the social consequences (ISC) of having a mental disorder. Symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression-Schizophrenia Scale (CGI-SCH). A battery of cognitive tests was used to assess neurocognition, while social functioning was assessed with the Global Assessment of Functioning Scale (GAF) and the Disability Assessment Schedule (DAS-sv). 

Results: During the acute phase, poor insight was significantly correlated with increased positive symptoms (IMD: p = 0.002; IEM: p = 0.003; ISC: p = 0.011) and general symptoms (IMD: p = 0.016; IEM p = 0.006). In the stable phase, insight remained significantly correlated with positive (IMD: p < 0.001; IEM: p = 0.010; ISC: p = 0.006) and general symptoms (IMD: p = 0.003; IEM: p = 0.023; ISC: p = 0.018). Negative symptoms (IMD: p = 0.002; IEM: p = 0.004; ISC: p = 0.004) and cognitive symptoms (via CGI-SCH) were also correlated with insight (IMD: p = 0.010; IEM: p = 0.020; ISC: p = 0.015). Neuropsychological performance was significantly associated to insight, with executive functioning correlating with IMD (Trail Making Test-A (TMT-A): p = 0.002; Trail Making Test-B (TMT-B): p = 0.014) and verbal memory correlating with IEM (short-term: p = 0.004; long-term: p = 0.043). Lower cognitive performance was associated with poorer insight (IMD: p = 0.002; IEM: p = 0.037; ISC: p = 0.008). Improved insight in IMD and ISC was associated with higher psychosocial functioning (GAF: p = 0.001; p = 0.005) and lower social disability (DAS-sv: p = 0.012; p = 0.004). Finally, insight improvements correlated with symptom reduction, as a decrease in PANSS positive symptoms was associated with better IMD (p < 0.001), while reduced general symptoms correlated with improved IEM (p = 0.024). IMD was the only dimension influenced by its acute-phase level (p = 0.004). 

Conclusion: Understanding the implications of insight in the course and prognosis of psychosis is crucial for achieving positive outcomes. Targeting the three key insight dimensions (insight into illness, medication necessity and social consequences), with tailored interventions adapted to different illness stages can help optimize treatment response.