Schizophrenia - Insight,
Depression: A correlation study
Ananda Reddy
Endreddy1, Subahani shaik2, Bhagawan Rajana3
1Dr Ananda Reddy Endreddy, 2Dr Subahani shaik, 3Dr Bhagawan Rajana, all
authors are affiliated with Departments of Psychiatry, Narayana Medical
College and Hospital, Nellore, Andhra Pradesh, India
Address for
Correspondence: Dr. Ananda Reddy Endreddy,
Associate professor, Department of psychiatry, Narayana Medical College
and Hospital, Nellore, Andhra Pradesh, India. E-mail:
anandendreddy@gmail.com
Abstract
Background:
Schizophrenia is one of the severe forms of mental illness which
demands enormous personal and economical costs. Recent years have
attracted considerable interest in the dual problem of depression in
schizophrenia and its relation to insight. Most clinicians believe that
poor insight in patients with schizophrenia, though problematic for
treatment adherence, may be protective with respect to suicide. Aims
and objectives: Our study was aimed to find out the correlation between
insight and depression in schizophrenic population. Materials and Methods: Present
study was a cross sectional, single centred, correlation study done in
total of 60 subjects. Subjects aged between 20 to 60years, diagnosed to
have schizophrenia as per ICD-10 and who have given written consent
been considered for the study. Subjects who had other psychiatric
disorders such as mood disorder, schizoaffective disorder, mental
retardation, epilepsy or detectable organic disease and co morbid
substance abuse were excluded from the study. Schizophrenics with acute
exacerbation were also excluded from the study. For insight assessment,
schedule for assessment of insight (SAI), a three item rating scale was
used. For the assessment of depressive symptoms, a nine item rating
scale, Calgary Depression Rating Scale (CDRS) was administrated. Results: Insight and
depression were strongly correlated in schizophrenic population with a
Pearson correlation coefficient of 0.758. The correlation between
insight and depression was high in subjects with less duration of
illness. Conclusions:
Our study suggests that poor insight may protect against depression in
the early stages of recovery from schizophrenia. The correlation
between insight and depression was high in subjects with less duration
of illness.
Keywords:
Depression, Insight, Schizophrenia
Manuscript received:
25th September 2016,
Reviewed: 6th October 2016
Author Corrected: 16th
October 2016, Accepted
for Publication: 31st October 2016
Introduction
Schizophrenia is one of the severe forms of mental illness which
demands enormous personal and economical costs. Globally it is
estimated that 25million people have schizophrenia [1]. Recent years
have attracted considerable interest in the dual problem of depression
in schizophrenia and its relation to insight. Among the primary
dimensions of insight, the following were included: 1) the awareness of
having an illness, its signs and symptoms. The awareness and
attribution of recognizable symptoms to that illness, the temporal
projection of the insight, distinguishing between actual or
retrospective insight, and assuming that insight may vary in different
stages of the psychotic process [2,3]. Semrad and Eissler, however, had
seen depression in schizophrenia as a moment of therapeutic
opportunity, when insight and mastery might overcome more primitive
defensive psychotic ego states as they receded [4]. Between 50% and 80%
of the patients diagnosed with schizophrenia have been shown to be
partially or totally lacking insight into the presence of their mental
disorder.
Although a causal chain connecting poor insight with poor treatment
adherence and thus with poorer outcome and functioning is straight
forward, numerous studies investigating correlates and long-term impact
of insight have provided differing results. In addition, higher levels
of insight in schizophrenia have been associated with depression and
hopelessness, but the causal direction of the relationship was unclear
and the data were inconclusive [5]. Schizophrenia is a highly
stigmatising disorder and many individuals with this diagnosis feel
devalued and discriminated [6]. Societal, and sometimes medical views
include the belief that it is a chronic, debilitating condition from
which individuals have little chance of recovering [7]. This
conceptualisation can be threatening and distressing to those given the
diagnosis, and is likely to contribute to the high level of depression
experienced by many people with schizophrenia [8]. Indeed, a number of
cross-sectional studies support a relationship between higher insight
and greater distress, including depression, [9] hopelessness, [10] and
suicidality [11].
Most clinicians believe that poor insight in patients with
schizophrenia, though problematic for treatment adherence, may be
protective with respect to suicide. The assumption is that patients who
do not believe that they are ill are less likely to be suicidal.
Alternatively, those patients with schizophrenia who recognize and
acknowledge the illness will be more suicidal [12]. As per Moore et al,
patients with a greater unawareness of their illness had relatively
less depressive symptomotology and relatively greater self deception.
This relationship was particularly strong for unawareness of the social
consequences of a mental disorder. These results suggest that the
presence of depressive symptomotology in schizophrenia is related to
insight [13].
Methodology
We have conducted a cross sectional, single centred, correlation study
in 60 subjects, from February to May 2016 at Katuri Medical College and
Hospital, Guntur.
Inclusion criteria:
Subjects aged between 20 to 60 years, who were diagnosed to have
schizophrenia as per ICD-10 and who have given written consent.
Exclusion criteria: Subjects
who had other psychiatric disorders such as mood disorder,
schizoaffective disorder, mental retardation, epilepsy or detectable
organic disease and co morbid substance abuse were excluded from the
study. Schizophrenics who have acute exacerbation were also excluded.
Our study was an outpatient based study; patients who have come for the
follow up were taken into the study. Each subject was informed about
the study in person and their consent was taken.
Instruments: For
insight assessment, Schedule for Assessment of Insight (SAI), a three
item rating scale is used [14]. The SAI evaluates insight in three
dimensions and was used to rate the insight in psychotic illness. For
depressive symptoms assessment a nine item rating scale, Calgary
Depression Rating Scale (CDRS) was administrated. Statistical analysis
was done by using SPSS 13.0 version. Descriptive statistics and tests
of correlation were used.
Results
Distribution of sample based on gender, marital status, and educational
status was shown in table 1 to table 3. Both the insight and depression
were more in male population with schizophrenia when compared to
females. Married patients have lesser insight and lesser depressive
ideas than the unmarried patients. Results were suggestive of higher
insight and higher depression in literates when compared to
illiterates. Both insight and depression were low among schizophrenic
patients with age above 40 years when compared to the patients aged
below 30 years. (table4)
Distribution of sample based on the duration of illness was shown in
table 5. Both insight and depression were low among schizophrenic
patients with duration of illness more than 5 years. Insight and
depression were high among schizophrenic patients with duration of
illness less than 2 years.
The correlation between insight and depression in overall sample was
shown table 6. The Pearson correlation coefficient is 0.758 and is
suggesting strong correlation between both variables. It is significant
at 0.01 levels (p value).
Table-1: Distribution of
sample based on gender Dimension.
|
Dimension
|
Variable
|
n
|
Mean of sample
|
Sd
|
t
|
P
|
|
Insight
|
Male
|
28
|
6.46
|
4.359
|
0.468
|
0.642
|
|
|
Female
|
32
|
5.94
|
4.347
|
|
|
|
Depression
|
Male
|
28
|
9.38
|
6.311
|
0.668
|
0.507
|
|
|
Female
|
32
|
8.25
|
6.733
|
|
|
Both the insight and depression were more in male population
with schizophrenia when compared to females.
Table-2: Distribution of
sample based on Marital Status
|
Dimension
|
Variable
|
n
|
Mean
|
Sd
|
t
|
P
|
|
Insight
|
Male
|
28
|
9.73
|
3.312
|
6.221
|
|
|
|
Female
|
32
|
4.13
|
3.434
|
|
0.001
|
|
depression
|
Male
|
28
|
13.45
|
5.894
|
4.779
|
0.001
|
|
|
Female
|
32
|
6.18
|
5.286
|
|
|
Married patients have lesser insight and lesser depressive
ideas than the unmarried patients.
Table-3: Distribution of
sample based on Literacy
|
Dimension
|
Variable
|
n
|
Mean
|
Sd
|
t
|
P
|
|
Insight
|
Literate
|
28
|
9.32
|
3.400
|
6.221
|
|
|
|
illeterate
|
32
|
3.44
|
2.972
|
|
0.001
|
|
depression
|
literate
|
28
|
13.32
|
5.320
|
4.779
|
0.001
|
|
|
Illeterate
|
32
|
4.94
|
4.704
|
|
|
Results were suggestive of higher insight and higher depression in
literates when compared to illiterates
Table-4: Distribution of
sample based on age
|
Dimension
|
variable
|
n
|
Mean
|
SD
|
t
|
p
|
|
Insight
|
below30
|
17
|
|
2.938
|
|
|
|
|
30-40
|
21
|
3.44
|
2.972
|
24.451
|
0.001
|
|
|
above 40
|
22
|
13.32
|
5.320
|
|
|
|
depression
|
below30
|
17
|
4.94
|
4.704
|
|
|
|
|
30-40
|
21
|
7.52
|
5.750
|
17.392
|
0.001
|
|
|
above 40
|
22
|
3.56
|
4.786
|
|
|
Both insight and depression were low among schizophrenic
patients with age above 40 years when compared to the patients aged
below 30 years
Table-5: Distribution of
sample based on Duration of schizophrenic illness
|
Dimension
|
variable
|
n
|
Mean
|
SD
|
t
|
p
|
|
|
<2yrs
|
24
|
9.96
|
2.881
|
|
|
|
Insight
|
2-5yrs
|
19
|
4.74
|
3.194
|
36.065
|
0.001
|
|
|
>5yrs
|
17
|
2.47
|
2.649
|
|
|
|
|
<2yrs
|
24
|
15.17
|
3.608
|
|
|
|
depression
|
2-5yrs
|
19
|
5.21
|
4.404
|
51.501
|
0.001
|
|
|
>5yrs
|
17
|
4.00
|
3.889
|
|
|
Distribution of sample based on the duration of illness was
shown in table 5. Both insight and depression were low among
schizophrenic patients with duration of illness more than 5 years.
Insight and depression were high among schizophrenic patients with
duration of illness less than 2 years.
Table-6: Correlation
between Insight and Depression in overall sample
|
Variables
|
Depression
|
|
Insight
|
0.758**
|
The correlation between insight and depression in overall
sample was shown table 6. The Pearson correlation coefficient is 0.758
and is suggesting strong correlation between both variables. It is
significant at 0.01 levels (p value).
Table-7: Correlation
between Insight and Depression with all variables
|
|
|
N
|
Pearson Correlation
|
Sig.
(2-tailed)
|
Sig. Level
|
|
Gender
|
Male
|
28
|
|
.000
|
0.01
|
|
|
female
|
32
|
.783**
|
.000
|
0.01
|
|
|
<30
|
17
|
|
|
0.01
|
|
Age
|
30-40
|
21
|
|
|
0.01
|
|
|
>40
|
22
|
|
|
0.05
|
|
Area of residence
|
Urban
|
|
.810
|
.000
|
0.01
|
|
rural
|
|
.327*
|
.003
|
0.05
|
|
Educational status
|
literate
|
28
|
|
.000
|
0.01
|
|
Illiterate
|
32
|
|
0.005
|
0.05
|
|
Marital status
|
Married
|
38
|
|
.000
|
0.01
|
|
Unmarried
|
32
|
|
.000
|
0.05
|
|
Duration of illness
|
<2yrs
|
24
|
|
0.012
|
0.01
|
|
2-5 yrs
|
19
|
|
|
0.05
|
|
>5yrs
|
17
|
|
|
0.05
|
In both males and females the correlation between insight
and depression is strong, as given by the Pearson coefficient more than
0.7 with significance at 0.01 levels (Table 7). The influence of age of
patient on the correlation was also well established. In the group with
age less than 30 yrs Pearson coefficient is 0.612 at a 0.01
significance level, whereas in other age group with age more than 40
years Pearson coefficient is 0.576 at a 0.05 significance level. The
residents of urban area have more correlation than rural residents with
Pearson coefficients.
Educational status of patient also shown its influence (Table 7),
literates had more correlation than illiterates with Pearson
coefficients of 0.641 and 0.282 and were significant at 0.01 and 0.05
respectively. Patients who were married have a strong correlation than
unmarried with Pearson coefficients of 0.633 and 0.451 and were
significant at 0.01 and 0.05 respectively. Patients in the early stages
of illness had more correlation than at later stages, as evidenced by
Pearson coefficients of 0.703, 0.229, 0.201 in <2yrs, 2-5yrs and
>5yrs duration of illness groups respectively (Table 7).
Discussion
Poor insight was sometimes seen as just another symptom or
manifestation of the disorder [15]. However, main conceptualisation was
that poor insight represents an individual response to the diagnosis of
schizophrenia and it has a relation to suicidal ideation [16]. Studies
led to the hypothesis that there was a chain of causality from insight,
to demoralisation, to depression, to suicidality [11]. In our study
there was a strong correlation between insight and depression in
schizophrenic population with a Pearson coefficient of 0.758. Our study
results were in accordance with previous studies, which suggest that
better insight is directly related to greater distress [9, 10, 11, 16].
In a study done by Rocca et al, [17] male gender was
associated with an increased severity of depressive symptoms. In
contrary to above study, our results doesn‟t document any difference in
the two genders in strength of correlation as both have >0.7
Pearson coefficient. In our study people residing in urban areas had
stronger correlation than those in rural areas, explicable by more
literacy rate, more exposure and more deficit awareness of the
schizophrenic illness. The distress associated with „deficit
awareness‟ was due to the insight of the practical constraints brought
about by these deficits.
Previous studies reported that depressive symptoms are less frequent in
schizophrenia patients in the chronic period than in the acute period
[18, 19]. Studies on first episode psychosis had shown comparable
higher levels of insight at the onset of illness (60%). A higher
insight during the baseline assessment in a first episode psychosis
patient was positively correlated with a higher prevalence of
depressive symptoms at this time [20]. A higher degree of insight
predicts a higher risk for a subsequent post-psychotic depression and a
higher risk of suicide during the first four years after receiving the
diagnosis of psychosis [21]. Approximately 11% of the first episode
psychosis patients, present self-harm episodes prior to their first
diagnosis with an increased risk associated to male gender, low social
class, depression, a longer Duration of Untreated Psychosis(DUP) and
increased insight [22].
In our study also, the results were suggestive of more correlation as
well as higher mean values of insight and depression in early stages of
schizophrenic illness. As the duration of illness increases the insight
about the illness diminishes and the rate of occurrence of depressive
symptoms also falls down. Age of the patients also had shown similar
trends, because most of the people experience the onset of
schizophrenic illness when they are young.
In our study literate population had a stronger correlation than the
illiterate population, explicable by more deficit awareness but this
finding was in contrary to the study done by Amador et al, who
documented that level of education and level of positive and negative
symptoms of the illness were unrelated to insight, suggesting that
deficits in illness awareness were not a consequence of educational
background [23]. Current study had shown that married subjects had a
lesser mean values of insight and depression than unmarried, but the
correlation between insight and depression was strong in married
subjects. This can be explained by the different coping mechanisms used
by the patients of schizophrenia. Out of the two styles of coping,
“Preference for positive reinterpretation and
growth” coping style correlated with lower distress and with
lower symptom awareness in married subjects who generally have a better
social support. “Social support-seeking” coping
style correlated with greater awareness of illness in unmarried
schizophrenic subjects [24].
Limitations-Our study was a cross sectional study and the patients were
not followed to measure the impact of insight. The results may not be
applicable to a large scale population as the sample size was small.
Treatment pattern of the patients and role of coping mechanisms were
not considered.
Conclusions
Better insight was significantly correlated with lower mood. In
addition, our study suggests that poor insight may protect against
depression in the early stages of recovery from schizophrenia. The
correlation between insight and depression was high in subjects with
less duration of illness. There was a positive cross-sectional
relationship between insight and depression, but the underlying
processes need further clarification.
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Ananda Reddy Endreddy, Subahani Shaik, Bhagawan Rajana. Schizophrenia -
Insight, Depression: A correlation study. Int J Med Res Rev
2016;4(10):1820-1825.doi:10.17511/ijmrr. 2016.i10.18.