Better Insight Predicts Worsening and Suicidality in Schizophrenia

OK to Lower Antipsychotics in Older Schizophrenia Patients
OK to Lower Antipsychotics in Older Schizophrenia Patients
New research suggests a temporal cascade from QoL to suicidality via depression in patients with schizophrenia.

Higher insight detrimentally affects the quality of life (QoL), depression, and suicidality in patients with schizophrenia, and it may suggest a temporal sequence, according to a study published in the Journal of Clinical Medicine.

In this multicenter, longitudinal study, researchers measured QoL, depression, and suicidality in clinically stable patients aged 15 to 65 years who were recruited into the FondaMental Academic Centers of Expertise for Schizophrenia (FACE-SZ) cohort between March 2010 and June 2017 (N=738). After being interviewed by senior psychiatrists or psychologists, patients were diagnosed with schizophrenia, schizoaffective disorder, or schizophreniform disorders based on the structured clinical interview for assessing Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision criteria.

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Patients were evaluated at inclusion and 1 year later; insight was assessed using both self-report and clinician-rated scales. Higher Birchwood Insight Scale (BIS) scores and lower Scale to assess Unawareness of Mental Disorder (SUMD) scores indicated better insight. Insight was defined as a latent variable with 3 indicators: BIS total score, mean of the 3 general items of the SUMD, and Positive And Negative Syndrome Scale item G12.

After the first evaluation, 370 patients completed the study after 368 (49.9%) dropped out. Baseline levels of insight predicted changes in suicidality, but baseline levels of suicidality did not predict changes in insight. This finding indicates that better insight underlies suicidality and predicts its worsening, which suggests an apparent temporal sequence of better insight leading to worse QoL, leading to increased depression and suicidality. Insight also affects the 3 variables in parallel.

Limitations of this study include a sample of clinically stabilized patients who were not randomly selected, which may mean that the results are not generalizable to the general population of patients with schizophrenia spectrum disorders. The characteristics of the sample were correlated with previous studies in terms of insight, thus improving generalizability with the population with stabilized schizophrenia spectrum disorders. Nearly half of the included patients were lost in follow-up with no survey to investigate reasons for dropping out. Researchers did not control for the presence of substance use disorders or distinguish between patients with schizophrenia, schizoaffective disorder, schizophreniform disorder, or patients with first-episode psychosis.

The researchers suggested a temporal cascade from QoL to suicidality via depression in patients with schizophrenia. This calls for monitoring of adverse effects of insight-targeted interventions by combining them with preventive strategies for depression. Such interventions should not be proposed to patients with major depression.


Ehrminger M, Urbach M, Passerieux C, et al. Modeling the longitudinal effects of insight on depression, quality of life and suicidality in schizophrenia spectrum disorders: results from the FACE-SZ cohort [published online August 10, 2019]. J Clin Med. doi: 10.3390/jcm8081196