Patient-Rated Insight Lower Than Clinician-Rated Insight in Schizophrenia

In schizophrenia, insight as rated by patients is not responsive to antipsychotic treatment, and should be considered a trait feature of the illness, according to new study.

Among patients with first-time episodes of schizophrenia spectrum disorders, self-rated insight improvements were much lower than clinician-rated insight improvements, even with noted progress in the areas of psychopathology, functionality, quality of life, neurological signs, and cognition, according to a study published in Schizophrenia Research.

Researchers analyzed changes in insight, both patient-rated and clinician-rated, from the first episode of schizophrenia spectrum disorder through 24 months of flupenthixol decanoate depot treatment. Treatment consisted of 1-week oral dosage of flupenthixol, followed by injections of flupenthixol decanoate every other week. Patient evaluations included the Birchwood Insight Scale, the Positive and Negative Syndrome Scale, and other clinical assessments.

Of the 105 patients recruited from first hospital admissions and community clinics in greater Cape Town area in South Africa, 74% were male, 77% were mixed ethnicity, and the mean age was 24.5 years old. The majority of the patients were diagnosed with schizophrenia (n=70), the mean untreated psychosis time period was 37 weeks, and the Positive and Negative Syndrome Scale indicated patients were moderately to markedly ill. Pronounced deficits in functionality, quality of life, neurological signs, and cognition were found at baseline.

Improvements were found from baseline to 6 months in the Positive and Negative Syndrome Scale (<.0001) and from baseline to 1 year in the Birchwood Insight Scale Need for Treatment subscale (=.01). According to general regression models, the Calgary Depression Scale for Schizophrenia score was an independent baseline predictor of end point patient-insight measures of the Birchwood Insight Scale total (=.008).

Future research needs to further analyze the complex role that cross-cultural factors play in the clinical assessment of insight, evaluate how education level impacts Birchwood Insight Scale interpretation, and assess if clinician-rating relies more on illness improvement than insight.

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The researchers concluded “there were minimal improvements in patient-rated insight, while clinicians rated highly significant improvements in global insight,” and “poor self-rated insight persisted in the majority of patients” after 24 months of treatment.

Disclosures: Bonga Chiliza has received speakers’ fees from Cipla, Lundbeck, and Sanofi. Robin Emsley has received speakers’ fees and participated in advisory boards from Janssen, Lundbeck, Servier and Otsuka, and has received research funding from Janssen and Lundbeck.


Phahladira L, Asmal, L, Kilian S, et al. Changes in insight over the first 24 months of treatment in schizophrenia spectrum disorders [published online October 29, 2018]. Schizophr Res. doi: 10.1016/j.schres.2018.10.013