Do treatments change insight in psychotic disorders? Schiz Res.March. 2013

18.04.2013

Psychotic disorders are marked by  lack of insight/ poor insight  in to the illness.Poor insight negatively affects adjustment, recovery,engagement and relationships. Insight ( the awareness of having a mental disorder and being able to recognise the symptoms and  the need for treatment or help from others) , though extremely important in the recovery process, is seldom addressed as primary outcome measure in research. Symptom improvement do not necessarily mean regain of insight.It could be a domain that is relatively independent of symptom improvement. Previous review on change in insight during treatments by  Henry and Ghaemi (2004) highlighted lack of studies in this area. Has the scene changed since then? Pijnenborg GH, van Donkersgoed RJ, David AS and Aleman A (Netherland and UK) report the results of a met analysis on this question.

The authors  included only randomised controlled trials in patients with schizophrenia or another psychotic disorder where insight was assessed with a validated measure. Search yielded 350 abstracts, 30 met the initial inclusion criteria. 19 studies were selected in the treatment effect analysis.

The mean weighted effect size of all studies on treatment-effects insight in psychosis together is 0.34 (95% CI = 0.12–0.57) . This is a medium effect size. No  publication bias was observed. Heterogeneity ( ie studies report a wide range of results ) of intervention effect was observed.

Interventions studied include CBT,Psycho-education,Adherence therapy ,Social skills training ,Video self-observation and Comprehensive Interventions.Three  of these encompassed at least 3 studies (CBT, psycho-education and adherence therapy). The ES for CBT was small, there was no significant effect for  psycho-education (may be due to a lack of power i.e. due to very small sample size ) and adherence therapy did not have an effect.There was only one medication(McEvoy et al., 2006) study and effect size after twelve weeks was small.

Two studies that examined comprehensive interventions (combination of psycho-education, skills training and CBT) showed  a large ES and are thus considered promising.

A few studies have looked at the effect of clozapine on insight. These studies did not use a randomized controlled design and was not included in this analysis.

Limitations: few studies,small sample sizes.

Conclusions:  Available evidence supports the possibility of improving insight with interventions.

Statistical bit: Effect size is used to quantify the difference between two groups ( control vs experimental) .ie  how much is the size of the difference?.  It is the standardised mean difference between the two groups. An Effect size of  .3 would mean that 62%  of control group participants would be below the average person in experimental group.

Summary of the article

Changes in insight during treatment for psychotic disorders: a meta-analysis.

Pijnenborg GH, van Donkersgoed RJ, David AS, Aleman A.Schizophr Res. 2013 Mar;144(1-3):109-17

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