Greater insight is related to improved course of schizophrenia , improved social functioning [2-3], decreased rates of rehospitalization, and improved treatment adherence [4-5] but also to greater hopelessness, depressive symptoms [1,6], and suicide risk [7-8]. We previously reported that middle-aged and older people with schizophrenia who received group cognitive-behavioral social skills training (CBSST) had significantly greater self-reported everyday functioning and coping skills knowledge than those who received treatment as usual (TAU) . Improvements in everyday functioning and coping skills knowledge were maintained in the CBSST group compared with the TAU group at 12-month posttreatment follow-up .
The present study was a secondary analysis that sought to determine whether insight moderated the effect of CBSST on treatment outcomes in our clinical trial . Given previous research demonstrating that greater insight is generally related to improved treatment outcomes in schizophrenia, we predicted that greater insight would moderate the effects of CBSST on functional outcomes. We suspected that the effectiveness of different treatment elements, from identifying dysfunctional performance beliefs to practicing social role playing, on functional outcomes would be affected by the level of awareness of having a mental illness that requires treatment. Specifically, individuals with greater awareness of illness may be more able to recognize their own maladaptive thoughts and social skills deficits that limit everyday functioning and may be more motivated to use skills taught in CBSST to improve their lives. Furthermore, since insight is a multidimensional construct, we wished to determine whether specific domains of insight (awareness of illness, relabeling of symptoms, or need for treatment) predicted benefit from CBSST. Building on prior research linking insight to hopelessness in schizophrenia [1,6] and a growing literature on the impact of cognitive-behavioral therapy (CBT) for psychosis on hopelessness (for a review, see Wykes et al. ), we analyzed post hoc the role of hopelessness in the relationship between insight and functioning in CBSST to better understand the varying impact of greater insight on course of schizophrenia. Individuals who better understand their illness and lack hope in their ability to improve their lives may be less motivated to use the skills taught in CBSST to improve their everyday functioning.
Community-dwelling middle-aged and older people (mean age 53 years; range 42-72 years) diagnosed with schizophrenia or schizoaffective disorder based on the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition  were recruited between 1999 and 2003 from treatment and residential settings through the University of California, San Diego, Advanced Center for Interventions and Services Research for Psychosis in Older Adults. Principal findings from this sample have been previously reported, including raw data for the outcome measures [9-10]. A subset (n = 62) of the total sample (N = 76) with complete insight ratings at baseline and 12-month follow-up is included in this article. No significant differences were found between participants included in this subsample and those excluded with respect to demographic variables (age, age of onset of illness, duration of illness, education, race [white vs other], residence [board and care vs other], sex) or clinical ratings (level of insight, everyday functioning, depressive symptoms).
The San Diego Human Subjects Committee of the University of California approved this study. We obtained written informed consent from all participants. The study was a clinical trial in which participants (76% male; 78% Caucasian) were randomized to either TAU (n = 31) or TAU plus CBSST (hereafter referred …