You have a patient who has been diagnosed with schizophrenia or schizoaffective disorder. His hospitalization was court mandated after he committed a violent act that was linked to his psychotic illness. Positive psychotic signs and symptoms have been attenuated secondary to treatment with an oral antipsychotic. But the patient lacks insight. You have been called to testify on suitability for release. What evidence-based psychiatric testimony can you offer?
Does insight play a role in medication compliance, and thus risk for relapse?
Using PubMed (www.pubmed.gov), Clinical Queries is selected, along with Prognosis and Sensitivity. "Insight and medication compliance in schizophrenia" is entered into the subject search. For a tutorial on PubMed, including an explanation of terms used, see Mayo Clinic Proceedings (78:87-91, 2003).
Using Medline, the following key words were combined in a search: schizophrenia, psychotic illness, patient compliance, insight, and awareness.
The 1-year relapse rate of patients with schizophrenia on maintenance treatment is 10%-30%, depending on the degree of treatment optimization. Up to 70% of patients not receiving maintenance treatment will relapse (J. Clin. Psychiatry 63:1121-28, 2002). Dr. Jose Luis Ayuso-Gutierrez has suggested that the most important factor related to relapse of patients with schizophrenia is medication noncompliance (Schizophr. Res. 28[2-3]:199-206, 1997).
Medication noncompliance is a multifaceted problem, but what role if any, does lack of insight play? Insight is an abstract notion relating to the patient's understanding of his illness. Part of this understanding is awareness of having an illness, understanding the symptoms of that illness, and understanding the need for treatment (J. Am. Acad. Psychiatry Law 27:33-49, 1999).
Dr. Bill Budd and his colleagues published a paper suggesting that insight was not related to medication compliance. The study group was prescribed depot antipsychotic formulations, thus weakening the authors' conclusions (Br. J. Clin. Psychol. 35[Pt. 3]:393-97, 1996). J. Garavan and colleagues came to a similar conclusion for a selected group of outpatients suffering with schizophrenia. Again, regular compliers were more likely to be treated with a depot medication (Compr. Psychiatry 39:215-19, 1998). Coming in with a more temperate conclusion, Xavier Amador, Ph.D., and his colleagues found that patients with no insight often comply with treatment (Am. J. Psychiatry 150:873-79, 1993).
Most of the evidence, however, suggests that the more insight a patient has, the more likely he is to be compliant with treatment. …