The concept of insight, as it applies to psychiatric illness, has long been considered important for engagement in treatment, psychotherapeutic progress and good prognosis¹

Although the concept is widely used in psychiatry, theoreticians, research scientists and clinicians alike have long debated its definition²

1. Greenfeld et al. Schizophrenia Bulletin 1989; 15:245-252

2. Goldberg et al. Journal of Nervous and Mental Disease 2001; 189:137-145

Insight can be defined as a patient’s degree of awareness and understanding about being ill³

Insight also often refers to the patient’s ability to recognize themselves as having a mental illness, their capacity of self-observation with self-knowledge about their psychopathological experiences, and awareness of the kind, severity and consequences of their mental disorder⁴

3. Kaplan & Saddock. Synopsis of Psychiatry 8^th Edition 1998;254

4. Sanz et al. Psychological Medicine 1998; 28:437-446

It has been frequently reported that patients with psychotic disorders usually have poor insight into their illness⁵. Studies have shown that usually more than 50% of the studied population have poor to moderate insight

These patients appear to deny, fail to acknowledge, or lack awareness of having a mental disorder or symptoms of a mental disorder⁶

5. Amador et al. Schizophrenia Bulletin 1991;17:113-132

6. Amador et al. American Journal of Psychiatry 1993; 150:873-879

The objective of this study is to describe the demographic data and also to assess the level of insight of inpatients who have been diagnosed to have Schizophrenia

This study is a cross-sectional descriptive study of patients who have been admitted to Hospital Permai.

Hospital Permai is a 2050 bedded psychiatric institution with a current occupation of 1400 patients, situated in Tampoi, Johor

Its catchment areas include Johor, Pahang, Kelantan, Terengganu, Negeri Sembilan and Melaka

The study will include all patients with Schizophrenia that were admitted to Hospital Permai from 1^st July, 2002 until 31^st July, 2002.

The patients that were admitted during that time have to fulfill the diagnoses of Schizophrenia, diagnosed by the treating doctors in Hospital Permai based on the Diagnostic & Statistical Manual-IVth Edition (DSM-IV)⁷

1. Aged 18 years and above

2. Able to give an informed verbal consent

3. Willing to participate in the study

4. Fulfilling the diagnosis of Schizophrenia according to DSM-IV

5. Inpatient at Hospital Permai

6. Able to understand Bahasa Malaysia, English or Mandarin

1. Below 18 years of age

2. Unable to give an informed verbal consent

3. Unwilling to participate in the study

4. Not fulfilling the diagnosis of Schizophrenia

5. Not an inpatient of Hospital Permai

6. Unable to understand Bahasa Malaysia, English or Mandarin

7. Acutely ill or psychotic patient

The questionnaire was constructed by McEvoy et al⁸. It consists of 11 questions and it’s rated by the interviewer.

It’s based on questions relating to;

It consists of a semistructured interview from which 11 items are scored from 0 (no insight) to 2 (good insight)

Each question is given a score from 0-2 and the scores are totaled. Poor insight has a score from 0-7, fair insight 8-14 and good insight 15-22

The questionnaire was conducted by the same interviewer for all the patients. The assessment of the patients was carried out during the first week of August

From the 1^st July 2002 till 31^st July 2002, there was a total of 158 patients with mental disorder that were admitted to Hospital Permai

Out of the 158 patients that were admitted during that time, 98 patients were diagnosed to have Schizophrenia according to DSM-IV⁷ by the treating doctors

Previous work has suggested that poor insight may have significant predictive power with respect to the long-term course of psychotic disorders and may have an impact on compliance with treatment regimes

The results of this study indicate that over half of the patients with Schizophrenia (54%) had moderate to poor insight of having a mental disorder

27% of the subjects had very poor insight and another 27% had only moderate insight. The results indicate that poor insight is a prevalent feature of schizophrenia

This finding is in agreement with the other studies ^9,10,11 where a majority of patients with schizophrenia appear to be unaware of having a mental disorder

High rates of non-compliance and relapse among patients treated only with medication renewed interest in psychological and psychosocial issues¹².Therefore, the treatment of schizophrenia involves more than mere pharmacological treatment. It also involves psychosocial modalities

9. Amador et al. Archives of General Psychiatry. 1994; 51:826-836

10. WHO: Report of the International Pilot Study of Schizophrenia. Geneva, Sweden. WHO Press .1973

11. Wilson et al. Comprehensive Psychiatry. 1986; 27:259-265

12. Kane JM. Journal of Clinical psychiatry. 1983;44-3-6

Comprehensive treatment programs (which include psychosocial modalities) for the treatment of schizophrenia are superior to medication treatment alone ¹³

13. Kaplan & Saddock. Comprehensive Textbook of Psychiatry-6^th Edition. 1995;997-998

14. Falloon et al. New England Journal of Medicine. 1982; 306:1437-1440

15. Leff et al . British Journal of Psychiatry. 1989; 154:58-66

Approaches include use of psychoeducational workshops for patients and families, multiple family groups, social skills training and vocational rehabilitation

Utilization of such approaches can significantly reduce the relapse rates of patients with schizophrenia

Does the conception of insight merit so much research?

David et al¹⁶ listed reasons why it is so: it may influence treatment compliance and affect the likelihood of symptomatic and social recovery

16. David et al. British journal of Psychiatry. 1995; 167:621-628

Psychiatrists and psychiatric staff are largely proactive individuals and they are continually doing their utmost for the betterment of patient-care, as are the medical staff of other disciplines

Hospital Permai was aware that it is important to incorporate psychosocial intervention in the patient’s treatment. The patients with severe psychotic illnesses usually have poor insight and therefore their compliance is at times questionable and thus jeopardizing the treatment outcome.

Therefore with a comprehensive treatment program, it is hoped that the patients’ treatment outcome will improve

Steps were taken and strategies were formed to tackle this potential dilemma

A few programs were started for the patients;

1. Greenfeld D, Strauss JS, Bowers MB, Mandelkern M: Insight and interpretation of illness in recovery from psychosis. Schizophrenia Bulletin 1989; 15:245-252

2. Goldberg RW, Green LD, Lehman AF, Gold JM: Correlates of insight in serious mental illness. Journal of Nervous and Mental Disease 2001; 189:137-145

3. Kaplan and Saddock: Synopsis of Psychiatry 8^th Edition 1998; 254

4. Sanz M, Constable G, Lopez-Ibor I,Kemp R, David AS: A comparative study of insight scales and their relationship to psychopathological and clinical variables. Psychological Medicine 1998; 28:437-446

5. Amador XF, Strauss DH, Yale SA, Gorman JM: Awareness of illness in schizophrenia. Schizophrenia Bulletin 1991; 17:113-132

6. Amador XF, Strauss DH et al: Assessment of insight in Psychosis. American Journal of Psychiatry 1993; 150:873-879

7. Diagnostic and Statistical Manual of Mental Disorder – 4^th Edition

8. McEvoy JP, Apperson LJ, Applebaum PS, Ortlip P, Brecosky J, Hammill K, Geller JL, Roth L: Insight into schizophrenia. Its relationship to acute psychopathology. Journal of Nervous and Mental Disease 1989a; 177: 43-47

9. Amador XF, Flaum M, Andreasen NC et al: Awareness of illness in schizophrenia and schizoaffective and mood disorders. Archives of General Psychiatry 1994; 51:826-836

10. World Health Organization: Report of the International Pilot Study of Schizophrenia. Geneva, Sweden. WHO Press 1973

11. Wilson WH, Ban TA, Guy W: Flexible system criteria in chronic schizophrenia. Comprehensive Psychiatry 1986; 27:259-265

12. Kane JM: Problems of compliance in the outpatient treatment of schizophrenia. Journal of Clinical Psychiatry 1983; 44:3-6

13. Kaplan & Saddock: Comprehensive textbook of Psychiatry 6^th Edition 1995; 997-998

14. Falloon IRH, Boyd JL, McGill CW et al: Family management in the prevention of exacerbations of schizophrenia. New England Journal of Medicine 1982; 306:1437-1440

15. Leff J, Berkowitz R, Shavit N et al: A trial of family therapy vs a relatives group for schizophrenia. British Journal of Psychiatry 1989;154:58-66

16. David et al: Insight into psychotic illness: cross-sectional and longitudinal associations. British Journal of Psychiatry 1995; 167-621-628