title: The "Insight Paradox" in Schizophrenia: Magnitude, Moderators and Mediators of the Association Between Insight and Depression.
abstract: The so-called "insight paradox" posits that among patients with schizophrenia higher levels of insight are associated with increased levels of depression. Although different studies examined this issue, only few took in account potential confounders or factors that could influence this association. In a sample of clinically stable patients with schizophrenia, insight and depression were evaluated using the Scale to assess Unawareness of Mental Disorder and the Calgary Depression Scale for Schizophrenia. Other rating scales were used to assess the severity of psychotic symptoms, extrapyramidal symptoms, hopelessness, internalized stigma, self-esteem, and service engagement. Regression models were used to estimate the magnitude of the association between insight and depression while accounting for the role of confounders. Putative psychological and sociodemographic factors that could act as mediators and moderators were examined using the PROCESS macro. By accounting for the role of confounding factors, the strength of the association between insight into symptoms and depression increased from 13% to 25% explained covariance. Patients with lower socioeconomic status (F = 8.5, P = .04), more severe illness (F = 4.8, P = .03) and lower levels of service engagement (F = 4.7, P = .03) displayed the strongest association between insight and depression. Lastly, hopelessness, internalized stigma and perceived discrimination acted as significant mediators. The relationship between insight and depression should be considered a well established phenomenon among patients with schizophrenia: it seems stronger than previously reported especially among patients with lower socioeconomic status, severe illness and poor engagement with services. These findings may have relevant implications for the promotion of insight among patients with schizophrenia.
authors.affiliation: Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genova, Italy; Department of Psychological Medicine, King's College London, London, UK; These authors contributed equally to this work. martino.belvederi@gmail.com.
authors.forename: Martino
authors.initials: M
authors.lastname: Belvederi Murri
authors.affiliation: Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genova, Italy; These authors contributed equally to this work.
authors.forename: Mario
authors.initials: M
authors.lastname: Amore
authors.affiliation: Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genova, Italy;
authors.forename: Pietro
authors.initials: P
authors.lastname: Calcagno
authors.affiliation: Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genova, Italy;
authors.forename: Matteo
authors.initials: M
authors.lastname: Respino
authors.affiliation: Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genova, Italy;
authors.forename: Valentina
authors.initials: V
authors.lastname: Marozzi
authors.affiliation: Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genova, Italy;
authors.forename: Mattia
authors.initials: M
authors.lastname: Masotti
authors.affiliation: Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genova, Italy;
authors.forename: Michele
authors.initials: M
authors.lastname: Bugliani
authors.affiliation: Department of Human Sciences, European University of Rome, Rome, Italy;
authors.forename: Marco
authors.initials: M
authors.lastname: Innamorati
authors.affiliation: Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy;
authors.forename: Maurizio
authors.initials: M
authors.lastname: Pompili
authors.affiliation: Department of Psychiatry, University of Naples SUN, Naples, Italy.
authors.forename: Silvana
authors.initials: S
authors.lastname: Galderisi
authors.affiliation: Department of Psychiatry, University of Naples SUN, Naples, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Maj
mesh_terms: D000328:Adult; D001364:Awareness / Q000502:physiology*; D003863:Depression / Q000503:physiopathology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D012559:Schizophrenia / Q000503:physiopathology*; D012565:Schizophrenic Psychology; D012649:Self Concept; D012647:Self-Assessment; D012720:Severity of Illness Index; D012923:Social Class
keywords: depression; insight; negative symptoms; schizophrenia; stigma; suicide