Psychiatric Quarterly

https://doi.org/10.1007/s11126-019-09631-6

ORIGINAL PAPER

Insight and Symptom Severity in an Inpatient

Psychiatric Sample

Vincent Rozalski 1,2 & Gerald M. McKeegan

3

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Individuals with a severe mental illness, particularly a psychotic disorder, often lack insight
into having a mental illness. This study sought to examine the differences in insight and
symptom severity between individuals with psychotic, bipolar, and depressive disorders in an
inpatient psychiatric sample. 199 participants were interviewed and medical records were
consulted. Results show that participants with a psychotic disorder had significantly less
insight into their illness, more debilitating symptoms, and reported less depression symptoms
after controlling for education, race, marital status, homelessness, age, gender, and history of
incarceration. Insight was shown to be a mediator between having a psychotic disorder and
symptom severity. Subjective quality of life did not differ by diagnosis. Substance use was not
associated with insight or overall symptom severity, while homelessness was associated with
having a psychotic disorder and more severe symptoms. Fostering insight during an inpatient
stay may be an important part of reducing symptom severity and preventing patient relapse.
However, greater insight may increase depression and suicidality, indicating a need for mood
management and safety planning along with psychoeducation of symptoms.

Keywords Insight . Schizophrenia . Inpatient . Diagnosis . Severity . Psychiatric

Introduction

Lack of insight or the lack of awareness of one’s mental health problems affects 30 to 50% of
patients with a schizophrenia spectrum disorder [1] and is often debilitating [2, 3]. Lack of
insight has been defined as a continuous and multidimensional construct that includes the

* Vincent Rozalski

1
University of Nevada, Las Vegas, Las Vegas, NV, USA
2
Martinez, USA
3
Spectrum Health, Grand Rapids, MI, USA
 Psychiatric Quarterly

following aspects: (1) awareness of having a mental illness, (2) an understanding of the need
for treatment, (3) awareness of the social consequences of mental disorders, (4) awareness of
symptoms, and (5) attribution of symptoms to a mental disorder [4]. Research has shown that
the relationship between the lack of awareness and the various aspects of a serious and
persistent mental disorder is complicated and affected by both aspects of the illness (e.g.,
symptom severity) and psychosocial factors (e.g., years of education, age, etc.). Lack of insight
has been postulated to impair functioning [4–7], quality of life [8], and increases the resistance
and lack of compliance to treatment (particularly psychotropic medications; [8–10]. Lack of
compliance with treatment is often followed by relapse and re-hospitalization [11, 12].
Lack of insight of the behaviors and symptoms associated with a psychiatric disorder has
been found to have a significant effect on clinical presentations. One study showed that the
presence of a high level of insight has been associated with impaired functioning, perception of
a lower quality of life, hopelessness, and depression [13]. It is possible that having an
awareness of having a serious mental illness results in resignation to a lower standard of
living and the giving up of one’s goals and aspirations, which may cause or exacerbate
depression. Depression in schizophrenia is a serious clinical problem as depression increases
the risk of suicide. Suicide rates in people living with schizophrenia are eight times higher than
in the general population, and 20–40% of people with schizophrenia attempt suicide [14].
The assessment of insight has been a subjective aspect of mental status examinations, based
on a clinical interview of undefined depth and intensity. To place more rigor on the assessment
of insight, Amador and colleagues developed the Scale to Assess Unawareness of a Mental
Disorder (SUMD; [15]). Some evidence shows that patients with bipolar disorder did not differ
significantly in the level of insight when compared to patients with schizophrenia [2, 16] and
that insight deficits were worse in psychotic and bipolar disorders compared to those with a
depressive disorder [17]. The results from the Pini, et al. [16] study showed that the assessed
psychosocial functioning of a patient using the Global Assessment of Functioning scale (GAF)
had a direct and significant effect on the level of insight. Thus, those with a psychotic and
bipolar disorder are likely to have worse insight and overall functioning compared to those
with a depressive disorder.
Because of its length (i.e., 17 items), however, the SUMD is seldom utilized in clinical
settings and practice [2]. A shorter version of the SUMD (i.e., 9 items) that can be done within
the time constraints of clinical settings was developed by the same group of authors. The
abbreviated version, the SUMD-A, has been shown to be a valid and reliable instrument to
assess insight in patients with schizophrenia [1]. This instrument has been used by others to
explore insight and medication adherence [8] and in a large clinical study by the developers
[2]. The authors concluded that the SUMD-A can be used in a clinical setting for reliable and
valid assessment of insight.
A review of the literature has shown that the research in which the SUMD has been used
has excluded participants whose psychotic symptoms were the result of intoxication related to
a substance use disorder, have a diagnosed organic disorder, or neurodevelopmental disorder;
some studies excluded all individuals not meeting criteria for a type of schizophrenia (i.e.,
paranoid type; [13]). In addition, the different samples used have been individuals that have
been residing in the community for an unspecified duration [13, 18], recently discharged from
the hospital [19], in remission [20], at-risk outpatients [21], attending a day treatment
program [8], or a mix of outpatients and individuals admitted to a public university
teaching hospital [22]. Studies that utilized a sample that reflects a Bstandard^ urban,
public psychiatric facility where the individuals were assessed shortly after being
Psychiatric Quarterly

admitted are lacking. Pini, et al. [16] did use consecutively hospitalized patients but the
assessments occurred one week prior to discharge when the patients were stable in their
symptoms and medications.
Studies have shown that there is a higher prevalence of substance abuse among persons
who are homeless and have a mental illness [23–25]. Co-occurring disorders can be difficult to
diagnose due to the complexity and severity of symptoms. One report cited that two million
people with mental illness are booked into jails each year, and that nearly 15% of male and
30% of female inmates recently admitted to jail have a serious mental illness [26]. The high
prevalence of substance use and homelessness in a psychiatric population may interact with
lack of insight.
There are several aims to the study. First, we wanted to examine the relationship between
diagnosis, symptom severity, and insight on variables relevant for this clinical population, such
as substance use and homelessness. We hypothesized that insight and symptom severity would
have significant associations with many of these clinical variables, and that substance use and
homelessness would be associated with worse symptom severity and insight. Second, we
aimed to look at the unique impact of diagnosis on clinical variables, including insight,
symptom severity, depression, and quality of life. We hypothesized that individuals with
a psychotic disorder would show greater problems on all measures compared to those
with a depressive or bipolar disorder after controlling for demographic variables.
Finally, we hypothesized that insight would act as a mediator between having a
psychotic disorder and symptom severity.

Method

Participants and Setting

The data collection took place at a state psychiatric facility located in a major metropolitan
city in the southwest area of the country. The city in which the hospital is located is
culturally diverse and one of the most diverse cities in the nation. The hospital has
approximately 120 beds. The average length of stay is less than 21 days. Patients were
all transferred to the hospital from an emergency room. All consecutive admissions on one
40 bed unit consisting of two interdisciplinary teams were assessed. All participants were
18 years of age or older.
Patients were assessed within the first three to five days after being admitted. Exclu-
sionary criteria were limited to exclude persons with severe decompensated
neurodevelopmental disorders (i.e., autism spectrum disorder with intellectual impairment)
and moderate to severe intellectual impairments. Patients were excluded if the person
refused to participate or complete the assessment. All participants provided written
informed consent upon admission. All clinical assessments were performed in routine
practice during treatment team meetings and results were reported back to the members of
the team as part of the routine treatment team review that was done for each working day
(Monday through Friday).
Upon admission into the unit, each participant’s chart was reviewed for admitting diagnoses
and demographics were collected if available. Demographic information that was uncertain or
unavailable during the chart review was obtained during the initial interview after admission or
through collateral information from family members. One of the two authors attended the
 Psychiatric Quarterly

initial treatment review and interview by the interdisciplinary team of each new admission.
The interdisciplinary team consisted of a board-certified psychiatrist, a licensed psychologist,
two licensed social workers and at least one registered nurse.

Measures

Participants were asked about socio-demographic information including ethnicity, living

arrangement, education, existing legal problems, and history and type of incarceration.
Information was gathered by interviewing the participant and available medical records.
Participants were asked clarifying questions regarding clinical characteristics if needed, in-
cluding substance use history and awareness of substance use when admitted into the hospital.
DSM 5 diagnoses were obtained from the admitting paperwork.

Clinical Global Impressions Scale (CGI) The Clinical Global Impressions Scale (CGI; [27]), is
a clinician-rated measurement of overall dysfunction due to illness. The measurement uses a
seven-point scale (1 = normal, 7 = extremely dysfunctional). It has been shown to have good
convergent validity with other assessments of functioning. Participants were assessed in terms
of functioning of several domains: cognitive status, perceptual experiences, mood, and social
functioning.

Calgary Depression Scale for Schizophrenia (CDSS) The Calgary Depression Scale for
Schizophrenia (CDSS; [28]) is a nine-item scale specifically designed for patients with
schizophrenia that evaluates depression independently of extra-pyramidal and negative symp-
toms. It has shown good predictive validity in evaluating depression in individuals with
schizophrenia compared to other instruments focused on depressive disorders.

World Health Organization Quality of Life (WHOQoL-BREF) The World Health Organization
Quality of Life (WHOQoL-BREF; [29]) is a widely used, 26 item self-report measure that
assesses aspects of daily life in four domains: physical health (activities of daily living,
dependence on medical treatment, energy and fatigue, mobility, pain, sleep and work capac-
ity); psychological health (body image and appearance, negative and positive feelings, self-
esteem, spirituality, and concentration); social relationships (personal relationships, social
support, sexual activity); and environment (finances, physical safety, access to health services,
home environment, opportunities to acquire new information, leisure activities, physical
environment, and transport). In addition to the domain scores, an overall score also is
calculated that includes questions regarding self-perceptions of overall well-being and health.
The WHOQoL-BREF has been used in assessing perceived quality of life in patients at risk in
developing a serious mental illness [21].

Subjective Unawareness of a Mental Disorder- Abbreviated (SUMD-A) The Subjective

Unawareness of a Mental Disorder- Abbreviated (SUMD-A) is a standardized nine item scale
based on a patient interview. The SUMD-A assesses current awareness of the following states:
a) having a mental disorder, b) consequences of a mental disorder, c) the effects of psycho-
tropic drugs, d) hallucinatory experiences, e) delusional ideas, f) disorganized thinking, g)
blunted affect, h) anhedonia, and i) lack of sociability. Higher scores represent less insight.
SUMD-A data was obtained during the initial interview or during another interview within
5 days after admission to the unit.
Psychiatric Quarterly

Results

Sample demographics are presented in Table 1. Mean age was 37.05 years. Most participants
were male (56.8%) and nearly half were Caucasian (49.2%); over half of the participants were
never married (66.8%) and nearly one third (31.6%) had some education after graduating from
high school. Forty-five percent were homeless, compared to a report that 33 % of homeless
individuals had a serious mental illness [30]. In addition, nearly two thirds either had past or
present substance abuse (65.8%) and more than half (56.6%) had a positive drug screen for
some type of illegal substance (including cannabis) when admitted. More than half (54.8%)
had a history of being incarcerated; of those reported having been incarcerated, 71% reported
having only been in jail, and not prison.

Table 1 Sample demographics

(N = 199) Age (years) M = 37.05
SD = 12.16
Sex:
Women 86 (43.2%)
Men 113 (56.8%)
Diagnosis:
Psychotic Disorder 130 (65.3%)
Depressive Disorder 38 (19.0%)
Bipolar/Mood Disorder 31 (15.5%)
Ethnicity:
Caucasian 98 (49.2%)
African American 52 (26.1%)
Asian 12 (6.0%)
Hispanic/Latino 31 (15.6%)
Other 6 (3.0%)
Marital Status:
Never Married 133 (66.8%)
Divorced/Separated 51 (25.6%)
Married 15 (7.5%)
Education Level:
Less than 9th grade 14 (7.0%)
Less than 12th grade 58 (29.1%)
High School Graduate 63 (31.6%)
More than high school 63 (31.6%)
Living Situation:
Homeless 90 (45.2%)
With family 53 (26.6%)
With roommates/friends 26 (13.1%)
Supervised living facility 13 (6.5%)
Substance Abuse History:
Present 131 (65.8%)
Absent 68 (34.2%)
Urine Drug Screen results (N = 150):
Positive 82 (56.6%)
Negative 68 (43.4%)
Incarceration History:
Incarcerated 109 (54.8%)
Never Incarcerated 90 (45.2%)
Incarceration Type (N = 104):
Jail Only 74 (71.1%)
Prison or Jail 30 (28.9%)
 Psychiatric Quarterly

Diagnoses were coded into three general categories listed in the DSM 5. The groupings that
were included were Schizophrenia Spectrum and Other Psychotic Disorders, Depressive
Disorders, and Bipolar and Related Disorders.
Correlations between the sociodemographic data and clinical variables are presented in
Table 2. Table 3 presents the correlations between the clinical characteristics, and Table 4
presents the correlations between demographic variables and clinical variables.
Correlation analyses show relationships between the psychosis category and non-Caucasian
race (r = .29, p < .01), less education (r = .15, p < .01), and younger age (r = −.14, p < .05).
Having a diagnosis within the psychotic category was positively correlated with all domains of
subjective well-being and life satisfaction (rs ranging from .20 to .38, ps < .05), and less
awareness of having taken an illegal substance on either the current or a prior admission
(r = .21, p < .05). Having a psychotic disorder was associated with higher total scores on the
SUMD-A (i.e., less insight; r = .47, p < .01) and the CGI (i.e., more severe impact on
functioning; r = .40, p < .01) and negatively associated with the CDSS (i.e., less depression;
r = −.28, p < .01).
Having a diagnosis of Bipolar disorder was associated with less subjective satisfaction in
three domains on the WHOQoL: physical health (r = −.24, p < .01), psychological health (r =
−.21, p < .05), and social relationships (r = −.18, p < .01). A bipolar diagnosis was also
associated with more insight (r = −.52, p < .01) and less severe symptoms (r = −.14, p < .05).
A depressive diagnosis was associated with worse psychological health (r = −.26, p < .01),
greater insight (r = −.34, p < .01), and less severe symptom severity (r = −.30, p < .05).
Having a depressive disorder was associated with lower quality of psychological health
(r = −.26, p < .01), greater awareness of symptoms (r = −.34, p < .05), and less symptom
severity (r = −.30, p < .01). Current depressive symptoms were associated with older age
(r = .19, p < .01), greater insight (r = −.21, p < .01), and with lower quality of life in all four
domains, as well as the total score (rs ranging from −.24 to −.54, ps < .01).
Being homeless was associated with being older (r = −.16, p < .05) and with non-Caucasian
race (r = .15, p < .05). Having a positive urine drug screen for illegal substances upon being
admitted was negatively associated with poorer medication compliance (r = −.18, p < .05).
Being unaware of current or past substance use was associated with less awareness of one’s
mental health problems (r = .36, p < .05), greater symptoms severity (r = .23, p < .01), and
decreased depressive symptoms (r = −.18, p < .05). Having a history of any type of

Table 2 Correlation matrix for examined variables

1 2 3 4 5 6 7 8 9

1. Age –
2. Gender .05 –
3. Education .03 −.18* –
4. Race −.20** −.04 −.16* –
5. Psychosis −.14* −.03 −.15* .29** –
6. CDSS .17* −.14 .02 −.14 −.28** –
7. CGI −.03 .01 −.09 .22* .36** −.12 –
8. SUMD-A −.17* .00 .07 .29** .47** .21** .60** –
9. WHOQoL −.08 .15 −.04 .13 −.15 .01 −.06 −.03 –

* p < .05, ** p < .01. WHOQoL World Health Organization Quality of Life – Brief Total Score, SUMD-A
Subjective Unawareness of a Mental Disorder, Abbreviated, CDSS Calgary Depressions Scale for Schizophrenia,
CGI Clinical Global Impressions Scale
Psychiatric Quarterly

Table 3 Correlation matrix for clinical measurements

1 2 3 4 5 6 7 8 9

1. QoL1 –
2. QoL2 .69** –
3. QoL3 .58** .67** –
4. QoL4 .71** .75** .71** –
5. WHOQoL .84** .88** .82** .94** –
6. SUMD-A .16 .25** .06 .07 −.03 –
7. CDSS −.37** −.54** −.36** −.42** −.24** −.21** –
8. MedComp .10 .20* .14 .14 .06 .09 −.15* –
9. CGI .07 .14 .02 .07 −.06 .59** −12 .08 –

* p < .05, ** p < .01. WHOQoL World Health Organization Quality of Life – Brief Total Score, QoL Domain 1
physical health, QoL Domain 2 psychological health, QoL Domain 3 social relationships, QoL Domain 4
environment, SUMD-A Subjective Unawareness of a Mental Disorder, Abbreviated, CDSS Calgary Depressions
Scale for Schizophrenia, MedComp Medication Compliance, CGI Clinical Global Impressions Scale

incarceration was only positively correlated with symptoms severity (r = .17, p < .05). Indi-
viduals who reported not being homeless (i.e., living with family, in a managed care facility, or
independently by oneself) were more likely to report greater psychological (r = .24, p < .05)
and environmental health (r = .21, p < .05), and overall quality of life (r = .22, p < .05).
Correlations between the clinical measures show positive correlations among the scores of
all the domains of the WHOQoL (rs from .58 to .71, ps < .01). Domain 2 of the WHOQoL
(Psychological Health) was correlated with less insight on the SUMD-A (r = .20, p < .01).
Less insight was strongly correlated with overall symptom severity (r = .59, p < .01) and
negatively correlated with depression symptoms (r = −.21, p < .01). Medication compliance
was also associated with fewer depression symptoms (r = −.15, p < .01).
To test for the effect of diagnosis, a MANCOVA was conducted. The three diagnostic
groups (i.e., psychotic disorders, bipolar disorders, and depressive disorders) were specified as
independent variables in the model. Symptom severity, awareness of symptoms, depression,
and quality of life were specified as dependent variables. Education level, race, marital status,
living situation, age, gender, and history of incarceration were specified as covariates. Results

Table 4 Correlation matrix for clinical measurements with demographics

QoL1 QoL2 QoL3 Qol4 QoLT SUM-D CDSS MedComp CGI

Age −.15 −.24** −.20 −.16 −.08 .17* .17* .02 −.03
Gender .13 .08 .18* .11 .15 .01 −.14 −.01 .01
Education .13 .08 .18* .11 .15 .01 −.02 .13 −.09
Race .16 .25** .20* .15 .13 .29* −.14 .07 .22**
Psychosis .31** .38** .24** .20* .013 .47** −.28** .07 .40**
Bipolar −.24** −.21* −.18* −.15 .03 −.52** .05 −.06 −.14*
Depression −.15 −.26** −.13 −.10 −.04 −.34** .29** −.03 −.30**
SA −.15 −.14 −.04 −.08 −.16 −.06 .12 −.18* −.08
SA Aware .06 .06 .16 .12 −.14 .36** −.18* −.10 .23**
Incarceration .02 −.04 −.03 −.02 −.15 .01 −.06 .01 .17*
Homelessness .15 .24** .07 .21* .22** .01 −.13 .13 −.03

* p < .05, ** p < .01. SA presence of substance abuse, SA Aware awareness of substance abuse, QoL Domain 1
physical health, QoL Domain 2 psychological health, QoL Domain 3 social relationships, QoL Domain 4
environment, QoLT World Health Organization Quality of Life – Brief Total Score, MedComp Medication
Compliance
 Psychiatric Quarterly

revealed a significant effect of diagnosis on symptom severity (F(2, 145) = 5.05, p < .01),
awareness of symptoms (F(2, 145) = 16.43, p < .001), and depression (F(2, 145) = 6.26,
p < .01). Diagnosis did not have an effect on quality of life (F(2, 145) = .89, p = .41).
Separate ANOVAs with planned contrasts were conducted to follow up the results of the
MANCOVA. Diagnosis was identified as the independent variable in all analyses. Contrasts
were conducted using a Bonferroni correction. For symptom severity, contrasts revealed a
significant difference between psychotic disorders (M = 5.08) and both bipolar disorders (M =
4.72, p < .01) and depressive disorders (M = 4.34, p < .001). Results showed that individuals
with psychotic symptoms showed more symptom severity compared to individuals with
depressive and mood disorders.
Contrasts of the awareness analysis revealed a significant difference between psy-
chotic disorders (M = 13.18) and both bipolar disorders (M = 7.46, p < .001) and depres-
sive disorders (M = 7.07, p < .001). Results showed that patients with psychotic disorders
were rated as being less aware of their symptoms and their effects than patients with
either bipolar disorders or depressive disorders. Contrasts of the depressive symptoms
analysis revealed a significant difference between depressive disorders (M = 9.57) and
psychotic disorders (M = 4.71, p < .001). Results showed that individuals with depressive
and mood disorders were more likely to report symptoms associated with depression than
by patients with psychotic disorders.
Awareness of psychiatric symptoms was tested as a mediator between having a psychotic
disorder and symptom severity. Separate correlations between the three variables were found
to be significant (see Table 2), satisfying the first three conditions of a mediator as defined by
Baron and Kenny [31]. Hierarchical multiple regression analysis was used to test the strength
of the relationship between having a psychotic disorder and symptom severity when in the
presence of awareness. In the first step, having a psychotic disorder was associated with greater
symptom severity (beta = .47, p < .001). In the second step, awareness was added a predictor to
the model. When awareness was entered into the model, having a psychotic disorder was no
longer a significant predictor (beta = .08, p = .18). Awareness was significantly associated with
symptom severity in the model (beta = .55, p < .001), indicating full mediation.

Discussion

This study sought to explore the link between diagnosis, insight into one’s own mental health
symptoms, and symptom severity in an urban inpatient psychiatric setting.
Patients who had less awareness of their own psychiatric symptoms were more likely to
have worse overall symptom severity, regardless of diagnosis. Symptom unawareness was also
related to being less aware of having taken illegal substances either in a previous or current
admission. However, having a history of substance abuse was not associated with symptom
severity, indicating that substance use is not a driving force behind unawareness and severe
mental illness.
While having little insight was associated with less awareness of having taken substances
(either in a past or present admission), it was not associated with substance use itself.
Additionally, substance use was only associated with a history of incarceration, having less
education, and being white. The lack of connection between substance use and both insight
and symptom severity suggests that substance use is related more to demographic factors in
this population rather than psychopathology. The lack of connection between substance use
Psychiatric Quarterly

and both insight and symptom severity indicate that substance use is not a driving force behind
why severely mentally ill patients struggle with insight and debilitating symptoms.
When insight and symptom severity were examined by diagnosis, patients with any
psychotic disorder exhibited greater unawareness of their illness and greater symptom severity
compared to patients with non-psychotic disorders after controlling for age, gender, race,
substance use history, education, and homelessness. This is in line with previous research
that found individuals with schizophrenia had worse insight into their symptoms than
those with bipolar disorder [32]. This finding speaks to the unique and debilitating
impact of psychotic symptoms. Complex psychosocial variables can greatly hinder
recovery and stability for a variety of reasons, but successful treatment of psychotic
symptoms and fostering insight may be a crucial first step in addressing issues of
substance use and homelessness in this population.
Awareness was found to fully mediate the relationship between having a psychotic disorder
and symptom severity. Individuals with psychotic disorders may be more prone to having their
symptoms debilitate their functioning as they may attribute their lack of functioning to other
sources (e.g., delusions, hallucinatory content). Emphasis on psychoeducation may be espe-
cially important for those who have a psychotic disorder.
Quality of life was negatively associated with depressive symptoms. After controlling for
psychosocial variables, quality of life was not associated with insight, general symptom
severity, or diagnosis. It is possible that individuals with psychotic disorders are so out of
touch with reality (as indicated by their high unawareness of symptoms and general symptom
severity) that they may not perceive their quality of life as being diminished. Additionally, our
population was comprised of individuals often receiving treatment against their will. A
population of patients with psychotic disorders that have shown treatment adherence and
stability may show differences in perspective of quality of life. With regard to patients with
bipolar disorder, it is likely that individuals in an active manic phase may also overinflate their
quality of life compared to those in a depressive state.
Quality of life was negatively associated with depressive symptoms, but those with a
depressive disorder did not overall endorse a worse quality of life after controlling for
demographic variables. The lack of connection between quality of life and having a depressive
disorder implies that other factors (e.g., homelessness, substance use) may better explain the
link between quality of life and depression in an inpatient population. The basic needs of this
sample were complex, and stress from a variety of areas may be reducing quality of life
significantly more than current depression.
Depression is often seen in schizophrenia. However, individuals with a psychotic disorder
in our sample were less likely to report depressive symptoms than those with other diagnoses.
It is possible that individuals with a psychotic disorder have fewer depressive symptoms when
they are in an episode of care that requires inpatient hospitalization. This is congruent with
research that found that greater insight increases depression, self-stigma, hopelessness [33] and
suicidality [34] in those with a schizophrenia diagnosis. Those with a psychotic disorder who
are in an inpatient episode of care should be given skills to manage depression and safety
planning that are necessary after insight increases.
These results have several important implications. Patient education may be an important
part of recovery, as increasing insight into mental health symptoms may reduce overall
symptom severity, regardless of diagnosis and specific symptoms. Patients who are unaware
of their diagnosis and symptoms will likely go longer without treatment and disagree about
needing treatment in the first place. Some patients may not have insight into when symptoms
 Psychiatric Quarterly

get worse, and may not get treatment until well into an episode (e.g., not recognizing early
signs of mania or depression). Education of signs and symptoms of how severe episodes start
may decrease overall symptom severity and reduce the number of hospitalizations. However, it
is important to note that greater insight may result in greater depression and thoughts of suicide
in those with a psychotic disorder, and so coping skills for depression are crucial during an
inpatient episode of care for this population.
This study also suggests a diminished role of substances and insight. Despite their mind-
altering effects and interactions with psychopathology, this sample did not show a significant
association between substances and either insight or symptom severity. However, there were
significant correlations with being white, homeless, and having been incarcerated. While
substance abuse should remain an important target of treatment, substance use seems to be
tied in with systemic and demographic problems that are often beyond the scope of treatment
for an inpatient psychiatric hospital. This suggests that referrals to quality resources, especially
around homelessness and being an ex-offender, are crucial for discharge planning.
There were several limitations to this study. This study used cross-sectional data, and so we
cannot say how insight changed over time. Participants were interviewed quickly after
admission due to the high census turnaround, so participants may have given different
responses if they were interviewed closer to discharge when they have regained some stability
and had a satisfactory discharge plan.

Compliance with Ethical Standards

Conflict of Interest Drs. Rozalski and McKeegan declare that we have no conflict of interest.

Ethical Approval All procedures performed in studies involving human participants were in accordance with
the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent was obtained from all individual participants included in the study.

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and
institutional affiliations.

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Dr. Vincent Rozalski is a psychology postdoctoral fellow in Behavioral Medicine with the VA Northern
California Health Care System.

Dr. Gerald McKeegan is a licensed clinical psychologist with the Spectrum Health organization.