The role of subjective illness beliefs and attitude toward recovery within the relationship of insight and depressive symptoms among people with schizophrenia spectrum disorders.

OBJECTIVE: Low levels of insight are a risk factor for treatment nonadherence in schizophrenia, which can contribute to poor clinical outcome. On the other hand, high levels of insight have been associated with negative outcome, such as depression, hopelessness, and lowered quality of life. The present study investigates mechanisms underlying the association of insight and depressive symptoms and protective factors as potential therapeutic targets. METHODS: One hundred and forty-two outpatients with schizophrenia or schizoaffective disorder (35.2% women, mean age of 44.83 years) were studied using questionnaires and interviews to assess insight, depressive symptoms, recovery attitude, and illness appraisals with regard to course, functional impairments, and controllability. Psychotic and negative symptoms were assessed as control variables. The cross-sectional data were analyzed using structural equation models and multiple linear regression analyses with latent variables. RESULTS: Higher levels of insight and psychotic symptoms were associated with more depressive symptoms. The association of negative symptoms with depressive symptoms was not significant. The relationship between insight and depressive symptoms was mediated by the participants' perception of their illness as being chronic and disabling, as well as suppressed by their expectation of symptom control due to treatment. Finally, the association of insight and depressive symptoms was less pronounced in the patients with a positive recovery attitude than in those without this protective factor. CONCLUSIONS: To achieve recovery, which includes symptom reduction, functional improvement, and subjective well-being, it is necessary to prevent depressive symptoms as indicators of a demoralization process, which may arise as a consequence of growing insight. Possible treatment strategies focusing on changes of dysfunctional beliefs about the illness and the self and inducing a positive recovery attitude are discussed.