Comorbid psychiatric disorders and long-term survival after liver transplantation in transplant facilities with a psychiatric consultation-liaison team: a multicenter retrospective study.

OBJECTIVE: Comorbid psychiatric disorders negatively affect the survival rate of patients with some physical disorders. In liver transplant recipients, various psychiatric disorders have been identified as worsening prognosis. However, little is known about how the presence of any comorbid (overall) disorders affect the survival rate of transplant recipients. In this study, we examined the effect of overall comorbid psychiatric disorders on survival rate in liver transplant recipients. METHODS: A total of 1006 recipients who underwent liver transplantation between September 1997 and July 2017 across eight transplant facilities with a psychiatric consultation-liaison team were identified consecutively. Recipients were categorized into those with comorbid psychiatric disorders and those without comorbid psychiatric disorders. In the comorbid psychiatric disorder group, psychiatric disorder diagnosis and time of diagnosis were investigated retrospectively. RESULTS: Of the 1006 recipients, 294 (29.2%) had comorbid psychiatric disorders. Comorbid psychiatric disorders in the 1006 recipients were insomnia (N = 107, 10.6%), delirium (N = 103, 10.2%), major depressive disorder (N = 41, 4.1%), adjustment disorder (N = 19, 1.9%), anxiety disorder (N = 17, 1.7%), intellectual disability (N = 11, 1.1%), autism spectrum disorder (N = 7, 0.7%), somatic symptom disorder (N = 4, 0.4%) schizophrenia (N = 4, 0.4%), substance use disorder (N = 24, 2.4%) and personality disorder (N = 2, 0.2%). The most common time of psychiatric disorder diagnosis was within the first 3 months after liver transplantation (51.6%). The final mortality in patients with comorbid psychiatric disorder diagnosis during the five periods (pretransplant, transplant to 3 months, months to 1 year, 1 to 3 years, and over 3 years posttransplant) was 16.2%, 18.8%, 39.1%, 28.6%, and 16.2% respectively, and there were no significant differences between the five periods (χ2 = 8.05, df = 4, p = 0.09). Overall comorbid psychiatric disorders were significantly associated with shorter survival time (log-rank test: p = 0.01, hazard ratio: 1.59 [95% confidence interval: 1.14-2.21], survival rate at the endpoint [%]: 62.0 vs. 83.3). However, after adjusting for confounding variables using Cox proportional hazards regression, there was no significant effect of overall comorbid psychiatric disorders on prognosis. CONCLUSION: Comorbid psychiatric disorders did not affect the survival rate of liver transplant recipients in this study.

[A multicenter study regarding schizophrenia patients' notification of the diagnosis].

Over 10 years have passed since the Japanese term for "schizophrenia" was changed from "seishin-bunretsu-byo" to "togo-shiccho-sho" in 2002. An awareness survey targeting doctors suggested that notification of the diagnosis has been encouraged since the Japanese name for schizophrenia was changed. However, no heuristic surveys targeting patients themselves have clarified an increased notification rate, and no multicenter studies of the notification rates have been conducted in recent years. This study targeted schizophrenia patients and their attending physicians to investigate the status of notification of the diagnosis at five medical facilities in Hokkaido, Japan. Questionnaires were distributed to the attending physicians of a total of 869 patients; in addition, the patients themselves filled out questionnaires. Questionnaires were collected from 858 physicians, and valid responses were recovered from 529 patients. This study investigated the status of notification of the diagnosis and compared the attributes of patients who were notified (notified group) with those of patients who were not notified (un-notified group). The results of the survey of attending physicians regarding notification of the diagnosis of schizophrenia indicated that a total of 65.0% patients had been notified, with 63.1% of patients being notified that they had "togo-shiccho-sho" and 2.0% of patients being notified that they had "seishin-bunretsu-byo." Physicians were unsure whether patients had been notified in 18.4% of cases. On excluding these cases, the results indicated that over 79.6% of patients had been notified that they had either "togo-shiccho-sho" or "seishin-bunretsu-byo." The patient questionnaire results regarding patients' awareness of the name of their disease showed that 55.2% answered "togo-shiccho-sho," 3.2% answered "seishin-bunretsu-byo," 9.5% answered the name of another disease, 17.4% answered that they did not know the name of their disease, and 14.7% answered that they knew the name of their disease but did not include any specific details. On excluding these unspecified answers, 68.5% of patients were aware that they had either "togo-shiccho-sho" or "seishin-bunretsu-byo." Comparison of the notified with the un-notified group revealed that the period from treatment initiation in the notified group was shorter than that in the un-notified group, and the mean age of the notified group at the time of the survey was lower than that of the un-notified group. Furthermore, significantly more patients started treatment before 2002, when the Japanese name for schizophrenia was changed, in the un-notified group. The results of this study suggested that the change of the Japanese name of schizophrenia to "togo-shiccho-sho" and historical background resulted in more active notification of the diagnosis.

Temperament and character profiles of Japanese university student suicide completers.

OBJECTIVE: The aims of this study were to investigate the personality traits of suicide completers using the Temperament and Character Inventory (TCI) scale. METHODS: Newly enrolled students who enrolled at Hokkaido University in 1999-2002 and 2004-2007 completed the TCI. Among these students, twenty subjects (2 females and 18 males) later completed suicide. We compared the TCI scales of these subjects with those of 60 (6 females and 54 males) well-matched controls. The controls were matched for age, gender, university department and year of enrollment in the university. Because the number of females was too small, the statistical analyses for the TCI subscales and logistic regression analysis were performed only with the 18 males. RESULTS: A univariate analysis of seven personality dimensions on the TCI revealed higher scores of harm avoidance (HA) in subjects with suicide completion (P=0.034). Analysis of the male subjects showed that suicide completers had higher scores for anticipatory worry (HA1, P=0.007) and fear of uncertainty (HA2, P=0.036) and lower scores for spiritual acceptance (ST3, P=0.038) than did the controls. A multivariate analysis, which was performed to adjust confounding factors, demonstrated significantly higher scores for HA1 among suicide completers (P=0.01, OR=1.32). CONCLUSIONS: These results suggest that higher HA scores may predict suicide completion.

Temperament and character profiles of Japanese university students with depressive episodes and ideas of suicide or self-harm: a PHQ-9 screening study.

OBJECTIVE: The aim of our study was to reveal the personality traits of individuals with major and other depressive episodes among the young adult population. Furthermore, character traits of individuals with ideas of suicide or self-harm were also investigated in this study. METHODS: The subjects of this study were 1421 university students who completed the Patient Health Questionnaire (PHQ-9) and the Temperament and Character Inventory (TCI). The subjects were divided into three separate groups: the major depressive episode group (N = 41), the other depressive episode group (N = 97), and the non-depressive controls (N = 1283). This separation was achieved using the PHQ-9 algorithm diagnosis. We compared the TCI scores using an analysis of variance. Moreover, the Cochran-Armitage trend test was used to determine the diagnosis, ideas of suicide or self-harm, and analysis of character profiles. RESULTS: The major depressive episode group had significantly higher HA (P < 0.001), lower RD (P < 0.001), lower SD (P < 0.001), and lower C (P < 0.001) scores than non-depressive controls. The other depressive episode group had significantly higher HA scores (P < 0.001) and lower SD scores (P < 0.001) than non-depressive controls. The Cochran-Armitage trend test revealed that the prevalence of depressive episodes decreased as the character profiles matured (χ(2)(trend) = 57.2, P < 0.0001). The same tendency was observed in individuals who had ideas of suicide or self-harm (χ(2)(trend) = 49.3, P < 0.0001). CONCLUSION: High HA and low SD scores were common personality traits among young adults with major depressive episodes. Furthermore, the immaturity of character profiles was clearly associated with depressive episodes and ideas of suicide or self-harm.

The valproate serum level in maintenance therapy for bipolar disorder in Japan.

The appropriate therapeutic serum valproate level in maintenance therapy for bipolar disorder is not well known. We studied the serum valproate levels in seventeen bipolar I and twenty-four bipolar II disorder outpatients who had been treated with stable doses of valproate successfully for at least 12 months as prophylactic therapy. The trough serum valproate levels were 52.2 +/- 20.4 microg/ml in bipolar I, and 41.0 +/- 18.3 microg/ml in bipolar II disorder patients, respectively. A greater trend towards a higher trough level (p = 0.07) was indicated in the bipolar I disorder group. We speculate that these valproate levels may be an approximation to the appropriate valproate levels in maintenance therapy and that there may be a correlation between the level of valproate required for stabilization and the subtype of the bipolar disorder. However, when interpreting these findings, certain limitations to this study? Need to be taken into account as follows. The sample size was small. We could not look at a group on valproate that had relapsed and a group that had dropped out of maintenance therapy. Further studies are needed.

Utility and limitations of PHQ-9 in a clinic specializing in psychiatric care.

BACKGROUND: The Patient Health Questionnaire-9 (PHQ-9), despite its excellent reliability and validity in primary care, has not been examined for administration to psychiatric patients. This study assesses the accuracy of PHQ-9 in screening for major depressive episode and in diagnosing major depressive episode in patients of a psychiatric specialty clinic. METHODS: We compared operational characteristics of PHQ-9 as a screening and diagnostic instrument to DSM-IV-TR diagnosis by a trained psychiatrist as a reference standard. The reference criteria were "current major depressive episode" or "current major depressive episode with major depressive disorder". PHQ-9 was used with two thresholds: diagnostic algorithm and summary scores (PHQ-9 ≥ 10). The optimal cut-off points of PHQ-9 summary scores were analyzed using a receiver operational characteristics (ROC) curve. RESULTS: For "current major depressive episode", PHQ-9 showed high sensitivity and high negative predictive value at both thresholds, but its specificity and positive predictive value were low. For "current major depressive episode with major depressive disorder", PHQ-9 also showed high sensitivity and high negative predictive value at both thresholds, but the positive predictive value decreased more than that for "current major depressive episode". The ROC analysis showed the optimal cut-off score of 13/14 for "current major depressive episode". CONCLUSIONS: PHQ-9 is useful for screening, but not for diagnosis of "current major depressive episode" in a psychiatric specialty clinic.

Social Anxiety/Taijin-Kyofu Scale (SATS): development and psychometric evaluation of a new instrument.

BACKGROUND: Taijin-kyofu (TK), especially the 'convinced' subtype of TK (c-TK; also known as the 'offensive' subtype of TK), is described as a Japanese culture-bound syndrome similar to social anxiety disorder (SAD). Recently, in Western countries, the symptoms of c-TK have been investigated in patients with SAD. We developed the Social Anxiety/Taijin-Kyofu Scale (SATS), a 12-item structured clinician-rated instrument designed to rate the severity of TK symptoms, and examined its reliability and validity. METHODS: The SATS was administered to 15 patients with c-TK diagnosed using the traditional Japanese TK criteria. Interviews used to score patients' symptoms were recorded on videotape. Additionally, the Clinical Global Impression-Severity Scale (CGI-S) was administered to assess convergent validity. Interrater reliability was assessed on 15 videotaped interviews; the interviews were independently rated by 10 other raters. Test-retest re-liability was assessed on 15 videotaped interviews by the same rater at an interval of more than 4 weeks. RESULTS: The SATS had high internal consistency (Cronbach's α = 0.97) and good interrater reliability (ICC = 0.88-0.93) and test-retest reliability (ICC = 0.94-0.99). The SATS total score correlated with the CGI-S scores (r = 0.77, p < 0.0001). CONCLUSION: The SATS appears to be a reliable and valid measure of the symptoms of TK.

Pulverizing medication as a harm reduction and intentional drug overdose prevention strategy: Two case studies.

AIMS: We explored the use of pulverized medication as a new method to prevent intentional drug overdose. METHODS: This case study presents data obtained from the medical records of two female patients, aged 19 and 27 years, who presented with schizophrenia and neurodevelopmental disorder, respectively. Both patients provided written informed consent. Medication was administered to the two patients in powdered form, as opposed to in tablet form, in an attempt to prevent intentional drug overdose. RESULTS: This administration method successfully prevented intentional drug overdose for 3 and 5 years in each case, respectively. However, case-control or prospective cohort studies are needed to rule out biases, including cognitive bias. CONCLUSION: Pulverizing medication is a simple and effective means of preventing intentional drug overdose by restricting access to the means of suicide, regardless of the type of mental disorder.

Associations between cognitive impairment and illness awareness in fully remitted bipolar outpatients.

The euthymic state of bipolar disorder is often characterized by impaired cognitive function. In this investigation, we hypothesized that subjective cognitive function is impaired and illness awareness is inadequate and we further explored the associations among cognitive complaints, objective cognitive functions, and current illness awareness in Japanese patients. Twenty-seven patients in remission and 27 healthy subjects were recruited in this study. The Japanese version of the Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA) and Scale to Assess Unawareness in Mental Disorders (Japanese, SUMD-J) were used to assess each patient. All patients underwent neuropsychological tests for the assessment of objective cognitive functions. Only SUMD2.C (current awareness of the effects of medication) was significantly correlated with COBRA, and the objective cognitive assessments, Word Fluency Test and Stroop Test Reaction Time, represented significant correlations with SUMD1.C (current awareness of mental illness). In remitted bipolar outpatients, both the objective and subjective cognitive functions were found to be associated with illness awareness. However, subjective and objective cognitive functions differed in the related illness awareness subscales in fully remitted bipolar outpatients.

Depression and major depressive disorder in patients with Parkinson's disease.

The prevalence of depression in Parkinson's disease (PD) varies greatly. In this study, we investigated major depressive disorder (MDD) and depressive symptoms without MDD in patients with PD. The psychopathological characteristics of depressive symptoms were assessed by a psychiatric interview. A total of 105 Japanese patients with PD without dementia were included. The Japanese version of the Beck Depression Inventory-II (BDI-II) with a cutoff score of 13/14 was used to screen for depression. Using a structured interview, a comprehensive psychiatric evaluation of patients with BDI-II scores >13 (high BDI patients) was completed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR. Forty patients (38%) had a BDI-II >13, but 29 did not show any depressed mood. Five cases met the criteria for MDD (three current, two past) and one patient was diagnosed with minor depressive disorder. A slight depressed mood that was associated with worrying about PD was seen in 6 of 34 patients without any depressive disorder and fluctuated with aggravation of PD symptoms in two of these patients. For the diagnosis of MDD, the number of positive items from the DSM-IV-TR definition of MDD is most important and useful for differentiating MDD and non-MDD. The low-prevalence rate of MDD in our patient population suggests that PD may be a psychological stressor for MDD, but does not necessarily induce MDD.

Associations between cognitive impairment and quality of life in euthymic bipolar patients.

During the euthymic state in bipolar disorder, cognitive functions often remain affected. Specifically, subjective and objective cognitive impairment might distinctly affect patients' quality of life (QoL); however, this question had not been examined previously in Japanese patients. Therefore, the current study investigated the associations between cognitive complaints, QoL, and objective cognitive functions. Forty patients in remission were recruited from the Hokkaido University Hospital, Sapporo, Japan and assessed with the translated version of the cognitive complaints in bipolar disorder rating assessment (COBRA), medical outcomes study 36-item short-form health survey version 2 (SF-36v2), and Sheehan disability scale (SDS). The Japanese adult reading scale, Wisconsin card sorting test, word fluency, continuous performance test, trail making test (TMT), auditory verbal learning, and Stroop test evaluated objective cognitive functions. Significant correlations were observed between the COBRA, SF-36v2, and SDS results, as well as the TMT scores. Overall, euthymic patients were aware of their cognitive dysfunction, which could be understood in relation to the decrease in satisfaction in their daily life. Therefore, even mild cognitive impairments can have ramifications for patients in the euthymic state of bipolar disorder.

Effect of co-administration of a serotonin-noradrenaline reuptake inhibitor and a dopamine agonist on extracellular monoamine concentrations in rats.

Recent studies have shown that dopamine agonists are useful for the treatment of not only Parkinson's disease, but also major depressive disorders. However, while these dopamine agonists provide a new treatment strategy for major depressive disorders, such as treatment-resistant cases, the antidepressant effect of dopamine agonists has yet to be investigated. To examine the mechanism of the antidepressive effect of dopamine agonists, we investigated the acute effect of the dopamine receptor agonist, cabergoline, and the serotonin-noradrenaline reuptake inhibitor, milnacipran, on extracellular noradrenaline, dopamine and serotonin concentrations in the rat medial prefrontal cortex. There was a greater increase in extracellular noradrenaline concentrations when acute milnacipran (30 mg/kg intraperitoneally) was administered after acute high-dose cabergoline (1 and 2 mg/kg subcutaneously) than when acute milnacipran was administered following acute vehicle or low-dose cabergoline (0.25 mg/kg subcutaneously). There were no significant differences noted in the dopamine or serotonin concentrations. These results suggest that the addition of cabergoline has the potential to strengthen the antidepressant effects of milnacipran and that the mechanism of action of the antidepressive effect of dopamine agonists might be due to enhancement of induced increases of extracellular noradrenaline.

A possible association between missense polymorphism of the breakpoint cluster region gene and lithium prophylaxis in bipolar disorder.

Lithium is one of the most commonly used drugs for the treatment of bipolar disorder. To prescribe lithium appropriately to patients, predictors of response to this drug were explored, and several genetic markers are considered to be good candidates. We previously reported a significant association between genetic variations in the breakpoint cluster region (BCR) gene and bipolar disorder. In this study, we examined a possible relationship between response to maintenance treatment of lithium and Asn796Ser single-nucleotide polymorphism in the BCR gene. Genotyping was performed in 161 bipolar patients who had been taking lithium for at least 1 year, and they were classified into responders for lithium mono-therapy and non-responders. We found that the allele frequency of Ser796 was significantly higher in non-responders than in responders. Further investigation is warranted to confirm our findings.

Depressive patients are more impulsive and inconsistent in intertemporal choice behavior for monetary gain and loss than healthy subjects--an analysis based on Tsallis' statistics.

OBJECTIVES: Depression has been associated with impaired neural processing of reward and punishment. However, to date, little is known regarding the relationship between depression and intertemporal choice (delay discounting) for gain and loss. This examination is potentially important for advances in neuroeconomics of intertemporal choice, because depression is associated with reduced serotonergic activities in the brain. DESIGN AND SETTING: We compared impulsivity and inconsistency in intertemporal choice for monetary gain and loss between depressive patients and healthy control subjects. METHODS: We conducted delay discounting tasks for gain and loss in depressed and healthy control subjects. We then quantified impulsivity and inconsistency in the delay discounting with parameters in the q-exponential discount function based on Tsallis' statistics. RESULTS: We observed that depressive patients were more impulsive and time-inconsistent in intertemporal choice action for gain and loss, in comparison to healthy controls. MAIN FINDINGS: Depressed patients were more irrational in temporal discounting. CONCLUSIONS: The usefulness of the q-exponential discount function for assessing the impaired decision-making by depressive patients was demonstrated. Furthermore, biophysical mechanisms underlying the altered intertemporal choice by depressive patients are discussed in relation to impaired serotonergic neural systems.

[Proper use of antidepressants in the acute and maintenance phase treatment of depression].

In spite of their different pharmacological profiles, a number of meta-analyses have shown that all antidepressants are equally effective in the treatment of major depression. However, there is the discordance between efficacy data and clinical observation. So then, how should we use antidepressants properly in the clinical setting? Toward rational pharmacotherapy, the selection of antidepressant medications will be based on their pharmacological profiles, clinical features of the patient, the anticipated side effects, and clinical trial data regarding the medication. During about 6 months following remission, the treatment that was effective in the acute phases should be used in the maintenance phase to prevent relapse.

[Clinical relevance of antidepressant-induced activation syndrome: from a perspective of bipolar spectrum disorder].

Recent concerns have been raised regarding whether antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) might increase suicidal tendencies and intense debate-rages over the pros and cons of their use. Although systematic reviews and population-based studies have been conducted, a consensus on this association remains to be established. Subsequently, the concept of so-called 'activation syndrome' associated with antidepressants has been accepted without its adequate verification. In the present report, we present our experience of seven cases considered of having 'activation syndrome' brought on by antidepressants, and examine its clinical relevance to bipolar spectrum disorder (Ghaemi, et al., 2001) both symptomatologically and diagnostically. Five patients, diagnosed as having major depressive disorder according to the diagnostic manual (DSM-IV), met the criteria of bipolar spectrum disorder and suffered from activation syndrome following the administration of SSRIs, mainly paroxetine. Similarly, hypomania developed in all five cases with depression; the diagnostic criteria of a hypomanic episode were not met. In the remaining two patients, who were both diagnosed with bipolar disorder, one showed irritability and insomnia through imipramine use, and the another developed a hypomanic and/or a mixed state after the co-administration of fluvoxamine and trazodone. From the results of our examination, 'bipolarity', which is the pivotal factor of bipolar spectrum, might exist behind the phenomenon recognized as activation syndrome, and be revealed by antidepressant treatment, just like manic switching. Moreover, the various problems encountered in the current practice of treating mood disorders, including unipolar-bipolar dichotomy, manic switching by antidepressants, and narrow criteria for a mixed episode, were pointed out a new through this concept of activation syndrome. Actually, the understanding of activation syndrome clinically leads to the prevention of suicidal behavior and the careful use of antidepressants for bipolar (spectrum) disorder, but we must be prudent when applying this concept, since it has not yet been established.

Lithium response and Val66Met polymorphism of the brain-derived neurotrophic factor gene in Japanese patients with bipolar disorder.

Lithium is a first-line agent for the treatment of bipolar disorder. A significant association between the Val66Met polymorphism of the brain-derived neurotrophic factor gene and bipolar disorder has been reported. We investigated whether this polymorphism is associated with the response to lithium treatment in Japanese patients with bipolar disorder. Patients had been treated with lithium carbonate for more than 1 year, and the response was retrospectively evaluated. No significant differences were found in the genotype distribution or allele frequency between responders and non-responders. Our results suggested that the brain-derived neurotrophic factor Val66Met polymorphism might not greatly contribute to the efficacy of lithium in bipolar disorder.

Long-term outcome of antidepressant-refractory depression: the relevance of unrecognized bipolarity.

BACKGROUND: The long-term outcome of antidepressant-refractory depression is not well known. Therefore, the present study investigated the long-term outcome of 26 antidepressant-refractory patients with depression, whom we had studied and treated in 1995. METHODS: Before being classified as nonresponse, these patients had been treated adequately with at least two tricyclic or heterocyclic antidepressants (a minimum of the equivalent of 150 mg of imipramine for 4 weeks). In 1995, 21 of 26 patients were diagnosed with unipolar depression, while 5 were diagnosed with bipolar depression. Mean follow-up was 5.7 years (range: 1-7 years) and changes in diagnosis, remission and treatment efficacy were evaluated. RESULTS: Following the long-term follow-up, 13 patients achieved full remission and demonstrated high social functioning (mean GAF score, 91). A further four depressed patients experienced full remission; however, subsequent recurrence was observed. In total, 17 of 26 patients experienced remission at least once during the long-term follow-up period despite the chronic depressive episodes observed at study entry. Adjuvant treatment with lithium, dopamine receptor agonists or thyroid hormone was effective for promoting full remission. Among the 21 patients initially diagnosed with unipolar depression in 1995, diagnoses were changed to bipolar disorder in 5 cases. LIMITATIONS: This naturalistic study had a relatively small sample size and treatment was not controlled. CONCLUSIONS: Long-term follow-up revealed that a substantial proportion of antidepressant-refractory depression is comprised of bipolar disorders. In addition, augmentation therapies are effective for promoting full remission among chronically depressed patients without a risk of serious side effects.

The relationship between insight and subjective experience in schizophrenia.

OBJECTIVES: To examine the relationship between level of insight and various subjective experiences for patients with schizophrenia. MATERIALS AND METHODS: Seventy-four patients with schizophrenia who were discharged from our hospital were evaluated. The level of insight into their illness and various subjective experiences were evaluated at discharge. We used the Scale to Assess Unawareness of Mental Disorder (SUMD) for evaluation of insight. In addition, five different rating scales were used to evaluate subjective experiences: Subjective Experience of Deficits in Schizophrenia (SEDS), Subjective Well-being under Neuroleptic drug treatment Short form (SWNS), Schizophrenia Quality of Life Scale (SQLS), Beck Depression Inventory (BDI), and the Drug Attitude Inventory (DAI)-30. RESULTS: The SWNS and the scores for awareness of mental disorder and awareness of the social consequences of mental disorder on SUMD showed a weak positive correlation. The DAI-30 showed a significant negative correlation with most general items on SUMD and a negative correlation between the subscale scores for the awareness and attribution of past symptoms. SEDS, SWNS, SQLS, and the BDI significantly correlated with the subscale scores for awareness of current symptoms on SUMD, and weakly correlated with the subscale scores for attribution of current negative symptoms. CONCLUSION: Awareness of subjective distress was related to awareness of having a mental disorder. Feeling subjective distress was related to awareness of current symptoms, as well as to the ability to attribute current negative symptoms to a mental disorder. Positive attitudes toward medication correlated with better general insight into the illness.