Stigma moderates the associations of insight with depressed mood, low self-esteem, and low quality of life in patients with schizophrenia spectrum disorders

Abstract

Background

Good insight into illness in patients with schizophrenia is related not only to medication compliance and high service engagement, but also to depression, low self-esteem, and low quality of life. The detrimental effects of insight pose a problem for treatment.

Aim

To investigate whether the negative associations of good insight are moderated by perceived stigma.

Method

Respondents were 114 patients with schizophrenia spectrum disorders. We used Analyses of Variance (ANOVA) and Structural Equation Modeling (SEM) to test moderation.

Results

Good insight was associated with high service engagement and high compliance. Also, good insight was associated with depressed mood, low quality of life, and negative self-esteem. This association was strong when stigma was high and weak when stigma was low. SEM showed that the constrained model performed significantly worse than the unconstrained model, in which detrimental associations of insight were free to vary across stigma groups (χ² = 19.082; df = 3; p < .001).

Conclusions

Our results suggest that the associations of insight with depression, low quality of life, and negative self-esteem are moderated by stigma. Patients with good insight who do not perceive much stigmatization seem to be best off across various outcome parameters. Those with poor insight have problems with service engagement and medication compliance. Patients with good insight accompanied by stigmatizing beliefs have the highest risk of experiencing low quality of life, negative self-esteem, and depressed mood. A clinical implication is that when it is attempted to increase insight, perceived stigma should also be addressed.

Introduction

In patients with schizophrenia, insight into illness is associated with fewer symptoms, better psychosocial functioning, and better compliance with antipsychotic medication (Francis and Penn, 2001, Kozuki et al., 2005, Lacro et al., 2002, Lysaker et al., 1998, Lysaker et al., 2002, Mohamed et al., 2009, Perkins, 2002, Rittmannsberger et al., 2004). Insight has been regarded as a necessary condition for anticipating needs, developing realistic goals (Lysaker et al., 2001, Young and Ensign, 1999) and promoting positive social and health outcomes (McEvoy, 1998, McGorry and McConville, 1999). However, there appears to be a downside. Recent studies show that insight is both cross-sectionally and longitudinally related to depression, hopelessness, lower self-esteem (Cooke et al., 2007, Karow and Pajonk, 2006, Lincoln et al., 2007a, Mohamed et al., 2009) and lower quality of life (Hasson-Ohayon et al., 2006, Kravetz et al., 2000, Pyne et al., 2001, Schwartz, 2001). These opposing effects of insight are reflected by diagnosed individuals who express the belief that they have two choices: either to accept their diagnosis and life as a “chronic case,” or to reject the diagnosis and retain some semblance of control (Barham and Hayward, 1998).

If insight leads to an impoverished sense of self, worse quality of life, and pessimism about the future, should attempts be made to increase it? More understanding is needed of the psychological processes at work. To a greater extent than those with other mental disorders, patients with schizophrenia experience stigma from family, partners, friends, and colleagues (Corrigan, 2004, Lee, 2005). Lysaker et al. (2006) argued that negative outcome of insight depends on the internalization of stigmatic beliefs, on the meaning that patients attach to their illness. While some patients believe that they no longer have the ability to achieve valued social roles, others disagree, remain hopeful and engage in active coping (Lysaker et al., 2005). A similar idea was published by Williams (2008) who based a description of post-diagnostic identities for patients with schizophrenia on two dimensions: (1) the amount of identification with the community of people with severe mental illness, and (2) the amount of stigma that is internalized in the self-narrative. Patients with high identification but low internalized stigma are assumed to be socially active and not experience diminished self-esteem. The hypothesis that good insight is related to negative outcome only when it is accompanied by stigmatizing beliefs was recently supported (Lysaker et al. 2006).

To the best of our knowledge, the study by Lysaker et al. (2006) is the only one to have tested this hypothesis. Although it was well conducted, specific elements of its design limit the extent to which its findings can be generalized. For instance, their sample was relatively small (n = 75), and its estimate of insight was based solely on a single item of the Positive and Negative Syndrome Scale. Also, a subscale of the Quality of Life Scale was used to reflect social functioning, but general quality of life was not included. And although its analyses included a scale of hopelessness, no measure of general depressive mood was used.

We investigated the same hypothesis as Lysaker et al. (2006), though using a larger sample, different outcome variables, other instruments, and more advanced statistical analyses. We hypothesized that service engagement and medication compliance are high in patients with good insight, independently of stigmatic beliefs. However, we also expected that stigma moderates the detrimental effects of insight.