Changes in insight and outcome over the early course of first-episode psychosis. The OPTiMiSE trial

Insight in psychosis has been associated with psychosis remission, treatment compliance and better functioning, but also with depression, increased suicide risk and worse subjective wellbeing. This insight paradox has not been sufficiently studied.

Participants (N = 443) came from the first-episode psychosis OPTiMiSE trial. Insight was assessed with the clinician-rated Positive and Negative Syndrome Scale for Schizophrenia (PANSS)-G12 item. We investigated the cross-sectional associations of insight with clinical measures at baseline and at 4 weeks and the effect of insight change over the 4-week follow-up on outcomes at that point, whilst adjusting for baseline insight and other potential confounders.

At baseline and at week 4 better insight was cross-sectionally associated with higher rates of psychosis remission, lower illness severity and better psychosocial functioning (p < .001). At baseline, but not at week 4, better insight was cross-sectionally linked with more severe depressive symptomatology (p = .001), higher suicidality levels (p = .033) and worse subjective wellbeing (p = .022). Insight improvement was associated with higher rates of psychosis remission (p < .001), lower illness severity (p < .001) and better functioning (p = .014) at 4 weeks. Better baseline insight, but not insight change, was related to more severe depression (p < .001) and worse subjective wellbeing (p = .001) at 4 weeks.

Insight was cross-sectionally associated with positive and negative clinical measures at baseline, but the latter was not replicated at 4 weeks. Improvement in insight over 4 weeks was not linked with any adverse outcome, offering reassurance to those making efforts to enhance insight early in treatment.