Illness Insight and Medication Adherence
Essential Concepts
Insight into illness is neither necessary nor sufficient for adherence to medications.
Illness insight is not a simple, all-or-nothing concept, but is dimensional: awareness of symptoms, acknowledgment of illness, and acceptance of need for treatment.
Some patients have an anosognosia-like deficit in recognizing that they are psychiatrically ill and could benefit from treatment.
To assess medication adherence, assess financial barriers, cognitive problems, and health beliefs (which involves a weighing of perceived risks and benefits from the patient’s viewpoint).
Effectiveness of a medicine is driven by its efficacy; nobody likes to take ineffective or marginally effective medications with many side effects.
“The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”
—Sir William Osler, Father of Modern Medicine, 1849-1919
“Everything should be made as simple as possible, but not simpler.”
—Albert Einstein
Adherence to antipsychotics is one of the most important determinants of prognosis in schizophrenia. Recognizing medication adherence problems and identifying reasons for nonadherence are therefore important considerations in the treatment of patients with schizophrenia. Note that “adherence” is now generally preferred over the older, more paternalistic term “compliance.”
Families frequently ask for “more therapy” for a nonadherent family member, revealing two assumptions about insight and adherence: (a) that insight is necessary and sufficient for adherence, and (b) that insight is a function of the amount of treatment provided (and hence can increase if enough treatment is
given). Unfortunately, insight does not necessarily translate into adherence; and lack of insight sides comfortably with excellent adherence.
given). Unfortunately, insight does not necessarily translate into adherence; and lack of insight sides comfortably with excellent adherence.
KEY POINT“Lack of insight” poses one of the biggest obstacles to the treatment of schizophrenia. However, the reverse is not correct: a good understanding of one’s illness and the proposed treatment is neither necessary nor sufficient for anyone to take medications.
INSIGHT INTO ILLNESS
In a seminal World Health Organization (WHO) study of schizophrenia, a key finding was that “lack of insight” was the most useful clinical feature in distinguishing schizophrenia from other mental disorders. Consequently, much work has been dedicated to better understand the nature of this lack of insight. Clearly, insight into illness is not the simple shorthand “patient has no insight” that psychiatrists sometimes use to describe patients, particularly patients who disagree with treatment recommendations. Some patients might very well agree with you that they suffer from a mental illness and that they have symptoms, but they do not see medications as the solution. The acceptance of need for treatment, in particular, is shaped by cultural expectations.
The most eloquent, clinical definition of “insight” comes from Sir Aubrey Lewis. He defined insight as “a correct attitude toward a morbid change in oneself.” More recent work has stressed that insight is best regarded as a multidimensional construct (David, 1990):
Awareness of symptoms—Ability to recognize inner experiences or observations as abnormal
Acknowledgment of illness—Ability to see oneself as suffering from an illness.
Acceptance of need for treatment—Ability to acknowledge that treatment could be useful, particularly to prevent relapse
TIPTo assess insight as it relates to taking antipsychotics, I focus on acknowledgment of illness and need for treatment: “Do you have any mental health problems? Do you need any treatment for mental health problems? Do your medications do you any good?” (Adapted from the Insight into Treatment Attitude Questionnaire, or ITAQ, developed by Dr. Joseph McEvoy; McEvoy et al., 1989.)
An important question is whether you can improve insight into illness. Some would say that psychosis (particularly delusions) by definition has an element of lack of insight built into the definition. However, patients who are just relapsing or patients in the prodrome of schizophrenia are often able to recognize that something is wrong (abnormal perceptions or attenuated psychosis) and seem to have at least partial insight. This capacity to self-observe and reflect gets lost once patients develop full-blown psychosis or mania. One observation that has been made is that depression adds to the ability to have insight, akin to pain as a warning that something is wrong (Freudenreich et al., 2004a). That said, there are probably some patients who are fundamentally unable to see their symptoms as such. This inability to recognize themselves as somebody with symptoms (suggesting an illness) has been compared to the anosognosia of neurology. Some studies suggest that this aspect of illness is a true neuropsychiatric deficit (Aleman et al., 2006) that you would not expect to be remedied by talking. However, in some patients, “denial” as a psychologic mechanism is probably operative (Cooke et al., 2005), where ongoing conversation can lead to improved insight.
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