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Insight in Inpatients with Psychotic Mania; Demographic and Clinical Factors

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 Manag Epidemiol Public Health, 2016, 1(1): 1-9
Dr. Amiri, Manuscript, MEPH-revision

Managerial Epidemiology & Public Health

(MEPH)
www.jmeph.com

Original Research

Insight in Inpatients with Psychotic Mania; Demographic and Clinical

Factors
Amir Mokhtarzadeha, Sara Farhanga, Fatemeh Ranjbara, Hassan Shahrokhia, Shahrokh Amiria*
a
Research Center of Psychiatry and Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran

Correspondence Abstract

Shahrokh Amiri, Research
Center of
Psychiatry and Behavioral
Sciences, Tabriz University of
Medical Sciences, Tabriz, Iran.
Tel/Fax: +98-413-3803353.
E-mail: Amirish@tbzmed.ac.ir
Keywords:
Insight
Bipolar disorder
Mania
Mental disorder
Psychosis
Submitted: June 27, 2016
Accepted: September 18, 2016
DOI: 10.13183/MEPH.v1i1.3
Purpose: To evaluate changes of insight in bipolar patients during the mania
phase using well-designed scales, and investigate its relation to demographic
and clinical factors.
Methods: Sixty inpatients with acute psychotic mania were initially assessed
using Scale to Assess Unawareness of Mental Disorder (SUMD-Abridged),
Young’s Mania Rating Scale (YMRS) and Global Assessment of Function (GAF).
The patients were reassessed at the time of symptom resolution.
Results: All aspects of insight improved significantly during the resolution of
acute mania (p<0.01). Patients with fewer admissions had improved insight into
the effects of medication (p=0.02). Those patients with more insight regarding
the consequences of the disorder at the time of resolution had a lower age at
the onset (p=0.03).
Conclusions: Different dimensions of patients’ insight having psychotic mania
improve significantly during the resolution of the acute psychotic mania.
Patients with the factors predicting poor insight may benefit from directed
interventions.

©2016 Swedish Science Pioneers, All rights reserved.

Introduction
Having insight into mental illness is a
multidimensional clinical phenomenon
affecting the course, treatment and outcome [1,
2]. Lack of insight is an important clinical
dilemma in psychotic, mood and anxiety
disorders [3]. A sophisticated assessment of
insight is the key to an accurate evaluation of
the patient’s cooperation with treatment,
prognosis and the risk for the patient and others
[4]. There are many questions concerning the
nature of insight and the associated factors.
Gaemi et al. (2000) [3] showed that in
patients with a mood or anxiety disorder, the
initial poor insight was not associated with a
poor outcome; however an improvement in
insight was associated with a better outcome
especially in bipolar disorder type I (BD I).
Insight seems to be trait-dependent in
schizophrenia while it is state-dependent in
mania and improves during the resolution of an
acute manic episode [5]. A significant
improvement in different dimensions of insight
during the recovery of a manic episode has been
reported as well [6]. However, two separate
studies have failed to find a significant
difference in insight of patients with BD I and
schizophrenia in the remission phase [7, 8]. In a
study by Michalakeas et al. [9] results showed
no significant improvement in insight after the

1
 Manag Epidemiol Public Health, 2016, 1(1): 1-9
treatment of schizophrenia and mania. In a
recent study [10] about patients with BD I,
insight decreased during the manic phase in
both groups of patients: those having their first
manic episode as well as those with repeated
episodes. Insight returned to a normal level only
in patients with a single manic episode.
Results of various studies indicate that
changes of insight during manic episodes are
not related to the clinical or sociodemographic
factors [6, 8, 11]. Another study showed that
male gender and psychotic features could
predict poor insight into having a mental
disorder in remitted BD I patients, while male
gender, shorter duration of the disorder and
psychotic features were the predictors of poorer
insight into relabeling of psychotic experiences
[1].
Describing the changes of insight level and
its relation to demographic and clinical factors
might provide us the ability to predict the
progress. At the moment, the number of studies
evaluating insight during the manic phase is not
considerable and their sample sizes are
relatively low. In these studies, patients with
both psychotic and nonpsychotic mania have
been studied together whereas some previous
studies have shown that psychotic symptoms
seriously affect the level and change patterns of
insight [1, 6, 12]. The present study aimed to
investigate the change pattern of insight in
carefully selected psychotic patients with BP I.
Methods
Subjects and procedures
This study was carried out at a Razi mental
hospital, Tabriz University of Medical Sciences,
Iran. The protocol has been approved by the
ethic committee of the same university and the
patients have given their informed written
consent. Before obtaining the consent, the aim
of this study and the process were explained to
patients and their caregivers during the acute
phase. However, a written consent from patients
was considered after resolution of mania.
During a 6-month period, all of the hospitalized
BD I patients experiencing a manic episode
with psychotic features were evaluated (n=72).
The inclusion criteria were the ages of 18-
65 years and being diagnosed with BD I, current
episode manic with psychotic features according
to the DSM-IV-TR criteria. The diagnosis was
established by two psychiatrists with more than
10 years of clinical experience. Patients with a
comorbid organic mental disorder, mental
retardation, dementia, delirium, personality
disorder, recent substance use problem (at least
in recent 6 months) were excluded.
2
Demographic factors and a detailed history were
recorded. From the total of 72 patients, 12
patients were removed from the study because
of disapproval or untimely discharge from
hospital. Characteristic of the study samples are
described in Table 1.
Patients were initially evaluated during the
first 5 days (i.e. acute phase) by using the
Persian versions of Scale to Assess
Unawareness of Mental Disorders (Abridged)
(SUMD), Young’s Mania Rating Scale
(YMRS), and Global Assessment of Function
(GAF). SUMD evaluates three dimensions of
insight including the insight into psychiatric
symptoms or mental disorder, the necessity for
treatment and the social consequences of
psychiatric symptoms or mental disorder. It
does not reflect the clinician’s views and each
symptom scale can be used independently [13,
14]. Three items of the original form (flat or
blunt affect, anhedonia and asociality) were
excluded regarding the nature of BD I. The
SUMD assesses awareness to each item using a
three-point scale (1, aware; 2, somewhat aware;
3, unaware) [7]. The psychometric properties of
Persian version of SUMD [15] and YMRS [16]
have been explained elsewhere.
During the treatment period, serial
assessments by YMRS were repeated every
other day to determine symptom resolution.
SUMD was repeated when YMRS reached ≤ 12
[2].
Statistical analysis
The data are described as number (percentage)
or mean (standard deviation) where appropriate.
The Wilcoxon test was used to evaluate the
change in insight while student’s T (for
quantitative variables) and Chi-Square tests (for
qualitative variables) were used to evaluate the
possible relation of each dimension of
Table 1. The initial characteristics of the
studied sample and drop outs.
Variable Studied sample Drop out
n (%) Mean (SD) n (%) Mean (SD)
Gender
Male 36 (60) 7 (58.3)
Female 24 (40) 5 (41.7)
Marital status
Single 25 (41.7) 6 (50)
Married 29 (48.3) 5 (41.7)
Divorced 6 (10) 1 (8.3)
Type of psychotic
symptoms
Mood congruent 45 (75) 9 (75)
 Manag Epidemiol Public Health, 2016, 1(1): 1-9
Mood incongruent 15 (25) 3 (25) insight at the acute phase and resolution time
with the demographic and clinical
Number of psychotic characteristics, patients were divided into two
symptoms groups and were compared: aware-somewhat
One symptom 34 (56.7) 7 (58.3) aware and unaware. Statistical tests were
Two symptom 26 (43.3) 5 (41.7) considered significant at p<0.05 level.

Having delusion 58 (96.7) 11 (91.7)

Results
Of the initial 72 patients, the protocol was
Having hallucination 28 (46.7) 6 (50)
completely performed on 60 patients. The
characteristics of the patients who completed
Age (yr) 33.8 (9.6)
the study and drop outs are described in Table
1. The mean score of YMRS at the symptom
Years of education 6.9 (5.2)
resolution time was decreased from
23.4 (5.2) to 7.3 (4.4). The mean interval
Duration of disorder (yr) 10.7 (9.0)
between admission and symptom resolution was
32.5 (21.0) days.
Age at onset (yr) 22.7 (7.3)
The level of awareness during the acute
phase and resolution time (into different aspects
Number of admissions 4.4 (6.4) of the disorder) was divided into three levels,
based on the questionnaire (Table 2). In the
YMRS† (Acute phase) 23.4 (5.2) acute phase, 66.7% of patients were unaware of
the disorder, 68.3% were unaware of
GAF‡ (Acute phase) 23.8 (2.3) consequences and 48.3% were unaware of
medication effects. At the resolution time of
YMRS, Young’s Mania Rating Scale. ‡GAF, Global Assessment
†
mania, 28.3% of patients were unaware of the
of Function
disorder, 30% were unaware of consequences,
and 13.3% were unaware of medication effects.
insight with demographic and clinical These results are described by showing the
characteristics. Possible association was direction of changes from the acute phase to the
investigated between the level of insight and symptom resolution time in Table 3.
age, gender, educational level, marital status, The awareness of the study sample improved
family history of mental disorder, duration of significantly regarding the disorder,
disorder, age of onset, number of admissions, consequences, effect of medications, psychotic
number of psychotic symptoms and psychosis- symptoms and formal thought problems at the
mood congruency. These analyses were carried time of symptom resolution while the GAF
out separately for the initial insight, insight score increased as well. The mean scores of
level at the symptom resolution and the change these items are shown in Table 4.
of the insight level. The associations between changes of insight
Moreover, the patients were divided into two level and demographic-clinical characteristics
groups according to insight improvement: one are presented in Tables 5 and 6. Patients with an
group consisted of patients whose insight improvement of insight into the effects of
improved and the second group included medication had significantly fewer admissions
patients with no change in the level of insight (t=2.42, p=0.02). The associations between
(excluding patients with complete awareness insight level at the symptom resolution time and
about a certain item of SUMD at both demographic-clinical characteristics are
assessments) and two groups were compared. presented in Tables 7 and 8. The disorder onset
To evaluate the association between the level of at an older age
Table 2. Level of awareness in psychotic Awareness of
manic inpatients in different insight consequences
dimensions in acute phase and symptom Acute 9 (15) 10 (16.7) 41 (68.3)
resolution time.
Resolution 28 (46.7) 14 (23.3) 18 (30)
Item Aware Somewhat
Aware/unaware Awareness of
medication effects
Awareness of
Acute 14 (23.3) 17 (28.3) 29 (48.3)
disorder
Resolution 38 (63.3) 14 (23.3) 8 (13.3)
Acute 3 (5) 17 (28.3)
Resolution 23 (38.3) 20 (33.3) Awareness of
hallucinations
0 (0) 2 (7.1) 26 (92.9)

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 Manag Epidemiol Public Health, 2016, 1(1): 1-9
Acute acute phase, they experienced more insight
Resolution 10 (35.7) 6 (21.4)
improvement in all aspects of insight during the
resolution time. However, there was no
Awareness of
delusions
statistically significant difference between
males and females.
Acute 0 (0) 3 (5.2)
Resolution 21 (36.2) 14 (24.1)

Awareness of
though disorder
Acute 1 (2.8)
Resolution 13 (36.1)
was associated with lower insight into the
consequences of the disorder at the time of
symptoms resolution (t=-2.25, P=0.03). The
associations between the acute phase insight
and demographicclinical characteristics are
presented in Tables 9 and 10. The insight of
patients in the acute phase was not associated
with any of clinical and demographic
characteristic. Though female patients had a
lower level of insight (in all aspects) during the
Table 3. The direction of changes in
the insight of patients with mania
during symptom resolution.
Item
Discussion
The current study described different aspects of
7 (19.4) insight on patients with psychotic mania and its
8 (22.2) relation to demographic and clinical factors.
These results showed that different dimensions
of insight have a significant improvement
during the symptom resolution of acute mania
which is in concordance with previous studies
[6, 9, 11, 17]. The results of these reports differ
mostly because of dissimilar scales measuring
insight level. According to the results of the
current study, the acute phase insight cannot
predict the level of insight after the resolution
of
*
Significant at 0.05 by Wilcoxon test. †YMRS, Young’s Mania
Rating Scale.
‡
GAF, Global Assessment of Functioning
N (%)

Improvement Unchanged
Awareness of disorder 33 (55) 27 (45)
Awareness of 31 (51.7) 28 (46.7)
consequences
Awareness of medication 32 (53.3) 26 (43.3)
effects
Awareness of 16 (57.1) 11 (39.3)
hallucinations
Awareness of delusions 34 (58.6) 23 (39.7)
Awareness of though 16 (44.4) 19 (52.8)
disorder
Table 4. The comparison of insight
scores in acute phase of mania and
at symptom resolution regarding
different dimensions of insight
Item Manic phase Symptom
resolution

Mean (SD) Range Mean (SD) Range

Awareness of 2.6 (0.8) 1-3 1.9 (0.8) 1-3
disorder
Awareness of 2.5 (0.7) 1-3 1.8 (0.8) 1-3
consequences
Awareness 2.2 (0.8) 1-3 1.5 (0.7) 1-3
of medication
effects
Awareness of 2.9 (0.2) 2-3 2.0 (0.8) 1-3
hallucinations
Awareness of 2.9 (0.2) 2-3 2.0 (0.8) 1-3
delusions
Awareness of 2.6 (0.5) 1-3 2.1 (0.8) 1-3
though disorder
YMRS† 23.4 (5.2) 12-36 7.2 (4.3) 0-12
GAF‡ 23.8 (2.3) 21-31 43.6 (12.6) 29-70

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 Manag Epidemiol Public Health, 2016, 1(1): 1-9

Table
5. The association between changes of insight level and demographic-clinical characteristics in psychotic manic
patients (Quantitative characteristics): t- test
Item Age Education Duration of disorder Age of onset No. of
admission
Mean (SD)
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Awareness of disorder
Improved 33.2 (9.8) 7.2 (4.9) 10.3 (8.8) 22.8 (8.0) 3.2 (4.3)

(N=33)

Unimproved 34.4 (9.7) 7.2 (5.6) 9.7 (8.7) 23.5 (6.4) 5.8 (8.6)

(N=24)

Awareness of consequences

Improved 33.2 (8.9) 6.7 (4.8) 10.6 (8.7) 21.6 (7.2) 3.9 (5.6)

(N=31)

Unimproved 34.4 (10.0) 8.4 (5.6) 9.3 (7.8) 25.2 (7.7) 5.4 (8.3)

(N=20)

Awareness of medication effects

Improved 32.5 (9.4) 7.8 (4.9) 10.4 (8.6) 22.1 (7.3) 3.1 (4.5)*

(N=32)

Unimproved 38.0 (10.2) 6.3 (5.1) 11.8 (9.6) 24.5 (7.5) 8.1 (9.6)*

(N=16)

Awareness of hallucination

Improved 35.5 (11.4) 6.0 (4.8) 10.6 (9.2) 23.0 (8.5) 4.7 (8.0)

(N=16)

Unimproved 32.5 (8.7) 6.9 (5.1) 12.5 (9.8) 20.5 (4.5) 3.5 (3.8)

(N=12)

Awareness of delusion

Improved 32.8 (8.5) 6.5 (5.0) 9.1 (8.4) 22.8 (7.6) 4.0 (6.2)

(N=34)

Unimproved 34.4 (10.0) 7.6 (5.3) 12.5 (9.1) 22.2 (7.1) 5.0 (6.9)

(N=24)

Awareness of thought disorder

Improved 32.5 (9.2) 6.1 (5.1) 9.2 (8.8) 21.5 (6.8) 4.8 (7.2)

(N=16)

Unimproved 36.9 (12.5) 5.5 (5.4) 13.1 (9.4) 23.8 (10.0) 6.0 (7.8)

(N=19)

*Significant at p = 0.02, t = 2.42 by t-test

Table 6. The association between insight changes and demographic-clinical characteristics in psychotic manic
patients
Item N (%)

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 Manag Epidemiol Public Health, 2016, 1(1): 1-9

Table
Sex Marital status Familial history Congruency of No. of psychotic
psychosis symptoms
Male Female Single/Divorced Married Positive Negative Congruent Non-c 1 2
Awareness of disorder
Improved 17 16 10 14 3 21 25 8 16 17

(51.5) (66.7) (34.5) (50) (23.1) (47.7) (58.1) (57.1) (48.5) (70.8)

Unimproved 16 8 19 14 10 23 18 6 17 7

(48.5) (33.5) (65.5) (50) (76.9) (52.3) (41.9) (42.9) (51.5) (29.2)

Awareness of consequences

Improved 15 16 9 11 5 15 22 9 15 16

(55.6) (66.7) (34.6) (44) (50) (36.6) (59.5) (64.3) (53.6) (69.6)

Unimproved 12 8 17 14 5 26 15 5 13 7

(44.4) (33.3) (65.4) (56) (50) (63.4) (40.5) (35.7) (46.4) (30.4)

Awareness of medication

effects

Improved 16 16 6 10 4 12 23 9 18 14

(61.5) (72.7) (26.1) (40) (40) (31.6) (63.9) (75) (64.3) (70)

Unimproved 10 6 17 15 6 26 13 3 10 6

(38.5) (27.3) (73.9) (60) (60) (68.4) (36.1) (25) (35.7) (30)

(Contd...)

6. Continued...
Item N (%)

Sex Marital status Familial history Congruency of No. of psychotic

psychosis symptoms
1 2
Male Female Single/Divorced Married Positive Negative Congruent Non-c
Awareness of hallucination
Improved 6 10 8 4 4 8 12 4 1 15

(42.9) (71.4) (50) (33.3) (50) (40) (57.1) (57.1) (33.3) (60)

Unimproved 8 4 8 8 4 12 9 3 2 10

(57.1) (28.6) (50) (66.7) (50) (60) (42.9) (42.9) (66.7) (40)

Awareness of delusion

Improved 17 17 12 12 7 17 26 8 20 14

(50) (70.8) (40) (42.9) (50) (38.6) (60.5) (53.3) (60.6) (56)

Unimproved 17 7 18 16 7 27 17 7 13 11

(50) (29.2) (60) (57.1) (50) (61.4) (39.5) (46.7) (39.4) (44)

Awareness of thought disorder

Improved 7 9 8 11 7 12 11 5 10 6

(38.9) (52.9) (47.1) (61.1) (77.8) (46.2) (44) (50) (47.6) (42.9)

Unimproved 11 8 9 7 2 14 14 5 11 8

(61.1) (47.1) (52.9) (38.9) (22.2) (53.8) (56) (50) (52.4) (57.1)

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 Manag Epidemiol Public Health, 2016, 1(1): 1-9

Table

Table 7. The association between level of insight at symptom resolution and demographic-clinical characteristics in
psychotic manic patients
Item Age Education Duration of disorder Age of onset No. of admission

Mean (SD)
Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Awareness of disorder
Aware/Somewhat aware (n = 43) 34.3 (9.5) 6.8 (5.2) 11.1 (9.1) 22.6 (8.1) 4.0 (5.7)
Unaware (n = 17) 32.6 (9.9) 7.2 (5.2) 9.6 (8.9) 23.0 (5.0) 5.4 (8.1)
Awareness of consequences
Aware/Somewhat aware (n = 42) 33.7 (9.6) 6.3 (5.1) 11.8 (9.7) 21.4 (6.7)* 3.7 (5.2)
Unaware (n = 18) 33.9 (9.8) 8.4 (5.3) 8.1 (6.5) 25.9 (7.8)* 6.0 (8.6)
Awareness of medication effects
Aware/Somewhat aware (n = 52) 33.9 (9.9) 6.6 (5.4) 11.0 (9.2) 22.5 (7.4) 4.1 (6.4)
Unaware (n = 8) 33.1 (7.8) 8.8 (3.7) 8.8 (7.2) 24.3 (6.7) 6.2 (6.6)
Awareness of hallucination
Aware/Somewhat aware (n = 16) 35.5 (11.4) 6.0 (4.8) 10.6 (9.2) 23.0 (8.5) 4.7 (8.0)
Unaware (n = 12) 32.5 (8.7) 6.9 (5.1) 12.5 (9.8) 20.5 (4.5) 3.5 (3.8)
Awareness of delusion
Aware/Somewhat aware (n = 35) 33.3 (8.9) 6.3 (5.1) 9.7 (9.0) 22.7 (7.5) 3.9 (6.1)
Unaware (n = 23) 33.7 (9.6) 7.9 (5.2) 11.7 (8.5) 22.3 (7.2) 5.3 (7.0)
Awareness of thought disorder
Aware/Somewhat aware (n = 21)
32.8 (9.7) 5.8 (4.9) 9.9 (9.5) 21.5 (8.0) 4.4 (6.6)
Unaware (n = 15) 38.2 (12.4) 5.3 (5.9) 14.4 (8.9) 23.8 (9.6) 6.8 (8.3)
*Significant at p = 0.03, t= -2.25 by t-test

mania. During the acute phase, insight is impaired in all aspects the mean number of admissions was lower in patients with

in most of the patients, though it improves noticeably after the improvements in other aspects of insight, but the correlation did

resolution of mania. As stated by Ghaemi and Rosenquist [5], not reach the significance. Yen et al. [10] showed that frequent

impaired insight may be one of the signs of acute mania. On episodes of mania affect insight negatively in a way that it might

the other hand, the improvable nature of insight after symptom not return to the initial level. Though the temporal relation is not

resolution is of a special importance. As insight is associated clear in this study, another explanation is that patients who have

with medication adherence, it is more important than other signs poor insight into the effects of medication have lower adherence

in acute mania. and this would result in several admissions. In other words,

Patients, who experienced improvements of insight into better insight leads to a better adherence and a good outcome

the effects of medication, had fewer admissions. Interestingly, reflected in a lower number of admissions. On the other hand; the

8. The association between symptom resolution time insight and demographic-clinical characteristics in
psychotic manic patients
Item N (%)

Sex Marital status Familial history Congruency of No. of psychotic

psychosis symptoms
1 2
Male Female Single/Divorced Married Positive Negative
Congruent Non-c
Awareness of disorder
Aware/Somewhat aware 25 18 23 20 12 31 32 11 23 20
(69.4) (75) (74.2) (69) (80) (68.9) (71.1) (73.3) (65.7) (80)

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 Manag Epidemiol Public Health, 2016, 1(1): 1-9

Table
Unaware 11 6 8 9 3 14 13 4 12 5
(30.6) (25) (25.8) (31) (20) (31.1) (28.9) (26.7) (34.3) (20)
Awareness of consequences
Aware/Somewhat aware 25 17 23 19 11 31 32 10 23 19
(69.4) (70.8) (74.2) (65.5) (73.3) (68.9) (71.1) (66.7) (65.7) (76)
Unaware 11 7 8 10 4 14 13 5 12 6
(30.6) (29.2) (25.8) (34.5) (26.7) (31.1) (28.9) (33.3) (34.3) (24)
Awareness of medication
effects
Aware/Somewhat aware 30 22 28 24 14 38 38 14 29 23
(83.3) (91.7) (90.3) (82.8) (93.3) (84.4) (84.4) (93.3) (82.9) (92)
Unaware 6 2 3 5 1 7 7 1 6 2
(16.7) (8.3) (9.7) (17.2) (6.7) (15.6) (15.6) (6.7) (17.1) (8)
Awareness of hallucination
Aware/Somewhat aware 6 10 8 8 4 12 12 4 1 15
(42.9) (71.4) (50) (66.7) (50) (60) (57.1) (57.1) (33.3) (60)
Unaware 8 4 8 4 4 8 9 3 2 10
(57.1) (28.6) (50) (33.3) (50) (40) (42.9) (42.9) (66.7) (40)
Awareness of delusion
Aware/Somewhat aware 17 18 18 17 8 27 27 8 20 15
(50) (75) (60) (60.7) (57.1) (61.4) (62.8) (53.3) (60.6) (60)
Unaware 17 6 12 11 6 17 16 7 13 10
(50) (25) (40) (39.3) (42.9) (38.6) (37.2) (46.7) (39.4) (40)
Awareness of thought
disorder
Aware/Somewhat aware 10 11 13 10 4 17 15 6 13 8
(52.6) (64.7) (64.7) (52.6) (40) (65.4) (60) (54.5) (59.1) (57.1)
Unaware 9 6 6 9 6 9 10 5 9 6
(47.4) (35.3) (35.3) (47.4) (60) (34.6) (40) (45.5) (40.9) (42.9)

recurrent nature of the disorder may force the patient to conclude with BD I in the remission phase. The latter study (Dias et al., that
medications are ineffective and results in low insight into the 2008) reports that younger and more educated patients have effects of
medication. higher insight into the effects of medications. These two studies
The other finding of this study was that the patients who evaluated patients in the remission phase. On the contrary, had an older
age at the onset were unaware of its consequences. some studies which are designed during the acute phase reject Patients may be
less flexible in an elder age and it may be an association between insight and demographic or clinical difficult for them to combine
these new experiences with their characteristics in patients with mania [6, 11, 17]. A possible own life experiences in a less stressful
way. Patients also may explanation is that the effect of demographic and clinical experience more social consequences when the
disorder begins characteristics might lose the significance when the biological at a younger age and thus may achieve better insight
with time. load and severity of the mental disorder is increased (i.e. acute This is reflected in the study of Dias et al. as well [18],
which phase) and thus the neurocognitive factors become more reveal that BD I patients in remission with a younger age of
important instead. This may be attuned with the view of insight as onset have more awareness about the social consequences of the a
complex phenomenon affected by some traits [i.e. intellectual disorder. ability ([19, 20], personality traits [21] and demographic
factors]
Level of insight was not significantly different between males and some states (such as clinical factors, different phases of the
and females in the current study but this relation is reported to illness and effects of treatments). The effect of these different be
significant in other studies. In a study by Yen et al. [1] male components on insight may be adjusted by the environmental gender
was associated with poor insight in remitted BD I. Dias and biological factors, severity and chronicity. In a prospective et al. [18]
reported more preserved insight among female patients study, Yen et al. showed that building insight is an important step
9. The association between acute phase insight and demographic-clinical characteristics in psychotic manic
patients
Item Age Education Duration of disorder Age of onset No. of admission

Mean (SD)
Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Awareness of disorder
36.4 (10.2) 6.3 (5.8) 12.9 (9.7) 22.4 (8.0) 5.0 (6.6)
Aware/Somewhat

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 Manag Epidemiol Public Health, 2016, 1(1): 1-9

Table
aware (n=20)
Unaware (n=40) 32.5 (9.1) 7.2 (4.9) 9.6 (8.5) 22.9 (7.0) 4.1 (6.3)
Awareness of consequences
Aware/Somewhat 34.4 (10.6) 6.1 (5.8) 12.8 (10.3) 21.8 (6.4) 3.1 (3.2)
aware (n=19)
Unaware (n=41) 33.5 (9.2) 7.3 (4.9) 9.7 (8.2) 23.1 (7.7) 5.0 (7.4)
Awareness of medication effects
Aware / Somewhat aware 34.4 (9.7) 6.5 (5.4) 11.8 (9.5) 21.9 (6.9) 4.9 (7.3)
(n=31)
Unaware (n=29) 33.1(9.6) 7.3(5.1) 9.4(8.4) 23.7(7.7) 3.9(5.3)
Awareness of hallucination
Aware/Somewhat aware (n=2)
45.0 (19.7) 6.0 (8.4) 17.5 (14.8) 27.5 (4.9) 5.5 (3.5)
Unaware (n=26) 33.4 (9.4) 6.4 (4.7) 11.0 (9.1) 21.5 (7.1) 4.1 (6.6)
Awareness of delusion
Aware/Somewhat aware (n=3) 35.3 (13.0) 8.0 (6.9) 12.3 (15.6) 23.0 (2.6) 1.0 (1.7)
Unaware (n=55) 33.4 (9.0) 6.9 (5.1) 10.4 (8.5) 22.5 (7.5) 4.6 (6.6)
Awareness of thought disorder
Aware/Somewhat aware (n=8) 36.7 (13.1) 4.5 (4.7) 12.2 (12.5) 21.0 (9.5) 6.0 (9.5)
Unaware (n=28) 34.5 (10.7) 5.9 (5.4) 11.6 (8.6) 22.9 (8.5) 5.3 (6.8)
Table 10. The association between acute phase insight and demographic-clinical characteristics in psychotic manic
patients
Item Sex Marital status Familial history Congruency of No. of psychotic
psychosis symptoms
1 2
Male Female Single/Divorced Married Positive Negative Congruent Non-c
Awareness of disorder
Aware/Somewhat aware 14 6 10 10 5 15 14 6 11 9
(38.9) (25) (32.3) (34.5) (33.3) (33.3) (31.1) (40) (31.4) (36)
Unaware 22 18 21 19 10 30 31 9 24 16
(61.1) (75) (67.7) (65.5) (66.7) (66.7) (68.9) (60) (68.6) (64)
Awareness of consequences
Aware/Somewhat aware 13 6 12 7 7 12 14 5 9 10
(36.1) (25) (38.7) (24.1) (46.7) (26.7) (31.1) (33.3) (25.7) (40)
Unaware 23 18 19 22 8 33 31 10 26 15
(63.9) (75) (61.3) (75.9) (53.3) (73.3) (68.9) (66.7) (74.3) (60)
Awareness of medication
effects
Aware/Somewhat aware 20 11 18 13 9 22 24 7 16 15
(55.6) (45.8) (58.1) (44.8) (60) (48.9) (53.3) (46.7) (45.7) (60)
Unaware 16 13 13 16 6 23 21 8 19 10
(44.4) (54.2) (41.9) (55.2) (40) (51.1) (46.7) (53.3) (54.3) (40)
Awareness of hallucination
Aware/Somewhat aware 2 0 0 2 0 2 1 1 1 1
(14.3) (0) (0) (16.7) (0) (10) (4.8) (14.3) (33.3) (4)
Unaware 12 14 16 10 8 18 20 6 2 24
(85.7) (100) (100) (83.3) (100) (90) (95.2) (85.7) (66.7) (96)

(Contd...)

10. Continued...
Item Sex Marital status Familial history Congruency of No. of psychotic
psychosis symptoms

Male Single/Divorced Positive

Female Married Negative Congruent Non-c 1 2

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 Manag Epidemiol Public Health, 2016, 1(1): 1-9

Table
Awareness of delusion
Aware/Somewhat aware
2 1 1 2 1 2 2 1 1 2
(5.9) (4.2) (3.3) (7.1) (7.1) (4.5) (4.7) (6.7) (3) (8)
Unaware 32 23 29 26 13 42 41 14 (93.3) 32 (97) 23 (92)
(94.1) (95.8) (96.7) (92.9) (92.1) (95.5) (95.3)
Awareness of thought
disorder
Aware/Somewhat aware 3 5 3 5 3 5 6 2 3 5
(15.8) (29.4) (17.6) (26.3) (30) (19.2) (24) (18.2) (13.6) (35.7)
Unaware 16 12 14 14 7 21 19 9 19 9
(84.2) (70.6) (82.4) (73.7) (70) (80.8) (76) (81.8) (86.4) (64.3)
for establishing medication adherence in bipolar patients [22]. Reference
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Some clinical and demographic factors have relations to the
insight of patients with psychotic mania and more studies into
mediating factors contributing these associations are required.
These results might be used to identify patients with poor
prognosis due to poor insight and special intervention to
address this pitfall could be devised.
Acknowledgement
Authors thank Dr. Shahrokh Sardarpur Goodarzi, Dr. Olimpia
Pop and Ms. Sepideh Batengol for their helpful assistance.
Funding
This work was funded by Research Center for Psychiatry and
Behavioral Sciences, Tabriz University of Medical Sciences.
Conflict of interests
The authors declare no conflict of interest.
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Ethical considerations
The present study was approved by Ethical Committee of
Tabriz University of Medical Sciences.
Authors’ Contribution
All authors participated in this study equally.

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