Manic episodes worsen clinical insight

By Lucy Piper, Senior medwireNews Reporter

Patients with bipolar disorder are more likely to have impaired clinical insight after, rather than before, manic exacerbations, researchers report.

This contradicts expectations and suggests that resolution of insight after manic episodes may be delayed.

The study authors Colin Depp (University of California, San Diego, La Jolla, USA) and colleagues explain: “[E]ven though insight may typically improve after a manic episode, manic symptoms represent a risk factor for residual poor insight.

“Thus, psychosocial interventions may be particularly useful after manic episodes. Additionally, it may be inferred that continued efforts to improve insight, particularly for patients experiencing recurrent manic episodes, is an important component to incorporate into future interventions.”

The team measured insight in 106 outpatients with bipolar I or II disorder using the Mood Disorders Insight Scale (MDIS). At baseline, the average MDIS score was 10.6, ranging from 2 to 12. A large proportion (44%) of the patients scored at ceiling (12 points), reflecting no impairment.

But scores fluctuated substantially between and within patients over the 6 months of follow-up, “which is consistent with the view that insight is a fluid construct rather than a trait in bipolar disorder,” the researchers note.

Manic symptoms contributed most strongly to insight, with more severe symptoms at baseline associated with significantly worse insight over follow-up, particularly diminished awareness of illness.

The was no association between poor insight at baseline and worsening of manic symptoms, however.

Refuting previous research, global cognitive abilities were not associated with baseline or future insight overall, although there was a significant association with perceived need for treatment.

Depressive symptoms were also not associated strongly with insight, but better insight at baseline was associated with an increased risk for depressive episodes at later assessments, despite it being reported to have protective effects.

Depp and co-workers point out in the Journal of Affective Disorders that, although manic symptoms were the strongest contributor to insight, they were only modest in association, meaning that a substantial proportion of the between- and within-person variation in insight remains unexplained.

“Given that insight has important ramifications for treatment outcome, future study should examine the influence of clinical features outside of the core aspects of bipolar disorder, which may include other symptom clusters, attitudinal and treatment-related factors,” they conclude.

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