Management of Psychiatric Disorders in Patients with Poor Insight
Cedric M. Smith
Cynthia A. Pristach
Correction of lack of insight in psychiatric patients has the potential to improve both the accuracy of diagnosis and the effectiveness of therapy. Specific aspects of insight include `awareness' by an individual of specific symptoms and behaviours, plus the awareness that such symptoms can be attributed (by the patient) to the presence of a mental disorder. Although this review focuses on adherence with medication, `insight' encompasses far more than just medications and adherence with medication regimens. Impaired or restricted insight may be the result of many factors, including inability to read or to cognitively understand, deficient `health literacy' and the presence of psychopathology such as delusions or hallucinations, among others. While there is a detrimental effect on therapy because of lack of insight, accurate and comprehensive diagnoses may also be negatively affected because the patient may be unable to provide an adequate history enabling the establishment of such a diagnosis. Nonadherence can now be predicted much more accurately, especially with the use of techniques that assess the insight of the patients and their significant others. A variety of management strategies can be implemented effectively with accurate monitoring of medications and treatment-related behaviours, and by measuring adherence and the prediction of nonadherence. Many factors have been identified which are amenable to diagnostic and therapeutic intervention. Among these are the many simple but frequently overlooked issues including the high cost of medication and general or specific health illiteracy sufficient to make understanding medication directions difficult. However, cost-effective education and truly effective collaborations with patients (and significant others) remain major challenges. The ideal programmes for most patients, and especially those with complex problems such as comorbid alcohol or drug use, are the more comprehensive, multidisciplinary rehabilitation programmes. Such comprehensive strategies are probably cost effective in the long term, although few cost analyses been carried out. Nevertheless, there is ample evidence that even patients who are difficult to manage can be effectively treated as inpatients and subsequently as outpatients. Perhaps the most important aspect of insight and adherence is early assessment and planning for those who are at risk of not cooperating with all kinds of therapy, including medication. The assessment and inventory of the positive factors that will facilitate cooperation and adherence to treatment regimens allows therapists to predict insight and adherence and to tailor their interventions and therapies so as to maximise the beneficial outcome.
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