Insight in patients with bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

ABSTRACT

Background:

There are limited number of studies evaluating insight among patients with bipolar disorder (BD).

Aim:

This study aimed to examine insight and its correlates in BD using the data from the multicenter BD course and outcome study from India (BiD-CoIN). The additional aim was to evaluate the insight in patients with BD using different scales and understand the correlates of insight.

Materials and Methods:

773 BD patients presently in clinical remission were evaluated on the Insight Scale for Affective Disorders (ISAD), insight items of the Hamilton Depression Rating Scale (HDRS), and the Young Mania Rating Scale (YMRS).

Results:

The assessment scales influenced the prevalence of poor insight. Poorer insight irrespective of the assessment scale was consistently associated with higher residual depressive and manic symptoms, and a higher level of cognitive impairment and disability. Poor insight as assessed by ISAD was associated with a higher number of episodes in the lifetime, shorter duration of current remission, a higher number of depressive episodes, a higher amount of time spent in depressive episodes, higher depressive affective morbidity, a higher number of manic episodes, and higher residual depressive and manic symptoms.

Conclusion:

Poor insight in BD is consistently associated with higher residual depressive and manic symptoms and a higher level of cognitive impairment and disability. However, in terms of course variables, the correlates vary depending on the assessment method.

INTRODUCTION

In psychiatry, insight into the illness is understood as the ability of the person to be consciously aware of their condition, recognize symptoms as an indicator of mental illness, and that these symptoms require treatment.[1,2] Insight in psychiatry is primarily discussed in the context of schizophrenia.[3] However, data suggest that many patients with other disorders such as bipolar disorder (BD) and obsessive–compulsive disorder also lack insight into the illness.[4-8]

Compared to schizophrenia, insight has received little attention in patients with BD. However, over recent years, studies from different parts of the world have evaluated insight in patients with BD. These studies suggest that persons with BD also experience impairments in insight both during the acute phase and during remission.[9-11] Because persons with BD have periods of exacerbation and remission, available studies suggest that insight into the illness of persons in clinical remission is better than that in an acute episode.[5,7] Accordingly, insight in BD is conceptualized as more of a state-dependent construct with alterations dependent on different phases of illness. Consequently, available studies have evaluated the insight of persons with BD in the phase of clinical remission,[12-16] mania,[14,17-19] or depressive phase[14,20] of illness. In general, data suggest that people with mania have significantly poorer insight when they are compared to those with mixed mania, bipolar depression, and unipolar depression.[11,17,21] Poorer insight has been linked with higher severity of mania[10,15] and severe depressive symptoms in mixed state.

In terms of correlates of insight in persons with BD, available data are inconclusive with respect to the association of insight with socio-demographic and clinical variables. Factors that have been inconsistently shown to be associated with better insight include higher age,[12,21,22] female gender,[13] higher number of hospitalizations, longer duration of illness, lower number of episodes at the time of assessment,[13,21,22] better cognitive functions,[23,24] better medication adherence,[25] better therapeutic alliance,[26-28] higher self-reported quality of life,[29] and a higher level of stigma.[30]The improvement in insight is associated with better psychosocial functioning.[31] A higher level of insight has also been shown to be associated with an increase in suicidal ideations.[25]

However, one of the major limitations of the available studies is that they have evaluated insight in persons with BD using scales primarily designed to assess insight in patients with schizophrenia,[12] or have relied on up to items of the Hamilton Depression Rating Scale (HDRS), Young Mania Rating Scale (YMRS), and scale for manic symptoms.[31] HDRS and YMRS assess insight based on a single item of the scale, which does not provide detailed information about various aspects of insight. Only a handful of studies have used affective disorder-specific scales such as Insight Scale for Affective Disorders (ISAD) and Mood Disorder Insight Scale (MDIS) to assess insight in persons with BD.[14,20,32] Overall, the sample size of studies that have evaluated insight among persons with BD has been relatively small, varying from 28 to 236 patients.[20]

Data on the insight of persons with BD from India are scarce. Available studies suggest that insight in persons with BD is state-dependent[14,33] and improves with improvement in psychopathology.[30] One study showed that the insight of persons with BD is better than that observed in patients with schizophrenia.[34] Considering that majority of the studies have included patients of variable duration of illness, have not used affective disorder-specific insight scale, and are of small sample size, we used the data from the multicenter BD course and outcome study from India (BiD-CoIN), to examine insight and its correlates in BD. An additional aim was to evaluate the insight in patients with BD using different scales and understand the influence of the same on the correlates of insight. It was hypothesized that better insight would be associated with better course and outcome (lower number of lifetime episodes), lower level of cognitive impairment, and lower level of disability.

MATERIALS AND METHODS

We conducted this study across 14 centers in India after approval from respective local ethics committees. The study methodology and sample description have been published before.[35] The study focused on course,[35] predominant polarity,[36,37] insight, disability, subjective cognitive impairments, residual psychopathology,[38] comorbid substance use disorder[39] and prescription patterns.[40] This paper focuses on insight.

Participants were recruited by purposive sampling after obtaining written informed consent. Inclusion criteria were the diagnosis of BD, as per the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), determined using the Mini-International Neuropsychiatric Interview (MINI-PLUS), age ≥18 years, illness duration of ≥10 years, currently in clinical remission (HDRS score of ≤7 and YMRS score ≤7), and able to read and write Hindi/English or the local language. Those with evidence of organic brain syndrome, intellectual disability, secondary BD, currently in an acute episode, or who were medically unfit to participate were excluded.

We assessed insight using the insight item of the HDRS and YMRS scales and the ISAD. The participants were also assessed on National Institute of Mental Health-Retrospective Life Charts, clinician version for assessment of the longitudinal clinical course of the illness (mean number of lifetime episodes—total, depressive, manic, hypomanic, mixed; mean number of episodes in lifetime—total, depressive, manic, hypomanic, mixed; time spent in each type of episodes, affective morbidity; mean severity of each type of episodes; polarity of the most recent episode; predominant polarity, recurrent mania course in the lifetime; presence/absence of life suicide attempt, psychotic symptoms, receiving electroconvulsive therapy (ECT), lifetime history of hospitalization; seasonality of the episodes, lifetime history of rapid cycling, comorbid substance dependence, lifetime history of breakthrough episodes, lifetime history of medication nonadherence; and current obesity and prescriptions) by the clinicians.

Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA)[40] was used for evaluation of cognitive functions and Indian Disability Evaluation Assessment Scale (IDEAS) was used for assessment of disability.[41]

ISAD is a 17-item scale, which is based on the Scale to Assess Unawareness of Mental Disorders (SUMD) scale. Each scale item is rated on a 6-point scale (0—cannot be evaluated or item not relevant to 5—no awareness). The scale has adequate face and content validity. As some of the items of ISAD assess more than one aspect of insight, we divided these items (e.g., item 2 of the scale states: awareness of treatment efficacy for current symptoms and for preventing relapses; we divided this into two separate items, one focusing on treatment efficacy for the current symptoms and other focusing on preventing relapses). The items that were divided include item number 2 (divided into two items), number 3 (divided into three items), and numbers 4–12 (each split into two items), resulting in a 29-item scale. We calculated the total score for all 29 items for calculating the total ISAD score. Further to maintain the comparability, we also calculated the total score for the 17 items as described by the original authors. For the items, which were divided into two or three parts, we took the higher score of the same item on any of its subparts for example, if a person was rated as 3 on subitem 2a and 4 on subitem of 2b, for calculating the total score for 17 items, the score of 2b, which was higher than the score of 2a, was considered. The ISAD was translated to Hindi using standard World Health Organization Methodology. ISAD in the present study was administered by the clinicians. In the present study, the scale of the ISAD-17 items was the primary outcome measure to evaluate the association of insight with demographic and clinical variables. However, the association with other measures of insight was also evaluated.

The insight item of HDRS is rated on a 3-point scale of 0–2, with “0” indicating no loss, “1” indicating partial or doubtful loss, and “2” showing loss of insight. The insight item of YMRS is rated on a 5-point scale, with a “0” rating suggestive of the patient admitting being ill and agreeing to the need for treatment, rating of “1” is given when the patient considers himself to be possibly ill, “2” indicating patient admitting behavior change, but denies illness, “3” suggesting patient accepting a possible behavior change, but denies illness, and finally “4” indicating denial of any behavior change.

COBRA[41] is a 16-item self-report instrument. It allows for assessing subjective cognitive dysfunctions in subjects with BD. The scale has high convergent validity and high internal consistency, and a score of >10 is considered an indicator of the presence of cognitive impairment.

IDEAS[42] was developed by a group of researchers from India. The government of India has approved it to certify disability in persons with various mental disorders. It assesses disability in four domains: self-care, interpersonal activities, communication and understanding, and work. Each item is scored on a 5-point scale with a range of 0–4, that is, from no (0) to profound disability (4). Additionally, the duration of illness is also given weightage while computing the global disability score. The global disability score is calculated by adding the “total disability score” and duration of illness score. A global disability score of more than 7 signifies a disability of >40%, which is considered a significant disability for any governmental benefits.

Statistical analysis was performed using Statistical Package for Social Sciences, 14^th Version (SPSS-14). Frequency and percentages were computed for the discontinuous variables. The mean and standard deviation were evaluated for the continuous variables. The association between different variables was studied using Pearson’s correlation coefficient and Spearman’s rank correlation coefficient. Considering the multiple associations, a statistical correction was performed to consider the P- value to be significant. For every insight variable, 28 correlations/comparisons were done. Accordingly, a P-value of 0.002 (0.05/28 = 0.0017) was considered significant.

RESULTS

The study included 773 participants recruited across 14 centers, with participants per center varying from 21 to 107, with 11 centers contributing at least 50 participants. The participants had a mean age of 45.66 (SD 10.5) years at the time of assessment, and the mean duration of education was 10.3 (Standard Deviation [SD] 4.45) years. About two-thirds of the participants were males (63.6%) and on paid employment (65.7%). Slightly more than four-fifths of the participants were married (82.7%). Three-fourths (73.2%) of the participants were Hindu by religion. Those from nuclear families (57.6%) and rural localities (53%) outnumbered nonnuclear families and urban localities, respectively. Participants were earning rupees 24,463 (SD: 21,665), with a range of 1000 to 1,00,000 and a median of 18,000 per month at the assessment time.

Table 1 shows the rating on the various insight scales for the study participants. The mean ISAD score for the 17 items was 23.23 (SD: 21.00) and that for 29 items of ISAD was 34.23 (33.69). The mean score for the insight item of HDRS was 0.3 (SD: 0.49), with a median of “0,” and that for YMRS was 0.39 (SD: 0.72), with a median of “0.”

Table 1.

Insight of the study participants

Sl. No	Items	Mean (SD)
1	Awareness of suffering from an affective disorder	1.72 (1.47)
2a	Awareness of treatment efficacy for current symptoms	1.64 (1.49)
2b	Awareness of treatment efficacy for preventing relapses	1.26 (1.56)
3a	Awareness of consequences of the illness on work	1.64 (1.50)
3b	Awareness of consequences of illness on family	1.17 (1.55)
3c	Awareness of consequences of illness on social life	1.19 (1.58)
4a	Awareness of suffering from a depressed mood	1.49 (1.58)
4b	Awareness of suffering from an expansive or irritable mood	1.18 (1.61)
5a	Awareness of suffering from a marked increase in pleasurable activities	1.42 (1.63)
5b	Awareness of suffering from a marked reduction in pleasurable activities	1.06 (1.55)
6a	Awareness of suffering from a significant increase in weight	1.23 (1.50)
6b	Awareness of suffering from a significant loss of weight	0.85 (1.41)
7a	Awareness of suffering from insomnia	1.31 (1.59)
7b	Awareness of suffering from hypersomnia	0.93 (1.52)
8a	Awareness of suffering from sluggishness	1.18 (1.51)
8b	Awareness of suffering from psychomotor agitation	0.89 (1.46)
9a	Awareness of suffering from fatigue	1.40 (1.65)
9b	Awareness of suffering from an excess of energy	0.99 (1.56)
10a	Awareness of suffering from feelings of uselessness or guilt	0.89 (1.35)
10b	Awareness of suffering from the feeling of exaggerated self-esteem or grandiosity	0.82 (1.40)
11a	Awareness of suffering from slowed speech	1.14 (1.52)
11b	Awareness of suffering from verbosity/garrulousness	0.91 (1.48)
12a	Awareness of suffering from bradypsychia	0.92 (1.41)
12b	Awareness of suffering from ideal flight	0.77 (1.38)
13	Awareness of having a short attention span	1.47 (1.73)
14	Awareness of having an untidy appearance	1.06 (1.52)
15	Awareness of having symptoms of confusion—disorientation	1.34 (1.74)
16	Awareness of having poor social relationships	1.33 (1.68)
17	Awareness of suffering from delusions and hallucination	1.00 (1.55)
The total score of 17 items of ISAD		23.23 (21.00)
The total score of 29 items of ISAD		34.23 (33.69)
Total HDRS score		3.10 (3.25)
Insight item score of HDRS (item number 17)		0.30 (0.49)
HDRS insight rating (item number 17)
0- Indicating no loss		558 (72.2)
1- Indicating partial or doubtful loss		201 (26.0)
2- Indicating loss of insight		14 (1.8)
Total YMRS score		2.3 (4.3)
Insight item score of YMRS (item number 11)		0.39 (0.72)
YMRS insight rating (item number 11)
0- Present; admits illness; agrees with the need for treatment		545 (70.5)
1- Possibly ill		184 (23.8)
2- behavior change but denies illness		26 (3.4)
3- Admits possible change in behavior but denies illness		7 (0.9)
4- Denies any behavior change		11 (1.4)

As is evident from Table 2, age at onset and duration of illness did not have any significant association with insight. The total time spent in the episodes had a significant positive correlation with the insight scores on ISAD, suggesting that a higher amount of time spent in episodes was associated with poorer insight. Poorer insight as assessed on ISAD was associated with a higher number of episodes (lifetime and episodes per year of illness), shorter duration of current remission, higher number of depressive episodes in the lifetime, higher number of manic episodes in the lifetime, higher residual depressive and manic symptoms, and a higher level of cognitive deficits and disability. When the associations were evaluated for HDRS insight, poor insight was associated with more time spent in depressive episodes, a higher number of manic episodes in the lifetime, more time spent in mania/hypomania/mixed episodes, higher residual depressive and manic symptoms, and a higher level of cognitive deficits and disability. Additionally, poor insight was associated with depression being the more recent episode, presence of at least one psychotic episode in the lifetime, history of seeking faith-healing treatment, hospitalization in the lifetime, and presence of cognitive impairment. Poor insight as assessed on YMRS was associated with a shorter duration of current remission, more time spent in mania/hypomania/mixed episodes, higher residual depressive and manic symptoms, and a higher level of cognitive deficits and disability. Additionally, poor insight as assessed on YMRS was associated with the presence of at least one episode with psychotic symptoms in the lifetime, history of seeking faith-healing treatment, hospitalization in the lifetime, receiving ECT in the lifetime, and presence of cognitive impairment [Table 3].

Table 2.

Correlation of insight with socio-demographic and clinical variables (Spearman’s rho)

Variables	Mean (SD) n=773	ISAD-17 item-total score rs (P)	ISAD-29 item-total score rs (P)	HDRS insight score rs (P)	YMRS insight score rs (P)
Age of onset (years)	26.30 (8.5)	-0.008 (0.82)	0.015 (0.66)	0.064 (0.07)	-0.005 (0.88)
Duration of illness (months)	231.17 (95.9)	-0.026 (0.46)	-0.047 (0.18)	0.006 (0.86)	0.008 (0.82)
Time spent in episodes (months)	27.24 (30.1)	0.14 (<0.001***)	0.128 (<0.001***)	-0.054 (0.13)	-0.035 (0.32)
Mean number of total episodes in the lifetime	8.58 (10.6)	0.138 (<0.001***)	0.140 (<0.001***)	-0.094 (0.009)	-0.086 (0.017)
Mean number of total episodes per year of illness	0.041 (0.062)	0.149 (<0.001***)	0.167 (<0.001***)	-0.090 (0.009)	-0.077 (0.033)
Duration of current remission (months)	32.84 (50.04)	-0.191 (<0.001***)	-0.195 (<0.001***)	-0.080 (0.026)	-0.138 (<0.001***)
Mean number of depressive episodes per year of illness	0.19 (0.39)	0.182 (<0.001***)	0.195 (<0.001***)	0.042 (0.24)	0.024 (0.50)
Time spent in depression (months)	2.43 (1.13)	0.149 (<0.001***)	0.134 (<0.001***)	0.174 (<0.001***)	0.027 (0.44)
The average severity of depressive episodes	1.87 (0.80)	0.054 (0.13)	0.021 (0.56)	0.043 (0.233)	-0.046 (0.20)
Affective morbidity index—depressive	17.59 (26.47)	0.232 (<0.001***)	0.234 (<0.001***)	0.088 (0.015)	0.050 (0.16)
Mean number of manic episodes per year of illness	0.21 (0.30)	0.128 (<0.001***)	0.146 (<0.001***)	-0.115 (0.001***)	-0.075 (0.037)
Time spent in mania/hypomania/mixed (months)	3.29 (3.67)	-0.023 (0.53)	-052 (0.14)	0.216 (<0.001***)	0.143 (<0.001***)
The average severity of manic/hypomanic/mixed episodes	2.19 (0.40)	0.083 (0.021)	0.141 (<0.001***)	0.011 (0.76)	-0.095 (0.008)
Mean HDRS score	3.10 (3.25)	0.187 (<0.001***)	0.173 (<0.001***)	0.44 (<0.001***)	0.323 (<0.001***)
Mean YMRS score	2.30 (4.3)	0.145 (<0.001***)	0.111 (0.002**)	0.33 (<0.001***)	0.520 (<0.001***)
Total COBRA score	9.79 (6.99)	0.260 (<0.001***)	0.24 (<0.001***)	0.19 (<0.001***)	0.194 (<0.001***)
Mean total IDEAS score	5.64 (2.22)	0.476 (<0.001***)	0.410 (<0.001***)	0.147 (<0.001***)	0.194 (<0.001***)

***P≤0.001

Table 3.

Association of insight with demographic and clinical variables

Clinical variables	Whole sample Mean (SD)/ n (%) n=773	Mean SD of ISAD-17 score	Comparison statistics [Z]	Mean SD of ISAD-29 score	Comparison statistics [Z]	HDRS insight score	Comparison statistics [Z]	YMRS insight score	Comparison statistics [Z]
Diagnosis n (%)
BD Type I	714 (92.37)	23.61 (21.16)	- 1.74 (0.082)	34.84 (34.12)	Z=-1.00 (0.316)	0.30 (0.49)	Z=-1.01 (0.311)	0.40 (0.74)	Z=-1.27 (0.203)
BD Type II	59 (7.63)	18.58 (18.48)		26.84 (27.17)		0.24 (0.46)		0.27 (0.55)
Polarity of the most recent episode
Depression	323 (41.8)	25.44 (19.89)	2.46 (0.014)	36.90 (32.22)	1.87 (0.061)	0.34 (0.51)	Z=-3.34 (0.001**)	0.36 (0.61)	Z=-1.18 (0.235)
Mania/hypomania/mixed	450 (58.2)	21.66 (21.65)		32.31 (33.11)		0.26 (0.47)		0.41 (0.80)
Lifetime suicidal attempts	242 (31.3)	22.18 (18.92)	0.939 (0.34)	31.59 (30.63)	1.47 (0.141)	0.25 (0.47)	Z=-1.76 (0.078)	0.32 (0.67)	Z=-2.21 (0.027)
Lifetime history of breakthrough episodes	282 (36.4)	24.75 (20.71)	-1.51 (1.31)	38.45 (33.67)	-2.648 (0.008)	0.32 (0.50)	Z=-1.11 (0.266)	0.40 (0.65)	Z=-1.39 (0.164)
Patients with substance use disorder	177 (22.5)	24.38 (22.41)	-0.82 (0.41)	36.41 (37.84)	-0.98 (0.32)	0.20 (0.41)	Z=-2.96 (0.003)	0.34 (0.78)	Z=-2.36 (0.018)
Lifetime history of faith-healing treatment	671 (86.7)	23.50 (21.18)	-0.89 (0.37)	34.87 (34.30)	-1.35 (0.17)	0.33 (0.51)	Z=-4.82 (<0.001***)	0.40 (0.70)	Z=-3.13 (0.002**)
Number of patients with history of relapse due to poor medication adherence	505 (65.2)	23.55 (20.02)	-0.55 (0.57)	36.38 (33.38)	-2.44 (0.015)	0.32 (0.49)	Z=-2.17 (0.029)	0.36 (0.58)	Z=-0.68 (0.491)
Any history of hospitalization	402 (51.9)	21.22 (20.59)	2.78 (0.006)	32.51 (33.63)	1.47 (0.142)	0.20 (0.42)	Z=-5.93 (<0.001***)	0.31 (0.77)	Z=-5.64 (<0.001***)
Any history of electroconvulsive therapy	183 (23.6)	22.15 (18.86)	0.79 (0.42)	33.57 (30.39)	0.300 (0.76)	0.23 (0.45)	Z=-1.89 (0.058)	0.27 (0.74)	Z=-4.08 (<0.001***)
COBRA categories
Cognitive impairment present	322 (41.7)	27.65 (21.73)	- 4.99 (<0.001***)	40.74 (35.37)	- 4.60 (<0.001***)	0.39 (0.53)	Z=-4.78 (<0.001***)	0.56 (0.84)	Z=-6.02 (<0.001***)
At least one lifetime episode with psychotic symptoms	326 (42.2)	21.03 (19.07)	2.49 (0.013)	29.94 (29.82)	3.03 (0.002**)	0.17 (0.42)	Z=-6.30 (<0.001***)	0.21 (0.65)	Z=-8.01 (<0.001***)

MS=Mood stabilizer, AP=Antipsychotics, AD=Antidepressant, BZDs=Benzodiazepines. Z: Mann–Whitney Z- (comparisons not marked as Z-values were done using unpaired t-test). ^#Body mass index more than equal to 25 kilograms per meter square. **P≤0.01; ***P≤0.001

DISCUSSION

We evaluated insight among patients with BD using ISAD, HDRS insight item, and YMRS insight item in a sample of 773 patients of BD in clinical remission. When we used the insight item of HDRS, one-fourth (26%) of the participants had a partial or doubtful loss of insight, and another 1.8% had a loss of insight. On YMRS, 30% scored from 1 to 4 on the insight item, suggesting some lack of insight in this proportion of patients. These findings suggest that the prevalence of poor insight in patients with BD may be affected by the assessment method.

Previous studies have also reported an association of poorer insight with a lower number of hospitalizations, shorter duration of illness, higher number of episodes at the time of assessment,[13,21,23] poorer cognitive functions,[23,24] poor medication adherence, poor therapeutic alliance,[19,23,26-28] poorer self-reported quality of life,[23] and lower level of stigma.[30]

The present study supports some of these associations. However, an important finding of the present study includes differences in the association of poor insight with the course and outcome variables depending on the scale used for the assessment of insight. In general, in the present study the correlates of insight as assessed using ISAD-17 and ISAD-29 were consistent. However, when we compare the correlates of insight as assessed by HDRS and YMRS, it is evident from the present study that irrespective of the assessment method, poor insight across all the scales was associated with outcome variables in the form of residual depressive and manic symptoms, and level of cognitive impairment and disability. However, similar consistency was not noted for the course variables. The course variables had a better correlation with the ISAD.

The association of poor insight with more episodes of either polarity and more severe episodes can be understood from various perspectives. It is quite possible that those with poor insight possibly more often become poorly adherent to medication and end up having more episodes and, due to poor medication adherence, develop severe episodes. Further, these patients also avoid hospitalization and hence are deprived of more intensive psychoeducation and continue to have poor insight. The association of poor insight with a higher level of cognitive dysfunction can be understood from the perspective that there is evidence to suggest that poor cognitive functioning leads to poor insight.[43,44] The association of poor insight with the occurrence of breakthrough episodes in a higher proportion of patients and a history of relapse due to poor medication adherence is self-explanatory and is supported by the existing literature[45-47] The association of poor insight with a higher level of residual symptoms and more frequent use of a combination of medication can be indicators of poor adherence, more severe illness, and possible indicators of higher use of medications without proper evaluation of medication adherence. Accordingly, it can be said that addressing insight, medication adherence, and cognitive dysfunction in patients with BD can help in reducing the number of episodes and severity of episodes.

This study has certain limitations. The assessment of insight was cross-sectional, and the association of insight with the longitudinal course may not be a true reflection of the impact of poor insight on the longitudinal course of illness. We have not established the cutoff scores for ISAD. The study was limited to the clinic-attending population, and the finding cannot be generalized to those in the community not seeking treatment. The study was limited to BD patients currently in clinical remission. The inter-rater reliability of the various raters across the different centers was not established.

To conclude, the present study suggests that the assessment of insight in patients with BD is influenced by the type of scale used for assessment. There is also some difference in the correlates of poor insight based on the type of assessment scale. Poor insight is in general associated with more severe illness in terms of time spent in episodes, higher number of episodes, higher level of cognitive dysfunction, and a higher level of residual symptoms and disability. Accordingly, these findings suggest that clinicians managing patients with BD should make all the efforts to improve the insight of patients with BD and to improve the overall outcome of the disorder. Psychoeducation and psychosocial interventions of patients with BD and their caregivers should target to improve the insight of the patient as this can have a significant impact on the long-term course and outcome of BD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.