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Fact Sheet:
LACK OF INSIGHT—a Barrier to Voluntary Treatment

"Lack of insight" (the inability of a person to realize, or accept, that he is suffering a mental illness) has long been believed to stem from defensive denial, partly because of the stigma associated with these diseases. While denial no doubt contributes to some people with mental illness refusing treatment, research shows that lack of insight just as frequently results from the underlying brain disorder itself. The brains of those who suffer from this particular symptom of mental illness are often structurally different from those who do not. Treatment refusals stemming from lack of insight are thus not "informed medical decisions." It is the malfunctioning of the brain itself that causes the impaired decision-making. There is nothing civilly right about denying treatment to people with impaired decision-making who are too sick to obtain help for themselves.

Many scientists in numerous professional publications have reported significant correlation between poor insight and deficits in frontal lobe functioning. Others, some of whom are quoted below, have reported on the devastating consequences of the lack of insight:

• Impaired insight is a very common symptom of schizophrenia and bipolar disorder. Both inpatients and outpatients with schizophrenia and bipolar disorder (manic depression) have shown the same rate of unawareness: about 50%. (Husted J. Journal of the American Academy of Psychiatry & Law Vol. 27, no. 1, 1999. Amador X, et. al. Archives of General Psychiatry, 1994.)

• Being unaware of being ill—lacking insight—is strongly correlated with non-adherence to treatment. (Amador X; Strauss D; Yale S; Gorman J & Endicott J. The American Journal of Psychiatry 150:873-879, 1993. )

• Patients with schizophrenia and schizoaffective disorder with poor insight have very poor adherence to either psychosocial treatment or medication even when they have expressed their desire to participate and work at the program. (Lysaker P; Bell M; Milstein R; Bryson G & Beam Goulet J. Insight and Psychiatry Vol. 57, November 1994.)

• Lack of insight not only leads to noncompliance with community treatment but leads to the revolving door of involuntary hospitalizations. (McEvoy J, Freter S, Everett G, Geller J, Appelbaum P, Apperson L & Roth L. Journal of Nervous and Mental Disease 177(1): 48-51, 1989.)

• There have been fewer studies of insight as it relates to affective disorders such as bipolar disorder, nevertheless, as in schizophrenia, studies of affective disorders find that lower levels of insight are correlated with a poorer course of illness, lack of adherence to treatment and increased involuntary hospitalizations. (Ghaemi N & Pope H, Jr. Lack of Insight in Psychotic and Affective Disorders: A Review of Empirical Studies. Harvard Review of Psychiatry, May/June: 22-33, 1994. Also see Amador et. al. Unawareness of Illness in Schizophrenia, Schizoaffective and Affective Disorders. Archives of General Psychiatry, 1994.)

• The inability of the noninsightful patients to understand they have a brain disorder or to accurately evaluated their living conditions and plan for daily needs supports the necessity for some form of "community Assisted Treatment." Without supervision or court order, the person may not seek treatment, or if temporarily coerced into treatment when hospitalized, be unable or unwilling after discharge to comply with the treatment regime. (Husted, J. Journal of the American Academy of Psychiatry & Law Vol. 27, no. 1, 1999)

� See the following journal articles: Young et. al. Schizophrenia Research, 1993; Lysaker et. al. Psychiatry, 1994; Kasapis et. al. Schizophrenia Research, 1996; McEvoy et. al. Schizophrenia Bulletin, 1996; Voruganti et. al. The Canadian Journal of Psychiatry, 1997; Lysaker et. al. Acta Psychiatrica Scandinavica, 1998; Young et. al. Journal of Nervous and Mental Disease, 1998; Morgan et. al. Schizophrenia Research, 1999a; Morgan et. al. in the journal Schizophrenia Research, 1999b; Smith et. al. Journal of Nervous and Mental Disease, 1999. Also see Bell et. al. in the book Insight & Psychosis, Amador and David, Eds., Oxford University Press.

***This document was compiled by the California Treatment Advocacy Coalition***

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