Psychiatric Quarterly

, Volume 88, Issue 1, pp 47–53 | Cite as

Correlation Between Insight Level and Suicidal Behavior/Ideation in Bipolar Depression

  • Rafael de Assis da SilvaEmail author
  • Daniel C. Mograbi
  • Jaqueline Bifano
  • Cristina M. T. Santana
  • Elie Cheniaux
Original Paper


Suicide is a relatively common outcome along the course of bipolar disorder. Studies have shown a positive correlation between ideation or attempts of suicide and higher insight in schizophrenic patients. Nevertheless there are still few studies that evaluate the relationship between suicide and insight in mood disorders. Evaluate the relationship between insight and suicidal ideation or behavior in bipolar depression. A group of 165 bipolar patients were followed up along 1 year. Each patient’s mood was assessed in every consultation according to DSM-IV-TR criteria. Suicidal ideation and behavior were prospectively assessed through item 3 of HAM-D whenever a major depressive episode was diagnosed. Insight was evaluated through the Insight Scale for Affective Disorders. A history of suicidal attempts was associated with worse insight in 60 patients with one episode of bipolar depression. The difference remained even when the supposed effect of depression over insight was controlled. No correlation between current suicidal ideation and insight level was found though. Our results suggest that a history of suicide attempts may correlate with higher impairment of insight in bipolar depression. No relationship was found between current suicidal ideation and insight.


Insight Suicide Bipolar depression 



Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Hawton K, Sutton L, Haw C, Sinclair J, Harriss L: Suicide and attempted suicide in bipolar disorder: A systematic review of risk factors. Journal of Clinical Psychiatry 66(6):693–704, 2005.CrossRefPubMedGoogle Scholar
  2. 2.
    Jamison KR: Suicide and bipolar disorder. Journal of Clinical Psychiatry 61(Suppl 9):47–51, 2000.PubMedGoogle Scholar
  3. 3.
    Angst J, Angst F, Gerber-Werder R, Gamma A: Suicide in 406 mood disorder patients with and without long-term medication: A 40 to 44 years’ follow-up. Archives of Suicide Research 9(3):279–300, 2005.CrossRefPubMedGoogle Scholar
  4. 4.
    Valtonen HM, Suominen K, Mantere O, Leppämäki S, Arvilommi P, Isometsä ET: Prospective study of risk factors for attempted suicide among patients with bipolar disorder. Bipolar Disorders 8(5 Pt 2):576–585, 2006.CrossRefPubMedGoogle Scholar
  5. 5.
    Leverich GS, Altshuler LL, Frye MA, Suppes T, Keck Jr PE, McElroy SL, et al.: Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network. Journal of Clinical Psychiatry 64(5):506–615, 2003.CrossRefPubMedGoogle Scholar
  6. 6.
    Amador XF, Flaum MM, Andreasen NC, Strauss DH, Yale SA, Clark SC, Gorman JM: Awareness of illness in schizophrenia and schizoaffective and mood disorders. Archives of General Psychiatry. 51:826–836, 1994.CrossRefPubMedGoogle Scholar
  7. 7.
    Sanz M, Constable G, Lopez-Ibor I, Kemp R, David AS: A comparative study of insight scales and their relationship to psychopathology and clinical variables. Psychological Medicine 28:437–446, 1998.CrossRefPubMedGoogle Scholar
  8. 8.
    Amador XF, Friedman JH, Kasapis C, Yale SA, Flaum M, Gorman JM: Suicidal behavior in schizophrenia and its relationship to awareness of illness. American Journal of Psychiatry. 153:1185–1188, 1996.CrossRefPubMedGoogle Scholar
  9. 9.
    Schwartz RC: Insight and suicidality in schizophrenia: A replication study. The Journal of Nervous and Mental Disease 188:235–237, 2000.CrossRefPubMedGoogle Scholar
  10. 10.
    Acosta FJ, Veja D, Torralba L, Navarro S, Ramallo-Fariña Y, Fiúza D, Hernández JL, Siris SG: Hopeleness and suicidal risk in bipolar disorder. A study in clinically nonsyndromal patients. Comprehensive Psychiatry 53:1103–1109, 2012.CrossRefPubMedGoogle Scholar
  11. 11.
    Yen CF, Cheng CP, Ko CH, Yen JY, Huang CF, Chen CS: Suicidality and its association with insight and neurocognition in Taiwanese patients with bipolar I disorder in remission. The Journal of Nervous and Mental Disease 196(6):462–467, 2008.CrossRefPubMedGoogle Scholar
  12. 12.
    Gonzalez VM: Recognition of mental illness and suicidality among individuals with serious mental illness. The Journal of Nervous and Mental Disorders 196:727–734, 2008.CrossRefGoogle Scholar
  13. 13.
    Del-Ben CM, Vilela JAA, Crippa JAS, Hallak JEC, Labate CM, Zuardi AW: Confiabilidade de “Entrevista Clínica Estruturada para o DSM-IV–Versão Clínica” traduzida para o português/Reliability of the structured clinical interview for DSM-IV—clinical version translated into Portuguese. Revista Brasileira de Psiquiatria 23:156–159, 2010.CrossRefGoogle Scholar
  14. 14.
    Young RC, Biggs JT, Ziegler VE, Meyer DA: A rating scale for mania: Reliability, validity and sensitivity. British Journal of Psychiatry 133:429–35, 1978.CrossRefPubMedGoogle Scholar
  15. 15.
    Hamilton M: A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 23:56–62, 1960.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Chaves AC, Shirakawa I: Positive and negative syndrome scale—PANSS and it use in Brazil. Revista de Psiquiatria Clínica 25:337–343, 1998.Google Scholar
  17. 17.
    Spearing MK, Post RM, Leverich GS, Brandt D, Nolen W: Modification of the clinical global impressions (CGI) Scale for use in bipolar illness (BP): The CGI-BP. Psychiatry Research 73:159–171, 1997.CrossRefPubMedGoogle Scholar
  18. 18.
    Olaya B, Marsà F, Ochoa S, Balanzá-Martínez V, Barbeito S, García-Portilla MP, González-Pinto A, Lobo A, López-Antón R, Usall J, Arranz B, Haro JM: Development of the insight scale for affective disorders (ISAD): Modification from the scale to assess unawareness. Journal of Affective Disorders 142:65–71, 2012.CrossRefPubMedGoogle Scholar
  19. 19.
    Silva RA, Mograbi DC, Filgueiras A, Camelo EVM, Morton GD, Landeira-Fernandez J, Cheniaux E: Cross-cultural adaptation, validation and factor structure of the Insight Scale for Affective Disorders. Journal of Affective Disorders 178:181–187, 2015.CrossRefGoogle Scholar
  20. 20.
    Williams CC, Collins A: Factors associated with insight among outpatients with serious mental illness. Psychiatric Services 53(1):96–98, 2002.CrossRefPubMedGoogle Scholar
  21. 21.
    Schwartz RC: Self-awareness in schizophrenia: Its relationship to depressive symptomatology and broad psychiatric impairments. The Journal of Nervous and Mental Disease 189(6):401–3, 2001.CrossRefPubMedGoogle Scholar
  22. 22.
    Schwartz RC, Smith SD: Suicidality and psychosis: The predictive potential of symptomatology and insight into illness. Journal of Psychiatric Research 38:185–191, 2004.CrossRefPubMedGoogle Scholar
  23. 23.
    Misdrahi D, Denard S, Swendsen J, Jaussent I, Courtet P: Depression in schizophrenia: The influence of the different dimensions of insight. Psychiatry Research 216(1):12–16, 2014.CrossRefPubMedGoogle Scholar
  24. 24.
    Bourgeois M, Swedenson J, Young F, Amador X, Pini S, Cassano GB, Lindenmayer J, Hsu C, Alphs L, Meltzer HY: Awareness of disorder and suicide risk in the treatment of schizophrenia: Results of the international suicide prevention trial. American Journal of Psychiatry 161:1494–1496, 2004.CrossRefPubMedGoogle Scholar
  25. 25.
    David AS: Insight and psychosis. British Journal of Psychiatry. 156:798–808, 1990.CrossRefPubMedGoogle Scholar
  26. 26.
    Kemp R, David A: Insight and compliance. In: Blackwell B (Ed): Insight and compliance. Newark (NJ): Gordon and Breach Publishing Group p. 61–84, 1996.Google Scholar
  27. 27.
    Yen CF, Lee Y, Tang TC, Yen JY, Ko CH, Chen CC: Predictive value of self-stigma, insight, and perceived adverse effects of medication for the clinical outcomes in patients with depressive disorders. The Journal of Nervous and Mental Disease 197(3):172–177, 2009.CrossRefPubMedGoogle Scholar
  28. 28.
    Silva RA, Mograbi DC, Silveira LAS, Nunes ALS, Novis FD, Landeira-Fernandez J, Cheniaux E: Insight across the different mood states of bipolar disorder. Psychiatric Quarterly 86:395–405, 2015.CrossRefGoogle Scholar
  29. 29.
    Silva RA, Mograbi DC, Camelo EVM, Bifano J, Wainstok M, Silveira LAS, Cheniaux E: Insight in bipolar disorder: A comparison between mania, depression and euthymia using the Insight Scale for Affective Disorders. Trends in Psychiatry and Psychotherapy. 37:152–156, 2015.CrossRefGoogle Scholar
  30. 30.
    Silva RA, Mograbi DC, Landeira-Fernandez J, Cheniaux E: O insight no transtorno bipolar: Uma reviso sistemtica. Journal Brasileiro de Psiquiatria. 63(3):242–254, 2014.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Rafael de Assis da Silva
    • 1
    • 2
    Email author
  • Daniel C. Mograbi
    • 3
    • 4
  • Jaqueline Bifano
    • 2
  • Cristina M. T. Santana
    • 2
    • 3
  • Elie Cheniaux
    • 2
    • 5
  1. 1.Universidade Federal do Estado do Rio de Janeiro (UNIRIO)Rio de JaneiroBrazil
  2. 2.Laboratório de transtorno bipolarInstituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB/UFRJ)Rio de JaneiroBrazil
  3. 3.Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio)Rio de JaneiroBrazil
  4. 4.Institute of PsychiatryKing’s College LondonLondonUK
  5. 5.Faculdade de Ciências Médicas da Universidade do Estado Do Rio de Janeiro (FCM/UERJ)Rio de JaneiroBrazil

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