The Impact of Pretreatment Symptoms and Insight On the Therapeutic Congruence During the Treatment of Schizophrenia

Background and purpose:Treatment for individuals with schizophrenia has been a great challenge for social workers in terms of providing and monitoring effective pharmacological and psychosocial interventions.  Therapeutic congruence (the extent to which clients and clinicians perceive treatment issues similarly) regarding the assessment of client reports of adverse events related to antipsychotic medication treatment and the impact of symptoms and insight has rarely been examined.  Knowledge about clients’ baseline symptoms and their insight into their symptoms and illness is an important consideration when evaluating the impact of symptoms on clients’ lives and the extent to which clients and clinicians assess medication adverse events similarly or not.

Methods:Data was obtained from a sample of 876 individuals with schizophrenia or schizoaffective disorder recruited from multi-site randomized controlled trials of antipsychotic medications from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) project supported by NIMH.  This study included demographic and diagnostic data for subjects who have therapeutic assessment congruence or discrepancy with their clinicians, measures of clients’ insight and symptoms, differences between groups with congruent assessment and discrepant assessment in terms of clients’ clinical symptoms and insight, and factors predicting congruent assessment on clients’ adverse events.  Two reliable measurement tools, the Insight and Treatment Attitude Questionnaire (ITAQ) and the Positive and Negative Syndrome Scale (PANSS), were administered to assess clients’ awareness of illness and attitudes toward medication or hospitalization and presence of negative symptoms of schizophrenia. T-test and multivariate logistic regression model were used to examine the crucial factors determining therapeutic congruence.

Results:  Seventy-three percent of clients with schizophrenia and their clinicians have congruent reports on their adverse events experienced related to antipsychotic medication.  Client insight into his or her illness was consistently higher in the therapeutic congruence group. Furthermore, greater insight and enhanced motivation about accepting psychiatric treatment was observed in the therapeutic congruence group. Clients in the therapeutic discrepancy group showed higher levels of both positive and negative symptomatology. A multivariate logistic regression model showed that having negative symptoms and good insight into one’s illness and the need for treatment can be significant predictors for therapeutic congruence between clients and clinicians.

Conclusions and implications:  The findings showed that clients with better insight into their illness and fewer negative symptoms are more likely to have therapeutic congruence with their clinicians. Clients who have higher awareness level of their mental symptoms and have actively sought treatment in the past are more likely to reach agreement with their clinicians’ assessment on their adverse events.  Negative symptoms, such as blunted affect, emotional withdrawal, and poor social rapport in the past, may lead clients into a more congruent therapeutic state with their clinicians.  The study’s implication encourages social workers in their future practice and research to identify the impact of a client’s negative symptoms and insight on the therapeutic congruence in clinical assessment.

Keywords:  schizophrenia, negative syndromes, insight, adverse events, therapeutic congruence