A cross-sectional study was conducted at the Acharya Vinobha Bhave Rural Hospital, Wradha, Maharashtra after getting approval from the Institutional Ethics Committee (MG/MS/IEC/Psy/24). Written informed consent was obtained from patients as well as care givers before including them in the study. The patients were included for over a period of 12 months, from January 2018-December 2018 during which 700 patients admitted to the psychiatry ward were screened. Of these, 100 eligible patients with schizophrenia were enrolled.

Inclusion and Exclusion criteria: This study included patients that satisfied the diagnostic criteria of schizophrenia according to the ICD-10 [9]. It included patients of both sexes aged above 18 years. Any patients having a physical disorder in addition to schizophrenia, other disorders attributable to organic disease, a disorder related to alcohol or drug-related intoxication, dependence, withdrawal, any patient pregnant or in the postpartum period were excluded from the study.

Insight was graded from 0 to 5. Starting at an insight of 0, where the patient denies the illness, it progresses to the patient realising he/she is unwell but denying the need for treatment (grade 1), claiming the illness to not be due to psychiatric but organic or external factors (grade 2), or due to unknown causes (grade 3). Gradually at grade 4 or intellectual insight, the patient is able to accept his/her psychiatric illness but doesn’t relate this to their future experiences whereas at grade 5 or emotional insight he/she is able to apply this knowledge to modify future attitude and behaviour [10].

After diagnosing patients with schizophrenia as per the ICD-10 classifications [9], The Schedule for Assessment of Insight Scale (SAI) [2] was used to determine the patient’s level of insight. Improvement in insight was objectively observed on a daily basis and the SAI was reapplied before discharge. The SAI is a semi-structured clinical interview that determines three aspects of insight. The lowest score of each dimension is zero, treatment compliance and relabeling of psychotic phenomena can be scored a maximum of 4 while recognition of illness can be scored a maximum of 6.

The insight scores of 100 patients with schizophrenia were obtained and tabulated. The proportion of patients with distinct socio-demographic characteristics, clinical profile, psychiatric diagnosis, and SAI scores were calculated. A paired t-test was used for elaborating the results. Analysis was done by strata 10 and the results were documented in percentage format. The p-value <0.05 was considered significant.

Socio-demographic characteristics revealed that majority of the sample were males (62%), between ages 21-40 years of age (68%) and Hindu by religion (86%). Despite 60% of the sample being from rural areas, 57% had completed at least primary education. Of the total sample size, 39% had been diagnosed with schizophrenia for less than 2 years and paranoid schizophrenia was the most common diagnosis [Table/Fig-1,2 and 3].

On SAI scale maximum score of 8 was noted for 6% of patients and zero was noted for 7% patients.

On the contrary, most of these patients showed a good insight at the time of discharge. One patient noted a score of five; five percent of patients noted score six, and seven percent of eight on the SAI scale. Two thirds (62%) of patients who noted scores from 9 to 12 on the SAI scale, demonstrated sustained gains in insight. A maximum score of 14 was noted by two percent of patients. The changes in insight scores from the time of admission (4.15) to the time of discharge (9.28) were statistically significant and similar in both males and females [Table/Fig-4] and results were statistically significant according to marital status [Table/Fig-5]. Significant improvement was seen in patients irrespective of their employment status [Table/Fig-6] or their educational status [Table/Fig-7].

Significant improvement in insight was seen in patients form both rural and urban areas [Table/Fig-8]. When comparing the types of schizophrenia, improvement in insight was seen in all the types. The p-value was significant for paranoid type of schizophrenia [Table/Fig-9].

Based on SAI scale scores the insight scores changed significantly from admission to before discharge. Seven percent of patients noted zero scores on the SAI scale on admission, suggesting complete denial of illness. A retrospective study showed a significant variability of insight in single episodes from the rest of the sample [11]. These findings are supported by a study that observed that as many as 80% of patients with schizophrenia either partially or completely deny acceptance of their mental illness [12].

Structured interventions and therapy proved to help improve and sustain better insight and treatment acceptance in hospitalised patients in a study conducted by Pijnenborg GHM et al., [13]. In this centre as well, Authors have done the intervention in the form of pharmacotherapy and psycho-education of family members. Insight evidently improves independent of psychotic symptoms remission, suggesting insight to be a distinct element of recovery [8,14]. While comparing the gain in insight during a hospital stay, it was found to be equal in males and females. It was higher in the married population. When comparing types of Schizophrenia, though improvement in insight was seen in all types, the p-value was significant in only paranoid type of Schizophrenia.

The literature on psychiatry and psychology readily acknowledges the importance of insight into the diagnosis and treatment of psychoses. The patients premorbid personality, duration of untreated psychoses, symptom intensity, intellectual level as well as social stigma may all contribute to the level of insight [15]. As persons with psychopathology start acknowledging their illness, they also realise the social stigma surrounding their condition making them prone to depression and low self-esteem [16]. A similar prospective study has shown that patients with a better insight into their illness show better compliance towards treatment and hence more improvement, other studies contradict these findings [17]. In conclusion, the results of present study provided an evidence to reinforce the findings of those studies which imply that poor insight prevails in patients of schizophrenia and that insight gradually improves during admission and treatment of functional psychoses [5,7,8,14,17,18].

As the study was time bound, it is better to have large sample, longer follow-up period and many other variables like type of anti-psychotics, treatment duration, dose and medication compliance with various grading of insight. Duration of admission was not considered as a variable in this study.

This study showed that the insight changes as the patient improves during the hospital stay. The change in insight scores as measured by SAI on admission and before discharge is statistically significant. This study highlights that poor insight is commonly seen in psychotic patients and the treatment considerably improves their insight.