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The Relationship between Insight and Suicide Risk in Early Psychosis: Key Findings from Our Latest Study

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Image shows a young man in distress and the article discussing the relationship between Insight and suicide risk

Introduction

The Insight Paradox: A Double-Edged Sword

First-episode psychosis (FEP) is a critical period filled with challenges, including a significantly increased risk of suicide, particularly during the first year of treatment1. This reality calls for a deeper understanding of the factors contributing to suicide risk and how we can mitigate it. Our latest research explores the intricate relationships between clinical awareness (commonly referred to as “insight”), depression, and suicidality2. With data from 264 participants enrolled in coordinated specialty care (CSC) services, our findings aim to guide improved care strategies for individuals navigating FEP.

In the context of psychosis, insight refers to an individual’s awareness of their condition and need for treatment. While greater insight often leads to better treatment adherence and social functioning, it can also increase depression and suicidal thoughts—a phenomenon known as the “insight paradox”3.

Our study found that individuals with better insight at admission into specialized care were more likely to experience suicidality at six and twelve months2. However, depression emerged as a key mediator, helping explain why better insight sometimes leads to higher suicide risk.

Depression: The Strongest Predictor of Suicide Risk

Depression, a common but often under-recognized aspect of FEP, played a central role in our findings. At admission, depression explained 27% of the effect of insight on suicidality at six months and nearly 20% at twelve months. Alarmingly, some participants experienced persistent depression over time. Of those who were depressed at admission, 18% continued to struggle at both six and twelve months. Depression was the strongest predictor of suicidality in our study, aligning with findings in the literature4. These results underscore the urgent need to identify and address depression early in psychosis care to prevent emotional suffering and reduce suicide risk.

Why It Matters

Understanding the link between insight, depression, and suicidality is critical for improving treatment outcomes in FEP. While gaining insight can be a step forward, it may also bring emotional challenges. Depression is common in FEP, affecting around 40% of individuals at illness onset5—a finding consistent with our study2. Depression during FEP does not just increase the risk of suicide; it also makes recovery more challenging, impacting functioning and quality of life4. Our study emphasizes the need for coordinated care that prioritizes mental health concerns like depression alongside psychosis management.

What Can Be Done?

For clinicians:

  • Monitor Depression Closely:

    Depression is common in FEP but often underrecognized. Regular assessments using validated tools such as the Calgary Depression Scale for Schizophrenia can help identify those in need of targeted interventions.

  • Provide Psychoeducation:

    Helping patients and families understand the emotional complexities of psychosis and insight can foster a supportive and empathetic environment.

  • Tailor Interventions:

    Individualized care plans, including therapy and appropriate medications, can address persistent depression and reduce suicide risk.

For Families and Caregivers:

Support from families and caregivers plays a crucial role in recovery. Being aware of emotional dynamics can help you provide better support. Encouraging open conversations and creating a safe environment for sharing feelings can make a significant difference. Check out our previous blog post for detailed advice on how to support someone with FEP experiencing depression.

It’s also important to watch for signs of suicidal thoughts or actions, such as sudden withdrawal, expressions of hopelessness, or changes in mood. If you notice these warning signs, don’t hesitate to reach out for help. In an emergency, call 911 or 988 (the suicide and crisis hotline).

For Individuals Experiencing FEP:

Understanding the connection between insight and emotional well-being can be empowering. Recovery is possible, and taking steps to care for your mental health can make a difference. Here’s what you can do:

  • Seek Support:

    Talk to a trusted family member, friend, or caregiver about how you’re feeling.

  • Reach Out for Professional Help:

    If you’re feeling sad, hopeless, or overwhelmed, contact a mental health provider. In an emergency, call 911 or 988.

  • Stick to Your Treatment Plan:

    Take medications as prescribed and attend therapy or follow-up appointments.

  • Engage in Activities You Enjoy:

    Find comfort in activities like listening to music, journaling, or walking.

  • Build a Support Network:

    Join a support group or involve loved ones in your recovery.

If you want to learn more about navigating psychosis, explore our resources to get started.

What’s Next?

Our findings point to a brighter future for early psychosis care. By integrating tools like standardized depression screening measures into routine assessments, clinicians can more effectively identify and monitor depression6. Targeted therapies, such as cognitive-behavioral therapy (CBT), show promise in addressing both depression and suicidal thoughts, offering hope for better outcomes7,8.

The future of FEP care depends on a holistic approach that prioritizes mental health alongside psychosis treatment. Proactive, comprehensive care not only has the potential to save lives but also to improve the overall quality of life for individuals navigating this challenging journey. Early detection and timely treatment are critical to preventing tragedy and ensuring better long-term outcomes.

For more information, you can follow the Provider Trainings and Family & Community Workshops hosted by the STEP Learning Collaborative, where experts discuss psychosis and offer support strategies  for both providers and families.

 

Author: Sumeyra Tayfur, PhD

References

  1. Bornheimer, L. A. (2019). Suicidal ideation in first‐episode psychosis (FEP): Examination of symptoms of depression and psychosis among individuals in an early phase of treatment. Suicide and Life‐Threatening Behavior, 49(2), 423-431. https://doi.org/10.1111/sltb.12440
  2. Tayfur, S.N., Song, Z., Li, F., Hazan, H., Gibbs-Dean, T., Purushothaman, D., Karmani, S., Ponce Terashima, J., Tek, C. and Srihari, V. (2025). Insight and suicidality in first-episode psychosis: The mediating role of depression. Schizophrenia Research, 275, 189-195. https://doi.org/10.1016/j.schres.2024.12.013.
  3. Davis, B.J., Lysaker, P.H., Salyers, M.P., Minor, K.S. (2020). The insight paradox in schizophrenia: a meta-analysis of the relationship between clinical insight and quality of life. Schizophrenia Research, 223, 9–17. https://doi.org/10.1016/j.schres.2020.07.017.
  4. McGinty, J., Haque, M. S., & Upthegrove, R. (2018). Depression during first episode psychosis and subsequent suicide risk: a systematic review and meta-analysis of longitudinal studies. Schizophrenia research, 195, 58-66. https://doi.org/10.1016/j.schres.2017.09.040.
  5. Sönmez, N., Romm, K. L., Andreasssen, O. A., Melle, I., & Røssberg, J. I. (2013). Depressive symptoms in first episode psychosis: a one-year follow-up study. BMC psychiatry, 13, 1-9. https://doi.org/10.1186/1471-244x-13-106.
  6. Bashir, Z., Griffiths, S.L., Upthegrove, R. (2022). Recognition and management of depression in early psychosis. BJPsych Bulletin, 46(2), 83–89. https://doi.org/10.1192/bjb.2021.15.
  7. Pelizza, L., Quattrone, E., Leuci, E., Paulillo, G., Azzali, S., Pupo, S., & Pellegrini, P. (2022). Anxious-depressive symptoms after a first episode of schizophrenia: response to treatment and psychopathological considerations from the 2-year “Parma Early Psychosis” program.Psychiatry research,317, 114887. https://doi.org/10.1016/j.psychres.2022.114887.
  8. Pelizza, L., Maestri, D., Leuci, E., Quattrone, E., Azzali, S., Paulillo, G., & Pellegrini, P. (2022). Individual psychotherapy can reduce suicidal ideation in first episode psychosis: Further findings from the 2‐year follow‐up of the ‘Parma early psychosis’ program.Clinical Psychology & Psychotherapy, 29(3), 982-989. https://doi.org/10.1002/cpp.2678.