Longitudinal studies of neurocognition in schizophrenia spectrum disorders (SSD) usually follow relatively young first-episode patients across several years. Comparatively little is known about the neurocognitive trajectory of samples also consisting of older patients. This is a 20-year follow-up study of participants who performed the baseline assessment at different ages and utilizes data from the Swedish Clinical Long-Term Psychosis Study (CLIPS). At baseline, 61 SSD patients were included and available for clinical assessment after 20 years. Of these, 28 performed neurocognitive assessment at both baseline and 20 years later. The test results from this group were used for this study. After 20 years, the participants exhibited significantly worsening cognitive flexibility, verbal learning, verbal retention memory, and verbal intellectual function compared to baseline. All the statistically significant differences from baseline to follow-up had large effect sizes. The other cognitive domains showed no statistically significant changes from baseline for either group. We conclude that although the overall picture was one of neurocognitive stability across 20 years, our participants showed signs of accelerated ageing in the verbal domain specifically.

Lifespan in schizophrenia spectrum disorders (SSD) is up to 20 years shorter than average. Introduction of new antipsychotic pharmaceuticals has not made any major improvement. Parallel care is provided as usual standard care (USD) in out-patients settings. The study aim was to evaluate if inclusion of Measurement Based Care (MBC) may prolong patients' lifespan. In total, 171 patients were followed with annual semi-structured examinations of psychiatric status, social situation, and somatic illnesses over 20 years, by case managers. Findings indicate that MBC contributed to prolonged lifespan in SSD from 55.6 to 69.4 years from beginning to end of the study.

Achieving symptomatic remission, as defined by the Remission in Schizophrenia Working Group, is intended to be a meaningful outcome for individuals with schizophrenia, resulting in enhanced well-being. Cross-sectional studies have reported an association between symptomatic remission and subjective quality of life (QoL). Longitudinal studies aimed at examining this association have showed mixed results. The aim of this study was to explore the relationship between symptomatic remission and subjective QoL, both cross-sectionally and longitudinally. The study comprised data from what were at most 386 patients with schizophrenia, of whom 122-140 were followed over a period of four years. Based on cross-sectional remission status and longitudinal remission pattern, differences in subjective QoL were explored. Remission status was assessed using the Positive and Negative Syndrome Scale (PANSS), and subjective QoL using the Short Form-36 Health Survey (SF-36). Both the cross-sectional and the longitudinal approach showed that patients in symptomatic remission had significantly higher subjective QoL. Patients who were in non-remission at baseline, but who achieved remission at follow-up, also had significantly higher subjective QoL at follow-up compared with baseline. The results from the study show a clear association between symptomatic remission and subjective QoL. However, achieving symptomatic remission does not appear to be a guarantee of sustained subjective QoL, and only continued stable remission appears to result in such an outcome.

Individuals with schizophrenia spectrum disorders (SSD) have significantly lower life-expectancy than healthy people. Previously, we have identified baseline neurocognitive function in general and verbal memory and executive function in particular as related to mortality nearly two decades later. In this study, we aim to replicate these findings with a larger and age-matched sample. The patient group consisted of 252 individuals, 44 of whom were deceased and 206 alive. Neurocognition was assessed with a comprehensive battery. Results showed that the deceased group, compared to the living group, had significantly more severe neurocognitive deficits across nearly all domains. There were no differences in sex, remission status, psychosis symptoms, or function level between the groups. Immediate verbal memory and executive function were the strongest predictors of survival status. These results were nearly identical to our previous studies, and we conclude that baseline neurocognitive function is an important predictor for mortality in SSD. Clinicians should be mindful of this relationship in patients with significant cognitive deficits.

Abstract Background Schizophrenia patients that lack capacity or motivation to follow treatment instructions show reduced possibility for stable improvement of clinical status and an increased risk for recurrent symptomatic episodes. The aim of this study is to assess the relationship between components known to be important for treatment adherence: patients’ satisfaction with pharmacological treatment, illness severity, cognitive capacity and insight in symptoms and disease. Methods Data are derived from 507 patients enrolled in a long-term prospective study in Sweden. All parameters were assessed at baseline for a cross-sectional relational analysis. Insight as well as remission state were also determined each year in a 3-year follow-up longitudinal study. Results Patients satisfied with treatment show less severe symptoms, are more often in remission and show a higher degree of insight in symptoms and disease. Neither satisfaction with treatment nor insight correlates to cognition in this study. During follow-up, insight scores increased in parallel to the number of patients in remission in the group where patients alternate between remission and not-remission. Insight in symptoms increased first and thereafter insight regarding underlying cause, is else schizophrenia as a disease. Conclusions Patients that clinically do better are more satisfied with treatment and show more insight in their symptoms and disease. Positive treatment results appear to directly improve patients’ satisfaction and insight, suggesting those to be a state phenomenon secondary to treatment outcome. This supports the need for stable symptomatic remission as treatment goal.

PURPOSE:Neurocognitive outcomes are frequently used as indicators of real-world functioning in schizophrenia spectrum disorders (SSD). These test results may be influenced by individual differences, such as affective dispositions. Here we investigate the relationship between positive and negative affect and neuropsychological test scores in a large, mixed-gender, population based group of participants without co-morbid substance abuse.MATERIALS AND METHODS:We assessed 129 male and female SSD patients with the Positive and Negative Affect Schedule (PANAS) and a comprehensive neuropsychological test battery.RESULTS AND CONCLUSIONS:The neuropsychological test scores were mainly predicted by age and gender, with small contributions from negative psychosis symptoms. There was a statistically significant relationship between Positive Affect and processing speed and between Negative Affect and verbal memory and executive function. However, the level of neurocognitive function variance explained by these affects was only 5%. Thus, the neurocognitive test results were not associated with trait affect in any clinically significant manner. This adds to previous findings of no relationship between affective dispositions and psychosis symptom variables in our participants. We suggest that affective traits constitute an independent dimension that may influence well-being, coping, and real-life outcome in SSD patients directly, and not through neurocognitive function.

Abstract Background Patients with schizophrenia spectrum disorder have a reduced life time expectancy with up to 20 years. Obesity and metabolic syndrome is highly prevalent and cardio vascular disease, CVD, remain the most common cause of the excess mortality. Despite studies showing the reduced life time expectancy and its causes the patients with schizophrenia spectrum disorder yet remain to benefit of the development of the healthcare. In this study we aim to focus on how the weight changes in different age groups and when do the cluster of conditions of metabolic syndrome start to occur. Methods In this naturalistic study we follow 71 patients, 47 man and 24 women diagnosed with schizophrenia spectrum disorder. We divided the patients into 5 different groups based on age. Group 1 aged 20–30 years, Group 2 aged 31–40 years, Group 3 aged 41–50 years, group 4 aged 51–60 years and Group 5 aged 61 years and elder. The longest time of observation was 18 years. Data on weight (kg) and disorders such as diabetes, hypertension and dyslipidemia were collected at baseline and then yearly thereafter. Data from baseline and the last yearly follow up were included in this study. Weight and the presence of the cluster of conditions that make up metabolic syndrome in the above-mentioned groups were analyzed. Results Patients in group 1 make the highest gain of weight with 0, 9 kg per year and group 2 with the least gain of weight only 0, 01 kg per year. Patients in group 3 have a weight loss of 0, 2 kg per year. At endpoint 9 out 19 patients in group 3 and 11 out of 21 patients in group 4 were treated for one, two or three conditions of the metabolic syndrome. Discussion In our study we show that weight gain appears at least 10 years before the development of metabolic syndrome. Despite the loss of weight that appear in group 3 the negative effects of the weight gained a decade earlier may be a factor that make patients aged 41 years and older to be at risk of developing metabolic syndrome.

Abstract Background Patients with schizophrenia have difficulties in judging their own performance. Patients with no or little practical experience of demands from active performance in society tends to overestimate their ability. Research has also found that patients who overestimate their function also runs a risk to be perceived as better functioning than what they actually are when judged by caregivers. The aim with this study is to examine if patients who overestimate their ability will receive less community support compared to patients who have an accurate perception of their ability? Methods The study population was 184 patients with schizophrenia spectrum disorder. They were tested with the Swedish version of the UCSD Performance-based Skills Assessment–Brief Version (UPSA-B). Before the test they were asked how they thought their functioning were in four different domains covered in the UPSA-B. After the test they were divided into four groups: “Good functioning with realistic perception”, “Good functioning but underestimating their function”, “Impaired function with realistic perception” and “Impaired function but overestimating their performance”. The amount of received community support were investigated and related to patients′ actual performance and self-perception. Results Analyzes showed that patients who had an impaired function and a realistic view of their ability had more support than those who were impaired but overestimated their ability. Also, patients with good functioning but underestimating their performance had more support than those who had a good ability and a realistic perception. Finally, there were no difference in community support to the patients in the two groups “Good function with realistic perception” and “Impaired function but overestimating their performance”. Discussion Our results indicate that patients with impaired functioning who overestimate their ability risk an insufficient community support. This in combination with earlier findings, that staff-members in psychiatric out-patient settings are likely to base their judgement on patients′ report consequential leading to false positive conclusions, may have both short- and long-term implications. Not achieving symptomatic remission, as a consequence of inability to follow medical prescriptions, and sub-optimal social functioning with isolation are two possible implications. The findings once again raises the need for the testing of patients′ function instead of only conducting interviews.

Neurocognitive variability exists within the schizophrenia spectrum disorder (SSD) population, with subgroups performing at the same level as healthy samples Here we study the relationship between different levels of neurocognitive responding and real-world functioning. The participants were 291 SSD patients and 302 healthy controls that were assessed with a comprehensive neurocognitive battery. In addition, the patients were assessed with the Specific Level of Functioning Scale (SLOF). The results showed that the mean neurocognitive test responses of the SSD group were significantly below that of the control group. However, there was considerable overlap between the cognitive scores of the two groups, with as many as 24% of the patients performing above the mean healthy score for some domains. Moreover, the patients with the highest level of neurocognitive functioning reached the highest levels of practical and work-related functioning outcome skills. There was no significant relationship between neurocognitive and social function skills. The large differences in cognitive performance and their associations with functional outcome within the patient group are rarely addressed in clinical practice, but indicate a clear need for individualized treatment of SSD. Early identification of cognitive risk factors for poor real-life functional outcome is necessary in order to alert the clinical and rehabilitation services about patients in need of extra care.

Cognitive impairment is an established feature of schizophrenia. From a cross-sectional perspective, studies have revealed associations between cognition and remission. Few studies have examined this relationship longitudinally. Here we examine which cognitive domains might be related to long-term remission and symptomatic severity. The present study followed 173 outpatients with schizophrenia for five years, divided into groups based on long-term remission status and symptomatic severity, assessed with the Positive and Negative Syndrome Scale. Cognitive functioning was assessed at baseline, with tests of vigilance, executive functions, processing speed, memory and learning, working memory, and premorbid functioning. Cognitive domains related to long-term remission status were executive functions, working memory, and premorbid functioning. The most prominent cognitive differences were found between the group in stable remission with minimal symptoms, and the non-remission group, the first group demonstrating better cognitive functioning. The study highlights the role of premorbid functioning as a cognitive feature in the prediction of long-term remission. It also indicates the possibility of viewing specific cognitive domains as markers for clinical outcome, highlighting the value of early assessment of cognition. In summary, a certain cognitive profile, in coexistence with long-term non-remission, suggests poorer outcome. Hence, this group is in need of increased support.

Abstract Background A high ability to understand symptoms and conceptualize illness, schizophrenia, may play a central role for long-term outcome. This based on the assumption that better insight will promote increased adherence. In this work insight is defined as patients′ ability to experience symptoms and furthermore understand what causes them. Cognitive performance and symptomatic remission are analyzed to explore in what way they are contributing to the level of insight. Methods The study population is 294 patients with schizophrenia spectrum disorder. Two items with focus on insight, each 1 to 4 points, are used to decide level of insight. The first item “Experience of symptom” and the second item “Understanding the reason for symptoms”, where 1 point representing high and 4 point low level of insight and with a total of 8 points. Patients are then divided into three groups, Good (2 points), Moderate (3 – 5 points) and Poor (6 –8 points). Cognitive domains identified to be impaired in schizophrenia are analyzed related to the three groups of insight. Symptomatic remission is compared to the total score of insight with a Mann-Whitney test and then the different categories of insight in a cross-tabulation and Chi-square test. Results Differences were found in insight between patients in symptomatic remission and those who are not. This in contrast to when patients were divided into the three insights groups and compared on cognitive performance. Only working memory and neurocognitive flexibility showed significant differences to insight. However, crystalized intelligence, as an expression of over-all cognitive ability, did not. Discussion In conclusion, only symptomatic remission seems to be related to insight indicating more of a state than a trait phenomenon. Surprisingly could not different levels of insight be connected to differences in cognitive ability. As this is a cross-sectional study, further research are needed where insight and symptomatic remission are analyzed in longitudinal conditions. Such a study has to focus on if successful treatment promote insight or the other way around.

The knowledge about factors contributing to remission among individuals with schizophrenia is still missing. Studies show that the number of individuals’ reaching remission is varying among psychiatric outpatient care centres. Therefore, the purpose was to investigate case managers (CM) perception of care interventions promoting remission. Semi-structured interviews were conducted with CM (n = 12) and data were analysed with qualitative content analysis. The results show that CM needs to possess competence, master assessment structure and process. These key-points appear to be of crucial importance for a successful promotion of remission among individuals with schizophrenia.

Symptomatic remission for patients with schizophrenia spectrum disorder is to some extent associated with a better functional outcome, and a higher level of insight of symptoms. Additional studies show that patients who overestimates their low function have no difference in level of total clinical symptoms compared to the ordinary functioning group. The aim of the present study is to examine whether overestimating functioning is associated with longitudinal symptomatic remission pattern. A total of 115 outpatients within the ongoing CLIPS-study (Clinical Long-term Investigation of Psychosis in Sweden), all diagnosed with schizophrenia spectrum disorder, were followed for five years. Remission status was assessed once a year with the Positive and Negative Syndrome Scale (PANSS), placing each participant in one out of three groups based on their long-term remission pattern (stable remission, unstable remission, non-remission). Furthermore, based on the individual result on UPSA-B combined with their self-rated level of function, the participants were divided into four groups (Ordinary function, accurate estimators; Ordinary function, under-estimators (due to a low degree of participants this group was excluded in the analysis); Low function, over-estimators; Low function, accurate estimators). Differences in long term remission patterns for the different groups based on insight of functioning were compared using non-parametric analyzes. Our analysis show statistically significant differences in long term symptomatic remission pattern, based on patients’ insight of functioning. Results from the post hoc test demonstrate differences in long term symptomatic remission pattern between the groups low function, accurate estimators and low function, over-estimators, indicating a higher degree of remission in the over-estimator’s group. It also shows differences in long term symptomatic remission pattern between low function, accurate estimators and ordinary function, accurate estimators, indicating ordinary function being associated with a higher degree of remission. The results show that not only better functioning is related to a higher likelihood of achieving long-term remission, but also overestimating ones’ low function. The results suggest that patients believing in an ordinary function, even if it means overestimating, could have an advantage in clinical long-term outcome of the disorder. Alternatively, it could also be that being in remission, leads to an overestimation of one’s function. Finally, the remission criterion is based on structured interviews with the PANSS. If the patients who overestimate their function also overestimate their symptomatic status, being in remission could be a false understanding, made by the clinicians based on the patients’ overestimation. The findings show how complex the schizophrenia spectrum disorder is, and the importance of several parallel examinations within different areas to be able to individualize the treatment for each patient.

A promising progress in the search for determinants of functional outcomes is defined as introspective accuracy (the self-assessment ability). Research about patients’ ability of rating their psychotic symptoms is established, but there is still a lack of knowledge about how patients perceive other important features of their illness, such as their level of functioning. The methods most frequently used to measure patients’ functioning are self-report questionnaires and reports from relatives and healthcare professionals. A previous study showed a significant relationship where patients, who overestimate their functioning, consistently got high scores in interview-based assessment regarding real-world functional performance. The aim of the present study was to explore if relationships between functional capacity and functional performance differ regarding patient’s introspective accuracy. Data collection took place within the ongoing project Clinical Long-term Investigation of Psychosis in Sweden (CLIPS), examining psychiatric outpatients. In this study, 222 patients with schizophrenia participated. They were divided into two groups; unimpaired introspective accuracy and impaired introspective accuracy, based on their self-rating ability and on their UCSD Performance-based Skills Assessment-Brief (UPSA-B) results. The two groups were assessed by clinicians and relatives and compared regarding functional performance on The Specific Level of Functioning Scale (SLOF). Pearson correlation were used to obtain correlation coefficients between functional capacity (UPSA-B) and functional performance (SLOF) in the two groups. The correlation between UPSA-B and SLOF were statistically significant, both when assessed by clinicians and relatives. The strength of the correlation coefficient was changed when the patients were divided into the two groups of introspective accuracy. It increased for patients who were aware of their functioning, slightly higher in the assessment by relatives, and showed a non-significant result for the patients who were not as aware of their functioning. A more detailed analysis showed that the SLOF domains assessed by clinicians that significantly correlated with UPSA-B was ‘Ability to take care of oneself’, ‘Activities’, and ‘Capacity to work’. The two later domains were also significant when the assessments were made by relatives. The present study focusses on the difficulties of producing objective and valid reports in the field of functional outcomes. The result also mirrors previous study results where patients who are not aware of their function, will be more difficult to assess. There were no major differences between the assessments made by clinicians and relatives. Our findings are important since impaired self-awareness could lead to less or inadequate support and treatment in the end. As a consequence of our findings, it is important to measure introspective accuracy independently of which method of functional performance that are being used. Introspective accuracy is also central to study in future investigations.

People with schizophrenia often demonstrate an impaired ability to assess and report aspects of their everyday functioning, and the aim of this study is to investigate how patients' self-rating ability regarding functional performance relates to neurocognitive performance and real-world functional performance. A total of 222 outpatients with a schizophrenia spectrum disorder participated in this study. They were divided into groups based on their self-rating ability (determined using self-rating questions) and their observed functional capacity (the UCSD Performance-Based Skills Assessment–Brief, UPSA-B). The results showed that patients with impaired functional capacity perform at a similar cognitive level, regardless of their self-rating ability. When comparing patients with unimpaired function to those with impaired function, we found differences in two cognitive domains; premorbid functioning and executive functioning. The results also reveal that clinicians seem to have greater difficulty assessing patients who over-estimate their functioning. Consequently, when clinicians assessed the patients with the Specific Levels of Functioning Scale (SLOF) no significant differences were found between the group with unimpaired function and the group of overestimators. Patients who overestimate their functioning risk receiving inadequate treatment and support.

The needs of people with schizophrenia are great, and having extensive knowledge of this patient group is crucial for providing the right support. The aim of this study was to investigate, over 4 years, the importance of repeated assessments by patients with schizophrenia and by professionals. Data were collected from evidence-based assessment scales, interviews, and visual self-assessment scales. The data processing used descriptive statistics, correlation and regression analyses. The results showed that the relationships between several of the patients’ self-rating assessments were stronger at the 4-year follow-up than at baseline. In parallel, the concordance rate between patient assessments and case manager assessments increased. The conclusions drawn are that through repeated assessments the patients’ ability to assess their own situation improved over time and that case managers became better at understanding their patients’ situation. This, in turn, provides a safer basis for assessments and further treatment interventions, which may lead to more patients achieving remission, which can lead to less risk for hospitalization and too early death.

Dysfunctional affectivity is common in schizophrenia spectrum disorders (SSD), and may influence quality of life, illness progression and treatment effects. This study describes Positive (PA) and Negative (NA) affect and their relationship to demographic and clinical variables in 135 individuals with SSD. Affect dimensions were assessed by the Positive and Negative Affect Schedule (PANAS). Stepwise regression analyses with affects as dependent variables and demographic and clinical factors as independent variables were performed. Relative to healthy norms, the participants exhibited lower PA and a similar NA level. The PA score was not influenced by demographic or clinical variables. The NA score was predicted by a combination of male gender, single status, and items of general psychopathology from the Positive and Negative Syndrome Scale (PANSS). There was no relation between affects and classical schizophrenia symptoms. In conclusion, the SSD patients exhibited abnormally low PA. The affect level was not influenced by psychosis symptom severity, indicating that the PANAS is a relatively unbiased rating tool of affective responding in SSD. Finally, male gender, single status and general distress were modestly related to NA.

Patients with schizophrenia have significantly greater mortality rates than the general population, with an estimated reduced lifespan of 10-20 years. We previously reported on a link between impairment in cognition and premature death in a prospective 20-year study. Patients who had died prematurely showed neurocognitive impairment in nine different cognitive tests compared to those who did not. Based on those findings, in this study the surviving patients in the cohort were divided into three different groups based on neurocognitive impairment and compared on symptom severity including remission status, RAND-36, weight and BMI at onset of illness and baseline of the study, and medical/physical symptomatology (i.e., blood pressure, symptom awareness, vertigo and orthostatic symptoms). Differences were most prominent between the cognitively unimpaired and severely cognitively impaired (SCI) groups, with remission, negative symptoms, general symptoms and PANSS total scores differing. For SF-36 (RAND) Physical functioning and Role limitations due to physical health subscales the SCI were worst. The findings indicate that greater impairments in cognitive ability during the illness are associated with several potential indicators of risk for early mortality. Together these factors may be of guidance for establishing an algorithm to detect patients at risk of premature death early in their illness. (C) 2018 Elsevier B.V. All rights reserved.

Patients with schizophrenia have about 20 years shorter lifetime expectancy compared to healthy population. The cause of this excess in mortality is due to both unnatural and natural causes. While the lifetime prevalence of death due to suicide among patients with schizophrenia is estimated to be 4.9%, Cardiovascular (CV) disease contributes to as much as 50% of the excess mortality in patients with schizophrenia. This study focuses on whether hypertension, diabetes, hyperlipidemia and tobacco could be related to the reduced lifetime expectancy in patients with schizophrenia spectrum disorder. From the Clinical Long-term Investigation of Psychosis in Sweden (CLIPS) study, 79 patients now deceased were analyzed at baseline. Data regarding occurrence of hypertension, diabetes, hyperlipidemia, tobacco but also data on the type of antipsychotic treatment were collected. Two patients, one with zero risk factors and one with 5 risk factors were omitted from the study. We created four categories based on the number of risk factors. 31 patients with one risk factor, 24 patients with two risk factors, 12 patients with three risk factors and 4 patients with four risk factors. The mean age for death was 61 years and the age varied between 35–83 years old. 18 percent were treated with typical antipsychotics and 61 percent with atypical antipsychotics. 18 percent had both atypical and typical antipsychotic treatment. 17 percent had treatment for diabetes, 27 percent had treatment for hypertonia, 8 percent had treatment for hyperlipidemia and 43 percent were using tobacco. The data collected pictures the occurrence of the different risk factors on average 6 years before their death. We compared the age of death for the four different risk factor groups with a Kruskal-Wallis Test and could not find any significant difference between them. Compared to the general population in Sweden there is an increased risk for diabetes in patients with schizophrenia, however the prevalence of hypertonia is the same, 27 percent for 18 years old and elder, in the general population. Daily tobacco use was rather high among patients with schizophrenia. Compared to general population, women and man with 10 percent respective 8 percent higher. Even if both diabetes and tobacco use has a high prevalence in patients with schizophrenia, it may not be enough to explain the reduced lifetime expectancy in patients with schizophrenia This study indicates that metabolic syndrome and the risk factors it contains need to be further studied in order to find its association to early death in patients with schizophrenia.

It is important to have extensive knowledge of the patients with schizophrenia, to provide the right support in outpatient care to create a good situation for the patient and prevent hospitalization. Lack of insight regarding the illness and symptoms might impair the patient’s ability to understand the illness, the treatment and relapses into psychotic episodes. Symptomatic remission is a well-established goal for treatment. If the core-symptoms do not affect their functions and the status is stable for at least six months, the patient is in remission. Previous research has shown an increased remission status from approximately 30% to more than 50% after using standardized remission criteria for patients with schizophrenia in Sweden. This study aims to investigate the relationship between both insight of symptoms and illness insight with cross-sectional remission. This is a cross-sectional study and the participants consisted of totally 289 patients with schizophrenia diagnosis. Of the participants 111 were women and 178 were men, with a mean age of 47 years (19–83 years old). Using semi-structured interviews and evidence-based assessment scales Remission Scale - Symptom (RS-S) and Psychosis Evaluation Tool for Common use by Caregivers (PECC) the data is collected. Cross tabulations were used to compare the distribution of the variables and the Pearson Chi-Square Tests for examine significant association. Insight of symptom: The results show that from the patients who are not in remission, 69.5% are missing insight to symptoms, while 30.5% are having insight of symptoms. When it comes to the patients within remission, 59.0% have an insight of symptoms, while 41.0% are missing this sort of insight. The findings in the analysis with Chi-Square Tests examine independence indicated significant association between insight of symptoms and remission status (1, x2 = 22.17), p = <0,001, phi = -0.28. Insight of illness: During the analysis of insight of illness, the results show that from the patients who are in remission, 61.9% possess insight of illness, compared to 38.1% of the patients lacking insight of illness. Concerning the insight of illness for the patients who are not in remission, 68.2% lack insight of illness, while 31.8% possess insight of illness. The Chi-Square Tests examine independence indicated significant association between insight of illness and remission status (1, x2 = 24.28), p = <0.001, phi = -0.29. The results show that there is a relationship between insight of symptoms and illness with the cross-sectional symptomatic remission. However, the question is still open if remission is a consequence of insight or if the insight changes over time according to the activity of the illness. By following patients over time and monitoring the activity of symptoms including the state of remission and insight, it will probably be visualized if changes occur related to each other or independently. Also, whether the main focus for success is pharmaceutical treatment aiming for maximal symptom reduction or psychoeducational treatment to develop patients’ ability to understand their illness. Finally, whether insight after being established is a state or a treatment phenomenon? Further research to explore this issue is needed.