The insight paradox posits that among patients with schizophrenia, better insight is associated with depressive symptoms. However, available studies are characterized by conflicting results.

First, we conducted a systematic review, a meta-analysis and a meta-regression based on 59 available correlational studies. Second, we examined a cross-sectional examination on 80 patients diagnosed with schizophrenia in stable phase of the illness. Measures of depressive dimension were based on the Calgary Depression Scale for Schizophrenia (CDSS) and Beck Depression Inventory (BDI), for insight the Scale to assess Unawareness of Mental Disorder (SUMD). Furthermore, we assessed self-stigma, self-esteem and psychotic symptoms to test mediating and moderating models (Preacher and Hayes models).

In the meta-analysis, global insight was associated weakly, but significantly with depression (effect size r=0.14), as were the insight into the mental disorder (r=0.14), insight into symptoms (r=0.14) and symptoms’ attributions (r=0.17). Whereas, insight into the social consequences of the disorder or into the need for treatment were not associated with symptoms of depression. Better cognitive insight was associated with higher levels of depression. Methodological and clinical factors moderated the magnitude of the association between insight and depression. Similar results were observed in the clinical sample, where self-stigma significantly mediated the association between insight and depression.

In conclusion, both literature and clinical findings indicate that better insight is associated with higher levels of depressive symptoms among patients with schizophrenia: interventions that are aimed at improving insight need to take into account the implications of these findings