Insight in Psychosis and Suicidality: A Scoping Review of a Paradoxical Relationship

Abstract

Suicide is a serious public health concern and a major cause of premature mortality among individuals with psychotic disorders. Although several risk factors for suicide have been established, much remains unknown about how these factors generalize to populations experiencing psychosis. Existing literature has described an “insight paradox,” whereby improvements in insight have been associated with increased emotional distress. However, the extent to which insight is associated with suicide-related outcomes across psychotic disorders has not been comprehensively synthesized. This scoping review aimed to examine the relationship between insight and suicidality in psychosis, identify patterns and gaps within the literature, and summarize potential mechanisms underlying this association, with secondary consideration of illness stage. A scoping review was conducted following PRISMA-ScR guidelines, with 26 studies meeting inclusion criteria. Overall, greater insight was more frequently associated with increased suicidality than with null findings, although considerable heterogeneity existed across insight domains, suicide-related outcomes, and study methodologies. Notably, no study identified greater insight as a protective factor against suicidality. Findings suggest that interventions promoting insight should also address accompanying emotional and psychosocial challenges, such as self-stigma and hopelessness, and remain cognizant of associated suicidality risk. Future research should further clarify the mechanisms underlying the insight paradox.