The Role of Subjective Illness Beliefs and Attitude Toward Recovery Within the Relationship of Insight and Depressive Symptoms Among People With Schizophrenia Spectrum Disorders Marialuisa Cavelti, 1 Eva-Marina Beck, 1 Sara Kvrgic, 1 Joe Kossowsky, 2 and Roland Vauth 1 1 Psychiatric University Hospital of Basel 2 University of Basel Objective: Low levels of insight are a risk factor for treatment nonadherence in schizophrenia, which can contribute to poor clinical outcome. On the other hand, high levels of insight have been associated with negative outcome, such as depression, hopelessness, and lowered quality of life. The present study investigates mechanisms underlying the association of insight and depressive symp- toms and protective factors as potential therapeutic targets. Methods: One hundred and forty-two outpatients with schizophrenia or schizoaffective disorder (35.2% women, mean age of 44.83 years) were studied using questionnaires and interviews to assess insight, depressive symptoms, recov- ery attitude, and illness appraisals with regard to course, functional impairments, and controllability. Psychotic and negative symptoms were assessed as control variables. The cross-sectional data were analyzed using structural equation models and multiple linear regression analyses with latent variables. Results: Higher levels of insight and psychotic symptoms were associated with more depressive symptoms. The association of negative symptoms with depressive symptoms was not significant. The relationship between insight and depressive symptoms was mediated by the participants’ perception of their illness as being chronic and disabling, as well as suppressed by their expectation of symptom control due to treatment. Finally, the association of insight and depressive symptoms was less pro- nounced in the patients with a positive recovery attitude than in those without this protective factor. Conclusions: To achieve recovery, which includes symptom reduction, functional improvement, and subjective well-being, it is necessary to prevent depressive symptoms as indicators of a demoral- ization process, which may arise as a consequence of growing insight. Possible treatment strategies focusing on changes of dysfunctional beliefs about the illness and the self and inducing a positive recovery attitude are discussed. C  2012 Wiley Periodicals, Inc. J. Clin. Psychol. 68:462–476, 2012. Keywords: psychosis; awareness; demoralization; illness perception; recovery; hope Insight in schizophrenia is a multidimensional construct. It is defined as follows: the awareness of having a mental disorder, of specific symptoms and their attribution to the disorder; the awareness of social consequences, and of need for treatment. For schizophrenia, rates of lacking insight, at least partially, have been reported to lie about 50% (Lincoln, Lullmann, & Rief, 2007). Low levels of insight are a risk factor for nonadherence to treatment, which is associated with poor clinical outcome, such as frequent relapses and rehospitalizations, high levels of positive and negative symptoms, and poor social and vocational functioning (Lincoln et al., 2007). On the other hand, high levels of insight have been linked to depression, hopelessness, and suicidal tendency as well as to lowered self-esteem, well-being, and quality of life (Barrett et al., 2010; Drake et al., 2004; Hasson-Ohayon, Kravetz, Meir, & Rozencwaig, 2009; Lysaker, Roe, & Yanos, 2007) a cluster of negative outcomes, which may well be subsumed under the concept of “demoralization.” Demoralization means a syndrome of existential distress, which can occur in individuals who suffer from a long-term mental illness that threatens integrity Correspondence concerning this article should be addressed to: Roland Vauth, Department of Psychi- atric Outpatient Treatment (Psychiatrische Universit¨ atspoliklinik), Psychiatric University Hospital of Basel, Claragraben 95, CH-4057 Basel, Switzerland. E-mail: roland.vauth@upkbs.ch JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 68(4), 462–476 (2012) C  2012 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.20872