186 Journal of Research in Medical Sciences | February 2012 |
Mood disorders insight scale: Validation of
Hajar Ahmadi Vazmalaei1, Atefeh Ghanbari Jolfaei2, Amir Shabani3
1 Psychiatrist, Tehran University of Medical Sciences, Tehran, Iran. 2 Assistant Professor, Department of Psychiatry, Mental Health
Research Center, Tehran University of Medical Sciences, Tehran, Iran. 3 Associate Professor, Department of Psychiatry, Mental
Health Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Background: Lack of insight in patients with bipolar I disorder has been associated with poor course and clinical outcome and
compromised therapeutic compliance. Therefore, it is important to evaluate insight and use more specialized scales such as Mood
Disorder Insight Scale (MDIS) in these patients. Our objective in this study was to assess validity and reliability of Persian version of
MDIS. Materials and Methods: A hundred forty five bipolar patients were selected from Iran Hospital of Psychiatry. They were
interviewed by The Persian Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorder, 4th edition's (DSM-
IV) axis I disorders (SCID-I) and the Scale to Assess Unawareness of Mental Disorder (SUMD). The translated version of MDIS in
Persian was subsequently completed by patients. Results: The internal consistency was satisfactory (Cronbach alpha coefficients =
0.8). The test-retest reliability (coefficient alpha) was 0.95 (p < 0.01). Construct validity and concurrent validity were supported by
factor analysis and Spearman rank correlation between MDIS and SUMD (0.85). Conclusions: Persian version of the MDIS could be a
useful instrument for assessing insight in patients with bipolar I disorder.
Key words: Validation Studies, Mood Disorder Insight Scale, Bipolar Disorder, Iran
Insight to a mental disorder has been defined as an
awareness of a variety of disorder-related issues such
as symptoms, probable cause and source of these
symptoms, need of treatment and repercussions of the
disorder.1-3 Insight is not an all-or-none phenomenon; a
patient may have insight into some signs and
symptoms of the disorder not to others.3
Most of the studies regarding insight have given much
attention to psychotic
schizophrenia,1-13 but some literature has focused on
insight in mood disorders particularly bipolar-I-
disorder (BID) and according to them in bipolar
patients poor insight was associated with poor
compliance to medical and psychological treatment
and poor course and outcome.14-21
A variety of insight scales have been developed but
most of them are suitable for psychotic patients and
cannot reflect the insight of patients with mood
disorders; therefore, it is better to use more specialized
scales such as Mood Disorder Insight Scale (MDIS) for
assessing insight in these patients. Sturman and
Sproule determined test-retest reliability (r = 0.75, n =
45) and also validity of MDIS using clinician ratings (r
= 0.49, n = 69).22 The objective of this study was to
assess validity and reliability of Persian version of
MATERIALS AND METHODS
Preparing the Persian version of MDIS
The original English text of the MDIS22 was translated
into Persian by four bilingual (English/Persian)
translators who were all psychiatrist and assistant
professor of university.
They reached an agreement on finalized translation of
items. Then it was back translated into English by
another professional bilingual
translator who had not seen the original items of
MDIS. The back-translated version was compared
with the original MDIS by primary translators and
appropriate modifications were made in the translated
text. The process of translation back-translation was
repeated until reaching an acceptable equivalence
between original MDIS and back-translated version.
Subjects were selected from Persian speaking
outpatients and inpatients with diagnosis of BID
disorders. The sampling was nonrandomized referred.
to Iran Hospital of Psychiatry, Tehran, Iran, from
December 2008 to September 2009. The diagnoses
were made based on the Persian Structured Clinical
Interview for Diagnostic and Statistical Manual of
Mental Disorder, 4th editionʹs (DSM-IV) axis I Patient
aged 18-65 years and gave informed consent and had
Address for correspondence: Atefeh Ghanbari Jolfaei, Assistant Professor, Department of Psychiatry, Mental Health Research Center, Tehran University
of Medical Sciences, Tehran, Iran. E-mail: firstname.lastname@example.org
Received: 05.04.2011; Revised: 06.06.2011; Accepted: 02.01.2012
Ahmadi Vazmalaei et al, Validation of Persian version of MDIS
cognitive, educational and mental ability for reading and
responding the items were included. The exclusion criteria
were having a severe disorder either in terms of behavior
or language that made the interview and responding to the
items almost impossible (e.g., moderate to severe mental
retardation, severe dementia and severe agitation). All
subjects were volunteers and did not receive compensation
for their participation. Finally, 145 (61% males) patients
were recruited. The method was ethically approved by
research committee of mental health research center.
The Persian Structured Clinical Interview for DSM-IV
axis I disorders (SCID-I)
SCID, a gold standard and widely used clinical tool for
diagnosis of psychiatric disorders based on DSM-IV criteria,
was used as a diagnostic tool in this study. It has been shown
to have reliability and feasibility and have fair to good
diagnostic agreements for most diagnostic categories (kappa =
0.55). Its acceptable specificity and sensitivity has been shown
on a large sample of Iranian patients.23
The Scale to Assess Unawareness of Mental Disorder
This instrument is a semi-structured interview with 9
items, and assesses: 1) Awareness of having a mental
disorder or psychiatric symptoms, 2) Awareness of need to
and effects of medication, and 3) Awareness of social
consequences of mental disorder.3 Each item includes
current and past state and each state is scored on a Likert
scale ranging from 1 to 3: 0 (not applicable), 1 (aware), 2
(somewhat aware/unaware), and 3 (severely unaware).
The higher score indicates lower insight. In the present
study, the SUMD was the gold standard comparator
against the MDIS and the inter-rater reliability of the
SUMD was determined on 45 patients. Amador et al.
indicated that the median inter-rater intra-class correlation
coefficients (ICC) for the SUMD was 0.89.3 In another
study, it was reported that there was 100% agreement (ICC
= 1.00) between SUMD ratings on several dimensions and
the diagnoses which were made according to DSMIV-TR
criteria by a psychiatrist.24
The Mood Disorder Insight Scale (MDIS)
MDIS is composed of eight items. It is a self-report
instrument assessing three basic sections of illness-awareness
consisting of 1) awareness of mental disorder, 2) A?ribution
of symptoms and 3) awareness of need for treatment through
both current and past episodes of mood disorder.22
Subjects can respond to each item as to whether they
agree, disagree, or are unsure. The MDIS takes between 2
and 3 minutes to be administered. Maximum score for each
of the sub-scores is 4 and maximum score for the whole
scale is 12. The higher scores mean higher insight. In
| February 2012 | Journal of Research in Medical Sciences 187
Sturman and Sproule study, the test–retest reliability of the
scale was 0.75 (p < 0.01) and there were significant
correlations between the scores on psychiatrists ratings and
the MDIS total score (r = 0.49, p < 0.001) and subscores.22
After collecting some demographic and clinical data, SCID
and SUMD were performed by two trained resident of
psychiatry for all patients. Then, the patients filled out the
MDIS. Test-retest reliability was evaluated through a
second test three days later, face to face for inpatients and
by phone for outpatients.
To analyze data, we used SPSS version 11.5 (Chicago, IL,
USA). Descriptive methods, intra-class correlation, factor
analysis and Spearman correlation was used.
Demographic and clinical data and their relationship with
MDIS and SUMD scores were shown in table 1. The test-
retest reliability (coefficient alpha) of the MDIS was 0.95
(p < 0.01) Inter-rater reliability of SUMD was 0.95 (p <
0.01). Internal consistency analysis of Persian MDIS
showed Cronbach alpha coefficients as 0.83 and intra-class
correlation coefficients as 0.82.
Table 1. Relationship between demographic
characteristics and MDIS and SUMD scores
Age(year) (mean ±
(mean ± SD )
S.: Statistically significant
N.S.: Not significant
3.9 ± 2.6 N.S. N.S.
126(86.9) S. S.
Ahmadi Vazmalaei et al, Validation of Persian version of MDIS
Table 2 shows correlation coefficients between items of
MDIS. Spearman rank correlation between MDIS and
SUMD was 0.85 and this result supported the concurrent
validity of MDIS. The mean scores of SUMD in patients
were 18.25 ± 6.82 (MAX = 27, MIN = 6). The mean scores of
MDIS in patients were 6.07 ± 3.43 (MAX = 10, MIN = 1).
Factor analyses revealed that Eigen value of the first and
second question was over 1, accounting for 67.6% of the
variance in MDIS scores. Scoring of the first item was
opposite of other items and because of that, MDIS had 2
factors, “poor insight” and “good insight”. The result
confirmed the construct validity (Table 3).
Table 2. Correlation between items of MDIS
188 Journal of Research in Medical Sciences | February 2012 |
of need for
of need for
1 0.582 0.604
0.582 1 0.775
0.6 0.77 1
Table 3. Factor Analysis of MDIS items
Good insight factor
Poor insight factor
Normalization, table entries are rotated components
*Eigen value 7.12, factor explains 47.51% of variance
**Eigen value 1.67, factor explains 11.18% of variance
*** Eigen value 1.34, factor explains 8.95% of variance
Test–retest reliability and the internal consistency showed the
reliability of Persian version of the MDIS. There are limitations
Components Analysis, Varimax Rotation with Kaiser
associated with the use of SUMD as the gold standard for validating
MDIS. SUMD was designed for psychotic patients and some of its
items asked the patients awareness about psychotic symptoms.
Although bipolar patients may experience psychosis, these items are
not suitable for those bipolar patients who did not experience
psychotic symptoms. In Sturman and Sproule study, the psychiatrists
rated the patients insight on 10-cm visual analogue scales and MDIS
scores were compared with these psychiatrist ratings of insight.22
Considering that MDIS also have two items about psychotic
experiences, we thought that using a standard scale would be better
and visual analogue scales does not seem to be reliable. Accordingly,
we used SUMD.
In our study, the mean scores of MDIS in BID patients were lower
than participants of Sturman and Sproule study. In opposition to that
study, most of our participants were inpatients and as it was seen in
both studies, insight in outpatients was significantly higher than
inpatients.22 Like other studies, there were no significant differences in
MDIS and SUMD scores based on different demographic
The limitation of the present study was that we did not evaluate
severity of symptoms, duration of treatment and type of episodes
and these characteristics were related to insight scores in some studies
but not in others.11,14,15,17-19,22,25-27 We recommend that MDIS could be
used for assessing insight in other mood disorders. Furthermore, it
has advantages in predicting the clinical course and the compliance in
Iranian patients suffering BID.
The authors would like to express their sincere
appreciations to Dr Sayed Vahid Shariat, Dr Vandad
Sharifi and Dr Aliakbar Nejatisafa for helping in
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How to cite this article: Ahmadi Vazmalaei H, Ghanbari Jolfaei A,
Shabani A. Mood disorders insight scale: Validation of Persian version. J
Res Med Sci 2012; 17(2): 186-9.
Source of Support: Nil, Conflict of Interest: None declared
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