Levels of evidence (1++ to 4) and grades of recommendation (A to D, and GPP) are defined at the end of the "Major Recommendations" field.
Question to Be Answered: Is cognitive behavioural therapy-based psychological intervention effective in the treatment of people with severe mental illness (SMI)?
C - In people with SMI, cognitive behavioural treatment can used combined with standard treatment to reduce positive symptomatology, mainly hallucinations.
C - People with SMI and persistent positive symptomatology can be offered a specific cognitive behavioural-orientated psychological intervention for this pathology, lasting for a prolonged period of time (more than one year), in order to improve the persistent symptomatology.
C - Incorporate cognitive therapy into the strategies aimed at preventing relapses of depressive symptomatology in people with SMI and diagnosis of bipolar disorder.
B - When the main objective of the intervention in people with SMI is to improve their social functioning, it is advisable to incorporate social skills training.
There is not sufficient evidence to make recommendations in the problem-solving area for people with SMI and a diagnosis of schizophrenia and related disorders.
Question to Be Answered: Is interpersonal therapy effective in the treatment of people with SMI?
C - The strategies aimed at preventing relapses in people with SMI and a diagnosis of bipolar disorder should evaluate the incorporation of interpersonal and social rhythm therapy (IPSRT) into the treatment.
Questions to Be Answered:
- Do family interventions in their different formats present benefits compared with nonintervention, or other types of psychosocial intervention, in people with SMI?
- At what time, during the course of the illness, is it best to start family intervention for people with SMI and their families?
- What is the most appropriate time framework for the family intervention programmes and/or sessions for people with SMI and their families?
B - For people with SMI and a diagnosis of schizophrenia and related disorders, and their families, family intervention should be offered as an integral part of the treatment.
B - In family interventions that are carried out with people with SMI and diagnosis of schizophrenia and related disorders, the intervention should be done in a single-family format.
B - The recommended duration in family interventions aimed at people with SMI and diagnosis of schizophrenia and related disorders must be at least 6 months and/or 10 or more sessions.
A - Psychosocial intervention programmes must be offered that include family intervention with a psychoeducational component and coping and social skills training techniques, added to the standard treatment for people with SMI and diagnosis of non-affective psychosis.
B - Family members and caregivers of people with SMI and a diagnosis of bipolar disorder must be offered group psychoeducational programmes that include information and coping strategies that permit discussions within a friendly emotional climate.
Questions to Be Answered:
- Are psychoeducational interventions effective in people with SMI?
- What are the key components in psychoeducational interventions in people with SMI?
- What is the most adequate level of psychoeducational intervention: individual, group or family?
A - Quality information must be provided about the diagnosis and the treatment, giving support and handling strategies to people with SMI and diagnosis of schizophrenia and related disorders, to family members and to the people with whom they live.
A - Psychoeducational programmes that are offered to people with SMI and diagnosis of schizophrenia and related disorders, must incorporate the family.
B - Group psychoeducational programmes aimed at people with SMI and a diagnosis of bipolar disorder must incorporate specific psychological techniques, carrying them out in a relatively stable period of their disorder and always as a supplement to the psychopharmacological treatment.
GPP - The psychoeducational programmes for people with SMI must be integrated as an additional intervention in an individualised treatment plan, whose duration will be proportional to the objectives proposed, considering a minimum of 9 months' intensive programme and the need for undefined refresher sessions.
Questions to Be Answered:
- Are cognitive rehabilitation interventions efficient in people with SMI and cognitive impairment?
- Which is the most adequate format of these interventions for people with SMI and cognitive impairment?
B - People with SMI and diagnosis of schizophrenia and related disorders that have cognitive impairment must be offered cognitive rehabilitation programmes.
B - Cognitive rehabilitation programmes aimed at people with SMI and cognitive impairment must be integrated into more extensive psychosocial rehabilitation programmes.
C - From the cognitive rehabilitation interventions or programmes aimed at people with SMI, it is advisable to choose those that include or are accompanied by "compensatory" interventions, in other words, changes in strategy, and training in coping skills or techniques.
Question to Be Answered: Do social insertion programmes — daily living skills programmes, residential programmes in the community, or programmes directed to leisure and spare time — improve the evolution of the illness and the quality of life of people with SMI?
GPP - Daily living skills training programmes could be offered to people with SMI in order to improve their personal independence and their quality of life.
D - For people with SMI who require support to remain in their accommodation, it is advisable that the community residential offers include more extensive psychosocial programmes.
D - People with SMI and deficiencies perceived in their social relations should follow community leisure and spare time programmes.
GPP - During the monitoring of the individualised therapeutic programme, it is advisable to systematically assess the need to use the spare time programmes and offer them to people with SMI who require them.
Programmes Aimed at Employment
Question to Be Answered: Which employment-related intervention format improves labour market insertion of people with SMI?
A - Sheltered employment programmes are necessary for people with SMI who express their desire to return to work or get a first job. Programmes based on placement models are recommended, with a short preliminary training period, immediate placement, and with frequent individual support.
C - Sheltered employment programmes aimed at searching for normalised employment must not be the only programmes related to labour activity that are offered to people with SMI.
D - It would be recommendable for the psychosocial rehabilitation centres that look after people with SMI and diagnosis of schizophrenia and related disorders, to include employment integration programmes.
B - When employment insertion programmes are offered to people with SMI, the preferences on the type of job to be carried out must be assessed and taken into account.
B - For people with SMI and diagnosis of schizophrenia and related disorders, who has a history of previous job failure, it would be advisable to incorporate cognitive rehabilitation as a part of the employment programmes they are going to participate in.
GPP - The mental health teams, in coordination with the institutions and other social agents involved, must advise about all types of employment resources, aimed at gainful occupation and production, and adapted to the local employment opportunities. Likewise, they must be orientated towards interventions that put into motion different devices adapted to the needs and to the ability level of people with SMI, to increase stable and productive occupation expectations.
Other Therapeutic Interventions: Art Therapy and Music Therapy
Question to Be Answered: Do therapeutic interventions, such as art therapy and music therapy, improve the evolution of the illness and the quality of life of people with SMI?
C - Music therapy and art therapy could be offered to people with SMI and schizophrenia and related disorders as a therapeutic complement to other types of interventions.
Service Level Interventions
Question to Be Answered: Which service supply system — day centres and/or psychosocial rehabilitation centres, community Mental Health centres, Assertive Community Treatment, Intensive Case Management (ICM), non-acute day hospitals or Case management (CM) — is more effective in people with SMI?
B - When people with SMI need to be readmitted several times into acute units, and/or there is a past history of difficulties to engage with the services with the subsequent risk of relapse or social crisis (as, for example, becoming a "homeless" person) it is advisable to provide assertive community treatment teams.
GPP - The continuity of the treatment must be favoured via the integration and coordination of the use of the different resources by the people with SMI, maintaining continuity of care and interventions, and in the psychotherapeutic relations established.
GPP - Care must be maintained from the perspective of the Community Mental Health Centres (CMHC) as a configuration of the most commonly implemented services in our context, based on teamwork, on service integration and not losing the perspective of being able to integrate other ways of configuring the services that might be developed.
GPP - When the needs of the people with SMI cannot be covered from the CMHC, continuity of assistance must be given from units that provide day care, and whose activity is organised around the principles of psychosocial rehabilitation, whatever the name of the resource are (Day Centres, Psychosocial Rehabilitation Centres, etc.).
GPP - A certain level of care can be offered to people with SMI whose needs cannot be satisfied by resources that provide day-care in rehabilitation orientated residential resources whatever the names of the resources are (hospital rehabilitation units, medium stay units, therapeutic communities, etc.).
Interventions with Specific Subpopulations
SMI with Dual Diagnosis
Question to Be Answered: What type of treatment has proven to be most effective in people with SMI and substance abuse: integral or parallel treatment?
B - People with SMI with dual diagnosis must follow psychosocial intervention programmes and drug-dependent treatment programmes, both in an integrated manner and parallel.
B - The treatment programmes offered to people with SMI with dual diagnosis must have a multi-component nature, be intensive and prolonged.
C - For people with SMI and dual diagnosis and in a homeless situation, the treatment programmes should incorporate sheltered housing as a service.
GPP - When the care for people with SMI and dual diagnosis is provided in parallel, it is necessary to guarantee continuity in the care and coordination among the different health and social levels.
"Homeless" with SMI
Question to Be Answered: Which intervention is more efficient in people with SMI and "homeless"?
A - For homeless people with SMI who require psychiatric care and psychosocial intervention, it is advisable for both to be supplied together via integral programmes where residential programme/housing is offered.
C - When there is no active substance abuse, it would be advisable to provide grouped accommodation to homeless people with SMI included in integral intervention programmes.
C - When it is not possible to use accommodation and support programmes in the integral psychosocial intervention of homeless people with SMI, the intervention of assertive community treatment team should be offered.
SMI and Low Intelligence Quotient (IQ)/Mental Retardation
Question to Be Answered: Which psychosocial treatment is more effective in people with SMI and a low IQ?
B - For people with SMI and a low IQ, and when there is a presence of persistent productive symptoms, it is recommendable to indicate cognitive behaviour therapy adapted to that condition.
GPP - To improve the diagnosis of psychiatric disorders included within the concept of SMI in people with a low IQ, adapted criteria and specific and validated instruments must be used.
Levels of Evidence
1++ - High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs) or RCTs with a very low risk of bias.
1+ - Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias.
1- - Meta-analyses, systematic reviews or RCTs with a high risk of bias.
2++ - High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with very low risk of confounding or bias and a high probability that the relationship is causal.
2+ - Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal.
2- - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal.
3 - Non-analytical studies, e.g., case reports and case series.
4 - Expert opinion.
Note: Studies classified as 1- and 2- should not be used in the process of developing recommendations due to their high possibility of bias.
Grades of Recommendation
A: At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+.
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++.
D: Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+.
Good Practice Point (GPP)*: Recommended best practice based on the clinical experience of the guideline development group.
*Sometimes the guideline development group becomes aware that there are some significant practical aspects they wish to emphasise and for which there is probably no supporting scientific evidence available. Generally, these cases are related to some aspect of the treatment, considered to be a good clinical practice and that nobody would normally question. These aspects are considered good clinical practice points. These messages are not an alternative to evidence based recommendations, but must be only considered when there is not another way to highlight the aspect mentioned above.