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Guideline Summary
Guideline Title
Clinical practice guideline for schizophrenia and incipient psychotic disorder.
Bibliographic Source(s)
Working Group of the Clinical Practice Guideline for Schizophrenia and Incipient Psychotic Disorder, Mental Health Forum, coordination. Clinical practice guideline for schizophrenia and incipient psychotic disorder. Madrid (Spain): Quality Plan for the National Health System of the Ministry of Health and Consumer Affairs, Catalan Agency for Health Technology Assessment and Research; 2009 Mar. 216 p. (Clinical practice guideline: CAHTA; no. 2006/05-2).  [240 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Schizophrenia and incipient psychotic disorder

Guideline Category
Evaluation
Management
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Psychiatry
Psychology
Intended Users
Nurses
Occupational Therapists
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Guideline Objective(s)
  • To provide recommendations for the management of patients with schizophrenia and incipient psychotic disorder that are preferably applicable in public use mental health services
  • To develop recommendations on diagnostic, therapeutic and rehabilitation interventions, with the aim of aiding professionals in decision-making
  • To tailor treatment to each patient's specific situation, providing several therapeutic and rehabilitation options for each phase of the disorder and the idiosyncratic characteristics of each patient
Target Population

Adults (18 and older) who have a diagnosis of schizophrenia and incipient disorder

Note: The working group agreed for the clinical practice guideline (CPG) update to focus on adult patients diagnosed with schizophrenia and also to include a new section on early intervention in psychosis, which can initiate in childhood or adolescence and also in adulthood.

Interventions and Practices Considered

Evaluation

  1. Weight and body mass index measurement (continued every 3-6 months)
  2. Fasting plasma glycaemia and lipid profiles
  3. Magnetic resonance imaging (MRI)
  4. Neurocognitive assessment
  5. Neurological assessment
  6. Electrocardiogram
  7. Illegal substance detection tests

Treatment/Management

  1. Pharmacological
    • Antipsychotic medications, including first and second generation, oral second generation, and clozapine
    • Antidepressants
  2. Psychosocial interventions
    • Cognitive-behavioural therapy (CBT)
    • Supportive psychotherapy
    • Psychodynamic psychotherapy
    • Psychoeducation
    • Family intervention
    • Cognitive rehabilitation
    • Social skills training
    • Training in activities of daily living
    • Occupational insertion support
    • Housing resources
  3. Follow-up
    • Community-based mental health teams
    • Case management
Major Outcomes Considered
  • Duration of untreated psychosis (DUP)
  • Response to antipsychotics
  • Overall functioning
  • Social and vocational functioning
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A general bibliographic search was carried out for clinical practice guidelines (CPGs) and recommendations on the management of schizophrenia and incipient psychotic disorder in the main medical and psychology databases: PubMed/Medline, The Cochrane Database of Systematic Reviews, The Cochrane Controlled Trials Register, The Health Technology Assessment Database, Database of Abstracts of Reviews of Effects (DARE), PsycINFO, Psicodoc and CPG directories such as the National Guideline Clearinghouse, the Scottish Intercollegiate Guidelines Network (SIGN), the New Zealand Guidelines Group, the National Institute for Clinical Excellence (NICE), the CPG INFOBASE and Evidence-Based Medicine guidelines. The same search terms used in the previous CPG were applied (see Annex 7 in the original guideline document). The search period spanned from the completion of the previous CPG (2002) to July 2007.

Additionally, with the aim of updating and expanding contents, several specific searches were performed, according to the area of intervention and some aspects that had not been addressed in the previous CPG, such as incipient psychotic disorder. These searches were conducted in the main medicine and psychology databases: PubMed/Medline, The Cochrane Database of Systematic Reviews, The Cochrane Controlled Trials Register, The Health Technology Assessment Database, DARE, Science Citation Index, PsycINFO, etc., and pages of different organizations, scientific societies, etc., were reviewed. A search was conducted for potential systematic reviews of the scientific evidence (SRSE) and, in some cases, randomized clinical trials (RCT), covering the 2002-2007 period. The different searches and main strategies of each one of them can be consulted in Annex 7 of the original guideline document. Furthermore, other manual searches of bibliographic references included in selected articles, or through other access channels. The bibliographic references obtained were managed using the Reference Manager program, which facilitated the detection of duplicates and the management of references in the development of the document.

Number of Source Documents

The literature search identified 1,360 references.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Scientific Evidence

Ia Scientific evidence obtained from meta-analyses of randomized clinical trials

Ib Scientific evidence obtained from at least one randomized clinical trial

IIa Scientific evidence obtained from at least one well-designed, non-randomized controlled prospective study

IIb Scientific evidence obtained from at least one well-designed, quasi experimental study

III Scientific evidence obtained from well-designed observational studies, such as comparative studies, correlation study or case-control studies

IV Scientific evidence obtained from documents or opinions of experts committees and/or clinical experiences of renowned opinion leaders

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

A development group composed of health care professionals was in charge of the review and synthesis of the scientific literature. The members of this group were divided into four subgroups that addressed the different aspects covered in the clinical practice guideline (CPG): biological treatment and somatic management, psychosocial interventions, psychosocial rehabilitation and modalities of care to the community.

The selection, review and synthesis of the biomedical literature were carried out by the four subgroups, according to the type or area of intervention. They performed a first selection of the scientific literature by reading the titles and summaries of recovered documents, which met the inclusion and exclusion criteria determined by the group (based on the clinical questions established, the study period, language, etc.). Finally, the last selection was carried out after the critical reading of the complete text of the studies included (see Figure 1 in the original guideline document). In cases of greater difficulty or methodological doubts, two independent reviewers performed the selection. The information extracted from the articles and their quality assessment was synthesized in tables of scientific evidence.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

A development group composed of health care professionals was in charge of the development of the recommendations that had to be updated. The members of this group were divided into four subgroups that addressed the different aspects covered in the clinical practice guideline (CPG): biological treatment and somatic management, psychosocial interventions, psychosocial rehabilitation and modalities of care to the community.

Each subgroup selected and reached consensus on the recommendations that were going to be formulated based on those extracted from the selected CPGs and from the scientific articles that completed the information. Annex 1 (in the original guideline document) presents the scale with the levels of evidence and the classification of recommendations used in this project.

In the 2009 update, the recommendations extracted from the selected CPGs maintain the grade of recommendation, even though they do not incorporate the level of scientific evidence that is already referenced in the original 2003 CPG.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

A (Levels of SE Ia, Ib) It requires at least one randomized clinical trial as part of the scientific evidence with overall good quality and consistency in terms of the specific recommendation.

B (Levels of SE IIa, IIb, III) It requires methodologically correct clinical trials that are not randomized clinical trials on the topic of recommendation. It includes studies that do not meet A or C criteria.

C (Level of SE IV) It requires documents or opinions of expert committees and/or clinical experiences of renowned opinion leaders. It indicates the absence of high quality, directly applicable clinical studies.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Clinical Validation-Pilot Testing
External Peer Review
Description of Method of Guideline Validation

External Review

The external review was performed by professionals from different fields and national health care settings, as well as by some representatives from schizophrenia foundations (see chapter on authorship and collaborations in the original guideline document). All reviewers received an assessment questionnaire. The form used and a summary of the responses obtained are presented in annex 8 of the original guideline document.

Finally, the changes suggested by the reviewers were discussed in the working group for later modification, applying the external review method of the schizophrenia patient outcomes research team (PORT) studies. That is, recommendations were modified only if they were supported by scientific evidence, meaning opinion by itself was not considered sufficient enough reason to modify the recommendation. In this sense, recent bibliography (outside the time range selected for the initial review and synthesis of the biomedical literature) has been included, given that the relevance of the contents justified their inclusion in the clinical practice guideline (CPG).

Performance of the Pilot Test

In the previous (2003) CPG, a pilot test was performed in which 22 professionals from different fields (psychologists, psychiatrists, nurses and social workers) and different community mental health centres, day hospitals and psychiatry services of general hospitals participated. In order to approve the CPG, they were delivered the document with an assessment questionnaire and a letter explaining the process to be followed to analyze both the presentation format and the feasibility of application and acceptance of recommendations. They were requested to use the CPG in their clinical practice over a period of two weeks and subsequently conduct their assessment. The suggestions obtained were incorporated into the format of algorithms and in a new pamphlet design, achieving the main objective: to improve the presentation of the CPG before its edition and publication.

Given that this CPG updates and complements specific aspects, the working group did not deem the performance of a new pilot test necessary.

Recommendations

Major Recommendations

Levels of evidence (I - IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

General Overview of the Management of Schizophrenia and Incipient Psychotic Disorder

Components of Psychiatric Management

Treatment Documentation

A - A therapeutic alliance enables the psychiatrist to acquire essential information regarding the patient and enables the patient to gain trust in the psychiatrist and the desire to cooperate in treatment. The identification of the patient's objectives and aspirations and relating them with results promotes treatment adherence, together with the therapeutic relationship (American Psychiatric Association, 2004).

Types and Scopes of Intervention

Pharmacological Intervention

General Recommendations for Antipsychotic Treatments

General Aspects

A - Whenever possible, antipsychotic medication should be prescribed in a non-coercive manner in combination with psychosocial interventions that include adherence-promoting strategies (Royal Australian and New Zealand College of Psychiatrists [RANZCP], 2005).

A - Antipsychotic medications are indicated in nearly all patients who experience an acute relapse; the choice of medication should be guided by the individual characteristics of each patient (Canadian Psychiatric Association, 2005).

C - Weight and body mass index should be measured at the beginning of treatment, then every month for six months, and after that every three months. Consultation with a dietitian is advisable, as well as encouraging regular physical exercise. It may also be necessary to consider a drug with a smaller risk of weight gain if weight does not change or is significant. Pros and cons should be assessed with the patient, and he/she should be provided with psychosocial support (RANZCP, 2005).

C - Fasting plasma glycaemia and lipid profiles should be measured at baseline and at regular intervals over its course (RANZCP, 2005).

C - An optimum initial assessment should include magnetic resonance imaging, neurocognitive assessment, neurological exam of neurological and motor disorders, an electrocardiogram, height and weight measurement (body mass index), illegal substance detection tests, lipid profiles and fasting plasma glycaemia (and/or HbA1c) (RANZCP, 2005).

Prescription of Antipsychotics and Side Effects

A - Pharmacological treatments should be prescribed with extreme caution in patients who have not undergone prior treatment, under the basic principle of producing the least harm possible, while obtaining the maximum benefit. This means a gradual introduction, after careful explanation, of low doses of antipsychotic medication together with antimania or antidepressant drugs when these syndromes are present (RANZCP, 2005).

A - In patients who initiate treatment for the first time, second-generation antipsychotic medication is recommended given that it is justified due to its better tolerance and lower risk of tardive dyskinesia (RANZCP, 2005).

A - The use of oral second-generation medication such as risperidone, olanzapine, quetiapine, amisulpride and aripiprazole is recommended as the first and second line of treatment in the first episode of psychosis. Initial doses should be low and then be gradually increased little by little at spaced out intervals only if response is low or incomplete. Secondary discomfort, insomnia and restlessness should be initially treated with benzodiazepines. Other symptoms such as mania and severe depression require specific treatment with mood stabilizers and antidepressants (RANZCP, 2005).

C - These doses probably will not have an early effect (during the first days) on discomfort, insomnia and behavioural disorders secondary to psychosis. Hence, a safe, supportive context, and regular and sufficient dose of benzodiazepines will provisionally represent essential components in the management of specialized nursing care (RANZCP, 2005).

C - If the risk-benefit relationship changes in certain patients due to, for example, weight gain, impaired glucose tolerance or sexual side effects associated with the development of second generation agents, an alternative first or second generation antipsychotic drug should be reconsidered (RANZCP, 2005).

C - In emergency situations it is recommended to avoid the first choice use of drugs that tend to undermine the future adherence to treatment due to the production of undesirable side effects that generate an aversive subjective effect. First generation drugs should be used only as a last resort in these circumstances, particularly haloperidol, given that they produce more rigidity than sedation (RANZCP, 2005).

C - If in the first episode of non-affective psychosis there are side effects, such as weight gain or metabolic syndrome, the use of a conventional antipsychotic is recommended. If response is insufficient, other causes should be assessed. If there are no side effects, doses should be increased. If adherence is poor, analyse the reasons, optimize the doses and provide therapeutic compliance therapy (RANZCP, 2005).

Technical Aspects of Prescription

A - Maintenance of pharmacotherapy is recommended for the prevention of relapse in stable and stabilization phases, with doses that are always within the recommended treatment range for first and second generation antipsychotics (Canadian Psychiatric Association, 2005).

B - Antipsychotic medication for the treatment of a first episode of psychosis should be maintained for at least two years after the first recovery from symptoms (Canadian Psychiatric Association, 2005).

B - In a first episode of psychosis, dosage should be initiated in the lower half of the treatment range; second generation antipsychotics are indicated due to the lower short and long term risk of extrapyramidal side effects (Canadian Psychiatric Association, 2005).

B - The use of clozapine is recommended in cases of persistent aggressiveness (Canadian Psychiatric Association, 2005).

B - The administration of multiple antipsychotic drugs, such as the combination of first and second generation drugs, should not be used except during the transition phases of switching medication (RANZCP, 2005).

C - Antipsychotic drugs, whether second or first generation, should not be prescribed simultaneously, except for brief periods of time during a transition phase (National Collaborating Centre for Mental Health, 2003).

C - The combination of two antipsychotics is not recommended, given that it could increase the risk of side effects and pharmacokinetic interactions (National Collaborating Centre for Mental Health, 2003).

C - The recommendation to combine an antipsychotic drug, a mood stabilizer and a benzodiazepine or antidepressant could be totally justified by the characteristics of comorbid symptoms, which are extremely common in psychotic disorders (RANZCP, 2005).

C - If parenteral treatment is deemed necessary, intramuscular administration is preferable to intravenous, from the point of view of safety. Intravenous administration should only be used in specific circumstances (National Collaborating Centre for Mental Health, 2003).

C - Vital signs should be monitored after parenteral administration of treatment. Blood pressure, pulse rate, body temperature and respiratory rate should be recorded at regular intervals, established by the multidisciplinary team, until the patient is active again. If he/she is asleep or seems to be so, more intensive monitoring is required (National Collaborating Centre for Mental Health, 2003).

C - Depot drugs should be reserved for two groups. Firstly, for those who clearly and voluntarily choose this administration route. Second generation injectable drugs are preferable due to their better tolerability and lower risk of tardive dyskinesia. Secondly, for those who, despite a series of comprehensive psychosocial interventions aimed at promoting adaptation and adherence, repeatedly fail to adhere to the necessary medication and present frequent relapses. This is even more pressing when the consequences of relapses are severe and entail substantial risk both for the patient and for others (RANZCP, 2005).

Resistance to Antipsychotic Treatment

A - Patients who are taking first generation antipsychotic drugs and who still present persistent positive or negative symptoms, or who experience uncomfortable side effects, should switch to oral second generation antipsychotic medication under close surveillance of a specialist (RANZCP, 2005).

A - If the risk of suicide is high or persistent despite treatment for depression, if antidepressant treatment is ineffective, or if depression is not severe, the immediate use of clozapine should be considered (RANZCP, 2005).

A - Second generation medication is recommended for patients who relapse in spite of good adherence to first generation antipsychotic medication, although other reversible causes of relapse should be taken into account (RANZCP, 2005).

A - If the patient is resistant to treatment, clozapine should be introduced with safety guarantees on the very first administration (RANZCP, 2005).

A - When there is no response to treatment with adequate administration of two different antipsychotics, the use of clozapine is recommended (Canadian Psychiatric Association, 2005).

B - Depot antipsychotic drugs should be considered for those patients who present poor adherence to medication (Canadian Psychiatric Association, 2005).

C - If schizophrenia symptoms do not respond to first generation antipsychotics, the use of a second generation antipsychotic should be considered before diagnosing treatment resistant schizophrenia and introducing clozapine. In these cases, the introduction of olanzapine or risperidone can be assessed. It is recommended to inform the patients (National Collaborating Centre for Mental Health, 2003).

C - The addition of a second antipsychotic to clozapine could be considered in people resistant to treatment in whom clozapine alone has not been proven to be sufficiently effective (National Collaborating Centre for Mental Health, 2003).

Comorbidity and Coadjuvant Medications

B - It is possible to introduce antidepressants as complementary treatment to antipsychotics when depressive symptoms fulfill the syndromic criteria of major depression or are severe, causing significant discomfort or interfering with the patient's functionality (American Psychiatric Association, 2004).

B - An episode of major depression in the stable phase of schizophrenia is an indication for treatment with an antidepressant drug (Canadian Psychiatric Association, 2005).

Electroconvulsive Therapy (ECT)

C - ECT may be indicated in refractory or medication-intolerant patients. It may also be occasionally useful when there is an evident psychotic episode and the disorder is characterized by catatonic or affective symptoms (RANZCP, 2005).

C - Some patients with persistent, chronic or neuroleptic-resistant schizophrenia could benefit from ECT (RANZCP, 2005).

Psychosocial Interventions

C - The choice of a specific approach will be determined by the patient, his/her clinical situation, needs, capacities and preferences, as well as by available resources at that time ("Consenso espanol," 2000).

C - It is recommended that psychosocial interventions are carried out by professionals with specific training, sufficient experience, qualifications (backed by supervision and technical expertise), as well as availability and constancy in order to maintain a long term relationship ("Strategies therapeutiques," 1994).

Cognitive-Behavioural Therapy

A - Cognitive-behavioural therapy (CBT) is recommended for the treatment of psychotic symptoms that are persistent despite receiving adequate pharmacological treatment (National Collaborating Centre for Mental Health, 2003).

A - CBT should be indicated for the treatment of positive symptoms of schizophrenia, especially hallucinations (Jones et al., 2004).

A - CBT is recommended as a treatment option to aid in the development of insight and to increase adherence to treatment (Jones et al., 2004).

A - CBT is recommended to prevent the evolution to psychosis in early intervention (Tarrier & Wykes, 2004).

A - CBT is recommended as a treatment option to prevent the prescription of drugs and reduce symptomatology in the management of incipient psychosis (Tarrier & Wykes, 2004).

A - CBT, together with standard care, is recommended in the acute phase to accelerate recovery and hospital discharge (RANZCP, 2005).

B - CBT should be considered for the treatment of stress, anxiety and depression in patients with schizophrenia and consequently the techniques employed should be adapted to other populations accordingly (Canadian Psychiatric Association, 2005).

Supportive Psychotherapy

C - It is recommended to develop the therapeutic alliance by providing emotional support and cooperation, given that this alliance plays an important role in the treatment of patients with schizophrenia (Ávila Espada & Poch Bullich, 1994).

C - Supportive therapy is not recommended as a specific intervention in the normal management of patients with schizophrenia if other interventions whose efficacy has been proven are indicated and available. In spite of this, patient preferences should be acknowledged, especially if other more effective psychological treatments are not available (Ávila Espada & Poch Bullich, 1994).

Psychodynamic Psychotherapy

C - Psychoanalytical and psychodynamic principles may be useful to help professionals understand the experience and interpersonal relationships of people with schizophrenia (National Collaborating Centre for Mental Health, 2003).

Psychoeducation

A - The routine implementation of psychoeducational interventions for patients and family members in treatment plans is recommended (Pekkala & Merinder, 2007).

C - It is recommended to transmit information gradually depending on the needs and uncertainties of the patient and his/her family and the phase of the disorder the patient is in (National Collaborating Centre for Mental Health, 2003).

Family Intervention

A - Family Intervention (FI) programs are recommended to reduce the burden on the family, improve social functioning of the patient and reduce economic cost (Barbato & D'Avanzo, 2000; Pitschel-Walz et al., 2001).

A - The application of FI therapy is recommended in patients who are moderately or severely impaired and, especially, in those with long evolution of the disorder. In patients with recent onset of the disease, each situation will have to be individually assessed (Barbato & D'Avanzo, 2000; Pitschel-Walz et al., 2001).

A - FI should be offered to families who live together or who are in contact with patients with schizophrenia, especially those who have relapsed or present relapse risk, and also in cases of persistent symptomatology (National Collaborating Centre for Mental Health, 2003).

A - Psychoeducational FI, based on the management of expressed emotion, is recommended to avoid relapses and improve the prognosis of the disease (its effects are maintained at 24 months) (Barbato & D'Avanzo, 2000; Pitschel-Walz et al., 2001; Butzlaff & Hooley, 1998; Pharoah, Mari, & Streiner, 2002; Bustillo et al., 2001; Huxley, Rendall, & Sederer, 2000).

A - Programs should be applied in groups comprised of family members of similar patients, taking expressed emotion into account and should include the patient to the greatest possible extent. These programs should be added to standard treatment and should never last under six months in order for them to be effective (Barbato & D'Avanzo, 2000; Pitschel-Walz et al., 2001).

A - Patients should be included, whenever possible, in FI sessions given that it significantly reduces relapses (National Collaborating Centre for Mental Health, 2003).

A - Prolonged FI (over six months) is recommended to reduce relapses (National Collaborating Centre for Mental Health, 2003).

A - Patients and their families usually prefer single family interventions rather than multifamily group interventions (National Collaborating Centre for Mental Health, 2003).

A - Programs should always include information for the families regarding the disease along with different strategies, such as stress coping strategies or problem-solving training (Sellwood et al., 2001; Barrowclough et al., 1999).

B - Referrals to patient and carer social networks is recommended (RANZCP, 2005).

B - FI programs should last more than nine months and include characteristics of commitment to attend the program, support and development of skills and should not simply provide information or shared knowledge (Canadian Psychiatric Association, 2005).

C - It is recommended to transmit information gradually depending on the needs and uncertainties of the patient and his/her family and the phase of the disorder the patient is in (National Collaborating Centre for Mental Health, 2003).

Cognitive Rehabilitation

A - The application of cognitive rehabilitation therapy, in all its modalities, is recommended as a technique that improves cognitive functioning in a wide range of clinical conditions of the patient with schizophrenia (McGurk et al., 2007).

A - The application of cognitive rehabilitation therapy in the daily environment of the patient with schizophrenia is recommended (Velligan et al., 2000)

Social Skills Training

A - The application of social skills training (based on the problem-solving model) is recommended for severely or moderately impaired patients (Marder et al., 1996).

B - Social skills training should be available to patients with difficulties and/or stress and anxiety related to social interaction (Canadian Psychiatric Association, 2005).

Training in Activities of Daily Living (ADLs)

B - Training in ADLs, based on scientific evidence, should be available to patients who have difficulties handling daily functioning tasks (Canadian Psychiatric Association, 2005).

Occupational Insertion Support

A - It is recommended to encourage people with schizophrenia to find employment. Mental health specialists should actively facilitate it and specific programs that incorporate this intervention should be widely established (RANZCP, 2005).

A - Supported employment programs are recommended for the occupational insertion of patients with schizophrenia, given that better outcomes are obtained when compared to other occupational rehabilitation interventions. (Killackey et al., 2006; Twamley, Jeste, & Lehman, 2003).

A - It is recommended to provide occupational support to moderately or mildly disabled patients and who are in the stable or maintenance phase (Bond et al., 2001; Crowther et al., 2001).

C - Mental health services, in collaboration with social and health care staff and other relevant local groups, should facilitate access to employment opportunities, including an array of support modalities adapted to the different needs and abilities of people with schizophrenia (National Collaborating Centre for Mental Health, 2003).

Housing Resources

B - It is recommended that housing resources focus on the interaction between the patient and his/her environment, activating the individual's personal resources and community resources with the aim of achieving as much autonomy as possible (Lascorz et al., 2009).

C - If possible, patient preferences in terms of housing and resource selection should be favoured, acknowledging the right of the patient to live in an environment that is as normalized as possible, articulating the necessary training programs and providing proper support so that the patient can access and remain in the aforementioned setting ("Modelo de Atención," 2006).

Modalities of Care and Intensive Follow-up in the Community

A - It is recommended that patients be treated in the least restrictive setting possible, while ensuring safety and enabling effective treatment (American Psychiatric Association, 2004).

Community Mental Health Teams

C - Outpatient management in a community mental health centre that provides pharmacological treatment, individual, group-based and/or family therapy, psychoeducational measures and different intensities of individualized treatment is recommended for stable patients with relatively mild disability ("Treatment of schizophrenia," 1999).

A - Outpatient management in a community mental health centre is recommended for patients with severe mental disorder given that it decreases deaths by suicide, dissatisfaction with care delivery and treatment dropout (Tyrer et al., 2002).

A - Community management with a comprehensive care plan for patients with severe mental disorder is recommended. The patient should be included in decision-making, emphasizing his/her ability to improve his/her degree of satisfaction and social recovery (Malm et al., 2003).

Case Management (CM) and Assertive Community Treatment (ACT)

A - CM and ACT programs are recommended for high risk patients with a history of rehospitalizations, difficult linkage to normal services or who are homeless (Lehman et al., 2004).

A - ACT is recommended for people with severe mental disorder aged 18 to 65 years, who require frequent inpatient care to substantially reduce hospital costs, improving patient outcomes and satisfaction (Marshall & Lockwood, 1998).

A - ACT is recommended for patients with a high risk of rehospitalization and who cannot continue with conventional community-based treatment (American Psychiatric Association, 2004).

A - CM is recommended for community-based management of patients with severe mental disorder with the aim of increasing linkage to services and improving therapeutic compliance (Marshall et al., 1998).

B - ACT and intensive case management programs are recommended for patients with schizophrenia who are frequent users of services (Mueser et al., 1998).

A - Intensive case management is recommended in patients with severe mental disorder when they use hospital services with the aim of reducing this consumption (Burns et al., 2007).

C - Intensive case management and community-based supportive services, coupled with the administration of psychoactive drugs and psychotherapy, is recommended in patients who present early onset schizophrenia (prior to 18 years of age) (American Academy of Child and Adolescent Psychiatry [AACAP], 2001).

Treatment in Different Phases of the Disorder and Specific Situations

Early Phases of Psychosis: Incipient Psychosis

High Risk Mental State Phase

A - Specific early intervention programs are recommended given that they can reduce and/or delay the transition to psychosis (Tarrier & Wykes, 2004; Olsen & Rosenbaum, 2006).

B - Specific early intervention programs are recommended to improve prepsychotic symptomatology and prevent social decline or stagnation (Olsen & Rosenbaum, 2006; Bechdolf et al., 2006; Broome et al., 2005; Nordentoft et al., 2006; Phillips et al., 2002).

C - It is recommended to carefully approach current symptomatology and suffering, both with the patient and with the family, with an empathetic and hopeful attitude (Johannessen, Martindale, & Culberg, 2008).

C - It is recommended to develop early intervention programs with comprehensive pharmacological (depending on symptomatology) and psychosocial (psychological treatment, family interventions and recovery support) interventions (Bertolote & McGorry, 2005).

C - Antipsychotic medication should not be prescribed as standard procedure unless there is accelerated deterioration, a high risk of suicide, if treatment with any other antidepressant has not been effective or if increasing aggression and hostility endanger other people (International Early Psychosis Association Writing Group, 2005).

First Psychotic Episode Phase

Pharmacological Intervention in a First Psychotic Episode

A - If there is no response to treatment or low adherence or persistent suicide risk, the use of clozapine is recommended (RANZCP, 2005).

A - Initiate the administration of low dose second generation antipsychotics (RANZCP, 2005).

C - A 24 to 48 hour antipsychotic-free observation period is recommended, but benzodiazepines may be used for anxiety and sleep disorders (RANZCP, 2005).

C - If there is response to treatment, maintain treatment over a period of 12 months, and if there is symptom remission gradually reduce dose over a few months with close follow-up (RANZCP, 2005).

C - If there is no response to treatment, assess the causes. If there is poor adherence, analyze the reasons, optimize the doses and provide help to improve compliance (RANZCP, 2005).

C - If there is no response to treatment, switch to another second generation antipsychotic and assess outcomes over a period of six to eight weeks (RANZCP, 2005).

C - If second generation antipsychotics are being used and there are side effects, the switch to a first-generation drug could be considered (RANZCP, 2005).

Psychosocial Intervention in a First Psychotic Episode

A - CBT is recommended for the prevention of psychosis progression in early intervention, reducing prescription of drugs and symptomatology (Tarrier & Wykes, 2004).

A - Treatments in early intervention teams or multi-element programs are recommended in first psychotic episodes (non-affective) (Garety et al., 2006; Penn et al., 2005; Jeppesen et al., 2005).

C - Informative campaigns are recommended to help recognize prodromal symptoms in the general population, general practitioners and professionals involved with the population at risk (Bertolote & McGorry, 2005).

C - Very accessible detection teams are recommended to reduce DUP and its corresponding outcomes (International Early Psychosis Association Writing Group, 2005).

C - Care should be provided in the least restrictive and coercive settings possible, while ensuring the safety of the patient and family (Bertolote & McGorry, 2005).

C - Supportive family interventions are recommended in accordance with their needs (Marshall & Rathbone, 2006).

C - Intensive case management and community-based support services, coupled with psychoactive drugs and psychotherapy, are recommended for some patients with early onset schizophrenia (AACAP, 2001).

Recovery Phase after the First Episode

Pharmacological Intervention in the Recovery from a First Psychotic Episode

A - If there are relapses, identify their causes, differentiating whether they are due to poor adherence or in spite of satisfactory adherence. If it is due to poor adherence, restore treatment (RANZCP, 2005).

A - If resistance to treatment is evident and two antipsychotic drugs have been used, and at least one of them is a second generation drug, switch to clozapine (RANZCP, 2005).

B - If there are tolerance problems with second generation medication, especially weight gain or metabolic syndrome, offer the possibility of switching to a different second or first generation antipsychotic (RANZCP, 2005).

C - If a first generation antipsychotic is being used, switch to a second generation one if response is not adequate or if there are tolerance problems (RANZCP, 2005).

C - If the patient has relapsed despite good adherence to a first generation antipsychotic, switch to a second generation one. If the patient presents with symptom remission, good quality of life, and has not presented tolerance problems to conventional medication, maintain its use (RANZCP, 2005).

C - As a last resort the switch to a first generation depot medication can be considered. However, long acting second generation injectable drugs may be considered an alternative to clozapine when there is low or uncertain adherence, especially if the patient prefers this option (RANZCP, 2005).

C - If there is no response to treatment or low adherence with frequent relapses, low dose first generation depot antipsychotics should be tried for a period of 3 to 6 months (RANZCP, 2005).

Psychosocial Interventions in the Recovery from a First Psychotic Episode

A - Early intervention programs for psychosis are recommended over traditional approaches (Garety et al., 2006; Marshall & Rathbone, 2006).

A - Psychosocial interventions are recommended in the treatment of first episodes (Tarrier & Wykes, 2004; Marshall & Rathbone, 2006; Penn et al., 2005).

B - Supported employment is recommended as the most effective method to promote occupational insertion of people with first episodes (Rinaldi et al., 2004).

C - Cognitive rehabilitation is recommended in patients with specific deficits, even though the objective should also include related functional deficits (Vishnu Gopal & Variend, 2005).

C - It is recommended to provide high quality intensive biopsychosocial care in a continued and active manner during the critical years following the onset of psychosis, preferably from specialized early intervention programs which also include pharmacotherapy, psychoeducation, stress management, relapse prevention, problem solving, reduction of harm due to substance use, supportive counseling and social and occupational rehabilitation, as well as family intervention and cognitive therapy (International Early Psychosis Association Writing Group, 2005).

Phases of Schizophrenia

Acute Phase (or Crisis)

Pharmacological Intervention in the Acute Phase

B - Pharmacological treatment should be initiated immediately, unless it interferes with diagnostic assessment, given that acute psychotic aggravation is associated with emotional discomfort, disturbances in the patient's life and considerable risk of behaviours that may endanger the life of the patient and others (American Psychiatric Association, 2004).

C - Patients and family members should be completely informed on the benefits and risks of pharmacological therapy and advised when choosing antipsychotic medication; the services of interpreters or cultural mediators should be used when necessary. In the case of not being able to openly discuss treatment options with the patient, as occurs in the case of some acute episodes, oral second generation medication should be the treatment of choice due to the lower risk of extrapyramidal symptoms (RANZCP, 2005).

C - When choosing a certain antipsychotic medication, the patient's prior response to treatment, the side effects profile, preferences for a certain drug based on prior experience and the foreseen administration route should be taken into account (McGlashan & Johannessen, 1996). The recommended doses of antipsychotics have been described in the corresponding tables in the original guideline document.

C - The key principle is to avoid the first choice use of drugs that tend to weaken future adherence due to the development of side effects. The immediate objective is not only the reduction of aggression, agitation and risk but also to make the patient feel subjectively better and calmer with good tolerability (RANZCP, 2005).

C - The first step of clinical management of resistant schizophrenia is to establish that antipsychotic medications have been adequately used in terms of dose, duration and adherence. Other causes of poor response should be considered in clinical assessments, such as the incorrect use of comorbid substances, poor adherence to treatment, simultaneous use of other prescribed drugs and physical disease (National Collaborating Centre for Mental Health, 2003).

C - If schizophrenia symptoms do not respond to first generation antipsychotics, the mental health professional and patients should consider the use of a second generation antipsychotic prior to the diagnosis of treatment-resistant schizophrenia or a trial with clozapine (National Collaborating Centre for Mental Health, 2003).

C - It is recommended that the use of medications such as lithium, carbamazepine, valproic acid or benzodiazepines be reserved for cases where clozapine is not appropriate in treatment-resistant patients due to poor efficacy, side effects, patient preference or likely lack of compliance of the surveillance program (Crowther et al., 2001).

Psychosocial Interventions in the Acute Phase

A - CBT is recommended in the acute phase, coupled with standard care, to accelerate recovery and hospital discharge (RANZCP, 2005).

Stabilization Phase (or Postcrisis)

Pharmacological Treatment in the Stabilization Phase

C - Due to the risk of fast relapse in the post crisis phase, the discontinuation or reduction of antipsychotic pharmacological treatment initiated in the acute phase should be avoided. The continuation of treatment over a period of one or two years after a crisis should be discussed, when appropriate, with the patient and family (National Collaborating Centre for Mental Health, 2003).

C - If possible, in patients with complete remission antipsychotic medication should be administered over a period of at least 12 months and a subsequent attempt should be made to gradually discontinue medication over a period of at least several weeks. Close monitoring should be followed by specialist follow-up over the next 12 months and any relapse should be promptly identified and treated. Patients should not be referred to primary care exclusively, as shared health care is the best option in all these phases (RANZCP, 2005).

Psychosocial Interventions in the Stabilization Phase

A - Health education programs are recommended in this phase given that they have been proven effective at teaching self-management of medication (maintenance antipsychotic treatment, side effects, etc.), self-management of symptoms (identification of the first signs of a relapse, their prevention, and refusal to consume drugs and alcohol), and basic social skills (Eckman et al., 1992; Wallace et al., 1992; Eckman et al., 1990).

A - The application of CBT is recommended for the treatment of positive and negative symptoms that are resistant to antipsychotics (Rector & Beck, 2001).

A - CBT is recommended for the treatment of positive symptoms in schizophrenia (Gaudiano, 2006) especially hallucinations (Jones et al., 2004).

A - CBT is recommended as a treatment option to aid in the development of insight (Jones et al., 2004).

A - CBT is recommended as a treatment option to increase adherence to treatment (Jones et al., 2004).

A - Patient psychoeducation is recommended given that it reduces relapse risk, probably by improving adherence, improves the patient's satisfaction with treatment and improves knowledge (RANZCP, 2005).

A - FI therapy is recommended in patients who are moderately or severely disabled and especially in patients with long evolution of the disease. In patients with recent onset of the disorder each situation should be individually assessed (Barbato & D'Avanzo, 2000; Pitschel-Walz et al., 2001).

A - FI should be offered to families who live or are in contact with patients with schizophrenia, especially those who have relapsed or present relapse risk and also in those cases with persistent symptomatology (National Collaborating Centre for Mental Health, 2003).

A - FI programs should include family members of patients with homogeneous diagnosis, enable the patient's participation and ensure that he/she is well-informed. FI should take place over a period of at least six months (Pitschel-Walz et al., 2001).

A - FI programs are recommended to reduce family burden, improve the patient's social functioning and decrease economic cost (Barbato & D'Avanzo, 2000; Pitschel-Walz et al., 2001).

A - Psychoeducational FI, based on the management of expressed emotion, is recommended to prevent relapses and improve disease prognosis (its effects are maintained at 24 months) (Barbato & D'Avanzo, 2000; Pitschel-Walz et al., 2001; Butzlaff & Hooley, 1998; Pharoah, Mari, & Streiner, 2002; Bustillo et al., 2001; Huxley, Rendall, & Sederer, 2000).

A - Programs should always include information for families regarding the disease and different strategies such as stress coping techniques or problem solving training (Sellwood et al., 2001; Barrowclough et al., 1999).

A - The application of social skills training (based on the problem-solving model) is recommended in patients who are severely or moderately disabled, given that it is effective in terms of social adaptation and its effects are maintained after two years (Marder et al., 1996).

B - Referral to patient and carer social networks is recommended given that support groups are effective at providing support to the family (RANZCP, 2005).

C - It is recommended to develop a therapeutic alliance based on emotional support and cooperation, given that it plays an important role in the treatment of people with schizophrenia (Ávila Espada & Poch Bullich, 1994)

C - Supportive therapy is not recommended as a specific intervention in the normal care of people with schizophrenia if other interventions with proven efficacy are indicated and available or if the patient expresses his/her preferences for this type of psychotherapy (Ávila Espada & Poch Bullich, 1994).

C - Supportive psychotherapy focused on reality, with realistic objectives, is recommended for patients who are moderately disabled and stable or intermittently stable ("Treatment of schizophrenia," 1999).

B - Adaptation to the community can be facilitated by establishing realistic objectives and avoiding excessive pressure on the patient to achieve high employment and social performance (American Psychiatric Association, 2004).

Stable Phase (or Maintenance Phase)

Pharmacological Intervention in the Stable Phase

A - Coadjuvant medication is frequently prescribed for comorbidity in patients with schizophrenia who are in the stable phase. Major depression and obsessive-compulsive disorder may respond to antidepressants (American Psychiatric Association, 2004).

C - Withdrawal of antipsychotic medication should be carried out gradually while performing regular monitoring of signs and symptoms that may indicate potential relapses (National Collaborating Centre for Mental Health, 2003).

C - A complete physical examination, including weight, blood pressure, lipid profile, electrocardiogram (ECG) and blood fasting glucose should ideally be performed in collaboration with the primary care physician at least once a year. Routine screening of cervical and breast cancer should be carried out in women. In patients over the age of 40, it is important to consider new symptoms and perform screening tests for the common types of cancer. If there are no guarantees that primary care will carry out this type of monitoring, it should be placed in the hands of the psychiatrist (RANZCP, 2005).

Psychosocial Interventions in the Stable Phase

As was presented throughout the CPG, psychosocial interventions that are effective in the stabilization phase are also effective in the stable or maintenance phase (see chapter on Psychosocial interventions). The following interventions can also be considered:

A - Supportive psychotherapy for problem solving is recommended given that it significantly reduces relapses and boosts social and occupational function when added to medication in patients treated on an outpatient basis (Level of Scientific Evidence: Ia) (Hogarty et al., "Three year trials, Part II: Effects," 1997; Hogarty et al., "Three year trials, Part I: Description," 1997; "Psychosocial interventions," 1998).

A - Cognitive rehabilitation is recommended in the patient’s social environment given that it has been shown to be effective (in contrast to traditional cognitive rehabilitation) in the prevention of relapses and social adaptation (Velligan et al., 2000).

A - It is recommended to provide occupational support to patients who are moderately or mildly disabled, given that it has been shown to be effective in the obtention of normalized employment (Bond et al., 2001; Crowther et al., 2001).

A - In patients with early onset schizophrenia social skills techniques are recommended, given that they result in better outcomes than supportive techniques (Marder et al., 1996).

A - The application of cognitive rehabilitation, in all its modalities, is recommended as a technique that improves cognitive functioning in a wide range of clinical conditions of the patient with schizophrenia (McGurk et al., 2007).

A - Patients with schizophrenia should be encouraged to find employment. Mental health specialists should actively facilitate this process and specific programs incorporating this intervention should be widely established (RANZCP, 2005).

A - The best outcomes in occupational insertion of people with schizophrenia are obtained with supported employment programs, when compared to other occupational rehabilitation interventions (Killackey et al., 2006; Twamley, Jeste, & Lehman, 2003; Crowther et al., 2008).

B - The strategies to tackle social stigma and discrimination of the mentally ill are more effective when education includes contact with schizophrenic people who share their story (Canadian Psychiatric Association, 2005).

B - An evidence-based format of training in abilities for daily living should be available to patients who have difficulties in daily functioning (Canadian Psychiatric Association, 2005).

C - If possible, patient preferences in terms of housing and resource selection should be favoured, acknowledging the right of the patient to live in an environment that is as normalized as possible, articulating the necessary training programs and providing proper support so that the patient can access and remain in the aforementioned setting (Ministerio de Trabajo y Asuntos Sociales [IMSERSO], 2006).

Specific Situations

Substance Use-Related Disorders

C - It is recommended that treatment objectives in patients with this associated pathology mirror the objectives of treatment of schizophrenia with no associated pathology, but adding the objectives relating to substance use problems, such as harm reduction, abstinence, relapse prevention and rehabilitation ("Practice guideline," 1997).

Schizophrenia and Suicide

C - It is recommended to increase the frequency of outpatient visits in patients who have recently been discharged from the hospital, given that it is a vulnerable period for the patient ("Practice guideline," 1997).

C - During inpatient care it is essential to adopt precautions to avoid suicide and closely monitor suicidal patients ("Practice guideline," 2004).

C - Patients who have been deemed to have high suicidal risk should be put into inpatient care, and the necessary measure to avoid suicide should be applied. It is important to optimize pharmacological treatment of psychosis and depression, and to address the suicidal inclination of the patient directly, with an empathetic and supportive approach. Close surveillance should be carried out on vulnerable patients during periods of personal crisis, environment changes or periods of hardship or depression over the course of the disease ("Practice guideline," 1997).

A - Treatment by community mental health teams is recommended in severe mental disorders to reduce deaths by suicide (Tyrer et al., 2002).

C - When discharged, the patient and his/her family members should be advised to stay alert to warning signs and initiate prevention measures if suicidal ideas reappear ("Practice guideline," 2004).

C - When a patient has been recently discharged, it is recommended that he/she undergoes more frequent outpatient management. The number of visits should be increased in times of personal crisis, significant changes in the patient's surroundings, increased discomfort or depression that is accentuated over the course of the disease ("Practice guideline," 2004).

Depressive Symptoms

A - Second generation antipsychotics are recommended for the treatment of depressive symptoms ("Practice guideline," 2004).

B - A major depression episode during the stable phase of schizophrenia is an indication for treatment with an antidepressant drug (Canadian Psychiatric Association, 2005).

B - It is possible to add antidepressants as complementary treatment to antipsychotics when depressive symptoms meet the syndromic criteria of major depression or are severe, causing significant discomfort or interfering with the patient's functionality ("Practice guideline," 2004).

Homeless Patients

B - Follow-up of patients after hospital discharge is recommended. Professionals should remain alert to comorbidity due to patient's substance use, psychiatric symptoms and overall function to prevent the risk of patients becoming homeless ("Practice guideline," 1997).

C - Treatment and support in transition to housing are recommended for homeless schizophrenic patients ("Practice guideline," 1997).

Definitions:

Levels of Scientific Evidence (SE)

Ia Scientific evidence obtained from meta-analyses of randomized clinical trials

Ib Scientific evidence obtained from at least one randomized clinical trial

IIa Scientific evidence obtained from at least one well-designed, non-randomized controlled prospective study

IIb Scientific evidence obtained from at least one well-designed, quasi-experimental study

III Scientific evidence obtained from well-designed observational studies, such as comparative studies, correlation study or case-control studies

IV Scientific evidence obtained from documents or opinions of experts committees and/or clinical experiences of renowned opinion leaders.

Grades of Recommendation

A (Levels of SE Ia, Ib) It requires at least one randomized clinical trial as part of the scientific evidence with overall good quality and consistency in terms of the specific recommendation.

B (Levels of SE IIa, IIb, III) It requires methodologically correct clinical trials that are not randomized clinical trials on the topic of recommendation. It includes studies that do not meet A or C criteria.

C (Level of SE IV) It requires documents or opinions of expert committees and/or clinical experiences of renowned opinion leaders. It indicates the absence of high quality, directly applicable clinical studies.

Clinical Algorithm(s)

The following algorithms are available in the original guideline document:

  • Algorithm of Pharmacological Intervention
  • Interventions According to the Phases of Incipient Psychosis
  • Interventions According to the Phases of Schizophrenia

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Safe and effective management of individuals with schizophrenia and incipient psychotic disorder

Potential Harms

Refer to Section 6.1 of the original guideline document for extensive information on the adverse effects of antipsychotic medications.

Contraindications

Contraindications
  • Pimozide is contraindicated in people with a past medical history of arrhythmia or congenital prolonged QT.
  • Sulpiride is contraindicated in people diagnosed with porphyria.
  • Zuclopenthixol acetate is contraindicated in patients diagnosed with porphyria.
  • Zuclopenthixol dihydrochloride is contraindicated in patients diagnosed with porphyria and in patients who present apathy or withdrawal states.
  • Clozapine is contraindicated in patients with prior hypersensitivity to clozapine; a history of drug-induced granulocytopenia/agranulocytosis; white blood cell count lower than 3,500/mm3; altered bone marrow function; alcoholic, toxic psychoses and comatose states; respiratory collapse and/or depression of the central nervous system due to any cause; severe liver, kidney or heart disease.
  • The possible abuse of benzodiazepines should be monitored, and it should be acknowledged that the combination of these drugs with clozapine and levomepromazine can be dangerous and contraindicated.

Qualifying Statements

Qualifying Statements

This clinical practice guideline (CPG) is an aid for decision-making in healthcare. It is not in any way an obliged requirement to adhere to every aspect of this CPG nor does it replace the clinical judgement of health care professionals.

Implementation of the Guideline

Description of Implementation Strategy

Dissemination

The clinical practice guideline (CPG) will be distributed by post to interested professionals, and will be communicated at congresses and presented officially in public events. It will be necessary to contact mental health services of different autonomous communities and the corresponding scientific societies.

The dissemination strategy includes the following actions:

  • Elaboration of press releases sent to the media, both scientific and general media
  • Individual delivery to potential professional users of the CPG. A shorter format of the guideline and the most important annexes with algorithms and figures are also sent to these users
  • Presentation to scientific societies and professional groups that are considered to be an objective sector of the public
  • Individualized distribution to opinion leaders and experts in accordance with criteria such as publication volume in scientific journals, presidency of scientific societies, members of the expert committees of biomedical journals, members of the scientific committees of congresses, etc.
  • Distribution of the guideline aimed at people with schizophrenia, and their families, friends or people they have a relationship with
  • Use of the CPC in academic activities related to the methodology and development of CPGs
  • Diffusion of the CPG in electronic format in the websites of the Catalan Agency for Health Technology Assessment and Research (CAHTA) and scientific societies
  • Presentation of the CPG in scientific activities (conferences, congresses, meetings)
  • Publication of the CPG in medical journals

Determination of Implementation Indicators

The objectives of implementing the CPG are:

  • To provide a comprehensive approach for the management of patients with incipient psychosis or schizophrenia which includes pharmacological treatment; individual, group based and family psychotherapy; and rehabilitation.
  • To provide an adequate idiosyncratic combination of treatments of patients with incipient psychosis and schizophrenia.

The indicator designed to measure its scope is the percentage of patients with schizophrenia or incipient psychosis attended who have been offered pharmacological treatment; psychosocial intervention and rehabilitation, in accordance with the recommendations suggested in this CPG.

Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
Foreign Language Translations
Mobile Device Resources
Patient Resources
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Working Group of the Clinical Practice Guideline for Schizophrenia and Incipient Psychotic Disorder, Mental Health Forum, coordination. Clinical practice guideline for schizophrenia and incipient psychotic disorder. Madrid (Spain): Quality Plan for the National Health System of the Ministry of Health and Consumer Affairs, Catalan Agency for Health Technology Assessment and Research; 2009 Mar. 216 p. (Clinical practice guideline: CAHTA; no. 2006/05-2).  [240 references]
Adaptation

Four clinical practice guidelines (CPGs) served as the basis for this update:

  • Schizophrenia. Full national clinical guideline on core interventions in primary and secondary care. National Collaborating Centre for Mental Health. National Institut for Clinical Excellence (NICE). The Royal College of Psychiatrists & The British Psychological Society. London, 2003.
  • McGorry P, Killackey E, Lambert T, Lambert M, Jackson H, Codyre D, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. Aust N Z J Psychiatry. 2005; 39(1-2):1-30.
  • Practice guideline for the treatment of patients with schizophrenia (Second Edition). American Psychiatric Association; Steering Committee on Practice Guidelines. 2004.
  • Clinical practice guidelines. Treatment of schizophrenia. Can J Psychiatry. 2005;(50) 13 Suppl 1: 7S-57S.
Date Released
2009 Mar
Guideline Developer(s)
Agency for Health Quality and Assessment of Catalonia (AQuAS) - State/Local Government Agency [Non-U.S.]
GuiaSalud - National Government Agency [Non-U.S.]
Ministry of Health (Spain) - National Government Agency [Non-U.S.]
Source(s) of Funding

This clinical practice guideline (CPG) has been funded by the agreement between the Carlos III Institute of Health, an autonomous organism of the Ministry of Health and Consumer Affairs (MSC), and the Catalan Agency for Health Technology Assessment and Research, within the framework of collaboration forecasted in the Quality Plan for the National Health System.

Guideline Committee

Working Group of the Clinical Practice Guideline for Schizophrenia and Incipient Psychotic Disorder

Composition of Group That Authored the Guideline

Coordinator Group: Lluís Lalucat, psychiatrist (coordinator), Centre for Mental Hygiene (CHM) Les Corts, Mental Health Forum (Barcelona); Judith Anglés, social worker, Individualised Services Plan, Les Corts-Sarrià-Sant, Gervasi, CHM Les Corts, Mental Health Forum (Barcelona); Ana Aznar, psychologist, Community Rehabilitation Services, CHM Les Corts, Mental Health Forum (Barcelona); David Bussé, psychiatrist, Adult Mental Health Centre Horta-Guinardó, Mental Health Forum (Barcelona); Maite Carbonero, psychiatrist, Adult Mental Health Centre, CHM Les Corts, Mental Health Forum (Barcelona); Rocio Casañas, psychologist, Research Department, CHM Les Corts, Mental Health Forum (Barcelona); Gustavo Faus, psychiatrist, Adult Mental Health Centre, right Eixample, CPB-SSM, Mental Health Forum (Barcelona); Imma Guillamón, psychologist, Agency for Health Technology Assessment and Research (Barcelona); Carles Martínez, psychiatrist, Adult Mental Health Centre, CHM Les Corts, Mental Health Forum (Barcelona); Laia Mas, psychologist, Department of Training, Teaching, Research and Publications, CHM Les Corts, Mental Health Forum (Barcelona); Mª Teresa Romero, nurse, Adult Mental Health Centre, Sarrià-Sant Gervasi, CHM Les Corts, Mental Health Forum (Barcelona); Raquel Rubio, psychologist, Community Rehabilitation Services, CHM Les Corts, Mental Health Forum (Barcelona); Maite San Emeterio, psychiatrist, Adult Mental Health Centre, CHM Les Corts, Mental Health Forum (Barcelona); Ignasi Sánchez, psychiatrist, Llúria Clinic Therapeutic Community, CPB-SSM, Mental Health Forum (Barcelona); Emília Sánchez, epidemiologist, Agency for Health Technology Assessment and Research (Barcelona); Mercè Teixidó, psychiatrist, Adult Mental Health Centre, Sarrià-Sant Gervasi, CHM, Les Corts, Mental Health Forum (Barcelona); Francisco Villegas, psychologist, Community Rehabilitation Services, CHM Les Corts, Mental Health Forum (Barcelona)

Development Group: Jordi Andreu, occupational therapist, Community Rehabilitation Services, CHM Les Corts, Mental Health Forum (Barcelona); Francisco Javier Aznar, psychologist, Day Hospital, Orienta Foundation, Mental Health Forum (Barcelona); Janina Carlson, psychologist, Research Department, CHM Les Corts, Mental Health Forum (Barcelona); Claudia Casanovas, psychologist, Els Tres Turons Foundation, Mental Health Forum (Barcelona); Gemma Castells, psychologist, Child and Adolescent Mental Health Centre, CHM Les Corts, Mental Health Forum (Barcelona); Juanjo Gil, nurse, Child and Adolescent Mental Health Centre, CHM Les Corts, Mental Health Forum (Barcelona); Elena Godoy, social worker, Community Rehabilitation Services, CHM Les Corts, Mental Health Forum (Barcelona); David Lascorz, social worker, Residencia Llúria, CPB-SSM, Mental Health Forum (Barcelona); Victòria López, psychologist, Community Rehabilitation Services, CPB-SSM, Mental Health Forum (Barcelona); Rosa Ordóñez, psychologist, Day Centre, left Eixample. Septimània, Mental Health Forum (Barcelona); Carmen Pinedo, nurse, Adult Mental Health Centre, right Eixample, CPB-SSM, Mental Health Forum (Barcelona); Mercedes Serrano, social worker, Community Rehabilitation Services, CHM Les Corts, Mental Health Forum (Barcelona); Sílvia Vidal, psychologist, Association for the Rehabilitation of the Mentally Ill (AREP), Mental Health Forum (Barcelona)

Expert Collaboration: Antoni Parada, documentalist, Agency for Health Technology and Research (Barcelona)

External Reviewers: Dr. Miquel Bernardo, Research Coordinator of the Clinical Institute of Neurosciences of the Clinical Hospital, Clinical Health Corporation (Barcelona); Dr. Antonio Ciudad, Clinical Research Unit, Lilly Research Laboratories (Madrid); Dr. Alberto Fernández, Spanish Association of Neuropsychiatry (Madrid); Dr. Mariano Hernández, Head of Mental Health Services, Spanish Association of Neuropsychiatry(Madrid); Dra. Roser Llop, Catalan Institute of Pharmacology Foundation (Barcelona); Sr. Jordi Masià, President of the Seny Foundation (Barcelona); Dr. Fermín Mayoral, Head of the Psychiatry Service of the Hospital Compound Carlos Haya Andalusian Association of Psychosocial Rehabilitation (Málaga); Dr. Rafael Penadés, Clinical Institute of Neurosciences, Clinical Hospital (Barcelona); Dr. José J. Uriarte, Zamudio Hospital, Spanish Federation of Psychosocial Rehabilitation Associations (Vizcaya); Dr. Óscar Vallina, Cantabria Health Service (Cantabria)

Financial Disclosures/Conflicts of Interest

All members of the working group (coordinator and development), as well as all external reviewers, have declared no conflict of interests by completing a form designed to this end (see annex 5 in the original guideline document). This guideline is editorially independent from the funding agency.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in English External Web Site Policy and Spanish External Web Site Policy from the GuíaSalud Web site. Also available from the Agency for Health Quality and Assessment of Catalonia (AQuAS) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Quick reference guides and summary versions are available in Spanish from the GuíaSalud Web site External Web Site Policy.
  • The Spanish version of the guideline is also available via a mobile application from the GuíaSalud Web site External Web Site Policy.
  • Updating clinical practice guidelines in the Spanish National Healthcare System: methodology handbook. Available from the GuíaSalud Web site External Web Site Policy.

In addition, implementation indicators are provided in Section 9.2 of the original guideline document External Web Site Policy.

Patient Resources

Patient information is available in Spanish from the GuíaSalud Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on November 2, 2011. The information was verified by the guideline developer on December 5, 2011. This summary was updated by ECRI Institute on July 10, 2013 following the U.S. Food and Drug Administration advisory on Valproate.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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