Canadian Treatment Guidelines on Psychosocial Treatment of Schizophrenia in Adults

Abstract

Objective:

It is generally recognised that psychosocial interventions are essential components of the effective treatment of schizophrenia in adults. A considerable body of research is being published regarding the effectiveness of such interventions. In the current article, we derive recommendations reflecting the current state of evidence for their effectiveness.

Methods:

Recommendations were formulated on the basis of a review of relevant guidelines, particularly those formulated by the Scottish Intercollegiate Guideline Network (SIGN) and National Institute for Health and Care Excellence (NICE).

Results:

There is evidence strongly supporting the use of family interventions, supported employment programs, and cognitive-behavioural therapy. There are also reasons to recommend the use of cognitive remediation, social skills training, and life skills training under specified circumstances. It is important that all patients and families be provided with education about the nature of schizophrenia and its treatment. Several recent innovative psychosocial approaches to treatment are awaiting more thorough evaluation.

Conclusions:

There continues to be strong evidence for the effectiveness of several psychosocial interventions in improving outcomes for adults with schizophrenia. In the past decade, innovative interventions have been described, several of which are the subject of ongoing evaluative research.

Several psychosocial interventions have been found to have benefits for individuals with schizophrenia spectrum disorders and their families. The review group would like to preface its recommendations by noting the importance of some general principles regarding the implementation of psychosocial interventions and indeed all treatment approaches to schizophrenia spectrum disorders. These include the following:

1. Optimal management requires the integration of medical and psychosocial interventions. Such interventions should not be seen as competing approaches but, in most cases, as necessary and complementary interventions to improve clinical symptoms, functional outcome, and quality of life.

2. Psychosocial interventions address many aspects of recovery, from reduction of acute symptoms to improvement in functioning and general well-being.

3. Genuinely listening and attending to patients’ concerns develops empathy, rapport, and good therapeutic relationships. It can also improve engagement and adherence to treatment.

4. It is important to encourage a realistically hopeful attitude for the future in patients and families. All clinicians, including physicians, are important contributors to this process.

5. All interventions should be undertaken within a recovery framework with the objective of the patient being able to obtain a good quality of life.

6. The clinical team, the patient, and family members should develop shared, short-term and long-term goals for treatment and recovery. Progress toward these goals should be carefully monitored and evaluated.

7. The delivery of effective psychosocial interventions requires specific and often nuanced and complex skills. It is essential that staff who provide psychosocial interventions should be appropriately trained.

8. Patients should be supported in developing effective self-management skills for improving their symptoms, functioning, and quality of life.

9. Common comorbid conditions such as substance abuse, anxiety disorders, and depression need to be recognised and addressed with psychosocial interventions.

10. Patient and family preferences should be considered in the identification of treatment goals and methods.

Methods

The methods for the Canadian Schizophrenia Guidelines are described in brief here; please see the Introduction and Methodology manuscript for an in-depth description.

The guidelines were developed using the ADAPTE process.¹ Recognising that the development of guidelines requires substantial resources, the ADAPTE process was created to take advantage of existing guidelines and reduce duplication of effort.

The first phase of the ADAPTE process, the setup phase, involved preparing for the ADAPTE process. We assembled a national multidisciplinary panel from across Canada, including stakeholders with expertise in schizophrenia and mental health, health policy, patient advocacy, and lived experience with schizophrenia. Endorsement bodies for the guidelines include the Canadian Psychiatric Association and the Schizophrenia Society of Canada, who were also heavily involved in the dissemination and implementation strategy.

The second phase of the ADAPTE process, the adaptation phase, involves the process of identifying specific health questions; searching for and retrieving guidelines, assessing guideline quality, currency, content, consistency, and applicability; decision making around adaptation; and preparing the draft-adapted guideline. We searched for guidelines on schizophrenia in guideline clearinghouses and on the websites of well-established guideline developers for mental health disorders, including the National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN), the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the European Psychiatric Association.²

A MEDLINE search was also performed using the term guideline as the publication type and schizophrenia as the title or clinical topic. Inclusion criteria were that the guideline needed to be published after 2010, be written in English, and that recommendations had to be developed using a defined and systematic process. We identified 8 current guidelines that were potentially suitable for adaptation. These guidelines were reviewed and evaluated in duplicate using the AGREE II tool,³ an instrument to evaluate the methodological rigour and transparency in which a guideline is developed. Based on this evaluation, we determined that the 6 guidelines were of suitable quality and content for adaptation (see Table 1). Recommendations from each guideline were extracted and divided based on content and reviewed by the relevant working group. Following the ADAPTE process, working groups selected between guidelines and recommendations to create an adapted guideline. Each working group carefully examined each recommendation, the evidence from which the recommendation was derived, and the acceptability and applicability of the recommendation to the Canadian context. After the reviewing the recommendations from the guidelines, the working groups decided which recommendations to accept and which to reject, as well as which recommendations were acceptable but needed to be modified. Care was taken when modifying existing recommendations not to change the recommendations to such an extent that they were no longer in keeping with the evidence upon which they were based. Please see the Appendix for how and why recommendations in this article were modified from their original form.

Table 1.

Clinical Practice Guidelines Used for the Canadian Schizophrenia Guidelines.

Guideline Developer	Guideline Title	Year Published
National Collaborating Centre for Mental Health Commissioned by the National Institute for Health and Care Excellence (NICE)	NICE National Clinical Guideline Number 178. Psychosis and Schizophrenia in Adults. Treatment and Management4	2014
National Collaborating Centre for Mental Health Commissioned by the National Institute for Health and Care Excellence (NICE)	NICE National Clinical Guideline Number 155. Psychosis and Schizophrenia in Children and Young People: Recognition and Management5	2013
National Collaborating Centre for Mental Health Commissioned by the National Institute for Health and Care Excellence (NICE)	NICE National Clinical Guideline Number 120. Psychosis with Coexisting Substance Misuse: Assessment and Management in Adults and Young People6	2011
Scottish Intercollegiate Guidelines Network (SIGN)	SIGN 131. Management of Schizophrenia7	2013
European Psychiatric Association	European Psychiatric Association Guidance on the Early Intervention in Clinical High Risk States of Psychoses8	2015
American Psychiatric Association	American Psychiatric Association Practice Guidelines for Psychiatric Assessment of Adults9	2016

De novo recommendations were made in situations where it was felt a recommendation was needed but none of the existing guidelines provided recommendations addressing the situation or topic. When de novo recommendations were created, the SIGN methodology was followed for the levels of evidence and the grades of recommendation (see Table 2).

Table 2.

Grade/strength of recommendation classification systems for included guidelines.^a

National Institute for Health and Care Excellence (NICE)
Strength of recommendations The wording used denotes the certainty with which the recommendation is made (the strength of the recommendation). Interventions that must (or must not) be used We usually use “must” or “must not” only if there is a legal duty to apply the recommendation. Occasionally, we use “must” (or “must not”) if the consequences of not following the recommendation could be extremely serious or potentially life threatening. Interventions that should (or should not) be used: a “strong” recommendation We use “offer” (and similar words such as “refer” or “advise”) when we are confident that, for the vast majority of patients, an intervention will do more good than harm and be cost-effective. Interventions that could be used We use “consider” when we are confident that an intervention will do more good than harm for most patients and be cost-effective, but other options may be similarly cost-effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient’s values and preferences than for a strong recommendation.
Scottish Intercollegiate Guidelines Network (SIGN) and European Psychiatric Association
Levels of evidence 1++: High-quality meta-analyses, systematic reviews of randomized controlled trials, or randomized controlled trials with a very low risk of bias; 1+: Well-conducted meta-analyses, systematic reviews, or randomized controlled trials with a low risk of bias; 1: Meta-analyses, systematic reviews, or randomized controlled trials with a high risk of bias 2++: High-quality systematic reviews of case control or cohort studies or high-quality case control or cohort studies with a 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: Nonanalytic studies (e.g., case reports, case series) 4: Expert opinion Grades of recommendation A: At least one meta-analysis, systematic review, or randomized controlled trial 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: recommended best practice based on the clinical experience of the guideline development group

^aThis is a condensed table; please see the Introduction and Methodology paper for full details.

Each working group developed a final list of recommendations from the included guidelines that were presented to the entire guideline panel at an in-person consensus meeting. Working group leaders presented each recommendation and its rationale to the panel. Anonymous voting by the entire panel using clicker technology was performed for each recommendation. Recommendations required agreement by 80% of the group to be included in the Canadian guidelines. If a recommendation did not receive 80% agreement, the group discussed the recommendation and if minor modifications to the recommendation would alter the likelihood that the recommendation would pass. In these situations, recommendations were modified (as described above) and the group revoted at a later date using an online anonymous survey. Whenever modifications in wording were made to original recommendations, the text ‘modified recommendation from’ appears in the Canadian Schizophrenia Guidelines, and the source of each recommendation is written beside the recommendation statement. The strength or grade of the recommendation is provided in brackets if applicable, using the system from which the recommendation came. The grades of recommendation for each reference guideline and their meaning are explained in brief in Table 2 (see Introduction and Methodology manuscript for a more detailed description). Once the voting and consensus process were completed, each working group created a separate manuscript that contained all the recommendations adapted from the included guidelines, with accompanying text explaining the rationale for each recommendation.

The working group for the current article elected not to include some negative recommendations from NICE and/or SIGN guidelines, such as recommendation that adherence therapy and group art therapy not be offered. Although there is not current strong evidence for the effectiveness of these interventions, there is no evidence of negative effects, and so strong prohibition does not seem warranted.

During the finalisation phase, the Canadian Schizophrenia Guidelines were externally reviewed by those who will be affected by its uptake: practitioners, policy makers, health administrators, patients, and their families. The external review asked questions about whether the users approve of the draft guideline, strengths and weaknesses, and suggested modifications. The process was facilitated through the Canadian Journal of Psychiatry and the Schizophrenia Society of Canada. The Canadian Psychiatric Association Clinical Practice Guidelines Committee reviewed and approved the guideline methodology process.²

Results

Recommendation 1

Family intervention should be offered to all individuals diagnosed with schizophrenia who are in close contact with or live with family members and should be considered a priority when there are persistent symptoms or a high risk of relapse. Ten sessions over a 3-month period should be considered the minimum effective dose. Family intervention should encompass

• Communication skills

• Problem solving

• Psychoeducation

                   [From SIGN 2013]

The occurrence of a psychotic disorder has implications for the family of the ill person,¹⁰ and families can play an important role in facilitating treatment and recovery.¹¹ How family members respond to the ill person and the associated emotional climate can have an effect on clinical outcomes.¹²

Both SIGN and NICE note strong evidence supporting the efficacy of family interventions designed to help families deal with the challenges posed by having a close relative with a schizophrenia spectrum disorder. The interventions emphasise providing support and education for the family, strengthening problem solving and communication, and addressing issues related to crisis management and preventing relapse.

The research reviewed in both NICE and SIGN guidelines indicates that randomised controlled trials yield strong evidence for the efficacy of such family interventions, leading to reductions in severity of patients’ symptoms and likelihood of hospitalisation. There is also some evidence of beneficial effects on functioning, knowledge regarding the disorder, and distress. The recommendation with respect to number and timing of sessions is based on a subgroup analysis within a large meta-analysis of relevant studies.¹³

We agree with the SIGN recommendation that “delivery of family interventions should take account of the whole family’s preference of either single-family intervention or multi-family intervention, and should not exclude offspring.”^7p29 It is also important that the intervention address the issue of enabling families to better communicate their concerns to mental health professionals.

Recommendation 2

Offer supported employment programs to people with psychosis or schizophrenia who wish to find or return to work (strong recommendation). Consider other occupational or educational activities, including prevocational training for people who are unable to work or unsuccessful in finding employment.

Recommendation 3

Mental health services should work in partnership with local stakeholders, including those representing minority groups, to enable people with psychosis or schizophrenia to stay in work or education and to assess new employment (including self-employment), volunteering, and educational activities

                   [Modified from NICE (Strong)]

Employment can provide financial benefits for an individual with a schizophrenia spectrum disorder, and meaningful activity such as employment may also yield benefits for symptoms and psychological well-being.^14,15

After reviewing relevant evidence, authors of the NICE guidelines concluded that “supported employment appears to be the most effective vocational rehabilitation method for obtaining competitive employment and for obtaining any occupation (paid, unpaid or voluntary). Furthermore, there is consistent evidence across a number of outcome measures that supported employment is more effective than prevocational training in increasing competitive employment. Evidence regarding earnings and being able to sustain employment or any occupation is less conclusive. Additionally, the long term benefits of supported employment are not known” (p. 560). The SIGN guidelines do not specially address employment-related interventions.

It is important that employment interventions include the key specific elements of supported employment, such as individually tailored job development, rapid job search, provision of ongoing job supports, and integration of vocational and mental health services.¹⁶

The NICE guidelines note that, while supported employment is most effective for those desiring competitive employment, alternate interventions such as prevocational training and support should be available to those who are not ready for such work. When patients are seeking support in returning to education or training programs, it should be provided. Although less is known about the critical components that are likely to be effective in this regard, the implementation of principles, parallel to those found effective in supported employment, seems desirable.

Recommendation 4

Cognitive-behavioural therapy (CBT) for psychosis should be offered to all individuals diagnosed with schizophrenia whose symptoms have not adequately responded to antipsychotic medication and are experiencing persisting symptoms, including anxiety or depression. CBT can be started during the initial phase, the acute phase, or recovery phase, including in-patient settings.

                   [Modified from SIGN (Evidence level A)]

Recommendation 5

It is important that CBT be delivered by appropriately trained therapists following established, effective protocols, with regular supervision being available. It should be delivered in a collaborative manner and include established principles of CBT, including patients monitoring the relationship between their thoughts, feelings, behaviours, and symptoms; reevaluation of perceptions, beliefs, and thought processes that contribute to symptoms; promotion of beneficial ways of coping with symptoms; reduction of stress; and improvement of functioning. The minimum dose of CBT should be regarded as 16 sessions.

                   [Modified from NICE (Strong)]

Both SIGN and NICE reviewed the results of multiple randomised controlled trials (RCTs) of cognitive therapy indicating effectiveness of CBT for psychosis for reducing symptom severity, hospitalisation, and relapse. Several studies also showed significant beneficial effects on level of depression.

There are no RCTs directly comparing group and individual CBT. Most of the evidence reviewed by NICE and SIGN evaluated individualised CBT, and both guidelines specifically recommended this approach. There have also been reports showing beneficial effects of CBT delivered in a group format.^17,18 We concluded that evidence regarding the comparative benefits of CBT or psychosis delivered individually versus in a group format is unclear at this time. Patient preferences should be taken into account, and ideally both should be available.

Although there is no direct evidence concerning the minimum number of treatment sessions required for therapeutic effect, most of the evidence base is derived from studies including at least 16 sessions, and so this is recommended as the minimum dose.

Recommendation 6

Cognitive remediation therapy (CRT) may be considered for individuals diagnosed with schizophrenia who have persisting problems associated with cognitive difficulties.

                   [From SIGN (Recommendation grade B)]

Various protocols have been developed and evaluated in recent years with the goal of reducing deficits in basic cognitive processes such as attention, memory, and problem solving, which can accompany schizophrenia spectrum disorders. NICE (as well as the Canadian Psychological Association [CPA] 2005 guidelines) concluded that the evidence for their effectiveness is insufficient to recommend their use. The SIGN guidelines concluded that “there is evidence the CRT improves cognitive domains at end of treatment, and limited evidence with inconsistencies in outcomes, that this may translate into improved social and functional outcomes. There is also some limited evidence that improvements in cognitive outcomes are maintained at follow-up.”^7p28 There is some evidence that cognitive remediation may have increased impact when offered at the same time as other psychosocial interventions.^19–21

Recommendation 7

Social skills training should be available for patients who are having difficulty and/or experiencing stress and anxiety related to social interaction.

                   [De novo recommendation (Evidence grade B)]

Social skills training uses basic learning principles to improve interpersonal skills related to social interaction, such as conversational skills, making friends, job interviews, and assertiveness. Methods include instruction about the significance of verbal and nonverbal aspects of social behaviour, modeling, role-playing, behavioural rehearsal, corrective but supportive feedback, and behavioural homework and practice to facilitate generalisation to the individual’s social environment.

Neither NICE nor SIGN strongly recommend the routine use of social skills training. Both guidelines note some evidence for the effects on social functioning and negative symptoms but little evidence for effects on positive symptoms, hospitalisation, or relapse. Given the increasing focus on improving functional outcomes for individuals with schizophrenia spectrum disorders and the prevalence of social anxiety and deficits in social functioning in this clinical population, we feel that having such interventions available is important. We, therefore, reiterated the relevant recommendation from the CPA 2005 guidelines.

Recommendation 8

Life skills training should be available for patients who are having difficulty with self-care related to housekeeping, transportation, financial management, and so on.

                   [De novo recommendation (Evidence level: Low)]

Some patients with schizophrenia spectrum disorders have deficits in skills related to practical aspects of living such as personal self-care, grooming and hygiene, domestic skills, transportation, and managing money. Life skills training programs target these deficits using assessment, feedback, and structured homework. Unfortunately, there has been little research evaluating the effectiveness of these interventions, and the few RCTs that have been reported do not yield strong evidence for their effectiveness.²²

Given the need for interventions to improve life skills for some patients with schizophrenia spectrum disorders and the absence of viable alternative approaches, the working group recommends that such interventions be available but notes the importance of research evaluating their effectiveness and critical components.

Recommendation 9

Appropriate education for patients about the nature and treatment of and recovery from schizophrenia should be an integral part of a program of treatment, but education interventions in themselves do not have robust effects on treatment outcomes.

                   [De novo recommendation (Evidence level: Low)]

Both NICE and SIGN report that there is not robust evidence for patient education about illness per se having a significant impact on critical outcomes such as symptomatology, relapse/rehospitalisation, adherence, or insight. Nevertheless, the working group considers it important that education about the nature of schizophrenia spectrum disorders, as well as factors that contribute to their onset, course, and treatment, be provided to patients (as well as their families) to address ethical concerns by facilitating empowerment and ability to make informed decisions about illness management.

New Developments

There are several promising recent developments related to psychosocial interventions for psychosis in general and schizophrenia in particular. These include mindfulness interventions,²³ avatar therapy,²⁴ training of social cognitive skills,²⁵ acceptance and commitment therapy,²⁶ individual and group peer support,²⁷ and compassion-focused therapy.²⁸ The existing research literature relevant to these is insufficient to justify recommendations currently, but further evaluative studies should be encouraged. An additional area of importance is the development and evaluation of interventions for common comorbidities in psychiatric disorders, such as anxiety and depression.^29,30