TABLE 2.

Practice Assessment Tool for the Care of Patients With a Diagnosis of Schizophrenia, part 1: assessment of patients meeting diagnostic criteria for schizophrenia^a

	Patient
Aspect of care and quality-related action	1	2	3	4	5	Total no. of patients with check mark in each rowb	Supporting evidence, resources, and clinical issues for consideration
1. Were the patient’s reasons for seeking treatment, goals, view of the illness, and preferences for treatment identified as part of the assessment?	□	□	□	□	□	__/5	This information will provide a framework for recovery and serve as a starting point for person-centered care and shared decision making with the patient, family, and other support persons (67–69). Such discussions may also foster a more collaborative therapeutic relationship and promote adherence. Identification of goals and preferences should not be limited to symptom relief and may include goals related to schooling, employment, living situation, relationships, leisure activities, and other aspects of functioning and quality of life.
2. Was a quantitative measure used as part of the initial evaluation to identify and determine the severity of symptoms and impairments of functioning?	□	□	□	□	□	__/5	The use of a quantitative measure as part of the assessment can help detect and determine the severity of psychosis and associated symptoms. Patient self-report ratings and clinician-based ratings can provide a structured replicable way to document baseline symptoms, determine which symptoms should be the target of intervention, and track whether nonpharmacological and pharmacological treatments are having their intended effect or whether a shift in the treatment plan is needed. A number of measures are available, as described in the full text of the guideline. The exact frequency at which measures are warranted will depend on clinical circumstances.
3. Was the patient assessed for current or past tobacco use (including vaping)?	□	□	□	□	□	__/5	The rate of tobacco use is high among individuals with schizophrenia (47–49, 53, 56) and contributes to morbidity and mortality (57, 70–73). Screening to identify tobacco use is a crucial step in educating patients and providing treatment and follow-up using health education, motivational interviewing approaches (74), and smoking cessation guidelines for the general population (73, 75–78). Smoking also induces CYP1A2c and, with cessation (either intentionally or with admission to a smoke-free facility), there will be a corresponding increase in the levels of drugs metabolized via CYP1A2, including clozapine and olanzapine (79).
4. Was the patient screened for use of cannabis, alcohol, and other substances?	□	□	□	□	□	__/5	Screening for use of cannabis, alcohol, and other substances is important because substance use is common (22, 45, 49, 50, 52, 54), can confound assessment of psychotic symptoms, and affect the course of schizophrenia (45, 80–82). It is important to determine whether the patient uses cannabis or other substances such as alcohol, caffeine, cocaine, opioids, sedative-hypnotic agents, stimulants, MDMA,d solvents, androgenic steroids, hallucinogens, or synthetic substances (e.g., “bath salts,” K2, Spice). The route by which substances are used (e.g., ingestion, smoking, vaping, intranasal, intravenous) is similarly important to document. SBIRTe can be integrated into a range of clinical settings (83, 84). In addition, assessment and screening for substance use disorders may include self-report corroborated by other sources such as family, friends, case managers, and treatment personnel and, as indicated, urine and blood toxicology and other tests such as liver function tests.
5. Was the patient assessed for risk of suicide and other self-harming behaviors?	□	□	□	□	□	__/5	Suicidal ideas are common among individuals who have had a psychotic experience (85), and death from suicide has been estimated to occur in about 4%–10% of individuals with schizophrenia (10, 12, 16, 18–20). Thus, it is important to consider the risk of suicide and other self-harming behaviors in initial evaluations and follow-up assessments at all stages of illness. Assessment of the risk for suicidal behaviors typically includes asking the patient and, when possible, the patient’s family about prior suicidal behaviors and current or prior thoughts, plans, or intentions to harm or kill oneself (82). Risk assessment also requires synthesizing information gathered in the history and mental status examination and identifying modifiable risk factors for suicide that can serve as targets of intervention.
							Patients with schizophrenia share the same risks for suicide fatalities and behaviors as the general population, including male sex, depressive symptoms, hopelessness, expressed suicidal ideation, a history of attempted suicide or other suicide-related behaviors, and the presence of alcohol use disorder or other substance use disorder (20, 86–90). Firearm access is an additional contributor to suicide risk (91–93).
							Additional factors that have been identified as increasing risk for suicide among individuals with schizophrenia include auditory command hallucinations, agitation or motor restlessness, fear of mental disintegration, recent loss events, recency of diagnosis or hospitalization, repeated hospitalizations, high intelligence, young age, and poor adherence to treatment (8, 20, 86, 88, 94–96).
							Despite identification of these risk factors, it is not possible to predict whether an individual patient will attempt or die by suicide. However, when an increased risk for such behaviors is present, it is important that the treatment plan reevaluate the care setting, address periods of increased risk (e.g., shortly after diagnosis, during incarceration, subsequent to hospital discharge), and implement approaches to target and reduce modifiable risk factors such as poor adherence, core symptoms of schizophrenia (e.g., hallucinations, delusions), co-occurring symptoms (e.g., depression, hopelessness, hostility, impulsivity), and co-occurring diagnoses (e.g., depression, alcohol use disorder, other substance use disorders).
6. Was the patient assessed for risk of dangerous or aggressive behaviors, including interpersonal aggression and harm to others?	□	□	□	□	□	__/5	Akin to assessment for suicide and other self-harming behaviors, it is important to consider the risk of dangerous or aggressive behaviors in the initial evaluation and follow-up assessments at all stages of illness. Assessment of the risk for aggressive behaviors typically includes asking the patient and, when possible, the patient’s family about current or prior thoughts, plans, or intentions of aggression toward others. Many factors associated with a risk of aggression are similar to findings among individuals without psychosis and include male sex, young age, access to firearms, the presence of substance use, traumatic brain injury, a history of attempted suicide or other suicide-related behaviors, or prior aggressive behavior, including that associated with legal consequences (87, 90, 97–103). Among individuals with psychotic illnesses, prior suicidal threats, angry affect, impulsivity, hostility, recent violent victimization, childhood sexual abuse, medication nonadherence, and a history of involuntary treatment have also been associated with an increased risk of aggressive behavior (90, 97, 102, 103). Command hallucinations can be relevant when assessing individuals for a risk of aggressive behaviors (102, 104), and persecutory delusions may also contribute to aggression risk, particularly in the absence of treatment or in association with significant anger (102, 105, 106).
							Despite identification of these risk factors, it is not possible to predict whether an individual patient will engage in aggressive behaviors. However, when an increased risk for such behaviors is present, it is important that the treatment plan reevaluate the care setting and implement approaches to target and reduce modifiable risk factors.
7. Was the patient assessed for co-occurring psychiatric disorders and other co-occurring health conditions?	□	□	□	□	□	__/5	Many individuals with schizophrenia will have co-occurring psychiatric disorders, including SUDsf or other co-occurring health conditions. These disorders may affect treatment options or need to be addressed in the treatment plan. For example, if SUDs are identified, a comprehensive integrated treatment model is suggested to address both conditions. Alternatively, the treatment plan should address both disorders, and there should be communication and collaboration among treating clinicians. For patients who do not recognize the need for treatment of a substance use disorder, a stagewise motivational approach can be used (74, 107).
							Individuals with schizophrenia may have experienced violent victimization (108–110) or childhood adversity (111–114), and PTSD should be identified and treated, if present (115–117). Depressive symptoms and anxiety are also common among individuals with schizophrenia and should be addressed as part of treatment planning.
							Other health conditions are frequent in individuals with serious mental illness in general (8, 26, 118, 119) and those with schizophrenia in particular (120). Such disorders include but are not limited to poor oral health, hepatitis C infection, HIV infection, cancer, sleep apnea, obesity, diabetes mellitus, metabolic syndrome, and cardiovascular disease (8, 15, 26, 27, 121–127). These disorders, if present, can contribute to reduced quality of life or mortality (9–17). Also, some may influence choice of medication or may be induced or exacerbated by psychiatric medications.
							Table 1 provides a discussion of suggested physical and laboratory assessments for patients with schizophrenia as part of initial evaluation and follow-up assessments. Such assessments are important to prevention, early recognition, and treatment of abnormalities such as glucose dysregulation, hyperlipidemia, metabolic syndrome, antipsychotic-induced movement disorders, and changes in cardiac conduction. It is also important that patients have access to primary care clinicians who can work with the psychiatrist to diagnose and treat concurrent physical health conditions (82). For women who are planning to become pregnant or who are pregnant or postpartum, it is essential to collaborate with the patient, her obstetrician-gynecologist or other obstetric practitioner, her infant’s pediatrician (if breastfeeding), and, if involved, her partner or other support persons.

^aInstructions: Choose five adult patients from your current psychiatric caseload who meet diagnostic criteria for schizophrenia. Review their charts to determine whether they have received assessment and treatment that was consistent with key evidence-based recommendations shown in the left-hand column of this table. If yes, check the appropriate box; if no or unknown, leave the box unchecked. Note that the right-hand column provides supporting evidence, resources, and clinical issues that can be considered in relation to a specified recommendation. For additional details, the reader is directed to the full guideline (66).

^bScoring: In the total column, tally the total number of check marks in each row. For any row for which the total is less than five, examine whether clinical or other circumstances explain why practice was not consistent with recommended care. Consider whether changes in your practice or use of any of the suggested clinical tools could strengthen the provision of evidence-based care.

^cCYP1A2, cytochrome P450 1A2.

^dMDMA, 3,4-methylenedioxy-methamphetamine.

^eSBIRT, screening, brief intervention, and referral to treatment.

^fSUDs, substance use disorders.