TABLE 3.

Practice Assessment Tool for the Care of Patients With a Diagnosis of Schizophrenia, part 2: treatment 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
8. Was a comprehensive and person-centered treatment plan developed and documented that includes evidence-based nonpharmacological and pharmacological treatments?	□	□	□	□	□	__/5	In treating individuals with schizophrenia, a person-centered treatment plan should be developed and documented in the medical record. Discussion with the patient, other treating health professionals, family members, and others involved in the patient’s life can each be vital in developing a full picture of the patient and formulating a person-centered treatment plan, using shared decision making whenever possible. The overarching aims of treatment planning are severalfold: to promote and maintain recovery, to maximize quality of life and adaptive functioning, and to reduce or eliminate symptoms. It is essential to consider both nonpharmacological and pharmacological treatment approaches and recognize that a combination of nonpharmacological and pharmacological treatments will likely be needed to optimize outcomes. In addition, strategies to promote adherence are always important to consider in developing a patient-centered treatment plan (128). As treatment proceeds, the treatment plan will require iterative reevaluation and updating prompted by factors such as inadequate treatment response, difficulties with tolerability or adherence, impairments in insight, changes in presenting issues or symptoms, or revisions in diagnosis. Factors that influence medication metabolism (e.g., age, sex, body weight, renal or hepatic function, smoking status, use of multiple concurrent medications) may also require adjustments to the treatment plan, in terms of either typical medication doses or frequency of monitoring. Tailoring of the treatment plan may also be needed on the basis of sociocultural or demographic factors with the aim of enhancing quality of life or aspects of functioning (e.g., social, academic, occupational). Other elements of the treatment plan may include, but are not limited to, determining the most appropriate treatment setting, addressing risks of harm to self or others (if present), engaging family members and others involved in the patient’s life, educating patients and families about treatment options and community resources, collaborating with other treating clinicians, and addressing co-occurring conditions.
9. Was treatment with an antipsychotic medication provided?	□	□	□	□	□	__/5	It is recommended that patients with schizophrenia be treated with an antipsychotic medication and, if symptoms improve, that antipsychotic treatment continue, generally with the same medication. The choice of a particular antipsychotic agent will typically occur in the context of discussion with the patient about the likely benefits and possible side effects of medication options and will incorporate patient preferences, the patient’s past responses to treatment (including symptom response and tolerability), the medication’s side effect profile, the presence of physical health conditions that may be affected by medication side effects, and other medication-related factors such as available formulations, potential for drug-drug interactions, receptor binding profiles, and pharmacokinetic considerations. Tables 3–9 in the full text of the guideline provide details on pharmacological properties of antipsychotic medications and can assist in the choice of an antipsychotic agent. If there is no significant improvement after several weeks of treatment (e.g., <20% improvement in symptoms) or if improvement plateaus before substantial improvement is achieved (e.g., >50% improvement in symptoms, minimal impairment in functioning), consider whether factors are present that would influence treatment response, such as concomitant substance use, rapid medication metabolism, poor medication absorption, interactions with other medications, or other effects on drug metabolism (e.g., smoking) that could affect blood levels of medication. If a patient has had minimal or no response to two trials of antipsychotic medication of two to four weeks duration at an adequate dose (129, 130), a trial of clozapine is recommended (see question 19 in Table 4).
10. Was the patient monitored for changes in blood pressure and pulse during treatment with an antipsychotic medication?	□	□	□	□	□	__/5	For questions 10-13, assessments are needed during treatment to monitor physical status and detect specific side effects of antipsychotic treatment, as outlined in Table 1. In addition to the suggested monitoring frequency described in Table 1, modifications to monitoring frequency will depend on the clinical circumstances of the individual patient and will be influenced by the antipsychotic that is prescribed as well as by the patient’s history, preexisting conditions, and use of other medications in addition to antipsychotic agents. For example, screening for symptoms of hyperprolactinemia may be needed more frequently if the patient is treated with an antipsychotic known to increase prolactin, whereas an ECGc may be indicated with a significant change in dose of chlorpromazine, droperidol, iloperidone, pimozide, thioridazine, or ziprasidone or with the addition of other medications that can affect QTcd interval in patients with cardiac risk factors or elevated baseline QTc intervals.
11. Was the patient monitored for changes in BMIe during treatment with an antipsychotic medication?	□	□	□	□	□	__/5
12. Was the patient monitored for metabolic syndrome during treatment with an antipsychotic medication?	□	□	□	□	□	__/5
13. Was the patient monitored for antipsychotic-induced movement disorders (acute dystonia, akathisia, parkinsonism, tardive syndromes) during treatment with an antipsychotic medication?	□	□	□	□	□	__/5
14. Was CBTpf offered?	□	□	□	□	□	__/5	The use of CBTp for individuals with schizophrenia has several potential benefits, including improvements in quality of life and global, social, and occupational function and reductions in core symptoms of illness, such as positive symptoms. CBTp focuses on guiding patients to develop their own alternative explanations for maladaptive cognitive assumptions, which are healthier and realistic and do not perpetuate the patient’s convictions regarding the veracity of delusional beliefs or hallucinatory experiences. CBTp can be started in any treatment setting, including inpatient settings, and during any phase of illness (131), although some initial reduction in symptoms may be needed for optimal participation. It can also be conducted in group and individual formats, either in person or via Web-based delivery platforms. At organizational or health system levels, attention to enhancing the availability of CBTp is important given the limited availability of CBTp in the United States.
15. Was patient psychoeducation provided?	□	□	□	□	□	__/5	Elements of psychoeducation are an integral part of good clinical practice and include providing the patient with education about the differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment (82). More formal psychoeducation is also recommended, in either an individual or a group format, often in conjunction with family members or other individuals who are involved in the patient’s life. Typically, psychoeducation involves approximately 12 sessions and incorporates multiple educational modalities such as workbooks (132), pamphlets, videos, and individual or group discussions to achieve its goals. Information commonly conveyed in a psychoeducation program includes key information about diagnosis, symptoms, psychosocial interventions, medications, and side effects as well as information about stress and coping, crisis plans, early warning signs, and suicide and relapse prevention (133). Information that may be useful to patients and families as a part of psychoeducation is available through SMI Adviser (smiadviser.org/).
16. Was the patient offered family interventions?	□	□	□	□	□	__/5	An important aspect of good psychiatric treatment is involvement of family members, support persons, and other individuals who play a key role in the patient’s life. These individuals include spouses, parents, children, or other biological or nonbiological relatives; people who reside with the patient; intimate partners; or close friends who are an integral part of the patient’s support network. Such individuals benefit from discussion of topics such as diagnosis and management of schizophrenia, types of support that are available, and ways to plan for and access help in a crisis. Other goals include helping individuals repair or strengthen their connections with family members and other members of their support system.
							Most patients want family to be involved in their treatment (134). However, even when a patient does not want a specific person to be involved in the patient’s care, the clinician may listen to information provided by that individual, as long as confidential information is not provided to the informant (82). General information that is not specific to the patient can be provided (e.g., common approaches to treatment, general information about medications and their side effects, available support and emergency assistance). Also, to prevent or lessen a serious and imminent threat to the health or safety of the patient or others, the Principles of Medical Ethics (135) and HIPAAg (136, 137) permit clinicians to disclose necessary information about a patient to family members, caregivers, law enforcement, or other persons involved with the patient. HIPAA also permits health care providers to disclose necessary information to the patient’s family, friends, or other persons involved in the patient’s care or payment for care when such disclosure is judged to be in the best interests of the patient and the patient is not present or is unable to agree or object to a disclosure because of incapacity or emergency circumstances (137).
							Family interventions go beyond the basics of family involvement and illness education that are important for good clinical care. Family interventions can be delivered in a variety of formats and approaches (138, 139) and have the greatest benefits when more than 10 treatment sessions are systematically delivered over a period of at least seven months (138). They may include structured approaches to problem solving, training in how to cope with illness symptoms, assistance with improving family communication, provision of emotional support, and strategies for reducing stress and enhancing social support networks (138–140). Guidance is available on developing family intervention programs focused on psychoeducation (141, 142). In addition, the National Alliance on Mental Illness has the Family-to-Family program, which has led to a significant expansion in the availability of family interventions (143, 144).
17. Were self-management skills and recovery-focused interventions offered?	□	□	□	□	□	__/5	Illness self-management training programs have been applied to help address many chronic conditions and are designed to improve knowledge about one’s illness and management of symptoms (145). Goals include reducing the risk of relapse, recognizing signs of relapse, developing a relapse prevention plan, and enhancing coping skills to address persistent symptoms with the aim of improving quality of life and social and occupational functioning. Evidence suggests better outcomes among patients who participate in at least 10 self-management intervention sessions. Self-management sessions are typically facilitated by clinicians, although peer-facilitated sessions have also been used. In addition, individually targeted interventions, either face to face or via computer-based formats (146), have been used.
							Recovery-focused interventions have also been developed that focus on fostering self-determination in relation to a patient’s personal goals, needs, and strengths. Such approaches may include elements of self-management skill development, psychoeducation, and peer-based interventions but also include components and activities that allow participants to share experiences and receive support, learn and practice strategies for success, and identify and take steps toward reaching personal goals.
							A tool kit for developing illness management and recovery-based programs in mental health is available (147). Other available resources are also described in the full text of the guideline and at SMI Adviser (smiadviser.org/individuals-families).
18. Were supported employment services offered?	□	□	□	□	□	__/5	Evidence consistently shows that supported employment is associated with a greater rate of competitive employment. Other benefits of supportive employment include greater number of hours worked per week, a longer duration of each job, a longer duration of total employment, and an increase in earnings (138). Individuals receiving supported employment are also more likely to obtain job-related accommodations than individuals with mental illness who are not receiving supported employment (148). Such accommodations typically relate to support from the supported employment coach but may also include flexible scheduling, reduced hours, modified job duties, and modified training and supervision.
							Supported employment differs from other vocational rehabilitation services in providing assistance in searching for and maintaining competitive employment concurrently with job training, embedded job support, and mental health treatment (149–151). For individuals whose goals are related to educational advancement before pursuit of employment, supported educational services may also be pursued (152).
							For clinicians and organizations that want to learn more about supported employment or develop supported employment programs, additional information is available through SMI Adviser (smiadviser.org/), Navigate (navigateconsultants.org/manuals/), and the Boston University Center for Psychiatric Rehabilitation (cpr.bu.edu/).

^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.

^cECG, electrocardiogram.

^dQTc, corrected QT interval.

^eBMI, body mass index.

^fCBTp, cognitive-behavioral therapy for psychosis.

^gHIPAA, Health Insurance Portability and Accountability Act.