Canadian

Psychiatric Association

Association des psychiatres

du Canada

The Canadian Journal of Psychiatry /

La Revue Canadienne de Psychiatrie
CPA Treatment Guidelines ª The Author(s) 2017
1-7

on Psychosocial Treatment Reprints and permission:

[Link]/[Link]
DOI: 10.1177/0706743717719894
of Schizophrenia in Adults [Link] | [Link]

Ross Norman, PhD1,2, Tania Lecomte, PhD3,4, Donald Addington, MD5,

and Elizabeth Anderson, BCC6

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.

Keywords
schizophrenia, psychosocial intervention

Several psychosocial interventions have been found to have therapeutic relationships. It can also improve
benefits for individuals with schizophrenia spectrum disor- engagement and adherence to treatment.
ders and their families. The review group would like to 4. It is important to encourage a realistically hopeful
preface its recommendations by noting the importance of attitude for the future in patients and families. All
some general principles regarding the implementation of
psychosocial interventions and indeed all treatment
approaches to schizophrenia spectrum disorders. These 1
include the following: Departments of Psychiatry and Epidemiology & Biostatistics, Western
University, London, Ontario
2
Prevention & Early Intervention Program for Psychoses (PEPP), London
1. Optimal management requires the integration of Health Sciences Centre, London, Ontario
3
medical and psychosocial interventions. Such inter- Department of Psychology, University of Montreal, Montreal, Quebec
4
ventions should not be seen as competing Centre de recherche de l’Institute universitaire en santé mentale de
Montréal, Quebec
approaches but, in most cases, as necessary and 5
Hotchkiss Brain Institute and Department of Psychiatry, University of
complementary interventions to improve clinical Calgary, Calgary, Alberta
6
symptoms, functional outcome, and quality of life. [Link], Calgary, Alberta
2. Psychosocial interventions address many aspects of
recovery, from reduction of acute symptoms to Corresponding Author:
Ross Norman, Department of Psychiatry, University of Western Ontario,
improvement in functioning and general well-being. London Health Sciences Centre–Victoria Hospital, A2-643, 800
3. Genuinely listening and attending to patients’ Commissioners, Road East, London, Ontario, N6A 5W9, Canada.
concerns develops empathy, rapport, and good Email: rnorman@[Link]
2 The Canadian Journal of Psychiatry

clinicians, including physicians, are important con- A MEDLINE search was also performed using the term
tributors to this process. guideline as the publication type and schizophrenia as the
5. All interventions should be undertaken within a title or clinical topic. Inclusion criteria were that the guide-
recovery framework with the objective of the line needed to be published after 2010, be written in English,
patient being able to obtain a good quality of life. and that recommendations had to be developed using a
6. The clinical team, the patient, and family mem- defined and systematic process. We identified 8 current
bers should develop shared, short-term and long- guidelines that were potentially suitable for adaptation.
term goals for treatment and recovery. Progress These guidelines were reviewed and evaluated in duplicate
toward these goals should be carefully monitored using the AGREE II tool,3 an instrument to evaluate the
and evaluated. methodological rigour and transparency in which a guideline
7. The delivery of effective psychosocial interventions is developed. Based on this evaluation, we determined that
requires specific and often nuanced and complex the 6 guidelines were of suitable quality and content for
skills. It is essential that staff who provide psycho- adaptation (see Table 1). Recommendations from each
social interventions should be appropriately trained. guideline were extracted and divided based on content and
8. Patients should be supported in developing effective reviewed by the relevant working group. Following the
self-management skills for improving their symp- ADAPTE process, working groups selected between guide-
toms, functioning, and quality of life. lines and recommendations to create an adapted guideline.
9. Common comorbid conditions such as substance Each working group carefully examined each recommenda-
abuse, anxiety disorders, and depression need to tion, the evidence from which the recommendation was
be recognised and addressed with psychosocial derived, and the acceptability and applicability of the rec-
interventions. ommendation to the Canadian context. After the reviewing
10. Patient and family preferences should be considered the recommendations from the guidelines, the working
in the identification of treatment goals and methods. 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
Methods existing recommendations not to change the recommenda-
The methods for the Canadian Schizophrenia Guidelines are tions to such an extent that they were no longer in keeping
described in brief here; please see the Introduction and with the evidence upon which they were based. Please see
Methodology manuscript for an in-depth description. the Appendix for how and why recommendations in this
The guidelines were developed using the ADAPTE pro- article were modified from their original form.
cess.1 Recognising that the development of guidelines De novo recommendations were made in situations where
requires substantial resources, the ADAPTE process was it was felt a recommendation was needed but none of the
created to take advantage of existing guidelines and reduce existing guidelines provided recommendations addressing
duplication of effort. the situation or topic. When de novo recommendations were
The first phase of the ADAPTE process, the setup phase, created, the SIGN methodology was followed for the levels
involved preparing for the ADAPTE process. We assembled of evidence and the grades of recommendation (see Table 2).
a national multidisciplinary panel from across Canada, Each working group developed a final list of recommen-
including stakeholders with expertise in schizophrenia and dations from the included guidelines that were presented to
mental health, health policy, patient advocacy, and lived the entire guideline panel at an in-person consensus meeting.
experience with schizophrenia. Endorsement bodies for the Working group leaders presented each recommendation and
guidelines include the Canadian Psychiatric Association and its rationale to the panel. Anonymous voting by the entire
the Schizophrenia Society of Canada, who were also heavily panel using clicker technology was performed for each rec-
involved in the dissemination and implementation strategy. ommendation. Recommendations required agreement by
The second phase of the ADAPTE process, the adaptation 80% of the group to be included in the Canadian guidelines.
phase, involves the process of identifying specific health If a recommendation did not receive 80% agreement, the
questions; searching for and retrieving guidelines, assessing group discussed the recommendation and if minor modifica-
guideline quality, currency, content, consistency, and applic- tions to the recommendation would alter the likelihood that
ability; decision making around adaptation; and preparing the recommendation would pass. In these situations, recom-
the draft-adapted guideline. We searched for guidelines on mendations were modified (as described above) and the
schizophrenia in guideline clearinghouses and on the web- group revoted at a later date using an online anonymous
sites of well-established guideline developers for mental survey. Whenever modifications in wording were made to
health disorders, including the National Institute for Health original recommendations, the text ‘modified recommenda-
and Care Excellence (NICE), the Scottish Intercollegiate tion from’ appears in the Canadian Schizophrenia Guide-
Guidelines Network (SIGN), the American Psychiatric lines, and the source of each recommendation is written
Association, the American Academy of Child and Adoles- beside the recommendation statement. The strength or grade
cent Psychiatry, and the European Psychiatric Association.2 of the recommendation is provided in brackets if applicable,
La Revue Canadienne de Psychiatrie 3

Table 1. Clinical Practice Guidelines Used for the Canadian administrators, patients, and their families. The external
Schizophrenia Guidelines. review asked questions about whether the users approve of
Year
the draft guideline, strengths and weaknesses, and suggested
Guideline Developer Guideline Title Published modifications. The process was facilitated through the Cana-
dian Journal of Psychiatry and the Schizophrenia Society of
National Collaborating NICE National Clinical 2014 Canada. The Canadian Psychiatric Association Clinical
Centre for Mental Guideline Number 178. Practice Guidelines Committee reviewed and approved the
Health Commissioned Psychosis and
guideline methodology process.2
by the National Institute Schizophrenia in Adults.
for Health and Care Treatment and
Excellence (NICE) Management4
National Collaborating NICE National Clinical 2013
Results
Centre for Mental Guideline Number 155. Family Intervention
Health Commissioned Psychosis and
by the National Institute Schizophrenia in Recommendation 1. Family intervention should be offered to
for Health and Care Children and Young all individuals diagnosed with schizophrenia who are in
Excellence (NICE) People: Recognition and close contact with or live with family members and should
Management5 be considered a priority when there are persistent symptoms
National Collaborating NICE National Clinical 2011 or a high risk of relapse. Ten sessions over a 3-month period
Centre for Mental Guideline Number 120.
should be considered the minimum effective dose. Family
Health Commissioned Psychosis with
by the National Institute Coexisting Substance intervention should encompass
for Health and Care Misuse: Assessment and
Excellence (NICE) Management in Adults  Communication skills
and Young People6  Problem solving
Scottish Intercollegiate SIGN 131. Management of 2013  Psychoeducation
Guidelines Network Schizophrenia7  [From SIGN 2013]
(SIGN)
European Psychiatric European Psychiatric 2015 The occurrence of a psychotic disorder has implications
Association Association Guidance for the family of the ill person,10 and families can play an
on the Early important role in facilitating treatment and recovery.11
Intervention in Clinical
How family members respond to the ill person and the
High Risk States of
Psychoses8 associated emotional climate can have an effect on clinical
American Psychiatric American Psychiatric 2016 outcomes.12
Association Association Practice Both SIGN and NICE note strong evidence supporting the
Guidelines for efficacy of family interventions designed to help families
Psychiatric Assessment deal with the challenges posed by having a close relative
of Adults9 with a schizophrenia spectrum disorder. The interventions
emphasise providing support and education for the family,
strengthening problem solving and communication, and
using the system from which the recommendation came. The addressing issues related to crisis management and prevent-
grades of recommendation for each reference guideline and ing relapse.
their meaning are explained in brief in Table 2 (see Intro- The research reviewed in both NICE and SIGN guide-
duction and Methodology manuscript for a more detailed lines indicates that randomised controlled trials yield
description). Once the voting and consensus process were strong evidence for the efficacy of such family interven-
completed, each working group created a separate manu- tions, leading to reductions in severity of patients’ symp-
script that contained all the recommendations adapted from toms and likelihood of hospitalisation. There is also some
the included guidelines, with accompanying text explaining evidence of beneficial effects on functioning, knowledge
the rationale for each recommendation. regarding the disorder, and distress. The recommendation
The working group for the current article elected not to with respect to number and timing of sessions is based on
include some negative recommendations from NICE and/or a subgroup analysis within a large meta-analysis of rele-
SIGN guidelines, such as recommendation that adherence vant studies.13
therapy and group art therapy not be offered. Although there We agree with the SIGN recommendation that ‘delivery
is not current strong evidence for the effectiveness of these of family interventions should take account of the whole
interventions, there is no evidence of negative effects, and so family’s preference of either single-family intervention or
strong prohibition does not seem warranted. multi-family intervention, and should not exclude offspring’
During the finalisation phase, the Canadian Schizophre- [SIGN, p. 29]. It is also important that the intervention
nia Guidelines were externally reviewed by those who will address the issue of enabling families to better communicate
be affected by its uptake: practitioners, policy makers, health their concerns to mental health professionals.
4 The Canadian Journal of Psychiatry

Table 2. Grade/Strength of Recommendation Classification Systems for Included Guidelines.a

Grade/Strength of Recommendation System

NICE
Strength of recommendations
The wording used in NICE recommendations 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.
SIGN and the European Psychiatric Association
Levels of evidence
1þþ High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias; 1þ Well-conducted meta-analyses,
systematic reviews, or RCTs with a low risk of bias; 1– Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2þþ 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; 2þ 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 1 meta-analysis, systematic review, or RCT rated as 1þþ and directly applicable to the target population or a body of evidence
consisting principally of studies rated as 1þ, directly applicable to the target population and demonstrating overall consistency of
results
B: A body of evidence including studies rated as 2þþ, directly applicable to the target population and demonstrating overall consistency of
results, or extrapolated evidence from studies rated as 1þþ or 1þ
C: A body of evidence including studies rated as 2þ, directly applicable to the target population and demonstrating overall consistency of
results, or extrapolated evidence from studies rated as 2þþ
D: Evidence level 3 or 4 or extrapolated evidence from studies rated as 2þ
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group

NICE, National Institute for Health and Care Excellence; RCT, randomised controlled trial; SIGN, Scottish Intercollegiate Guidelines Network.
a
Condensed table; please see Introduction and Methodology table for full details.

Supported Employment Programs After reviewing relevant evidence, authors of the NICE
guidelines concluded that ‘supported employment appears to
Recommendation 2. Offer supported employment programs to
be the most effective vocational rehabilitation method for obtain-
people with psychosis or schizophrenia who wish to find or
ing competitive employment and for obtaining any occupation
return to work (strong recommendation). Consider other
(paid, unpaid or voluntary). Furthermore, there is consistent evi-
occupational or educational activities, including prevoca-
dence across a number of outcome measures that supported
tional training for people who are unable to work or unsuc-
employment is more effective than prevocational training in
cessful in finding employment.
increasing competitive employment. Evidence regarding earn-
ings and being able to sustain employment or any occupation is
Recommendation 3. Mental health services should work in part- less conclusive. Additionally, the long term benefits of supported
nership with local stakeholders, including those representing employment are not known’ (p. 560). The SIGN guidelines do
minority groups, to enable people with psychosis or schizophre- not specially address employment-related interventions.
nia to stay in work or education and to assess new employment It is important that employment interventions include the
(including self-employment), volunteering, and educational key specific elements of supported employment, such as
activities (strong recommendation). [Modified from NICE] individually tailored job development, rapid job search, pro-
Employment can provide financial benefits for an indi- vision of ongoing job supports, and integration of vocational
vidual with a schizophrenia spectrum disorder, and mean- and mental health services.16
ingful activity such as employment may also yield benefits The NICE guidelines note that, while supported employ-
for symptoms and psychological well-being.14,15 ment is most effective for those desiring competitive
La Revue Canadienne de Psychiatrie 5

employment, alternate interventions such as prevocational schizophrenia who have persisting problems associated
training and support should be available to those who are with cognitive difficulties. [From SIGN—recommenda-
not ready for such work. When patients are seeking support tion grade B]
in returning to education or training programs, it should be Various protocols have been developed and evaluated
provided. Although less is known about the critical compo- in recent years with the goal of reducing deficits in basic
nents that are likely to be effective in this regard, the imple- cognitive processes such as attention, memory, and
mentation of principles, parallel to those found effective in problem solving, which can accompany schizophrenia
supported employment, seems desirable. spectrum disorders. NICE (as well as the Canadian Psy-
chological Association [CPA] 2005 guidelines) concluded
that the evidence for their effectiveness is insufficient to
Cognitive-Behavioural Therapy recommend their use. The SIGN guidelines concluded
Recommendation 4. Cognitive-behavioural therapy (CBT) for that ‘there is evidence the CRT improves cognitive
psychosis should be offered to all individuals diagnosed with domains at end of treatment, and limited evidence with
schizophrenia whose symptoms have not adequately inconsistencies in outcomes, that this may translate into
responded to antipsychotic medication and are experiencing improved social and functional outcomes. There is also
persisting symptoms, including anxiety or depression. CBT some limited evidence that improvements in cognitive
can be started during the initial phase, the acute phase, or outcomes are maintained at follow-up’ [SIGN, p. 28].
recovery phase, including in-patient settings (evidence level There is some evidence that cognitive remediation may
A). [Modified from SIGN] have increased impact when offered at the same time as
other psychosocial interventions.19-21
Recommendation 5. It is important that CBT be delivered by
appropriately trained therapists following established, effec-
tive protocols, with regular supervision being available. It
Social Skills Training
should be delivered in a collaborative manner and include Recommendation 7. Social skills training should be available
established principles of CBT, including patients monitoring for patients who are having difficulty and/or experiencing
the relationship between their thoughts, feelings, behaviours, stress and anxiety related to social interaction. [De novo
and symptoms; reevaluation of perceptions, beliefs, and recommendation; evidence grade B]
thought processes that contribute to symptoms; promotion Social skills training uses basic learning principles to
of beneficial ways of coping with symptoms; reduction of improve interpersonal skills related to social interaction,
stress; and improvement of functioning. The minimum dose such as conversational skills, making friends, job interviews,
of CBT should be regarded as 16 sessions (strong recom- and assertiveness. Methods include instruction about the sig-
mendation). [Modified from NICE] nificance of verbal and nonverbal aspects of social beha-
Both SIGN and NICE reviewed the results of multiple viour, modeling, role-playing, behavioural rehearsal,
randomised controlled trials (RCTs) of cognitive therapy indi- corrective but supportive feedback, and behavioural home-
cating effectiveness of CBT for psychosis for reducing symp- work and practice to facilitate generalisation to the individ-
tom severity, hospitalisation, and relapse. Several studies also ual’s social environment.
showed significant beneficial effects on level of depression. Neither NICE nor SIGN strongly recommend the routine
There are no RCTs directly comparing group and individ- use of social skills training. Both guidelines note some evi-
ual CBT. Most of the evidence reviewed by NICE and SIGN dence for the effects on social functioning and negative
evaluated individualised CBT, and both guidelines specifi- symptoms but little evidence for effects on positive symp-
cally recommended this approach. There have also been toms, hospitalisation, or relapse. Given the increasing focus
reports showing beneficial effects of CBT delivered in a on improving functional outcomes for individuals with schi-
group format.17,18 We concluded that evidence regarding the zophrenia spectrum disorders and the prevalence of social
comparative benefits of CBT or psychosis delivered indivi- anxiety and deficits in social functioning in this clinical
dually versus in a group format is unclear at this time. Patient population, we feel that having such interventions available
preferences should be taken into account, and ideally both is important. We, therefore, reiterated the relevant recom-
should be available. mendation from the CPA 2005 guidelines.
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
Life Skills Training
sessions, and so this is recommended as the minimum dose. 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
Cognitive Remediation on (de novo recommendation). [Evidence level: Low]
Recommendation 6. Cognitive remediation therapy (CRT) Some patients with schizophrenia spectrum disorders
may be considered for individuals diagnosed with have deficits in skills related to practical aspects of living
6 The Canadian Journal of Psychiatry

such as personal self-care, grooming and hygiene, domestic or education, and to assess new employment (including self-
skills, transportation, and managing money. Life skills train- employment), volunteering, and educational activities.
ing programs target these deficits using assessment, feed- Reason for modification: Given the ethnic diversity of
back, and structured homework. Unfortunately, there has Canada and the need to address other aspects of identity of
been little research evaluating the effectiveness of these possible concern (e.g., gender identity issues), we elected to
interventions, and the few RCTs that have been reported use the more generic wording of ‘minority groups’ rather
do not yield strong evidence for their effectiveness.22 than specify particular ethnic or other identities.
Given the need for interventions to improve life skills for SIGN/Recommendation 4: Individual CBT should be
some patients with schizophrenia spectrum disorders and the offered to all individuals diagnosed with schizophrenia
absence of viable alternative approaches, the working group whose symptoms have not adequately responded to antipsy-
recommends that such interventions be available but notes chotic medication and where persisting symptoms, and/or
the importance of research evaluating their effectiveness and depression and/or anxiety are being experienced.
critical components. Reason for modification: This was modified to include
anxiety because of the prevalence of anxiety symptoms in
Patient Education patients with schizophrenia and the availability of effective
CBT interventions for anxiety.
Recommendation 9. Appropriate education for patients about NICE [Link]/Recommendation 5: CBT should be deliv-
the nature and treatment of and recovery from schizophrenia ered on a one-to-one basis over at least 16 planned sessions
should be an integral part of a program of treatment, but and (strong recommendation):
education interventions in themselves do not have robust
effects on treatment outcomes (de novo recommendation).  Follow a treatment manual so that:
[Evidence level: Low]  People can establish links between their thoughts,
Both NICE and SIGN report that there is not robust feelings or actions, and their current or past symp-
evidence for patient education about illness per se having toms and/or functioning.
a significant impact on critical outcomes such as sympto-  The reevaluation of people’s perceptions, beliefs,
matology, relapse/rehospitalisation, adherence, or insight. or reasoning relates to the target symptoms.
Nevertheless, the working group considers it important that  Also include at least one of the following components:
education about the nature of schizophrenia spectrum dis-
 People monitoring their own thoughts, feelings, or
orders, as well as factors that contribute to their onset,
behaviours with respect to their symptoms or
course, and treatment, be provided to patients (as well as
recurrence of symptoms
their families) to address ethical concerns by facilitating
 Promoting alternative ways of coping with the
empowerment and ability to make informed decisions
target symptom
about illness management.
 Reducing distress
 Improving functioning (2009)
New Developments
Replaced with:
There are several promising recent developments related to It is important that CBT be delivered by appropriately
psychosocial interventions for psychosis in general and schi- trained therapists following established, effective protocols,
zophrenia in particular. These include mindfulness interven- with regular supervision being available. It should be deliv-
tions,23 avatar therapy,24 training of social cognitive skills,25 ered in a collaborative manner and include established prin-
acceptance and commitment therapy,26 individual and group ciples of CBT, including patients monitoring the relationship
peer support,27 and compassion-focused therapy.28 The between their thoughts, feelings, behaviours, and symptoms;
existing research literature relevant to these is insufficient reevaluation of perceptions, beliefs, and thought processes,
to justify recommendations currently, but further evaluative which contribute to symptoms; promotion of beneficial ways
studies should be encouraged. An additional area of impor- of coping with symptoms; reduction of stress; and improve-
tance is the development and evaluation of interventions for ment of functioning. The minimum dose of CBT should be
common comorbidities in psychiatric disorders, such as regarded as 16 planned sessions.
anxiety and depression.29,30 Reason for modification: This was modified to be more
succinct and to remove specific mention of delivery on an
Appendix: Justification for Modified individual basis as it was concluded that the evidence was
Recommendations insufficient to justify this aspect of the recommendation.

NICE [Link]/Recommendation 3: Mental health services

should work in partnership with local stakeholders, includ- Declaration of Conflicting Interests
ing those representing Black, Asian and minority ethnic The author(s) declared no potential conflicts of interest with respect
groups, to enable people with schizophrenia to stay in work to the research, authorship, and/or publication of this article.
La Revue Canadienne de Psychiatrie 7

Funding results of an international study of individual placement and

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toward work, and quality of life among people with schizophre-
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