Assigment

Canadian Schizophrenia Guidelines

Canadian Practice Guidelines for Comprehensive Community Treatment for Schizophrenia and Schizophrenia Spectrum Disorders

Donald Addington, MD 1 , Elizabeth Anderson, MA

2 , Martina Kelly, MbBCh

3 ,

Alain Lesage, MD 4 , and Chris Summerville, DMin

5

Abstract Objective: The objective of this review is to identify the features and components of a comprehensive system of services for people living with schizophrenia. A comprehensive system was conceived as one that served the full range of people with schizophrenia and was designed with consideration of the incidence and prevalence of schizophrenia. The system should provide access to the full range of evidence-based services, should be recovery oriented, and should provide patient-centred care.

Method: A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum dis- orders. The guidelines were rated by at least 2 raters, and recommendations adopted were primarily drawn from the National Institute for Clinical Excellence (2014) Guideline on Psychosis and Schizophrenia in adults and the Scottish Intercollegiate Guidelines Network guidelines on management of schizophrenia.

Results: The recommendations adapted for Canada cover the range of services required to provide comprehensive services.

Conclusions: Comprehensive services for people with schizophrenia can be organized and delivered to improve the quality of life of people with schizophrenia and their carers. The services need to be organized in a system that provides access to those who need them.

Keywords schizophrenia spectrum and other psychotic disorders, clinical practice guidelines, epidemiology, community mental health services, health services research, health care policy

This paper addresses the need for an organized mental health

system and the evidence-based interventions or programs to

be delivered by the mental health system. Successful treat-

ment of schizophrenia requires an organized, recovery-

oriented, mental health system with coordinated services that

range from accessible community mental health teams to

high-security forensic services. The mental health system

should include supportive living arrangements, such as

structured programs with on-site staff as well as support for

families who are the usual providers of personal support and

housing for young people with schizophrenia. In addition,

the mental health system should include evidence-based,

coordinated specialty care programs ranging from accessible

first-episode psychosis services to assertive community

treatment (ACT) programs.

In Canada, mental health services are delivered

through provincially funded health services. The organi-

zation, funding and delivery of mental health services

vary from province to province; there are no national

standards for mental health service delivery, although

there is a national strategy. 1

Many provinces have adopted the framework of the

national mental health strategy, but there is limited evidence

that this has led to improvement in service delivery and

1 Department of Psychiatry, Hotchkiss Brain Institute, Foothills Hospital,

University of Calgary, Calgary, Alberta 2

Being Mentally Healthy Company, Calgary, Alberta 3

Department of Family Medicine, University of Calgary, Calgary, Alberta 4 Department of Psychiatry, Faculty of Medicine, Université de Montréal,

Montreal, Québec 5

Schizophrenia Society of Canada, Winnipeg, Manitoba

Corresponding Author:

Donald Addington, MD, Foothills Hospital, Department of Psychiatry, 1403

29 Street NW, Calgary, Alberta, Canada T2N 2T9.

Email: addingto@ucalgary.ca

Canadian Psychiatric Association

Association des psychiatres du Canada

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie

2017, Vol. 62(9) 662-672 ª The Author(s) 2017

Reprints and permission: sagepub.com/journalsPermissions.nav

DOI: 10.1177/0706743717719900 TheCJP.ca | LaRCP.ca

outcomes. Clear policies, standards and performance mea-

sures for access, quality and outcome of mental health ser-

vices are lacking. Most provinces also lack the infrastructure

to provide technical support and training for evidence-based,

coordinated specialty care programs delivered in the

community.

We begin by describing broad recommendations that sup-

port comprehensive care systems and a recovery-oriented

approach. Next, we list recommendations that support pro-

grams or services. Finally, we make recommendations that

address the role of primary care in promoting the health of

individuals with schizophrenia.

Recovery has been conceptualized in 2 broad ways. First,

recovery has been conceptualized as a subjective experience

that has many definitions, including “a way of living a satis-

fying, hopeful and contributing life even within the limita-

tions caused by illness.” 2

In Canada, the Mental Health

Strategy identifies supporting recovery as a core value for

mental health services. 1

A systematic review of the recovery

literature identified 5 key recovery processes: connected-

ness, hope, identity, meaning and empowerment (the

CHIME framework). 3

A number of specific evidence-

based practices have been identified as supporting a recovery

orientation, such as supported employment, but these prac-

tices still need to be offered in a way that supports recovery. 4

The second approach to defining recovery is a more func-

tional approach and combines symptomatic and/or func-

tional recovery. A consensus approach to remission in

schizophrenia based on symptoms alone has been identi-

fied. 5

Liberman et al 6

proposed a broader definition of

recovery based on a combination of symptom remission,

vocational functioning, independent living and peer relation-

ships. The subjective and objective approaches to recovery

differ conceptually and have different goals and objectives.

The subjective approach emphasises the role of the individ-

ual as central, with health and social services supporting the

individual’s recovery. The objective approach has a role in

clinical research and outcome measurement because func-

tional recovery sets a higher target for treatment than simply

statistically significant reductions in symptoms.

Although a recovery orientation has been widely dis-

cussed in mental health care, patient-centred care is an

approach to health care delivery that has been examined in

the general health care system. Patient-centred care has been

described as exploring the patient’s main reason for seeking

health care, developing an integrated understanding of the

patient’s worldview, finding common ground on the prob-

lem and its management, enhancing health promotion and

maintaining an ongoing relationship. 7

Patient-centred care

also can be considered at the system or policy level. 8

Patient-centred care can be measured from the patient’s per-

spective, particularly if care is focused on a specific encoun-

ter with a focus on shared decision making. 9

The potential of

shared decision making in schizophrenia has been

described, 10

but a Cochrane review found only 2 studies

examining the impact of shared decision making for people

with mental health conditions. 11

Decision aids are interven-

tions or tools designed to facilitate shared decision making

and patient participation in health care decisions. Decision

aids help people in considering choices, describe where and

why choice exists, and provide information about options

including, where reasonable, the option of taking no

action. 12

We found no published decision aids for facilitating

shared decision making in schizophrenia.

Methods

The methods for the Canadian Schizophrenia Guidelines are

described in brief here; please see the Introduction and

Guideline Development Process article for an in-depth

description. The guidelines were developed using the

ADAPTE process. 13

Because 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 ADAPTE, the set-up phase, involved

preparing for the ADAPTE process. We assembled a

national multidisciplinary panel from across Canada, includ-

ing stakeholders with expertise in schizophrenia and mental

health, health policy, patient advocacy and lived experience

with schizophrenia. Endorsement bodies for the guidelines

included the Canadian Psychiatric Association and the Schi-

zophrenia Society of Canada, which were also heavily

involved in the dissemination and implementation strategy.

The second phase of the ADAPTE process, the adaptation

phase, involves identifying specific health questions; search-

ing for and retrieving guidelines; assessing guideline quality,

currency, content, consistency and applicability; making

decisions regarding adaptation; and preparing the draft

adapted guideline. We searched for guidelines on schizo-

phrenia in guideline clearinghouses and on the websites of

well-established guideline developers for mental health dis-

orders, 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. A MEDLINE search

was also performed using the term guideline as publication

type and schizophrenia as title or clinical topic. Inclusion

criteria were that the guideline had to be published after

2010, the guideline had to be written in English, and the

recommendations had to be developed using a defined and

systematic process. We identified 8 current guidelines that

were potentially suitable for adaptation. 14-19

These guide-

lines were reviewed and evaluated in duplicate using the

AGREE II tool, 20

an instrument used to evaluate the meth-

odological rigour and transparency with which a guideline is

developed. Based on this evaluation, we determined that 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 were reviewed

by the relevant working group. The community treatment

La Revue Canadienne de Psychiatrie 62(9) 663

group also identified 2 recommendations from the Institute

of Health Economics (IHE) Consensus Statement on

Improving Mental Health Transitions. 21

The Consensus

Development Conference has a unique format based on a

jury trial, which provides an independent and critical review

of issues by an unbiased panel. The conference is a survey of

the best available evidence, which informs a Consensus

Statement that is relevant for policy and practice. The con-

ference involves 20 to 25 experts who deliver scientific evi-

dence addressing 5 to 8 questions in a given field over 2 days

of hearings attended by a jury or panel of about 12 members

and an audience of delegates. We identified 2 recommenda-

tions from the IHE that focused on broader issues regarding

provision of community-based services than are generally

addressed in the more targeted recommendations found in

disease-specific clinical practice guidelines. After selection,

those 2 recommendations were subjected to the same process

as other guideline recommendations.

Following the ADAPTE process, working groups

selected items from 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 con-

text. After reviewing the recommendations from the guide-

lines, the working groups decided which recommendations

to accept and which to reject and 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 on which they were based.

Each working group developed a final list of recommenda-

tions from the included guidelines that was 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 recommen-

dation. Recommendations required agreement by 80% of the group to be included in the Canadian guidelines. If a recom-

mendation did not receive 80% agreement, the group discussed

Table 1. 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 1þþ: High-quality meta-analyses, systematic reviews of randomized controlled trials, or randomized controlled trials with a very low risk of

bias; 1þ: 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

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 one meta-analysis, systematic review, or randomized controlled trial 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 Point: recommended best practice based on the clinical experience of the guideline development group

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

664 The Canadian Journal of Psychiatry 62(9)

the recommendation and whether minor modifications to the

recommendation would alter the likelihood that the recommen-

dation would pass. In these situations, recommendations were

modified (as described above) and the group re-voted

later using an online anonymous survey. Whenever mod-

ifications in wording were made to original recommen-

dations, 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 parentheses if applica-

ble, using the system from which the recommendation

originated. The grades of recommendation for each ref-

erence guideline and their meaning are explained in

brief in Table 1 (see Introduction and Guideline Devel-

opment Process article for a more detailed description).

Once the voting and consensus process was completed,

each working group created a separate manuscript con-

taining all the recommendations adapted from the

included guidelines, with accompanying text explaining

the rationale for each recommendation.

During the finalization phase, the Canadian Schizo-

phrenia Guidelines were externally reviewed by those

who will be affected by their uptake: practitioners, policy

makers, health administrators, patients and their families.

The external review asked questions about whether the

users approved of the draft guideline, about strengths and

weaknesses and about suggested modifications. The pro-

cess was facilitated through the Canadian Journal of

Psychiatry and the Schizophrenia Society of Canada. The

Canadian Psychiatric Association Clinical Practice Guide-

lines Committee reviewed and approved the guideline

methodological process.

Results

Recommendation 1: Comprehensive Care across All Phases

All mental health services serving a defined population

should offer a comprehensive range of interventions consis-

tent with this guideline to people with psychosis or

schizophrenia.

[NICE (Strong)]

The planning of treatment services for individuals with

schizophrenia can be organized around population-based

estimates of prevalence and treatment need. 22

Although this

is possible, there is little evidence that population-based

estimates form the basis for mental health planning and

delivery in Canada. 23

Models of population-based mental

health service delivery across levels of economic develop-

ment have been compared. 24

Results suggest that in devel-

oped countries such as Canada, services to a defined

population should include a range of services such as out-

patient clinics, community mental health teams (CMHTs),

acute inpatient care and community residential care, together

with more specialised services such as programs for

treatment-resistant schizophrenia, ACT teams, early

intervention teams, alternatives to acute inpatient care,

alternative types of community residential care and alter-

native occupation and rehabilitation. 24

An integrated

framework for funding and delivering evidence-based

mental health services in the Canadian health system was

presented and endorsed in an IHE Consensus Statement

in 2014. 21

The economic modeling suggests that combi-

nations of optimal evidence-based treatments for schizo-

phrenia are cost-effective compared with systems that

provide less evidence-based practices. 25

In the real

world, it is harder to find clear links between outcomes

and different service patterns and costs due to the com-

plex interplay of culture, social service provision and

health care service provision. 26

However, in recent

American and Italian real-life cluster-randomized trials,

integration of first-onset psychosis-specific programs in

regular public managed care has proven feasible, effec-

tive and cost-beneficial. 26,27,28

Recommendation 2: Full Range of Interventions

Mental health services should be able to offer the full range

of psychological, pharmacological, social, occupational and

culturally safe interventions recommended.

� Be competent to provide all interventions offered. � Place emphasis on engagement rather than risk

management.

� Provide treatment and care in the least restrictive and least stigmatising environment possible.

� Better service the country’s diverse population by offering diversity-related practices for inclusion.

[NICE (Strong)]

This recommendation addresses the quality delivery of

specific services. This requires the mental health system to

have capacity to assess the quality of services delivered and

the skills of clinicians to deliver the services. The term

fidelity has been used to refer to the degree of implemen-

tation of an evidence-based practice, and fidelity scales can

be used to reliably measure fidelity. 27

Fidelity can be

assessed at the level of a service such as supported employ-

ment 28

or a first-episode psychosis service. 29

The develop-

ment of Provincial Technical Assistance Centres (PTACs)

was endorsed by the IHE Consensus Statement in 2014. 21

The concept of a technical assistance centre is based on a

centre developed in Ontario to support the deployment of

ACT teams, or the current Centre national d’excellence en

santé mentale in Québec (http://www.douglas.qc.ca/sec

tion/cnesm-298?locale¼en), or the Assertive Community Treatment Advanced Practice Panel in British Columbia.

At the individual clinical level, specific skills are required

to deliver evidence-based psychosocial programs such as

La Revue Canadienne de Psychiatrie 62(9) 665

cognitive behaviour therapy for psychosis or family educa-

tion and support.

Recommendation 3: Community Mental Health Teams (CMHTs) Serving a Defined Population

� Community mental health services shall be available for all patients with schizophrenia, other severe men-

tal disorders, and their families, and the provider

should be accountable for the services available.

� CMHTs shall expect to cover about 1.5% of the population.

� These community mental health teams must be suffi- ciently resourced to provide high-intensity support (1

staff per 10 patients) to 10% of people with schizo- phrenia, to apply the standards of ACT and medium-

intensity support (1 staff per 20 patients) to another

20% of people with schizophrenia and to apply the standards of intensive case management (ICM) to the

remaining 70%. � The majority of patients shall receive conventional

clinical, rehabilitative and social services with 1

member of the CMHT acting as case manager (1 staff

per 80 patients).

[IHE consensus recommendation]

Recommendation 4: Service User Experience

Improve the experience of care for people with psychosis or

schizophrenia using mental health services.

� Work in partnership with people with schizophrenia and their carers.

� Offer help, treatment and care in an atmosphere of hope, optimism and recovery-orientation.

� Take time to build supportive and empathic relation- ships as an essential part of care.

� Aim to foster people’s autonomy, promote active par- ticipation in treatment decisions and support self-

management.

[NICE (Strong)]

A systematic review of studies that included patient satis-

faction as an outcome measure found that greater clinician

warmth, less nurse negativity and greater clinician listening

were associated with greater patient satisfaction. 30

Qualita-

tive studies of the carer’s experience of care have suggested

ways of better addressing carers’ concerns. 31

Several rando-

mized controlled studies have shown statistically significant

positive impacts of the intervention on carers’ outcomes.

Several components were common to many of these pro-

grams and included psychoeducation, managing problem

behaviours, setting realistic expectations, problem solving

training, communication training, stress management for

relatives, challenging unhelpful beliefs, relapse prevention

and maintaining social networks. 32

Recommendation 5: Communication with People Who Have Schizophrenia from Diverse Backgrounds and Their Carers

� Avoid using clinical language, or keep it to a minimum.

� Ensure that comprehensive written information is available in the appropriate language and in audio

format if possible.

� Provide and work proficiently with interpreters if needed.

� Offer a list of local education providers who can pro- vide English-language teaching for people who have

difficulties speaking and understanding English.

[SIGN (Grade D)]

According to Statistics Canada, in 2011 Canada had a

foreign-born population of about 6,775,800 people, repre-

senting 20.6% of the total population. This is the highest proportion among the G8 countries and is one reason that it

is essential to have services that can support this

population.

Specific systemic components of a balanced mental health care system for people with schizophrenia and their families

Recommendation 6: Assertive Community Treatment

Assertive outreach should be provided for people with seri-

ous mental disorders (including people with schizophrenia)

who make high use of inpatient services, who show residual

psychotic symptoms and who have a history of poor engage-

ment with services leading to frequent relapse and/or social

breakdown (e.g., homelessness, imprisonment).

[SIGN (Grade B)]

Case management has been examined at 3 levels of

intensity. ACT is the highest level of intensity, ICM pro-

vides an intermediate level of care, and standard case man-

agement offers the lowest intensity of care but is sufficient

to support individuals with complex needs. The IHE con-

sensus statement cited above for CMHTs suggests that

ACT be considered an essential component of comprehen-

sive community mental health services and be integrated

with the CMHTs.

ACT combines a team-based and outreach approach to

case management. ACT teams have a high staff to patient

ratio (i.e., 1:10) and some teams are on call 24 hours, 7 days

a week. Staff members operate in both clinical settings and

patients’ community environment. Staff provide a specia-

lized approach to treatment of patients with psychotic dis-

orders who are more clearly disabled. 33

ACT programs are

now available in most jurisdictions and have been shown to

be effective in reducing hospital readmission rates and

improving housing and occupational functioning as well as

quality of life and service satisfaction. 34

These programs do

666 The Canadian Journal of Psychiatry 62(9)

not lead to any differential improvement in clinical state and

do not change the overall costs of care. 35,36

The impact of

ACT is highest where there is a high rate of hospitalization,

which may reflect the quality of the routine mental health

services that have been the control groups in research

studies. 37

Recommendation 7: Intensive Case Management

Consider ICM for people with psychosis or schizophrenia

who are likely to disengage from treatment or services.

[NICE (Conditional)]

The ICM model was designed to meet the needs of high

service users who were not being adequately engaged by

brokerage and clinical case management practices. 38

Like

the ACT model, ICM uses a low patient to staff ratio, pro-

vides assertive outreach in the community and assists with

daily living skills. One difference between ICM and ACT

models is that caseloads are not shared between clinicians

in ICM.

Research results on case management outcomes are

mixed. 39

One Cochrane review found that in comparison

with standard care, case management increased hospital

admissions and length of stay, resulting in increased costs.

However, case management increased the number of

patients in contact with service and hence with medication.

The general practice is to use case management for patients

who have complex service needs. ACT and ICM are more

often used for hard-to-engage or treatment-resistant patients.

A combination of the 3 levels of care was endorsed by the

IHE Consensus Statement in 2014 21

cited above. The con-

sensus statement insisted that community mental health ser-

vices must be sufficiently resourced to provide the 3 levels

of care.

Recommendation 8: First-onset Psychosis Models of Care

Individuals in the first episode of psychosis should receive

treatment within the context of an evidence-based coordi-

nated specialty service. This should be multidisciplinary and

encompass the following:

� Engagement/assertive outreach approaches � Family involvement and family interventions � Access to psychological interventions and psycholo-

gically informed care

� Vocational/educational interventions � Access to antipsychotic medication

[SIGN (Grade A)]

Evidence in support of coordinated specialty care services

for individuals with a first-episode psychosis has accumu-

lated over the last 20 years. The NICE recommendations

were made based on 4 major international studies, 1 each

from Denmark and Norway and 2 smaller studies from the

United Kingdom. 40-43

Since then, 2 large-scale, pragmatic,

cluster-randomized controlled trials, 1 from the United

States and 1 from Italy, have shown positive results. 44,45

Although variations exist in the organization and mix of

services provided in different countries, there is a growing

international consensus on the essential evidence-based

components of first-episode psychosis services. 46

The qual-

ity of care delivered for first-episode psychosis can be

assessed by the First Episode Psychosis Fidelity Scale

(FEPS-FS), a reliable and valid measure that assesses quality

of care across different team models. 29

Self-report surveys of

selected first-episode psychosis services in Canada and the

United States suggest that although there are some variations

in populations served and the access and funding of services,

the majority of the programs surveyed delivered evidence-

based services, even though these 2 studies did not provide

outcomes or cost-effectiveness compared with other service

configurations, like integrating the model into regular

CMHTs. 47,48

Recommendation 9

People presenting to early intervention in psychosis services

should be assessed without delay. If the service cannot pro-

vide urgent intervention for people in a crisis, refer to other

urgent care services.

[NICE (Strong)]

Two lines of evidence support the need for early inter-

vention. One is the negative outcomes associated with

untreated psychosis, including attempted suicide, aggression

and violence. Attempted suicide, which is often the event

that precipitates referral for treatment, occurs in 15% to 29% of patients.

49,50 Aggression and violence are also common in

untreated psychosis. In one population-based cohort, 1 in 3

patients with psychosis was aggressive at the time of pre-

sentation. One patient in 14 engaged in violence that caused,

or was likely to cause, injury to other people. 51

The other

clinically relevant reason for early intervention is the asso-

ciation between the duration of untreated psychosis (DUP)

and longer term outcome. The longer the DUP, the poorer

the outcome. 52,53

In England, NICE has identified 8 quality

measures for first-episode psychosis services including one

for timeliness of access. Fifty percent of new referrals to

mental health services with a first-episode psychosis should

be seen within 2 weeks. 54

Recommendation 10: Early Intervention

Early intervention by psychosis services should be accessi-

ble to all people with a first episode or first presentation of

psychosis, irrespective of the person’s age or the duration of

untreated psychosis.

[NICE (Strong)]

La Revue Canadienne de Psychiatrie 62(9) 667

The age of onset of schizophrenia was initially deter-

mined by the date of first admission to hospital. 55

More

detailed studies of the onset of symptoms yield earlier onset

but similar patterns, revealing a mean age of onset for men at

21.4 years and women at 27.4. These results have significant

implications for service delivery, because 27% of women have an onset over the age of 35.

56

Recommendation 11: Crisis Resolution and Home Treatment Teams

Offer crisis resolution and home treatment teams as a first-

line service to support people with psychosis or schizophre-

nia during an acute episode in the community if the severity

of the episode, or the level of risk to self or others, exceeds

the capacity of the early intervention in psychosis services or

other community teams to effectively manage it.

[NICE (Conditional)]

Crisis resolution has been defined as any type of crisis-

oriented treatment of an acute psychiatric episode by staff

with a specific remit to deal with such situations during and

beyond office hours. The teams are multidisciplinary and

include nurses, psychiatrists and nonprofessional mental

health staff. In England, where these teams have been imple-

mented as a matter of policy, they assess all patients being

considered for admission. A recent Cochrane review found

only 8 small studies that could be included; these studies had

unclear blinding, reporting and attrition bias, and the evi-

dence for the main outcomes of interest was of low to mod-

erate quality. The authors concluded that the approach

appears to be a viable and acceptable way of treating people

with serious mental illnesses. However, more evaluative

studies are still needed. This intervention has not been

widely adopted in Canada.

Recommendation 12: Crisis Houses or Acute Day Facilities

Consider acute community treatment within crisis resolu-

tion and home treatment teams before admission to an inpa-

tient unit and as a means to enable timely discharge from

inpatient units. Crisis houses or acute day facilities may be

considered in addition to crisis resolution team and other

home treatment teams depending on the person’s prefer-

ence and need.

[NICE (Conditional)]

Crisis houses are residential alternatives to acute admis-

sion during a crisis. Research is limited, but 1 fair-sized

study compared crisis houses with standard care. 57,58

NICE

rated the quality of evidence as low.

Acute day hospitals are units that provide diagnostic and

treatment services for acutely ill individuals who otherwise

would be treated in traditional inpatient units. A Cochrane

review included 10 studies. 58

On several measures, no dif-

ferences were found between home care and inpatient care.

The day hospital group spent less time in hospital over the

following year, and so day hospital care has been considered

an alternative for patients with support at home in the eve-

ning and night.

Recommendation 13: Hospitalisation

If a person with psychosis or schizophrenia needs hospital

care, think about the impact on the person, his or her carers

and other family members, especially if the inpatient unit is a

long way from where they live. If hospital admission is

unavoidable, ensure that the setting is suitable for the per-

son’s age, gender and level of vulnerability; it must also

support their carers.

[NICE (Strong)]

According to Thornicroft and Tansella, 24

“There is no

evidence that a balanced system of mental health care can

be provided without acute beds.” Hospitalisation is required

for many people with schizophrenia, including those who

need urgent medical assessment, those with severe comorbid

medical and psychiatric conditions, those experiencing

severe psychiatric relapse and behavioural disturbance or

those with high levels of suicidality or assaultiveness. Inpa-

tient services need to be as close as possible to the commu-

nity in which patients and their carers live in order to provide

continuity of support during hospitalization and graduated

discharge.

Recommendation 14: Supported Employment

Offer supported employment programs to people with psy-

chosis or schizophrenia who wish to find or return to work.

[NICE (Strong)]

Supported employment, referred to as individual place-

ment and support (IPS), is an approach to vocational rehabi-

litation based on a number of key principles including a focus

on competitive employment, eligibility based on consumer

choice, rapid job searches, the integration of rehabilitation

and mental health and attention to consumer preference. 59

The

results of 18 studies with 3476 participants showed that sup-

ported employment was more effective than prevocational

training for the outcomes of gaining competitive employment,

hours/weeks worked, length of time in longest job, time to

first competitive job and length of time worked. 17

Recommendation 15: Supported Housing and Long-term Residential Care

� People with schizophrenia shall live in housing of their choice.

� Supported housing in the community shall be avail- able for each person with schizophrenia.

� Given that many people with schizophrenia have indi- cated that they prefer to live in small, homelike

668 The Canadian Journal of Psychiatry 62(9)

environments, governments also need to consider the

role of noninstitutional residential facilities. In partic-

ular, facilities that create a homelike environment and

provide a safe and dignified long-term home for peo-

ple with schizophrenia who cannot live independently

should be considered.

[IHE consensus recommendation]

The reduction in the number of long-term mental hospital

beds has led to problems in housing individuals with severe

and persistent mental disorders in the community. 60

A large

proportion of this population have schizophrenia, often with

comorbid substance use disorders. Supported housing is a

service model that couples provision of independent housing

with provision of community-based supports for individuals

with mental disorders who are at risk of homelessness. 61

Sup-

ported housing has been contrasted with traditional sequential

residential rehabilitation programs, which begin with acute or

long-term treatment and step down to levels of accommoda-

tion with reducing levels of support and a requirement that

residents participate in mandatory treatment plans. 62

The larg-

est study of supported housing was carried out in Canada

using a model known as Housing First, which was applied

to homeless individuals. 63

The model is characterised by a

combination of access to good housing in noncongregate

facilities, often through supplement to rent, and support by

an ACT team or ICM team (see above). Results showed that

the model could be applied across a range of contexts and

populations. Furthermore, those receiving the Housing First

model achieved superior housing outcomes and more rapid

outcomes in community functioning and quality of life com-

pared with those receiving treatment as usual. 64

Recommendation 16: Peer Support and Self-management

Consider peer support for people with schizophrenia to help

improve service user experience and quality of life. Peer

support services should be delivered by a trained peer sup-

port worker who has recovered from psychosis and remains

stable. Peer support workers should receive support from

their whole team and support and mentorship from experi-

enced peer workers.

[NICE (Conditional)]

Peer support work has been defined as “social emotional

support, frequently coupled with instrumental support, that is

mutually offered or provided by persons having a mental

health condition to others sharing a similar mental health

condition to bring about a desired social or personal

change.” 65

The challenge in assessing the evidence to sup-

port such programs is the variety of outcomes that are

desired by participants and funders. The NICE guidelines

found low- to very-low-quality evidence that peer support

increased self-rated recovery but not empowerment or qual-

ity of life. Nonetheless, these programs are offering

opportunities for service users to obtain recognition and pro-

vide support to others.

In Canada, the Peer Support and Accreditation and Certi-

fication Canada (PSACC) promotes the recognition, growth

and accessibility of peer support. This is a national organi-

zation that has established the PSACC Standards of Practice.

The organization uses these standards as the platform from

which to promote mental health peer support through edu-

cation and awareness. The organization also certifies quali-

fied peer supporters and accredits qualified peer support

training programs. Peer support workers can be found work-

ing in a variety of programs such as CMHTs and ACT teams

as well as a range of residential programs and nonprofit

organizations such as the Schizophrenia Society and Cana-

dian Mental Health Association. In Quebec, the Ministry of

Health and Social Services recognizes the importance of

peer support workers and funds 2 nongovernmental organi-

zations to offer training and supervision of peer support

workers and family peer support workers.

Recommendation 17: Return to Primary Care

For people with psychosis or schizophrenia whose symp-

toms have responded effectively to treatment and remain

stable, offer the option to return to primary care for further

management. If a service user wishes to do this, record this

in his or her notes and coordinate transfer of responsibilities.

[NICE (Strong)]

Recommendation 18: Relapse and Re-referral to Secondary Care

When a person with an established diagnosis of psychosis or

schizophrenia presents with a suspected relapse (for exam-

ple, with increased psychotic symptoms or a significant

increase in the use of alcohol or other substances), primary

health care professionals should refer to the crisis section of

the care plan.

[NICE (Strong)]

The NICE recommendations on return to primary care

and re-referral are made within the context of the very struc-

tured National Health Service. In the National Health Ser-

vice, this would include a care plan written by a mental

health professional in collaboration with the patient, which

would be shared with the primary care provider. In addition,

the patient would be registered in a primary care practise–

based register to monitor physical and mental health. In the

Canadian context, neither mental health services nor primary

care is as structured. It would be appropriate to consider

referral to primary care if the patient is stable, has recovered

and does not need services such as psychological or rehabi-

litation interventions that are available only in the multidis-

ciplinary CMHT. The resources available in the primary care

setting would need to be considered, as they vary from

La Revue Canadienne de Psychiatrie 62(9) 669

individual office practices to multidisciplinary care teams

within primary care networks or family medicine groups.

Recommendation 19: Transfer between Health Regions

When a person with psychosis or schizophrenia is planning

to move to the catchment area of a different health regions or

provinces, a meeting should be arranged between the ser-

vices involved and the service user to agree a transition plan

before transfer. The person’s current care plan should be sent

to the new secondary care and primary care providers.

[NICE (Strong)]

This recommendation, which appears clear-cut within the

context of the National Health Service, needs to be adapted

to the varied organization of health mental health services

across Canada. The large distances involved are also an

important consideration. The key message in this recommen-

dation is the need to take an active approach to ensuring

continuity of care.

Conclusions

We have identified a set of recommendations that provide

guidelines for a comprehensive system of care for people

with schizophrenia. The recommendations include both spe-

cific evidenced-based services and recommendations about

coordinating these services in a system that serves the pop-

ulation with schizophrenia and schizophrenia spectrum dis-

orders. Most of the specific evidence-based practices

identified in this guideline can be found in mental health

services across Canada, but these practices are rarely inte-

grated into a comprehensive, accessible system and rarely

assessed for access, quality and outcome. These recommen-

dations have the potential to improve the quality of life of

people with schizophrenia and their carers, but the services

need to be organized in a system that provides access to

those who need them.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect

to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

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