Canadian

Psychiatric Association

Association des psychiatres

Canadian Schizophrenia Guidelines du Canada

The Canadian Journal of Psychiatry /

La Revue Canadienne de Psychiatrie
Canadian Treatment Guidelines 2017, Vol. 62(9) 617-623
ª The Author(s) 2017
on Psychosocial Treatment of Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0706743717719894
Schizophrenia in Adults TheCJP.ca | LaRCP.ca

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
benefits for individuals with schizophrenia spectrum disor-
ders and their families. The review group would like to
preface its recommendations by noting the importance of
some general principles regarding the implementation of
psychosocial interventions and indeed all treatment
approaches to schizophrenia spectrum disorders. These
include the following:
1. Optimal management requires the integration of
medical and psychosocial interventions. Such inter-
ventions should not be seen as competing
approaches but, in most cases, as necessary and
complementary interventions to improve clinical
symptoms, functional outcome, and quality of life.
2. Psychosocial interventions address many aspects of
recovery, from reduction of acute symptoms to
improvement in functioning and general well-being.
3. Genuinely listening and attending to patients’
concerns develops empathy, rapport, and good
therapeutic relationships. It can also improve
engagement and adherence to treatment.
4. It is important to encourage a realistically hopeful
attitude for the future in patients and families. All
1
Departments of Psychiatry and Epidemiology & Biostatistics, Western
University, London, Ontario
2
Prevention & Early Intervention Program for Psychoses (PEPP), London
Health Sciences Centre, London, Ontario
3
Department of Psychology, University of Montreal, Montreal, Quebec
4
Centre de recherche de l’Institute universitaire en santé mentale de
Montréal, Quebec
5
Hotchkiss Brain Institute and Department of Psychiatry, University of
Calgary, Calgary, Alberta
6
Beingmentallyhealthy.com, Calgary, Alberta
Corresponding Author:
Ross Norman, PhD, Department of Psychiatry, University of Western
Ontario, London Health Sciences Centre–Victoria Hospital, A2-643, 800
Commissioners, Road East, London, Ontario, N6A 5W9, Canada.
Email: rnorman@uwo.ca
618
clinicians, including physicians, are important con-
tributors to this process.
5. All interventions should be undertaken within a
recovery framework with the objective of the
patient being able to obtain a good quality of life.
6. The clinical team, the patient, and family mem-
bers should develop shared, short-term and long-
term goals for treatment and recovery. Progress
toward these goals should be carefully monitored
and evaluated.
7. The delivery of effective psychosocial interventions
requires specific and often nuanced and complex
skills. It is essential that staff who provide psycho-
social interventions should be appropriately trained.
8. Patients should be supported in developing effective
self-management skills for improving their symp-
toms, functioning, and quality of life.
9. Common comorbid conditions such as substance
abuse, anxiety disorders, and depression need to
be recognised and addressed with psychosocial
interventions.
10. Patient and family preferences should be considered
in the identification of treatment goals and methods.
Methods
The methods for the Canadian Schizophrenia Guidelines are
described in brief here; please see the Introduction and
Methodology manuscript for an in-depth description.
The guidelines were developed using the ADAPTE pro-
cess.1 Recognising that the development of guidelines
requires substantial resources, the ADAPTE process was
created to take advantage of existing guidelines and reduce
duplication of effort.
The first phase of the ADAPTE process, the setup phase,
involved preparing for the ADAPTE process. We assembled
a national multidisciplinary panel from across Canada,
including stakeholders with expertise in schizophrenia and
mental health, health policy, patient advocacy, and lived
experience with schizophrenia. Endorsement bodies for the
guidelines include the Canadian Psychiatric Association and
the Schizophrenia Society of Canada, who were also heavily
involved in the dissemination and implementation strategy.
The second phase of the ADAPTE process, the adaptation
phase, involves the process of identifying specific health
questions; searching for and retrieving guidelines, assessing
guideline quality, currency, content, consistency, and applic-
ability; decision making around adaptation; and preparing
the draft-adapted guideline. We searched for guidelines on
schizophrenia in guideline clearinghouses and on the web-
sites of well-established guideline developers for mental
health disorders, including the National Institute for Health
and Care Excellence (NICE), the Scottish Intercollegiate
Guidelines Network (SIGN), the American Psychiatric
Association, the American Academy of Child and Adoles-
cent Psychiatry, and the European Psychiatric Association.2
The Canadian Journal of Psychiatry 62(9)
A MEDLINE search was also performed using the term
guideline as the publication type and schizophrenia as the
title or clinical topic. Inclusion criteria were that the guide-
line needed to be published after 2010, be written in English,
and that recommendations had to be developed using a
defined and systematic process. We identified 8 current
guidelines that were potentially suitable for adaptation.
These guidelines were reviewed and evaluated in duplicate
using the AGREE II tool,3 an instrument to evaluate the
methodological rigour and transparency in which a guideline
is developed. Based on this evaluation, we determined that
the 6 guidelines were of suitable quality and content for
adaptation (see Table 1). Recommendations from each
guideline were extracted and divided based on content and
reviewed by the relevant working group. Following the
ADAPTE process, working groups selected between guide-
lines and recommendations to create an adapted guideline.
Each working group carefully examined each recommenda-
tion, the evidence from which the recommendation was
derived, and the acceptability and applicability of the rec-
ommendation to the Canadian context. After the reviewing
the recommendations from the guidelines, the working
groups decided which recommendations to accept and which
to reject, as well as which recommendations were acceptable
but needed to be modified. Care was taken when modifying
existing recommendations not to change the recommenda-
tions to such an extent that they were no longer in keeping
with the evidence upon which they were based. Please see
the Appendix for how and why recommendations in this
article were modified from their original form.
De novo recommendations were made in situations where
it was felt a recommendation was needed but none of the
existing guidelines provided recommendations addressing
the situation or topic. When de novo recommendations were
created, the SIGN methodology was followed for the levels
of evidence and the grades of recommendation (see Table 2).
Each working group developed a final list of recommen-
dations from the included guidelines that were presented to
the entire guideline panel at an in-person consensus meeting.
Working group leaders presented each recommendation and
its rationale to the panel. Anonymous voting by the entire
panel using clicker technology was performed for each rec-
ommendation. Recommendations required agreement by
80% of the group to be included in the Canadian guidelines.
If a recommendation did not receive 80% agreement, the
group discussed the recommendation and if minor modifica-
tions to the recommendation would alter the likelihood that
the recommendation would pass. In these situations, recom-
mendations were modified (as described above) and the
group revoted at a later date using an online anonymous
survey. Whenever modifications in wording were made to
original recommendations, the text ‘modified recommenda-
tion from’ appears in the Canadian Schizophrenia Guide-
lines, and the source of each recommendation is written
beside the recommendation statement. The strength or grade
of the recommendation is provided in brackets if applicable,
La Revue Canadienne de Psychiatrie 62(9) 619

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
Centre for Mental Guideline Number 155.
Results
Health Commissioned Psychosis and Family Intervention
by the National Institute Schizophrenia in
for Health and Care Children and Young Recommendation 1
Excellence (NICE) People: Recognition and Family intervention should be offered to all individuals diag-
Management5
nosed with schizophrenia who are in close contact with or
National Collaborating NICE National Clinical 2011
Centre for Mental Guideline Number 120. live with family members and should be considered a prior-
Health Commissioned Psychosis with ity when there are persistent symptoms or a high risk of
by the National Institute Coexisting Substance relapse. Ten sessions over a 3-month period should be con-
for Health and Care Misuse: Assessment and sidered the minimum effective dose. Family intervention
Excellence (NICE) Management in Adults should encompass
and Young People6
Scottish Intercollegiate SIGN 131. Management of 2013  Communication skills
Guidelines Network Schizophrenia7
(SIGN)
 Problem solving
European Psychiatric European Psychiatric 2015  Psychoeducation
Association Association Guidance [From SIGN 2013]
on the Early The occurrence of a psychotic disorder has implications
Intervention in Clinical
for the family of the ill person,10 and families can play an
High Risk States of
Psychoses8 important role in facilitating treatment and recovery.11 How
American Psychiatric American Psychiatric 2016 family members respond to the ill person and the associated
Association Association Practice emotional climate can have an effect on clinical outcomes.12
Guidelines for Both SIGN and NICE note strong evidence supporting the
Psychiatric Assessment efficacy of family interventions designed to help families
of Adults9 deal with the challenges posed by having a close relative
with a schizophrenia spectrum disorder. The interventions
emphasise providing support and education for the family,
using the system from which the recommendation came. The strengthening problem solving and communication, and
grades of recommendation for each reference guideline and addressing issues related to crisis management and prevent-
their meaning are explained in brief in Table 2 (see Intro- ing relapse.
duction and Methodology manuscript for a more detailed The research reviewed in both NICE and SIGN guide-
description). Once the voting and consensus process were lines indicates that randomised controlled trials yield strong
completed, each working group created a separate manu- evidence for the efficacy of such family interventions, lead-
script that contained all the recommendations adapted from ing to reductions in severity of patients’ symptoms and like-
the included guidelines, with accompanying text explaining lihood of hospitalisation. There is also some evidence of
the rationale for each recommendation. beneficial effects on functioning, knowledge regarding the
The working group for the current article elected not to disorder, and distress. The recommendation with respect to
include some negative recommendations from NICE and/or number and timing of sessions is based on a subgroup anal-
SIGN guidelines, such as recommendation that adherence ysis within a large meta-analysis of relevant 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 off-
During the finalisation phase, the Canadian Schizophre- spring.”7p29 It is also important that the intervention address
nia Guidelines were externally reviewed by those who will the issue of enabling families to better communicate their
be affected by its uptake: practitioners, policy makers, health concerns to mental health professionals.
620 The Canadian Journal of Psychiatry 62(9)

Table 2. Grade/strength of recommendation classification systems for included guidelines.a

National Institute for Health and Care Excellence (NICE)

Strength of recommendations
The wording used denotes the certainty with which the recommendation is made (the strength of the recommendation).
Interventions that must (or must not) be used
We usually use “must” or “must not” only if there is a legal duty to apply the recommendation. Occasionally, we use “must” (or “must not”)
if the consequences of not following the recommendation could be extremely serious or potentially life threatening.
Interventions that should (or should not) be used: a “strong” recommendation
We use “offer” (and similar words such as “refer” or “advise”) when we are confident that, for the vast majority of patients, an intervention
will do more good than harm and be cost-effective.
Interventions that could be used
We use “consider” when we are confident that an intervention will do more good than harm for most patients and be cost-effective, but
other options may be similarly cost-effective. The choice of intervention, and whether or not to have the intervention at all, is more likely
to depend on the patient’s values and preferences than for a strong recommendation.

Scottish Intercollegiate Guidelines Network (SIGN) and European Psychiatric Association

Levels of evidence
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.

Supported Employment Programs
Recommendation 2
Offer supported employment programs to people with psycho-
sis or schizophrenia who wish to find or return to work (strong
recommendation). Consider other occupational or educational
activities, including prevocational training for people who are
unable to work or unsuccessful in finding employment.
Recommendation 3
Mental health services should work in partnership with
local stakeholders, including those representing minority
groups, to enable people with psychosis or schizophrenia
to stay in work or education and to assess new employment
(including self-employment), volunteering, and educa-
tional activities
[Modified from NICE (Strong)]
Employment can provide financial benefits for an indi-
vidual with a schizophrenia spectrum disorder, and mean-
ingful activity such as employment may also yield benefits
for symptoms and psychological well-being.14,15
After reviewing relevant evidence, authors of the NICE
guidelines concluded that “supported employment appears to
be the most effective vocational rehabilitation method for obtain-
ing competitive employment and for obtaining any occupation
(paid, unpaid or voluntary). Furthermore, there is consistent evi-
dence across a number of outcome measures that supported
employment is more effective than prevocational training in
increasing competitive employment. Evidence regarding earn-
ings and being able to sustain employment or any occupation is
less conclusive. Additionally, the long term benefits of supported
employment are not known” (p. 560). The SIGN guidelines do
not specially address employment-related interventions.
It is important that employment interventions include the
key specific elements of supported employment, such as
individually tailored job development, rapid job search,
La Revue Canadienne de Psychiatrie 62(9)
provision of ongoing job supports, and integration of voca-
tional and mental health services.16
The NICE guidelines note that, while supported employ-
ment is most effective for those desiring competitive
employment, alternate interventions such as prevocational
training and support should be available to those who are
not ready for such work. When patients are seeking support
in returning to education or training programs, it should be
provided. Although less is known about the critical compo-
nents that are likely to be effective in this regard, the imple-
mentation of principles, parallel to those found effective in
supported employment, seems desirable.
Cognitive-Behavioural Therapy
Recommendation 4
Cognitive-behavioural therapy (CBT) for psychosis should
be offered to all individuals diagnosed with schizophrenia
whose symptoms have not adequately responded to antipsy-
chotic medication and are experiencing persisting symp-
toms, including anxiety or depression. CBT can be started
during the initial phase, the acute phase, or recovery phase,
including in-patient settings.
[Modified from SIGN (Evidence level A)]
Recommendation 5
It is important that CBT be delivered by appropriately
trained therapists following established, effective protocols,
with regular supervision being available. It should be deliv-
ered in a collaborative manner and include established prin-
ciples of CBT, including patients monitoring the relationship
between their thoughts, feelings, behaviours, and symptoms;
reevaluation of perceptions, beliefs, and thought processes
that contribute to symptoms; promotion of beneficial ways
of coping with symptoms; reduction of stress; and improve-
ment of functioning. The minimum dose of CBT should be
regarded as 16 sessions.
[Modified from NICE (Strong)]
Both SIGN and NICE reviewed the results of multiple
randomised controlled trials (RCTs) of cognitive therapy indi-
cating effectiveness of CBT for psychosis for reducing symp-
tom severity, hospitalisation, and relapse. Several studies also
showed significant beneficial effects on level of depression.
There are no RCTs directly comparing group and individ-
ual CBT. Most of the evidence reviewed by NICE and SIGN
evaluated individualised CBT, and both guidelines specifi-
cally recommended this approach. There have also been
reports showing beneficial effects of CBT delivered in a
group format.17,18 We concluded that evidence regarding the
comparative benefits of CBT or psychosis delivered indivi-
dually versus in a group format is unclear at this time. Patient
preferences should be taken into account, and ideally both
should be available.
621
Although there is no direct evidence concerning the min-
imum number of treatment sessions required for therapeutic
effect, most of the evidence base is derived from studies
including at least 16 sessions, and so this is recommended
as the minimum dose.
Cognitive Remediation
Recommendation 6
Cognitive remediation therapy (CRT) may be considered
for individuals diagnosed with schizophrenia who have
persisting problems associated with cognitive difficulties.
[From SIGN (Recommendation grade B)]
Various protocols have been developed and evaluated
in recent years with the goal of reducing deficits in basic
cognitive processes such as attention, memory, and
problem solving, which can accompany schizophrenia
spectrum disorders. NICE (as well as the Canadian Psy-
chological Association [CPA] 2005 guidelines) concluded
that the evidence for their effectiveness is insufficient to
recommend their use. The SIGN guidelines concluded
that “there is evidence the CRT improves cognitive
domains at end of treatment, and limited evidence with
inconsistencies in outcomes, that this may translate into
improved social and functional outcomes. There is also
some limited evidence that improvements in cognitive
outcomes are maintained at follow-up.”7p28 There is some
evidence that cognitive remediation may have increased
impact when offered at the same time as other psychoso-
cial interventions.19-21
Social Skills Training
Recommendation 7
Social skills training should be available for patients who are
having difficulty and/or experiencing stress and anxiety
related to social interaction.
[De novo recommendation (Evidence grade B)]
Social skills training uses basic learning principles to
improve interpersonal skills related to social interaction,
such as conversational skills, making friends, job interviews,
and assertiveness. Methods include instruction about the sig-
nificance of verbal and nonverbal aspects of social beha-
viour, modeling, role-playing, behavioural rehearsal,
corrective but supportive feedback, and behavioural home-
work and practice to facilitate generalisation to the individ-
ual’s social environment.
Neither NICE nor SIGN strongly recommend the routine
use of social skills training. Both guidelines note some evi-
dence for the effects on social functioning and negative
symptoms but little evidence for effects on positive symp-
toms, hospitalisation, or relapse. Given the increasing focus
on improving functional outcomes for individuals with schi-
zophrenia spectrum disorders and the prevalence of social
622
anxiety and deficits in social functioning in this clinical
population, we feel that having such interventions available
is important. We, therefore, reiterated the relevant recom-
mendation from the CPA 2005 guidelines.
Life Skills Training
Recommendation 8
Life skills training should be available for patients who are
having difficulty with self-care related to housekeeping,
transportation, financial management, and so on.
[De novo recommendation (Evidence level: Low)]
Some patients with schizophrenia spectrum disorders
have deficits in skills related to practical aspects of living
such as personal self-care, grooming and hygiene, domes-
tic skills, transportation, and managing money. Life skills
training programs target these deficits using assessment,
feedback, and structured homework. Unfortunately, there
has been little research evaluating the effectiveness of
these interventions, and the few RCTs that have been
reported do not yield strong evidence for their
effectiveness.22
Given the need for interventions to improve life skills for
some patients with schizophrenia spectrum disorders and the
absence of viable alternative approaches, the working group
recommends that such interventions be available but notes
the importance of research evaluating their effectiveness and
critical components.
Patient Education
Recommendation 9
Appropriate education for patients about the nature and treat-
ment of and recovery from schizophrenia should be an inte-
gral part of a program of treatment, but education
interventions in themselves do not have robust effects on
treatment outcomes.
[De novo recommendation (Evidence level: Low)]
Both NICE and SIGN report that there is not robust
evidence for patient education about illness per se having
a significant impact on critical outcomes such as sympto-
matology, relapse/rehospitalisation, adherence, or insight.
Nevertheless, the working group considers it important that
education about the nature of schizophrenia spectrum dis-
orders, as well as factors that contribute to their onset,
course, and treatment, be provided to patients (as well as
their families) to address ethical concerns by facilitating
empowerment and ability to make informed decisions
about illness management.
New Developments
There are several promising recent developments related to
psychosocial interventions for psychosis in general and
The Canadian Journal of Psychiatry 62(9)
schizophrenia in particular. These include mindfulness inter-
ventions,23 avatar therapy,24 training of social cognitive
skills,25 acceptance and commitment therapy,26 individual
and group peer support,27 and compassion-focused ther-
apy.28 The existing research literature relevant to these is
insufficient to justify recommendations currently, but further
evaluative studies should be encouraged. An additional area
of importance is the development and evaluation of inter-
ventions for common comorbidities in psychiatric disorders,
such as anxiety and depression.29,30
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.
Supplementary Material
Supplementary material is available for this article online.
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