Performance in Practice: Practice Assessment Tool for the Care of Patients With Schizophrenia
Abstract
Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.
Schizophrenia is associated with significant health, social, occupational, and economic burdens as a result of its early onset and its severe and often persistent symptoms (Box 1) (1–4). For example, unemployment, homelessness, and incarceration are more likely among individuals with schizophrenia than among individuals without a psychiatric disorder (4–7). In addition, schizophrenia is associated with a very high global burden of disease, making it one of the top 20 causes of disability worldwide (8).
BOX 1. DSM-5 criteria for schizophreniaa
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g. frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e. diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g. odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).
a Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric Association. Used with permission.
Individuals with schizophrenia also have a shortened life span and standardized mortality ratios that are reported to be twofold to fourfold those of the general population (9–17). About 4%−10% of persons with schizophrenia die by suicide (10, 12, 16, 18–20). Other contributors to death are co-occurring psychiatric disorders (21), including substance use disorders (22); accidents and traumatic injuries; and physical conditions, such as malignancies and cardiovascular, respiratory, and infectious diseases (1, 9–17). These increases in morbidity and mortality are likely associated with factors such as obesity, diabetes, hyperlipidemia, greater use of cigarettes, reduced engagement in health maintenance (e.g., diet, exercise), lack of access to psychiatric treatment, and disparities in access to preventive health care and treatment for physical conditions among individuals with schizophrenia (23–32).
Optimizing the care of individuals with schizophrenia is essential to reducing the considerable economic and human costs of this disorder. In addition, performance in practice approaches may be able to reduce gaps in care. For example, studies have suggested that a significant proportion of individuals with treatment-resistant schizophrenia do not receive treatment with clozapine, despite the evidence for its effectiveness (33–39). Similarly, long-acting injectable formulations of antipsychotic medications are often underused but can provide many benefits for patients and families (40–43). Even among those receiving pharmacologic treatments, appropriate and timely monitoring for benefits and side effects of treatment are less than optimal (44). Co-occurring psychiatric disorders, including nicotine dependence and other substance use disorders, are often unrecognized or unaddressed (22, 45–57). Evidence also suggests low rates of guideline-concordant monitoring for metabolic risk factors, including hyperlipidemia, diabetes, and obesity (58, 59), which is of particular concern given the association between metabolic risk factors and poor health outcomes (see Table 1). Psychosocial interventions for schizophrenia have not typically been part of behavioral health quality measures (60, 61), yet national data (62) and anecdotal observations (63) also suggest significant underuse of these interventions. These gaps in care are troubling because evidence-based psychosocial and psychopharmacologic interventions can reduce symptoms and improve functioning among individuals with schizophrenia.
| Assessment | Initial or baseline | Follow-up |
|---|---|---|
| Monitoring physical status or detecting concomitant physical conditions | ||
| Vital signs | Pulse, blood pressure | Pulse, blood pressure, temperature as clinically indicated |
| Body weight and height | Body weight, height, and BMI | BMI every visit for six months and at least quarterly thereafter |
| Hematology | CBC, including ANCb | CBC, including ANC if clinically indicated (e.g., patients treated with clozapine) |
| Blood chemistries | Electrolytes, renal function tests, liver function tests, TSHc | As clinically indicated |
| Pregnancy | Pregnancy test for women of childbearing potential | |
| Toxicology | Drug toxicology screen, if clinically indicated | Drug toxicology screen, if clinically indicated |
| Electrophysiological studies | EEG, if indicated on the basis of neurological exam or history | |
| Imaging | Brain imaging (CT or MRI, with MRI preferred), if indicated based on neurological exam or history | |
| Genetic testing | Chromosomal testing, if indicated on the basis of physical exam or history, including developmental history | |
| Monitoring for specific side effects of treatment | ||
| Diabetes | Screening for diabetes risk factors, fasting blood glucose | Fasting blood glucose or HbA1c four months after initiating a new treatment and at least annually thereafter |
| Hyperlipidemia | Lipid panel | Lipid panel four months after initiating a new antipsychotic medication and at least annually thereafter |
| Metabolic syndrome | Determine whether metabolic syndrome criteria are met | Determine whether metabolic syndrome criteria are met four months after initiating a new antipsychotic medication and at least annually thereafter. |
| QTcd prolongation | ECG before treatment with chlorpromazine, droperidol, iloperidone, pimozide, thioridazine, or ziprasidone or in the presence of cardiac risk factors | ECG with significant change in dose of chlorpromazine, droperidol, iloperidone, pimozide, thioridazine, or ziprasidone or with the addition of other medications that can affect QTc interval among patients with cardiac risk factors or elevated baseline QTc intervals |
| Hyperprolactinemia | Screening for symptoms of hyperprolactinemia; prolactin level, if indicated on the basis of clinical history | Screening for symptoms of hyperprolactinemia at each visit until stable, then yearly if treated with an antipsychotic known to increase prolactin; prolactin level, if indicated on the basis of clinical history |
| Antipsychotic-induced movement disorders | Clinical assessment of akathisia, dystonia, parkinsonism, and other abnormal involuntary movements, including tardive dyskinesia; Assessment with a structured instrument (e.g. AIMS, DISCUSe) if such movements are present | Clinical assessment of akathisia, dystonia, parkinsonism, and other abnormal involuntary movements, including tardive dyskinesia, at each visit. Assessment with a structured instrument (e.g. AIMS, DISCUS) at a minimum of every 6 months in patients at high risk of tardive dyskinesia and at least every 12 months in other patients as well as if a new onset or exacerbation of pre-existing movements is detected at any visit |
TABLE 1. Suggested physical and laboratory assessments for patients with schizophreniaa
Given the high levels of morbidity, mortality, and health, social, occupational, and economic burdens of disease associated with schizophrenia, the Performance in Practice (PIP) Practice Assessment Tool for the Care of Patients With Schizophrenia was developed to assist psychiatrists in optimizing patient care and meeting Maintenance of Certification, part IV (MOC IV), requirements of the American Board of Psychiatry and Neurology and the American Board of Medical Specialties. It can also be used in partial fulfillment of Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program requirements related to practice improvement activities (64). Continuing medical education information and directions for completing the activity are presented in Box 2.
BOX 2. CME information and directions for completing the activity
Completion of Stages A, B, and C in sequence is designated by the American Psychiatric Association for 20 AMA Physician’s Recognition Award (AMA PRA) category 1 credits. Begin date: October 1, 2020 - End Date: October 1, 2023
This activity is approved by the American Board of Psychiatry and Neurology for Maintenance of Certification, part 4, Clinical Module (PIP) until October 1, 2023
The course is completed online at education.psychiatry.org. APA members log in with their APA username and password. Nonmember FOCUS subscribers e-mail [email protected] to be enrolled in the online course.
Completion of three stages (A, chart review; B, improvement plan; and C, second chart review), evaluation of each stage, and credit claim for each stage of the Performance in Practice (PIP): Practice Assessment Tool for the Care of Patients With Schizophrenia takes place in the online course in the APA Education Portal, education.psychiatry.org.
The tool presented here is used to complete stages A and C and is available for download in the online course. Chart review data are for the use of the participant only and are not submitted to APA.
Three stages are involved in each PIP unit:
Stage A—the baseline retrospective chart review of at least five patients in the specified category, which is then compared with quality measures (i.e., published best practices, practice guidelines, peer-based standards).
Stage B—the design and implementation of a practice improvement plan
After comparing your recorded patient data with quality measures in stage A, you should initiate and document a plan for improvement. You may decide to access additional resources as part of your improvement plan. Your improvement plan is not submitted to APA but is for your own use.
Suggested interventions: For a more thorough presentation of specific clinical and psychosocial issues relating to the treatment of patients with schizophrenia, physicians and others interested in strengthening the quality of care provided to their patients with schizophrenia are strongly encouraged to carefully review the APA Practice Guideline for the Treatment of Patients With Schizophrenia (http://psychiatryonline.org/guidelines.aspx).
Other suggested activities and resources that may be used as part of your improvement plan include the following:
Use of specific recommendations and clinical resources outlined in stage A of the module.
FOCUS: The Journal of Lifelong Learning in Psychiatry, special issue on schizophrenia (Volume 18, Issue 4): review original articles and influential publications on schizophrenia published in this issue.
Continuing medical education course—APA Practice Guideline for the Treatment of Patients With Schizophrenia (www.apaeducation.org)
Stage C—subsequent remeasurement via a second chart review of five patients in the same category within 24 months after the initial chart review.
The American Psychiatric Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Physicians should claim only the credit commensurate with their participation in the activity.
The PIP tool draws on the structure and content of the 2012 version of the Performance in Practice: Physician Practice Assessment Tool for the Care of Adults With Schizophrenia (65). However, it has been significantly revised and updated on the basis of clinically significant evidence-based assessment and treatment recommendations from APA’s most recent Practice Guideline for the Treatment of Patients With Schizophrenia (66). This evidence-based guideline was developed through a systematic review of relevant literature and critical evaluation of the scientific research by experts in the assessment and treatment of schizophrenia. The guideline highlights critical issues related to evidence-based treatment and notes the importance of formulating a person-centered plan using shared decision making whenever possible, establishing a therapeutic alliance to identify barriers to the patient’s ability to participate in treatment, and engaging the patient’s family members and other significant support persons when able. Careful review of the full guideline is recommended to obtain additional details on assessment and treatment of individuals with schizophrenia.
In addition to providing key evidence-based recommendations that relate to the assessment and treatment of schizophrenia, the PIP tool is also intended to provide a simple retrospective chart review tool for physicians to determine whether their own assessment and treatment practices are consistent with the latest evidence-based recommendations and to offer valuable clinical resources related to screening, assessment, and treatment interventions, including possible ways to improve the clinical care of individuals with schizophrenia. In addition to its value as a self-assessment tool, this tool could also be used for peer review initiatives or broader systematic efforts by organizations and health care delivery systems to improve the assessment and treatment of patients with schizophrenia.
This PIP clinical tool has been designed to be relevant across different clinical settings, is straightforward to complete, and can be used in a pen-and-paper format to aid adoption. The PIP tool includes three sections related to patient assessment (Table 2); general treatment approaches, including both psychopharmacology and psychosocial treatments (Table 3); and treatments that are indicated by patient-specific needs and circumstances (Table 4). Each section highlights aspects of care that have significant public health implications or for which gaps in guideline adherence are common, as described earlier.
| Patient | |||||||
|---|---|---|---|---|---|---|---|
| Aspect of care and quality-related action | 1 | 2 | 3 | 4 | 5 | Total no. of patients with check mark in each rowb | Supporting evidence, resources, and clinical issues for consideration |
| 1. Were the patient’s reasons for seeking treatment, goals, view of the illness, and preferences for treatment identified as part of the assessment? | □ | □ | □ | □ | □ | __/5 | This information will provide a framework for recovery and serve as a starting point for person-centered care and shared decision making with the patient, family, and other support persons (67–69). Such discussions may also foster a more collaborative therapeutic relationship and promote adherence. Identification of goals and preferences should not be limited to symptom relief and may include goals related to schooling, employment, living situation, relationships, leisure activities, and other aspects of functioning and quality of life. |
| 2. Was a quantitative measure used as part of the initial evaluation to identify and determine the severity of symptoms and impairments of functioning? | □ | □ | □ | □ | □ | __/5 | The use of a quantitative measure as part of the assessment can help detect and determine the severity of psychosis and associated symptoms. Patient self-report ratings and clinician-based ratings can provide a structured replicable way to document baseline symptoms, determine which symptoms should be the target of intervention, and track whether nonpharmacological and pharmacological treatments are having their intended effect or whether a shift in the treatment plan is needed. A number of measures are available, as described in the full text of the guideline. The exact frequency at which measures are warranted will depend on clinical circumstances. |
| 3. Was the patient assessed for current or past tobacco use (including vaping)? | □ | □ | □ | □ | □ | __/5 | The rate of tobacco use is high among individuals with schizophrenia (47–49, 53, 56) and contributes to morbidity and mortality (57, 70–73). Screening to identify tobacco use is a crucial step in educating patients and providing treatment and follow-up using health education, motivational interviewing approaches (74), and smoking cessation guidelines for the general population (73, 75–78). Smoking also induces CYP1A2c and, with cessation (either intentionally or with admission to a smoke-free facility), there will be a corresponding increase in the levels of drugs metabolized via CYP1A2, including clozapine and olanzapine (79). |
| 4. Was the patient screened for use of cannabis, alcohol, and other substances? | □ | □ | □ | □ | □ | __/5 | Screening for use of cannabis, alcohol, and other substances is important because substance use is common (22, 45, 49, 50, 52, 54), can confound assessment of psychotic symptoms, and affect the course of schizophrenia (45, 80–82). It is important to determine whether the patient uses cannabis or other substances such as alcohol, caffeine, cocaine, opioids, sedative-hypnotic agents, stimulants, MDMA,d solvents, androgenic steroids, hallucinogens, or synthetic substances (e.g., “bath salts,” K2, Spice). The route by which substances are used (e.g., ingestion, smoking, vaping, intranasal, intravenous) is similarly important to document. SBIRTe can be integrated into a range of clinical settings (83, 84). In addition, assessment and screening for substance use disorders may include self-report corroborated by other sources such as family, friends, case managers, and treatment personnel and, as indicated, urine and blood toxicology and other tests such as liver function tests. |
| 5. Was the patient assessed for risk of suicide and other self-harming behaviors? | □ | □ | □ | □ | □ | __/5 | Suicidal ideas are common among individuals who have had a psychotic experience (85), and death from suicide has been estimated to occur in about 4%–10% of individuals with schizophrenia (10, 12, 16, 18–20). Thus, it is important to consider the risk of suicide and other self-harming behaviors in initial evaluations and follow-up assessments at all stages of illness. Assessment of the risk for suicidal behaviors typically includes asking the patient and, when possible, the patient’s family about prior suicidal behaviors and current or prior thoughts, plans, or intentions to harm or kill oneself (82). Risk assessment also requires synthesizing information gathered in the history and mental status examination and identifying modifiable risk factors for suicide that can serve as targets of intervention. |
| Patients with schizophrenia share the same risks for suicide fatalities and behaviors as the general population, including male sex, depressive symptoms, hopelessness, expressed suicidal ideation, a history of attempted suicide or other suicide-related behaviors, and the presence of alcohol use disorder or other substance use disorder (20, 86–90). Firearm access is an additional contributor to suicide risk (91–93). | |||||||
| Additional factors that have been identified as increasing risk for suicide among individuals with schizophrenia include auditory command hallucinations, agitation or motor restlessness, fear of mental disintegration, recent loss events, recency of diagnosis or hospitalization, repeated hospitalizations, high intelligence, young age, and poor adherence to treatment (8, 20, 86, 88, 94–96). | |||||||
| Despite identification of these risk factors, it is not possible to predict whether an individual patient will attempt or die by suicide. However, when an increased risk for such behaviors is present, it is important that the treatment plan reevaluate the care setting, address periods of increased risk (e.g., shortly after diagnosis, during incarceration, subsequent to hospital discharge), and implement approaches to target and reduce modifiable risk factors such as poor adherence, core symptoms of schizophrenia (e.g., hallucinations, delusions), co-occurring symptoms (e.g., depression, hopelessness, hostility, impulsivity), and co-occurring diagnoses (e.g., depression, alcohol use disorder, other substance use disorders). | |||||||
| 6. Was the patient assessed for risk of dangerous or aggressive behaviors, including interpersonal aggression and harm to others? | □ | □ | □ | □ | □ | __/5 | Akin to assessment for suicide and other self-harming behaviors, it is important to consider the risk of dangerous or aggressive behaviors in the initial evaluation and follow-up assessments at all stages of illness. Assessment of the risk for aggressive behaviors typically includes asking the patient and, when possible, the patient’s family about current or prior thoughts, plans, or intentions of aggression toward others. Many factors associated with a risk of aggression are similar to findings among individuals without psychosis and include male sex, young age, access to firearms, the presence of substance use, traumatic brain injury, a history of attempted suicide or other suicide-related behaviors, or prior aggressive behavior, including that associated with legal consequences (87, 90, 97–103). Among individuals with psychotic illnesses, prior suicidal threats, angry affect, impulsivity, hostility, recent violent victimization, childhood sexual abuse, medication nonadherence, and a history of involuntary treatment have also been associated with an increased risk of aggressive behavior (90, 97, 102, 103). Command hallucinations can be relevant when assessing individuals for a risk of aggressive behaviors (102, 104), and persecutory delusions may also contribute to aggression risk, particularly in the absence of treatment or in association with significant anger (102, 105, 106). |
| Despite identification of these risk factors, it is not possible to predict whether an individual patient will engage in aggressive behaviors. However, when an increased risk for such behaviors is present, it is important that the treatment plan reevaluate the care setting and implement approaches to target and reduce modifiable risk factors. | |||||||
| 7. Was the patient assessed for co-occurring psychiatric disorders and other co-occurring health conditions? | □ | □ | □ | □ | □ | __/5 | Many individuals with schizophrenia will have co-occurring psychiatric disorders, including SUDsf or other co-occurring health conditions. These disorders may affect treatment options or need to be addressed in the treatment plan. For example, if SUDs are identified, a comprehensive integrated treatment model is suggested to address both conditions. Alternatively, the treatment plan should address both disorders, and there should be communication and collaboration among treating clinicians. For patients who do not recognize the need for treatment of a substance use disorder, a stagewise motivational approach can be used (74, 107). |
| Individuals with schizophrenia may have experienced violent victimization (108–110) or childhood adversity (111–114), and PTSD should be identified and treated, if present (115–117). Depressive symptoms and anxiety are also common among individuals with schizophrenia and should be addressed as part of treatment planning. | |||||||
| Other health conditions are frequent in individuals with serious mental illness in general (8, 26, 118, 119) and those with schizophrenia in particular (120). Such disorders include but are not limited to poor oral health, hepatitis C infection, HIV infection, cancer, sleep apnea, obesity, diabetes mellitus, metabolic syndrome, and cardiovascular disease (8, 15, 26, 27, 121–127). These disorders, if present, can contribute to reduced quality of life or mortality (9–17). Also, some may influence choice of medication or may be induced or exacerbated by psychiatric medications. | |||||||
| Table 1 provides a discussion of suggested physical and laboratory assessments for patients with schizophrenia as part of initial evaluation and follow-up assessments. Such assessments are important to prevention, early recognition, and treatment of abnormalities such as glucose dysregulation, hyperlipidemia, metabolic syndrome, antipsychotic-induced movement disorders, and changes in cardiac conduction. It is also important that patients have access to primary care clinicians who can work with the psychiatrist to diagnose and treat concurrent physical health conditions (82). For women who are planning to become pregnant or who are pregnant or postpartum, it is essential to collaborate with the patient, her obstetrician-gynecologist or other obstetric practitioner, her infant’s pediatrician (if breastfeeding), and, if involved, her partner or other support persons. | |||||||
TABLE 2. Practice Assessment Tool for the Care of Patients With a Diagnosis of Schizophrenia, part 1: assessment of patients meeting diagnostic criteria for schizophreniaa
| Patient | |||||||
|---|---|---|---|---|---|---|---|
| Aspect of care and quality-related action | 1 | 2 | 3 | 4 | 5 | Total no. of patients with check mark in each rowb | Supporting evidence, resources, and clinical issues for consideration |
| 8. Was a comprehensive and person-centered treatment plan developed and documented that includes evidence-based nonpharmacological and pharmacological treatments? | □ | □ | □ | □ | □ | __/5 | In treating individuals with schizophrenia, a person-centered treatment plan should be developed and documented in the medical record. Discussion with the patient, other treating health professionals, family members, and others involved in the patient’s life can each be vital in developing a full picture of the patient and formulating a person-centered treatment plan, using shared decision making whenever possible. The overarching aims of treatment planning are severalfold: to promote and maintain recovery, to maximize quality of life and adaptive functioning, and to reduce or eliminate symptoms. It is essential to consider both nonpharmacological and pharmacological treatment approaches and recognize that a combination of nonpharmacological and pharmacological treatments will likely be needed to optimize outcomes. In addition, strategies to promote adherence are always important to consider in developing a patient-centered treatment plan (128). As treatment proceeds, the treatment plan will require iterative reevaluation and updating prompted by factors such as inadequate treatment response, difficulties with tolerability or adherence, impairments in insight, changes in presenting issues or symptoms, or revisions in diagnosis. Factors that influence medication metabolism (e.g., age, sex, body weight, renal or hepatic function, smoking status, use of multiple concurrent medications) may also require adjustments to the treatment plan, in terms of either typical medication doses or frequency of monitoring. Tailoring of the treatment plan may also be needed on the basis of sociocultural or demographic factors with the aim of enhancing quality of life or aspects of functioning (e.g., social, academic, occupational). Other elements of the treatment plan may include, but are not limited to, determining the most appropriate treatment setting, addressing risks of harm to self or others (if present), engaging family members and others involved in the patient’s life, educating patients and families about treatment options and community resources, collaborating with other treating clinicians, and addressing co-occurring conditions. |
| 9. Was treatment with an antipsychotic medication provided? | □ | □ | □ | □ | □ | __/5 | It is recommended that patients with schizophrenia be treated with an antipsychotic medication and, if symptoms improve, that antipsychotic treatment continue, generally with the same medication. The choice of a particular antipsychotic agent will typically occur in the context of discussion with the patient about the likely benefits and possible side effects of medication options and will incorporate patient preferences, the patient’s past responses to treatment (including symptom response and tolerability), the medication’s side effect profile, the presence of physical health conditions that may be affected by medication side effects, and other medication-related factors such as available formulations, potential for drug-drug interactions, receptor binding profiles, and pharmacokinetic considerations. Tables 3–9 in the full text of the guideline provide details on pharmacological properties of antipsychotic medications and can assist in the choice of an antipsychotic agent. If there is no significant improvement after several weeks of treatment (e.g., <20% improvement in symptoms) or if improvement plateaus before substantial improvement is achieved (e.g., >50% improvement in symptoms, minimal impairment in functioning), consider whether factors are present that would influence treatment response, such as concomitant substance use, rapid medication metabolism, poor medication absorption, interactions with other medications, or other effects on drug metabolism (e.g., smoking) that could affect blood levels of medication. If a patient has had minimal or no response to two trials of antipsychotic medication of two to four weeks duration at an adequate dose (129, 130), a trial of clozapine is recommended (see question 19 in Table 4). |
| 10. Was the patient monitored for changes in blood pressure and pulse during treatment with an antipsychotic medication? | □ | □ | □ | □ | □ | __/5 | For questions 10-13, assessments are needed during treatment to monitor physical status and detect specific side effects of antipsychotic treatment, as outlined in Table 1. In addition to the suggested monitoring frequency described in Table 1, modifications to monitoring frequency will depend on the clinical circumstances of the individual patient and will be influenced by the antipsychotic that is prescribed as well as by the patient’s history, preexisting conditions, and use of other medications in addition to antipsychotic agents. For example, screening for symptoms of hyperprolactinemia may be needed more frequently if the patient is treated with an antipsychotic known to increase prolactin, whereas an ECGc may be indicated with a significant change in dose of chlorpromazine, droperidol, iloperidone, pimozide, thioridazine, or ziprasidone or with the addition of other medications that can affect QTcd interval in patients with cardiac risk factors or elevated baseline QTc intervals. |
| 11. Was the patient monitored for changes in BMIe during treatment with an antipsychotic medication? | □ | □ | □ | □ | □ | __/5 | |
| 12. Was the patient monitored for metabolic syndrome during treatment with an antipsychotic medication? | □ | □ | □ | □ | □ | __/5 | |
| 13. Was the patient monitored for antipsychotic-induced movement disorders (acute dystonia, akathisia, parkinsonism, tardive syndromes) during treatment with an antipsychotic medication? | □ | □ | □ | □ | □ | __/5 | |
| 14. Was CBTpf offered? | □ | □ | □ | □ | □ | __/5 | The use of CBTp for individuals with schizophrenia has several potential benefits, including improvements in quality of life and global, social, and occupational function and reductions in core symptoms of illness, such as positive symptoms. CBTp focuses on guiding patients to develop their own alternative explanations for maladaptive cognitive assumptions, which are healthier and realistic and do not perpetuate the patient’s convictions regarding the veracity of delusional beliefs or hallucinatory experiences. CBTp can be started in any treatment setting, including inpatient settings, and during any phase of illness (131), although some initial reduction in symptoms may be needed for optimal participation. It can also be conducted in group and individual formats, either in person or via Web-based delivery platforms. At organizational or health system levels, attention to enhancing the availability of CBTp is important given the limited availability of CBTp in the United States. |
| 15. Was patient psychoeducation provided? | □ | □ | □ | □ | □ | __/5 | Elements of psychoeducation are an integral part of good clinical practice and include providing the patient with education about the differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment (82). More formal psychoeducation is also recommended, in either an individual or a group format, often in conjunction with family members or other individuals who are involved in the patient’s life. Typically, psychoeducation involves approximately 12 sessions and incorporates multiple educational modalities such as workbooks (132), pamphlets, videos, and individual or group discussions to achieve its goals. Information commonly conveyed in a psychoeducation program includes key information about diagnosis, symptoms, psychosocial interventions, medications, and side effects as well as information about stress and coping, crisis plans, early warning signs, and suicide and relapse prevention (133). Information that may be useful to patients and families as a part of psychoeducation is available through SMI Adviser (smiadviser.org/). |
| 16. Was the patient offered family interventions? | □ | □ | □ | □ | □ | __/5 | An important aspect of good psychiatric treatment is involvement of family members, support persons, and other individuals who play a key role in the patient’s life. These individuals include spouses, parents, children, or other biological or nonbiological relatives; people who reside with the patient; intimate partners; or close friends who are an integral part of the patient’s support network. Such individuals benefit from discussion of topics such as diagnosis and management of schizophrenia, types of support that are available, and ways to plan for and access help in a crisis. Other goals include helping individuals repair or strengthen their connections with family members and other members of their support system. |
| Most patients want family to be involved in their treatment (134). However, even when a patient does not want a specific person to be involved in the patient’s care, the clinician may listen to information provided by that individual, as long as confidential information is not provided to the informant (82). General information that is not specific to the patient can be provided (e.g., common approaches to treatment, general information about medications and their side effects, available support and emergency assistance). Also, to prevent or lessen a serious and imminent threat to the health or safety of the patient or others, the Principles of Medical Ethics (135) and HIPAAg (136, 137) permit clinicians to disclose necessary information about a patient to family members, caregivers, law enforcement, or other persons involved with the patient. HIPAA also permits health care providers to disclose necessary information to the patient’s family, friends, or other persons involved in the patient’s care or payment for care when such disclosure is judged to be in the best interests of the patient and the patient is not present or is unable to agree or object to a disclosure because of incapacity or emergency circumstances (137). | |||||||
| Family interventions go beyond the basics of family involvement and illness education that are important for good clinical care. Family interventions can be delivered in a variety of formats and approaches (138, 139) and have the greatest benefits when more than 10 treatment sessions are systematically delivered over a period of at least seven months (138). They may include structured approaches to problem solving, training in how to cope with illness symptoms, assistance with improving family communication, provision of emotional support, and strategies for reducing stress and enhancing social support networks (138–140). Guidance is available on developing family intervention programs focused on psychoeducation (141, 142). In addition, the National Alliance on Mental Illness has the Family-to-Family program, which has led to a significant expansion in the availability of family interventions (143, 144). | |||||||
| 17. Were self-management skills and recovery-focused interventions offered? | □ | □ | □ | □ | □ | __/5 | Illness self-management training programs have been applied to help address many chronic conditions and are designed to improve knowledge about one’s illness and management of symptoms (145). Goals include reducing the risk of relapse, recognizing signs of relapse, developing a relapse prevention plan, and enhancing coping skills to address persistent symptoms with the aim of improving quality of life and social and occupational functioning. Evidence suggests better outcomes among patients who participate in at least 10 self-management intervention sessions. Self-management sessions are typically facilitated by clinicians, although peer-facilitated sessions have also been used. In addition, individually targeted interventions, either face to face or via computer-based formats (146), have been used. |
| Recovery-focused interventions have also been developed that focus on fostering self-determination in relation to a patient’s personal goals, needs, and strengths. Such approaches may include elements of self-management skill development, psychoeducation, and peer-based interventions but also include components and activities that allow participants to share experiences and receive support, learn and practice strategies for success, and identify and take steps toward reaching personal goals. | |||||||
| A tool kit for developing illness management and recovery-based programs in mental health is available (147). Other available resources are also described in the full text of the guideline and at SMI Adviser (smiadviser.org/individuals-families). | |||||||
| 18. Were supported employment services offered? | □ | □ | □ | □ | □ | __/5 | Evidence consistently shows that supported employment is associated with a greater rate of competitive employment. Other benefits of supportive employment include greater number of hours worked per week, a longer duration of each job, a longer duration of total employment, and an increase in earnings (138). Individuals receiving supported employment are also more likely to obtain job-related accommodations than individuals with mental illness who are not receiving supported employment (148). Such accommodations typically relate to support from the supported employment coach but may also include flexible scheduling, reduced hours, modified job duties, and modified training and supervision. |
| Supported employment differs from other vocational rehabilitation services in providing assistance in searching for and maintaining competitive employment concurrently with job training, embedded job support, and mental health treatment (149–151). For individuals whose goals are related to educational advancement before pursuit of employment, supported educational services may also be pursued (152). | |||||||
| For clinicians and organizations that want to learn more about supported employment or develop supported employment programs, additional information is available through SMI Adviser (smiadviser.org/), Navigate (navigateconsultants.org/manuals/), and the Boston University Center for Psychiatric Rehabilitation (cpr.bu.edu/). | |||||||
TABLE 3. Practice Assessment Tool for the Care of Patients With a Diagnosis of Schizophrenia, part 2: treatment of patients meeting diagnostic criteria for schizophreniaa
| Patient | |||||||
|---|---|---|---|---|---|---|---|
| Aspect of care and quality-related action | 1 | 2 | 3 | 4 | 5 | Total no. of patients with check marks OR circled NAs in each rowb | Supporting evidence, resources, and clinical issues for consideration |
| 19. Clozapine, for individuals with treatment-resistant symptoms | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Clozapine should be offered to individuals with schizophrenia who have treatment-resistant schizophrenia because its use is associated with a higher rate of treatment response, reduction in psychotic symptoms, and lower rates of all-cause mortality, hospitalization, and treatment discontinuation resulting from lack of efficacy (138). A common definition of treatment-resistant schizophrenia is that a patient’s symptoms have shown no response or partial and suboptimal response to two antipsychotic medication trials of at least six weeks each at an adequate dose of medication, and some definitions specify using medications from different classes (e.g., second-generation antipsychotic vs. first-generation antipsychotic). However, if there is no significant improvement after several weeks of treatment (e.g., <20% improvement in symptoms), the likelihood of substantial improvement (e.g., >50% improvement in symptoms) is small (129, 130), and a longer trial of the medication may not be warranted. It should also be noted that a medication trial cannot be viewed as adequate if it is truncated in terms of duration or dosage because of poor tolerability or if limited by poor adherence. |
| 20. Clozapine, for individuals with a substantial risk for suicide attempts or suicide despite other treatments | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Regardless of whether criteria for treatment-resistant schizophrenia are met, clozapine should be offered to individuals with schizophrenia who have substantial risk for suicide attempts or suicide despite other treatments because clozapine use is associated with lower rates of self-harm, suicide attempts, and hospitalizations to prevent suicide (138). |
| 21. Clozapine, for individuals with a substantial risk for aggressive behavior despite other treatments | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Although evidence is less robust than for use of clozapine for treatment-resistant schizophrenia or persistent risk of suicide, treatment with clozapine can also be effective in reducing aggressive behavior. As in other circumstances in which patients do not appear to be responding fully to treatment, attention to adherence is crucial. |
| 22. An LAIc antipsychotic, for individuals with a history of poor or uncertain adherence, or a preference for LAI treatment | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | An LAI formulation of an antipsychotic medication is suggested for individuals with schizophrenia who prefer LAI medication or have a history of poor or uncertain adherence. In addition to patients who have had difficulty in adhering to oral medications, this may include individuals who have limited awareness of having an illness, who have not responded to treatment with an oral medication, who have a history of frequent relapses on oral medication, or who are transitioning between treatment settings where adherence may be difficult. Although randomized controlled trials do not show evidence of benefit from LAIs relative to oral antipsychotic medications, observational data from nationwide registry databases, cohort studies, and “mirror image” studies suggest that use of LAI antipsychotic agents as compared with oral antipsychotic medications is associated with a decreased risk of mortality, reduced risk of hospitalization, and decreased rates of study discontinuation, including discontinuation due to inefficacy (153–158). Thus, the benefits associated with use of an LAI formulation of an antipsychotic medication are at least as good as the benefits of an oral formulation and may be better, with no significant differences in side effects between oral and LAI formulations. |
| 23. Anticholinergic medications, for individuals with acute dystonia associated with antipsychotic therapy | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Clinical experience suggests that acute dystonia can be ameliorated by administration of diphenhydramine, a histamine receptor antagonist with anticholinergic properties. Typically, it is administered intramuscularly to treat acute dystonia, but it can also be administered intravenously in emergent situations, as with acute dystonia associated with laryngospasm. Alternatively, benztropine can be administered intramuscularly. Once the acute dystonia has resolved, it may be necessary to continue an oral anticholinergic medication such as benztropine or trihexyphenidyl to prevent recurrence, at least until other changes in medications can take place, such as reducing the dose of medication or changing to an antipsychotic medication that is less likely to be associated with acute dystonia. Whenever an anticholinergic medication is prescribed, it is important to be mindful of the potential for medication side effects and interactions with other medications that a patient is taking. |
| 24. Medication changes, for individuals with parkinsonism associated with antipsychotic therapy | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | For patients who have parkinsonism associated with antipsychotic therapy, the following options can be considered: lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, or treating with an anticholinergic medication. However, before reducing the dose of medication or changing to another antipsychotic medication, the benefits of reduced parkinsonism should be weighed against the potential for an increase in psychotic symptoms. The use of an anticholinergic medication is another option, either on a short-term basis, until a change in dose or a change in medication can occur, or on a longer term basis, if a change in dose or change in medication is not feasible. It should be noted that different symptoms of parkinsonism (e.g., rigidity, tremors, akinesia) may have a differential response to anticholinergic medications, and different treatment approaches may be needed to address each of these symptoms. If an anticholinergic medication is prescribed, it is important to be mindful of the potential for medication side effects and interactions with other medications that a patient is taking. |
| 25. Medication changes, for individuals with akathisia associated with antipsychotic therapy | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | For patients who have akathisia associated with antipsychotic therapy, the following options can be considered: lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine medication, or adding a beta-adrenergic blocking agent. In contrast, akathisia tends not to respond to anticholinergic agents (159). Before reducing the dose of medication or changing to another antipsychotic medication, the benefits of reduced akathisia should be weighed against the potential for an increase in psychotic symptoms. In addition, it is important to assess for dysphoria, which may be associated with akathisia, and to distinguish between akathisia and restlessness or agitation associated with anxiety or psychosis. |
| 26. VMAT2d medications, for individuals with moderate to severe or disabling tardive dyskinesia | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Evaluation for the presence of tardive syndromes is important to identify them, minimize worsening, and institute clinically indicated treatment. Regular assessment of patients for tardive syndromes through clinical examination or use of a structured evaluative tool (e.g., AIMS, DISCUSe) can aid in identifying tardive syndromes, clarifying their likely etiology, monitoring their longitudinal course, and determining the effects of medication changes or treatments for tardive dyskinesia (see Table 1). If no contributing etiology is identified, as discussed in the full text of the guideline, and moderate to severe or disabling tardive dyskinesia persists, treatment is recommended with a reversible VMAT2 inhibitor. Treatment with a VMAT2 inhibitor can also be considered for patients with mild tardive dyskinesia on the basis of factors such as patient preference, associated impairment, or effect on psychosocial functioning. In general, deutetrabenazine or valbenazine are preferred over tetrabenazine because of the greater evidence base supporting their use. However, tetrabenazine and deutetrabenazine are contraindicated for individuals with hepatic impairment, whereas valbenazine is not recommended for use with individuals with severe renal impairment. In addition, anticholinergic medications are not helpful and may worsen tardive dyskinesia (160). |
| 27. CSCf program (e.g., NAVIGATE/RAISE), for individuals experiencing a first episode of psychosis | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | CSC programs, which are sometimes referred to as team-based, multicomponent interventions, provide a comprehensive package of treatment that integrates collaborative, shared decision making with approaches such as family involvement and education, individual resiliency training, supported employment and education, and individualized medication treatment (161, 162). Similar CSC programs have also been used for treatment of early psychosis (163–165). When CSC programs are unavailable, advocacy may be needed to encourage program development; materials are available to help guide the establishment of new programs with evidence-based approaches (162, 166, 167). |
| 28. ACT,g for individuals with a history of poor engagement with services leading to frequent relapse or social disruption (e.g., homelessness, legal issues) | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | ACT is a multidisciplinary, team-based approach in which patients receive personalized and flexible care outside of a formal clinical setting with the aim of addressing patients’ needs and preferences without time limits or other constraints on services. Because availability of ACT programs is often limited, advocacy may be needed to encourage program development and high fidelity to ACT program standards (168–171). |
| 29. Supportive psychotherapy, for individuals who are not able to receive or prefer not to receive an evidence-based psychotherapy for psychosis | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Supportive psychotherapy is commonly a part of the treatment plan for individuals with schizophrenia who are not receiving other modes of psychotherapy (e.g., CBTph). Supportive psychotherapy commonly aims to help patients cope with symptoms, improve adaptive skills, and enhance self-esteem. Examples of techniques used to foster these goals include reassurance, praise, encouragement, explanation, clarification, reframing, guidance, suggestion, and use of a conversational, nonconfrontational style of communication. Many of the common elements that have been identified in effective psychotherapies, including a positive therapeutic alliance, are also integral to supportive psychotherapy (172, 173). Because the evidence related to its benefits is limited, supportive psychotherapy should not take precedence over other evidence-based psychosocial treatments (e.g., coordinated specialty care, CBTp, psychoeducation). |
| 29. Cognitive remediation, for individuals with cognitive difficulties | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Cognitive remediation approaches are intended to address cognitive difficulties that can accompany schizophrenia with the aim of enhancing function and quality of life. A number of different cognitive remediation approaches have been used, typically in group- or computer-based formats, in an effort to enhance cognitive processes such as attention, memory, executive function, social cognition, or meta‐cognition (174–178). Some programs add aspects of social and communication skills to neurocognitive elements of remediation (179). The primary barriers to use of cognitive remediation are related to program availability. Advocacy may be needed to encourage program development (174, 178). Web-based programs have been used in clinical trials and may provide options for patients without access to in-person programs (180, 181). |
| 30. Social skills training, for individuals who have a therapeutic goal of enhanced social functioning | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Social skills training has an overarching goal of improving interpersonal and social skills, but it can also improve core illness symptoms and negative symptoms more than usual care (138). Social skills training can include cognitive-behavioral, social-cognitive, interpersonal, and functional adaptive skills training (55, 182, 183). It is delivered in a group format and includes homework assignments to facilitate skill acquisition. In some social skills training programs, group sessions are augmented with video or technologically based interventions, community trips to practice social skills (184, 185), and involvement of support people who are accessible, pleasant, and knowledgeable about the local environment’s resources and limitations (185, 186). Advocacy may be needed to encourage program development; information about social skills training is available for organizations that want to develop such programs (187–189). |
TABLE 4. Practice Assessment Tool for the Care of Patients With a Diagnosis of Schizophrenia, part 3: treatments indicated for patient-specific needs or circumstancesa
The left column of the tool inquires whether a specific quality-related action was taken. The middle portion of the tool provides checkboxes to record whether the action was taken for up to five patients who are being reviewed. It is important to note that the American Board of Psychiatry and Neurology MOC IV program requires review of at least five patients as part of each PIP unit; however, larger samples will provide a more accurate estimate of the quality of care within a practice. The last column of the tool provides guideline-supported recommendations and clinical resources to assist in identifying knowledge gaps and engaging in practice improvement efforts.
After using the PIP tool to assess the pattern of care provided to patients, the physician should determine whether specific aspects of care need to be improved. Assessment and treatment recommendations provided in the practice guidelines are generally intended to be relevant to the majority of individuals. However, patients vary widely in their preferences for treatment, clinical presentation, history of treatment and prior response, presence of co-occurring physical and psychiatric conditions, and other factors that may influence clinical decision making. Because patients with schizophrenia have high levels of complex symptomatology and co-occurring psychiatric and other medical comorbidities, divergence from evidence-based recommendations may occur. Deviations from guidelines may also arise when recommended treatments have been tried but have not led to full response of symptoms or return to baseline levels of functioning. In addition, practice guidelines and quality indicators are often derived from findings of efficacy and effectiveness trials in which stringent enrollment criteria are used; thus, individuals in clinical trials often differ in important ways from those seen in routine clinical practice. Although this tool is intended to highlight current evidence-based assessment and treatment recommendations for patients with schizophrenia, justifiable variations from recommended care may occur.
Guided by the PIP tool findings and a subsequent practice assessment, physicians may determine that deviations from the quality indicators are clinically appropriate and justified, or they may choose to acquire new knowledge and modify their practice to improve quality. For example, if patients with schizophrenia in a physician’s current psychiatric caseload are not routinely screened for tobacco or other substance use, an area for improvement could involve implementation of systematic screening for alcohol and tobacco use, which is especially common among patients with schizophrenia. Use of the PIP tool may also highlight potential treatment service gaps, which may include, for example, lack of availability of cognitive-behavioral therapy for psychosis, assertive community treatment, substance use treatment services, or supported employment programs. It is hoped that this tool, together with the evidence-based guideline, may be useful in optimizing use of evidence-based treatment and advocating for increased availability of critically needed core services to help improve the lives and functioning of individuals with schizophrenia.
1 Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC, American Psychiatric Publishing, 2013Google Scholar
2 : Prevalence and medical costs of chronic diseases among adult Medicaid beneficiaries. Am J Prev Med. 2017;53(6S2):S143-s54Crossref, Google Scholar
3 : The societal cost of schizophrenia: a systematic review. Pharmacoeconomics 2017; 35:25–42Crossref, Google Scholar
4 : The economic burden of schizophrenia in the United States in 2013. J Clin Psychiatry 2016; 77:764–771Crossref, Google Scholar
5 : Individual-level predictors for becoming homeless and exiting homelessness: a systematic review and meta-analysis. J Urban Health 2019; 96:741–750Crossref, Google Scholar
6 : Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry 2005; 162:370–376Crossref, Google Scholar
7 : Understanding and treating offenders with serious mental illness in public sector mental health. Behav Sci Law 2017; 35:303–318Crossref, Google Scholar
8 : Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:1789–1858Crossref, Google Scholar
9 : Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000-2014. Br J Psychiatry 2017; 211:175–181Crossref, Google Scholar
10 : Mortality among patients with schizophrenia and reduced psychiatric hospital care. Psychol Med 2005; 35:725–732Crossref, Google Scholar
11 : Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. Lancet Psychiatry 2017; 4:295–301Crossref, Google Scholar
12 : Excess early mortality in schizophrenia. Annu Rev Clin Psychol 2014; 10:425–448Crossref, Google Scholar
13 : A widening longevity gap between people with schizophrenia and general population: a literature review and call for action. Schizophr Res 2018; 196:9–13Crossref, Google Scholar
14 : Increased mortality among people with schizophrenia and other non-affective psychotic disorders in the community: a systematic review and meta-analysis. J Psychiatr Res 2018; 102:245–253Crossref, Google Scholar
15 : Premature mortality among adults with schizophrenia in the United States. JAMA Psychiatry 2015; 72:1172–1181Crossref, Google Scholar
16 : Mortality in schizophrenia: 30-year nationwide follow-up study. Acta Psychiatr Scand 2018; 138:492–499Crossref, Google Scholar
17 : Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry 2015; 72:334–341Crossref, Google Scholar
18 : The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry 2005; 62:247–253Crossref, Google Scholar
19 : OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis. One-year follow-up of a randomised controlled trial. Br J Psychiatry Suppl 2002; 43:s98–s106Crossref, Google Scholar
20 : Risk factors for suicide in schizophrenia: systematic review and clinical recommendations. Acta Psychiatr Scand 2014; 130:418–426Crossref, Google Scholar
21 : Exploring comorbidity within mental disorders among a Danish national population. JAMA Psychiatry 2019; 76:259–270Crossref, Google Scholar
22 : Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990-2017: systematic review and meta-analysis. Drug Alcohol Depend 2018; 191:234–258Crossref, Google Scholar
23 : Inequalities in lung cancer care of elderly patients with schizophrenia: an observational cohort study. Psychosom Med 2014; 76:215–220Crossref, Google Scholar
24 : Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 2011; 10:52–77Crossref, Google Scholar
25 : Mental disorders and use of cardiovascular procedures after myocardial infarction. JAMA 2000; 283:506–511Crossref, Google Scholar
26 : Review of the evidence: prevalence of medical conditions in the United States population with serious mental illness. Gen Hosp Psychiatry 2015; 37:199–222Crossref, Google Scholar
27 : Cancer-related mortality in people with mental illness. JAMA Psychiatry 2013; 70:209–217Crossref, Google Scholar
28 : Inequitable access for mentally ill patients to some medically necessary procedures. CMAJ 2007; 176:779–784Crossref, Google Scholar
29 : Association of secondary preventive cardiovascular treatment after myocardial infarction with mortality among patients with schizophrenia. JAMA Psychiatry 2018; 75:1234–1240Crossref, Google Scholar
30 : The epidemiology of excess mortality in people with mental illness. Can J Psychiatry 2010; 55:752–760Crossref, Google Scholar
31 : Promoting physical health for people with schizophrenia by reducing disparities in medical and dental care. Acta Psychiatr Scand 2015; 132:109–121Crossref, Google Scholar
32 : Twelve-month health care use and mortality in commercially insured young people with incident psychosis in the United States. Schizophr Bull 2017; 43:1262–1272Crossref, Google Scholar
33 : Conformance to evidence-based treatment recommendations in schizophrenia treatment services. Can J Psychiatry 2012; 57:317–323Crossref, Google Scholar
34 : International trends in clozapine use: a study in 17 countries. Acta Psychiatr Scand 2017; 136:37–51Crossref, Google Scholar
35 : An initiative to improve clozapine prescribing in New York state. Psychiatr Serv 2016; 67:369–371Crossref, Google Scholar
36 : Community adherence to schizophrenia treatment and safety monitoring guidelines. J Nerv Ment Dis 2014; 202:6–12Crossref, Google Scholar
37 : Clozapine for schizophrenia: State variation in evidence-based practice. Psychiatr Serv 2016; 67:152Crossref, Google Scholar
38 : Geographic and clinical variation in clozapine use in the United States. Psychiatr Serv 2014; 65:186–192Link, Google Scholar
39 : Prescribing of clozapine and antipsychotic polypharmacy for schizophrenia in a large Medicaid program. Psychiatr Serv 2017; 68:579–586Crossref, Google Scholar
40 : State and demographic variation in use of depot antipsychotics by Medicaid beneficiaries with schizophrenia. Psychiatr Serv 2014; 65:121–124Link, Google Scholar
41 : The use of long-acting injectable antipsychotics in schizophrenia: evaluating the evidence. J Clin Psychiatry 2016; 77(Supplement 3):1–24Crossref, Google Scholar
42 : Racial differences in antipsychotic use: claims database analysis of Medicaid-insured patients with schizophrenia. Ann Clin Psychiatry 2015; 27:242–252Google Scholar
43 : Antipsychotic utilization patterns among patients with schizophrenic disorder: a cross-national analysis in four countries. Eur J Clin Pharmacol 2019; 75:1005–1015Crossref, Google Scholar
44 : Monitoring metabolic side effects when initiating treatment with second-generation antipsychotic medication. Clin Schizophr Relat Psychoses 2012; 5:201–207Crossref, Google Scholar
45 : Demographic and clinical correlates of substance use disorders in first episode psychosis. Schizophr Res 2018; 194:4–12Crossref, Google Scholar
46 : Psychiatric comorbidities and schizophrenia. Schizophr Bull 2009; 35:383–402Crossref, Google Scholar
47 : Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation. JAMA 2014; 311:172–182Crossref, Google Scholar
48 : Cigarette smoking by patients with serious mental illness, 1999-2016: an increasing disparity. Psychiatr Serv 2018; 69:147–153Crossref, Google Scholar
49 : Comorbidity of severe psychotic disorders with measures of substance use. JAMA Psychiatry 2014; 71:248–254Crossref, Google Scholar
50 : Rate of cannabis use disorders in clinical samples of patients with schizophrenia: a meta-analysis. Schizophr Bull 2010; 36:1115–1130Crossref, Google Scholar
51 : Comorbidity of axis I and II mental disorders with schizophrenia and psychotic disorders: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Can J Psychiatry 2009; 54:477–486Crossref, Google Scholar
52 : Substance use disorders in schizophrenia, bipolar disorder, and depressive illness: a registry-based study. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1267–1276Crossref, Google Scholar
53 : Smoking and mental illness in the U.S. population. Tob Control 2014; 23(e2):e147–e153Crossref, Google Scholar
54 : Prevalence of substance use disorders in psychiatric patients: a nationwide Danish population-based study. Soc Psychiatry Psychiatr Epidemiol 2016; 51:129–140Crossref, Google Scholar
55 : Social skills programmes for schizophrenia. Cochrane Database Syst Rev 2015; 6:
56 Tobacco Use Among Adults With Mental Illness and Substance Use Disorders. Atlanta, GA, Centers for Disease Control and Prevention. www.cdc.gov/tobacco/disparities/mental-illness-substance-use/index.htm. Accessed Dec 31, 2018Google Scholar
57 The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA, Centers for Disease Control and Prevention, 2014. www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm. Accessed Dec 29, 2018Google Scholar
58 : Guideline concordant monitoring of metabolic risk in people treated with antipsychotic medication: systematic review and meta-analysis of screening practices. Psychol Med 2012; 42:125–147Crossref, Google Scholar
59 : Metabolic screening after the American Diabetes Association’s consensus statement on antipsychotic drugs and diabetes. Diabetes Care 2009; 32:1037–1042Crossref, Google Scholar
60 : The current state of behavioral health quality measures: where are the gaps? Psychiatr Serv 2015; 66:865–871Link, Google Scholar
61 : Quality measures for mental health and substance use: gaps, opportunities, and challenges. Health Aff (Millwood) 2016; 35:1000–1008Crossref, Google Scholar
62 : Patterns and quality of treatment for patients with schizophrenia in routine psychiatric practice. Psychiatr Serv 2005; 56:283–291Crossref, Google Scholar
63 : Stepped care as an implementation and service delivery model for cognitive behavioral therapy for psychosis. Community Ment Health J 2019; 55:755–767Crossref, Google Scholar
64 Improvement Activities Requirements. Woodlawn, MD, Centers for Medicare & Medicaid Services, qpp.cms.gov/mips/improvement-activities. Accessed Mar 29, 2020Google Scholar
65 : Performance in practice: physician practice assessment tool for the care of adults with schizophrenia. Focus 2012; 10:157–171Link, Google Scholar
66 Practice Guidelines for the Treatment of Patients with Schizophrenia, 3rd ed. Washington, DC, American Psychiatric Association Publishing, 2020Google Scholar
67 : Treatment engagement of individuals experiencing mental illness: review and update. World Psychiatry 2016; 15:13–20Crossref, Google Scholar
68 : Why and how family caregivers should participate in shared decision making in mental health. Psychiatr Serv 2019; 70:418–421Crossref, Google Scholar
69 SAMHSA’s Working Definition of Recovery: 10 Guiding Principles of Recovery. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2012. store.samhsa.gov/system/files/pep12-recdef.pdf. Accessed Aug 3, 2019Google Scholar
70 : Cigarette smoking and all-cause and cause-specific adult mortality in the United States. Demography 2018; 55:1855–1885Crossref, Google Scholar
71 : Mortality rates and excess death rates for the seriously mentally ill. J Insur Med 2018; 47:212–219Crossref, Google Scholar
72 : Smoking and the reduced life expectancy of individuals with serious mental illness. Am J Prev Med 2016; 51:958–966Crossref, Google Scholar
73 : Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG. NPJ Prim Care Respir Med 2017; 27:38Crossref, Google Scholar
74 : Motivational Interviewing for Clinical Practice. Washington, DC, American Psychiatric Publishing, 2017Crossref, Google Scholar
75 Quit Smoking. Bethesda, MD, National Cancer Institute, https://smokefree.gov/quit-smoking. Accessed Dec 31, 2018Google Scholar
76 Tobacco Cessation. Rockville, MD, Center of Excellence for Integrated Health Solutions, 2020Google Scholar
77 ; Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015; 163:622–634Crossref, Google Scholar
78 : National guidelines for smoking cessation in primary care: a literature review and evidence analysis. NPJ Prim Care Respir Med 2017; 27:2Crossref, Google Scholar
79 : Pharmacokinetic drug interactions with tobacco, cannabinoids and smoking cessation products. Clin Pharmacokinet 2016; 55:1353–1368Crossref, Google Scholar
80 : Rates and predictors of 18-months remission in an epidemiological cohort of 661 patients with first-episode psychosis. Soc Psychiatry Psychiatr Epidemiol 2017; 52:1089–1099Crossref, Google Scholar
81 : The effect of substance use on 10-year outcome in first-episode psychosis. Schizophr Bull 2017; 43:843–851Crossref, Google Scholar
82 Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd ed. Arlington, VA, American Psychiatric Association Publishing, 2016Google Scholar
83 : Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. J Psychoactive Drugs 2012; 44:307–317Crossref, Google Scholar
84 SBIRT: Screening, Brief Intervention, and Referral to Treatment. Rockville, MD, Center of Excellence for Integrated Health SolutionsGoogle Scholar
85 : Association between psychotic experiences and subsequent suicidal thoughts and behaviors: a cross-national analysis from the World Health Organization World Mental Health surveys. JAMA Psychiatry 2017; 74:1136–1144Crossref, Google Scholar
86 : Risk factors for suicidality in patients with schizophrenia: a systematic review, meta-analysis, and meta-regression of 96 studies. Schizophr Bull 2018; 44:787–797Crossref, Google Scholar
87 : Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: a 38-year total population study in Sweden. Lancet Psychiatry 2014; 1:44–54Crossref, Google Scholar
88 : Completed and attempted suicides among 18,154 subjects with schizophrenia included in a large simple trial. J Clin Psychiatry 2014; 75:e184–e190Crossref, Google Scholar
89 : Associations between substance use disorders and suicide or suicide attempts in people with mental illness: a Danish nation-wide, prospective, register-based study of patients diagnosed with schizophrenia, bipolar disorder, unipolar depression or personality disorder. Addiction 2017; 112:1250–1259Google Scholar
90 : The relationship between suicide and violence in schizophrenia: analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) dataset. Schizophr Res 2014; 154:61–67Crossref, Google Scholar
91 : Weaker gun state laws are associated with higher rates of suicide secondary to firearms. J Surg Res 2018; 221:135–142Crossref, Google Scholar
92 : The association between gun ownership and statewide overall suicide rates. Suicide Life Threat Behav 2018; 48:204–217Crossref, Google Scholar
93 : Firearm ownership and suicide rates among US men and women, 1981-2013. Am J Public Health 2016; 106:1316–1322Crossref, Google Scholar
94 : Suicide attempts in schizophrenia: the role of command auditory hallucinations for suicide. J Clin Psychiatry 2003; 64:871–874Crossref, Google Scholar
95 : Acute risk of suicide and suicide attempts associated with recent diagnosis of mental disorders: a population-based, propensity score-matched analysis. Can J Psychiatry 2014; 59:531–538Crossref, Google Scholar
96 : Command hallucinations and clinical characteristics of suicidality in patients with psychotic spectrum disorders. Compr Psychiatry 2013; 54:611–617Crossref, Google Scholar
97 : Correlates of future violence in people being treated for schizophrenia. Am J Psychiatry 2019; 176:694–701Crossref, Google Scholar
98 : Schizophrenia and violence: systematic review and meta-analysis. PLoS Med 2009; 6:
99 : Prevalence and risk of violent ideation and behavior in serious mental illnesses: an analysis of 63,572 patient records. J Interpers Violence (Epub March 13, 2018). Google Scholar
100 : Triggers for violent criminality in patients with psychotic disorders. JAMA Psychiatry 2016; 73:796–803Crossref, Google Scholar
101 : A novel approach to determining violence risk in schizophrenia: developing a stepped strategy in 13,806 discharged patients. PLoS One 2012; 7:
102 : A national study of violent behavior in persons with schizophrenia. Arch Gen Psychiatry 2006; 63:490–499Crossref, Google Scholar
103 : Risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies. PLoS One 2013; 8:
104 : The relationship between command hallucinations and violence. Psychiatr Serv 2000; 51:1288–1292Crossref, Google Scholar
105 : The relationship between delusions and violence: findings from the East London first episode psychosis study. JAMA Psychiatry 2013; 70:465–471Crossref, Google Scholar
106 : Association of violence with emergence of persecutory delusions in untreated schizophrenia. Am J Psychiatry 2014; 171:332–339Crossref, Google Scholar
107 : A randomized trial of motivational interviewing: cessation induction among smokers with low desire to quit. Am J Prev Med 2016; 50:573–583Crossref, Google Scholar
108 : Prevalence rate and risk factors of victimization in adult patients with a psychotic disorder: a systematic review and meta-analysis. Schizophr Bull 2019; 45:114–126Crossref, Google Scholar
109 : Sociodemographic, clinical and childhood correlates of adult violent victimisation in a large, national survey sample of people with psychotic disorders. Soc Psychiatry Psychiatr Epidemiol 2016; 51:269–279Crossref, Google Scholar
110 : Criminal behavior and victimization among homeless individuals with severe mental illness: a systematic review. Psychiatr Serv 2014; 65:739–750Link, Google Scholar
111 : Prevalence of self-reported childhood abuse in psychosis: a meta-analysis of retrospective studies. Psychiatry Res 2013; 210:8–15Crossref, Google Scholar
112 : Environmental adversities and psychotic symptoms: the impact of timing of trauma, abuse, and neglect. Schizophr Res 2019; 205:4–9Crossref, Google Scholar
113 : The impact of childhood adversity on the persistence of psychotic symptoms: a systematic review and meta-analysis. Psychol Med 2015; 45:2481–2498Crossref, Google Scholar
114 : Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophr Bull 2012; 38:661–671Crossref, Google Scholar
115 : Do trauma-focussed psychological interventions have an effect on psychotic symptoms? A systematic review and meta-analysis. Schizophr Res 2018; 195:13–22Crossref, Google Scholar
116 : Current and potential pharmacological and psychosocial interventions for anxiety symptoms and disorders in patients with schizophrenia: structured review. Hum Psychopharmacol (Epub Aug 15, 2017).Google Scholar
117 : Psychological interventions for post-traumatic stress disorder (PTSD) in people with severe mental illness. Cochrane Database Syst Rev 2017; 1:
118 : The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry 2019; 6:675–712Crossref, Google Scholar
119 : Interventions to address medical conditions and health-risk behaviors among persons with serious mental illness: a comprehensive review. Schizophr Bull 2016; 42:96–124Google Scholar
120 : Pathophysiological mechanisms of increased cardiometabolic risk in people with schizophrenia and other severe mental illnesses. Lancet Psychiatry 2015; 2:452–464Crossref, Google Scholar
121 : Hepatitis C treatment: clinical issues for psychiatrists in the post-interferon era. Psychosomatics 2017; 58:1–10Crossref, Google Scholar
122 : The prevalence and predictors of type two diabetes mellitus in people with schizophrenia: a systematic review and comparative meta-analysis. Acta Psychiatr Scand 2015; 132:144–157Crossref, Google Scholar
123 : The prevalence and predictors of obstructive sleep apnea in major depressive disorder, bipolar disorder and schizophrenia: a systematic review and meta-analysis. J Affect Disord 2016; 197:259–267Crossref, Google Scholar
124 : Diabetes mellitus in people with schizophrenia, bipolar disorder and major depressive disorder: a systematic review and large scale meta-analysis. World Psychiatry 2016; 15:166–174Crossref, Google Scholar
125 : Risk of metabolic syndrome and its components in people with schizophrenia and related psychotic disorders, bipolar disorder and major depressive disorder: a systematic review and meta-analysis. World Psychiatry 2015; 14:339–347Crossref, Google Scholar
126 : The oral health of people with chronic schizophrenia: a neglected public health burden. Aust N Z J Psychiatry 2016; 50:685–694Crossref, Google Scholar
127 : Primary and secondary HIV prevention among persons with severe mental illness: recent findings. Curr HIV/AIDS Rep 2015; 12:406–412Crossref, Google Scholar
128 : Psychopharmacology; in The American Psychiatric Association Publishing Textbook of Psychiatry, 7th ed. Edited by Roberts LW. Washington, DC, American Psychiatric Association Publishing, 2019Google Scholar
129 : Treatment-resistant schizophrenia: Treatment Response and Resistance In Psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. Am J Psychiatry 2017; 174:216–229Crossref, Google Scholar
130 : Early improvement as a predictor of later response to antipsychotics in schizophrenia: A diagnostic test review. Am J Psychiatry 2015; 172:617–629Crossref, Google Scholar
131 : Cognitive behavior therapy for schizophrenia. Am J Psychiatry 2006; 163:365–373Crossref, Google Scholar
132 McCrary KJ, Weiden PJ, Gever MP: Schizophrenia: Understanding Your Illness. www.floridasdc4.com/01_understanding.pdf. Accessed March 30, 2019Google Scholar
133 : Psychoeducation: a basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophr Bull 2006; 32(Supplement 1):S1–S9Crossref, Google Scholar
134 : Preferences for family involvement in care among consumers with serious mental illness. Psychiatr Serv 2013; 64:257–263Link, Google Scholar
135 The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, 2013 ed. Arlington, VA, American Psychiatric Association, 2013. www.psychiatry.org/File%20Library/Psychiatrists/Practice/Ethics/principles-medical-ethics.pdf. Accessed Nov 18, 2018Google Scholar
136 Information Related to Mental and Behavioral Health, Including Opioid Overdose. Washington, DC, U.S. Department of Health and Human Services, 2017. www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/index.html. Accessed Nov 18, 2018Google Scholar
137 HIPAA Privacy Rule and Sharing Information Related to Mental Health. Washington, DC, U.S. Department of Health and Human Services, 2017. www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf. Accessed Nov 18, 2018Google Scholar
138 McDonagh MS, Dana T, Selph S, et al: Treatment for Schizophrenia in Adults: A Systematic Review. Rockville, MD, Agency for Healthcare Research and Quality, 2017. effectivehealthcare.ahrq.gov/topics/schizophrenia-adult/research-2017. Accessed May 10, 2019Google Scholar
139 : Family interventions for schizophrenia and the psychoses: a review. Fam Process 2016; 55:460–482Crossref, Google Scholar
140 : Psychosocial treatments for schizophrenia. Annu Rev Clin Psychol 2013; 9:465–497Crossref, Google Scholar
141 Glynn SM, Cather C, Gingerich S, et al: NAVIGATE Family Education Program. www.navigateconsultants.org/wp-content/uploads/2017/05/FE-Manual.pdf. Accessed Oct 9, 2019Google Scholar
142 Family Psychoeducation: How to Use the Evidence-Based Practices KITs. Rockville, MD, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2009. store.samhsa.gov/product/Family-Psychoeducation-Evidence-Based-Practices-EBP-KIT/sma09-4423. Accessed Oct 1, 2019Google Scholar
143 NAMI Family & Friends. Arlington, VA, National Alliance on Mental Illness, www.nami.org/find-support/nami-programs/nami-family-friends. Accessed Sep 29, 2019Google Scholar
144 NAMI Family-to-Family. Arlington, VA, National Alliance on Mental Illness, www.nami.org/Find-Support/NAMI-Programs/NAMI-Family-to-Family. Accessed April 11, 2019Google Scholar
145 : Self-management: a comprehensive approach to management of chronic conditions. Am J Public Health 2014; 104:e25–e31Crossref, Google Scholar
146 : Self-management interventions for people with severe mental illness: systematic review and meta-analysis. Br J Psychiatry 2019; 214:260–268Crossref, Google Scholar
147 Illness Management and Recovery Evidence-Based Practices (EBP) KIT. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2010. store.samhsa.gov/product/Illness-Management-and-Recovery-Evidence-Based-Practices-EBP-KIT/sma09-4463. Accessed Apr 6, 2019Google Scholar
148 : Workplace accommodations for people with mental illness: a scoping review. J Occup Rehabil 2015; 25:197–206Crossref, Google Scholar
149 : A Working Life for People With Severe Mental Illness. New York, Oxford University Press, 2003Crossref, Google Scholar
150 : Supported employment: Meta-analysis and review of randomized controlled trials of individual placement and support. PLoS One 2019; 14:
151 Supported Employment Evidence-Based Practices (EBP) KIT. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2010. store.samhsa.gov/product/supported-employment-evidence-based-practices-ebp-kit/sma08-4365. Accessed Aug 19, 2019Google Scholar
152 Supported Education Evidence-Based Practices (EBP) KIT. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2012. store.samhsa.gov/product/Supported-Education-Evidence-Based-Practices-EBP-KIT/SMA11-4654CD-ROM. Accessed Aug 19, 2019Google Scholar
153 : Effectiveness of long-acting injectable vs oral antipsychotics in patients with schizophrenia: a meta-analysis of prospective and retrospective cohort studies. Schizophr Bull 2018; 44:603–619Crossref, Google Scholar
154 : Long-acting injectable versus oral antipsychotics in schizophrenia: a systematic review and meta-analysis of mirror-image studies. J Clin Psychiatry 2013; 74:957–965Crossref, Google Scholar
155 : Comparative effectiveness of antipsychotic drugs for rehospitalization in schizophrenia—a nationwide study with 20-year follow-up. Schizophr Bull 2018; 44:1381–1387Crossref, Google Scholar
156 : Antipsychotics and mortality in a nationwide cohort of 29,823 patients with schizophrenia. Schizophr Res 2018; 197:274–280Crossref, Google Scholar
157 : A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry 2011; 168:603–609Crossref, Google Scholar
158 : Real-world effectiveness of antipsychotic treatments in a nationwide cohort of 29823 patients with schizophrenia. JAMA Psychiatry 2017; 74:686–693Crossref, Google Scholar
159 : The assessment and treatment of antipsychotic-induced akathisia. Can J Psychiatry 2018; 63:719–729Crossref, Google Scholar
160 : Anticholinergic medication for antipsychotic-induced tardive dyskinesia. Cochrane Database Syst Rev 2018; 1:
161 : The NAVIGATE program for first-episode psychosis: rationale, overview, and description of psychosocial components. Psychiatr Serv 2015; 66:680–690Crossref, Google Scholar
162 Recovery After an Initial Schizophrenia Episode (RAISE). Bethesda, MD, National Institute of Mental Health. Available at: www.nimh.nih.gov/health/topics/schizophrenia/raise/state-health-administrators-and-clinics.shtml. Accessed Mar 31, 2019Google Scholar
163 : Effectiveness of early psychosis intervention: comparison of service users and nonusers in population-based health administrative data. Am J Psychiatry 2018; 175:443–452Crossref, Google Scholar
164 : The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ 2004; 329:1067Crossref, Google Scholar
165 : Ten-year follow-up of the OPUS specialized early intervention trial for patients with a first episode of psychosis. Schizophr Bull 2015; 41:617–626Crossref, Google Scholar
166 Study Manuals. RAISE Early Treatment Program. www.navigateconsultants.org/manuals/ . Accessed Mar 31, 2019Google Scholar
167 Resources. New York, OnTrackNY, ontrackny.org/Resources. Accessed Mar 31, 2019Google Scholar
168 Assertive Community Treatment. Cleveland, OH, Center for Evidence-Based Practices at Case Western Reserve University, www.centerforebp.case.edu/practices/act. Accessed Mar 31, 2019Google Scholar
169 : Program fidelity and beyond: multiple strategies and criteria for ensuring quality of assertive community treatment. Psychiatr Serv 2012; 63:743–750Crossref, Google Scholar
170 : Adoption of a blended training curriculum for ACT in New York State. Psychiatr Serv 2016; 67:940–942Crossref, Google Scholar
171 Assertive Community Treatment (ACT) Evidence-Based Practices (EBP) KIT. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2008. store.samhsa.gov/product/Assertive-Community-Treatment-ACT-Evidence-Based-Practices-EBP-KIT/sma08-4345. Accessed Mar 31, 2019Google Scholar
172 : Persuasion and healing: a comparative study of psychotherapy, 3rd ed. Baltimore, Johns Hopkins University Press, 1991Google Scholar
173 : How important are the common factors in psychotherapy? An update. World Psychiatry 2015; 14:270–277Crossref, Google Scholar
174 : Translating cognitive behavioral interventions from bench to bedside: the feasibility and acceptability of cognitive remediation in research as compared to clinical settings. Schizophr Res 2019; 203:49–54Crossref, Google Scholar
175 : The feasibility and acceptability to service users of CIRCuiTS, a computerized cognitive remediation therapy programme for schizophrenia. Behav Cogn Psychother 2016; 44:288–305Crossref, Google Scholar
176 : A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry 2011; 168:472–485Crossref, Google Scholar
177 : Rehabilitation of frontal/executive impairments in schizophrenia. Aust N Z J Psychiatry 1996; 30:760–767Crossref, Google Scholar
178 : Cognitive Remediation for Psychological Disorders: Therapist Guide (Treatments That Work), 2nd ed. New York, Oxford University Press, 2018Google Scholar
179 : Cognitive remediation therapy plus standard care versus standard care for people with schizophrenia. Cochrane Database Syst Rev 2017; 11:
180 : A randomized controlled trial comparing a “bottom-up” and “top-down” approach to cognitive training in schizophrenia. J Psychiatr Res 2019; 109:118–125Crossref, Google Scholar
181 : A randomized controlled trial examining a cognitive behavioral therapy intervention enhanced with cognitive remediation to improve work and neurocognition outcomes among persons with schizophrenia spectrum disorders. Schizophr Res 2018; 197:400–406Crossref, Google Scholar
182 : Recent advances in social skills training for schizophrenia. Schizophr Bull 2006; 32(Supplement 1):S12–S23Crossref, Google Scholar
183 : A meta-analysis of social skills training and related interventions for psychosis. Schizophr Bull 2018; 44:475–491Crossref, Google Scholar
184 : Supplementing clinic-based skills training with manual-based community support sessions: effects on social adjustment of patients with schizophrenia. Am J Psychiatry 2002; 159:829–837Crossref, Google Scholar
185 : Randomized trial of social rehabilitation and integrated health care for older people with severe mental illness. J Consult Clin Psychol 2010; 78:561–573Crossref, Google Scholar
186 : Enlisting indigenous community supporters in skills training programs for persons with severe mental illness. Psychiatr Serv 2000; 51:1428–1432Crossref, Google Scholar
187 Bellack AS, Goldberg RW: VA Psychosocial Rehabilitation Training Program Social Skills Training for Serious Mental Illness.. www.mirecc.va.gov/visn5/training/sst/sst_clinicians_handbook.pdf. Accessed Apr 11, 2019Google Scholar
188 : Social Skills Training for Schizophrenia: A Step-by-Step Guide, 2nd ed. New York, Guilford Press, 2004Google Scholar
189 : Cognitive-Behavioral Social Skills Training for Schizophrenia: A Practical Treatment Guide. New York, Guilford Press, 2016Google Scholar
