Canadian Psychiatric Association

Association des psychiatres du Canada

Canadian Schizophrenia Guidelines

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

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2017, Vol. 62(9) 662-672 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743717719900 TheCJP.ca | LaRCP.ca

Donald Addington, MD1, Elizabeth Anderson, MA2, Martina Kelly, MbBCh3, Alain Lesage, MD4, and Chris Summerville, DMin5

Abstract Objective: The objective of this review is to identify the features and components of a comprehensive system of services for people living with schizophrenia. A comprehensive system was conceived as one that served the full range of people with schizophrenia and was designed with consideration of the incidence and prevalence of schizophrenia. The system should provide access to the full range of evidence-based services, should be recovery oriented, and should provide patient-centred care. Method: A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum disorders. The guidelines were rated by at least 2 raters, and recommendations adopted were primarily drawn from the National Institute for Clinical Excellence (2014) Guideline on Psychosis and Schizophrenia in adults and the Scottish Intercollegiate Guidelines Network guidelines on management of schizophrenia. Results: The recommendations adapted for Canada cover the range of services required to provide comprehensive services. Conclusions: Comprehensive services for people with schizophrenia can be organized and delivered to improve the quality of life of people with schizophrenia and their carers. The services need to be organized in a system that provides access to those who need them. Keywords schizophrenia spectrum and other psychotic disorders, clinical practice guidelines, epidemiology, community mental health services, health services research, health care policy This paper addresses the need for an organized mental health system and the evidence-based interventions or programs to be delivered by the mental health system. Successful treatment of schizophrenia requires an organized, recoveryoriented, mental health system with coordinated services that range from accessible community mental health teams to high-security forensic services. The mental health system should include supportive living arrangements, such as structured programs with on-site staff as well as support for families who are the usual providers of personal support and housing for young people with schizophrenia. In addition, the mental health system should include evidence-based, coordinated specialty care programs ranging from accessible first-episode psychosis services to assertive community treatment (ACT) programs. In Canada, mental health services are delivered through provincially funded health services. The organization, funding and delivery of mental health services

vary from province to province; there are no national standards for mental health service delivery, although there is a national strategy.1 Many provinces have adopted the framework of the national mental health strategy, but there is limited evidence that this has led to improvement in service delivery and 1

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Department of Psychiatry, Hotchkiss Brain Institute, Foothills Hospital, University of Calgary, Calgary, Alberta Being Mentally Healthy Company, Calgary, Alberta Department of Family Medicine, University of Calgary, Calgary, Alberta Department of Psychiatry, Faculty of Medicine, Universite´ de Montre´al, Montreal, Que´bec Schizophrenia Society of Canada, Winnipeg, Manitoba

Corresponding Author: Donald Addington, MD, Foothills Hospital, Department of Psychiatry, 1403 29 Street NW, Calgary, Alberta, Canada T2N 2T9. Email: [email protected]

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outcomes. Clear policies, standards and performance measures for access, quality and outcome of mental health services are lacking. Most provinces also lack the infrastructure to provide technical support and training for evidence-based, coordinated specialty care programs delivered in the community. We begin by describing broad recommendations that support comprehensive care systems and a recovery-oriented approach. Next, we list recommendations that support programs or services. Finally, we make recommendations that address the role of primary care in promoting the health of individuals with schizophrenia. Recovery has been conceptualized in 2 broad ways. First, recovery has been conceptualized as a subjective experience that has many definitions, including “a way of living a satisfying, hopeful and contributing life even within the limitations caused by illness.”2 In Canada, the Mental Health Strategy identifies supporting recovery as a core value for mental health services.1 A systematic review of the recovery literature identified 5 key recovery processes: connectedness, hope, identity, meaning and empowerment (the CHIME framework). 3 A number of specific evidencebased practices have been identified as supporting a recovery orientation, such as supported employment, but these practices still need to be offered in a way that supports recovery.4 The second approach to defining recovery is a more functional approach and combines symptomatic and/or functional recovery. A consensus approach to remission in schizophrenia based on symptoms alone has been identified.5 Liberman et al6 proposed a broader definition of recovery based on a combination of symptom remission, vocational functioning, independent living and peer relationships. The subjective and objective approaches to recovery differ conceptually and have different goals and objectives. The subjective approach emphasises the role of the individual as central, with health and social services supporting the individual’s recovery. The objective approach has a role in clinical research and outcome measurement because functional recovery sets a higher target for treatment than simply statistically significant reductions in symptoms. Although a recovery orientation has been widely discussed in mental health care, patient-centred care is an approach to health care delivery that has been examined in the general health care system. Patient-centred care has been described as exploring the patient’s main reason for seeking health care, developing an integrated understanding of the patient’s worldview, finding common ground on the problem and its management, enhancing health promotion and maintaining an ongoing relationship.7 Patient-centred care also can be considered at the system or policy level. 8 Patient-centred care can be measured from the patient’s perspective, particularly if care is focused on a specific encounter with a focus on shared decision making.9 The potential of shared decision making in schizophrenia has been described,10 but a Cochrane review found only 2 studies examining the impact of shared decision making for people

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with mental health conditions.11 Decision aids are interventions or tools designed to facilitate shared decision making and patient participation in health care decisions. Decision aids help people in considering choices, describe where and why choice exists, and provide information about options including, where reasonable, the option of taking no action.12 We found no published decision aids for facilitating shared decision making in schizophrenia.

Methods The methods for the Canadian Schizophrenia Guidelines are described in brief here; please see the Introduction and Guideline Development Process article for an in-depth description. The guidelines were developed using the ADAPTE process.13 Because the development of guidelines requires substantial resources, the ADAPTE process was created to take advantage of existing guidelines and reduce duplication of effort. The first phase of ADAPTE, the set-up phase, involved preparing for the ADAPTE process. We assembled a national multidisciplinary panel from across Canada, including stakeholders with expertise in schizophrenia and mental health, health policy, patient advocacy and lived experience with schizophrenia. Endorsement bodies for the guidelines included the Canadian Psychiatric Association and the Schizophrenia Society of Canada, which were also heavily involved in the dissemination and implementation strategy. The second phase of the ADAPTE process, the adaptation phase, involves identifying specific health questions; searching for and retrieving guidelines; assessing guideline quality, currency, content, consistency and applicability; making decisions regarding adaptation; and preparing the draft adapted guideline. We searched for guidelines on schizophrenia in guideline clearinghouses and on the websites 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 Adolescent Psychiatry and the European Psychiatric Association. A MEDLINE search was also performed using the term guideline as publication type and schizophrenia as title or clinical topic. Inclusion criteria were that the guideline had to be published after 2010, the guideline had to be written in English, and the recommendations had to be developed using a defined and systematic process. We identified 8 current guidelines that were potentially suitable for adaptation.14-19 These guidelines were reviewed and evaluated in duplicate using the AGREE II tool,20 an instrument used to evaluate the methodological rigour and transparency with which a guideline is developed. Based on this evaluation, we determined that 6 guidelines were of suitable quality and content for adaptation (see Table 1). Recommendations from each guideline were extracted and divided based on content and were reviewed by the relevant working group. The community treatment

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Table 1. Grade/strength of recommendation classification systems for included guidelines.a National Institute for Health and Care Excellence (NICE) Strength of recommendations The wording used denotes the certainty with which the recommendation is made (the strength of the recommendation). Interventions that must (or must not) be used We usually use “must” or “must not” only if there is a legal duty to apply the recommendation. Occasionally, we use “must” (or “must not”) if the consequences of not following the recommendation could be extremely serious or potentially life threatening. Interventions that should (or should not) be used: a “strong” recommendation We use “offer” (and similar words such as “refer” or “advise”) when we are confident that, for the vast majority of patients, an intervention will do more good than harm and be cost-effective. Interventions that could be used We use “consider” when we are confident that an intervention will do more good than harm for most patients and be cost-effective, but other options may be similarly cost-effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient’s values and preferences than for a strong recommendation. Scottish Intercollegiate Guidelines Network (SIGN) and European Psychiatric Association Levels of evidence 1þþ: High-quality meta-analyses, systematic reviews of randomized controlled trials, or randomized controlled trials with a very low risk of bias; 1þ: Well-conducted meta-analyses, systematic reviews, or randomized controlled trials with a low risk of bias; 1: Meta-analyses, systematic reviews, or randomized controlled trials with a high risk of bias 2þþ: High-quality systematic reviews of case control or cohort studies or high-quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal; 2þ: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal; 2: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3: Nonanalytic studies (e.g., case reports, case series) 4: Expert opinion Grades of recommendation A: At least one meta-analysis, systematic review, or randomized controlled trial rated as 1þþ and directly applicable to the target population or a body of evidence consisting principally of studies rated as 1þ, directly applicable to the target population, and demonstrating overall consistency of results B: A body of evidence including studies rated as 2þþ, directly applicable to the target population, and demonstrating overall consistency of results or extrapolated evidence from studies rated as 1þþ or 1þ C: A body of evidence including studies rated as 2þ, directly applicable to the target population, and demonstrating overall consistency of results or extrapolated evidence from studies rated as 2þþ D: Evidence level 3 or 4 or extrapolated evidence from studies rated as 2þ Good Practice Point: recommended best practice based on the clinical experience of the guideline development group a

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

group also identified 2 recommendations from the Institute of Health Economics (IHE) Consensus Statement on Improving Mental Health Transitions.21 The Consensus Development Conference has a unique format based on a jury trial, which provides an independent and critical review of issues by an unbiased panel. The conference is a survey of the best available evidence, which informs a Consensus Statement that is relevant for policy and practice. The conference involves 20 to 25 experts who deliver scientific evidence addressing 5 to 8 questions in a given field over 2 days of hearings attended by a jury or panel of about 12 members and an audience of delegates. We identified 2 recommendations from the IHE that focused on broader issues regarding provision of community-based services than are generally addressed in the more targeted recommendations found in disease-specific clinical practice guidelines. After selection, those 2 recommendations were subjected to the same process as other guideline recommendations. Following the ADAPTE process, working groups selected items from guidelines and recommendations to

create an adapted guideline. Each working group carefully examined each recommendation, the evidence from which the recommendation was derived, and the acceptability and applicability of the recommendation to the Canadian context. After reviewing the recommendations from the guidelines, the working groups decided which recommendations to accept and which to reject and which recommendations were acceptable but needed to be modified. Care was taken when modifying existing recommendations not to change the recommendations to such an extent that they were no longer in keeping with the evidence on which they were based. Each working group developed a final list of recommendations from the included guidelines that was presented to the entire guideline panel at an in-person consensus meeting. Working group leaders presented each recommendation and its rationale to the panel. Anonymous voting by the entire panel using clicker technology was performed for each recommendation. 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

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the recommendation and whether minor modifications to the recommendation would alter the likelihood that the recommendation would pass. In these situations, recommendations were modified (as described above) and the group re-voted later using an online anonymous survey. Whenever modifications in wording were made to original recommendations, the text “modified recommendation from” appears in the Canadian Schizophrenia Guidelines, and the source of each recommendation is written beside the recommendation statement. The strength or grade of the recommendation is provided in parentheses if applicable, using the system from which the recommendation originated. The grades of recommendation for each reference guideline and their meaning are explained in brief in Table 1 (see Introduction and Guideline Development Process article for a more detailed description). Once the voting and consensus process was completed, each working group created a separate manuscript containing all the recommendations adapted from the included guidelines, with accompanying text explaining the rationale for each recommendation. During the finalization phase, the Canadian Schizophrenia Guidelines were externally reviewed by those who will be affected by their uptake: practitioners, policy makers, health administrators, patients and their families. The external review asked questions about whether the users approved of the draft guideline, about strengths and weaknesses and about suggested modifications. The process was facilitated through the Canadian Journal of Psychiatry and the Schizophrenia Society of Canada. The Canadian Psychiatric Association Clinical Practice Guidelines Committee reviewed and approved the guideline methodological process.

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acute inpatient care and community residential care, together with more specialised services such as programs for treatment-resistant schizophrenia, ACT teams, early intervention teams, alternatives to acute inpatient care, alternative types of community residential care and alternative occupation and rehabilitation. 24 An integrated framework for funding and delivering evidence-based mental health services in the Canadian health system was presented and endorsed in an IHE Consensus Statement in 2014.21 The economic modeling suggests that combinations of optimal evidence-based treatments for schizophrenia are cost-effective compared with systems that provide less evidence-based practices. 25 In the real world, it is harder to find clear links between outcomes and different service patterns and costs due to the complex interplay of culture, social service provision and health care service provision. 26 However, in recent American and Italian real-life cluster-randomized trials, integration of first-onset psychosis-specific programs in regular public managed care has proven feasible, effective and cost-beneficial.26,27,28

Recommendation 2: Full Range of Interventions Mental health services should be able to offer the full range of psychological, pharmacological, social, occupational and culturally safe interventions recommended.    

Results Recommendation 1: Comprehensive Care across All Phases All mental health services serving a defined population should offer a comprehensive range of interventions consistent with this guideline to people with psychosis or schizophrenia. [NICE (Strong)] The planning of treatment services for individuals with schizophrenia can be organized around population-based estimates of prevalence and treatment need.22 Although this is possible, there is little evidence that population-based estimates form the basis for mental health planning and delivery in Canada.23 Models of population-based mental health service delivery across levels of economic development have been compared.24 Results suggest that in developed countries such as Canada, services to a defined population should include a range of services such as outpatient clinics, community mental health teams (CMHTs),

Be competent to provide all interventions offered. Place emphasis on engagement rather than risk management. Provide treatment and care in the least restrictive and least stigmatising environment possible. Better service the country’s diverse population by offering diversity-related practices for inclusion. [NICE (Strong)]

This recommendation addresses the quality delivery of specific services. This requires the mental health system to have capacity to assess the quality of services delivered and the skills of clinicians to deliver the services. The term fidelity has been used to refer to the degree of implementation of an evidence-based practice, and fidelity scales can be used to reliably measure fidelity. 27 Fidelity can be assessed at the level of a service such as supported employment28 or a first-episode psychosis service.29 The development of Provincial Technical Assistance Centres (PTACs) was endorsed by the IHE Consensus Statement in 2014.21 The concept of a technical assistance centre is based on a centre developed in Ontario to support the deployment of ACT teams, or the current Centre national d’excellence en sante´ mentale in Que´bec (http://www.douglas.qc.ca/sec tion/cnesm-298?locale¼en), or the Assertive Community Treatment Advanced Practice Panel in British Columbia. At the individual clinical level, specific skills are required to deliver evidence-based psychosocial programs such as

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cognitive behaviour therapy for psychosis or family education and support.

Recommendation 3: Community Mental Health Teams (CMHTs) Serving a Defined Population  Community mental health services shall be available for all patients with schizophrenia, other severe mental disorders, and their families, and the provider should be accountable for the services available.  CMHTs shall expect to cover about 1.5% of the population.  These community mental health teams must be sufficiently resourced to provide high-intensity support (1 staff per 10 patients) to 10% of people with schizophrenia, to apply the standards of ACT and mediumintensity support (1 staff per 20 patients) to another 20% of people with schizophrenia and to apply the standards of intensive case management (ICM) to the remaining 70%.  The majority of patients shall receive conventional clinical, rehabilitative and social services with 1 member of the CMHT acting as case manager (1 staff per 80 patients). [IHE consensus recommendation]

Recommendation 4: Service User Experience Improve the experience of care for people with psychosis or schizophrenia using mental health services.  Work in partnership with people with schizophrenia and their carers.  Offer help, treatment and care in an atmosphere of hope, optimism and recovery-orientation.  Take time to build supportive and empathic relationships as an essential part of care.  Aim to foster people’s autonomy, promote active participation in treatment decisions and support selfmanagement. [NICE (Strong)] A systematic review of studies that included patient satisfaction as an outcome measure found that greater clinician warmth, less nurse negativity and greater clinician listening were associated with greater patient satisfaction.30 Qualitative studies of the carer’s experience of care have suggested ways of better addressing carers’ concerns.31 Several randomized controlled studies have shown statistically significant positive impacts of the intervention on carers’ outcomes. Several components were common to many of these programs and included psychoeducation, managing problem behaviours, setting realistic expectations, problem solving training, communication training, stress management for relatives, challenging unhelpful beliefs, relapse prevention and maintaining social networks.32

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

 

Avoid using clinical language, or keep it to a minimum. Ensure that comprehensive written information is available in the appropriate language and in audio format if possible. Provide and work proficiently with interpreters if needed. Offer a list of local education providers who can provide English-language teaching for people who have difficulties speaking and understanding English. [SIGN (Grade D)]

According to Statistics Canada, in 2011 Canada had a foreign-born population of about 6,775,800 people, representing 20.6% of the total population. This is the highest proportion among the G8 countries and is one reason that it is essential to have services that can support this population.

Specific systemic components of a balanced mental health care system for people with schizophrenia and their families Recommendation 6: Assertive Community Treatment Assertive outreach should be provided for people with serious mental disorders (including people with schizophrenia) who make high use of inpatient services, who show residual psychotic symptoms and who have a history of poor engagement with services leading to frequent relapse and/or social breakdown (e.g., homelessness, imprisonment). [SIGN (Grade B)] Case management has been examined at 3 levels of intensity. ACT is the highest level of intensity, ICM provides an intermediate level of care, and standard case management offers the lowest intensity of care but is sufficient to support individuals with complex needs. The IHE consensus statement cited above for CMHTs suggests that ACT be considered an essential component of comprehensive community mental health services and be integrated with the CMHTs. ACT combines a team-based and outreach approach to case management. ACT teams have a high staff to patient ratio (i.e., 1:10) and some teams are on call 24 hours, 7 days a week. Staff members operate in both clinical settings and patients’ community environment. Staff provide a specialized approach to treatment of patients with psychotic disorders who are more clearly disabled.33 ACT programs are now available in most jurisdictions and have been shown to be effective in reducing hospital readmission rates and improving housing and occupational functioning as well as quality of life and service satisfaction.34 These programs do

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not lead to any differential improvement in clinical state and do not change the overall costs of care.35,36 The impact of ACT is highest where there is a high rate of hospitalization, which may reflect the quality of the routine mental health services that have been the control groups in research studies.37

Recommendation 7: Intensive Case Management Consider ICM for people with psychosis or schizophrenia who are likely to disengage from treatment or services. [NICE (Conditional)] The ICM model was designed to meet the needs of high service users who were not being adequately engaged by brokerage and clinical case management practices.38 Like the ACT model, ICM uses a low patient to staff ratio, provides assertive outreach in the community and assists with daily living skills. One difference between ICM and ACT models is that caseloads are not shared between clinicians in ICM. Research results on case management outcomes are mixed.39 One Cochrane review found that in comparison with standard care, case management increased hospital admissions and length of stay, resulting in increased costs. However, case management increased the number of patients in contact with service and hence with medication. The general practice is to use case management for patients who have complex service needs. ACT and ICM are more often used for hard-to-engage or treatment-resistant patients. A combination of the 3 levels of care was endorsed by the IHE Consensus Statement in 201421 cited above. The consensus statement insisted that community mental health services must be sufficiently resourced to provide the 3 levels of care.

Recommendation 8: First-onset Psychosis Models of Care Individuals in the first episode of psychosis should receive treatment within the context of an evidence-based coordinated specialty service. This should be multidisciplinary and encompass the following:  Engagement/assertive outreach approaches  Family involvement and family interventions  Access to psychological interventions and psychologically informed care  Vocational/educational interventions  Access to antipsychotic medication [SIGN (Grade A)] Evidence in support of coordinated specialty care services for individuals with a first-episode psychosis has accumulated over the last 20 years. The NICE recommendations were made based on 4 major international studies, 1 each

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from Denmark and Norway and 2 smaller studies from the United Kingdom.40-43 Since then, 2 large-scale, pragmatic, cluster-randomized controlled trials, 1 from the United States and 1 from Italy, have shown positive results.44,45 Although variations exist in the organization and mix of services provided in different countries, there is a growing international consensus on the essential evidence-based components of first-episode psychosis services.46 The quality of care delivered for first-episode psychosis can be assessed by the First Episode Psychosis Fidelity Scale (FEPS-FS), a reliable and valid measure that assesses quality of care across different team models.29 Self-report surveys of selected first-episode psychosis services in Canada and the United States suggest that although there are some variations in populations served and the access and funding of services, the majority of the programs surveyed delivered evidencebased services, even though these 2 studies did not provide outcomes or cost-effectiveness compared with other service configurations, like integrating the model into regular CMHTs.47,48

Recommendation 9 People presenting to early intervention in psychosis services should be assessed without delay. If the service cannot provide urgent intervention for people in a crisis, refer to other urgent care services. [NICE (Strong)] Two lines of evidence support the need for early intervention. One is the negative outcomes associated with untreated psychosis, including attempted suicide, aggression and violence. Attempted suicide, which is often the event that precipitates referral for treatment, occurs in 15% to 29% of patients.49,50 Aggression and violence are also common in untreated psychosis. In one population-based cohort, 1 in 3 patients with psychosis was aggressive at the time of presentation. One patient in 14 engaged in violence that caused, or was likely to cause, injury to other people.51 The other clinically relevant reason for early intervention is the association between the duration of untreated psychosis (DUP) and longer term outcome. The longer the DUP, the poorer the outcome.52,53 In England, NICE has identified 8 quality measures for first-episode psychosis services including one for timeliness of access. Fifty percent of new referrals to mental health services with a first-episode psychosis should be seen within 2 weeks.54

Recommendation 10: Early Intervention Early intervention by psychosis services should be accessible to all people with a first episode or first presentation of psychosis, irrespective of the person’s age or the duration of untreated psychosis. [NICE (Strong)]

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The age of onset of schizophrenia was initially determined by the date of first admission to hospital.55 More detailed studies of the onset of symptoms yield earlier onset but similar patterns, revealing a mean age of onset for men at 21.4 years and women at 27.4. These results have significant implications for service delivery, because 27% of women have an onset over the age of 35.56

Recommendation 11: Crisis Resolution and Home Treatment Teams Offer crisis resolution and home treatment teams as a firstline service to support people with psychosis or schizophrenia during an acute episode in the community if the severity of the episode, or the level of risk to self or others, exceeds the capacity of the early intervention in psychosis services or other community teams to effectively manage it. [NICE (Conditional)] Crisis resolution has been defined as any type of crisisoriented treatment of an acute psychiatric episode by staff with a specific remit to deal with such situations during and beyond office hours. The teams are multidisciplinary and include nurses, psychiatrists and nonprofessional mental health staff. In England, where these teams have been implemented as a matter of policy, they assess all patients being considered for admission. A recent Cochrane review found only 8 small studies that could be included; these studies had unclear blinding, reporting and attrition bias, and the evidence for the main outcomes of interest was of low to moderate quality. The authors concluded that the approach appears to be a viable and acceptable way of treating people with serious mental illnesses. However, more evaluative studies are still needed. This intervention has not been widely adopted in Canada.

Recommendation 12: Crisis Houses or Acute Day Facilities Consider acute community treatment within crisis resolution and home treatment teams before admission to an inpatient unit and as a means to enable timely discharge from inpatient units. Crisis houses or acute day facilities may be considered in addition to crisis resolution team and other home treatment teams depending on the person’s preference and need. [NICE (Conditional)] Crisis houses are residential alternatives to acute admission during a crisis. Research is limited, but 1 fair-sized study compared crisis houses with standard care.57,58 NICE rated the quality of evidence as low. Acute day hospitals are units that provide diagnostic and treatment services for acutely ill individuals who otherwise would be treated in traditional inpatient units. A Cochrane review included 10 studies.58 On several measures, no differences were found between home care and inpatient care.

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The day hospital group spent less time in hospital over the following year, and so day hospital care has been considered an alternative for patients with support at home in the evening and night.

Recommendation 13: Hospitalisation If a person with psychosis or schizophrenia needs hospital care, think about the impact on the person, his or her carers and other family members, especially if the inpatient unit is a long way from where they live. If hospital admission is unavoidable, ensure that the setting is suitable for the person’s age, gender and level of vulnerability; it must also support their carers. [NICE (Strong)] According to Thornicroft and Tansella,24 “There is no evidence that a balanced system of mental health care can be provided without acute beds.” Hospitalisation is required for many people with schizophrenia, including those who need urgent medical assessment, those with severe comorbid medical and psychiatric conditions, those experiencing severe psychiatric relapse and behavioural disturbance or those with high levels of suicidality or assaultiveness. Inpatient services need to be as close as possible to the community in which patients and their carers live in order to provide continuity of support during hospitalization and graduated discharge.

Recommendation 14: Supported Employment Offer supported employment programs to people with psychosis or schizophrenia who wish to find or return to work. [NICE (Strong)] Supported employment, referred to as individual placement and support (IPS), is an approach to vocational rehabilitation based on a number of key principles including a focus on competitive employment, eligibility based on consumer choice, rapid job searches, the integration of rehabilitation and mental health and attention to consumer preference.59 The results of 18 studies with 3476 participants showed that supported employment was more effective than prevocational training for the outcomes of gaining competitive employment, hours/weeks worked, length of time in longest job, time to first competitive job and length of time worked.17

Recommendation 15: Supported Housing and Long-term Residential Care   

People with schizophrenia shall live in housing of their choice. Supported housing in the community shall be available for each person with schizophrenia. Given that many people with schizophrenia have indicated that they prefer to live in small, homelike

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environments, governments also need to consider the role of noninstitutional residential facilities. In particular, facilities that create a homelike environment and provide a safe and dignified long-term home for people with schizophrenia who cannot live independently should be considered. [IHE consensus recommendation] The reduction in the number of long-term mental hospital beds has led to problems in housing individuals with severe and persistent mental disorders in the community.60 A large proportion of this population have schizophrenia, often with comorbid substance use disorders. Supported housing is a service model that couples provision of independent housing with provision of community-based supports for individuals with mental disorders who are at risk of homelessness.61 Supported housing has been contrasted with traditional sequential residential rehabilitation programs, which begin with acute or long-term treatment and step down to levels of accommodation with reducing levels of support and a requirement that residents participate in mandatory treatment plans.62 The largest study of supported housing was carried out in Canada using a model known as Housing First, which was applied to homeless individuals.63 The model is characterised by a combination of access to good housing in noncongregate facilities, often through supplement to rent, and support by an ACT team or ICM team (see above). Results showed that the model could be applied across a range of contexts and populations. Furthermore, those receiving the Housing First model achieved superior housing outcomes and more rapid outcomes in community functioning and quality of life compared with those receiving treatment as usual.64

Recommendation 16: Peer Support and Self-management Consider peer support for people with schizophrenia to help improve service user experience and quality of life. Peer support services should be delivered by a trained peer support worker who has recovered from psychosis and remains stable. Peer support workers should receive support from their whole team and support and mentorship from experienced peer workers. [NICE (Conditional)] Peer support work has been defined as “social emotional support, frequently coupled with instrumental support, that is mutually offered or provided by persons having a mental health condition to others sharing a similar mental health condition to bring about a desired social or personal change.”65 The challenge in assessing the evidence to support such programs is the variety of outcomes that are desired by participants and funders. The NICE guidelines found low- to very-low-quality evidence that peer support increased self-rated recovery but not empowerment or quality of life. Nonetheless, these programs are offering

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opportunities for service users to obtain recognition and provide support to others. In Canada, the Peer Support and Accreditation and Certification Canada (PSACC) promotes the recognition, growth and accessibility of peer support. This is a national organization that has established the PSACC Standards of Practice. The organization uses these standards as the platform from which to promote mental health peer support through education and awareness. The organization also certifies qualified peer supporters and accredits qualified peer support training programs. Peer support workers can be found working in a variety of programs such as CMHTs and ACT teams as well as a range of residential programs and nonprofit organizations such as the Schizophrenia Society and Canadian Mental Health Association. In Quebec, the Ministry of Health and Social Services recognizes the importance of peer support workers and funds 2 nongovernmental organizations to offer training and supervision of peer support workers and family peer support workers.

Recommendation 17: Return to Primary Care For people with psychosis or schizophrenia whose symptoms have responded effectively to treatment and remain stable, offer the option to return to primary care for further management. If a service user wishes to do this, record this in his or her notes and coordinate transfer of responsibilities. [NICE (Strong)]

Recommendation 18: Relapse and Re-referral to Secondary Care When a person with an established diagnosis of psychosis or schizophrenia presents with a suspected relapse (for example, with increased psychotic symptoms or a significant increase in the use of alcohol or other substances), primary health care professionals should refer to the crisis section of the care plan. [NICE (Strong)] The NICE recommendations on return to primary care and re-referral are made within the context of the very structured National Health Service. In the National Health Service, this would include a care plan written by a mental health professional in collaboration with the patient, which would be shared with the primary care provider. In addition, the patient would be registered in a primary care practise– based register to monitor physical and mental health. In the Canadian context, neither mental health services nor primary care is as structured. It would be appropriate to consider referral to primary care if the patient is stable, has recovered and does not need services such as psychological or rehabilitation interventions that are available only in the multidisciplinary CMHT. The resources available in the primary care setting would need to be considered, as they vary from

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individual office practices to multidisciplinary care teams within primary care networks or family medicine groups.

Recommendation 19: Transfer between Health Regions When a person with psychosis or schizophrenia is planning to move to the catchment area of a different health regions or provinces, a meeting should be arranged between the services involved and the service user to agree a transition plan before transfer. The person’s current care plan should be sent to the new secondary care and primary care providers. [NICE (Strong)] This recommendation, which appears clear-cut within the context of the National Health Service, needs to be adapted to the varied organization of health mental health services across Canada. The large distances involved are also an important consideration. The key message in this recommendation is the need to take an active approach to ensuring continuity of care.

Conclusions We have identified a set of recommendations that provide guidelines for a comprehensive system of care for people with schizophrenia. The recommendations include both specific evidenced-based services and recommendations about coordinating these services in a system that serves the population with schizophrenia and schizophrenia spectrum disorders. Most of the specific evidence-based practices identified in this guideline can be found in mental health services across Canada, but these practices are rarely integrated into a comprehensive, accessible system and rarely assessed for access, quality and outcome. These recommendations have the potential to improve the quality of life of people with schizophrenia and their carers, but the services need to be organized in a system that provides access to those who need them. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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