schizophrenia patient case study

Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

Edorium Journals

• About Edorium Journals
• Browse Journals
• Abstracting & Indexing
• Testimonials

Article Outline

• Introduction

Case Report

• Supporting Information

Related Articles

“One in a million”: A case of a very early onset schizophrenia

1 Assistant Professor of Psychiatry, Department of Psychiatry, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA

2 PGY4-Child and Adolescent Psychiatry Fellow, Department of Psychiatry, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA

Address correspondence to:

Daisy Vyas Shirk

DO, 875 Stoverdale Road, Hummelstown, Pennsylvania 17036,

Message to Corresponding Author

Article ID: 100083Z06DS2020

doi: 10.5348/100083Z06DS2020CR

Access full text article on other devices

Access pdf of article on other devices, how to cite this article.

Introduction: Very early onset schizophrenia (VEOS), psychosis prior to age 13, is rare with an incidence of less than 0.04%. Its clinical presentation, course, and outcome differ from early onset (ages 13–18) and adult onset (ages 18 and up) schizophrenia. It is associated with poor response to treatment, poorer prognosis, and multiple hospitalizations. Early identification and intervention has shown to improve overall functioning.

Case Report: We present a case of a 12-year-old female with significant family history of psychosis, admitted due to physical and verbal aggression, sexual inappropriateness, destruction of property, response to internal stimuli, decline in functioning, and 10 month history of social isolation. She responded to risperidone treatment. The patient was discharged to partial hospitalization program but could not tolerate the group setting resulting in discharge to outpatient services. Psychosocial supports were put in place to help with environmental and family dynamics to improve outcome.

Conclusion: As per a recent study, one-third of children and adolescents with psychosis initially present with negative symptoms. It has also been reported that 30% of those with negative symptoms develop treatment failure with antipsychotics. Given these statistics and the treatment challenges of this case, it was imperative to provide additional psychosocial supports to the patients and families, to improve overall functioning and long-term prognosis.

Keywords: Compliance, Intellectual disability, Psychotic disorders, Psychosocial support systems

INTRODUCTION

Very early onset schizophrenia (VEOS), defined as onset of psychosis prior to age 13, is considered to be very rare [1] . It has been shown to differ in its clinical presentation, course, and outcome compared to early onset (between ages 13 and 18) and adult onset (ages 18 and up) schizophrenia. It is associated with poorer prognosis, worse overall functioning, and multiple hospitalizations [2] . Early childhood adversity and borderline intellectual functioning have also been shown to contribute to development of psychosis [3] , [4] , [5] . Early identification and intervention have been shown to reduce the morbidity of the illness and improve overall functioning. Here we present the case of a young girl with very early onset schizophrenia.

CASE REPORT

This is a case of a 12-year-old female child who was admitted in the inpatient child psychiatry unit due to physical and verbal aggression toward peers and staff, sexually inappropriate touching, destruction of property, attempting to run out into traffic, and responding to internal stimuli.

The patient was reportedly doing well until 10 months prior to her hospitalization, after which she exhibited school refusal and declining grades. The only trigger reported was school bullying. She was noted to become more verbally and physically aggressive toward peers and school staff, with daily outbursts, eloping from school, poor sleep, and social isolation. At home, she was observed to sit in the halls in the middle of the night, conversing with herself. She changed from a child who “used to love talking, playing board games, and card game with her cousins” into someone who “now sits by herself and does not say anything to them or do anything with them.” She was also found one time sitting on her porch eating leaves.

She was referred and underwent partial hospitalization. During that treatment, she was observed to be impulsive, hyperactive, withdrawn, had difficulty with peer interactions, appeared internally preoccupied, laughed inappropriately, talked to herself, sing, or would dance alone without music. She struggled with boundaries and attempted few times to choke staffs with their lanyards or with her hands. She destroyed property, made verbal threats toward staff and peers, and made sexually inappropriate comments and gestures. She was given a trial of lithium and risperidone. She did not tolerate lithium but responded to risperidone 1 mg daily. Upon discharge, there was no follow-up and patient ran out of medication. This led to a deterioration of behaviors resulting in inpatient treatment.

Patient’s developmental history and medical histories are unremarkable. Her family history is significant for schizophrenia in her father who reportedly went from being a straight A student, attending college on a full scholarship to dropping out of school, having multiple incarcerations and now has been institutionalized in a long-term psychiatric facility for the past 10 years. The patient’s mother also received inpatient treatment after patient’s birth and there was a threat of all three children being removed by Children and Youth Services (CYS). At the time of hospitalization, she lived with her mother, 9-year-old sister, and 3-year-old brother. Child protection services were involved at the time of admission due to concerns of a possible sexual abuse based on patient’s sexualized behaviors.

Mental status examination at the time of admission

The patient had fair grooming but was agitated and uncooperative during the interview. Her eye contact varied from fair to intense staring. She did not display any motor abnormalities including tics or tremors. She spoke loudly and often repeated the phrase, “I don’t give a f***” to many questions. She refused to describe her mood and her affect was bizarre and labile; though content was characteristic of paranoia and perseverations. She refused to answer questions related to perceptual disturbances, suicidality, and homicidality. Her orientation, memory, and knowledge could not be fully assessed. Her attention, insight, and judgment were impaired.

Admission diagnosis

Unspecified psychosis was not revealed due to a substance or known physiological condition.

Course of inpatient treatment

The patient was diagnosed with unspecified psychosis on admission. Workup ( Table 1 , Table 2 , Table 3 , Table 4 , Table 5 , Table 6 ) was done and the patient was restarted on risperidone for her aggression and hallucinations. On her first three days of hospitalization, she displayed aggressive, impulsive, and disruptive behaviors toward peers and staffs. Her risperidone was titrated up to 1.75 mg/day. Her aggression subsided and she was able to attend groups. However, she had difficulty engaging with others, often preferring to sit by herself and away from the crowd. She initially endorsed auditory and visual hallucinations where she saw shadows or gravesite with numbers. She would occasionally have difficulty distinguishing reality from fiction, often asking staff if they were real or part of her imagination. Early on in her treatment, the patient had several days when she reported “itching” on her chest stating that she was being stabbed by someone. Once that was resolved, she became preoccupied by her fingertips and would often be seen picking at the tips of her fingers. She struggled with being able to process information and was often mute or would repeat things that had been said to her or perseverate on a specific sentence. She displayed paranoia on the unit, often worrying that someone would come in and hurt her and at times feared that the staff would hurt her. Initially, she had trouble sleeping at night and would often stand in her doorway staring at staff for the majority of the night. She was allowed to sleep on a mattress in her doorway which seemed to help at times but not consistently. Later, she denied having hallucinations although she appeared internally preoccupied throughout the stay.

Neuropsychological assessment was completed which revealed that the patient’s IQ was likely in the borderline range (70–79). She had limited verbal comprehension and expression, relative weakness in verbal knowledge, fluid reasoning, set-shifting, visual-motor integration, phonemic and semantic fluency, and rote verbal memory. She also had significant deficits in executive functioning and negative and positive symptoms of psychosis.

Medical issues

Started on Vitamin D3 to correct for low Vitamin D.

Interventions at discharge

Due to the many challenges this patient presented and concerns about compliance with aftercare recommendations, she was referred to as many outpatient services as possible to help improve her prognosis. These services included partial hospitalization, involvement of children and youth services, case management services, family support in the form of patient’s paternal grandmother, referral for electroencephalogram (EEG) and magnetic resonance imaging (MRI) of brain and school involvement.

Partial hospital treatment

Upon arrival to partial hospitalization, patient’s behaviors had deteriorated due to non-compliance with medications for a week as a result of problem with insurance. She reported sporadic hallucinations, giggled by herself, displayed thought blocking, disorganized behaviors, made random, unrelated, bizarre statements, sometimes loudly and perseverated on them and was paranoid.

During her partial hospitalization, she was disruptive, made sexually inappropriate comments and became verbally and physically aggressive toward staff. As a result of these behaviors and her inability to tolerate the group setting of partial hospitalization, she had to be discharged to outpatient services. As was the case during her discharge from inpatient treatment, patient’s mother did not show up for her discharge and CYS had to find her.

When found, her mother once again claimed she was unaware of the discharge.

Follow-up in outpatient treatment

In the outpatient clinic, risperidone was titrated up to 1 mg orally twice a day, with a good response. Patient’s mother reported that the patient was doing well in school and seemed to be at her baseline after dose increase. During outpatient visits, the patient denied hallucinations, thought blocking was noted to improve, and the patient was answering questions and smiling appropriately most of the times.

Response latency and processing time remained slow but showed improved from previous visits. Family based mental health (FBMHS) services were recommended and started with in-home therapy 2–3 times a week. A case manager through CYS was recommended to support family in managing follow-up appointments.

Share Image:

Very early onset psychosis, defined as psychosis before the age of 13, is an extremely rare occurrence with an incidence of less than 0.04% [1] , [6] . One-third of children and adolescents with psychosis initially present with negative symptoms and 30% of those who present with negative symptoms at baseline go on to develop treatment failure with antipsychotics. Confounding these statistics is that VEOS is often difficult to diagnose, especially in this case due to lack of reliable collateral information from family. Our patient presented with several risk factors including father’s diagnosis of schizophrenia requiring institutionalization for the past 10 years. There was also a strong suspicion of mental illness in patient’s mother. Environmentally, our patient had a history of trauma in the form of bullying at school and she lacked social supports and lack of follow-up with treatment recommendations.

Additionally, our patient had several premorbid symptoms such as social withdrawal, poverty of speech, and steady decline in social and academic performance over the course of her educational history. Freeman et al. [4] have reported that there is a direct correlation between lower intellectual functioning and development of psychosis due to alteration in the way stimuli and events are interpreted. Another study demonstrated a significant association with psychosis and auditory hallucinations “that remained significant after controlling for age, gender, current social class and ethnicity” [5] . Childhood adversity, as experienced by this patient, also increases the risk of psychosis. A review by Varese et al. [3] showed that exposure to all types of adversity (except parental death) was related to an increased risk of psychosis. Furthermore, a recent study of adolescents experiencing psychosis suggested early intervention by a specialist team may improve treatment outcomes in both positive and negative symptoms [7] . This may also hold true for VEOS. At presentation, our patient displayed the following negative symptoms of schizophrenia: blunted affect, emotional withdrawal, poor rapport, social isolation, poverty of speech, mutism, and psychomotor retardation.

Comorbidities for this patient included oppositional defiant behaviors, borderline intellectual functioning and trauma in the form of physical and emotional abuse by peers, and suspicion of possible sexual abuse given her sexual acting out behaviors.

Our patient provided several treatment challenges due to her mother’s mental state and inability to provide reliable collateral information, non-compliance with follow-up with patient’s outpatient services, and non-compliance with following medication recommendations. Additionally, the lack of sufficient services for young children with psychosis made aftercare recommendations challenging for the treatment team.

Given the many complications this patient presented, the treatment team focused on utilizing the resources that were available such as patient’s paternal grandmother’s increased involvement in her care. There was also collaboration of care with outside agencies such as Children and Youth Services, Case Management, and her school. These services provided support to her mother and made her accountable for complying with aftercare plans and recommendations.

One-third of children and adolescents with psychosis initially present with negative symptoms and 30% of those with negative symptoms, develop treatment failure with antipsychotics. Given these statistics and the treatment challenges of treating children with psychosis, it is imperative to provide additional psychosocial supports to the patients and families, to improve overall functioning and long-term prognosis. This case presents an excellent example of many challenges that are faced in treating early onset psychosis.

SUPPORTING INFORMATION

Daisy Vyas Shirk - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Meenal Pathak - Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Jasmin Gange Lagman - Acquisition of data, Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Khurram S Janjua - Acquisition of data, Analysis of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The corresponding author is the guarantor of submission.

Written informed consent was obtained from the patient for publication of this article.

All relevant data are within the paper and its Supporting Information files.

Authors declare no conflict of interest.

© 2020 Daisy Vyas Shirk et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.

Comment on Article

Pulmonary embolism identified prior to anesthesia induction in a low-risk patient

Fatal arrhythmias despite early recognized successful treatment of digoxin toxicity

Unusual presentation of giant schwannoma in the sciatic nerve

• Article Access
• Abstract HTML
• Full Text PDF
• Full Text XML
• Download PDF
• Download Citation
• Print Article
• Share Article
• Via Facebook
• Via Twitter
• Via LinkedIn

Page Views: 924

PDF Downloads: 100

XML Downloads:

ePub Downloads:

Citations: 0

Reader Comments: 0

• Subject Areas

Message To Corresponding Author

• Frontiers in Psychiatry
• Schizophrenia
• Research Topics

Case Reports in Schizophrenia and Psychotic Disorders: 2023

Total Downloads

Total Views and Downloads

About this Research Topic

Frontiers in Psychiatry is proud to present our Case Reports series. Our case reports aim to highlight unique cases of patients that present with an unexpected/unusual diagnosis, including complexity and differential diagnosis and/or co-morbid diagnoses, treatment outcome, or clinical course. Case reports ...

Keywords : schizophrenia, case reports, psychotic, disorders

Important Note : All contributions to this Research Topic must be within the scope of the section and journal to which they are submitted, as defined in their mission statements. Frontiers reserves the right to guide an out-of-scope manuscript to a more suitable section or journal at any stage of peer review.

Topic Editors

Topic coordinators, recent articles, submission deadlines.

Participating Journals

Manuscripts can be submitted to this Research Topic via the following journals:

total views

• Demographics

No records found

total views article views downloads topic views

Top countries

Top referring sites, about frontiers research topics.

With their unique mixes of varied contributions from Original Research to Review Articles, Research Topics unify the most influential researchers, the latest key findings and historical advances in a hot research area! Find out more on how to host your own Frontiers Research Topic or contribute to one as an author.

Case study: treatment-resistant schizophrenia

WELLCOME CENTRE HUMAN NEUROIMAGING/SCIENCE PHOTO LIBRARY

Learning objectives

After reading this article, individuals should be able to:

• Describe the management of schizophrenia;
• Understand pharmaceutical issues that occur during treatment with antipsychotics, especially clozapine ;
• Explain how the Mental Health Act 1983 impacts on care;
• Understand the importance of multidisciplinary and patient-centred care in managing psychosis.

Around 0.5–0.7% of the UK population is living with schizophrenia. Of these individuals, up to one-third are classified as treatment-resistant. This is defined as schizophrenia that has not responded to two different antipsychotics ​[1,2]​ .

Clozapine is the most effective treatment for such patients ​[3]​ . It is recommended by the National Institute for Health and Care Excellence (NICE)[4], and is the only licensed medicine for this patient group ​[4,5]​ . For treatment-responsive patients, there should be a collaborative approach when choosing a treatment ​[4]​ . More information on the recognition and management of schizophrenia can be found in a previous article here , and in accompanying case studies  here . 

This case study aims to explore a patient’s journey in mental health services during a relapse of schizophrenia. It also aims to highlight good practice for communicating with patients with severe mental illness in all settings, and in explaining the role of clozapine. 

Case presentation

Mr AT is a male, aged 26 years, who has been diagnosed with paranoid schizophrenia. He moved to the UK with his family from overseas five years ago. He lives with his parents in a small flat in London. His mother calls the police after he goes missing, finding his past two months’ medication untouched. 

He is found at an airport, attempting to go through security without a ticket. He is confused and paranoid about the police asking him to come with them. 

He is taken to A&E and is medically cleared (see Box 1) ​[6]​ . 

Box 1: Common differentials for psychotic symptoms

Medical conditions can present as psychosis. These include:

• Intoxication/effects of drugs (cannabis, stimulants, opioids, corticosteroids);
• Cerebrovascular disease;
• Temporal lobe epilepsy.

Mr AT’s history is taken by a psychiatrist, and his crisis plan sought (as per NICE recommendations) but he does not have one ​[7]​ .

He has been under the care of mental health services for two years and disputes his diagnosis of paranoid schizophrenia. He was admitted to a psychiatric hospital 18 months ago where he was prescribed the antipsychotic amisulpride at 600mg daily. 

He is teetotal, smokes ten cigarettes a day and smokes cannabis every day. His BMI is 26 and he has hypercholesterolaemia (total cholesterol = 6.1mmol/L, reference range <5mmol/L) but all other tests are normal. 

He has no allergies. His only medication is amisulpride 600mg each morning, which he does not take. 

Medicines reconciliation

Mr AT is transferred to a psychiatric ward and placed under Section 2 of the Mental Health Act , allowing detention for up to 28 days for assessment and treatment (see Box 2).

Box 2: The Mental Health Act 1983

This legislation allows for the detention and treatment of patients with serious mental illness, where urgent care is required. This is often referred to as “sectioning”.

It includes regulations about treatment against a patient’s consent to safeguard patients’ liberty, which become more stringent with longer detentions.

Patients may only be given medication to treat their mental illness without their consent and may refuse physical health treatment. 

He denies any mental illness and tells the team they are conspiring with MI6. He is visibly experiencing auditory hallucinations: seen by him talking to himself and looking to empty corners of the room. Amisulpride is re-prescribed at 300mg, which he declines to take. 

A pharmacy technician completes a medicines reconciliation and contacts the care coordinator. The technician provides information about Mr AT’s treatment and feels he is still unwell as he has continued to express paranoid beliefs about his neighbours and MI6.

The ward pharmacist speaks to the patient. As per NICE guidance on medicines adherence , they adopt a non-judgemental attitude ​[8]​ . Mr AT is provided with information on the benefits and side effects of the medication and is asked open questions regarding his reluctance to take it. For more information on non-adherence to medicines and mental illness, see Box 3 ​[9]​ .

Box 3: Medicines adherence and mental health

Adherence to medication is similar for both physical and mental health medicines: only about 50% of patients are adherent. 

Side effects and lack of involvement in decision making often lead to poor adherence. 

In mental illness, other factors are: 

• Denial of illness (poor ‘insight’); 
• Lack of contact by services;
• Cultural factors, such as family, religious or personal beliefs around mental illness or medication.

Mr AT reports gynaecomastia and impotence, and says that he will not take any antipsychotics as they are “poison designed by MI6”, although is unable to concentrate on the discussion owing to hearing voices. 

He is prescribed clonazepam 1mg twice daily owing to his distress, which is to be reduced as treatment controls his psychosis. He is offered nicotine replacement therapy but decides to use an e-cigarette on the ward. 

He is unable to weigh up information to make decisions owing to his chaotic thinking and is felt to not have capacity to make decisions on his treatment. The team debates what treatment to offer.

Patient preference

Mr AT refuses all options presented to him. A decision is made to administer against his will and aripiprazole is chosen as it is less likely to cause hyperprolactinaemia and sexual dysfunction. He then agrees to take tablets “if it will get me out of hospital”. 

After eight weeks of treatment with orodispersible aripiprazole 15mg, Mr AT is able have a more coherent conversation, but is hallucinating and distressed. He is clearly under treated. The pharmacist attempts to complete a side-effect rating scale ( Glasgow Antipsychotic Side-effect Scale [GASS] ) but he declines. He is pacing around the ward in circles: it is felt he may be experiencing akathisia (restlessness) — a common side effect of antipsychotics (see  Table 1 ). 

Treatment review

The team feels clozapine is the best option owing to the treatment failure of two antipsychotics.  

The team suggests this to Mr AT. He refuses, stating the ward is experimenting on him with new medication and he refuses to take another antipsychotics. 

The pharmacist meets the patient with an occupational therapist to discuss what his goals are. Mr AT states he wants to go to college to become a carpenter. They discuss routes to achieve this, which all involve the first step of leaving hospital and the conclusion that clozapine is the best way to achieve this. The pharmacist clarifies the patient’s aripiprazole will not continue once clozapine is established. They leave information about clozapine with the patient and offer to return to discuss it further. 

Mr AT agrees to take clozapine a week later (see Box 4) ​[10–14]​ . Aripiprazole is tapered and stopped.

Box 4: Clozapine characteristics

Clozapine significantly prolongs life and improves quality of life ​[10]​ . Delaying clozapine is associated with poorer outcomes for patients ​[11]​ . 

Clozapine is under-prescribed owing to healthcare professionals’ anxiety and unfamiliarity around its use ​[12–14]​ .

It causes neutropenia in up to 3% of patients so regular monitoring is required . Twice-weekly monitoring is needed if neutrophils are <2 x10 9 /L. Most patients should stop clozapine if neutrophils are <1.5×10 9 /L. These ranges can differ from some laboratory definitions of neutropenia. 

Other side effects include sedation, hypersalivation and weight gain. See  Table 2  for red flags for serious side effects. 

Clozapine is titrated up slowly to avoid cardiovascular complications. A treatment break of >48 hours warrants specialist advice for a retitration plan. 

The pharmacist meets with Mr AT to discuss clozapine. He is told that this is likely to be a long-term treatment. The pharmacist acknowledges that the patient disagrees with his diagnosis, but this treatment is likely to prevent him from returning to hospital. 

He is started on clozapine at 12.5mg at night, which is slowly increased. Pre- and post-dose monitoring of his vital signs is completed. 

On day nine of the titration, his pulse is 115bpm. He otherwise feels well and blood tests show no signs of myocarditis (see   Table 2), so the titration is continued but slowed.

After 3 weeks he is taking 150mg twice daily of clozapine and his symptoms have significantly improved: he is regularly bathing, not visibly hallucinating and engaging with staff.

The pharmacy technician completes a GASS form. Mr AT reports constipation, hypersalivation and sedation. 

A pharmacist meets the patient to reiterate important counselling points, and discuss questions he may have about his treatment and how to manage side effects. Medication changes are made with the patients’ input: 

• His constipation is monitored with a stool chart and he is started on senna 15mg at night;
• He is started on hyoscine hydrobromide 300 micrograms at night for salivation;
• He is switched to clozapine 300mg once daily at night to simplify his regime and reduce daytime sedation. His clonazepam is reduced and stopped.

Smoking is discussed owing to tobacco’s role as an enzyme inducer (more information on tobacco smoking and its potential drug interactions can be found in a previous article here ). Mr AT states he will continue to use an e-cigarette for now. He is informed that if he starts smoking again, his clozapine may become less effective and he should immediately inform his team. 

He is discharged a few weeks later via a home treatment team and attends a clinic once weekly. On each attendance, he has a full blood count taken and analysed on site. He is assessed by a pharmacy technician and nurse for side effects and adherence to treatment, and his smoking status is clarified. 

The technician asks what he thinks the clozapine has done for him. Mr AT states he is still unsure about having a mental illness, but recognises that clozapine has helped him out of hospital and intends to continue taking it. 

Good practice in the pharmaceutical care of psychosis involves:

• Active patient involvement in discussions on treatment decisions;
• Regular review of treatment: discussing efficacy, side effects and the patient’s view and understanding of treatment; 
• Multidisciplinary approaches to helping patients choose treatment;
• For patients who dispute their diagnosis and the need for treatment, open dialogue is important. Such discussions should involve the patient’s goals, which are likely to be shared by the team (rapid discharge, preventing admissions, reducing distress); 
• Information about treatment should be provided regularly in both written and verbal form;
• Where appropriate, involve carers/next of kin in decision making and information sharing. 

Important points

• Schizophrenia affects 1 in 200 people, meaning such patients will present regularly in all settings;
• Patients with acute psychosis, who are in recovery, may be managed by specialist teams, who are the best source of information for a patient’s care;
• Collaborating with the patient on a viable long-term treatment plan improves adherence;
• Clozapine is recommended where two antipsychotics have failed;
• Clozapine is a high-risk medicine, but the risks are manageable;
• Hydrocarbons produced by smoking (but not nicotine replacement therapy, e-cigarettes or chewing tobacco) induce the enzyme CYP1A2, which reduces clozapine levels markedly (up to 20–60%). Starting or stopping smoking could precipitate relapse or induce toxicity, respectively.
• 1 Conley RR, Kelly DL. Management of treatment resistance in schizophrenia. Biological Psychiatry. 2001; 50 :898–911. doi: 10.1016/s0006-3223(01)01271-9
• 2 Gillespie AL, Samanaite R, Mill J, et al. Is treatment-resistant schizophrenia categorically distinct from treatment-responsive schizophrenia? a systematic review. BMC Psychiatry. 2017; 17 . doi: 10.1186/s12888-016-1177-y
• 3 Taylor DM. Clozapine for Treatment-Resistant Schizophrenia: Still the Gold Standard? CNS Drugs. 2017; 31 :177–80. doi: 10.1007/s40263-017-0411-6
• 4 Psychosis and schizophrenia in adults: prevention and management. NICE. 2014. https://www.nice.org.uk/guidance/cg178/ (accessed Jan 2022).
• 5 Clozaril 25 mg tablets. Electronic medicines compendium. 2020. https://www.medicines.org.uk/emc/product/4411/smpc (accessed Jan 2022).
• 6 Psychosis and schizophrenia: what else might it be? NICE. 2020. https://cks.nice.org.uk/topics/psychosis-schizophrenia/diagnosis/differential-diagnosis/ (accessed Jan 2022).
• 7 Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services. NICE. 2011. https://www.nice.org.uk/guidance/cg136/ (accessed Jan 2022).
• 8 Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence . NICE. 2009. https://www.nice.org.uk/guidance/cg76/ (accessed Jan 2022).
• 9 Taylor D, Barnes T, Young A. The Maudsley Prescribing Guidelines in Psychiatry . 13th ed. Hoboken, New Jersey: : Wiley 2018.
• 10 Meltzer HY, Burnett S, Bastani B, et al. Effects of Six Months of Clozapine Treatment on the Quality of Life of Chronic Schizophrenic Patients. PS. 1990; 41 :892–7. doi: 10.1176/ps.41.8.892
• 11 Üçok A, Çikrikçili U, Karabulut S, et al. Delayed initiation of clozapine may be related to poor response in treatment-resistant schizophrenia. International Clinical Psychopharmacology. 2015; 30 :290–5. doi: 10.1097/yic.0000000000000086
• 12 Whiskey E, Barnard A, Oloyede E, et al. An Evaluation of the Variation and Underuse of Clozapine in the United Kingdom. SSRN Journal. 2020. doi: 10.2139/ssrn.3716864
• 13 Nielsen J, Dahm M, Lublin H, et al. Psychiatrists’ attitude towards and knowledge of clozapine treatment. J Psychopharmacol. 2009; 24 :965–71. doi: 10.1177/0269881108100320
• 14 Verdoux H, Quiles C, Bachmann CJ, et al. Prescriber and institutional barriers and facilitators of clozapine use: A systematic review. Schizophrenia Research. 2018; 201 :10–9. doi: 10.1016/j.schres.2018.05.046
• This article was corrected on 31 January 2022 to clarify that tobacco is an enzyme inducer, not an enzyme inhibitor

Useful structured introduction to the subject for clinical purposes

Thank you Amrit for your feedback, we are pleased that you found this article useful.

Michael Dowdall, Executive Editor, Research & Learning

Please note that smoking causes enzyme INDUCTION not INHIBITION as stated. (Via aromatic polyhydrocarbons, not nicotine)

Hi James. Thank you for bringing this to our attention. This has now been corrected. Hannah Krol, Deputy Chief Subeditor

Only with Herbal formula I was able to cure my schizophrenia Illness with the product I purchase from Dr Sims Gomez Herbs A Clinic in South Africa

  Cancel reply

You must be logged in to post a comment.

You might also be interested in…

Psilocybin may be as effective as escitalopram in treating depression, study suggests

Special report: the stressors burning out pharmacists

How to assess mental health when prescribing

Very Early-Onset Schizophrenia in a Six-Year-Old Boy

Information & authors, metrics & citations, view options, key points/clinical pearls, acknowledgments, information, published in.

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu .

To download the citation to this article, select your reference manager software.

There are no citations for this item

View options

Login options.

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR ® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Share article link

Copying failed.

PREVIOUS ARTICLE

Next article, request username.

Can't sign in? Forgot your username? Enter your email address below and we will send you your username

If the address matches an existing account you will receive an email with instructions to retrieve your username

Create a new account

Change password, password changed successfully.

Your password has been changed

Reset password

Can't sign in? Forgot your password?

Enter your email address below and we will send you the reset instructions

If the address matches an existing account you will receive an email with instructions to reset your password.

Your Phone has been verified

As described within the American Psychiatric Association (APA)'s Privacy Policy and Terms of Use , this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences. Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

• Dermatology
• Gastroenterology
• Geriatric Medicine and Gerontology
• Gynecology and Obstetrics
• Heart and Vascular
• Neurology and Neurosurgery
• Ophthalmology
• Orthopaedics
• Otolaryngology–Head and Neck Surgery
• Physical Medicine and Rehabilitation
• Plastic and Reconstructive Surgery
• Psychiatry and Behavioral Sciences
• Pediatric Specialties
• Pediatric Diabetes and Endocrinology
• Pediatrics Florida
• Pediatric Gastroenterology and GI Surgery
• Pediatric Heart
• Pediatrics Maryland/DC
• Pediatric Neurology & Neurosurgery
• Pediatric Orthopaedics
• Physician Affiliations
• Health Care Technology
• High-Value Health Care
• Clinical Research Advancements
• Precision Medicine Excellence
• Patient Safety

Case Study Illustrates How Schizophrenia Can Often Be Overdiagnosed

Share Fast Facts

Study shows how schizophrenia can often be over diagnosed. Learn how. Click to Tweet

Study author Russell Margolis, director of the Johns Hopkins Schizophrenia Center, answers questions on misdiagnosis of the condition and reiterates the importance of thorough examination.

It’s not uncommon for an adolescent or young adult who reports hearing voices or seeing things to be diagnosed with schizophrenia, but using these reports alone can contribute to the disease being overdiagnosed, says  Russell Margolis , clinical director of the Johns Hopkins Schizophrenia Center. 

Many clinicians consider hallucinations as the sine qua non, or essential condition, of schizophrenia, he says. But even a true hallucination might be part of any number of disorders — or even within the range of normal. To diagnose a patient properly, he says, “There’s no substitute for taking time with patients and others who know them well. Trying to [diagnose] this in a compressed, shortcut kind of way leads to error.”

A case study he shared recently in the  Journal of Psychiatric Practice  illustrates the problem. Margolis, along with colleagues Krista Baker, schizophrenia supervisor at Johns Hopkins Bayview Medical Center, visiting resident Bianca Camerini, and Brazilian psychiatrist Ary Gadelha, described a 16-year-old girl who was referred to the Early Psychosis Intervention Clinic at Johns Hopkins Bayview for a second opinion concerning the diagnosis and treatment of suspected schizophrenia.

The patient made friends easily but had some academic difficulties. Returning to school in eighth grade after a period of home schooling, she was bullied, sexually groped and received texted death threats. She then began to complain of visions of a boy who harassed her, as well as three tall demons. The visions waxed and waned in relation to stress at school. The Johns Hopkins consultants determined that this girl did not have schizophrenia (or any other psychotic disorder), but that she had anxiety. They recommended psychotherapy and viewing herself as a healthy, competent person, instead of a sick one. A year later, the girl reported doing well: She was off medications and no longer complained of these visions.

Margolis answers  Hopkins Brain Wise ’s questions.

Q: How are anxiety disorders mistaken for schizophrenia?

A:  Patients often say they have hallucinations, but that doesn’t always mean they’re experiencing a true hallucination. What they may mean is that they have very vivid, distressing thoughts — in part because hallucinations have become a common way of talking about distress, and partly because they may have no other vocabulary with which to describe their experience. 

Then, even if it  is  a true hallucination, there are features of the way psychiatry has come to be practiced that cause difficulties. Electronic medical records are often designed with questionnaires that have yes or no answers. Sometimes, whether the patient has hallucinations is murky, or  possible —  not yes or no. Also, one can’t make a diagnosis based just on a hallucination; the diagnosis of disorders like schizophrenia is based on a constellation of symptoms. 

Q: How often are patients in this age range misdiagnosed?

A:  There’s no true way to know the numbers. Among a very select group of people in our consultation clinic where questions have been raised, about half who were referred to us and said to have schizophrenia or a related disorder did not. That is not generalizable.

Q:   Why does that happen?

A:  There is a lack of attention to the context of symptoms and other details, and there’s also a tendency to take patients literally. If a patient complains about x, there’s sometimes a pressure to directly address x. In fact, that’s not appropriate medicine. It is very important to pay attention to a patient’s stated concerns, but to place these concerns in the bigger picture. Clinicians can go too far in accepting at face value something that needs more exploration. 

Q: What lessons do you hope to impart by publishing this case?

A:  I want it to be understood that the diagnosis of schizophrenia has to be made with care. Clinicians need to take the necessary time and obtain the necessary information so that they’re not led astray. Eventually, we would like to have more objective measures for defining our disorders so that we do not need to rely totally on a clinical evaluation. 

Learn more about Russell Margolis’ research regarding the challenges of diagnosing schizophrenia .

• About Johns Hopkins Medicine
• Contact Johns Hopkins Medicine
• Centers & Departments
• Maps & Directions
• Find a Doctor
• Patient Care
• Terms & Conditions of Use
• Privacy Statement

Connect with Johns Hopkins Medicine

Join Our Social Media Communities >

Clinical Connection

• Otolaryngology—Head and Neck Surgery
• Contact Johns Hopkins

© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. All rights reserved.

Privacy Policy and Disclaimer

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 24 February 2022

Systematic literature review of schizophrenia clinical practice guidelines on acute and maintenance management with antipsychotics

• Christoph U. Correll   ORCID: orcid.org/0000-0002-7254-5646 1 , 2 , 3 ,
• Amber Martin 4 ,
• Charmi Patel 5 ,
• Carmela Benson 5 ,
• Rebecca Goulding 6 ,
• Jennifer Kern-Sliwa 5 ,
• Kruti Joshi 5 ,
• Emma Schiller 4 &
• Edward Kim   ORCID: orcid.org/0000-0001-8247-6675 7  

Schizophrenia volume  8 , Article number:  5 ( 2022 ) Cite this article

16k Accesses

59 Citations

14 Altmetric

Metrics details

• Schizophrenia

Clinical practice guidelines (CPGs) translate evidence into recommendations to improve patient care and outcomes. To provide an overview of schizophrenia CPGs, we conducted a systematic literature review of English-language CPGs and synthesized current recommendations for the acute and maintenance management with antipsychotics. Searches for schizophrenia CPGs were conducted in MEDLINE/Embase from 1/1/2004–12/19/2019 and in guideline websites until 06/01/2020. Of 19 CPGs, 17 (89.5%) commented on first-episode schizophrenia (FES), with all recommending antipsychotic monotherapy, but without agreement on preferred antipsychotic. Of 18 CPGs commenting on maintenance therapy, 10 (55.6%) made no recommendations on the appropriate maximum duration of maintenance therapy, noting instead individualization of care. Eighteen (94.7%) CPGs commented on long-acting injectable antipsychotics (LAIs), mainly in cases of nonadherence (77.8%), maintenance care (72.2%), or patient preference (66.7%), with 5 (27.8%) CPGs recommending LAIs for FES. For treatment-resistant schizophrenia, 15/15 CPGs recommended clozapine. Only 7/19 (38.8%) CPGs included a treatment algorithm.

Similar content being viewed by others

A meta-analysis of effectiveness of real-world studies of antipsychotics in schizophrenia: Are the results consistent with the findings of randomized controlled trials?

Factors associated with successful antipsychotic dose reduction in schizophrenia: a systematic review of prospective clinical trials and meta-analysis of randomized controlled trials

All-cause mortality risk in long-acting injectable versus oral antipsychotics in schizophrenia: a systematic review and meta-analysis

Introduction.

Schizophrenia is an often debilitating, chronic, and relapsing mental disorder with complex symptomology that manifests as a combination of positive, negative, and/or cognitive features 1 , 2 , 3 . Standard management of schizophrenia includes the use of antipsychotic medications to help control acute psychotic episodes 4 and prevent relapses 5 , 6 , whereas maintenance therapy is used in the long term after patients have been stabilized 7 , 8 , 9 . Two main classes of drugs—first- and second-generation antipsychotics (FGA and SGA)—are used to treat schizophrenia 10 . SGAs are favored due to the lower rates of adverse effects, such as extrapyramidal effects, tardive dyskinesia, and relapse 11 . However, pharmacologic treatment for schizophrenia is complicated because nonadherence is prevalent, and is a major risk factor for relapse 9 and poor overall outcomes 12 . The use of long-acting injectable (LAI) versions of antipsychotics aims to limit nonadherence-related relapses and poor outcomes 13 .

Patient treatment pathways and treatment choices are determined based on illness acuity/severity, past treatment response and tolerability, as well as balancing medication efficacy and adverse effect profiles in the context of patient preferences and adherence patterns 14 , 15 . Clinical practice guidelines (CPG) serve to inform clinicians with recommendations that reflect current evidence from meta-analyses of randomized controlled trials (RCTs), individual RCTs and, less so, epidemiologic studies, as well as clinical experience, with the goal of providing a framework and road-map for treatment decisions that will improve quality of care and achieve better patients outcomes. The use of clinical algorithms or other decision trees in CPGs may improve the ease of implementation of the evidence in clinical practice 16 . While CPGs are an important tool for mental health professionals, they have not been updated on a regular basis like they have been in other areas of medicine, such as in oncology. In the absence of current information, other governing bodies, healthcare systems, and hospitals have developed their own CPGs regarding the treatment of schizophrenia, and many of these have been recently updated 17 , 18 , 19 . As such, it is important to assess the latest guidelines to be aware of the changes resulting from consideration of updated evidence that informed the treatment recommendations. Since CPGs are comprehensive and include the diagnosis as well as the pharmacological and non-pharmacological management of individuals with schizophrenia, a detailed comparative review of all aspects of CPGs for schizophrenia would have been too broad a review topic. Further, despite ongoing efforts to broaden the pharmacologic tools for the treatment of schizophrenia 20 , antipsychotics remain the cornerstone of schizophrenia management 8 , 21 . Therefore, a focused review of guideline recommendations for the management of schizophrenia with antipsychotics would serve to provide clinicians with relevant information for treatment decisions.

To provide an updated overview of United States (US) national and English language international guidelines for the management of schizophrenia, we conducted a systematic literature review (SLR) to identify CPGs and synthesize current recommendations for pharmacological management with antipsychotics in the acute and maintenance phases of schizophrenia.

Systematic searches for the SLR yielded 1253 hits from the electronic literature databases. After removal of duplicate references, 1127 individual articles were screened at the title and abstract level. Of these, 58 publications were deemed eligible for screening at the full-text level, from which 19 were ultimately included in the SLR. Website searches of relevant organizations yielded 10 additional records, and an additional three records were identified by the state-by-state searches. Altogether, this process resulted in 32 records identified for inclusion in the SLR. Of the 32 sources, 19 primary CPGs, published/issued between 2004 and 2020, were selected for extraction, as illustrated in the PRISMA diagram (Fig. 1 ). While the most recent APA guideline was identified and available for download in 2020, the reference to cite in the document indicates a publication date of 2021.

SLR systematic literature review.

Of the 19 included CPGs (Table 1 ), three had an international focus (from the following organizations: International College of Neuropsychopharmacology [CINP] 22 , United Nations High Commissioner for Refugees [UNHCR] 23 , and World Federation of Societies of Biological Psychiatry [WFSBP] 24 , 25 , 26 ); seven originated from the US; 17 , 18 , 19 , 27 , 28 , 29 , 30 , 31 , 32 three were from the United Kingdom (British Association for Psychopharmacology [BAP] 33 , the National Institute for Health and Care Excellence [NICE] 34 , and the Scottish Intercollegiate Guidelines Network [SIGN] 35 ); and one guideline each was from Singapore 36 , the Polish Psychiatric Association (PPA) 37 , 38 , the Canadian Psychiatric Association (CPA) 14 , the Royal Australia/New Zealand College of Psychiatrists (RANZCP) 39 , the Association Française de Psychiatrie Biologique et de Neuropsychopharmacologie (AFPBN) from France 40 , and Italy 41 . Fourteen CPGs (74%) recommended treatment with specific antipsychotics and 18 (95%) included recommendations for the use of LAIs, while just seven included a treatment algorithm Table 2 ). The AGREE II assessment resulted in the highest score across the CPGs domains for NICE 34 followed by the American Psychiatric Association (APA) guidelines 17 . The CPA 14 , BAP 33 , and SIGN 35 CPGs also scored well across domains.

Acute therapy

Seventeen CPGs (89.5%) provided treatment recommendations for patients experiencing a first schizophrenia episode 14 , 17 , 18 , 19 , 22 , 23 , 24 , 28 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 39 , 40 , 41 , but the depth and focus of the information varied greatly (Supplementary Table 1 ). In some CPGs, information on treatment of a first schizophrenia episode was limited or grouped with information on treating any acute episode, such as in the CPGs from CINP 22 , AFPBN 40 , New Jersey Division of Mental Health Services (NJDMHS) 32 , the APA 17 , and the PPA 37 , 38 , while the others provided more detailed information specific to patients experiencing a first schizophrenia episode 14 , 18 , 19 , 23 , 24 , 28 , 33 , 34 , 35 , 36 , 39 , 41 . The American Association of Community Psychiatrists (AACP) Clinical Tips did not provide any information on the treatment of schizophrenia patients with a first episode 29 .

There was little agreement among CPGs regarding the preferred antipsychotic for a first schizophrenia episode. However, there was strong consensus on antipsychotic monotherapy and that lower doses are generally recommended due to better treatment response and greater adverse effect sensitivity. Some guidelines recommended SGAs over FGAs when treating a first-episode schizophrenia patient (RANZCP 39 , Texas Medication Algorithm Project [TMAP] 28 , Oregon Health Authority 19 ), one recommended starting patients on an FGA (UNHCR 23 ), and others stated specifically that there was no evidence of any difference in efficacy between FGAs and SGAs (WFSBP 24 , CPA 14 , SIGN 35 , APA 17 , Singapore guidelines 36 ), or did not make any recommendation (CINP 22 , Italian guidelines 41 , NICE 34 , NJDMHS 32 , Schizophrenia Patient Outcomes Research Team [PORT] 30 , 31 ). The BAP 33 and WFBSP 24 noted that while there was probably no difference between FGAs and SGAs in efficacy, some SGAs (olanzapine, amisulpride, and risperidone) may perform better than some FGAs. The Schizophrenia PORT recommendations noted that while there seemed to be no differences between SGAs and FGAs in short-term studies (≤12 weeks), longer studies (one to two years) suggested that SGAs may provide benefits in terms of longer times to relapse and discontinuation rates 30 , 31 . The AFPBN guidelines 40 and Florida Medicaid Program guidelines 18 , which both focus on use of LAI antipsychotics, both recommended an SGA-LAI for patients experiencing a first schizophrenia episode. A caveat in most CPGs was that physicians and their patients should discuss decisions about the choice of antipsychotic and that the choice should consider individual patient factors/preferences, risk of adverse and metabolic effects, and symptom patterns 17 , 18 , 19 , 22 , 24 , 28 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 39 , 41 .

Most CPGs recommended switching to a different monotherapy if the initial antipsychotic was not effective or not well tolerated after an adequate antipsychotic trial at an appropriate dose 14 , 17 , 18 , 19 , 22 , 23 , 24 , 28 , 32 , 33 , 35 , 36 , 39 . For patients initially treated with an FGA, the UNHCR recommended switching to an SGA (olanzapine or risperidone) 23 . Guidance on response to treatment varied in the measures used but typically required at least a 20% improvement in symptoms (i.e. reduction in Positive and Negative Syndrome Scale or Brief Psychiatric Rating Scale scores) from pre-treatment levels.

Several CPGs contained recommendations on the duration of antipsychotic therapy after a first schizophrenia episode. The NJDMHS guidelines 32 recommended nine to 12 months; CINP 22 recommended at least one year; CPA 14 recommended at least 18 months; WFSBP 25 , the Italian guidelines 41 , and NICE 34 recommended 1 to 2 years; and the RANZCP 39 , BAP 33 , and SIGN 35 recommended at least 2 years. The APA 17 and TMAP 28 recommended continuing antipsychotic treatment after resolution of first-episode symptoms but did not recommend a specific length of therapy.

Twelve guidelines 14 , 18 , 22 , 24 , 28 , 30 , 31 , 33 , 34 , 35 , 36 , 39 , 40 (63.2%) discussed the treatment of subsequent/multiple episodes of schizophrenia (i.e., following relapse). These CPGs noted that the considerations guiding the choice of antipsychotic for subsequent/multiple episodes were similar to those for a first episode, factoring in prior patient treatment response, adverse effect patterns and adherence. The CPGs also noted that response to treatment may be lower and require higher doses to achieve a response than for first-episode schizophrenia, that a different antipsychotic than used to treat the first episode may be needed, and that a switch to an LAI is an option.

Several CPGs provided recommendations for patients with specific clinical features (Supplementary Table 1 ). The most frequently discussed group of clinical features was negative symptoms, with recommendations provided in the CINP 22 , UNHCR 23 , WFSBP 24 , AFPBN 40 , SIGN 35 , BAP 33 , APA 17 , and NJDMHS guidelines; 32 negative symptoms were the sole focus of the guidelines from the PPA 37 , 38 . The guidelines noted that due to limited evidence in patients with predominantly negative symptoms, there was no clear benefit for any strategy, but that options included SGAs (especially amisulpride) rather than FGAs (WFSBP 24 , CINP 22 , AFPBN 40 , SIGN 35 , NJDMHS 32 , PPA 37 , 38 ), and addition of an antidepressant (WFSBP 24 , UNHCR 23 , SIGN 35 , NJDMHS 32 ) or lamotrigine (SIGN 35 ), or switching to another SGA (NJDMHS 32 ) or clozapine (NJDMHS 32 ). The PPA guidelines 37 , 38 stated that the use of clozapine or adding an antidepressant or other medication class was not supported by evidence, but recommended the SGA cariprazine for patients with predominant and persistent negative symptoms, and other SGAs for those with full-spectrum negative symptoms. However, the BAP 33 stated that no recommendations can be made for any of these strategies because of the quality and paucity of the available evidence.

Some of the CPGs also discussed treatment of other clinical features to a limited degree, including depressive symptoms (CINP 22 , UNHCR 23 , CPA 14 , APA 17 , and NJDMHS 32 ), cognitive dysfunction (CINP 22 , UNHCR 23 , WFSBP 24 , AFPBN 40 , SIGN 35 , BAP 33 , and NJDMHS 32 ), persistent aggression (CINP 22 , WFSBP 24 , CPA 14 , AFPBN 40 , NICE 34 , SIGN 35 , BAP 33 , and NJDMHS 32 ), and comorbid psychiatric diagnoses (CINP 22 , RANZCP 39 , BAP 33 , APA 17 , and NJDMHS 32 ).

Fifteen CPGs (78.9%) discussed treatment-resistant schizophrenia (TRS); all defined it as persistent, predominantly positive symptoms after two adequate antipsychotic trials; clozapine was the unanimous first choice 14 , 17 , 18 , 19 , 22 , 23 , 24 , 28 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 39 . However, the UNHCR guidelines 23 , which included recommendations for treatment of refugees, noted that clozapine is only a reasonable choice in regions where white blood cell monitoring and specialist supervision are available, otherwise, risperidone or olanzapine are alternatives if they had not been used in the previous treatment regimen.

There were few options for patients who are resistant to clozapine therapy, and evidence supporting these options was limited. The CPA guidelines 14 therefore stated that no recommendation can be given due to inadequate evidence. Other CPGs discussed options (but noted there was limited supporting evidence), such as switching to olanzapine or risperidone (WFSBP 24 , TMAP 28 ), adding a second antipsychotic to clozapine (CINP 22 , NICE 34 , TMAP 28 , BAP 33 , Florida Medicaid Program 18 , Oregon Health Authority 19 , RANZCP 39 ), adding lamotrigine or topiramate to clozapine (CINP 22 , Florida Medicaid Program 18 ), combination therapy with two non-clozapine antipsychotics (Florida Medicaid Program 18 , NJDMHS 32 ), and high-dose non-clozapine antipsychotic therapy (BAP 33 , SIGN 35 ). Electroconvulsive therapy was noted as a last resort for patients who did not respond to any pharmacologic therapy, including clozapine, by 10 CPGs 17 , 18 , 19 , 22 , 24 , 28 , 32 , 35 , 36 , 39 .

Maintenance therapy

Fifteen CPGs (78.9%) discussed maintenance therapy to various degrees via dedicated sections or statements, while three others referred only to maintenance doses by antipsychotic agent 18 , 23 , 29 without accompanying recommendations (Supplementary Table 2 ). Only the Italian guideline provided no reference or comments on maintenance treatment. The CINP 22 , WFSBP 25 , RANZCP 39 , and Schizophrenia PORT 30 , 31 recommended keeping patients on the same antipsychotic and at the same dose on which they had achieved remission. Several CPGs recommended maintenance therapy at the lowest effective dose (NJDMHS 32 , APA 17 , Singapore guidelines 36 , and TMAP 28 ). The CPA 14 and SIGN 35 defined the lower dose as 300–400 mg chlorpromazine equivalents or 4–6 mg risperidone equivalents, and the Singapore guidelines 36 stated that the lower dose should not be less than half the original dose. TMAP 28 stated that given the relapsing nature of schizophrenia, the maintenance dose should often be close to the original dose. While SIGN 35 recommended that patients remain on the same antipsychotic that provided remission, these guidelines also stated that maintenance with amisulpride, olanzapine, or risperidone was preferred, and that chlorpromazine and other low-potency FGAs were also suitable. The BAP 33 recommended that the current regimen be optimized before any dose reduction or switch to another antipsychotic occurs. Several CPGs recommended LAIs as an option for maintenance therapy (see next section).

Altogether, 10/18 (55.5%) CPGs made no recommendations on the appropriate duration of maintenance therapy, noting instead that each patient should be considered individually. Other CPGs made specific recommendations: Both the Both BAP 33 and SIGN 35 guidelines suggested a minimum of 2 years, the NJDMHS guidelines 32 recommended 2–3 years; the WFSBP 25 recommended 2–5 years for patients who have had one relapse and more than 5 years for those who have had multiple relapses; the RANZCP 39 and the CPA 14 recommended 2–5 years; and the CINP 22 recommended that maintenance therapy last at least 6 years for patients who have had multiple episodes. The TMAP was the only CPG to recommend that maintenance therapy be continued indefinitely 28 .

Recommendations on the use of LAIs

All CPGs except the one from Italy (94.7%) discussed the use of LAIs for patients with schizophrenia to some extent. As shown in Table 3 , among the 18 CPGs, LAIs were primarily recommended in 14 CPGs (77.8%) for patients who are non-adherent to other antipsychotic administration routes (CINP 22 , UNHCR 23 , RANZCP 39 , PPA 37 , 38 , Singapore guidelines 36 , NICE 34 , SIGN 35 , BAP 33 , APA 17 , TMAP 28 , NJDMHS 32 , AACP 29 , Oregon Health Authority 19 , Florida Medicaid Program 18 ). Twelve CPGs (66.7%) also noted that LAIs should be prescribed based on patient preference (RANZCP 39 , CPA 14 , AFPBN 40 , Singapore guidelines 36 , NICE 34 , SIGN 35 , BAP 33 , APA 17 , Schizophrenia PORT 30 , 31 , AACP 29 , Oregon Health Authority 19 , Florida Medicaid Program 18 ).

Thirteen CPGs (72.2%) recommended LAIs as maintenance therapy 18 , 19 , 24 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 39 , 40 . While five CPGs (27.8%), i.e., AFPBN 40 , RANZCP 39 , TMAP 28 , NJDMHS 32 , and the Florida Medicaid Program 18 recommended LAIs specifically for patients experiencing a first episode. While the CPA 14 did not make any recommendations regarding when LAIs should be used, they discussed recent evidence supporting their use earlier in treatment. Five guidelines (27.8%, i.e., Singapore 36 , NICE 34 , SIGN 35 , BAP 33 , and Schizophrenia PORT 30 , 31 ) noted that evidence around LAIs was not sufficient to support recommending their use for first-episode patients. The AFPBN guidelines 40 also stated that LAIs (SGAs as first-line and FGAs as second-line treatment) should be more frequently considered for maintenance treatment of schizophrenia. Four CPGs (22.2%, i.e., CINP 22 , UNHCR 23 , Italian guidelines 41 , PPA guidelines 37 , 38 ) did not specify when LAIs should be used. The AACP guidelines 29 , which evaluated only LAIs, recommended expanding their use beyond treatment for nonadherence, suggesting that LAIs may offer a more convenient mode of administration or potentially address other clinical and social challenges, as well as provide more consistent plasma levels.

Treatment algorithms

Only Seven CPGs (36.8%) included an algorithm as part of the treatment recommendations. These included decision trees or flow diagrams that map out initial therapy, durations for assessing response, and treatment options in cases of non-response. However, none of these guidelines defined how to measure response, a theme that also extended to guidelines that did not include treatment algorithms. Four of the seven guidelines with algorithms recommended specific antipsychotic agents, while the remaining three referred only to the antipsychotic class.

LAIs were not consistently incorporated in treatment algorithms and in six CPGs were treated as a separate category of medicine reserved for patients with adherence issues or a preference for the route of administration. The only exception was the Florida Medicaid Program 18 , which recommended offering LAIs after oral antipsychotic stabilization even to patients who are at that point adherent to oral antipsychotics.

Benefits and harms

The need to balance the efficacy and safety of antipsychotics was mentioned by all CPGs as a basic treatment paradigm.

Ten CPGs provided conclusions on benefits of antipsychotic therapy. The APA 17 and the BAP 33 guidelines stated that antipsychotic treatment can improve the positive and negative symptoms of psychosis and leads to remission of symptoms. These CPGs 17 , 33 as well as those from NICE 34 and CPA 14 stated that these treatment effects can also lead to improvements in quality of life (including quality-adjusted life years), improved functioning, and reduction in disability. The CPA 14 and APA 17 guidelines noted decreases in hospitalizations with antipsychotic therapy, and the APA guidelines 17 stated that long-term antipsychotic treatment can also reduce mortality. The UNHCR 23 and the Italian 41 guidelines noted that early intervention increased positive outcomes. The WFSBP 24 , AFPBN 40 , CPA 14 , BAP 33 , APA 17 , and NJDMHS 32 affirmed that relapse prevention is a benefit of continued/maintenance treatment.

Some CPGs (WFSBP 24 , Italian 41 , CPA 14 , and SIGN 35 ) noted that reduced risk for extrapyramidal adverse effects and treatment discontinuation were potential benefits of SGAs vs. FGAs.

The risk of adverse effects (e.g., extrapyramidal, metabolic, cardiovascular, and hormonal adverse effects, sedation, and neuroleptic malignant syndrome) was noted by all CPGs as the major potential harm of antipsychotic therapy 14 , 17 , 18 , 19 , 22 , 23 , 24 , 28 , 29 , 30 , 31 , 32 , 34 , 35 , 36 , 37 , 39 , 40 , 41 , 42 . These adverse effects are known to limit long-term treatment and adherence 24 .

This SLR of CPGs for the treatment of schizophrenia yielded 19 most updated versions of individual CPGs, published/issued between 2004 and 2020. Structuring our comparative review according to illness phase, antipsychotic type and formulation, response to antipsychotic treatment as well as benefits and harms, several areas of consistent recommendations emerged from this review (e.g., balancing risk and benefits of antipsychotics, preferring antipsychotic monotherapy; using clozapine for treatment-resistant schizophrenia). On the other hand, other recommendations regarding other areas of antipsychotic treatment were mostly consistent (e.g., maintenance antipsychotic treatment for some time), somewhat inconsistent (e.g., differences in the management of first- vs multi-episode patients, type of antipsychotic, dose of antipsychotic maintenance treatment), or even contradictory (e.g., role of LAIs in first-episode schizophrenia patients).

Consistent with RCT evidence 43 , 44 , antipsychotic monotherapy was the treatment of choice for patients with first-episode schizophrenia in all CPGs, and all guidelines stated that a different single antipsychotic should be tried if the first is ineffective or intolerable. Recommendations were similar for multi-episode patients, but factored in prior patient treatment response, adverse effect patterns, and adherence. There was also broad consensus that the side-effect profile of antipsychotics is the most important consideration when making a decision on pharmacologic treatment, also reflecting meta-analytic evidence 4 , 5 , 10 . The risk of extrapyramidal symptoms (especially with FGAs) and metabolic effects (especially with SGAs) were noted as key considerations, which are also reflected in the literature as relevant concerns 4 , 45 , 46 , including for quality of life and treatment nonadherence 47 , 48 , 49 , 50 .

Largely consistent with the comparative meta-analytic evidence regarding the acute 4 , 51 , 52 and maintenance antipsychotic treatment 5 effects of schizophrenia, the majority of CPGs stated there was no difference in efficacy between SGAs and FGAs (WFSBP 24 , CPA 14 , SIGN 35 , APA 17 , and Singapore guidelines 36 ), or did not make any recommendations (CINP 22 , Italian guidelines 41 , NICE 34 , NJDMHS 32 , and Schizophrenia PORT 30 , 31 ); three CPGs (BAP 33 , WFBSP 24 , and Schizophrenia PORT 30 , 31 ) noted that SGAs may perform better than FGAs over the long term, consistent with a meta-analysis on this topic 53 .

The 12 CPGs that discussed treatment of subsequent/multiple episodes generally agreed on the factors guiding the choices of an antipsychotic, including that the decision may be more complicated and response may be lower than with a first episode, as described before 7 , 54 , 55 , 56 .

There was little consensus regarding maintenance therapy. Some CPGs recommended the same antipsychotic and dose that achieved remission (CINP 22 , WFSBP 25 , RANZCP 39 , and Schizophrenia PORT 30 , 31 ) and others recommended the lowest effective dose (NJDMHS 32 , APA 17 , Singapore guidelines 36 , TMAP 28 , CPA 14 , and SIGN 35 ). This inconsistency is likely based on insufficient data as well as conflicting results in existing meta-analyses on this topic 57 , 58 , 59 .

The 15 CPGs that discussed TRS all used the same definition for this condition, consistent with recent commendations 60 , and agreed that clozapine is the primary evidence-based treatment choice 14 , 17 , 18 , 19 , 22 , 23 , 24 , 28 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 39 , reflecting the evidence base 61 , 62 , 63 . These CPGs also agreed that there are few options well supported by evidence for patients who do not respond to clozapine, with a recent meta-analysis of RCTs showing that electroconvulsive therapy augmentation may be the most evidence-based treatment option 64 .

One key gap in the treatment recommendations was how long patients should remain on antipsychotic therapy after a first episode or during maintenance therapy. While nine of the 17 CPGs discussing treatment of a first episode provided a recommended timeframe (varying from 1 to 2 years) 14 , 22 , 24 , 32 , 33 , 34 , 35 , 39 , 41 , the APA 17 and TMAP 28 recommended continuing antipsychotic treatment after resolution of first-episode symptoms but did not recommend a specific length of therapy. Similarly, six of the 18 CPGs discussing maintenance treatment recommended a specific duration of therapy (ranging from two to six years) 14 , 22 , 25 , 32 , 39 , while as many as 10 CPGs did not point to a firm end of the maintenance treatment, instead recommending individualized decisions. The CPGs not stating a definite endpoint or period of maintenance treatment after repeated schizophrenia episodes or even after a first episode of schizophrenia, reflects the different evidence types on which the recommendation is based. The RCT evidence ends after several years of maintenance treatment vs. discontinuation supporting ongoing antipsychotic treatment; however, naturalistic database studies do not indicate any time period after which one can safely discontinue maintenance antipsychotic care, even after a first schizophrenia episode 8 , 65 . In fact, stopping antipsychotics is associated not only with a substantially increased risk of hospitalization but also mortality 65 , 66 , 67 . In this sense, not stating an endpoint for antipsychotic maintenance therapy should not be taken as an implicit statement that antipsychotics should be discontinued at any time; data suggest the contrary.

A further gap exists regarding the most appropriate treatment of negative symptoms, such as anhedonia, amotivation, asociality, affective flattening, and alogia 1 , a long-standing challenge in the management of patients with schizophrenia. Negative symptoms often persist in patients after positive symptoms have resolved, or are the presenting feature in a substantial minority of patients 22 , 35 . Negative symptoms can also be secondary to pharmacotherapy 22 , 68 . Antipsychotics have been most successful in treating positive symptoms, and while eight of the CPGs provided some information on treatment of negative symptoms, the recommendations were generally limited 17 , 22 , 23 , 24 , 32 , 33 , 35 , 40 . Negative symptom management was a focus of the PPA guidelines, but the guidelines acknowledged that supporting evidence was limited, often due to the low number of patients with predominantly negative symptoms in clinical trials 37 , 38 . The Polish guidelines are also one of the more recently developed and included the newer antipsychotic cariprazine as a first-line option, which although being a point of differentiation from the other guidelines, this recommendation was based on RCT data 69 .

Another area in which more direction is needed is on the use of LAIs. While all but one of the 19 CPGs discussed this topic, the extent of information and recommendations for LAI use varied considerably. All CPGs categorized LAIs as an option to improve adherence to therapy or based on patient preference. However, 5/18 CPGs (27.8%) recommended the use of LAI early in treatment (at first episode: AFPBN 40 , RANZCP 39 , TMAP 28 , NJDMHS 32 , and Florida Medicaid Program 18 ) or across the entire illness course, while five others stated there was not sufficient evidence to recommend LAIs for these patients (Singapore 36 , NICE 34 , SIGN 35 , BAP 33 , and Schizophrenia PORT 30 , 31 ). The role of LAIs in first-episode schizophrenia was the only point where opposing recommendations were found across CPGs. This contradictory stance was not due to the incorporation of newer data suggesting benefits of LAIs in first episode and early-phase patients with schizophrenia 70 , 71 , 72 , 73 , 74 in the CPGs recommending LAI use in first-episode patients, as CPGs recommending LAI use were published between 2005 and 2020, while those opposing LAI use were published between 2011 and 2020. Only the Florida Medicaid CPG recommended LAIs as a first step equivalent to oral antipsychotics (OAP) after initial OAP response and tolerability, independent of nonadherence or other clinical variables. This guideline was also the only CPG to fully integrate LAI use in their clinical algorithm. The remaining six CPGs that included decision tress or treatment algorithms regarded LAIs as a separate paradigm of treatment reserved for nonadherence or patients preference rather than a routine treatment option to consider. While some CPGs provided fairly detailed information on the use of LAIs (AFPBN 40 , AACP 29 , Oregon Health Authority 19 , and Florida Medicaid Program 18 ), others mentioned them only in the context of adherence issues or patient preference. Notably, definitions of and means to determine nonadherence were not reported. One reason for this wide range of recommendations regarding the placement of LAIs in the treatment algorithm and clinical situations that prompt LAI use might be due to the fact that CPGs generally favor RCT evidence over evidence from other study designs. In the case of LAIs, there was a notable dissociation between consistent meta-analytic evidence of statistically significant superiority of LAIs vs OAPs in mirror-image 75 and cohort study designs 76 and non-significant advantages in RCTs 77 . Although patients in RCTs comparing LAIs vs OAPs were less severely ill and more adherent to OAPs 77 than in clinical care and although mirror-image and cohort studies arguably have greater external validity than RCTs 78 , CPGs generally disregard evidence from other study designs when RCT evidence exits. This narrow focus can lead to disregarding important additional data. Nevertheless, a most updated meta-analysis of all 3 study designs comparing LAIs with OAPs demonstrated consistent superiority of LAIs vs OAPs for hospitalization or relapse across all 3 designs 79 , which should lead to more uniform recommendations across CPGs in the future.

Only seven CPGs included treatment algorithms or flow charts to guide LAI treatment selection for patients with schizophrenia 17 , 18 , 19 , 24 , 29 , 35 , 40 . However, there was little commonality across algorithms beyond the guidance on LAIs mentioned above, as some listed specific treatments and conditions for antipsychotic switches, while others indicated that medication choice should be based on a patient’s preferences and responses, side effects, and in some cases, cost effectiveness. Since algorithms and flow charts facilitate the reception, adoption and implementation of guidelines, future CPGs should include them as dissemination tools, but they need to reflect the data and detailed text and be sufficiently specific to be actionable.

The systematic nature in the identification, summarization, and assessment of the CPGs is a strength of this review. This process removed any potential bias associated with subjective selection of evidence, which is not reproducible. However, only CPGs published in English were included and regardless of their quality and differing timeframes of development and publication, complicating a direct comparison of consensus and disagreement. Finally, based on the focus of this SLR, we only reviewed pharmacologic management with antipsychotics. Clearly, the assessment, other pharmacologic and, especially, psychosocial interventions are important in the management of individuals with schizophrenia, but these topics that were covered to varying degrees by the evaluated CPGs were outside of the scope of this review.

Numerous guidelines have recently updated their recommendations on the pharmacological treatment of patients with schizophrenia, which we have summarized in this review. Consistent recommendations were observed across CPGs in the areas of balancing risk and benefits of antipsychotics when selecting treatment, a preference for antipsychotic monotherapy, especially for patients with a first episode of schizophrenia, and the use of clozapine for treatment-resistant schizophrenia. By contrast, there were inconsistencies with regards to recommendations on maintenance antipsychotic treatment, with differences existing on type and dose of antipsychotic, as well as the duration of therapy. However, LAIs were consistently recommended, but mainly suggested in cases of nonadherence or patient preference, despite their established efficacy in broader patient populations and clinical scenarios in clinical trials. Guidelines were sometimes contradictory, with some recommending LAI use earlier in the disease course (e.g., first episode) and others suggesting they only be reserved for later in the disease. This inconsistency was not due to lack of evidence on the efficacy of LAIs in first-episode schizophrenia or the timing of the CPG, so that other reasons might be responsible, including possibly bias and stigma associated with this route of treatment administration. Lastly, gaps existed in the guidelines for recommendations on the duration of maintenance treatment, treatment of negative symptoms, and the development/use of treatment algorithms whenever evidence is sufficient to provide a simplified summary of the data and indicate their relevance for clinical decision making, all of which should be considered in future guideline development/revisions.

The SLR followed established best methods used in systematic review research to identify and assess the available CPGs for pharmacologic treatment of schizophrenia with antipsychotics in the acute and maintenance phases 80 , 81 . The SLR was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including use of a prespecified protocol to outline methods for conducting the review. The protocol for this review was approved by all authors prior to implementation but was not submitted to an external registry.

Data sources and search algorithms

Searches were conducted by two independent investigators in the MEDLINE and Embase databases via OvidSP to identify CPGs published in English. Articles were identified using search algorithms that paired terms for schizophrenia with keywords for CPGs. Articles indexed as case reports, reviews, letters, or news were excluded from the searches. The database search was limited to CPGs published from January 1, 2004, through December 19, 2019, without limit to geographic location. In addition to the database sources, guideline body websites and state-level health departments from the US were also searched for relevant CPGs published through June 2020. A manual check of the references of recent (i.e., published in the past three years), relevant SLRs and relevant practice CPGs was conducted to supplement the above searches and ensure and the most complete CPG retrieval.

This study did not involve human subjects as only published evidence was included in the review; ethical approval from an institution was therefore not required.

Selection of CPGs for inclusion

Each title and abstract identified from the database searches was screened and selected for inclusion or exclusion in the SLR by two independent investigators based on the populations, interventions/comparators, outcomes, study design, time period, language, and geographic criteria shown in Table 4 . During both rounds of the screening process, discrepancies between the two independent reviewers were resolved through discussion, and a third investigator resolved any disagreement. Articles/documents identified by the manual search of organizational websites were screened using the same criteria. All accepted studies were required to meet all inclusion criteria and none of the exclusion criteria. Only the most recent version of organizational CPGs was included for data extraction.

Data extraction and synthesis

Information on the recommendations regarding the antipsychotic management in the acute and maintenance phases of schizophrenia and related benefits and harms was captured from the included CPGs. Each guideline was reviewed and extracted by a single researcher and the data were validated by a senior team member to ensure accuracy and completeness. Additionally, each included CPG was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Following extraction and validation, results were qualitatively summarized across CPGs.

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

The data that support the findings of the SLR are available from the corresponding author upon request.

Correll, C. U. & Schooler, N. R. Negative symptoms in schizophrenia: a review and clinical guide for recognition, assessment, and treatment. Neuropsychiatr. Dis. Treat. 16 , 519–534 (2020).

Article   PubMed   PubMed Central   Google Scholar  

Kahn, R. S. et al. Schizophrenia. Nat. Rev. Dis. Prim. 1 , 15067 (2015).

Article   PubMed   Google Scholar  

Millan, M. J. et al. Altering the course of schizophrenia: progress and perspectives. Nat. Rev. Drug Discov. 15 , 485–515 (2016).

Article   CAS   PubMed   Google Scholar  

Huhn, M. et al. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet 394 , 939–951 (2019).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Kishimoto, T., Hagi, K., Nitta, M., Kane, J. M. & Correll, C. U. Long-term effectiveness of oral second-generation antipsychotics in patients with schizophrenia and related disorders: a systematic review and meta-analysis of direct head-to-head comparisons. World Psychiatry 18 , 208–224 (2019).

Leucht, S. et al. Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet 379 , 2063–2071 (2012).

Carbon, M. & Correll, C. U. Clinical predictors of therapeutic response to antipsychotics in schizophrenia. Dialogues Clin. Neurosci. 16 , 505–524 (2014).

Correll, C. U., Rubio, J. M. & Kane, J. M. What is the risk-benefit ratio of long-term antipsychotic treatment in people with schizophrenia? World Psychiatry 17 , 149–160 (2018).

Emsley, R., Chiliza, B., Asmal, L. & Harvey, B. H. The nature of relapse in schizophrenia. BMC Psychiatry 13 , 50 (2013).

Correll, C. U. & Kane, J. M. Ranking antipsychotics for efficacy and safety in schizophrenia. JAMA Psychiatry 77 , 225–226 (2020).

Kane, J. M. & Correll, C. U. Pharmacologic treatment of schizophrenia. Dialogues Clin. Neurosci. 12 , 345–357 (2010).

Kane, J. M., Kishimoto, T. & Correll, C. U. Non-adherence to medication in patients with psychotic disorders: epidemiology, contributing factors and management strategies. World Psychiatry 12 , 216–226 (2013).

Correll, C. U. et al. The use of long-acting injectable antipsychotics in schizophrenia: evaluating the evidence. J. Clin. Psychiatry 77 , 1–24 (2016).

Remington, G. et al. Guidelines for the pharmacotherapy of schizophrenia in adults. Can. J. Psychiatry 62 , 604–616 (2017).

American Psychiatric Association. Treatment recommendations for patients with schizophrenia. Am. J. Psychiatry 161 , 1–56 (2004).

Institute of Medicine (US) Committee to Advise the Public Health Service on Clinical Practice Guidelines, Field, M. J., & Lohr, K. N. (Eds.). Clinical Practice Guidelines: Directions for a New Program. (National Academies Press (US), 1990).

American Psychiatric Association. Practice Guideline for the Treatment of Patients With Schizophrenia , 3rd edn. (2021). https://doi.org/10.1176/appi.books.9780890424841 .

Florida Medicaid Drug Therapy Management Program. 2019–2020 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults . (2020). Available at: https://floridabhcenter.org/wp-content/uploads/2021/04/2019-Psychotherapeutic-Medication-Guidelines-for-Adults-with-References_06-04-20.pdf .

Mental Health Clinical Advisory Group, Oregon Health Authority. Mental Health Care Guide for Licensed Practitioners and Mental Health Professionals. (2019). Available at: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le7548.pdf .

Krogmann, A. et al. Keeping up with the therapeutic advances in schizophrenia: a review of novel and emerging pharmacological entities. CNS Spectr. 24 , 38–69 (2019).

Fountoulakis, K. N. et al. The report of the joint WPA/CINP workgroup on the use and usefulness of antipsychotic medication in the treatment of schizophrenia. CNS Spectr . https://doi.org/10.1017/S1092852920001546 (2020).

Leucht, S. et al. CINP Schizophrenia Guidelines . (CINP, 2013). Available at: https://www.cinp.org/resources/Documents/CINP-schizophrenia-guideline-24.5.2013-A-C-method.pdf .

Ostuzzi, G. et al. Mapping the evidence on pharmacological interventions for non-affective psychosis in humanitarian non-specialised settings: A UNHCR clinical guidance. BMC Med. 15 , 197 (2017).

Hasan, A. et al. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 1: Update 2012 on the acute treatment of schizophrenia and the management of treatment resistance. World J. Biol. Psychiatry 13 , 318–378 (2012).

Hasan, A. et al. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 2: Update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects. World J. Biol. Psychiatry 14 , 2–44 (2013).

Hasan, A. et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia - a short version for primary care. Int. J. Psychiatry Clin. Pract. 21 , 82–90 (2017).

Moore, T. A. et al. The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2006 update. J. Clin. Psychiatry 68 , 1751–1762 (2007).

Texas Medication Algorithm Project (TMAP). Texas Medication Algorithm Project (TMAP) Procedural Manual . (2008). Available at: https://jpshealthnet.org/sites/default/files/inline-files/tmapalgorithmforschizophrenia.pdf .

American Association of Community Psychiatrists (AACP). Clinical Tips Series, Long Acting Antipsychotic Medications. (2017). Accessed at: https://drive.google.com/file/d/1unigjmjFJkqZMbaZ_ftdj8oqog49awZs/view .

Buchanan, R. W. et al. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr. Bull. 36 , 71–93 (2010).

Kreyenbuhl, J. et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr. Bull. 36 , 94–103 (2010).

New Jersey Division of Mental Health Services. Pharmacological Practice Guidelines for the Treatment of Schizophrenia . (2005). Available at: https://www.state.nj.us/humanservices/dmhs_delete/consumer/NJDMHS_Pharmacological_Practice_Guidelines762005.pdf .

Barnes, T. R. et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J. Psychopharmacol. 34 , 3–78 (2020).

National Institute for Health and Care Excellence (NICE). Psychosis and schizophrenia in adults: prevention and management. (2014). Available at: http://www.nice.org.uk/guidance/cg178 .

Scottish Intercollegiate Guidelines Network (SIGN). Management of Schizophrenia: A National Clinical Guideline . (2013). Available at: https://www.sign.ac.uk/assets/sign131.pdf .

Verma, S. et al. Ministry of Health Clinical Practice Guidelines: Schizophrenia. Singap. Med. J. 52 , 521–526 (2011).

CAS   Google Scholar  

Szulc, A. et al. Recommendations for the treatment of schizophrenia with negative symptoms. Standards of pharmacotherapy by the Polish Psychiatric Association (Polskie Towarzystwo Psychiatryczne), part 1. Rekomendacje dotyczace leczenia schizofrenii z. objawami negatywnymi. Stand. farmakoterapii Polskiego Tow. Psychiatrycznego, czesc 1. 53 , 497–524 (2019).

Google Scholar  

Szulc, A. et al. Recommendations for the treatment of schizophrenia with negative symptoms. Standards of pharmacotherapy by the Polish Psychiatric Association (Polskie Towarzystwo Psychiatryczne), part 2. Rekomendacje dotyczace leczenia schizofrenii z. objawami negatywnymi. Stand. farmakoterapii Polskiego Tow. Psychiatrycznego, czesc 2. 53 , 525–540 (2019).

Galletly, C. et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust. N. Z. J. Psychiatry 50 , 410–472 (2016).

Llorca, P. M. et al. Guidelines for the use and management of long-acting injectable antipsychotics in serious mental illness. BMC Psychiatry 13 , 340 (2013).

De Masi, S. et al. The Italian guidelines for early intervention in schizophrenia: development and conclusions. Early Intervention Psychiatry 2 , 291–302 (2008).

Article   Google Scholar  

Barnes, T. R. Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology. J. Psychopharmacol. 25 , 567–620 (2011).

Correll, C. U. et al. Efficacy of 42 pharmacologic cotreatment strategies added to antipsychotic monotherapy in schizophrenia: systematic overview and quality appraisal of the meta-analytic evidence. JAMA Psychiatry 74 , 675–684 (2017).

Galling, B. et al. Antipsychotic augmentation vs. monotherapy in schizophrenia: systematic review, meta-analysis and meta-regression analysis. World Psychiatry 16 , 77–89 (2017).

Pillinger, T. et al. Comparative effects of 18 antipsychotics on metabolic function in patients with schizophrenia, predictors of metabolic dysregulation, and association with psychopathology: a systematic review and network meta-analysis. Lancet Psychiatry 7 , 64–77 (2020).

Rummel-Kluge, C. et al. Second-generation antipsychotic drugs and extrapyramidal side effects: a systematic review and meta-analysis of head-to-head comparisons. Schizophr. Bull. 38 , 167–177 (2012).

Angermeyer, M. C. & Matschinger, H. Attitude of family to neuroleptics. Psychiatr. Prax. 26 , 171–174 (1999).

CAS   PubMed   Google Scholar  

Dibonaventura, M., Gabriel, S., Dupclay, L., Gupta, S. & Kim, E. A patient perspective of the impact of medication side effects on adherence: results of a cross-sectional nationwide survey of patients with schizophrenia. BMC Psychiatry 12 , 20 (2012).

McIntyre, R. S. Understanding needs, interactions, treatment, and expectations among individuals affected by bipolar disorder or schizophrenia: the UNITE global survey. J. Clin. Psychiatry 70 (Suppl 3), 5–11 (2009).

Tandon, R. et al. The impact on functioning of second-generation antipsychotic medication side effects for patients with schizophrenia: a worldwide, cross-sectional, web-based survey. Ann. Gen. Psychiatry 19 , 42 (2020).

Zhang, J. P. et al. Efficacy and safety of individual second-generation vs. first-generation antipsychotics in first-episode psychosis: a systematic review and meta-analysis. Int. J. Neuropsychopharmacol. 16 , 1205–1218 (2013).

Zhu, Y. et al. Antipsychotic drugs for the acute treatment of patients with a first episode of schizophrenia: a systematic review with pairwise and network meta-analyses. Lancet Psychiatry 4 , 694–705 (2017).

Kishimoto, T. et al. Relapse prevention in schizophrenia: a systematic review and meta-analysis of second-generation antipsychotics versus first-generation antipsychotics. Mol. Psychiatry 18 , 53–66 (2013).

Leucht, S. et al. Sixty years of placebo-controlled antipsychotic drug trials in acute schizophrenia: systematic review, Bayesian meta-analysis, and meta-regression of efficacy predictors. Am. J. Psychiatry 174 , 927–942 (2017).

Samara, M. T., Nikolakopoulou, A., Salanti, G. & Leucht, S. How many patients with schizophrenia do not respond to antipsychotic drugs in the short term? An analysis based on individual patient data from randomized controlled trials. Schizophr. Bull. 45 , 639–646 (2019).

Zhu, Y. et al. How well do patients with a first episode of schizophrenia respond to antipsychotics: a systematic review and meta-analysis. Eur. Neuropsychopharmacol. 27 , 835–844 (2017).

Bogers, J. P. A. M., Hambarian, G., Michiels, M., Vermeulen, J. & de Haan, L. Risk factors for psychotic relapse after dose reduction or discontinuation of antipsychotics in patients with chronic schizophrenia. A systematic review and meta-analysis. Schizophr. Bull. Open 46 , Suppl 1 S326 (2020).

Tani, H. et al. Factors associated with successful antipsychotic dose reduction in schizophrenia: a systematic review of prospective clinical trials and meta-analysis of randomized controlled trials. Neuropsychopharmacology 45 , 887–901 (2020).

Uchida, H., Suzuki, T., Takeuchi, H., Arenovich, T. & Mamo, D. C. Low dose vs standard dose of antipsychotics for relapse prevention in schizophrenia: meta-analysis. Schizophr. Bull. 37 , 788–799 (2011).

Howes, O. D. et al. Treatment-resistant schizophrenia: treatment response and resistance in psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. Am. J. Psychiatry 174 , 216–229 (2017).

Masuda, T., Misawa, F., Takase, M., Kane, J. M. & Correll, C. U. Association with hospitalization and all-cause discontinuation among patients with schizophrenia on clozapine vs other oral second-generation antipsychotics: a systematic review and meta-analysis of cohort studies. JAMA Psychiatry 76 , 1052–1062 (2019).

Siskind, D., McCartney, L., Goldschlager, R. & Kisely, S. Clozapine v. first- and second-generation antipsychotics in treatment-refractory schizophrenia: systematic review and meta-analysis. Br. J. Psychiatry 209 , 385–392 (2016).

Siskind, D., Siskind, V. & Kisely, S. Clozapine response rates among people with treatment-resistant schizophrenia: data from a systematic review and meta-analysis. Can. J. Psychiatry 62 , 772–777 (2017).

Wang, G. et al. ECT augmentation of clozapine for clozapine-resistant schizophrenia: a meta-analysis of randomized controlled trials. J. Psychiatr. Res. 105 , 23–32 (2018).

Tiihonen, J., Tanskanen, A. & Taipale, H. 20-year nationwide follow-up study on discontinuation of antipsychotic treatment in first-episode schizophrenia. Am. J. Psychiatry 175 , 765–773 (2018).

Taipale, H. et al. Antipsychotics and mortality in a nationwide cohort of 29,823 patients with schizophrenia. Schizophr. Res . 197 , 274–280 (2018).

Taipale, H. et al. 20-year follow-up study of physical morbidity and mortality in relationship to antipsychotic treatment in a nationwide cohort of 62,250 patients with schizophrenia (FIN20). World Psychiatry 19 , 61–68 (2020).

Carbon, M. & Correll, C. U. Thinking and acting beyond the positive: the role of the cognitive and negative symptoms in schizophrenia. CNS Spectr. 19 (Suppl 1), 38–52 (2014).

PubMed   Google Scholar  

Krause, M. et al. Antipsychotic drugs for patients with schizophrenia and predominant or prominent negative symptoms: a systematic review and meta-analysis. Eur. Arch. Psychiatry Clin. Neurosci. 268 , 625–639 (2018).

Kane, J. M. et al. Effect of long-acting injectable antipsychotics vs usual care on time to first hospitalization in early-phase schizophrenia: a randomized clinical trial. JAMA Psychiatry 77 , 1217–1224 (2020).

Schreiner, A. et al. Paliperidone palmitate versus oral antipsychotics in recently diagnosed schizophrenia. Schizophr. Res. 169 , 393–399 (2015).

Subotnik, K. L. et al. Long-acting injectable risperidone for relapse prevention and control of breakthrough symptoms after a recent first episode of schizophrenia. A randomized clinical trial. JAMA Psychiatry 72 , 822–829 (2015).

Tiihonen, J. et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am. J. Psychiatry 168 , 603–609 (2011).

Zhang, F. et al. Efficacy, safety, and impact on hospitalizations of paliperidone palmitate in recent-onset schizophrenia. Neuropsychiatr. Dis. Treat. 11 , 657–668 (2015).

Kishimoto, T., Nitta, M., Borenstein, M., Kane, J. M. & Correll, C. U. Long-acting injectable versus oral antipsychotics in schizophrenia: a systematic review and meta-analysis of mirror-image studies. J. Clin. Psychiatry 74 , 957–965 (2013).

Kishimoto, T. et al. Effectiveness of long-acting injectable vs oral antipsychotics in patients with schizophrenia: a meta-analysis of prospective and retrospective cohort studies. Schizophr. Bull. 44 , 603–619 (2018).

Kishimoto, T. et al. Long-acting injectable vs oral antipsychotics for relapse prevention in schizophrenia: a meta-analysis of randomized trials. Schizophr. Bull. 40 , 192–213 (2014).

Kane, J. M., Kishimoto, T. & Correll, C. U. Assessing the comparative effectiveness of long-acting injectable vs. oral antipsychotic medications in the prevention of relapse provides a case study in comparative effectiveness research in psychiatry. J. Clin. Epidemiol. 66 , S37–41 (2013).

Kishimoto, T., Hagi, K., Kurokawa, S., Kane, J. M. & Correll, C. U. Long-acting injectable versus oral antipsychotics for the maintenance treatment of schizophrenia: a systematic review and comparative meta-analysis of randomised, cohort, and pre-post studies. Lancet Psychiatry 8 , 387–404 (2021).

Cook, D. J., Mulrow, C. D. & Haynes, R. B. Systematic reviews: synthesis of best evidence for clinical decisions. Ann. Intern. Med. 126 , 376–380 (1997).

Higgins, J. P. T. & Green, S. Cochrane Collaboration Handbook for Systematic Reviews of Interventions . (The Cochrane Collaboration and John Wiley & Sons, Ltd, 2008).

Download references

Acknowledgements

This study received financial funding from Janssen Scientific Affairs.

Open Access funding enabled and organized by Projekt DEAL.

Author information

Authors and affiliations.

The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA

• Christoph U. Correll

Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA

Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany

Evidera, Waltham, MA, USA

Amber Martin & Emma Schiller

Janssen Scientific Affairs, LLC, Titusville, NJ, USA

Charmi Patel, Carmela Benson, Jennifer Kern-Sliwa & Kruti Joshi

Goulding HEOR Consulting Inc., Vancouver, BC, Canada

Rebecca Goulding

Biohaven Pharmaceuticals, New Haven, CT, USA

You can also search for this author in PubMed   Google Scholar

Contributions

C.C., A.M., R.G., C.P., C.B., K.J., J.K.S., E.S. and E.K. contributed to the conception and the design of the study. A.M., R.G. and E.S. conducted the literature review, including screening, and extraction of the included guidelines. All authors contributed to the interpretations of the results for the review; A.M. and C.C. drafted the manuscript and all authors revised it critically for intellectual content. All authors gave their final approval of the completed manuscript.

Corresponding author

Correspondence to Christoph U. Correll .

Ethics declarations

Competing interests.

C.C. has received personal fees from Alkermes plc, Allergan plc, Angelini Pharma, Gedeon Richter, Gerson Lehrman Group, Intra-Cellular Therapies, Inc, Janssen Pharmaceutica/Johnson & Johnson, LB Pharma International BV, H Lundbeck A/S, MedAvante-ProPhase, Medscape, Neurocrine Biosciences, Noven Pharmaceuticals, Inc, Otsuka Pharmaceutical Co, Inc, Pfizer, Inc, Recordati, Rovi, Sumitomo Dainippon Pharma, Sunovion Pharmaceuticals, Inc, Supernus Pharmaceuticals, Inc, Takeda Pharmaceutical Company Limited, Teva Pharmaceuticals, Acadia Pharmaceuticals, Inc, Axsome Therapeutics, Inc, Indivior, Merck & Co, Mylan NV, MedInCell, and Karuna Therapeutics and grants from Janssen Pharmaceutica, Takeda Pharmaceutical Company Limited, Berlin Institute of Health, the National Institute of Mental Health, Patient Centered Outcomes Research Institute, and the Thrasher Foundation outside the submitted work; receiving royalties from UpToDate; and holding stock options in LB Pharma. A.M., R.G., and E.S. were all employees of Evidera at the time the study was conducted on which the manuscript was based. C.P., C.B., K.J., J.K.S., and E.K. were all employees of Janssen Scientific Affairs, who hold stock/shares, at the time the study was conducted.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Supplementary information, reporting summary, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Correll, C.U., Martin, A., Patel, C. et al. Systematic literature review of schizophrenia clinical practice guidelines on acute and maintenance management with antipsychotics. Schizophr 8 , 5 (2022). https://doi.org/10.1038/s41537-021-00192-x

Download citation

Received : 26 February 2021

Accepted : 02 November 2021

Published : 24 February 2022

DOI : https://doi.org/10.1038/s41537-021-00192-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

This article is cited by

Psychosis superspectrum ii: neurobiology, treatment, and implications.

• Roman Kotov
• William T. Carpenter
• Katherine G. Jonas

Molecular Psychiatry (2024)

A Long-Term Safety and Tolerability Study of TV-46000 for Subcutaneous Use in Patients with Schizophrenia: A Phase 3, Randomized, Double-Blinded Clinical Trial

• John M. Kane

CNS Drugs (2024)

Sex Differences Between Female and Male Individuals in Antipsychotic Efficacy and Adverse Effects in the Treatment of Schizophrenia

• Megan Galbally
• Karen Wynter
• Susanna Every-Palmer

Antipsychotic Discontinuation through the Lens of Epistemic Injustice

• Helene Speyer
• Lene Falgaard Eplov

Community Mental Health Journal (2024)

Delphi panel to obtain clinical consensus about using long-acting injectable antipsychotics to treat first-episode and early-phase schizophrenia: treatment goals and approaches to functional recovery

• Celso Arango
• Andrea Fagiolini

BMC Psychiatry (2023)

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

• Search Menu
• Sign in through your institution
• Advance articles
• Editor's Choice
• Supplements
• Submission Site
• Author Guidelines
• Open Access
• Why publish with this journal?
• About Schizophrenia Bulletin
• About the University of Maryland School of Medicine
• About the Maryland Psychiatric Research Center
• About the NIH Public Access Policy
• Editorial Board
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Dispatch Dates
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Introduction, case report, considerations.

• < Previous

The Curious Case of a Catatonic Patient

• Article contents
• Figures & tables
• Supplementary Data

John H. Enterman, Dyllis van Dijk, The Curious Case of a Catatonic Patient, Schizophrenia Bulletin , Volume 37, Issue 2, March 2011, Pages 235–237, https://doi.org/10.1093/schbul/sbq110

• Permissions Icon Permissions

Catatonia is a syndrome characterized by the coexistence of psychiatric and motor symptoms. 1 It is associated with a wide range of psychiatric, medical, neurological, and drug-induced disorders. 2 The concept of catatonia was first described by the German psychiatrist Kahlbaum in 1874. 3 It is more frequently found among patients diagnosed with mania, depression, and neurotoxic syndromes than among those with schizophrenia. Yet, it is mainly classified as a form of schizophrenia. 4 The exact cause of catatonia has not been elucidated.

The syndrome of catatonia is defined by the objective presence of motor signs, over 40 of which have been described. These catatonic signs are listed in table 1 . There is no agreed threshold for the number or duration of symptoms that should be present to justify a diagnosis of catatonia. Research has suffered from this, and studies can rarely be compared with confidence. 7

Principal Features of Catatonia 5 , 6

There are consistent clinical reports that benzodiazepines are effective in acute catatonia syndromes, particularly stuporous conditions, but no placebo-controlled randomized studies have been published. 8 , 9 However, benzodiazepines are the drugs of choice for catatonia. 10 In most cases, lorazepam is administered parenterally or orally beginning with 3 mg/d and increasing rapidly to effective resolution. Dosages of 20–30 mg/d are occasionally necessary. 5 Patients who are unresponsive or insufficiently responsive to benzodiazepines need electroconvulsive therapy (ECT). 5 , 10

Patient A is a 28-year-old male of Mediterranean origin diagnosed with paranoid schizophrenia at the age of 23. He was hospitalized several times due to psychotic episodes characterized by religious delusions and auditory and visual hallucinations. He is living in an assisted living facility, where the medication is offered to the residents, but where they have to take it by themselves. He uses cannabis daily and does not use any other substances. Drug history mentions the use of risperidone and flupentixol decanoate, the latter since 2008 up to the present. At the end of 2008, he developed a progressive condition in which he showed less mimicry, staring, negativism, mutism, and immobility. There were no signs of autonomic dysregulation, such as increased body temperature or unstable blood pressure.

Because catatonia was assumed in April 2009, he was orally treated with lorazepam, starting at 2 mg a day. The lorazepam dose was increased based on the clinical state until 40 mg a day without any subjective or objective effects. He was admitted to the psychiatric ward to receive parenterally administered lorazepam up to 60 mg daily. After 2 days, there still was no measurable effect nor was there any effect on his consciousness. We resumed oral treatment with lorazepam 40 mgs daily and patient agreed to undergo ECT. During the lorazepam and ECT treatment, the patient continued to receive 30 mg of flupentixol decanoate every 2 weeks. After 3 ECT sessions (Mecta 5000, bilateral, 1 ms, 40 hz 2 s, 128 mC, 800 mA, [a relatively low, common, dosage]), the catatonic signs receded rapidly and patient refused to take the lorazepam, because “he was cured.” He soon afterward developed an acute catatonic state, in which he was found completely immobile next to his bed. He received lorazepam immediately and ECT the following days. After 2 more ECT sessions, the catatonic signs receded again. During the weeks afterward, patient received 40 mgs lorazepam daily, which was reduced and finally stopped on his demand.

A few months afterward, patient presented to the acute psychiatric service with signs of acute dystonia (cervical dystonia and dysphagia). He was treated with biperiden 2 mg and the dystonia almost immediately disappeared. Flupentixol decanoate dosage was lowered to 20 mgs every 2 weeks. Patient denied the use of any drugs except cannabis and urine examination confirmed this. After this episode, patient experienced several other episodes of dystonia, each time successfully treated with biperiden 2 mgs.

This case has many remarkable features. To begin with, the simple fact of a slowly progressive, during multiple months, catatonic state emerging elicited our curiosity. We could not relate it to a mood disorder nor to excessive cannabis use. Then again, the administration of doses of lorazepam up to 60 mg per day without any effects whatsoever seems remarkable, especially in the case of a young man not habituated to benzodiazepines. Of interest to those practicing ECT is the remarkable fact that the quality of the ECT did not suffer under the administration of high doses of benzodiazepines. We used the dosage titration method to determine the energy level needed for the ECT. We chose to temporarily halt the action of the lorazepam with the administration of 0.5 mg of flumazenil i.v. immediately prior to the ECT and achieved a therapeutically sufficient convulsion at a relatively low energy level. After 2 ECT sessions in this manner, we chose to try a treatment session without the use of flumazenil. This had no influence on the energy necessary for the ECT; on the contrary, we obtained a convulsion of the same length and electroencephalogram waveform as we did using the flumazenil, at precisely the same energy level. After the fifth treatment session, the patient did not return for further treatment sessions, in spite of his incomplete remission and in spite of his having been warned of the possibility of relapse. He was observed to be in worse condition in his home, but he himself seemed to be less distressed by his condition than his caregivers did, in spite of the many observations that catatonia is usually accompanied by anxiety. Because of the outpatient situation, there were limitations according to physical and blood examinations and the medication intake during the (acute) catatonic state of our patient. We have had our doubts of his acceptance of the benzodiazepines, but during his stay on the ward, the administration has been closely supervised by trained psychiatric nursing staff. Unfortunately, we did not determine a plasma level of benzodiazepines. Other laboratory results were unremarkable.

Should we consider other diagnoses than catatonia, and, if so, which? Perhaps a syndrome caused by cannabis consumption?

Does such a diagnosis explain the progression, over months, of the “catatonic-like” state?

How is the absence of an effect on the necessary ECT energy level by benzodiazepines to be explained?

How should we interpret the absence of distress?

Have we used the correct treatments or should we have had other considerations?

Submissions should be sent to the email address as listed in the author information. Any outcome will subsequently be published in this journal.

The Authors have declared that there are no conflicts of interest in relation to the subject of this study.

Google Scholar

Google Preview

Email alerts

Citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1745-1701
• Print ISSN 0586-7614
• Copyright © 2024 Maryland Psychiatric Research Center and Oxford University Press
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Open access
• Published: 27 June 2023

Recovery journey of people with a lived experience of schizophrenia: a qualitative study of experiences

• Zhidao Shi 2 ,
• Yanhong Chen 3 &
• Xiquan Ma 4  

BMC Psychiatry volume  23 , Article number:  468 ( 2023 ) Cite this article

3123 Accesses

Metrics details

Mental health recovery involves an integration of clinical and psychosocial frameworks. The recovery journey of individuals diagnosed with schizophrenia and the factors that influence it have been extensively studied. Because the recovery journey is culturally influenced, we examined the recovery process expriences of individuals diagnosed with schizophrenia in China, focusing on the influence of a Confucian-dominated collectivist and family-centred culture.

An Interpretive Phenomenological Analysis (IPA) study was conducted; data were gathered through in-depth interviews with 11 individuals with lived experience of schizophrenia.

Four themes were identified in this study: traumatic illness experiences, influence of the family, motives for recovery, and posttraumatic growth, comprising ten subthemes. “For the family” and “relying on oneself” are the main drivers of recovery for individuals with a Chinese cultural background. Some people believe that taking care of themselves is an important way to ease the burden on their families and treat them well. There is a link between ‘for the family’ and ‘relying on oneself.

Conclusions

Individuals living with schizophrenia in China have undergone significant traumatic experiences and have profound interactions with their families. Post-traumatic growth reflects an increase in the individual’s connection to others and individual agency. It also suggests that the individual is not receiving enough support outside of the family. The impact of individual agency and family relationships should be considered in services that promote recovery, and clinic staff should enhance support outside the home to the individuals.

Peer Review reports

Schizophrenia is a severe psychiatric disease, and it usually causes social dysfunction in individuals [ 1 ]. In 2017, 19.78 million individuals were diagnosed with schizophrenia worldwide, a 62.74% increase from 1990 [ 2 ]. In a 2022 report prompted, although the crude incidence of schizophrenia has decreased in China, the age-standardized incidence rate (ASIR), ,crude disability-adjusted life year (DALY) rate and age-standardized DALYs rate (ASDR)all showed a generally increasing trend over the last three decades [ 3 ]. In China, schizophrenia has become an important public health problem [ 4 ].

With the rise of the recovery movement, individuals are increasingly writing about their treatment experiences and journey to recovery, raising awareness that recovery from schizophrenia is possible [ 5 , 6 , 7 , 8 ]. The results reported in these studies indicate that approxmately half of the participants recover or significantly improve over the long term, suggesting that remission or recovery is much more common than previously thought [ 9 , 10 ]. On the other hand, by studying the stories of those who have recovered, it is possible to tease out what recovery means to them, what factors affected and helped their recovery and what they think is critical to the recovery process [ 11 ].

Spaniol and his colleagues pointed out that the four broad stages of mental illness recovery are being overwhelmed by the illness, fighting with the illness, coexisting with the illness, and surpassing the illness. The three main steps related to the recovery process are (1) an interpretive framework for understanding the experience of severe mental problems (2) gradually controlling mental illness and (3) obtaining a meaningful, productive, and valuable status in society. For individuals, understanding the experience of serious mental problems is their first step towards recovery [ 12 ].

Brammer believes that recovery is neither a matter of biomedical/clinical nor psychosocial recovery; it is an integration of clinical and psychosocial frameworks [ 13 ].

Sambeek and colleagues point out that researchers often ignore the sociocultural context of the narrative [ 14 ] or focus only on its personal or social dimensions [ 15 ].

Some cross-cultural studies suggest that cultural differences can lead to differences in individuals’ stigmatizing attitudes towards mental illness [ 16 , 17 ] and can also influence the psychological experience of family members in caring for individuals and how they care for them [ 18 , 19 ].

Chinese culture is dominated by collectivism under Confucianism. In Chinese culture, family and individual bonds are solid and interdependent [ 20 ]. In this context, does the recovery process differ from that in the West?

Some researchers have explored the field, and Yen-Ching Chang has highlighted the influence of Chinese culture on recovery-oriented services. He identified the search for cooperation from family members and the elimination of stigmatizing influences as the main challenges faced by professionals in a non-Western context [ 21 ].

Eva Yin-han Chung’s review of several papers argues that the concepts and philosophies of Western community-based rehabilitation cannot be directly applied to the Chinese context. Chinese cultural values have influenced CBR practice in Chinese communities [ 22 ]. Traditional peasant culture, traditional Chinese philosophy, and socialist ideology primarily influence current rehabilitation and CBR practices in China. Traditional cultural beliefs influence community members’ views of health, disability, autonomy, and family relationships [ 23 ]. For this reason, many argue that introducing externally planned CBR programs is counterproductive because they need to consider local needs and existing local practices. Therefore Eva Yin-han Chung claims an appropriate model or framework is needed to adapt to the unique Chinese cultural context and to guide practice in the Chinese community [ 22 ].

The above research suggests that the theory of recovery in China needs to consider Chinese culture. Researching Chinese people with lived experiences of schizophrenia recovery can help us understand the recovery process of individuals and consider the similarities and differences in the recovery journey of people with lived experiences of schizophrenia acoss cultures.

Participants and methods

Participants.

Participants were recruited through clinical staff at the Wuhan Mental Health Centre from November 2017 - March 2018. Participation was voluntary and was possible only with informed consent. The Inclusion criteria were (1) being diagnosed with schizophrenia according to the International Statistical Classification of Diseases and Related Health Problems “Diagnostic criteria for schizophrenia in the 10th edition; (2) having experienced at least two relapses or having residual symptoms but a current BPRS score of less than 35 on the 18-item BPRS as scored by the psychiatrist responsible for recruitment. [ 12 ](The verbal expression of individual with the severe condition are impacted. Therefore we used the BPRS as a screening tool. We wanted the participants to be able to express themselves well enough to articulate the themes we wanted to explore. ); (3) recieving a participant information sheets from staff, from which potential participants could ask questions of the staff; and (4) being wlling to participate in the qualitative research interview and signing an informed consent form after reading the informed consent form. The exclusion criteria were (1) having an intellectual disability; (2) having severe physical or cerebral organic diseases; (3) abusing or being dependent on psychoactive substance. Eleven individuals were finally enrolled.

The study’s sample selection mainly used the purposive sampling method and followed the principle of saturation. The interviews are conducted face-to-face; each lastiong from 1 to 1.5 h. The interview location was in the psychotherapy room of the hospital. After obtaining the individual’s consent, signed the informed consent form, the interview was performed and recorded. The research team consisted of three psychiatrists and a graduate student in psychology. The interviewer was a graduate student in psychology. All of the researchers were trained in and had previously conducted qualitative research. Some individuals underwent supplementary interviews according to the needs of the investigator. We used a code assigned to each participant to ensure anonymity.

We adopt the interpretative phenomenological analysis (IPA) method in this study. IPA was developed by Jonathan A. As a qualitative research method in the fields of health psychology and social science, IPA focuses on how people perceive experience, that is, it studies their experience living in the world [ 24 , 25 ]. The hypothesis of IPA is that the content of the participant’s psychological world that the analyst pays attention to may be manifested in the form of belief and structured by the participant’s words, or the participant’s story itself represents the identity of the participant [ 25 , 26 ]. IPA researchers want to analyse in detail how participants perceive and attach meaning to events that happen to them, so they need a flexible means of data collection. IPA mainly uses semistructured interviews to collect data [ 26 , 27 ].

This study aimed at exploring the illness-related experiences and recovery processes of people who have experienced schizophrenia. The interviews mainly focused on how they get sick, how they think about the illness and the impact of the illness on themselves. How do they cope with these effects? How is recovery perceived, what is good for recovery, and what is bad for recovery. We also asked individuals to report their current living conditions. (An outline of the interview is available within the Supplementary Material) The interview was semistructured and interactive. The researcher asked open questions and clarified the answers encouraged the individual to express themselves as completely as possible until they felt there was nothing more to say.

The interviews and our analysis were conducted in Chinese. The initial writing was also done in Chinese, and then, a final translation into English was conducted, using direct translations where possible but using paraphrases for difficult parts. This section resulted in a loss of information, and to minimize this, the research team discussed the translation content and made it acceptable to each researcher.

The interviewers converted the recordings into verbatim transcripts after each interview, and IPA was conducted following Smith and colleagues’ (2009) guidelines [ 28 ]: (1) reading and rereading; (2) initial noting; (3) developing emergent themes; (4) searching for connections across emergent themes; (5) moving to the next case, (6) looking for patterns across cases.

Each interview was first analysed individually by MM and CYH. After several readings of the transcripts for familiarity, the first emergent themes, which included descriptive, verbal, and conceptual comments, were identified through an initial coding process. These emergent themes were then grouped into higher-order categories, creating a list of superordinate themes for each interview. The research team then reviewed these themes until a consensus was reached and looked for links between the superordinate themes throughout the interviews. The research team then moved on to the next case and finally looked for patterns across cases.

The Ethics Committee of the Wuhan Mental Health Centre approved the study. All potential participants were informed of the purpose of the study and their right to refuse participation without any adverse effect on their support or relationship with the organization and measures to ensure confidentiality. Following this explanation, all individuals agreed to participate in the study and provided written consent to participate.

Participant characteristics

The participants were aged between 22 and 55 years, with an average age of 38.5 years; five men and six women took part; the participants were mostly single or never married (63.6%)and lived with their families (63.6%).

The participant’s general information is shown in Table  1 .

Four themes were identified in this study: traumatic illness experiences, influence of the family, motives for recovery, and posttraumatic growth, comprising ten subthemes. (Table  2 ), each supported by quotes from participants’ records.

Traumatic illness experiences

Each participant referred to the traumatic experience of having schizophrenia, which included symptom-induced distress, stigma, and feelings of powerlessness.

Symptom-induced distress.

These included both bodily and psychological distress. Even after the individual’s symptoms were under controll, the pain remained fresh in the individual’s mind. The distressed experience might be why the individual continues in treatment or wants to seek help from a doctor.

“It is so unbearable, worse than death, and people who have never had the illness cannot feel the pain. The onset of the illness is too painful, too torturous. It’s all about the physical discomfort and the pain. The pain in my body is so bad that I can get sick at any time, my chest and back feel like a nail is stuck there; my hands and feet are numb, and it is particularly uncomfortable. “(G) . “It (referring to the symptoms) is not cyclical. It suddenly comes and goes, but wait a bit. The key is not to be anxious; once it happens, your thoughts will not work if you are anxious. You don’t think about anything. I don’t want to think about anything. “(F) . “It’s just hard, hard. I can’t stop thinking about problems. I can’t control them. I don’t want to think about problems. My mind will still think about them. I want to clear my mind, but there are voices in my head that keep talking. It’s hard. I can’t help it. I can’t think about extreme problems, but my head gets dizzy when I think about unnecessary problems.“ (C) . “Couldn’t sleep the next day. My mental state was terrible, and my condition was worse. “(B) .

Stigma and self-stigma

Some participants reported being talked about, shunned, isolated, and devalued. They felt lonely, devalued, restricted, and angry. One participant complained that her child was also being bullied. Some participants said they felt low self-esteem because of mental illness, felt pessimistic about the future, avoided contact with the outside world, or feared that others would know about their illness.

“I walk out. People point at me and murmur: she is the wife of whoever, she is the daughter of whoever. And she has a mental illness. It’s like I’m boxed inside that dungeon.“ “I found that everyone ignored me when I returned from the hospital. They don’t care about me. They teach the children to ignore me. En, I’m so lonely and isolated there. No one wants to care about me.“ “Even my child was bullied. The other kid was bigger and hit my kid on the leg with a big stone. I went to argue, and he ignored me.“ (A) . “The psychological impact of the illness, maybe, is inferiority and a little pessimistic about the future. The inferiority complex means that people with the mental disorders are often looked down upon by others. A person is often looked down upon by others. His life is over. Pessimism means that you feel very pessimistic about your future.“ (B) . “We, as patients, are also stigmatized in society. I was afraid to tell anyone about my illness. But it affected me all my life. Right? I can’t even talk about it. Maybe someday I’ll meet someone I love. I can’t even talk about it. Friends, I lost a lot of friends that I used to have. I initiated contact with them, and they didn’t talk to me. “(J) .

Loss of hope, feeling of powerlessness

Most participants described a loss of hope and powerlessness, while others felt scared. Some participants had this feeling for a while after the illness, and some had in this feeling all the time. This feeling was related to being diagnosed with schizophrenia, being on medication for a long time, or having recurrent illness episodes.

“After I found out my diagnosis was schizophrenia, I felt like I just lost hope in life, I didn’t want to care about anything, I didn’t want to do anything” (F) . “It felt scary, saying something about (the diagnosis of) schizophrenia; it just felt quite scary and could scare people to death. …… When does the second life start? The first life was given to me by my mother; I feel like there is no second life, and I feel like a wasted person when I keep taking medication and eating.“ (L) . “When I got out of the hospital, my ability to survival was poor. I was weak. When I heard the doorbell, I was scared.“ (J) . “It just wasn’t good; I didn’t feel so lucky. Quite a lot of my classmates that I hang out with don’t have it, and I’m the only one who has it.“ (C) . “A bit pessimistic about the future, I guess …… pessimistic means feeling very pessimistic and disappointed about the future.“ “My parents are old, 50 or 60 years old. If they die, how do I do.“ “Schizophrenia, well, can’t be cured completely, mentally very tortured.“ (B) .

Influence of the family

Most of the participants lived with their families. Among the three participants (D, E, and I) who did not live with their families, 2 (E and I) also had close contact with their families. Only participant D stated that he rarely communicated with his family. All participants had a permanent home and no experience of homelessness. Most participants stayed at home for some time after being diagnosed with schizophrenia or discharged from the hospital. They reduced their contact with the outside world. As individuals stayed at home, family members interacted intensely with them.

Interactions with family members significantly impacted the participants’ moods and behaviours. Family members’ attitudes and behavior towards the participants’ medication also significantly impacted the participants’ treatment and mood.

Staying at home

The participants found coping with the stress of relationships and work challenging, so they returned to their homes and had less contact with the outside world. Some participants felt relaxed staying at home, but others experienced diminished capacity and were concerned about their diminished capacity.

“I do not have a good relationship with strangers and would rather be alone at home with a book and TV. At least I feel more relaxed.“ (K) . “I want to go out to work like everyone else. I cannot do anything if I have this symptom all the time. It’s better not to have those kinds of grumpy people in my cirle. I work in that circle, and if I have that kind of people messing around every, I get a bit unhappy when I face them. I don’t want to see him. He’ll affect my mood.“(C) . “After a while, I was in a bad mood, and my ability to work was weak. Unlike before, I did not want to work for quite a long time. I always stay home, lie in bed, watch TV, and do not want to go out. Then, I returned to the old state of poor performance, that feeling.“(J) .

Impact on mood

The attitude of family members towards the individual has a great impact on the individual’s mood. Criticism and blame from family members can cause anger or depression, and worries from family members can increase an individual’s apprehension and depression. When family members are encouraging, understanding, and affirming, the individual will increase communication with family members and will be able to maintain positive behavious.

Discrimination, blame from family members

The participants experienced impatience, unconcern, and blame from family members, for which the participants felt angry and depressed.

“My husband, if people ask him who she (meaning A) is. His attitude then becomes like this, too, just saying to ignore her and not to talk to her. I once tried cross-stitching, which requires a lot of patience. When I was halfway through the embroidery, my husband said, ‘What are you embroidering? You can’t even do your housework properly and still embroider this’. He denied me. What housework did I fail to do? Did I not cook, did I not take care of my children, did I not take care of my mother-in-law? “(In an outraged tone) (A) . “The children don’t come to see me either, and I’m particularly depressed and bitter emotionally” (D) . “My parents pick on my sore spot and talk nonsense. En, all this talk is making me feel bad.“(E) .

Family worries

The participants experienced a variety of worries from family members, such as family members worrying about their condition, the side effects of medication, the relationships, and the future. Family members’ worries about the individual could add to the individual’s fears.

“As long as I have this symptom, I can’t do anything. My parents are worried and afraid that my interpersonal relationship outside are shallow. If I want to do something, I need a person to lead me to do it. My parents don’t have anyone right now.“ (C) . “ My mother was disappointed in me. She said I would become a farmer like them if I were still so negative. I was a little worried about myself. En, I swallowed the whole bottle of pills. A bottle of clozapine.“ (K) .

Family communication, encouragement

The participants experienced that their family members wanted to listen to what was bothering them, cared about them, or were encouraging them and affirming the positive changes they were making. Listening, caring, and support from family members made the participants want to talk and care more about their family members.

“My parents also say that I’m a different person. They all think I’m good. I’m good to them. (J) “I talk to her (referring to the daughter) a little bit, a little bit (about the condition), sometimes she opens up and tells me to, um, learn to control myself, and she also, she asks me to, but I can’t do it, I told her that too, I said I can’t do it.“ (D) . “My daughter lives where she works, and she’s very concerned about me and often calls me. After all, I was worried about her being a girl, but I have since discovered that she is capable, so I am relieved now.“ (I) .

Role in medication compliance

Family members had an important influence on the participants’ medication use. Family members reminded the participants to take their medication. Some family members accompanied the participants to hospital appointments and help with prescriptions, and the participants felt supported. However, some family members made taking medication an essential thing for the participant, constantly reminding the participant and equating failure to take the medication with the onset of the participant’s illness. Other family members force-fed medicines to the participant, and these coercive methods made the participant unhappy and resentful. Some family members were also concerned about the side effects of the medication and asked the participants to stop taking it.

“I was then always very positive and cooperative in my treatment. At first, it was my 70-year-old father who brought me to the doctor, and then later, I slowly came to the doctor on my own.“ (J) . “My family always asked me if I had eaten or taken my medication. I had to remember to take my medicine and not forget to do so. These were just a few words. I felt like I had accomplished a considerable task.“ (A) . “My mother was afraid I would get sick from my medicine, so she told me not to take it.“ (B) . “Whenever I get angry and don’t take my medicine, my parents think I will be sick.“ (L) . “They (referring to parents) would take a scoop, open my mouth with the scoop, and ask me to take my medicine, and I also felt disgusted.” (E) .

Motives for recovery

Individuals wanted to get better, but taking the initiative to take steps to start getting better, rather than avoiding people and situations that made it difficult for them, required a driving force. The individual’s narrative revealed that being for the family and relying on oneself were the motivating factors to increase individual initiative.

For the family

Individuals took responsibility for their families and wanted to be able to take care of them, such as their elderly parents, younger siblings, and children, to “take on the burden of the family” and to provide financial and emotional care for them. The participants interpreted the improvement of their situation as a way of not “causing trouble” for their families. “easing the burden” on them, and taking responsibility for them.

“My father is dead too, …. My mother is old, and I have two younger sisters, so I have to bear the burden of my family.“ “If I lose touch with society and drag my family down with me, at the end of the day, it’s all; it’s all hurting myself, it’s all hurting my family.“ (F). “My mum and dad are very old and emaciated…. I want to lighten the burden on my family” “My mum and dad are physically ill. I think this burden I have to pick up. Then I went out to work again, and I forced myself when I was working. Slowly I was able to do the job.“ “Now I can take part of the responsibility of the family, and I also care for my sister, my brother-in-law, my niece, my dad, and my mum.“ (J). “I hope not to give my daughter any trouble. When she needs money, I can help her. The first is not to be hospitalized. I want my life to be about taking medicine, eating, closing my eyes, and not being hospitalized again. When I was in the hospital, those who cared about me, including my parents and my daughter, were affected. I was also sick and had much pain.“(I) .

Relying on oneself

Four participants referred to ‘relying on oneself’, which included relying on oneself to manage life’s chores, regulate one’s emotions, take care of oneself, and encourage oneself. Relying on oneself is also an expression of taking responsibility for one’s life and supporting oneself.

“The reality is that you still have to rely on yourself, you have to do a lot of tedious things in real life by yourself, you can’t be a little bit lazy, it’s like taking care of yourself, if you are a little bit lazy, you will end up not wanting to do it more and more.“ “If you don’t make any progress at all, if you’re not willing to go in a good direction and improve yourself, then the doctor can’t do anything with you, and the medicine can’t do anything with you.“ (I) . “You have to unlock the locks yourself, but if your heart is locked, you can’t open it,“ “You have to rely on yourself, you have to rely on yourself.“ (F) . “We ordinary people, we have to rely on ourselves, …… can’t give up on ourselves.“ (G) . “Now it’s about being strong on your own. Keep yourself in an optimistic frame of mind and look down on some things a little bit.“ (H) .

Posttraumatic growth

Some participants reported positive changes associated with their experiences. Posttraumatic growth is the recovery and improvement of physical and mental health from adversity and regaining control over one’s life; posttraumatic growth took time and did not develop linearly. Post-traumatic growth included the subthemes of increased connection with others and individual agency.

Connections with others

The emotional connection to relationships with others had two components: on the one hand, the individual trusted others, communicated more with them, and felt more supported by them; on the other hand, the individual felt more supported by others.

Feeling supported by others

Developing trust in others and increased interaction leads to a feeling of support from others. These others were often family members or health professionals, and one participant also talked about relationships with friends.

“I see how a doctor treats another patient with warmth, the little gestures, the little things taken into consideration, and it touches my heart, and I feel trustworthy. “ (G) . “(I’m) annoyed or unhappy, I feel uncomfortable, but then, well, I talk to the girl.” (E) . “I now talk to my sister when I’m upset about something.” (I) . “I have a friend who knows about my illness and recovery. She’s always been there for me, and she’s very open about it. I cherish this friend.” (J) .

Support for others

The participants were more likely to help, had more tolerance for others, and could work with others and share benefits.

“I am not as aggressive as I used to be, and I can get along well with other people.“, " Because of this illness, no matter how strong people are, there is still a day when they fall. Many things are unexpected. One has to be open-minded, healthy is a must, and living is a victory.“ “In the company, I feel that a team is more powerful than a single person, and I have learned to share now. What I used to have, commission or not, performance or not, I have to take it all into my arms. Now I take some of it out and share it with others.“, “My parents also say I’m better than I used to be. I’m more caring; I used to be very selfish. I used to spend all my money on myself. Now I can take responsibility for my family…Mum and Dad can rely on me. I’m proud of myself now.“ (J) .

Individual agency

Individual agency is reflected in how individuals adopt methods to improve their emotions, cope with symptoms, try new behaviours and ultimately empower themselves.

Emotional self-regulation

The participants used methods to reduce their discomfort and improve their mood when experiencing painful feelings or mental symptoms; they used self-encouragement when it was challenging to continue to persevere in their actions.

“When I’m upset or unhappy, I feel uncomfortable, but I tell my daughter that I’m not uncomfortable, and sometimes I just go and play with my jumper by myself. It calms me down, so I like to do it” (E) . “If I feel uncomfortable, I’ll walk with my head down for a few minutes or go to bed.“ (C) . “When I’m not happy, I think of something happy, or I go and play cards with my friends.“ “It’s still hard to take the trouble to do something for yourself every day and take care of things at home, but it’s better to cheer yourself up and be strong with this. I reassure myself, ‘If I fail, I’ll try again’.“ (F) .

Proactive behaviour

The participants took action to try, learn and accomplish things, such as household chores, financial management, and work. Gradual improvement in the ability to do things in action was followed by self-affirmation and increased autonomy. Completing tasks often required constant experimentation and could fluctuate and be repetitive.

“Sometimes there was supposed to be a price to keep track of when selling things, and (I) didn’t do much of that. Now it’s different, I write down the price sometimes, and I can sell it.“ “Now I do more housework; sometimes I clean the house. I wipe the sofa and mop the floor.“ (C) . “Since I have this illness, I can’t say I’ll never do anything for the rest of my life; what if I get old? Then I can only do some simple things and slowly recover that ability. I then went to work overseas for two years.“ (F) . “At home, I bought groceries, started keeping accounts, and basically wrote down everything I bought. I hope not to give my daughter trouble. She needs help when she needs enough money because I used to spend so much money on my daughter. If there is a need for financial help, who can she call? I have to go to help her. I do not need to eat or drink very well in my own life, as I am also gaining weight and cannot eat too well now. That is mainly for my daughter. I do not want to give her trouble.“ (I) . “Once I started working, my ability came back quite OK. I started working and took a few orders, and my boss impressed me. However, after a while, my mood and my ability to work were weaker. Unlike before, I didn’t want to work for quite a long time. I always stayed at home, lying in bed, watching TV, not wanting to go out. I don’t have any orders, and then I’m back to my old, kind of poor state, that kind of feeling. Later, I thought that this would not work, as my mother and father were both ill, and I felt that I had to take up this burden. Then I went back to work, and when I worked, I forced myself to work. Slowly, I was able to do the job. I went from feeling quite overwhelmed at the beginning to getting used to it, and then eventually, I could do it.“ (J) .

It is evident from the accounts of the individual in this study that the illness causes great suffering to individuals and that after developing schizophrenia, individuals experience or have experienced a lack of hope, a lack of strength, and a lack of ability to face life again in the future.

Previous studies have suggested that developing schizophrenia is a traumatic experience for individuals [ 29 , 30 , 31 ]. Some studies have linked traumatic experiences to psychotic symptoms and treatment experiences [ 32 ], while others have linked traumatic experiences to shame [ 33 , 34 ].

People with severe mental illness (SMI) often encounter stigmatizing perceptions of mental illness [ 35 ]. These perceptions can lead to social exclusion, discrimination, and microaggressions against people with serious mental illnesses [ 36 , 37 , 38 ]. The effects of stigma include self-stigma, where a person internalizes socially stigmatizing messages about mental illness. Self-stigma can lead to depression, low morale, lower self-esteem, poor disease management, social avoidance, and impediments to pursuing and achieving recovery goals [ 39 , 40 , 41 , 42 ].

Isabella Berardelli suggested that demoralization is a syndrome of existential distress. This symptom may occur in people with chronic mental illness that threatens the integrity of existence or the meaning of people as participants in the world [ 43 ]. Frank identified low morale as helplessness, incompetence, declining self-esteem, despair, being stuck in a rut, loneliness, and meaninglessness, possibly followed by a wish to die [ 44 ]. Onken argued that the low morale can be a significant obstacle in the recovery process [ 45 ]. Ritsher argued that three sub-themes of self-change, pessimism about the future, and feelings of control construct the individual’s sense of powerlessness [ 46 ]. A study by Liu Liang and colleagues. on Chinese individuals who had a lived experienced schizophrenia found that individuals lacked clear judgments about their personal experiences in many areas, including physical experiences, mental states, and related factors. The participants often felt nervous, sensitive, and vulnerable in their daily lives and were unsure whether their feelings or judgements were ‘normal’. They lose confidence and become powerless in their lives [ 47 ].

However, this suffering comes not only from a sense of stigma and powerlessness but also from the symptoms themselves. The painful experience of symptoms is why individuals seek treatment, and some use hospitalization as the ultimate solution to cope with the pain of their symptoms. Some individuals are opposed to treatment and feel that hospitalization is forced upon them and that prolonged medication increases their sense of powerlessness.

After a traumatic illness experience, individuals often choose to stay at home to reduce the stress on them in terms of relationships and work. As staying in the home becomes more interactive with the family the influence of the family on the individual becomes more apparent.

Many researchers have reported on the effects of family on people with schizophrenia. Individuals who a lived experience of schizophrenia who came from families with high emotional expression (expressing high levels of criticism, hostility, or excessive involvement) have higher relapse rates than those with schizophrenia from families without similar problems [ 48 , 49 , 50 ].

Family warmth and positive remarks have been found to have a protective effect and reduce the likelihood of relapse [ 51 ].

Johannes Jungbauer and colleagues, in a study of German people diagnosed with schizophrenia, found that at the time of the interview, 41% of the people were still living with their parents or had moved back to their homes [ 52 ].

90% of people diagnosed with schizophrenia in China live with their families, compared to 60% in the UK and 40% in the US [ 53 ]. Such a high proportion of individuals live with their families and interact more with them, and the influence of family members on individuals is more evident.

This study suggests that an individual’s interaction with family members significantly affects the individual’s mood and behaviour. With family discrimination and blaming, the individual develops negative emotions and impulsive behaviours; he or she may also develop depressive and withdrawal behaviours. Family members’ worries may also increase individuals’ worries about the future and the outside world. At the same time, family members’ willingness to communicate with individuals may also improve their communication with family members strengethening the connection between individuals and their families.

A study by Johannes Jungbauer and colleagues found that re-enforcement of the parent-child relationship may lead to decreased social contact outside the individual’s family [ 52 ]. Whereas all of the participants in this study, except D, maintained close relationships with their families. Some participants also had much social contact outside the home. Therefore, the differences between individuals with much social interaction and those with little social contact should be further studied. One possible reason for little social contact outside the home is that family members feel uneasy about the outside world, thus discouraging individuals from social contact with the outside world, For example, in the case of C. A qualitative study by Zhang Yanqing and colleagues in Taiwan also found that when families were not actively involved or supportive of their relatives’ recovery journeys or could not work with their relatives, individuals’ recovery was negatively affected. This study also suggested that families’ overprotection or fear of making changes for their relatives with mental illness prevented people with mental illness from participate in independent learning and decision-making [ 54 ].

Because of the prominent influence of family members on individuals, Chinese individuals who experience schizophrenia need to improve their family-individual interactions and change the overprotective response of family members. Family influence was found in this study to manifest in individuals’ motivation to recover.

With medication, the influence of family members is also evident, as individuals are more likely to accept medication if their family members are gently supportive. In contrast, family members ordering or even forcing medication can cause anger in the individual and lead to tension between the family and the individual.

Joanna referred to the primary motivation for recovery as the ‘drive to move forwards’, which is the foundation or starting point for recovery. This forwards momentum includes hope, optimism, determination, belief in a higher power, and an awakening of motivation. In his study, some participants spoke of recovery as a spiritual journey and a connection to a higher power. Finding meaning and purpose is a key part of recovery, and some people seek and find this meaning in their religious beliefs [ 55 ].

Janne claimed that religion and spirituality hold a great deal of power in the search for meaning in the lives of people with mental illness [ 56 ].

In contrast, the participants in this study did not mention religious beliefs. What, then, constitutes meaning in their lives? According to some participants, “for family” has become the meaning of life. Several participants in this study described that taking responsibility for one’s family was often the turning point in their decision to work towards recovery. Their description suggests that for Chinese participants, family not only has an important influence on them but is also a source of motivation for recovery.

This phenomenon is related to the psychological characteristics of the Chinese people. Yang Guoshu suggests that familism is a major indigenous set of Chinese psychological and behavioural principles and a complex indigenous cultural phenomenon in Chinese society. Familism is the Chinese idea and practice of putting the family first in all matters. Familism aims to maintain the strength and harmony of the family, for which the children must pass on the family line and support and obey their parents. The basis of its ideology is filial piety. The responsibility a child to provide for one’s parents is an important part of familism, and it forms an important part of Chinese life [ 57 ]. Eva Yin-han Chung also argued that for Chinese people, identification and connection to family give meaning to life; responsibility and commitment are important factors that motivate people and empower them to live meaningful lives [ 58 ].

Abdullah argued that in Asian populations, individuals’ inability to care for their parents when they are old and sick can create a sense of stigma for the individual diagnosed with schizophrenia [ 16 ]. In a study by Yin-Ling Irene Wong and colleagues on Chinese individuals diagnosed with schizophrenia and their families, participants with schizophrenia expressed a sense of shame and low self-esteem, and talked about being a burden to their families [ 53 ].

This study shows that individuals’ renewed responsibility for parental support, assisting a younger sibling, and raising and helping children is an essential expression of their life’s meaning and catalyses the their recovery. Individuals feel proud if they can achieve these goals. Therefore in the eyes of Chinese individuals, being able to achieve the task of caring for their families gives them a sense of pride, while not being able to do so increases their sense of stigma.

On the other hand, the particpants also express that they are “relying on oneself”, dealing with life’s chores, regulating their emotions, taking responsibility for their lives, and supporting themselves.

Nonetheless, the participants also stated that they wanted to be “relying on oneself” a concept that requires self-support and motivates individuals to take action to deal with life’s chores, regulate their emotions, and take responsibility for their own lives to achieve self-support.

The factors suggestive of traumatic growth in this study are the connection with others and the individual’s agency. The other connections mentioned more often by individuals were relationships with family members.

“For the family” and “relying on oneself” are cognitive demands, while individual agency is a behavioural response. Guided by the concepts of “for the family” and “relying on oneself " individuals adopt proactive behaviours directed towards helping the family, thus strengthening the individual’s bond with the family.

Several researchers have described recovery as a transformative process of self-discovery and self-renewal, which involves adjusting one’s attitudes, feelings, perceptions, beliefs, roles, and life goals [ 12 , 58 , 59 ]. Yulia and colleagues’ study considered the individual’s sustained efforts towards positive transformation and improvement as the basis of the recovery process. The opposite of this is abandonment, i.e., the acceptance of the individual’s negative identity as an individual with a chronic illness and the lack of intrinsic motivation to want to get better [ 60 ]. Larry Davidson claimed that rebuilding an “enhanced sense of self” protects people from being struck down by illness and provides a solid foundation for their recovery [ 49 ]. Onken argued that rejuvenation is often rooted in agency and self-activity [ 45 ]. A study by Deegan and colleagues identified the right to individual choice and empowerment as important elements of recovery [ 61 ]. Markowitz suggested that for individuals to recover from the trauma of schizophrenia, the healing process involves not only a new lifestyle and control of symptoms but also increasing proficiency in overcoming stigma and discriminatory experiences in the social sphere [ 62 ].

It is an important direction of recovery to promote the development of self-discovery and the self-ability of the individual.

It is worth noting that some participants in this study took good care of themselves as an important way to relieve their families’ burden and treat them well. They reported if they are not well, their families will suffer; if they are well, they can ease the burden on their families. Thus, “relying on oneself” is associated with “for one’s family”.

It is clear from this study that both the self and the family are emphasized in the individual’s experience of recovery. The individual is an individual in the family. The honour and shame of the individual are closely linked to the honour and shame of the family. Therefore, the individual’s efforts can improve the family’s situation. So the individual’s efforts are as much for himself as for his family.

Limitations

The study may be limited for several reasons. The participants had certain geographical limitations. The study was carried out in only one large city in China. Our sampling method may have resulted in selection and response bias. The participants were recruited through clinical staff. In addition to recommending individuals who fit the study’s inclusion criteria, clinical staff tended to refer people with good relationships.

People with schizophrenia living in China have undergone significant traumatic experiences and have profound interactions with their families. Posttraumatic growth enables an increase in the individual’s connection to others and autonomy. The study also found that individuals did not receive adequate support outside their families. These findings suggest that the impact of individual autonomy and family relationships should be considered in services that promote recovery and that support outside the home should be enhanced.

Careful consideration of the impact of Chinese culture on individuals and the establishment of recovery in a Chinese cultural context is an important issue in Chinese psychiatric recovery services.

Data availability

The datasets generated and analysed during the current study are not publicly available due [ this is a Qualitative Study ] but are available from the corresponding author on reasonable request.

WHO, Schizophrenia. (2019). Available online at: https://www.who.int/news-room/fact-sheets/detail/schizophrenia (accessed January 10, ]2022). [Google Scholar]

He H, Liu Q, Li N, Guo L, Gao F, Bai L, et al. Trends in the incidence and DALYs of schizophrenia at the global, regional and national levels: results from the global burden of Disease Study 2017. Epidemiol Psychiatr Sci. 2020;29:e91. [. Google Scholar].

Article   PubMed   PubMed Central   Google Scholar  

Wanyue DongYunningLiuJianzhong, Sun Y, Liu Z, Sun R, Bai. Temporal Trends in the incidence and disability adjusted Life years of Schizophrenia in China over 30 years,Front Psychiatry. 2022 Mar 9;13:831188. doi: https://doi.org/10.3389/fpsyt.2022.831188 . [PMC free article] [PubMed] [Google Scholar].

Phillips MR, Characteristics, experience, and treatment of schizophrenia in China, Dialogues Clin Neurosci., Patrick D, McGorry, John M. Kane;Improving outcomes of first-episode psychosis: an overview, World Psychiatry. 2017 Oct;16(3):251–265. doi: 10.1002/wps.20446. [PubMed][Google Scholar].

Patriciae Deegan. Recovery: the lived experience of rehabilitation. Psychosocial Rehabilitation Journa Volume 11 Number 4:April 1988:11–9. [Google Scholar].

Kelly M, Gamble C. Exploring the concept of recovery in schizophrenia. J Psychiatr Ment Health Nurs. 2005;12:245–51. [PubMed][Google Scholar].

Article   CAS   PubMed   Google Scholar  

Jackie Liggins. Healing the heart of recovery. Int J Soc Psychiatry. 2018 Nov;64(7):660–7. doi: 100020764018796538. [PubMed] [CrossRef] [Google Scholar].

Em.1177/sley R, Chiliza B, Asmal L, Lehloenya K. The concepts of remission and recovery in schizophrenia. Curr Opin Psychiatry. 2011;24:114–21. [PubMed][Google Scholar].

Google Scholar  

Zipursky RB. Why are the outcomes in patients with schizophrenia so poor? J Clin Psychiatry. 2014;75(2 Suppl):20–4. [PubMed][Google Scholar].

Article   PubMed   Google Scholar  

Zipursky RB, Agid O. Recovery, not progressive deterioration, should be the expectation in schizophrenia. World Psychiatry. 2015;14:94–6. [PMC free article] [PubMed] [Google Scholar].

Mead S, Copeland ME. What recovery means to us: consumers’ perspectives. Community Ment Health J. 2000 Jun;36(3):315–28. https://doi.org/10.1023/a:1001917516869 . [PubMed] [Google Scholar].

Spaniol L, Wewiorsky N, Gagne C, Anthony W. The process of recovery from schizophrenia. Int Rev Psychiatry. 2002;14:327–36. [CrossRef] [Google Scholar].

Article   Google Scholar  

Janne Brammer Damsgaard and Sanne, AngelInt J, Environ. Living a Meaningful Life while struggling with Mental Health: challenging aspects regarding personal recovery encountered in the Mental Health System. Res Public Health. 2021 Mar;18(5):2708. https://doi.org/10.3390/ijerph18052708 . [PMC free article][PubMed][Google Scholar].

van Nienke A, Baart G, Franssen S, van Geelen. Floortje Scheepers. Recovering Context in Psychiatry: what contextual analysis of service users’ narratives can teach about recovery support. Front Psychiatry 2021 Dec 20;12:773856. doi: https://doi.org/10.3389/fpsyt.2021.773856 . eCollection 2021. [PMC free article] [PubMed] [Google Scholar].

Murray M. Levels of narrative analysis in health psychology. J Health Psychol. 2000;5:337–47. [PubMed] [Google Scholar].

Abdullah T, Brown TL. Mental illness stigma and ethnocultural beliefs, values, and norms: an integrative review. Clin Psychol Rev Clin Psychol Rev. 2011 Aug;31(6):934–48. [PubMed] [Google Scholar].

Rao D, Feinglass J, Corrigan P. Racial and ethnic disparities in mental illness stigma. J Nerv Ment Dis. 2007;195(12):1020–3. [PubMed] [Google Scholar].

Mijung Park. Filial piety and parental responsibility: an interpretive phenomenological study of family caregiving for a person with mental illness among Korea. BMC Nurs 2012 Dec 20;11:28. doi: https://doi.org/10.1186/1472-6955-11-28 . [PMC free article] [PubMed] [Google Scholar].

Yu Yu, Li T-X, Li Y-L, Xi DQiuShi-Jun. Shui-Yuan Xiao, Jacob Kraemer Tebes. A cross-sectional study on spouse and parent differences in caregiving experiences of people living with schizophrenia in rural China. BMC Psychiatry. 2020 May 12;20(1):226. doi: https://doi.org/10.1186/s12888-020-02633-w . [PMC free article] [PubMed] [Google Scholar].

Wong Y-LI, Kong D, Tu L, Frasso R. My bitterness is deeper than the ocean”: understanding internalized stigma from the perspectives of persons with schizophrenia and their family caregivers. Int J Ment Health Syst. 2018;12:14doi. https://doi.org/10.1186/s13033-018-0192-4 . [PMC free article] [PubMed] [Google Scholar].

Yen-Ching Chang L-H, Chang S-TH, Huang M-W. Professional perspectives on providing recovery-oriented services in Taiwan: a qualitative study.BMC Psychiatry.2021 Mar 16;21(1):154.doi: 10.1186/ s12888-021-03152-y. [PMC free article] [PubMed] [Google Scholar].

Eva Yin-han, Chung T, Packer M, Yau. When East meets Wests: community-based rehabilitation in chinese communities. Disabil Rehabil. 2011;33(8):697–705. [PubMed] [Google Scholar].

Roger MK, Ng V, Pearson M, Lam CW, Law, Cindy PY, Chiu, Eric YH, Chen. What does recovery from schizophrenia mean? Perceptions of long-term patients. Int J Soc Psychiatry 2008 Mar;54(2):118–30. doi: 10.1177/0020764007084600. [PubMed] [Google Scholar].

Stefan Leucht JM, Kane W, Kissling J, Hamann E, Etschel R, Engel. Clinical implications of brief Psychiatric Rating Scale scores. Br J Psychiatry. 2005 Oct;187:366–71. [PubMed] [Google Scholar].

Davidsen AS. Phenomenological approaches in psychology and Health Sciences.Qual Res psychol. 2013 Jul;10(3):318–39. doi: https://doi.org/10.1080/14780887.2011.608466 . [PMC free article] [PubMed] [Google Scholar].

Brew B, Shannon C, Storey L, Boyd A, Mulholland C. A qualitative phenomenological analysis of the subjective experience and understanding of the at risk mental state.Int J qual Stud Health Well-being. 2017 Dec;12(1):1342504. doi: 10.1080/17482631.2017.1342504. [PMC free article] [PubMed] [Google Scholar].

Pringle J, Drummond J, McLafferty E, Hendry C. Interpretative phenomenological analysis: a discussion and critique. Nurse Res. 2011;18(3):20–4. https://doi.org/10.7748/nr2011.04.18.3.20.c8459 . [PubMed] [CrossRef] [Google Scholar].

Smith J, Flowers P, Larkin M. Interpretative phenomenological analysis: theory, method and research. London: Sage; 2009.

Jane E, Dunkley 1 GW, Bates, Bruce M, Findlay. Understanding the trauma of first-episode psychosis. Early Interv Psychiatry. 2015 Jun;9(3):211–20. https://doi.org/10.1111/eip.12103 . Epub 2013 Nov 20. [PubMed] [Google Scholar].

Rebecca Rodrigues, Kelly K, Anderson. The traumatic experience of first-episode psychosis: a systematic review and meta-analysis. Schizophr Res. 2017 Nov;189:27–36. https://doi.org/10.1016/j.schres.2017.01.045 . [PubMed] [Google Scholar].

Carolina Campodonico FV, Berry K. Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life. BMC Psychiatry. 2022 Mar 24;22(1):213. doi: https://doi.org/10.1186/s12888-022-03808-3 . [PMC free article] [PubMed] [Google Scholar].

Weili Lu KT, Mueser SD, Rosenberg PT, Yanos. Neisrein Mahmoud. Posttraumatic Reactions to Psychosis: A Qualitative Analysis. Front Psychiatry. 2017 Jul 19;8:129. doi: https://doi.org/10.3389/fpsyt.2017.00129 . eCollection 2017. [PMC free article] [PubMed] [Google Scholar].

Esmina Avdibegović 1, Mevludin Hasanović. The Stigma of Mental Illness and Recovery. Psychiatr Danub. 2017 Dec;29(Suppl 5):900–5. [PubMed] [Google Scholar].

Wilma A, Boevink. From being a disorder to dealing with life: an Experiential Exploration of the Association between Trauma and Psychosis.Schizophr Bull. 2006 Jan; 32(1): 17–9. doi: https://doi.org/10.1093/schbul/sbi068 . [PMC free article] [PubMed] [Google Scholar].

Lauren K, O’Connor MA, Philip T, Yanos. and Ruth L. Correlates and moderators of Stigma Resistance among people with severe Mental illness. FirminPsychiatry Res 2018 Dec; 270: 198–204doi: 10.1016/j.psychres.2018.09.040. [PMC free article] [PubMed] [Google Scholar].

Gonzales L, Davidoff KC, Nadal KL, Yanos PT. Microaggressions experienced by persons with mental illnesses: an exploratory study. Psychiatric rehabilitation journal. Psychiatr Rehabil J. 2015 Sep;38(3):234–41. https://doi.org/10.1037/prj0000096 . Epub 2014 Nov 17. [PubMed] [Google Scholar].

Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, INDIGO Study Group. (2009). Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross- sectional survey. Lancet. 2009 Jan 31;373(9661):408 – 15. doi: https://doi.org/10.1016/S0140-6736(08)61817-6 . [PubMed] [Google Scholar].

Catherine van Zelst. Stigmatization as an environmental risk in schizophrenia: a user perspectiveSchizophr bull. 2009 Mar;35(2):293–6. doi: https://doi.org/10.1093/schbul/sbn184 . [PMC free article] [PubMed] [Google Scholar].

Clara I, Morgades-Bamba. María José Fuster-Ruizdeapodaca, Fernando Molero. The impact of stigma on subjective well-being in people with mental disorders.Clin Schizophr Relat Psychoses 2017 Aug 4. doi: https://doi.org/10.3371/CSRP.CBMF.071317 . [PubMed] [Google Scholar].

Watson AC, Corrigan PW, Larson JE, Sells M. Self-stigma in people with mental illness. Schizophr Bull. 2007;33:1312–8. [PMC free article] [PubMed] [Google Scholar].

Sirey JA, Bruce ML, Alexopoulos GS, et al. Stigma as a barrier to recovery: perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatr Serv. 2001 Dec;52(12):1615–20. https://doi.org/10.1176/appi.ps.52.12.1615 . [PubMed] [Google Scholar].

Sirey JA, Bruce ML, Alexopoulos GS, et al. Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. Am J Psychiatry. 2001 Mar;158(3):479–81. https://doi.org/10.1176/appi.ajp.158.3.479 . [PubMed] [Google Scholar].

Isabella Berardelli SS et al. Elena Rogante The Role of Demoralization and Hopelessness in Suicide Risk in Schizophrenia: A Review of the Literature. Medicina (Kaunas). 2019 May 23;55(5):200. doi: https://doi.org/10.3390/medicina55050200 . [PMC free article] [PubMed] [Google Scholar].

Frank JD. Psychotherapy: the restoration of morale. Am J Psychiatry. 1974;131:271–4. [PubMed] [Google Scholar].

Onken SJ, Craig CM, Ridgway P, Ralph RO, Cook JA. An analysis of the definitions and elements of recovery: a review of the literature. Psychiatr Rehabil J. 2007 Summer;31(1):9–22. [PubMed] [Google Scholar].

Ritsher [Boyd] JB, Phelan J. Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry Res. 2004 Dec 30;129(3):257 – 65. doi: 10.1016/j.psychres.2004.08.003.[PubMed] [Google Scholar].

Liu L, Ma X, Zhao X. What do psychotic Experiences Mean to Chinese Schizophrenia Patients? Qual Health Res.2012(12),1707–16. [PubMed] [Google Scholar].

Marc J, Weintraub DL, Hall, Julia Y, Carbonella, et al. Integrity of literature on expressed emotion and relapse in patients with Schizophrenia verified by a p-Curve analysis. Fam Process. 2017 Jun;56(2):436–44. [PMC free article] [PubMed] [Google Scholar].

Gregg L, Calam R, Drake RJ, Wolfenden L. Expressed emotion and attributions in parents with Schizophrenia. Front Psychiatry. 2021;12:799626. https://doi.org/10.3389/fpsyt.2021.799626 . [PMC free article] [PubMed] [Google Scholar].

Butzlaff RL, Hooley JM. Expressed emotion and psychiatric relapse: a meta-analysis. Arch Gen Psychiatry. 1998 Jun;55(6):547–52. https://doi.org/10.1001/archpsyc.55.6.547 . [PubMed] [Google Scholar].

Ma CF, Chan SKitW, Chung YL et al. The predictive power of expressed emotion and its components in relapse of schizophrenia: a meta-analysis and meta-regression. Psychol Med 2021 Feb;51(3):365–75. doi: 10.1017/S0033291721000209. [PubMed] [Google Scholar].

Jungbauer J, Stelling K, Dietrich S, Matthias C, Angermeyer. Schizophrenia: problems of separation in families. J Adv Nurs 2004 Sep;47(6):605–13. doi: https://doi.org/10.1111/j.1365-2648.2004.03157 .x. [PubMed] [Google Scholar].

Wong Y-LI, Kong D, Tu L. Rosemary Frasso.“My bitterness is deeper than the ocean”: understanding internalized stigma from the perspectives of persons with schizophrenia and their family caregivers. Int J Ment Health Syst 2018 Apr 3;12:14. doi: https://doi.org/10.1186/s13033-018-0192-4 . [PMC free article] [PubMed] [Google Scholar].

Yen-Ching Chang L-H, Chang S-T, Hsu M-W, Huang. Professional perspectives on providing recovery-oriented services in Taiwan: a qualitative study. BMC Psychiatry.2021 Mar 16;21(1):154. doi: https://doi.org/10.1186/s12888-021-03152-y . [PMC free article] [PubMed] [Google Scholar].

Joanna Ochocka G, Nelson R. Janzen. Moving forward: negotiating self and external circumstances in recovery. Psychiatr Rehabil J. 2005 Spring;28(4):315 – 22. doi: 10.2975/28.2005.315.322. [PubMed] [Google Scholar].

Damsgaard JB, Angel S. Living a Meaningful Life while struggling with Mental Health: challenging aspects regarding personal recovery encountered in the Mental Health System. Int J Environ Res Public Health. 2021 Mar;18(5):2708. https://doi.org/10.3390/ijerph18052708 . [PMC free article] [PubMed] [Google Scholar].

Yang Guoshu. Chinese psychology and behavior: a localized study. Beijing: Renmin University of China Press; 2004. pp. 143–4.

Mead S, Opeland C M.E. What recovery means to us: consumers’ perspective. Commun Ment Health J. 2000;36:315–28. [PubMed] [Google Scholar].

Article   CAS   Google Scholar  

Davidson L, Strauss JS. (1992) Sense of self in recovery from severe mental illness. Br J Med Psychol. 1992. 65: 131–145. Sense of self in recovery from severe mental illness. [PubMed] [Google Scholar]

Yulia Kartalova-O’Doherty, Donna Tedstone Dohert. Recovering from recurrent mental health problems: giving up and fighting to get better. Int J Ment Health Nurs. 2010;Feb19(1):3–15. [PMC free article] [PubMed] [Google Scholar].

Deegan P. Recovery as a journey of the heart. Psychiatric: Rehabilitation Journal. 1996;19:3,91–7. [Google Scholar].

Markowitz FE. Modeling processes in recovery from mental illness: Relationships between symptoms, life satisfaction, and self-concept. J Health Soc Behav. 2001 Mar;42(1):64–79. [PubMed] [Google Scholar].

Download references

Acknowledgements

We would like to thank Dr. Dehui Zhou and Chunyan Wu for their help in writing and Chunyan Wu for her work in the translation of the thesis.

The program was funded by the Wuhan Municipal Health and Wellness Commission (WX17B14).

Author information

Authors and affiliations.

Wuhan Mental Health center, Wuhan Hospital for Psychotherapy, Rehabilitation Department, Wuhan, China

Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China

China University of Geosciences Wuhan, Wuhan, China

Yanhong Chen

Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China

You can also search for this author in PubMed   Google Scholar

Contributions

MM and SZD wrote the main manuscript text, CH was the interviewer, and MXQ prepared the timetable. All authors participated in the interpretive phenomenological analysis of the data. Zhidao Shi is co-first author. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Xiquan Ma .

Ethics declarations

Ethics approval and consent to participate.

The study was carried out in accordance with ethical principles for medical research involving humans (WMA, Declaration of Helsinki). Ethical approval was obtained from the Wuhan Mental Health Center Ethics Committee (KY2016(52)). All subjects provided written informed consent to participate.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 Timetable

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Ma, M., Shi, Z., Chen, Y. et al. Recovery journey of people with a lived experience of schizophrenia: a qualitative study of experiences. BMC Psychiatry 23 , 468 (2023). https://doi.org/10.1186/s12888-023-04862-1

Download citation

Received : 02 October 2022

Accepted : 11 May 2023

Published : 27 June 2023

DOI : https://doi.org/10.1186/s12888-023-04862-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Schizophrenia
• Qualitative research

BMC Psychiatry

ISSN: 1471-244X

• General enquiries: [email protected]

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

Understanding Schizophrenia: A Case Study

Schizophrenia is characterized mainly, by the gross distortion of reality, withdrawal from social interaction, disorganization and fragmentation of perception, thoughts and emotions. Insight is an important concept in clinical psychiatry, a lack of insight is particularly common in schizophrenia patient. Previous studies reported that between 50-80% of patients with schizophrenia do not believe, they have a disorder. By the help of psychological assessment, we can come to know an individual's problems especially in cases, where patient is hesitant or has less insight into illness. Assessment is also important for the psychological management of the illness. Knowing the strengths and weaknesses of that particular individual with psychological analysis tools can help to make better plan for the treatment. The present study was designed to assess the cognitive functioning, to elicit severity of psychopathology, understanding diagnostic indicators, personality traits that make the individual vulnerable to the disorder and interpersonal relationship in order to plan effective management. Schizophrenia is a chronic disorder, characterized mainly by the gross distortion of reality, withdrawal from social interaction, and disorganization and fragmentation of perception, thought and emotion. Approximately, 1% world population suffering with the problem of Schizophrenia. Both male and female are almost equally affected with slight male predominance. Schizophrenia is socioeconomic burden with suicidal rate of 10% and expense of 0.02-1.65% of GDP spent on treatment. Other co-morbid factors associated with Schizophrenia are diabetes, Obesity, HIV infection many metabolic disorders etc. Clinically, schizophrenia is a syndrome of variables symptoms, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. The expression of these manifestations varies across patients and over the time, but the effect of the illness is always severe and is usually long-lasting. Patients with schizophrenia usually get relapse after treatment. The most common cause for the relapse is non-adherent with the medication. The relapse rate of schizophrenia increases later time on from 53.7% at 2 years to

Related Papers

Bangladesh Journal of Psychiatry

Luna Krasota Nur Laila

Schizophrenia is a chronic psychiatric illness with high rate of relapse which is commonly associated with noncompliance of medicine, as well as stress and high expressed emotions. The objective of the study was to determine the factors of relapse among the schizophrenic patients attending in outpatient departments of three tertiary level psychiatric facilities in Bangladesh. This was a cross sectional study conducted from July, 2001 to June, 2002. Two hundred patients including both relapse and nonrelapse cases of schizophrenia and their key relatives were included by purposive sampling. The results showed no statistically significant difference in terms of relapse with age, sex, religion, residence, occupation and level of education (p&gt;0.05), but statistically significant difference was found with marital status and economic status (p&lt;0.01). The proportion of non-compliance was found to be 80% and 14%, of high expressed emotion was 17% and 2% and of the occurrence of stressf...

Ashok Kumar Patel

BMC Psychiatry

Bonginkosi Chiliza

Revista Brasileira de Psiquiatria

Helio Elkis

OBJECTIVES: The heterogeneity of clinical manifestations in schizophrenia has lead to the study of symptom clusters through psychopathological assessment scales. The objective of this study was to elucidate clusters of symptoms in patients with refractory schizophrenia which may also help to assess the patients&#39; therapeutical response. METHODS: Ninety-six treatment resistant patients were evaluated by the anchored version Brief Psychiatric Rating Scale (BPRS-A) as translated into Portuguese. The inter-rater reliability was 0.80. The 18 items of the BPRS-A were subjected to exploratory factor analysis with Varimax rotation. RESULTS: Four factors were obtained: Negative/Disorganization, composed by emotional withdrawal, disorientation, blunted affect, mannerisms/posturing, and conceptual disorganization; Excitement, composed of excitement, hostility, tension, grandiosity, and uncooperativeness, grouped variables that evoke brain excitement or a manic-like syndrome; Positive, compo...

Nicholas Tarrier

Annals of Clinical and Laboratory Research

James Mwaura

Sou Agarwal

Schizophrenia Bulletin

Joseph Goldberg

International journal of mental health nursing

Inayat ullah Shah

Despite a large body of research evaluating factors associated with the relapse of psychosis in schizophrenia, no studies in Pakistan have been undertaken to date to identify any such factors, including specific cultural factors pertinent to Pakistan. Semistructured interviews and psychometric measures were undertaken with 60 patients diagnosed with schizophrenia (49 male and 11 female) and their caregivers at four psychiatric hospitals in the Peshawar region in Pakistan. Factors significantly associated with psychotic relapse included treatment non-adherence, comorbid active psychiatric illnesses, poor social support, and high expressed emotion in living environments (P &lt; 0.05). The attribution of symptoms to social and cultural values (97%) and a poor knowledge of psychosis by family members (88%) was also prevalent. In addition to many well-documented factors associated with psychotic relapse, beliefs in social and cultural myths and values were found to be an important, and p...

Octavian Vasiliu

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

RELATED PAPERS

International Journal of Medicine and Public Health

amresh srivastava

Epidemiologia e psichiatria sociale

Rita Roncone

Progress in Neuro-Psychopharmacology and Biological Psychiatry

Archives of Psychiatric Nursing

Karen Schepp

Derege Kebede

ncbi.nlm.nih.gov

Swapnesh Tiwari

Actas españolas de psiquiatría

Enrique Echeburúa

European Psychiatry

Schizophrenia Research

Jonathan Rabinowitz

Adellah Sariah

Rikus Knegtering

Actas espanolas de psiquiatria

Manuel Bousono

The Journal of Nervous and Mental Disease

Andrea Affaticati , Rebecca Ottoni

Psychiatry Research

Massimo Tusconi

zewdu shewangizaw

IOSR Journals

Annals of General Psychiatry

Andreas Schreiner

Journal of psychiatry & neuroscience: JPN

Lawrence Annable

ROMANIAN JOURNAL …

Cornelia Rada

Ifeta Licanin

American family physician

Stephen Schultz

RELATED TOPICS

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Lippincott Open Access
• PMC10990032

Evidence-based psychosocial interventions in schizophrenia: a critical review

Stefano barlati.

a Department of Clinical and Experimental Sciences, University of Brescia

b Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy

Gabriele Nibbio

Antonio vita, purpose of review.

Schizophrenia Spectrum Disorders (SSD) are severe conditions that frequently produce significant impairment in cognitive performance, social skills and psychosocial functioning. As pharmacological treatment alone often provides only limited improvements on these outcomes, several psychosocial interventions are employed in psychiatric rehabilitation practice to improve of real-world outcomes of people living with SSD: the present review aims to provide a critical overview of these treatments, focusing on those that show consistent evidence of effectiveness.

Recent findings

Several recent systematic reviews and meta-analyses have investigated in detail the acceptability, the effectiveness on several specific outcomes and moderators of response of different psychosocial interventions, and several individual studies have provided novel insight on their implementation and combination in rehabilitation practice.

Cognitive remediation, metacognitive training, social skills training, psychoeducation, family interventions, cognitive behavioral therapy, physical exercise and lifestyle interventions, supported employment and some other interventions can be fully considered as evidence-based treatments in SSD. Psychosocial interventions could be of particular usefulness in the context of early intervention services. Future research should focus on developing newer interventions, on better understanding the barriers and the facilitators of their implementation in clinical practice, and exploring the opportunities provided by novel technologies.

INTRODUCTION

Schizophrenia Spectrum Disorders (SSD) represent severe and debilitating mental conditions, frequently characterized by impaired cognitive performance [ 1 , 2 ], poor real-world functional outcomes [ 3 , 4 ], reduced quality of life [ 5 , 6 ], high levels of internalized stigma [ 7 – 9 ] and low levels of life engagement [ 10 , 11 ]. In people living with SSD, a combination of reduced access to medical care, unhealthy lifestyles and biological factors lead to an average reduction of life expectancy of 14.5 years, mainly due to cardiovascular disease and cancer [ 12 ▪▪ , 13 ].

Pharmacological treatment represents the cornerstone of SSD treatment, and indeed a massive body of evidence reports that antipsychotic medications are consistently effective in improving psychotic symptoms, preventing relapses and even extending life expectancy in people living with SSD [ 14 – 16 ]. However, pharmacological treatment alone is not currently effective in improving several clinical and functional outcomes, such as cognitive performance, social skills and quality of life, and in improving real-world outcomes, such as finding and maintaining a job or having meaningful personal relationships; in fact, most people living with SSD currently experience only small improvements in outcomes that are important for them in their personal perspective and do not achieve full functional and personal recovery [ 17 – 19 ].

This is where psychosocial interventions come into play. Complementing and enhancing the effects of pharmacological treatments, and targeting domains and features that are not currently improved by antipsychotic treatment, various psychosocial interventions have shown consistent effectiveness on several different outcomes [ 20 ▪ , 21 ▪▪ ], and are now recommended as evidence-based treatments for SSD in many national and international guidelines [ 14 , 22 – 24 , 25 ▪ ].

Considering that SSD represent a clinically heterogeneous spectrum and no valid one-size-fits-all treatment protocol exists, having a good understanding of the different available evidence-based psychosocial interventions is essential to devise and implement personalized treatment programs, with specific interventions for the specific needs of specific patients [ 18 ]: this currently represents a fundamental step to provide the most effective treatment for people living with SSD. 

no caption available

Rather than providing an assessment of the overall effectiveness of psychosocial interventions in SSD, the present work will focus on each specific evidence-based psychosocial intervention, reporting and commenting the available and recent evidence regarding its effectiveness on global as well as on specific outcomes. A summary is reported in Table ​ Table1. 1 . Discussion regarding the gaps in current scientific literature and the intrinsic limitations of specific psychosocial interventions, as well as considerations on the current state of the art and on the implementation of these interventions in clinical practice will also be provided.

Evidence-based psychosocial interventions in Schizophrenia Spectrum Disorders

COGNITIVE REMEDIATION

Cognitive Remediation (CR) is a behavioral training-based intervention targeting cognitive performance with the aim of providing a durable improvement to psychosocial functioning [ 26 , 27 ]. It currently represents the psychosocial intervention with the highest degree of recommendation in the European Psychiatric Association guidelines for the treatment of cognitive impairment in schizophrenia [ 25 ▪ ].

Two high-quality meta-analyses have recently explored the effectiveness of CR, one including both interventions targeting neurocognitive performance and interventions targeting social cognition [ 28 ], and one considering only neurocognition-targeting programs [ 29 ]. Both meta-analyses yielded very similar results, showing that CR provided significant benefits in global cognitive performance as well as in specific cognitive domains that were translated into significant improvement in psychosocial functioning. The effectiveness of social cognition training was also explored in a dedicated meta-analysis, reporting significant improvements in social cognition domains and generalization to the executive functions neurocognitive domain [ 30 ].

Considering treatment-related moderators of effect, the presence of an active and trained therapist delivering the intervention, the structured development of novel cognitive strategies, the implementation of techniques to transfer cognitive gains into the real world and the integration with structured psychiatric rehabilitation programs or other evidence-based psychosocial interventions significantly improved outcomes: these factors emerged as core treatment ingredients, and programs including all these elements provided moderate-sized effects on both global cognition and psychosocial functioning. As regards participant-related predictors of response, no specific characteristics represented a barrier to effectiveness, but more clinically compromised participants reported greater improvements [ 28 ].

The acceptability of CR interventions was also systematically assessed: a recent meta-analysis investigated CR trials drop-outs, and found that CR overall has a good acceptability profile, in line with that of other psychosocial interventions [ 31 ▪ ]. Evidence from low-income settings also suggest that CR can be feasible and implemented in clinical practice also with very limited available resources [ 32 ].

The main limitation of CR interventions is that, on themselves, they provide no substantial benefits as regards psychotic symptoms. The results of an earlier meta-analysis suggested that CR can provide improvements in negative symptoms [ 33 ], but more recent meta-analyses including more high quality studies reported that these gains, if statistically significant, are too small sized to be of clinical relevance [ 28 , 29 ].

METACOGNITIVE TRAINING

Metacognitive training for psychosis (MCT) is a psychosocial intervention that combines elements of psychoeducation, cognitive bias modification and strategy teaching, aiming at improving positive symptoms, and persistent symptoms more in general, by improving metacognitive function; it represent the most employed and most investigated metacognitive intervention, a group of treatments that also includes metacognitive therapy and metacognitive insight and reflection therapy [ 34 ].

A recent and high-quality meta-analysis explored the effectiveness of MCT on several different outcomes: MTC provided significant long-term improvement in positive symptoms, particularly delusions, and psychosocial functioning; significant, albeit smaller effects were also observed in negative symptoms, cognitive biases and self-esteem [ 35 ▪ ].

Another meta-analysis investigated the effectiveness of metacognitive interventions on insight: MCT improved self-reflectiveness and overall cognitive insight both after treatment and at follow-up observations, and self-certainty after treatment only. Findings on clinical insight could not be quantitatively synthesized, but trials results suggest that MCT can be effective also in this aspect [ 36 ].

SOCIAL SKILLS TRANING

Social skills training (SST) is a psychosocial intervention that targets interpersonal and social skills with the aim of improving real-world outcomes such as social performance and social interactions. Meta-analytic evidence shows that SST provides improvements in social outcomes as well as significant albeit small improvements in negative and general psychopathology symptoms [ 37 , 38 ].

As the overall effectiveness of SST in SSD has already been well documented and established for several years [ 39 ], recent studies have focused in on combining SST with other psychosocial interventions, in particular components of cognitive behavioral psychological interventions, CR and MCT, showing positive synergies on different outcomes with these combined treatments [ 40 – 44 ].

PSYCHOEDUCATION

Psychoeducation encompasses all the interventions focused on the education of an individual living with a psychiatric disorder regarding topics that may improve the outcomes of treatment and rehabilitation, enabling a behavioral change in the participant; in the treatment of SSD, psychoeducation has been recognized since several years as an intervention that can consistently improve relapse prevention and treatment adherence [ 45 ], and some evidence also suggests that it can improve psychosocial functioning and some psychopathological domains, albeit not core SSD symptoms [ 46 ]. A recent and high-quality network meta-analysis exploring the effectiveness of different psychosocial interventions on relapse prevention confirmed that psychoeducation has a good effectiveness on this specific outcome; this positive effect however was not observed at follow-up observations longer than 12 months [ 47 ].

A recent systematic review explored the effects of psychoeducation on individuals at clinical high risk for psychosis: the results highlighted a good feasibility and acceptability profile of the interventions in this population, and some studies also reported positive effects on psychosocial functioning and psychopathological outcomes, but more high-quality research is currently needed to evaluate the effectiveness of psychoeducation in this population, particularly on high-relevance outcomes such as transition to psychosis [ 48 ▪ ].

FAMILY INTERVENTIONS

It has been widely demonstrated that family environment plays a pivotal role in the long-term course of SSD, as well as in the recovery process [ 49 ]. In this context, several different family interventions models have been developed [ 50 , 51 ].

A recent high-quality network meta-analysis explored the effectiveness of different family interventions in relapse prevention: the vast majority of interventions included some element of family psychoeducation, and almost all interventions were effective in preventing relapse even at follow-up observations longer than 12 months; family psychoeducation alone emerged as the most effective intervention, superior to more complex models that include other treatment elements and showing a moderate-to-large effect size, while the less effective approach were community-based interventions involving family members [ 52 ▪ ].

Another recent meta-analysis explored and attested the effectiveness of family interventions on several different family-level (family's mental health, attitude towards the disorder, family burden, family coping, family health and well being, family functioning) and patient-level (treatment satisfaction and adherence, quality of life, psychiatric symptoms, illness insight, psychosocial functioning, rehospitalization) outcomes: moderate-to-large effect sizes were observed in both categories, with superior effects in family outcomes. Interventions targeting individual family units and delivered only to the family caregivers emerged as superior. The results of this meta-analysis, however, have to be considered with caution as significant publication bias was reported [ 53 ].

Overall, family interventions appear to represent one of the most clinically meaningful categories of psychosocial interventions, but to date the number of studies exploring their effectiveness is still somehow limited, compared to that available for other psychosocial interventions: in this regard, more research on this field is warranted.

COGNITIVE BEHAVIORAL THERAPY

Cognitive Behavioral Therapy for psychosis (CBTp) is a structured psychotherapy intervention that focuses on the connections between thoughts, behaviors, and emotions targeted and adapted for the treatment of SSD. It represents an evidence-based psychotherapy intervention that has been shown to be effective in improving several outcomes, and in particular in reducing the severity of positive symptoms [ 54 , 55 ].

A recent umbrella review of meta-analyses and randomized controlled trials showed a consistent effectiveness of CBT positive symptoms, which represents one of its primary outcomes, while small and nonconsistent effects were observed for negative symptoms [ 56 ▪▪ ].

A recent meta-analysis investigated the effectiveness of CBTp delivered in a group setting: the results of this work partially contested those of previous meta-analyses, showing no significant benefit as regards the severity of positive and negative symptoms, but reported positive effects on other important outcomes such as psychosocial functioning and global psychopathological severity [ 57 ▪ ].

Another recent meta-analysis investigated the use of CBTp in the prodromal phases of psychosis: the results showed that this intervention is indeed effective in reducing the transition to full psychosis at all considered time-points and also in reducing attenuated psychotic symptoms [ 58 ▪ ]. These results are very interesting in a clinical perspective, as this population may represent a target that benefits in particular manner for CBTp, with significant and important long-term consequences.

PHYSICAL EXERCISE AND LIFESTYLE INTERVENTIONS

Physical exercise can be considered to all intents and purposes as a fully evidence-based psychosocial intervention for people living with SSD, capable of improving not only physical fitness, but also psychopathological outcomes [ 59 ] and cognitive performance [ 60 – 62 ].

A recent and large meta-analysis focused on moderators of effects of cognitive improvement, and confirmed that the most effective form of physical exercise for this outcome is aerobic exercise; it also reported a superior effect of group exercise, that supervision of trained exercise professionals substantially enhanced effectiveness and that positive results could be observed with a dose-dependent effect starting from a duration of ≥90 min per week for ≥12 weeks [ 63 ▪ ]. Recent evidence also suggest that combining physical exercise with CR produces a synergic effect, providing faster gains in cognitive performance [ 64 , 65 ].

Another recent meta-analysis explored the effectiveness of physical exercise in people living with SSD on psychosocial functioning: positive and moderate-sized effects were observed for global functioning, for social functioning and for daily life functioning [ 66 ▪▪ ].

Finally, physical exercise, as well as diet and lifestyle interventions were investigated regarding their effectiveness on several different outcomes: anthropometric measures such as BMI weight and waist circumference showed significant lasting benefits, alongside psychopathological, cognitive and functional measure, including quality of life [ 61 ]. In this regard, physical exercise and lifestyle interventions represent an intervention that might be suitable for the vast majority of people living with SSD and be particularly useful in cases where targeting cognitive performance represents a priority.

SUPPORTED EMPLOYMENT

Supported employment and, overall, interventions specifically targeting employment represent a very particular category of psychosocial interventions that, when delivered to people living with SSD, have been show to improve the likelihood of obtaining a competitive job and to improve the number of hours worked in any job [ 67 ].

A recent meta-analysis explored the effectiveness of individual placement and support, a rehabilitation program focused on employment outcomes, across all different psychiatric diagnoses: the results showed that the intervention was effective in all the included populations, but it was more effective in people with severe mental illness and with SSD in particular. The effectiveness of the intervention, however, emerged as limited by symptoms severity [ 68 ▪ ].

Despite this limitation, the evidence supporting the usefulness of this approach is consistent, and is recently leading to the development of novel intervention programs and protocols [ 69 ].

In clinical practice, interventions targeting employment may represent a valuable asset to progress in the recovery process of subjects with a stable clinical condition and good cognitive performance, or where clinical recovery and cognitive performance improvement were already obtained.

OTHER INTERVENTIONS

Several other interventions have been explored in the treatment of different aspects of SSD.

Assertive Community Treatment (ACT) represents an intensive mental health program model including multidisciplinary approaches that can improve clinical and functional outcomes [ 70 ]. A recent study has investigate whether a flexible and less resource-demanding format of ACT can be equally effective, but reported negative findings, with the full ACT group emerging as superior on personal and social functioning outcomes [ 71 ].

Compensatory interventions for cognitive impairment do not directly target cognitive performance, but rather provide targeted aids and strategies to improve functioning despite cognitive deficits: a meta-analysis exploring the effectiveness of this approach has indeed observed functional improvements that were maintained at follow-up observations [ 72 ]. Elements of these interventions could be combined with CR interventions to further increase functioning gains, and they appear to be ideal in participants that do not respond to CR.

Illness self-management interventions, focusing on teaching and training skills to autonomously manage the physical, social and emotional impact of a disorder, provided small but significant improvements in different outcomes in two meta-analyses [ 73 , 74 ].

Motivational interviewing has recently been explored in a meta-analysis in people with SSD and comorbid substance use disorders, reporting mostly negative results [ 75 ]. A systematic review investigating the effectiveness on medication adherence was also conducted, again reporting mostly negative findings [ 76 ].

Mindfulness-based interventions [ 77 ] have also been investigated in people living with SSD, and the results of some studies suggests that they might be effective in improving clinical and functional outcomes [ 78 ]; however, the quantity and the quality of the studies investigating this intervention is not currently sufficient to consider it as fully evidence-based.

EARLY INTERVENTION SERVICES

Early intervention services are designed specifically to provide treatment in first episode or early phase of psychosis subjects, and indeed a wealth of recent literature shows that multidisciplinary teams of mental health professionals providing multimodal treatment in this population produces considerable long-term benefits [ 79 ]. In fact, recent high-quality evidence shows that providing evidence-based psychosocial interventions in early phase subjects clearly represents the most cost-effective course of action, and possibly the overall most effective approach [ 21 ▪▪ ].

However, implementing early intervention services in routine clinical practice is often accompanied by many challenges, mostly linked to the difficulty of accurately identifying and intercepting early-phase subjects and of building an effective therapeutic alliance with subjects and their families. Organization and resource availably issues might also occur, as maintaining an effective multidisciplinary intervention service might represent a complex endeavor in and of itself [ 80 ].

CONLCUSIONS AND FUTURE DIRECTIONS

Several different psychosocial interventions for people living with SSD have shown consistent evidence of effectiveness in different clinically and personally relevant outcomes.

Most interventions have shown a measure of effectiveness on psychosocial functioning outcomes, and most people living with SSD, despite the recommendations provided in national and international guidelines, at the present time receive only pharmacological treatment [ 81 ]. In this perspective, most people living with SSD would currently benefit in a considerable manner from receiving any kind of evidence-based psychosocial intervention.

However, in the perspective of personalizing and optimizing the treatment options, improving the chances of recovery and accelerating the recovery process [ 18 ], identifying the most appropriate intervention for each individual, and even the most appropriate intervention for the specific phase of the illness and of the recovery journey, actually represents the optimal approach.

CRT and physical exercise are particularly effective in improving cognitive performance: they could be useful in the vast majority of patients, and particularly in those that show cognitive impairment.

Physical exercise may also be particularly useful in subjects showing metabolic issues and medication -related metabolic adverse effects [ 82 , 83 ]. CBTp may also be useful in most patients, and, as MCT, may help in improving positive symptoms that persist with pharmacological treatment. Family interventions and individual psychoeducation could also be of use in the vast majority of patients but may provide the most important results in people with multiple or frequent relapses. SST may be combined with most other interventions to further improve functioning and be suited to individuals with social skills deficits. Finally, supported employment could be of use in individuals with less severe symptoms and smaller clinical impairment, or individuals that have already regained more basic skills and abilities.

It is also important to note that combining different interventions often produces synergic effects, so integrating interventions often represents an effective strategy if the available resources allow this approach [ 28 , 43 , 64 ].

Future research should focus on developing newer, more effective and more optimized interventions and treatment programs, but also on better understanding the barriers and the facilitators of the implementation in real-world everyday clinical practice of evidence-based interventions, aiming to further reduce and resolve the bench-to-bedside gap [ 84 , 85 ].

Finally, research on the usefulness of new digital technologies, including telemedicine and immersive virtual reality approaches, to deliver evidence-based interventions [ 86 – 89 ] could open new avenues and perspective to improve the recovery process of people living with SSD.

Acknowledgements

Financial support and sponsorship, conflicts of interest.

There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

• ▪ of special interest
• ▪▪ of outstanding interest

Personalize Your Experience

Log in or create an account for a personalized experience based on your selected interests.

Already have an account? Log In

Free standard shipping is valid on orders of $45 or more (after promotions and discounts are applied, regular shipping rates do not qualify as part of the $45 or more) shipped to US addresses only. Not valid on previous purchases or when combined with any other promotional offers.

Home / Mental Health / Understanding care and treatments for schizophrenia

Understanding care and treatments for schizophrenia

Please login to bookmark.

Username or Email Address

Remember Me

If you or a loved one has been living with schizophrenia, understanding the condition — and how to move forward after diagnosis — can be overwhelming.

It’s not unusual to feel worried, or perhaps even dismissive, about your need for care. But schizophrenia is a lifelong condition that requires — and deserves — attention and support in addition to a realistic, comprehensive treatment plan. Demystifying exactly how schizophrenia is treated, both in day-to-day life and long term, can help keep you proactively on track with your symptoms and needs.

There are a number of effective treatment options to manage schizophrenia, including medication, social and familial interventions, and talk therapy. And the good news is that with the right care, at least 1 in 3 people with schizophrenia will be able to fully recover from symptoms.

To help you understand the basics, Jonathan G. Leung, Pharm.D., R.Ph., BCCP, a Mayo Clinic expert and psychiatric clinical pharmacist, goes over the core strategies for schizophrenia management and what to expect from treatment.

Medication — the first line of treatment

According to Dr. Leung, medication will likely be the first, and most important, part of your treatment plan. The exact medications depend on the person and the type of schizophrenia, but antipsychotics, mood stabilizers and antidepressants are commonly used to treat and manage symptoms.

Although the exact cause of the condition isn’t yet understood, researchers do know that schizophrenia is a brain disease that impacts the brain structure and the central nervous system. Dopamine and glutamate — two neurotransmitters, also known as messengers, that help the brain and central nervous system communicate — are thought to play a part in schizophrenia. As a result, many antipsychotic medications work by blocking certain dopamine receptors in the brain.

“Most antipsychotic medications for schizophrenia currently focus on reducing excess dopamine and addressing symptoms, such as hallucinations, delusions and disorganization,” says Dr. Leung.In clinical trials, antipsychotics have been shown to effectively treat symptoms and behaviors associated with schizophrenia. With the right medication and care, it’s possible to experience remission of psychosis.

However, it’s important to understand that not everyone will respond the same — or as well — to first line antipsychotic medications. Treatment-resistant schizophrenia occurs when symptoms persist or don’t improve enough despite treatment. In these situations, Dr. Leung says your healthcare team may recommend clozapine, a Food and Drug Administration (FDA)-approved antipsychotic used for treatment-resistant schizophrenia. In general, clozapine is reserved for those who haven’t responded well to prior medications, as it can come with a range of side effects.

Likewise, Dr. Leung says there is much progress to be made when it comes to treating other symptoms, such as lack of motivation, inability to feel pleasure, flat affect and speech issues. There’s also progress to be made with cognitive schizophrenia symptoms, including attention and memory issues. All of the symptoms above can have significant impact on daily functioning and quality of life. At the moment, there are no specific FDA-approved medication options for these symptoms. However, Dr. Leung says your healthcare team may recommend certain antipsychotics, antidepressants or supplements to manage these symptoms.

Finally, your healthcare team may recommend mood stabilizers or antidepressants. Often, mood stabilizers are used when someone has the bipolar type of schizoaffective disorder, a type of schizophrenia that can include episodes of mania and depression. As the name implies, mood stabilizers can help “level out” your mood and help treat bipolar symptoms.

For people with the depressive type of schizoaffective disorder — or those who experience depressive episodes, but not mania — your healthcare team may recommend antidepressants to help improve sleep, focus and feelings of hopelessness.

Bringing in therapy, social support and other holistic care

Although medication is critical to managing schizophrenia, most people do best when they combine the right medications with psychological, personal and social support.

Since schizophrenia can impact many aspects of life — including personal relationships, employment and basic task management — Dr. Leung says an integrated approach to care is often most effective for long-term management. Integrated care emphasizes holistic, whole-person support in addition to medication.

This type of comprehensive care can involve family intervention and education, community outreach services, and talk or group therapy. You may also consider social skills or work rehabilitation training, which focus on communication, learning to navigate daily tasks and interactions, and improving job skills and retention.

Some therapies combine different methods to address multiple symptoms and concerns. Cognitive behavioral therapy (CBT) blends talk therapy with social skills training and behavioral intervention to reduce the intensity of hallucinations and delusions, improve social skills, and lower the risk of relapse.

If you’re unsure of what support you may need or what free or low-cost services exist in your area, consult with a case manager, a social services representative or a member of your healthcare team.

Setting expectations for schizophrenia treatment

Schizophrenia is a serious, often debilitating, condition — and it’s important to have realistic expectations around treatment. First and foremost, schizophrenia requires continuous, lifelong care. And in many cases, it can take some trial and error before finding out exactly what treatment methods work best for you.

For example, Dr. Leung says it’s not uncommon for people with schizophrenia to go through a few different medications, combinations of medications or different dosages to find the right balance. This process can take weeks or months as symptoms and side effects are monitored. Additionally, antipsychotics can cause a number of side effects and some, such as the movement disorder called tardive dyskinesia, may be permanent.

Between cycling through medications and navigating side effects, it can be incredibly frustrating to stick with your treatment plan. But Dr. Leung says it’s never a good idea to discontinue your medications or taper off without consulting with your healthcare team. Instead, let your healthcare team know your concerns and decide together how to best move forward.

Finally, it’s important to understand that at some point your symptoms may become severe enough that you need to stay in the hospital or an in-treatment facility. Receiving this type of care is not a failure on your part. Always reach out to a loved one, case worker or your healthcare team if you are noticing changing or worsening symptoms or simply need help.

Discover more Mental Health content from articles, podcasts, to videos.

You May Also Enjoy

Privacy Policy

We've made some updates to our Privacy Policy. Please take a moment to review.

Information

• Author Services

Initiatives

You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.

All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .

Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.

Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.

Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.

Original Submission Date Received: .

• Active Journals
• Find a Journal
• Proceedings Series
• For Authors
• For Reviewers
• For Editors
• For Librarians
• For Publishers
• For Societies
• For Conference Organizers
• Open Access Policy
• Institutional Open Access Program
• Special Issues Guidelines
• Editorial Process
• Research and Publication Ethics
• Article Processing Charges
• Testimonials
• Preprints.org
• SciProfiles
• Encyclopedia

Article Menu

• Subscribe SciFeed
• Recommended Articles
• Google Scholar
• on Google Scholar
• Table of Contents

Find support for a specific problem in the support section of our website.

Please let us know what you think of our products and services.

Visit our dedicated information section to learn more about MDPI.

JSmol Viewer

Sociodemographic variables in offender and non-offender patients diagnosed with schizophrenia spectrum disorders—an explorative analysis using machine learning.

1. Introduction

2. materials and methods, 2.1. study population, 2.1.1. forensic psychiatric subpopulation (op), 2.1.2. general psychiatric subpopulation (nop), 2.2. data source and extraction, 2.3. selection of predictor variables, 2.4. data analysis using machine learning, 2.4.1. preprocessing, 2.4.2. training of the algorithm, 2.4.3. validation of the algorithm, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

• El Naqa, I.; Murphy, M.J. What Is Machine Learning? In Machine Learning in Radiation Oncology: Theory and Applications ; El Naqa, I., Li, R., Murphy, M.J., Eds.; Springer International Publishing: Cham, Switzerland, 2015; pp. 3–11. [ Google Scholar ]
• Rebala, G.; Ravi, A.; Churiwala, S. Machine Learning Definition and Basics. In An Introduction to Machine Learning ; Rebala, G., Ravi, A., Churiwala, S., Eds.; Springer International Publishing: Cham, Switzerland, 2019; pp. 1–17. [ Google Scholar ]
• Nasteski, V. An overview of the supervised machine learning methods. Horizons B 2017 , 4 , 51–62. [ Google Scholar ] [ CrossRef ]
• Kirchebner, J. A collection of medical findings using machine learning and their relevance to psychiatry. Swiss Arch. Neurol. Psychiatry Psychother. 2022 , 173 , w03251. [ Google Scholar ] [ CrossRef ]
• Gutierrez, D.D. Machine Learning and Data Science: An Introduction to Statistical Learning Methods with R ; Technics Publications: Sedona, AZ, USA, 2015. [ Google Scholar ]
• Oquendo, M.A.; Baca-Garcia, E.; Artés-Rodríguez, A.; Perez-Cruz, F.; Galfalvy, H.C.; Blasco-Fontecilla, H.; Madigan, D.; Duan, N. Machine learning and data mining: Strategies for hypothesis generation. Mol. Psychiatry 2012 , 17 , 956–959. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Silva-Ayçaguer, L.C.; Suárez-Gil, P.; Fernández-Somoano, A. The null hypothesis significance test in health sciences research (1995–2006): Statistical analysis and interpretation. BMC Med. Res. Methodol. 2010 , 10 , 44. [ Google Scholar ] [ CrossRef ]
• Ryffel, F.A. Alpha and beta error (accumulation). In The International Encyclopedia of Communication Research Methods ; John Wiley & Sons: Hoboken, NJ, USA, 2017; pp. 1–5. [ Google Scholar ]
• Popper, K.R. Logik der Forschung: Zur Erkenntnistheorie der Moderner Naturwissenschaft ; Verlag von Julius Springer: Berlin/Heidelberg, Germany, 1935. [ Google Scholar ]
• Szucs, D.; Ioannidis, J.P.A. When Null Hypothesis Significance Testing Is Unsuitable for Research: A Reassessment. Front. Hum. Neurosci. 2017 , 11 , 390. [ Google Scholar ] [ CrossRef ]
• Krueger, J. Null hypothesis significance testing: On the survival of a flawed method. Am. Psychol. 2001 , 56 , 16. [ Google Scholar ] [ CrossRef ]
• Balluerka, N.; Gómez, J.; Hidalgo, D. The Controversy over Null Hypothesis Significance Testing Revisited. Methodology 2005 , 1 , 55–70. [ Google Scholar ] [ CrossRef ]
• Krantz, D.H. The Null Hypothesis Testing Controversy in Psychology. J. Am. Stat. Assoc. 1999 , 94 , 1372–1381. [ Google Scholar ] [ CrossRef ]
• Sedgwick, P.M.; Hammer, A.; Kesmodel, U.S.; Pedersen, L.H. Current controversies: Null hypothesis significance testing. Acta Obs. Gynecol Scand 2022 , 101 , 624–627. [ Google Scholar ] [ CrossRef ]
• Ingram, R.E.; Luxton, D.D. Vulnerability-stress models. Dev. Psychopathol. A Vulnerability-Stress Perspect. 2005 , 46 , 32–46. [ Google Scholar ]
• Cheng, S.C.; Walsh, E.; Schepp, K.G. Vulnerability, Stress, and Support in the Disease Trajectory from Prodrome to Diagnosed Schizophrenia: Diathesis–Stress–Support Model. Arch. Psychiatr. Nurs. 2016 , 30 , 810–817. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Darrell-Berry, H.; Berry, K.; Bucci, S. The relationship between paranoia and aggression in psychosis: A systematic review. Schizophr. Res. 2016 , 172 , 169–176. [ Google Scholar ] [ CrossRef ]
• Fava, G.A. The Intellectual Crisis of Psychiatric Research. Psychother. Psychosom. 2006 , 75 , 202–208. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Zhou, J.; Gandomi, A.H.; Chen, F.; Holzinger, A. Evaluating the quality of machine learning explanations: A survey on methods and metrics. Electronics 2021 , 10 , 593. [ Google Scholar ] [ CrossRef ]
• Parmigiani, G.; Barchielli, B.; Casale, S.; Mancini, T.; Ferracuti, S. The impact of machine learning in predicting risk of violence: A systematic review. Front. Psychiatry 2022 , 13 , 1015914. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Watts, D.; Moulden, H.; Mamak, M.; Upfold, C.; Chaimowitz, G.; Kapczinski, F. Predicting offenses among individuals with psychiatric disorders—A machine learning approach. J. Psychiatr. Res. 2021 , 138 , 146–154. [ Google Scholar ] [ CrossRef ]
• Trinhammer, M.L.; Merrild, A.C.H.; Lotz, J.F.; Makransky, G. Predicting crime during or after psychiatric care: Evaluating machine learning for risk assessment using the Danish patient registries. J. Psychiatr. Res. 2022 , 152 , 194–200. [ Google Scholar ] [ CrossRef ]
• Kirchebner, J.; Lau, S.; Machetanz, L. Offenders and non-offenders with schizophrenia spectrum disorders: Do they really differ in known risk factors for aggression? Front. Psychiatry 2023 , 14 , 1145644. [ Google Scholar ] [ CrossRef ]
• Machetanz, L.; Lau, S.; Habermeyer, E.; Kirchebner, J. Suicidal Offenders and Non-Offenders with Schizophrenia Spectrum Disorders: A Retrospective Evaluation of Distinguishing Factors Using Machine Learning. Brain Sci 2023 , 13 , 97. [ Google Scholar ] [ CrossRef ]
• Farrington, D.P.; Loeber, R.; Ttofi, M.M. Risk and protective factors for offending. In The Oxford Handbook of Crime Prevention ; Oxford University Press: Oxford, UK, 2012; pp. 46–69. [ Google Scholar ]
• Jolliffe, D.; Farrington, D.P.; Piquero, A.R.; Loeber, R.; Hill, K.G. Systematic review of early risk factors for life-course-persistent, adolescence-limited, and late-onset offenders in prospective longitudinal studies. Aggress. Violent Behav. 2017 , 33 , 15–23. [ Google Scholar ] [ CrossRef ]
• Takahashi, A. The role of social isolation stress in escalated aggression in rodent models. Neurosci. Res. 2022 . [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Fazel, S.; Gulati, G.; Linsell, L.; Geddes, J.R.; Grann, M. Schizophrenia and violence: Systematic review and meta-analysis. PLoS Med 2009 , 6 , e1000120. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Fazel, S.; Långström, N.; Hjern, A.; Grann, M.; Lichtenstein, P. Schizophrenia, Substance Abuse, and Violent Crime. JAMA 2009 , 301 , 2016–2023. [ Google Scholar ] [ CrossRef ]
• Fazel, S.; Sariaslan, A. Victimization in people with severe mental health problems: The need to improve research quality, risk stratification and preventive measures. World Psychiatry 2021 , 20 , 437. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Latalova, K.; Kamaradova, D.; Prasko, J. Violent victimization of adult patients with severe mental illness: A systematic review. Neuropsychiatr. Dis. Treatment. 2014 , 10 , 1925–1939. [ Google Scholar ] [ CrossRef ]
• Rajula, H.S.R.; Verlato, G.; Manchia, M.; Antonucci, N.; Fanos, V. Comparison of Conventional Statistical Methods with Machine Learning in Medicine: Diagnosis, Drug Development, and Treatment. Medicina 2020 , 56 , 455. [ Google Scholar ] [ CrossRef ]
• World Health Organization. ICD-10: International Statistical Classification of Diseases and Related Health Problems: Tenth Revision ; World Health Organization: Geneva, Switzerland, 2004. [ Google Scholar ]
• Slee, V.N. The International classification of diseases: Ninth revision (ICD-9). Ann. Intern. Med. 1978 , 88 , 424–426. [ Google Scholar ] [ CrossRef ]
• Seifert, D. Die Entwicklung des psychiatrischen Massregelvollzugs (§ 63StGB) in Nordrhein-Wesfalen. Psychiat Prax 1997 , 24 , 237–244. [ Google Scholar ]
• Brennan, P.F.; Hays, B.J. Focus on psychometrics the kappa statistic for establishing interrater reliability in the secondary analysis of qualitative clinical data. Res. Nurs. Health 1992 , 15 , 153–158. [ Google Scholar ] [ CrossRef ]
• Osisanwo, F.; Akinsola, J.; Awodele, O.; Hinmikaiye, J.; Olakanmi, O.; Akinjobi, J. Supervised machine learning algorithms: Classification and comparison. Int. J. Comput. Trends Technol. (IJCTT) 2017 , 48 , 128–138. [ Google Scholar ]
• Bischl, B.; Lang, M.; Kotthoff, L.; Schiffner, J.; Richter, J.; Studerus, E.; Casalicchio, G.; Jones, Z. Machine learning in RJ Mach. Learn. Res 2016 , 17 , 5938–5942. [ Google Scholar ]
• Joseph, V.R. Optimal ratio for data splitting. Stat. Anal. Data Min. ASA Data Sci. J. 2022 , 15 , 531–538. [ Google Scholar ] [ CrossRef ]
• Thomas, T.; Rajabi, E. A systematic review of machine learning-based missing value imputation techniques. Data Technol. Appl. 2021 , 55 , 558–585. [ Google Scholar ] [ CrossRef ]
• Ying, X. An overview of overfitting and its solutions. J. Phys. Conf. Ser. 2019 , 1168 , 022022. [ Google Scholar ] [ CrossRef ]
• James, G.; Witten, D.; Hastie, T.; Tibshirani, R. An Introduction to Statistical Learning: With Applications in R ; Springer New York: New York, NY, USA, 2013. [ Google Scholar ]
• Hastie, T.; Tibshirani, R.; Friedman, J. Model Assessment and Selection. In The Elements of Statistical Learning: Data Mining, Inference, and Prediction ; Springer New York: New York, NY, 2009; pp. 219–259. [ Google Scholar ]
• Varoquaux, G.; Colliot, O. Evaluating Machine Learning Models and Their Diagnostic Value. In Machine Learning for Brain Disorders ; Colliot, O., Ed.; Springer US: New York, NY, USA, 2023; pp. 601–630. [ Google Scholar ]
• King, R.D.; Orhobor, O.I.; Taylor, C.C. Cross-validation is safe to use. Nat. Mach. Intell. 2021 , 3 , 276. [ Google Scholar ] [ CrossRef ]
• Dykxhoorn, J.; Hollander, A.C.; Lewis, G.; Magnusson, C.; Dalman, C.; Kirkbride, J.B. Risk of schizophrenia, schizoaffective, and bipolar disorders by migrant status, region of origin, and age-at-migration: A national cohort study of 1.8 million people. Psychol. Med. 2019 , 49 , 2354–2363. [ Google Scholar ] [ CrossRef ]
• Henssler, J.; Brandt, L.; Muller, M.; Liu, S.; Montag, C.; Sterzer, P.; Heinz, A. Migration and schizophrenia: Meta-analysis and explanatory framework. Eur. Arch. Psychiatry Clin. Neurosci. 2020 , 270 , 325–335. [ Google Scholar ] [ CrossRef ]
• Selten, J.P.; van der Ven, E.; Termorshuizen, F. Migration and psychosis: A meta-analysis of incidence studies. Psychol. Med. 2020 , 50 , 303–313. [ Google Scholar ] [ CrossRef ]
• Gabrielsen, G.; Kramp, P. Forensic psychiatric patients among immigrants in Denmark–diagnoses and criminality. Nord. J. Psychiatry 2009 , 63 , 140–147. [ Google Scholar ] [ CrossRef ]
• Fazel, S.; Wolf, A.; Palm, C.; Lichtenstein, P. 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 , 44–54. [ Google Scholar ] [ CrossRef ]
• Bianchi, M.; Buonanno, P.; Pinotti, P. Do Immigrants Cause Crime? J. Eur. Econ. Assoc. 2012 , 10 , 1318–1347. [ Google Scholar ] [ CrossRef ]
• Adelman, R.; Reid, L.W.; Markle, G.; Weiss, S.; Jaret, C. Urban crime rates and the changing face of immigration: Evidence across four decades. J. Ethn. Crim. Justice 2017 , 15 , 52–77. [ Google Scholar ] [ CrossRef ]
• Ousey, G.C.; Kubrin, C.E. Immigration and Crime: Assessing a Contentious Issue. Annu. Rev. Criminol. 2018 , 1 , 63–84. [ Google Scholar ] [ CrossRef ]
• Woodward, A.; Howard, N.; Wolffers, I. Health and access to care for undocumented migrants living in the European Union: A scoping review. Health Policy Plan. 2014 , 29 , 818–830. [ Google Scholar ] [ CrossRef ]
• Hacker, K.; Anies, M.; Folb, B.L.; Zallman, L. Barriers to health care for undocumented immigrants: A literature review. Risk Manag Health Policy 2015 , 8 , 175–183. [ Google Scholar ] [ CrossRef ]
• Bilger, V.; Hollomey, C.; Wyssmüller, C.; Efionayi-Mäder, D. Health Care for Undocumented Migrants in Switzerland ; Federal Office of Public Health: Bern, Switzerland, 2011. [ Google Scholar ]
• Rüefli, C.; Huegli, E. Krankenversicherung und Gesundheitsversorgung von Sans Papiers, Bericht zur Beantwortung des Postulats Heim (09.3484). 2011. Available online: https://www.beobachtungsstelle.ch/fileadmin/user_upload/pdf_divers/Berichte/2012/Bericht_Postulat_Heim_komplett_d.pdf (accessed on 22 August 2024).
• Dickson, H.; Hedges, E.P.; Ma, S.Y.; Cullen, A.E.; MacCabe, J.H.; Kempton, M.J.; Downs, J.; Laurens, K.R. Academic achievement and schizophrenia: A systematic meta-analysis. Psychol. Med. 2020 , 50 , 1949–1965. [ Google Scholar ] [ CrossRef ]
• Gubbels, J.; van der Put, C.E.; Assink, M. Risk Factors for School Absenteeism and Dropout: A Meta-Analytic Review. J. Youth Adolesc. 2019 , 48 , 1637–1667. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Rosenthal, L.; Moro, M.R.; Benoit, L. Migrant Parents of Adolescents With School Refusal: A Qualitative Study of Parental Distress and Cultural Barriers in Access to Care. Front. Psychiatry 2019 , 10 , 942. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Nahm, F.S. Receiver operating characteristic curve: Overview and practical use for clinicians. Korean J. Anesth. 2022 , 75 , 25–36. [ Google Scholar ] [ CrossRef ]
• Trevethan, R. Sensitivity, Specificity, and Predictive Values: Foundations, Pliabilities, and Pitfalls in Research and Practice. Front. Public Health 2017 , 5 , 307. [ Google Scholar ] [ CrossRef ]
• Carbone, M.R. When not to use machine learning: A perspective on potential and limitations. MRS Bull. 2022 , 47 , 968–974. [ Google Scholar ] [ CrossRef ]
• Sambasivan, N.; Kapania, S.; Highfill, H.; Akrong, D.; Paritosh, P.; Aroyo, L.M. “Everyone wants to do the model work, not the data work”: Data Cascades in High-Stakes AI. In Proceedings of the 2021 CHI Conference on Human Factors in Computing Systems, Yokohama, Japan, 8–13 May 2021; pp. 1–15. [ Google Scholar ]
• Talari, K.; Goyal, M. Retrospective Studies—Utility and Caveats. J. R. Coll. Physicians Edinb. 2020 , 50 , 398–402. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Vabalas, A.; Gowen, E.; Poliakoff, E.; Casson, A.J. Machine learning algorithm validation with a limited sample size. PLoS ONE 2019 , 14 , e0224365. [ Google Scholar ] [ CrossRef ]
• Dietterich, T. Overfitting and undercomputing in machine learning. ACM Comput. Surv. (CSUR) 1995 , 27 , 326–327. [ Google Scholar ] [ CrossRef ]
• Heymans, M.W.; Twisk, J.W.R. Handling missing data in clinical research. J. Clin. Epidemiol. 2022 , 151 , 185–188. [ Google Scholar ] [ CrossRef ]
• Schafer, J.L.; Graham, J.W. Missing data: Our view of the state of the art. Psychol. Methods 2002 , 7 , 147–177. [ Google Scholar ] [ CrossRef ]
• Tortora, L. Beyond Discrimination: Generative AI Applications and Ethical Challenges in Forensic Psychiatry. Front. Psychiatry 2024 , 15 , 1346059. [ Google Scholar ] [ CrossRef ]
• Joyce, D.W.; Kormilitzin, A.; Smith, K.A.; Cipriani, A. Explainable artificial intelligence for mental health through transparency and interpretability for understandability. NPJ Digit. Med. 2023 , 6 , 6. [ Google Scholar ] [ CrossRef ]
• Xu, F.; Uszkoreit, H.; Du, Y.; Fan, W.; Zhao, D.; Zhu, J. Explainable AI: A Brief Survey on History, Research Areas, Approaches and Challenges. In Natural Language Processing and Chinese Computing ; Springer: Cham, Switzerland, 2019; pp. 563–574. [ Google Scholar ]

Click here to enlarge figure

Share and Cite

Hofmann, A.B.; Dörner, M.; Machetanz, L.; Kirchebner, J. Sociodemographic Variables in Offender and Non-Offender Patients Diagnosed with Schizophrenia Spectrum Disorders—An Explorative Analysis Using Machine Learning. Healthcare 2024 , 12 , 1699. https://doi.org/10.3390/healthcare12171699

Hofmann AB, Dörner M, Machetanz L, Kirchebner J. Sociodemographic Variables in Offender and Non-Offender Patients Diagnosed with Schizophrenia Spectrum Disorders—An Explorative Analysis Using Machine Learning. Healthcare . 2024; 12(17):1699. https://doi.org/10.3390/healthcare12171699

Hofmann, Andreas B., Marc Dörner, Lena Machetanz, and Johannes Kirchebner. 2024. "Sociodemographic Variables in Offender and Non-Offender Patients Diagnosed with Schizophrenia Spectrum Disorders—An Explorative Analysis Using Machine Learning" Healthcare 12, no. 17: 1699. https://doi.org/10.3390/healthcare12171699

Article Metrics

Article access statistics, further information, mdpi initiatives, follow mdpi.

Subscribe to receive issue release notifications and newsletters from MDPI journals