As was stated in the introduction, the objective of this CPG is to offer recommendations on diagnostic, therapeutic and rehabilitation interventions for people who have schizophrenia or incipient psychotic disorder which are applicable via action directives of the National Health System.

Hence, applicability conditions should be examined in terms of the general healthcare system and the characteristics and development achieved by public use mental health networks in particular.

Our healthcare setting offers favourable conditions for the management of people with a schizophrenic disorder. In the first place, it is a system that guarantees universal access to healthcare services. Secondly, it offers a sectorized and scalonating healthcare system. And, thirdly, it offers healthcare networks specialized in mental health care.

However, the different level of general evolution of the healthcare system and psychiatric reform in particular, the different degrees of integration of psychiatric care in the general system and the uneven development of social resources greatly condition the accessibility, utilization and coordination of these resources.

The first level of the general healthcare network offers primary care, which is the starting point of care for early detection and referral to specialized services, and also constitutes the ideal setting for continued care of the patient’s general state and support to families. It would be advisable for primary and specialized care levels to agree upon certain referral, interconsultation and coordination criteria. This would also gradually enable increasing integration of mental health care and corresponsibility of management of patients.

Established public use mental health networks tend to be inspired by the ideas and principles of community psychiatry, and present a series of action directives for addressing the different phases and circumstances experienced by people with schizophrenia or incipient psychotic disorder.

Overall, a great number of services differ in their outpatient vs in-hospital characteristics in offering total or partial care, in being aimed at child-adolescent and adult populations, and in the amount of time and hours it takes per day to provide such services. They also differ in the accessibility, intensity and continuity of care they provide.

These networks tend to include outpatient or in-hospital treatment services in the form of mental health centres, inpatient care for acute and sub acute patients, therapeutic community care, mid- and long-term inpatient care or hospital rehabilitation, partial hospitalization units such as day hospitals, emergency services and psychosocial rehabilitation services, psychiatric residences and assisted living apartments. These services also present differences when they accommodate child and adolescent, adult or elderly populations.

The formulation of ideal conditions for mental health services should acknowledge the interrelationship between the different phases of evolution and the current characteristics of the disorder, the therapeutic objectives of each phase, different available action directives and the services these directives can facilitate.

The main scopes of specialized intervention aimed at patients with incipient psychotic disorder or schizophrenia encompass the following services:

1. Mental Health Centres (MHC): They embody the standard setting for treatment of patients with incipient psychotic disorders or schizophrenia in the community in all phases and moments of the disorder. To provide proper care, it is necessary for MHCs to have the resources needed to develop programs and interventions adapted to each situation. It is also necessary for these centres to identify the individual therapeutic plan of each patient and articulate and coordinate interventions with other professionals and services involved in the management of patients, in a concomitant and successive manner.
2. Inpatient care (Acute and subacute patients unit, therapeutic community): it is usually indicated for patients who present serious risk of harming themselves or others, or such intense disorganization or extreme delusions or hallucinations that they are unable to take care of themselves and require constant supervision. Voluntary hospitalization of these patients should be sought. If they refuse, they may be hospitalized against their will if their state meets the criteria established for involuntary admittance according to current legal regulations.

Other indications for inpatient care are general medical or psychiatric problems and comorbidities in which outpatient management would not be safe or effective.

Based on the phase of evolution, clinical assessment, detectable risk and therapeutic plan, the most adequate hospitalization scheme should be selected.

1. Partial hospitalization (Day hospital): it can be used as an immediate alternative to inpatient care for patients with incipient psychotic disorder or acute phases who do not present a risk of harming themselves or others and who may favourably respond to intensive outpatient management. It can also be indicated in the recovery phase of the first episode or in the stabilization phase after an acute episode, as a relapse prevention measure or during the beginning of treatment processes in patients with high outpatient care needs.
2. Community Rehabilitation Services: Community Rehabilitation Services, psychosocial services and day centres are indicated for patients who require rehabilitation interventions that facilitate psychosocial integration into the community, adapted to each phase of the disorder. These interventions should be integrated within one same individualized therapeutic plan and carried out in coordination with other professionals and services.
3. Modalities of care and intensive follow-up in the community: these more intensive interventions, case management and assertive community treatment, are indicated for patients who are not connected to healthcare services or who present significant difficulties doing so or maintaining a continuity of care. These intervention modalities have been less developed in our system in spite of the evidence recommending their use. This is likely due to the difficulties of creating a new array of services adapted to our healthcare setting. However, basic aspects of the philosophy of case management and assertive community treatment have been incorporated into community-based programs aimed at incipient psychosis and schizophrenia in mental health centres, be it with the design of care continuity programs with a pronounced assertive approach or the incorporation of professionals who carry out case management tasks.

The following tables summarize the mental health objectives, services and interventions indicated in each phase of incipient psychotic disorder and schizophrenia.

Table 10. Mental health provision in the different early phases of psychosis: therapeutic objectives, services and interventions

PHASE	OBJECTIVES	SERVICES	INTERVENTIONS
HRMS	To avoid, delay or minimize the risk of transition to psychosis To treat current symptoms and dysfunctions	Mental health centers: program for the specific care of incipient psychotic disorder	Diagnosis, assessment and therapeutic plan Symptomatic pharmacological treatment (non-antipsychotic) Individual and family psychosocial interventions and recovery support
First psychotic episode	To reduce psychotic and associated symptomatology To prevent harm To achieve functional recovery To introduce the idea of disorder To transmit hope To provide the therapeutic relationship	Mental health centres: program for the specific care of incipient psychotic disorder Day hospital Inpatient care for acute patients Emergency services Rehabilitation service	Diagnosis, assessment and therapeutic plan Pharmacological treatment Individual and family psychosocial interventions and recovery support Health education and psychoeducation
Recovery from the first episode	To support adherence to treatment To achieve functional recovery and insertion To treat associated problems	Mental health centres: program for the specific care of incipient psychotic disorder Day hospital Rehabilitation service	Continued assessment and adaptation of the therapeutic plan Pharmacological treatment Individual and family psychosocial interventions and recovery support Health education and psychoeducation Rehabilitation and insertion: social skills, cognitive and occupational rehabilitation, community insertion support

Table 11. Mental health provision in the different phases of schizophrenia: therapeutic objectives, services and interventions

PHASE	OBJECTIVES	SERVICES	INTERVENTIONS
Acute	To reduce/eliminate acute symptoms To prevent harm To achieve functional recoveryl	Mental health centres Inpatient care for subacute patients Day hospital Emergency services	Diagnosis, assessment and therapeutic plan Pharmacological treatment Individual and family psychosocial interventions and recovery support
STABILIZATION	To achieve continued reduction of symptoms To improve community adaptation To provide support for the reduction of stress To consolidate remission and reduce the chance of relapse	Mental health centres Day hospital Therapeutic community Inpatient care for subacute patients Mid- and long-term hospital stay/rehabilitation hospital units Rehabilitation services	Diagnosis, assessment and therapeutic plan Pharmacological treatment Individual and family psychosocial interventions and recovery support Health education and psychoeducation
STABLE	To maintain symptomatic reduction To reduce the risk of relapse and early detection To support functional and community adaptation To improve quality of life	Mental health centres Rehabilitation service Social clubs Occupational insertion services Assisted living apartments Psychiatric residences	Continued assessment and adaptation of the therapeutic plan Pharmacological treatment Individual and family psychosocial interventions and stability support Health education and psychoeducation Social skills Cognitive rehabilitation Occupational rehabilitation Community insertion support Home-based support Housing support

The existence of two large phases in incipient psychotic disorder and schizophrenia and the diversity of action directives, programs and services that take part in the diagnosis/assessment, treatment and rehabilitation/insertion of these disorders present us with the problem of continuity of care and articulation and coordination of different healthcare resources.

A line of response to this problem is the design of longitudinal programs for coordination of action directives and services, as well as the implementation of cross-sectional programs that organize healthcare provision. In both cases the objective is to guarantee minimum healthcare quality in the treatment of people with incipient psychotic disorder and schizophrenia and to ensure continuity of care and articulation of interventions.

Longitudinal programs should ensure continuity of care between services, and especially between outpatient and in-hospital settings, with the aim of avoiding treatment interruption and the disconnection of patients from the healthcare network. They should also ensure the transmission of relevant diagnostic, clinical and therapeutic information.

On the other hand, cross-sectional programs should be aimed at adequately integrating different services that overlap at a given time and the patient and family’s adherence to the care provided.

Some of the programs that try to reach these objectives acknowledge different evolution phases such as, for example, early phases of psychosis or more advanced phases of schizophrenia. There are also programs that stem from the specific difficulties of linkage with services or greater clinical severity of outpatient conditions, mirroring assertive community treatment or case management.

Finally, it is important for these interventions and programs to acknowledge deontological and legal regulations relating to healthcare practice and which should preside in the relationship between healthcare teams and people with incipient psychotic disorder or schizophrenia and their families. This is especially important when the intention is to incorporate patients as active participants in decision-making and in the entire healthcare process.

Figures and tables

Table 10. Mental health provision in the different early phases of psychosis: therapeutic objectives, services and interventions (pdf, 38 Kb.)

Table 11. Mental health provision in the different phases of schizophrenia: therapeutic objectives, services and interventions (pdf, 45 Kb)