nursing case study schizophrenia

Schizophrenia Nursing Diagnosis and Nursing Care Plan

Last updated on May 14th, 2024 at 12:05 am

Schizophrenia Nursing Care Plans Diagnosis and Interventions

Schizophrenia is a serious mental disorder highly associated with psychosis or the disconnection from reality. It leads to a wide range of manifestations such as hallucinations, delusions, disorganized speech, and cognitive impairment.

There is still no cure for schizophrenia at present; however, there are treatments available to help manage the condition and control serious complications.

Signs and Symptoms of Schizophrenia

Causes of schizophrenia.

Despite extensive research on this condition, the exact cause of schizophrenia is still unknown.

Complications of Schizophrenia

Diagnosis of schizophrenia.

The following are the procedures that can be performed to help achieve a diagnosis:

Treatment of Schizophrenia

Nursing diagnosis for schizophrenia, nursing care plan for schizophrenia 1.

  Desired Outcome: The patient will be able to establish reality-based thought process and effective verbal communication.

Nursing Care Plan for Schizophrenia 2

Nursing Care Plan for Schizophrenia 3

Nursing Diagnosis: Defensive coping related to perceived threat to self as evidenced by agitation/ aggression, anxiety, suspiciousness, confusion, irritability, hallucinations/delusions, difficulty establishing relationships, and verbalization of powerlessness

Nursing Care Plan for Schizophrenia 4

Nursing Diagnosis: Impaired Social Interaction is related to an exaggerated response to alerting stimuli secondary to schizophrenia as manifested by dysfunctional communication with others; looking bothered, flustered, or troubled when others come in close contact or try to take her part in an activity; Observed usage of ineffective social communications behaviors.

Nursing Care Plan for Schizophrenia 5

Nursing Diagnosis: Fear related to suspicion of the motives of others secondary to schizophrenia as evidenced by fearful feelings.

Nursing Care Plan for Schizophrenia 6

Nursing Diagnosis: Disturbed sensory perception related to biochemical factors such as manifested by inability to concentrate secondary to schizophrenia as manifested by changes in communication patterns, disorientation to person, place, and time, auditory distortions, reported or measured change in sensory acuity, hallucinations, and mumbling to self, talking or laughing to self.

More Schizophrenia Nursing Diagnosis

Nursing references.

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

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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

6 Schizophrenia Nursing Care Plans

Schizophrenia is a complex mental disorder that requires comprehensive assessment and care planning . This article explores the essential assessment , nursing diagnosis , goals, interventions for schizophrenia and offers practical guidance on how to manage this condition effectively.

Table of Contents

What is schizophrenia, nursing problem priorities, nursing assessment, nursing diagnosis, nursing goals, 1. promoting client safety, 2. establishing therapeutic relationships and promoting therapeutic communication, 3. improving thought organization and reality orientation, 4. promoting effective coping strategies, 5. initiating patient education and health teachings, 6. administer medications and provide pharmacologic support, recommended resources, references and sources.

Schizophrenia refers to a group of severe, disabling psychiatric disorders marked by withdrawal from reality, illogical thinking, possible delusions and hallucinations , and emotional, behavioral, or intellectual disturbance. Traditionally, symptoms have been divided into two main categories: positive symptoms, which include hallucinations, delusions, and formal thought disorders, and negative symptoms such as anhedonia, poverty of speech, and lack of motivation (Hany et al., 2023).

The diagnosis of schizophrenia is clinical, made exclusively after obtaining a full psychiatric history and excluding other causes of psychosis (Hany et al., 2023). The most common early warning signs of schizophrenia are usually detected until adolescence. These include depression , social withdrawal, unable to concentrate, hostility or suspiciousness, poor expressions of emotions, insomnia , lack of personal hygiene , or odd beliefs.

According to the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), two or more of the following symptoms must be present for a significant portion of time during a one-month period:

• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms

There are at least two sets of risk factors for schizophrenia: genetic and perinatal.

• Genetic. The risk of schizophrenia is elevated in biological relatives of persons with schizophrenia but not in adopted relatives. The risk of schizophrenia in first-degree relatives of persons with schizophrenia is 10%. If both parents have schizophrenia, the risk of their child is 40% (Frankenburg & Xiong, 2021).
• Perinatal factors. Women who are malnourished or who have certain viral illnesses during pregnancy may be at greater risk of giving birth to children who later develop schizophrenia. Obstetric complications may also be associated with a higher incidence of schizophrenia. Children born in the winter months may be at greater risk for developing schizophrenia (Frankenburg & Xiong, 2021).

The American Psychiatric Association (APA) removed schizophrenia subtypes from the DSM-5 because they did not appear to be helpful for providing better-targeted treatment or predicting treatment response (Frankenburg & Xiong, 2021).

Nursing Care Plans and Management

Nursing care plans and management for schizophrenia involve recognizing schizophrenia, assessing positive and negative symptoms, establishing trust and rapport, reducing symptoms, enhancing communication , maximizing the level of functioning, improving social functioning, developing coping strategies, promoting medication compliance , and evaluating the support system.

The following are the nursing priorities for patients with schizophrenia:

• Establish therapeutic rapport and trust
• Monitor and manage symptoms
• Administer antipsychotic medications
• Provide education and support
• Assist with daily living skills
• Collaborate with interdisciplinary team
• Ensure a safe environment

Assess for the following subjective and objective data :

• Delusions – Persistent false beliefs
• Hallucinations – Sensory experiences without external stimuli
• Disorganized thinking – Incoherent or illogical thought processes
• Abnormal motor behavior – Unusual or unpredictable movements
• Reduced emotional expression – Diminished display of emotions
• Social withdrawal – Decreased interest in social interactions
• Lack of motivation – Decreased drive or initiative
• Impaired cognition – Difficulties with attention, memory , and problem-solving

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with schizophrenia based on the nurse ’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Goals and expected outcomes may include:

• The client will express thoughts and feelings in a coherent, logical, goal-directed manner.
• The client will demonstrate reality-based thought processes in verbal communication .
• The client will spend time with one or two other people on structured activity-neutral topics.
• The client will spend two to three five-minute sessions with the nurse sharing observations in the environment within three days.
• The client will be able to communicate in a manner that can be understood by others with the help of medication and attentive listening by the time of discharge.
• The client will learn one or two diversionary tactics that work for him/her to decrease anxiety , hence improving the ability to think clearly and speak more logically.
• The client will maintain interaction with another client while doing an activity (e.g., a simple board game, or drawing).
• The client will demonstrate interest to start coping skills training when ready for learning .
• The client will engage in one or two activities with minimal encouragement from the nurse or family members .
• The client will state that he or she is comfortable in at least three structured activities that are goal-directed.
• The client will learn ways to refrain from responding to hallucinations..
• The client will state that the voices are no longer threatening, nor do they interfere with his or her life.
• The client will state, using a scale from 1 to 10, that “the voices” are less frequent and threatening when aided by medication and nursing intervention.
• The client will identify personal interventions that decrease or lower the intensity or frequency of hallucinations (e.g., listening to music, wearing headphones, reading out loud, jogging, and socializing).
• The client will demonstrate techniques that help distract him or her from the voices.
• The client remains free from injury as evidenced by the absence of wounds and abrasions.
• The client will develop trust in at least one staff member within one week.
• The client will sustain attention and concentration to complete tasks or activities.
• The client will state that the “thoughts” are less intense and less frequent with the help of medications and nursing interventions .
• The client will talk about concrete happenings in the environment without talking about delusions for five minutes.
• The client will demonstrate two effective coping skills that minimize delusional thoughts.
• The client will be free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts.
• The client will demonstrate learn the ability to remove himself or herself from situations when anxiety begins to increase with the aid of medications and nursing interventions .
• The client will demonstrate decreased suspicious behaviors regarding interaction with others.
• The client will be able to apply a variety of stress/anxiety-reducing techniques on their own.
• The client will acknowledge that medications will lower suspiciousness.
• The client will state that he/she feels safe and more in control with interactions with the environment/family/work/social gatherings.
• The family and/or significant others will recount in some detail the early signs and symptoms of relapse in their ill family member, and know whom to contact in case.
• The family and/or significant others will state and have written information identifying the signs of potential relapse and whom to contact before discharge.
• The family and/or significant others will state that they have received needed support from community and agency resources that offer education, support, coping skills training, and/or social network development (psychoeducational approach).
• The family and/or significant others will state what medications can do for their ill family member, the side effects and toxic effects of the drugs, and the need for adherence to medication at least 2 to 3 days before discharge.
• The family and/or significant others will name and have a complete list of community supports for ill family members and supports for all members of the family at least 2 days before the discharge.
• The family and/or significant others will attend at least one family support group (single family, multiple families) within 4 days from the onset of the acute episode.
• The family and/or significant others will meet with the nurse/physician/social worker on the first day of hospitalization and begin to learn about neurologic/biochemical disease, treatment, and community resources.
• The family and/or significant others will problem-solve, with the nurse, two concrete situations within the family that all would like to discharge.
• The family and/or significant others will recount in some detail the early signs and symptoms of relapse in their ill family member, and know whom to contact.
• The family and/or significant others will demonstrate problem-solving skills for handling tensions and misunderstandings among the family member.
• The family and/or significant others will have access to family/multiple family support groups and psycho-educational training.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with schizophrenia may include:

Clients with schizophrenia are prone to injury due to auditory and visual hallucinations caused by abnormalities in the brain ‘s processing of sensory information. These hallucinations can be distressing and interfere with the client’s ability to function in daily life. These clients may have difficulty distinguishing between reality and their hallucinations, leading to further confusion and disorientation . Clients diagnosed with schizophrenia also have a risk of substance abuse and violence, which can also result in injuries to the client or to others around them.

Be alert for signs of increasing fear , anxiety, or agitation. This might herald hallucinatory activity, which can be very frightening to the client, and the client might act upon command hallucinations (harm self or others). A few clients may act violently as a result of command hallucinations or delusions, or the violence may be associated with substance abuse . These violent acts are often highly publicized, and the intense publicity has the unfortunate consequence of exacerbating the stigma of the disease (Frankenburg & Xiong, 2021).

Explore how the hallucinations are experienced by the client. Exploring the hallucinations and sharing the experience can help give the person a sense of power that he or she might be able to manage the commanding, hallucinatory voices. One of the paradoxical features of self in schizophrenia is that the I is neither fully oneself nor another, but an in-between state between pure observation (passivity) and participation, The client might experience a vicious circle in which phases of psychosis feed into and reinforce each other (Humpston & Broome, 2020).

Assess for the potential of substance abuse . Alcohol and drug abuse are common in schizophrenia, for reasons that are not entirely clear. For some people, these drugs provide relief from symptoms of the illness or the adverse effects of antipsychotic drugs, and the drive for this relief is strong enough to allow even clients who are impoverished and disorganized to find substances to abuse (Frankenburg & Xiong, 2021).

Observe for obsessive-compulsive symptoms. A number of clients with schizophrenia display obsessive-compulsive symptoms, such as the need to check, count, or repeat certain activities. Obsessive-compulsive symptoms are a known adverse effect of some antipsychotic medications, particularly clozapine (Frankenburg & Xiong, 2021).

Help the client to identify the needs that might underlie the hallucination. What other ways can these needs be met? Hallucinations might reflect needs for anger, power, self-esteem , and sexuality. Clients diagnosed with schizophrenia revealed in a study that sometimes when they have a problem that is a burden on their minds they tend to want to tell their problems to family members. However, they are afraid to tell their family members because they feel that when they tell them their problems, their family members will also be burdened by the problem. Thus, clients choose to keep their problems to themselves (Siregar et al., 2021).

Accept the fact that the voices are real to the client, but explain that you do not hear the voices. Refer to the voices as “your voices” or “voices that you hear”. Validating that your reality does not include voices can help the client cast “doubt” on the validity of his or her voice. Do not argue with the hallucinations or deluded observations of the client. Instead, explain to the client that you each have your own perceptions of the world; do not focus on correcting their negative thoughts or encouraging their distorted reality (Smith & Bressler, 2022).

Help the client identify times when the hallucinations are most prevalent and frightening. This helps both nurse and client identify situations and times that might be most anxiety-producing and threatening to the client. Complications occur when the hallucinations command the client to hurt themselves or others. The paracusia, perceived as coming through the ears, on the surface of the body, in the mind, or anywhere in an external space, can also be so self-deprecating that they cause the client to attempt suicide (Thakur & Gupta, 2023).

• If voices tell the client to harm themself or others, take necessary environmental precautions.
• Notify others and police, physician, and administration according to unit protocol.
• If in the hospital, use unit protocols for suicide or threats of violence if the client plans to act on commands.
• If in the community, evaluate the need for hospitalization.

In many cases, swift, decisive intervention can prevent a person from committing suicide or harming others. Because of this preventable aspect of suicide, recognizing and taking action if the potential arises is critical. Based on the clinical assessment and all of the information available, if the person is indeed suicidal or homicidal, the intervention should consist of multiple steps (Soreff & Xiong, 2022).

Clearly document what the client says, and if he/she is a threat to others, document who was contacted and notified (use agency protocol as a guide). People often obey hallucinatory commands to kill themselves or others. Early assessment and intervention might save lives. A clear and complete evaluation and clinical interview provide the information upon which to base a suicide intervention. Suicidal ideation is highly linked to completed suicide. If suicidal ideation is present, the next question must be about any plans for suicidal acts (Soreff & Xiong, 2022)s.

Stay with clients when they are starting to hallucinate and direct them to tell the “voices they hear” to go away. Repeat often in a matter-of-fact manner. The client can sometimes learn to push voices aside when given repeated instructions. especially within the framework of a trusting relationship. The individual must not be left alone. In the emergency department, such a recommendation is handled easily by hospital security personnel. In other settings, summon assistance quickly. Involve family or friends; they can remain with the client while treatment arrangements are made (Frankenburg & Xiong, 2021).

Decrease environmental stimuli when possible (low noise, minimal activity). This decreases the potential for anxiety that might trigger hallucinations and helps calm the client. Stress and anxiety can trigger or worsen hallucinations, delusions, and other symptoms, leading to increased distress and impaired functioning. Creating a calm environment can reduce sensory overload, providing a stable and predictable atmosphere that can help the client manage their symptoms more effectively.

Intervene with one-on-one, seclusion, or PRN medication (As ordered) when appropriate. Intervene before anxiety begins to escalate. If the client is already out of control, use chemical or physical restraints following unit protocols. The suicidal client should be treated initially in a secure, safe, and highly supervised place. Inpatient care at a hospital offers one of the best settings. Most managed care companies recognize the medical necessity of hospitalization in situations in which the suicide danger is acute (Soreff & Xiong, 2022).

Keep to simple, basic, reality-based topics of conversation. Help the client focus on one idea at a time. The client’s thinking might be confused and disorganized; this intervention helps the client focus and comprehend reality-based issues. The client may also show thought blocking, in which long pauses occur before they answer a question. The client has little insight into their problems, therefore, reinforcing reality is necessary (Frankenburg & Xiong, 2021).

Work with the client to find which activities help reduce anxiety and distract the client from hallucinatory material. Practice new skills with the client. If clients’ stress triggers hallucinatory activity, they might be more motivated to find ways to remove themselves from a stressful environment or try distraction techniques. Engaging the client in vocational and art therapy can improve self-esteem and help integrate their functioning (Thakur & Gupta, 2023).

Engage the client in reality-based activities such as card playing, writing, drawing, doing simple arts and crafts, or listening to music. Redirecting the client’s energies to acceptable activities can decrease the possibility of acting on hallucinations and help distract from voices. The nurse should remember that the activity has to be within the client’s functioning level. Some activities to consider are drawing, reading, listening to music, or walking . These are activities in the “here and now”. Keeping the client focused on reality-based activities is important in helping them cope with these symptoms (Madick, 2022).

Administer clozapine, as indicated. See Pharmacologic Management

Arrange referrals for a dual-diagnosis treatment program for a client with substance abuse. Clients who abuse substances may fare better in dual-diagnosis treatment programs, in which principles from the mental health field can be integrated with principles from the chemical dependency field (Frankenburg & Xiong, 2021).

Remove all dangerous objects in the client’s room. Remove anything that the client may use to hurt or kill themselves. Remove sharp or potentially dangerous objects. Ask the client for any weapon, such as knives or pills, and secure them away from the client. Removal of ligature points (places where things like ropes could be attached) is associated with significant reductions in the overall psychiatric inpatient suicide rate and in the rate of inpatient suicide by hanging (Frankenburg & Xiong, 2021).

Prepare the client for cognitive behavioral therapy (CBT). A study of brief CBT in a cohort of active-duty military personnel who either attempted suicide or experienced suicidal ideation found the treatment effective in preventing follow-up suicide attempts. Data showed that soldiers treated with brief CBT were approximately 60% less likely to attempt suicide than soldiers who did not receive the therapy (Soreff & Xiong, 2022).

Establishing a therapeutic relationship and promoting communication with patients with schizophrenia involves creating a safe and non-judgmental environment where the individual feels comfortable expressing themselves. Active listening , empathy, and validating their experiences can foster trust and encourage open communication. Using clear and simple language, providing visual aids if necessary, and allowing ample time for the patient to process information can enhance understanding and facilitate effective communication.

Assess if incoherence in speech is chronic or if it is more sudden, as in an exacerbation of symptoms. Establishing a baseline facilitates the establishment of realistic goals, the foundation for planning effective care. In measuring disorganized speech, communication impairment focuses on the communication failures in speech, rather than the underlying thought disorder. Communication impairment can be assessed very sensitively and reliably and has been found to be elevated in first-degree relatives of people with schizophrenia (Merrill et al., 2017).

Identify the duration of the psychotic medication of the client. Therapeutic levels of an antipsychotic aid clear thinking and diminishes derailment or looseness of association. The client may be calmer and less agitated almost immediately during the beginning of antipsychotic medications, but the alleviation of the psychosis itself takes several weeks (Frankenburg & Xiong, 2021).

Measure the extent of the client’s communication impairment by the Communication Disturbances Index (CDI). One conceptualization of disorganized speech is communication impairment, which refers to frequent instances of significant speech unclarity and is typically measured by the CDI. the CDI rates speech based on the occurrence of language that fails to communicate the intended message through unclear references or grammatical disturbances (Merrill et al., 2017).

Look for themes in what is said, even though spoken words appear incoherent (e.g., fear , sadness, guilt). Often the client’s choice of words is symbolic of feelings. The client’s speech may be difficult to follow because of the looseness of his or her associations; the sequence of thoughts follows a logic that is clear to the client but not to the interviewer. The speech may be circumstantial (the client takes a long time and uses many words in answering a question) or tangential (the client speaks at length but never actually answers the question) (Frankenburg & Xiong, 2021).

Keep the voice in a low manner and speak slowly as much as possible. A high-pitched/loud tone of voice can elevate anxiety levels while slow speaking aids understanding. Emotions are subjective feelings about an event. The way the person communicates and relates with others is influenced by his or her emotional state. Emotions such as sadness, anxiety, anger, and fear affect health workers’ communication with others (Siregar et al., 2021).

Keep the environment calm, quiet, and as free of stimuli as possible. A calm environment helps keep anxiety from escalating and increasing confusion and hallucinations/delusions. Stress and anxiety can trigger or worsen hallucinations, delusions, and other symptoms, leading to increased distress and impaired functioning. Creating a calm environment can reduce sensory overload, providing a stable and predictable atmosphere.

Plan short, frequent periods with a client throughout the day. Short periods are less stressful, and periodic meetings give a client a chance to develop familiarity and safety.  Clients with schizophrenia may struggle with organization and planning. A structured, short period of activity can help the client manage their daily activities and self-care routines.

Use clear or simple words, and keep directions simple as well. The client might have difficulty processing even simple sentences. The client may show thought blocking, in which long pauses occur before he or she answers a question. The client’s thoughts may also be disorganized, stereotyped, or perseverative (Frankenburg & Xiong, 2021).

Use simple, concrete, and literal explanations. Minimizes misunderstanding and/or incorporates those misunderstandings into delusional systems. The client also has difficulty with abstract thinking, demonstrated by the inability to understand common proverbs or idiosyncratic interpretations of them (Frankenburg & Xiong, 2021).

Focus on and direct the client’s attention to concrete things in the environment. This helps draw focus away from delusions and focus on reality-based things. Don not focus on correcting their psychotic thinking or encourage their distorted reality. Emphasize that you are there as a support and can get help if need be. Reinforce reality by expressing that each has its own perceptions of the world (Smith & Bressler, 2022).

When you do not understand a client, let him/her know you are having difficulty understanding. Pretending to understand limits your credibility in the eyes of your client and lessens the potential for trust. Do not argue with the hallucinations or deluded observations. It is not useful to challenge the person who is struggling. Instead, refrain from being judgemental and work to stay engaged with the client (Smith & Bressler, 2022).

When the client is ready, introduce strategies that can minimize anxiety and lower voices, and “worrying” thoughts, and teach the client to do the following:

• Focus on meaningful activities.
• Learn to replace negative thoughts with constructive thoughts.
•  Learn to replace irrational thoughts with rational statements.
• Perform deep breathing exercises.
• Read aloud to self.
• Seek support from staff, family, or other supportive people.
• Use a calming visualization or listen to music.

Helping the client to use tactics to lower anxiety can help enhance functional speech. People with schizophrenia will experience cognitive, emotional, perceptual, and behavioral disturbances. Distortion of negative thoughts that appear in schizophrenic clients can trigger mental stress, resulting in anxiety, depression, or even an urge to commit suicide. This is a consequence that must be avoided at all costs (Siregar et al., 2021).

Use therapeutic techniques (clarifying feelings when speech and thoughts are disorganized) to try to understand the client’s concerns. Even if the words are hard to understand, try getting to the feelings behind them. Therapeutic communication is consciously planned communication, aims, and activities centered on the client’s recovery. In this relationship, the client feels valued, accepted, and directed. Clients will voluntarily express their feelings and thoughts so that the emotional burden and tension they feel can disappear entirely and return to normal (Siregar et al., 2021).

Establish rapport and build a trusting relationship with the client. Trust is needed to build effective communication between nurses and clients. This variable occurs in the implementation of therapeutic communication at each phase. The trust built from the start creates a sense of comfort and creates a therapeutic environment. Building a trusting relationship will make the relationship smoother going forward because the client and the nurse are more open about the problems they face (Siregar et al., 2021) (Siregar et al., 2021).

Provide positive feedback and appreciation to the client. Praise given to clients when they do something positive is considered more valuable. With sincere appreciation, clients will feel valued and cared for. Giving appreciation is a form of reward for clients. This can be done during the work and termination phases of the nurse-client relationship (Siregar et al., 2021).

Assess if the medication has reached therapeutic levels. Many of the positive symptoms of schizophrenia (hallucinations, delusions, racing thoughts) will subside with medications, which will facilitate interactions. Study data showed that the long-acting injectable (LAI) antipsychotic formulation of risperidone proved superior to oral risperidone on measures of relapse and symptom control. It also provided better control of hallucinations and delusions (Frankenburg & Xiong, 2021).

Identify with the client the symptoms he experiences when he or she begins to feel anxious around others. Increased anxiety can intensify agitation, aggressiveness, and suspiciousness. Many clients with schizophrenia report symptoms of anxiety. It is unclear whether such anxiety is an independent problem, part of schizophrenia, a reaction to schizophrenia, or a complication of treatment. Anxiety may precede the onset of schizophrenia for several years (Frankenburg & Xiong, 2021).

Keep the client in an environment as free of stimuli (loud noises, crowding) as possible. The client might respond to noises and crowding with agitation, anxiety, and an increased inability to concentrate on outside events. A calm environment can be an essential component of treatment for clients with schizophrenia. It can help reduce stress and anxiety, provide a sense of safety and security, and provide structure and routine, all of which can help the client manage their symptoms more effectively and lead to better outcomes.

Avoid touching the client. Touch by an unknown person can be misinterpreted as a sexual or threatening gesture. This is particularly true for a paranoid client. It appears that some social processing systems are intact or largely intact in schizophrenia, whereas others are clearly impaired. For example, social cue recognition, the ability to process a diverse array of social cues from faces, voices, and body movements, is impaired ins schizophrenia (Green et al., 2018).

Ensure that the goals set are realistic;  whether in the hospital or community. This avoids pressure on the client and a sense of failure on the part of the nurse/family. This sense of failure can lead to a mutual withdrawal. If goals are set too high or unrealistic, the client may become frustrated and discouraged, leading to decreased motivation and engagement in treatment. Achieving goals, even small ones, can help the client feel a sense of accomplishment and increase their confidence and motivation.

Structure activities that work at the client’s pace and activity. The client can lose interest in activities that are too ambitious, which can increase a sense of failure. Motivation refers to what people are willing to do and includes the direction, intensity, and persistence of goal-directed behavior (Green et al., 2018). 

Structure times each day to include planned times for brief interactions and activities with the client on a one-on-one basis This helps the client to develop a sense of safety in a non-threatening environment. The problems of social motivation in schizophrenia can stem from disturbances in either type of motivational drive. For example, those with prominent clinically rated asociality show diminished social approach motivation and a lack of motivation to seek out social interactions. However, others show elevated social avoidance in that they are interested in social connections but do not attempt to engage due to fear of rejection (Green et al., 2018).

If the client is unable to respond verbally or in a coherent manner, spend frequent, short periods with clients. An interested presence can provide a sense of being worthwhile. Clients with schizophrenia may experience social isolation due to the stigma associated with the disorder or the symptoms they experience. The quiet presence of the nurse can provide a social connection for clients, helping them feel less alone.

If the client is found to be very paranoid, solitary or one-on-one activities that require concentration are appropriate. The client is free to choose his level of interaction; however, concentration can help minimize distressing paranoid thoughts or voices. Most clients with schizophrenia may act violently as a result of command hallucinations or delusions. Engaging in short periods of cognitive activity, such as playing a game, reading a book, or doing a puzzle, can help improve cognitive function and enhance overall mental health.

If the client is delusional/hallucinating or is having trouble concentrating at this time, provide very simple concrete activities with the client (e.g., looking at a picture or doing a painting). Even simple activities help draw clients away from delusional thinking into reality in the environment. Art therapy activities such as coloring or drawing can help the client improve their concentration and reduce stress. Encourage them to choose a simple coloring book or sketch pad and focus on the colors and shapes as they create.

If the client is very withdrawn, one-on-one activities with a “safe” person initially should be planned. Learn to feel safe with one person, then gradually might participate in a structured group activity. Many clients with schizophrenia report symptoms of depression. It is unclear whether such depression is an independent problem, part of schizophrenia, a reaction to schizophrenia, or a complication of treatment. Addressing this issue is important because of the high rate of suicide among these clients (Frankenburg & Xiong, 2021).

Try to incorporate the strengths and interests the client had when not as impaired into the activities planned. This increases the likelihood of the client’s participation and enjoyment. By focusing on the things that the client enjoys and is good at, the nurse can help them feel more motivated and engaged in their treatment. This can increase their overall satisfaction with the therapy and may lead to better outcomes.

Teach the client to remove himself briefly when feeling agitated and work on some anxiety relief exercises (e.g., meditations, rhythmic exercise, deep breathing exercise). Teach the client skills in dealing with anxiety and increasing a sense of control. Techniques such as deep breathing , mindfulness, and progressive muscle relaxation can help clients calm down and feel more in control. Encouraging the client to practice these techniques regularly can help them build skills for managing their agitation.

Useful coping skills that the client will need include conversational and assertiveness skills. These are fundamental skills for dealing with the world, which everyone uses daily with more or less skill. Problem-solving with constructive coping is problem-solving in a positive way.  Nurses teach this to the clients to build an understanding of their problems so that they can solve them in a positive way (Merrill et al., 2017).

Remember to give acknowledgment and recognition for positive steps the client takes in increasing social skills and appropriate interactions with others. Recognition and appreciation go a long way to sustaining and increasing a specific behavior. Provide appreciation by praising the client when they do something positive. This will be more valuable to the client than appreciation in the form of goods. This way, the client will feel more valued and cared for (Merrill et al., 2017).

Provide opportunities for the client to learn adaptive social skills in a non-threatening environment. Initial social skills training could include basic social behaviors (e.g., appropriate distance, maintaining good eye contact, calm manner/behavior, moderate voice tone). Social skills training helps the client adapt and function at a higher level in society and increases the client’s quality of life. Abilities linked to social processes referred to as social cognition include such processes as perceiving social cues, sharing other people’s experiences, and inferring other people’s thoughts and emotions. Social cognition tends to have stronger associations with a social disability, suggesting that social cognitive abilities are building blocks for interpersonal interactions and productive activities (Green et al., 2018).

As the client progresses, provide the client with graded activities according to the level of tolerance e.g., (1) simple games with one “safe” person; (2) slowly add a third person into “safe”. Gradually the client learns to feel safe and competent with increased social demands. Socialization group activity therapy is an effort to facilitate the socialization skills of a number of clients with social relationship problems, which aims to improve social relations within a group gradually, where clients can introduce themselves, are able to get acquainted with group members, are able to converse with group members, and are able to convey and discuss conversational topics (Pardede & Ramadia, 2021).

As the client progresses, coping skills training should be available to him/her (nurse, staff, or others). Basically the process:

• Define the skill to be learned.
• Model the skill.
• Rehearse skills in a safe environment, then in the community.
• Give corrective feedback on the implementation of skills.

This increases the client’s ability to derive social support and decreases loneliness. Clients will not give up the substance of abuse unless they have alternative means to facilitate socialization they belong. Studies have concluded that coping skills training is effective in improving mental and physical health and mitigating behavioral and social problems. Another study showed that coping skills training increased self-esteem and improved group interaction, while it led to a decrease in depression and isolation (Esmaeilimotlagh et al., 2018).

Eventually engage other clients and significant others in social interactions and activities with the client (card games, ping pong, sing-a-songs, group sharing activities) at the client’s level. The client continues to feel safe and competent in a graduated hierarchy of interactions. Schizophrenia affects the person’s whole family, and the family’s responses can affect the trajectory of the person’s illness. Some studies have found that family therapy or family interventions may prevent relapse, reduce hospital admission, and improve medication adherence (Frankenburg & Xiong, 2021).

Prepare the client for cognitive remediation. Cognitive remediation is a treatment modality derived from principles of neuropsychological rehabilitation and is based, in part, on the idea that the brain has some plasticity and that brain exercises can encourage neurons to grow. Cognitive remediation works best when clients are stable. Improvement occurs across numerous cognitive functions (Frankenburg & Xiong, 2021).

Refer the client to vocational rehabilitation. Most clients with schizophrenia would like to work; employment can improve income, self- esteem , and social status. Supported employment programs currently thought to be most effective are those that offer individualized, supported, and rapid job assignments and that is integrated with other services. These programs are associated with higher rates of employment (Frankenburg & Xiong, 2021).

Helping patients with thought organization involves assisting them in organizing their thoughts, encouraging logical thinking, and addressing any disorganized thought processes. Reality orientation involves gently reminding patients of the current time, place, and situation, and helping the patient differentiate between what is real and what may be distorted or influenced by their illness, thereby promoting a clearer perception of reality.

Identify feelings related to delusions. For example:

• If a client believes someone is going to harm him/her, the client is experiencing fear.
• If a client believes someone or something is controlling his/her thoughts, the client is experiencing helplessness.

When people believe that they are understood, anxiety might lessen. Asking if the client is hearing voices can be an early intervention. If the client is experiencing hallucinations, this must be reported immediately. Hallucinations, delusions, and paranoia are scary for them. Understanding and patience are the most important characteristics of caring for this client (Madick, 2022).

Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. According to a study, thoughts and other internal mental processes turn inwards as objects of observation. Clients can experience a sense of not being in control of one’s mental processes. As one continues this introspective process, willingly or not, thoughts become increasingly alien and detached from the very self that is supposed to protect the integrity of thinking (Humpston & Broome, 2020).

Recognize the client’s delusions as the client’s perception of the environment. Recognizing the client’s perception can help you understand the feelings he or she is experiencing. Do not pretend to see or hear the client’s hallucinations. Likewise, do not agree with the delusions or paranoia. Do not try to convince the client that what they are experiencing is not real. To them it is real. State that “I know the voices are real to you, but I do not hear them” to allow the nurse to be honest and help the client accept that the voices are not real. This allows the client to gain control over the thoughts (Madick, 2022).

Assess attention span and distractibility. Note the level of anxiety. Attention span and ability to attend or concentrate may be severely shortened, which both causes and potentiates anxiety, affecting thought processes. The client may become agitated or anxious. Offer empathy such as “You seem anxious. How can I help you?” this offers validation of the client’s feelings and reinforces trust (Madick, 2022).

Explain the procedures and try to be sure the client understands the procedures before carrying them out. When the client has full knowledge of procedures, he or she is less likely to feel tricked by the staff. It is important to remember that clients with schizophrenia can have difficulty with memory. Repeating steps or phrases several times may be required (Madick, 2022).

Interact with clients on the basis of things in the environment. Try to distract clients from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects, etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. This helps focus attention externally. When a client experiences delusions, it is important to focus on reality. Activities should be one-on-one for a suspicious client some activities to consider are drawing, reading, or walking . Keeping the client focused on reality-based activities is important in helping them cope with their symptoms (Madick, 2022).

Do not touch the client; use gestures carefully. Suspicious clients might misinterpret touch as either aggressive or sexual in nature and might interpret it as a threatening gesture. People who are psychotic need a lot of personal space. Nonverbal communication involves what is not said but rather involves tone of voice, stance, eye contact, facial expressions, and movements. When interacting with the client be sure to face the person, maintain eye contact, stand near the person but not too close, and try to position at the client’s level, facial expression should show your interest or concern, and speak slowly and calmly (Madick, 2022).

Initially do not argue with the client’s beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase the client’s defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood. It is okay to ask about the delusion to obtain assessment information, however, do not argue or deny the belief. The client may be using delusions as an attempt to understand their environment (Madick, 2022).

• Encourage healthy habits to optimize functioning:
• Maintain medication regimen.
• Maintain regular sleep patterns.
• Maintain self-care .
• Reduce alcohol and drug intake.

All are vital in helping keep the client in remission. Adherence is usually overestimated by both the client and the healthcare provider. Nonadherence can be partial or complete, but even partial adherence is associated with relapse. Many psychotropic medications can cause weight gain and changes in glucose or lipid metabolism. Therefore, the client should be encouraged to be as physically active as possible (Frankenburg & Xiong, 2021).

Show empathy regarding the client’s feelings; reassure the client of your presence and acceptance. The client’s delusion can be distressing. Empathy conveys your caring, interest, and acceptance of the client. Notice that the responsibility of understanding the client is placed on the nurses or caregivers . This helps the client understand how they are being perceived and alleviates any anxiety or blame for the client (Madick, 2022).

Teach the client coping skills that minimize “worrying” thoughts. Coping skills include:

• Going to a gym
• Phoning a helpline
• Singing or listening to a song.
• Talking to a trusted friend

When the client is ready, teach strategies the client can do alone. Coping strategies capture a variety of trait-dependent activities approached to deal with challenges driven by stressful experiences. It has been reported that clients with schizophrenia tend to prefer avoidance coping over adaptive coping. A lower preference for active coping strategies and a preference for dysfunctional coping has also been associated with greater severity of positive and depressive symptoms as well as cognitive impairment (Kasznia et al., 2022).

Utilize safety measures to protect clients or others, if the client believes they need to protect themselves against a specific person. Precautions are needed. During the acute phase, clients’ delusional thinking might dictate to them that they might have to hurt others or themselves in order to be safe. External controls might be needed. The nurse should first take measures to protect themselves. When interacting with the client, make sure that the door is closer to not between the nurse and the client. A clear escape route should be accessible if needed. The nurse should call for help if needed and never try to handle the situation themselves (Madick, 2022).

Maintain consistency in staff assigned to the client to the extent possible. This provides the client with feelings of stability, familiarity, and control of the situation. If the client is suspicious, attempt to promote trust by using the same staff if possible and being honest with the client (Madick, 2022).

Arrange for referrals to cognitive remediation therapy. Cognitive remediation creates improvements across numerous cognitive functions, and changes are found in brain imaging that reflect these changes in brain functioning. Cognitive remediation techniques are time-intensive and labor -intensive. Because cognitive deficits are multiple and vary from person to person, such techniques seem to work best when specifically tailored to each client (Frankenburg & Xiong, 2021).

Promote smoking cessation. Most clients with schizophrenia smoke. This may be a result of previous conventional antipsychotic treatment, in that nicotine may ameliorate some of the adverse effects of these drugs. Smoking may also be related to the boredom associated with hospitalizations, the peer pressure from other clients to smoke, or the anomie associated with unemployment (Frankenburg & Xiong, 2021).

Coping strategies for patients with schizophrenia involve developing adaptive ways to manage symptoms and daily challenges. These may include engaging in stress-reducing activities such as exercise, practicing relaxation techniques, participating in supportive therapy or support groups, maintaining a structured routine, and utilizing problem-solving skills to address specific difficulties. Developing a strong support network of family, friends, and mental health professionals can also provide valuable emotional and practical support in coping with the impact of schizophrenia.

Assess and observe clients regularly for signs of increasing anxiety and hostility. Intervene before the client loses control. Persons with schizophrenia may display strange and poorly understood behaviors. These include drinking water to the point of intoxication, staring at themselves in the mirror, performing stereotyped activities, hoarding useless objects, and mutilating themselves. Their wake- sleep cycle may also be disturbed, further predisposing the client to anxiety and the development of hostility (Frankenburg & Xiong, 2021).

Asses for causes or predisposing factors of the agitation or violence. Individuals with schizophrenia and a positive history of adverse childhood experiences (ACEs) tend to show higher levels of psychotic symptoms, greater cognitive deficits, worse response to antipsychotic treatment, and greater functional impairment. The Childhood Experience of Care and Abuse Questionnaire (CECA-Q) is used to collect data on exposure to ACEs (Kasznia et al., 2022). Additionally, substance abuse may be associated with violence in clients with schizophrenia (Frankenburg & Xiong, 2021).

Note expressions of indecision, dependence on others, and the inability to manage own activities of daily living . This may indicate the need to lean on others for a time. Early recognition and intervention can help the client regain equilibrium . A lower preference for active coping strategies and a preference for dysfunctional coping have been associated with greater severity of positive and depressive symptoms as well as cognitive impairment , making the client more dependent upon others (Kasznia et al., 2022).

Assess the presence of positive coping skills and inner strengths. When the client has coping skills that have been successful in the past, they may be used in the current situation to relieve tension and preserve the client’s sense of control. However, limitations of the condition may impact the choices available to the client, such as listening to rock music is not recommended for clients experiencing auditory hallucinations.

Explain to the client what you are going to do before you do it. This prepares the client beforehand and minimizes misinterpreting their intent as hostile or aggressive. Clients diagnosed with schizophrenia due to adverse childhood experiences may be more prone to experience subsequent adversities through increased stress sensitivity and threat anticipation (Kasznia et al., 2022).

Use a nonjudgemental, respectful, and neutral approach with the client. There is less chance for a suspicious client to misinterpret intent or meaning if the content is neutral and the approach is respectful and non-judgemental. Stating “I know that the voices are real to you, I do not hear them” allows the nurse to be honest and may help the client accept that the voices are not real. This allows the client to gain control of hallucinations and delusions (Madick, 2022).

Use clear and simple language when communicating with a suspicious client. This minimizes the opportunity for miscommunication and misconstruing the meaning of the message. The client may also exhibit concrete or literal thinking. Avoid using abstract phrases or cliches such as “the early bird gets the worm”. This can be misinterpreted by the client. Clarify what the client is stating by asking, “I am not sure what you mean or I am not sure what you are trying to tell me. Can you try to explain it to me again please?” (Madick, 2022).

Diffuse angry verbal attacks with a non-defensive stand. When staff becomes defensive, anger escalates for both the client and staff. A non-defensive and non-judgemental attitude provides an atmosphere in which feelings can be explored more easily. When interacting with the client, be sure to face the client, maintain eye contact, stand near the client but not too close so they can still have their personal space, try to position at the client’s level, facial expressions should show interest or concern, and speak slowly and calmly (Madick, 2022).

Set limits in a clear matter-of-fact way, using a calm tone. “Giving threatening remarks is unacceptable. We can talk more about the proper ways in dealing with your feelings”. A calm and neutral approach may diffuse the escalation of anger. Offer an alternative to verbal abuse by finding appropriate ways to deal with feelings. When these behaviors cause problems, it is important to develop reasonable rules and to set consequences for breaking those rules. This process is called setting limits. It can be helpful to all people involved because it sets out clearly what is acceptable and what is not. The type of limits set would depend on the client’s situation (UNC School of Medicine, 2023).

Be honest and consistent with the client regarding expectations and enforcing rules. Suspicious people are quick to discern honesty. Honesty and consistency provide an atmosphere in which trust can grow. In order for the rules to work, the nurse must make sure that they are willing to follow through on consequences. The client should clearly understand the rules and the consequences (UNC School of Medicine, 2023).

Maintain a low level of stimuli and enhance a non-threatening environment (avoid groups). Noisy environments might be perceived as threatening. Knowing what to expect from the client and what triggers the symptoms is important to care for the client. The nurse should also recognize if the client is agitated, anxious, or stressed. Furthermore, it is important to know what can be done to help alleviate the client’s discomfort (Madick, 2022).

Be aware of the client’s tendency to have ideas of reference; do not do things in front of the client that can be misinterpreted, such as laughing or whispering and talking quietly when the client can see but not hear what is being said. Suspicious clients will automatically think that they are the target of the interaction and interpret it in a negative manner (e.g., you are laughing or whispering about them). Furthermore, be aware that the client may believe that their food is poisoned or controlled. Offer food that they can open themselves with supervision or allow them to choose between actions so they feel some control over their environment (Madick, 2022).

Initially, provide solitary, non-competitive activities that take some concentration. Later a game with one or more clients that takes concentration (e.g., chess checkers, thoughtful card games such as ridge or rummy). If a client is suspicious of others, solitary activities are the best. Concentrating on environmental stimuli minimizes paranoid rumination. Results of a study indicate that there is an effect of Socialization Group Activity Therapy on the socialization ability of respondents before and after the intervention. Problems in interacting with other people stemmed from the absence of action or stimulus that can change maladaptive behavior patterns and a less therapeutic environment (Pardede & Ramadia, 2021).

Provide verbal/physical limits when the client’s hostile behavior escalates: “We cannot allow you to verbally attack someone here. If you can’t hold/control yourself, we are here in order to help you”. Often verbal limits are effective in helping a client gain self-control. If help is needed, the nurse should call for one and never attempt to handle the situation alone. The door should be closer to not between the nurse and the client and a clear escape route should be there if needed. The nurse should always be aware of the surroundings and understand how to recognize agitation or anxiety in the client (Madick, 2022).

Encourage family members or parents to provide emotional support. There is an important role of parental support that enhances the development of more adaptive coping strategies. Early parental loss may exceed the individual cognitive capacity to understand and cope with this experience as well as it may disrupt the further development of coping strategies. Adults who experienced early parental loss have been shown to report more substance use, behavioral disengagement, and emotional eating (Kasznia et al., 2022).

Establish a therapeutic nurse-client relationship. The client may feel less inhibited in the context of this relationship to verbalize feelings of helplessness and powerlessness and feel more freedom to discuss changes that may be necessary for the client’s life to improve the situation. Trust is needed to build effective communication, and the trust built from the start creates a sense of comfort and a therapeutic environment (Siregar et al., 2021).

Patient education and health teachings for patients with schizophrenia involve providing information about the illness, its symptoms, and treatment options, as well as teaching coping skills, medication management, and stress reduction techniques. By empowering patients with knowledge and practical strategies, they can actively participate in their own care, make informed decisions, and improve their ability to manage their condition effectively.

Assess the family member’s current level of knowledge about the disease and medications used to treat the disease. Family might have misconceptions and misinformation about schizophrenia and treatment or no knowledge at all. Teach the client’s and family’s level of understanding and readiness to learn . Lack of knowledge about mental illness has been described as one of the components of the stigma construct itself. Poorer knowledge about mental illness has been linked to stigmatizing attitudes in several studies (Koschorke et al., 2017).

Identify the family’s ability to cope (e.g., the experience of loss, caregiver burden, needed support). The family’s needs must be addressed to stabilize the family unit. Family burden in schizophrenia has certain established domains, of which family relations and social interactions are important. Objective burdens of care reflect the tangible aspects of caregiving, such as financial issues, while subjective burdens reflect how caregivers perceive and evaluate their situations in relation to an illness (Shiraishi & Reilly, 2018).

Assess role expectations of family members and encourage discussion about them. Each person may see the situation in their own individual manner, and clear identification and sharing of these expectations promote understanding. Role theory considers the unmet expectations of caregivers from an ill person as a major cause of their mental burdens. Individuals have their own roles within a family and are expected to fulfill these roles. However, schizophrenia often makes it difficult to satisfy these expectations, which has a negative impact on family relationships (Shiraishi & Reilly, 2018).

Note cultural and religious beliefs. These affect the client and family members’ reaction and adjustment to the diagnosis, treatment, and outcomes. According to a study, the majority of caregivers were female, in keeping with the commonly observed preponderance of women in caregiving roles in India. Overall, female caregivers seemed to be more closely involved in the care of the client with schizophrenia, and were sometimes the only ones left in the family who were still in contact with the client. Male caregivers, on the other hand, appeared generally more distant to the client, and possibly less isolated through stigma (Koschorke et al., 2017).

Inform the client’s family in clear, simple terms about psychopharmacologic therapy: dose, duration, indication, side effects, and toxic effects. Written information should be given to the client and family members as well. Understanding the disease and the treatment of the disease encourages greater family support and client adherence. The nature of schizophrenia makes it a potentially difficult illness for clients and family members to understand. Nevertheless, teaching them to understand the importance of medication adherence and of abstinence from alcohol and other drugs of abuse is important (Frankenburg & Xiong, 2021).

Teach the client and family the warning symptoms of relapse. Rapid recognition of early warning symptoms can help ward off potential relapse when immediate medical attention is sought. It is helpful to work with the client so that both client and family can learn to recognize early signs of decompensation such as insomnia or increased irritability. Education may improve adherence to medication and may help the client and family members cope with the illness better in other ways (Frankenburg & Xiong, 2021).

Provide information on disease and treatment strategies at the family’s level of understanding. This meets family members’ needs for information. Because other illnesses are common in schizophrenia, education about the importance of a healthy lifestyle and regular healthcare is helpful. Counseling with respect to sexuality, pregnancy, and sexually transmitted diseases is important for these clients and their families too (Frankenburg & Xiong, 2021).

Provide an opportunity for the family to discuss feelings related to an ill family member and identify their immediate concerns. Nurses and staff can best intervene when they understand the family’s experience and needs. Most caregivers reported in a study a great emotional burden as the result of the client’s condition. Caregivers’ reported emotions were dominated by an emphasis on worry and tension. Furthermore, caregivers expressed feelings of frustration and anger toward the client, often triggered by having to look after them with very little support. In addition, some revealed feelings of shame associated with the client’s appearance or behavior in public, or simply having a mentally ill family member (Koschorke et al., 2017).

Provide information on client and family community resources for the client and family after discharge: day hospitals, support groups, organizations, psychoeducational programs, community respite centers (small homes), etc. Schizophrenia is an overwhelming disease for both the client and the family. Family members can be referred to the National Alliance on Mental Illness (NAMI). These groups can provide education and support (Frankenburg & Xiong, 2021). Groups, support groups, and psychoeducational centers can help:

• Access caring
• Access resources
• Access support
• Develop family skills
• Improve the quality of life for all family members
• Minimizes isolation

Listen for expressions of helplessness and hopelessness . The joy of the recovery of the client is often quickly replaced by grief and anger at the “loss” of the pre-diseased person and the necessity of dealing with the new person that the family does not know and may not even like. Prolongation of these feelings may result in depression.

Provide information about the family intervention. Family intervention has been established as an evidence-based practice to reduce relapse and rehospitalization in clients with this disorder (Shiraishi & Reilly, 2018). Familial “high expressed emotion” (hostile overinvolvement and intrusiveness) leads to more frequent relapses. Some studies found that family therapy or family interventions may also improve medication adherence (Frankenburg & Xiong, 2021).

Identify and encourage the use of previously successful coping behaviors. Most people have developed effective coping skills that can be useful in dealing with the current situation. Health services for clients with schizophrenia need to create spaces where caregivers can speak openly about their own experiences of stigma and other needs. Respite help, contact with peer support groups, and opportunities to access healthcare, and emotional, and social support in their own right should be facilitated for caregivers where feasible and appropriate (Koschorke et al., 2017)

Schizophrenia medications include typical antipsychotics and atypical antipsychotics. These medications work by modulating dopamine and serotonin receptors to manage positive and negative symptoms of schizophrenia, and the choice of medication depends on individual factors and symptom severity. Clozapine, a unique atypical antipsychotic, may be used for treatment-resistant cases, and additional medications like mood stabilizers and benzodiazepines may be prescribed to address specific symptoms or comorbidities.

Typical Antipsychotics:

• Chlorpromazine This medication helps to alleviate symptoms of psychosis by blocking dopamine receptors in the brain. It can help reduce hallucinations and delusions but may also cause side effects such as sedation and movement disorders.
• Haloperidol Another dopamine receptor antagonist, haloperidol is known for its effectiveness in treating positive symptoms of schizophrenia. It has a lower risk of sedation compared to some other antipsychotics but may have a higher potential for movement -related side effects.
• Fluphenazine Like other typical antipsychotics, fluphenazine blocks dopamine receptors. It can be administered orally or by injection and may have side effects such as sedation, movement disorders, and sexual dysfunction .

Atypical Antipsychotics

• Risperidone This medication targets both dopamine and serotonin receptors, making it effective in treating positive and negative symptoms of schizophrenia. Risperidone is available in both oral and long-acting injection forms.
• Olanzapine Olanzapine also acts on dopamine and serotonin receptors and is effective in managing both positive and negative symptoms. It is available in oral and injection formulations and may be associated with weight gain and metabolic side effects.
• Quetiapine Quetiapine is primarily a dopamine and serotonin receptor antagonist, used for both positive and negative symptoms of schizophrenia. It is generally well-tolerated but can cause sedation and weight gain.
• Aripiprazole Aripiprazole functions as a partial dopamine agonist, balancing dopamine activity in the brain. It is effective in managing positive symptoms and may have a lower risk of movement-related side effects.
• Ziprasidone Ziprasidone targets dopamine and serotonin receptors, reducing both positive and negative symptoms. It may have a lower risk of weight gain but can cause changes in heart rhythm.

Clozapine Clozapine is sometimes recommended for the treatment of clients with schizophrenia who are violent. It is the oldest atypical antipsychotic agent and probably the most effective. Approximately one-third of clients who have not responded to conventional antipsychotic agents do better on clozapine. Violence, hostility, and suicidality may be diminished with the use of clozapine (Frankenburg & Xiong, 2021).

Mood stabilizers (e.g., lithium carbonate, valproate) These medications are sometimes used in conjunction with antipsychotics to manage mood symptoms and stabilize mood fluctuations in individuals with schizophrenia.

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Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Other care plans for mental health and psychiatric nursing:

• Alcohol Withdrawal | 5 Care Plans
• Anxiety and Panic Disorders  | 7 Care Plans
• Bipolar Disorders  | 6 Care Plans
• Major Depression  | 9 Care Plans UPDATED!
• Personality Disorders  | 4 Care Plans
• Schizophrenia  | 6 Care Plans UPDATED!
• Sexual Assault  | 1 Care Plan
• Substance Dependence and Abuse | 8 Care Plans UPDATED!
• Suicide Behaviors  | 3 Care Plans

References and recommended sources for this care plan guide for schizophrenia:

• Esmaeilimotlagh, M., Oveisi, K., Alizadeh, F., Kheirabadi, M. A., & Jamalpour, H. (2018). An Investigation on Coping Skills Training Effects on Mental Health Status of University Students. Journal of Humanities Insights , 2 (1).
• Frankenburg, F. R., & Xiong, G. L. (2021). Schizophrenia: Practice Essentials, Background, Pathophysiology . Medscape Reference. Retrieved April 25, 2023.
• Green, M. F., Horan, W. P., Lee, J., McCleery, A., Reddy, L. F., & Wynn, J. K. (2018, March). Social Disconnection in Schizophrenia and the General Community. The Journal of Psychoses and Related disorders , 44 (2).
• Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (2023, January 30). Schizophrenia – StatPearls . NCBI. Retrieved April 25, 2023.
• Humpston, C. S., & Broome, M. R. (2020, July). Thinking, believing, and hallucinating self in schizophrenia. The Lancet Psychiatry , 7 (7).
• Kasznia, J., Pytel, A., Stanczykiewicz, B., Samochowiec, J., Waszczuk, K., Kulik, M., Cyran, A., & Misiak, B. (2022). The Impact of Adverse Childhood Experiences on Coping Strategies in Schizophrenia Spectrum Disorders: A Case-Control Study. Psychology Research and Behavior Management (14).
• Koschorke, M., Padmavati, R., Kumar, S., Cohen, A., Weiss, H. A., Chatterjee, S., Pereira, J., Naik, S., John, S., Dabholkar, H., Balaji, M., Chavan, A., Varghese, M., Thara, R., Patel, V., & Thornicroft, G. (2017, April). Experiences of stigma and discrimination faced by family caregivers of people with schizophrenia in India. Social Science & Medicine , 178 .
• Madick, K. (2022, January 10). Schizophrenia – Care of the Patient Course | CNA Ceu . CEUfast. Retrieved April 26, 2023.
• Merrill, A. M., Karcher, N. R., Cicero, D. C., Becker, T. M., Docherty, A. R., & Kerns, J. G. (2017, March). Evidence that communication impairment in schizophrenia is associated with generalized poor task performance. Psychiatry Research , 249 .
• Moorhouse, M. F., Murr, A. C., & Doenges, M. E. (2010). Nursing Care Plans : Guidelines for Individualizing Client Care Across the Life Span . F.A. Davis Company.
• Pardede, J. A., & Ramadia, A. (2021). The Ability to Interact with Schizophrenic Patients through Socialization Group Activity Therapy. International Journal of Contemporary Medicine , 9 (1).
• Shiraishi, N., & Reilly, J. (2018, October). Positive and negative impacts of schizophrenia on family caregivers: a systematic review and qualitative meta-summary. Social Psychiatry and Psychiatric Epidemiology , 54 (277).
• Siregar, I., Rahmadiyah, F., & Siregar, A. F. Q. (2021, December). Therapeutic Communication Strategies in Nursing Process of Angry, Anxious, and Fearful Schizophrenic Patients. British Journal of Nursing Studies .
• Smith, K., & Bressler, R. (2022). Schizoprenia: Understanding Hallucinations and Delusions . Psycom.net. Retrieved April 25, 2023.
• Soreff, S., & Xiong, G. L. (2022, June 29). Suicide: Practice Essentials, Overview, Etiology . Medscape Reference. Retrieved April 26, 2023.
• Thakur, T., & Gupta, V. (2023, February 13). Auditory Hallucinations – StatPearls . NCBI. Retrieved April 26, 2023.
• UNC School of Medicine. (2023). Setting Limits – UNC Center for Excellence in Community Mental Health . UNC School of Medicine. Retrieved April 27, 2023.

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Schizophrenia Nursing Diagnosis & Care Plan: Doing Best

#i',$content, -1); --> table of contents schizophrenia nursing diagnosis steps & symptoms recognition schizophrenia nursing assessment: symptoms, their depth and care plan schizophrenia nursing questions to determine patients’ condition what is a nursing care plan for schizophrenia defining what is important in nursing care for schizophrenia nursing interventions for schizophrenia: management and support in the united states, mental health illnesses are widely recognized and actively being studied. to divide their existing multiplicity, the national institute of mental health uses the terms any mental illness (ami) and serious mental illness (smi). nursing specialists recognize schizophrenia as the one leading to significant disability. people with this personality disorder experience difficulty in all personal, professional, and social areas of life. early diagnosis is not just important but crucial. in the case of suspected schizophrenia, nursing diagnosis and further interventions can play a critical role in the individual’s future. not to mention the global role of healthcare interventions and supporting patient adaptation to life with their diagnosis. schizophrenia nursing diagnosis steps & symptoms recognition.

• Admission/Application Essay
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Nurse diagnosis takes a frontline position in diagnosing schizophrenia. It identifies the problems an ailing person is facing and helps guide the development of treatment and care plans.

In the process of making a schizophrenia nursing diagnosis, there are indicative steps nurses can follow:

Step 1: collect the information. It includes interviewing, observing, reviewing medical records, and performing physical examinations. Step 2: information analysis. Nurses analyze the information collected to determine the issues the individual is experiencing. Step 3: making a diagnosis. It should based on expert conclusions on the symptoms, the individual’s medical history, mental state, and social functioning.

The health system considers schizophrenia to be a genetically determined SMI. It has not yet been determined which genes this illness is associated with, but it is clear lifestyle provokes it. This disorder is considered early-onset, and the first signs can appear in adolescence. In families with genetic risk, monitoring possible symptoms for early nursing diagnosis is essential.

The exact causes and mechanisms of occurrence have yet to be studied. But experts identify genetics, hormones, psychological events, and environmental risk factors. That’s why, when collecting anamnesis to a nursing diagnosis for schizophrenia, it is vital to take into account all factors. However, it is the symptoms that determine the diagnosis.

Schizophrenia Nursing Assessment: Symptoms, Their Depth and Care Plan

Nursing assessment for schizophrenia patients is the process of gathering info about someone with this SMI. The goal is to assess the symptoms of the disease and their depth and create a care plan.

The first thing a specialist determines in diagnosis is the symptoms. WHO defines them without dividing them into groups. But there is also a grouping into positive, negative, and others. And yet, the main ones significantly change a person’s reality.

• They see objects or hear sounds or voices that do not exist in reality.
• They think someone else reads their minds and controls their thoughts and behavior.
• They have beliefs they do not give up despite convincing evidence to the contrary.
• They have difficulty expressing emotions. They do not show any emotion on their face, or they have a flat or monotone voice.
• They have difficulty experiencing pleasure. They do not feel happy, joyful, or excited by things, usually bringing pleasure to other people.
• They cannot plan, follow a schedule, organize activities, or make decisions.
• They have reduced or no interest in social life.

Additionally, schizophrenia nursing assessment considers cognitive symptoms:

• Disability to navigate in space and time.
• Disability to think logically or consistently.
• Incoherent speech that means the patient jumps from one thought to another or speaks in a way that makes no sense.

Signs can appear and disappear and vary from person to person. However, there are some common and severe ones when it comes to this diagnosis. The nurse assessment in such a case serves as the basis for treatment plans and support. And further questioning helps to evaluate the depth of the condition.

Schizophrenia Nursing Questions to Determine Patients’ Condition

When diagnosing and assessing the patient’s condition, health workers use schizophrenia nursing questions. To create the questionnaire, they use the DSM-5 or similar ICD-11 manuals. The questionnaire consists of two parts.

The first part includes questions about symptoms, such as hearing or seeing something that does not exist or believing in others who want to cause harm. The second contains questions about the ailings’ social adaptation. Or more precisely, about study or job, relatives or friends, etc. You might use them as a nurse when musing upon how to write a nursing care plan .

What Is a Nursing Care Plan for Schizophrenia

A nursing care plan for schizophrenia is a crucial document developed individually for each patient. It describes the intervention goals and actions to be taken to achieve those goals. Nurses work it out with the patient and involve their family. Within mental health, the caring plan has only two goals – the maximum possible reduction of symptoms and socialization.

BSN students often face the need to write essay about schizophrenia . The care plan plays an integral part in this assignment. It helps to understand how nurses care about individuals and how they help them achieve the best possible level of functioning.

Defining What Is Important in Nursing Care for Schizophrenia

This severe disease is among the top 15 causes of disability worldwide and refers to chronic. The most essential part of nursing care for schizophrenia is to help the ailings adapt to life with the diagnosis. To reach these goals, specialists use medication and individual and family therapy. Constant monitoring and timely plan correlations are also significant.

The nurse’s task is personalized support and to help individuals learn to live with it. They must learn a lot from accepting their situation and recognizing warning signs to lead the most fulfilling lifestyle possible as far as possible in their situation. Because of the stigma surrounding these people, nurses need to work closely with them and their families. And that’s where the schizophrenia nursing interventions plan part starts.

Nursing Interventions for Schizophrenia: Management and Support

At its core, nursing interventions for schizophrenia are a general concept of all measures and actions within the competence of nursing staff. It consists of activities aimed at supporting patients.

• Medical intervention. Nurses play an essential role in patients’ support. They work with patients directly and constantly, informing them about the importance of taking medications under prescription. The nurse monitors the side effects of drugs and reports any medication-related problems to physicians so that they can adjust dosages.
• Psychosocial rehabilitation. Psychotherapy is a valuable addition to the rehab of people with such a diagnosis. It helps to adjust to daily challenges and manage symptoms. It is a highly effective way to manage patients’ conditions, and it can even help reduce the risk of symptoms reoccurring. In addition to the traditional “talk to me” approach, therapy uses other methods: yoga, art therapy, etc. The nursing intervention includes attendance control and assistance sticking to the care plan.
• Family involvement. Since stigma is often these patients’ reality, nurses must work closely with them and their families. It includes family therapy and educational programs, acknowledging family members about the disease, what they can expect, and how to help their loved one manage it. Nursing intervention here also aims to work with the family, minimizing stigma and helping to avoid self-isolation and related problems.
• Social support and monitoring. There are special supporting programs. For complex situations, this is the Assertive Community Treatment program. For first-episode-psychosis people, these are recovery-focused programs. Constant nursing care allows nurses to monitor the patient’s condition closely and identify any changes promptly.

Schizophrenia is a severe illness. Its complexity lies in its symptoms and the stigma accompanying people. Maintaining a high level of nursing education in recognizing signs, quality nursing assessment and accurate diagnosis, and developing individualized care plans are essential. It is also crucial to work with the public to raise awareness and promote social adaptation for patients.

Quality and Safety Education for Nurses

Strategy submission, schizophrenia unfolding case study.

Amanda Eymard, Co-Author: Linda Manfrin-Ledet

Associate Professor

Institution:

Nicholls State University College of Nursing and Allied Health

[email protected]

Competency Categories:

Evidence-Based Practice, Informatics, Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration

Learner Level(s):

Pre-Licensure BSN

Learner Setting(s):

Strategy Type:

Independent Study

Learning Objectives:

Strategy Overview:

Submitted Materials:

Schizophrenia-Unfolding-Case-Study_2.ppt - https://drive.google.com/open?id=1-xNAUmNfVJmD3Zwv7nZ44oXcYhd53i0i&usp=drive_copy

Atypical-Antipsychotics-and-Metabolic-article.pdf - https://drive.google.com/open?id=1tshbJ4ljXk9TdySiRsw2xlqb-O3Tx5Oo&usp=drive_copy

Emyard-246-TS-final-approved.pdf - https://drive.google.com/open?id=1dHs32ZW2Jo_mRRNrZ-dFVgDosO1Ua6fu&usp=drive_copy

Additional Materials:

Evaluation Description:

15.1 Schizophrenia

Learning objectives.

By the end of this section, you will be able to:

• Define schizophrenia and its prevalence, course, and causes
• Understand the symptoms associated with schizophrenia
• Explain the stages of schizophrenia
• Outline approaches used to treat schizophrenia
• Plan nursing care for a client living with schizophrenia

The severe mental illness and disturbance involving a collection of cognitive, affective, and behavioral symptoms that negatively affect social, educational, and/or occupational functioning is called schizophrenia . The course of the disorder varies. Some individuals endure episodes of the disease with asymptomatic breaks between them. Other people have continuous symptoms of the disorder with no remission. There are several theories of how this disturbance emerges, but there is no single etiology and no cure, only treatment for symptoms, including medications, therapies, and psychoeducation. The nurse’s role is to assess clients for critical signs of the disorder, evaluate the impact of these symptoms on their functioning, plan and implement care during treatment, review the efficacy of drug and psychosocial interventions, and check for adverse events with medications.

Unfolding Case Study

Schizophrenia: part 1.

The nurse is assessing a twenty-year-old male who reports to the emergency department with his mother and best friend.

• change in personality of client over past several weeks
• blood pressure 130/80 mmHG
• client oriented to time
• client hearing voices in his head
• respiratory rate 22 breaths/minute
• client is agitated and suspicious
• oxygen saturation 98 percent on room air
• heart rate 98 beats/minute

Defining Prevalence, Course, and Causes of Schizophrenia

It is posited that schizophrenia is created from a diverse genetic, environmental, and neurobiological etiology that manifests in specific neuronal changes in childhood that result in a cluster of positive, negative, and cognitive symptoms. The disturbance is seen globally and in all ethnic groups, and it usually emerges in early adulthood.

Prevalence of Schizophrenia

Schizophrenia affects nearly twenty-four million people or one in 222 adults (World Health Organization, 2022). Schizophrenia is found in every culture and population across the globe. Although it is not as common as other mental health disorders, the burden of the disease is high. Costs associated with schizophrenia in the United States exceed $150 billion annually (Kadakia et al., 2022). Aside from health-care costs like frequent hospital admissions, there are expenses related to lost work productivity of the person with the disorder and their caregivers and expenditures for legal problems encountered by those with symptoms. Individuals with schizophrenia have a higher risk of suicide, greater involvement with the legal system and incarceration, and increased incidence of homelessness. Schizophrenia is associated with significant functional limitations, distress, and familial and social impairment. The lifespan of those burdened with the disturbance is fifteen years shorter than average due to common comorbidities, such as cardiovascular disease, metabolic disturbance, other mental health disorders, substance misuse, suicide, and infection (Hjorthøj et al., 2017).

The Course of Illness

The age of onset for schizophrenia varies with the average first episode at 23.7 years of age. Youth-onset schizophrenia’s average age of onset is 13 years, and late-onset schizophrenia appears on average at 60.7 years of age. Earlier onset is associated with a poorer prognosis (Immonen et al., 2017). Subtle signs of the illness, such as language, motor, and cognitive abnormalities, may be present during childhood. Children who later develop schizophrenia demonstrate some social disturbances such as social withdrawal. Children who experience subtle prepsychotic symptoms are at higher risk for developing psychotic disorders later in life. These children may present with neuromotor delays, speech or language impairments, and lower IQ or declining IQ scores (Liu et al., 2015).

The course of the illness is highly variable. Some clients will have a single acute episode and then achieve complete remission; some may have several acute episodes with remissions in between them, while others may have continuous psychosis. Long term, however, most clients achieve remission and recovery after the initial illness, can go several years between psychotic episodes, and can find meaningful employment.

Potential Causes of Schizophrenia

The cause of schizophrenia is unknown. There are no biomarkers to assist in the diagnosis. Laboratory exams and radiographic studies do not confirm the diagnosis. There are some genetic and environmental factors that do, however, appear to increase individual risk for developing schizophrenia.

Heritability appears to have a significant influence on the development of schizophrenia. The risk of schizophrenia in the general population is 1 percent. Those with siblings diagnosed with schizophrenia have a 10 percent risk of developing the disease. Monozygotic twins will have a concordance rate of 40 to 50 percent rate of disease expression while dizygotic twins have a 15 percent rate (Imamura et al., 2020).

There is also evidence that in utero stressors may alter neurodevelopment (changes in glutamate receptors) and predispose a client to developing schizophrenia. These stressors include exposure to viruses, starvation, and complications during pregnancy. Other risk factors during early development include paternal age over fifty and under twenty, winter birth (in the Northern Hemisphere), and birth in urban areas. Risk factors during childhood and adolescence include being raised in an urban environment, migration, cannabis use, stressful life events, and trauma. Other factors that raise the risk of developing the disturbance include epilepsy or Huntington disease, head injury, tumors, cerebrovascular accidents, myxedema , Wilson disease , being from a lower socioeconomic class, having inadequate nutrition, and the absence of prenatal care.

There are three general neurobiological theories for the causes of schizophrenia. The first theory is that there is hyperactivity of dopamine in the mesolimbic pathway of the brain. The mesolimbic pathway connects the ventral tegmental area and the nucleus accumbens in the limbic system. It is here that the brain manages the reward system and desires. An overload of dopamine in this system increases the potential for aggression and psychotic symptoms.

The second hypothesis involves the neurotransmitter glutamate. Glutamate is a major excitatory neurotransmitter in the brain and is responsible for transmitting most of the sensory information in the body. The theory holds that due to genetic influences, changes in utero, or during critical neurodevelopmental stages, a hypofunction occurs in the N-methyl-D-aspartate (NMDA) receptors on glutamatergic neurons. This hypofunction results in two downstream effects: (1) too much dopamine in the mesolimbic dopamine pathways causing signs of psychosis, and (2) hypofunction in the mesocortical dopamine pathway in the prefrontal cortex causing the cognitive and negative symptoms of schizophrenia (Steullet et al., 2016). The final theory involves the neurotransmitter serotonin and its receptors. Hyperfunction, or too much activity at these receptors, causes the same hyperactivity in the mesolimbic dopamine pathway, leading to symptoms of psychosis.

There are four major dopamine pathways in the brain. These are important to know because the medications used to treat psychosis impact all four of them and potentially cause side effects:

• Mesolimbic pathway: This pathway connects the ventral tegmental area in the midbrain to the ventral striatum of the basal ganglia in the forebrain. This pathway is responsible for memory, emotions, arousal, and pleasure. Increases in dopamine cause psychosis and aggression.
• Mesocortical pathway: This pathway connects the prefrontal cortex to the ventral tegmentum. It promotes higher-order functions, such as cognition, planning, organization, motivation, learning, and social behaviors. Decreased dopamine in this pathway can cause adverse symptoms, such as affective flattening, apathy, anhedonia, and lack of motivation.
• Nigrostriatal pathway: This pathway connects the substantia nigra and the basal ganglia. It is involved with bodily movement. Decreases in dopamine or neuronal degeneration in this pathway are associated with Parkinson disease and extrapyramidal symptoms, such as tardive dyskinesia .
• Tuberoinfundibular: This pathway connects the hypothalamus with the pituitary gland and manages metabolism, temperature control, thirst, digestion, and other endocrine actions. Decreases in dopamine in this pathway can cause amenorrhea or galactorrhea.

Symptoms of Schizophrenia

According to the DSM-5 , to be diagnosed with schizophrenia, a client must experience at least two of the following symptoms for most of the time during a one-month period: (1) the presence of delusions, (2) hallucinations, (3) disorganized speech, (4) disorganized or catatonic behavior, (5) or negative symptoms. One of the two symptoms must be delusions, hallucinations, or disorganized speech. Signs of these symptoms must be present continuously for at least six months, and they cannot result from a medical disorder, another mental health disorder, or a substance. In addition, those with schizophrenia often experience cognitive deficits, such as memory problems, attentional shortfalls, and issues with problem-solving.

Defining Psychosis

As defined, psychosis is a severe mental condition where a person loses the ability to recognize reality or has lost contact with external reality, causing a loss of function and disorganization of personality. Schizophrenia is one type of psychotic disorder, though psychosis can be caused by medical illnesses, such as brain tumor and hyperthyroidism ; substance misuse; or disorders, such as schizophrenia, schizoaffective disorders, delusional disorder , mania, severe depression , and personality disorders. The symptoms of psychosis include one or more of the following: delusions, hallucinations, disorganized thinking or speech, disorganized behavior, and negative symptoms.

Positive and Negative Symptoms of Schizophrenia

Active symptoms of schizophrenia include both positive symptoms and negative symptoms. Positive symptoms are symptoms that are “added” to a person who is nonpsychotic. These include any changes to behaviors or thought content, consisting of excessive, distorted thoughts and perceptions and the presence of symptoms, including hallucinations and delusions. Negative symptoms are symptoms that involve the “subtraction” or lessening of normal functions being “taken away” or are in deficit, such as behaviors that the individual is no longer demonstrating, including cognitive decline, apathy, anhedonia, and so forth.

Positive Symptoms of Schizophrenia

Positive symptoms of schizophrenia include delusions, hallucinations, and disorganized thoughts, speech, and behavior. These are symptoms the disease has “added” to the person. This section will cover some of the most common positive symptoms of schizophrenia.

A delusion is a fixed false belief that cannot be changed in the mind of those who hold them despite evidence to the contrary. Delusions can exist as a symptom of schizophrenia or as a symptom of a separate disorder called delusional disorder, which is discussed in detail in 15.3 Delusional Disorder . There are a number of different types of delusions experienced by clients who have been diagnosed with schizophrenia.

• Paranoid delusions, also known as persecutory delusions, are beliefs that the person who holds them is being watched, harmed, or stalked.
• Referential delusions are beliefs that ordinary events have a message or hidden meaning specifically for them.
• Grandiose delusions or delusions of grandeur are those where the individual believes they have unique gifts, are essential, or are influential.
• Somatic delusions are those that involve bodily functions or health. The individual believes that something is wrong with them despite evidence to the contrary.
• Religious delusions involve faith-based themes. These beliefs are outside normative cultural beliefs and usually involve the individual believing they are a supreme being or the devil.
• Erotomatic delusions feature unfounded assumptions that others are in love with them.
• Nihilistic delusions are those where the person believes that they have no existence, that life has no meaning, or that something catastrophic will happen. These delusions are commonly found in those diagnosed with severe depression and paranoid schizophrenia.

Delusions can be classified further as bizarre or non-bizarre; a bizarre delusion involves fixed false beliefs with content that is not reasonably possible in this world. They are strange, eccentric, and unrealistic. An example of a bizarre delusion is when an individual believes that an alien has implanted a chip in the person’s head, and that their parents are speaking to them through the chip. A non-bizarre delusion is a fixed false belief containing content that is plausible but inconsistent with evidence. An example of a non-bizarre delusion is one where the individual believes that a provider has removed their hymen during a medical procedure (a pap smear) and is insistent that the provider put it back. Sometimes it is difficult to discern a non-bizarre delusion from reality, especially if the client has experienced significant trauma, torture, political upheaval, or unrest.

Another common symptom of schizophrenia, a hallucination is the perception of sensory experiences without natural external stimuli. Types of hallucinations include auditory, visual, tactile, gustatory, and olfactory. An auditory hallucination is the altered perception of hearing in the absence of external stimuli. These hallucinations can be single or multiple voices or murmuring. They can include noise, music, or other sounds. A subset, command auditory hallucinations direct the individual to do things, like commit violence toward self or others. The person experiencing the symptom may or may not heed the command. A visual hallucination is a false sensory experience that is seen. They can be people, things, or flashes of light, sometimes in the periphery. A tactile hallucination is a false sensory perception involving the sense of touch; something is on the skin, crawling, biting, or touching.

Having a gustatory hallucination involves a false perception involving taste. It is usually strange or unpleasant flavors, such as something metallic. An olfactory hallucination , or phantosmia , is a false sensory experience involving the sense of smell.

These are more commonly caused by head injuries, aging, seizures, and tumors and often involve detecting scents not in the person’s immediate environment.

Many people afflicted with schizophrenia exhibit signs of disorganized thoughts, speech, and behavior. Table 15.1 provides information on these language and behavioral abnormalities and examples.

Negative Symptoms of Schizophrenia

The negative symptoms of schizophrenia “take away” from normative emotional expression. Negative symptoms often involve a decrease or absence of motivation, interest, and expression. Two specific and common negative symptoms include diminished or inappropriate affect and anhedonia. A diminished affect occurs when there is a decrease in the emotional expression of the client. It can range from restricted to flat, a complete lack of emotional expression. Inappropriate affects are emotional expressions incongruous with a current situation, such as crying during a comedy or laughing during a sad event, and anhedonia, an inability to feel pleasure. Other negative symptoms include poverty of speech (alogia), general apathy, lack of interest in self-care or physical energy, and lack of concentration.

Cognitive Symptoms of Schizophrenia

Some clients experience cognitive symptoms , deficits in their ability to think or reason. These symptoms can include deficits in working memory, such as the ability to do mental math; decision-making capabilities, such as the ability to make choices; organization, such as making mental arrangements or coordinating activities; problem-solving, such as identifying causes, solutions, and implementing processes; and, finally, the overall ability to process information.

Moreover, some clients may not understand that they are ill or psychotic. When a client is unaware that they are ill because of the illness itself, it is called anosognosia . It creates a situation where they often do not engage in treatment, leading to nonadherence to medications. Nonadherence to medication results in adverse outcomes, such as symptom relapse, repetitive hospitalizations, and interactions with the legal system (involuntary commitments or incarceration). Clients who are experiencing paranoia may become aggressive or assaultive, but those with the disease are more likely to be victims than aggressors. Table 15.2 summarizes the symptoms of schizophrenia.

Psychosocial Considerations

Implicit bias and psychosis.

Implicit bias includes humans’ automatic and often unintentional beliefs based on experiences, thoughts, and other previously learned behaviors. These biases are learned associations or pairings that can occur with human or social qualities, ethnicities, or gender; they can influence health outcomes. In mental health, provider implicit bias influences client interactions, treatment decisions, and health outcomes. Some providers have perceived Black and Latinx clients as less adherent, noncooperative, and as having risky behaviors. As a result, these clients are more likely to receive a diagnosis of a severe mental illness, such as schizophrenia than their White counterparts. At the same time, they are less likely than White clients to receive the most effective treatments (Kopera et al., 2015).

Management of implicit bias in nursing starts with education on implicit bias and self-assessment. The National Institutes of Health offers a free implicit bias course specific to health-care professionals. Additionally, individuals can anonymously assess self-implicit associations through Project Implicit , a partnership with Harvard University. Through this nonprofit organization, the individual can select an implicit association test through the study portal to facilitate self-awareness.

Additional strategies to mitigate bias in the health-care workplace include:

• identifying and transforming strategies to eliminate norms that perpetuate bias
• establishing monitoring systems in client outcomes
• implementing clinical procedures that protect clinicians and nurses from the high cognitive load that can perpetuate implicit bias

Stages of Schizophrenia

There are three phases of schizophrenia : prodromal, acute, and recovery. The prodromal phase is when nonspecific symptoms first appear. Active psychotic symptoms characterize the acute phase. The recovery phase is when the individual begins to notice symptoms diminishing.

Prodromal Phase

The first phase is the prodromal phase , which occurs before the first signs of psychosis appear. During the prodromal phase, there is a gradual onset of nonspecific behaviors, such as sleep disturbances, suspiciousness, decreased attention to activities of daily living, disconnection with peers and family members, depressed mood, irritability, and problems focusing or understanding. The prodromal phase can last for a few weeks to several years. Of those diagnosed with schizophrenia, almost 75 percent have expressed prodromal symptoms.

Acute Phase

The second phase is the acute phase , which features active psychotic symptoms. During this phase, clients often encounter the medical and mental health system of care for the first time. During this phase, the disease is most visible and clients exhibit both the positive and negative symptoms of psychosis.

Schizophrenia: Part 2

See Schizophrenia: Part 1 for a review of the client data.

• protect the friend
• remind the client that they are not permitted to assault others
• determine whether the client has sustained an injury
• ensure that the client will not harm other people

Recovery Phase

The next stage of the progression is called the recovery or residual phase. During this phase, there is a quieting of the symptoms, a diminishing of the active symptoms or “clearing,” and more clarity of thought. In this phase, additional mood symptoms can emerge, such as depression , as the client considers the impact of the disease on the trajectory of their life. Although the residual phase is mainly devoid of active, psychotic symptoms, clients in this phase often do report blunted affect, conceptual disorganization, and social withdrawal. The progression or continuation in this stage depends on treatment, medication adherence, and determinants of health, such as housing, transportation, education, income, access to food, language, health literacy skills, and social support.

The phases may not be entirely linear. Remember that clients can lapse into another active phase of psychosis at any time; most clients with schizophrenia relapse multiple times during their lifetime. Risk factors of relapse include nonadherence to medications, substance misuse, another mental health diagnosis, short treatment duration, disparities in mental health treatment, and preexisting childhood adversity (Saria et al., 2014).

Real RN Stories

Nurse: Maria, staff nurse Years in Practice: Three Clinical Setting: Inpatient adult unit Geographic Location: Urban

A nurse assessed a twenty-one-year-old male who was a musician in a professional marching band. His friends and bandmates noticed he was “not himself” and had not been that way for some time. About seven months ago, he changed from being outgoing and garrulous to being withdrawn and noncommunicative. He stayed in his room most of the day in his bed, refusing to come out for practice or for social time with his best friends. He began to be more and more paranoid. When his friends came to his room, he would crack open the door and peer out at them from the opening. He would not let them in the room and stopped taking their phone calls. He was not taking care of himself, going for days without showering. Finally, his employer contacted his parents due to concerns about his behavior; he had not attended work or practice in weeks.

When his parents arrived at his apartment, he refused to let them in. He told them they were “imposters” and that “aliens had implanted chips in his head and told him that his parents were not real.” On hearing this, his parents contacted the police, and the client was brought to the hospital for evaluation and treatment. The psychiatric nurse provider completed an evaluation. The client refused inpatient hospitalization. A petition for commitment was submitted and completed by an outside provider, which resulted in the client being involuntarily committed to the facility for psychotic behavior. After admission to the psychiatric unit, the client refused to leave his room. Instead, he would stare at the nursing staff through the crack in the door.

He told them the “aliens were reporting to him that no one was real.” These “aliens” were also telling the client that he “should not trust anyone” and that he “should escape now!” These hallucinations prompted the client to make several escape attempts from the unit.

During one of the elopements, the client attempted to jump out of a second-story window after listening to the alien voices telling him “to jump to escape the imposters.” The client refused nursing and medical intervention multiple times. Finally, staff administered injectable antipsychotic medications. As the client became responsive to the medications and the psychotic symptoms began to clear, he became more communicative with the nursing staff and his family. The voices in his head seemed “duller” and less “clear,” and he became less paranoid of those around him. As the client continued his recovery, he noted that he had no memory of the events that led up to and during the first days of his hospitalization.

Treatment of Schizophrenia

Treatment options for schizophrenia require ongoing assessment and management of active symptoms and how they manifest and impair daily functioning. Collaboration with the family and/or primary caregivers and mental health providers is essential in developing the treatment platform. Families can be affected by stigma, stress, grief, anxiety , and isolation as they navigate the trajectory of the disturbance with their loved ones. Recommendations for family support groups and family therapy are paired with improved outcomes in those with schizophrenia. Finally, the inclusion of community-based resources helps clients to optimize treatment outcomes. Treatment for those with schizophrenia should be client-centered and include a combination of medication and psychosocial interventions.

Client-Centered Care Approaches

When a client presents for care with a possible diagnosis of schizophrenia, it is essential to take a client-centered care approach. Client-centered care considers client preferences, health literacy, treatment barriers, cultural beliefs, and lifestyle when helping clients to make decisions about their health. Determine realistic outcomes and psychosocial interventions that align with the client’s availability of resources and support systems. Clients diagnosed with schizophrenia have optimal outcomes when they have psychopharmaceutical intervention in conjunction with nonpharmacological options. Part of determining the best treatment options is to complete a full assessment inclusive of medical and social history, medication history, family history, and support systems. Safety is paramount; risk for suicide and violence should be part of every assessment.

Medications

Medications used to treat schizophrenia belong to a class called antipsychotic medications. These medications generally block dopamine to reduce the positive symptoms of psychosis. Antipsychotics were developed as a preanesthetic medication in the 1950s, but with further research, the first medication, chlorpromazine, treated mania effectively, ultimately leading to the first generation of antipsychotic medications.

First-Generation Antipsychotics

After the invention of chlorpromazine , a dopamine and serotonin receptor antagonist, in the 1950s, the first-generation antipsychotics, or neuroleptics , were introduced into mainstream psychiatry. These medications included haloperidol , trifluoperazine , thioridazine , and fluphenazine , and their primary function was to block dopamine (D2) receptors. They also have some actions at histamine, cholinergic, and alpha-adrenergic receptors. The high-potency medications (haloperidol, trifluoperazine, and fluphenazine) have a high risk for extrapyramidal side effects . The low potency medications (chlorpromazine and thioridazine) have significant anticholinergic properties, are sedating, and can cause weight gain, but do not cause as many extrapyramidal side effects. Overall, any of these first-generation antipsychotics can cause extrapyramidal symptoms, sedation, anticholinergic symptoms, prolactin elevation, QT prolongation and potential for sudden death, lowering of the seizure threshold, orthostatic hypotension, sexual dysfunction, and metabolic disturbance. They have significant drug/drug interactions. Due to the sedating nature of some of these medications, assessment for fall risk is essential, especially in vulnerable populations.

Second-Generation Antipsychotics

Second-generation antipsychotics entered psychiatric practice in the 1970s with the invention of clozapine. These drugs function by antagonizing dopamine and serotonin (2A) receptors. This atypical antipsychotic medication class has fewer extrapyramidal symptoms due to their dual actions on dopamine and serotonin receptors. Second-generation antipsychotics include aripiprazole , asenapine , brexpiprazole , cariprazine , clozapine , iloperidone , lumateperone , lurasidone , olanzapine , paliperidone , pimavanserin , quetiapine , risperidone , and ziprasidone . Like their first-generation family members, second-generation antipsychotics also have potential interactions with other medications. Table 15.3 summarizes antipsychotic medications.

Medication recommendations depend upon different variables, such as the presence of positive or negative symptoms, medication efficacy, side effect management, and nonadherence. The first-line choice for managing positive symptoms is second-generation antipsychotics, except for clozapine due to its risk for neutropenia. The second line choice is clozapine and first-generation antipsychotics. In acute cases, choices for managing positive symptoms include first- and second-generation antipsychotics and benzodiazepine s. For the treatment of mainly negative symptoms, second-generation antipsychotics are the first choice, with antidepressants, modafinil, and clozapine as secondary choices. First-line choices for clients concerned about weight gain include ziprasidone, lurasidone, and aripiprazole. To enhance sedation, the best choices include quetiapine, clozapine, asenapine, and olanzapine. First-line choices for clients concerned about sedation include ziprasidone, lurasidone, and aripiprazole. Finally, for clients who struggle with nonadherence, choose depot forms of both first- and second-generation antipsychotics (National Library of Medicine, 2016). Depots are long-acting injectable forms of antipsychotic medications. They promote medication adherence because the drug is injected every two to six months. Table 15.4 summarizes the nursing interventions for the side effects of antipsychotic medications.

The blockade of dopamine in the nigrostriatal pathway has the potential to cause movement disorders and side effects called extrapyramidal side effects ( Table 15.5 ). These can be movement side effects, such as dystonia, pseudoparkinsonism, tardive dyskinesia , and akathisia, or critical side effects, such as neuroleptic malignant disturbance , a medical emergency.

Clinical Judgment Measurement Model

Side effects: aims.

A twenty-three-year-old client has been admitted to the inpatient psychiatric unit after spending two days waiting on a bed in the emergency department. The client had been experiencing auditory and visual hallucinations and delusions that the government has been watching them. The client was irritable and aggressive while in the emergency department. They were given several doses of haloperidol 5 mg with 25 mg of Benadryl by mouth during their time in the emergency department. Upon arrival to the inpatient unit, the client is calm but still experiencing hallucinations. The client was given an additional dose of haloperidol 5 mg with another 25 mg of Benadryl. During their one month on inpatient, the client was transferred to risperidone, and is now taking 3 mg by mouth at bedtime. One evening, after the nighttime dose of their medication, the client approached the nurse complaining that their mouth felt like it was “twitching.” Consider these skills in the assessment of this client using the Abnormal Involuntary Movement Scale (AIMS) (see Appendix B Abnormal Involuntary Movement Scale ).

1. Recognize cues: The RN uses assessment skills to evaluate potential side effects of antipsychotic medications, such as extrapyramidal side effects like tardive dyskinesia. Using the AIMS assessment tool, the entire examination can be completed in ten minutes by the nurse. There are twelve items on the scale that are assessed in various areas of the body.

The first step in completing the AIMS exam is to monitor the client discreetly while at rest. Then ask if they are wearing dentures or mouth fixtures. If so, do they or their teeth hurt the client? Then ask the client to sit with their hands on their knees and feet flat on the floor. Observe for movement. Then ask the client to put their hands between their knees unsupported. Observe again for movement. Then ask if there is any unusual movement in their body. If the answer is yes, ask if the movement is bothersome or interferes with any daily activities. Then have the client open their mouth and stick their tongue out twice. Observe any tongue movements. Then ask the client to tap their fingers to their thumbs rapidly. Have them do this on both hands. Then ask the client to stand. Observe the client in profile and look for any abnormal movements. Then have them extend their hands out with palms down. Observe for movement. Then have the client walk back and forth. Have them do this twice, observing for abnormal movement. After this is done, complete the AIMS form.

2. Analyze cues: Analyze any cues to abnormal movements in the body. Are there any mouth or facial movements, any in the hands or legs? Is the client aware of these movements, and if so, are they bothersome to the client? If it is bothersome to the client, how bothersome? This is also a good time to assess for any other extrapyramidal symptoms, such as parkinsonism, dystonia, and akathisias.

3. Prioritize hypotheses: If there are signs and symptoms of tardive dyskinesia, identify possible medications that could be contributing to the adverse events. While antipsychotics are the most likely culprits, other medications have been known to cause the symptoms: antidepressants, antiemetics, and stimulants.

4. Generate solutions: The intended outcome is reduction in adverse events related to the medication.

5. Act: Notify provider of assessment details, take vital signs, administer medications as needed, monitor client response per agency policy, and evaluate the effects of the medications by reassessing the client one-hour postadministration.

6. Evaluate outcomes: Evaluate the client’s response to the medications provided. Assess for worsening of symptoms, worsening of side effects, and functional impairment.

Psychosocial Treatments

Psychopharmaceutical treatments are the cornerstone for managing clients with schizophrenia. But the long-term success for clients also depends on the psychosocial and rehabilitative treatment options available in medical, nursing, and community settings. Treatment options include social skills training , cognitive remediation , cognitive behavioral therapy, family therapy , support groups, peer-to-peer counseling, occupational therapy, school and work assistance programs, and care management. Communication and collaboration between care providers, avoiding gaps in service delivery, and managing transitions of care are all critical in managing psychosocial treatment s for clients.

Social Skills Training

Clients diagnosed with schizophrenia frequently experience symptoms causing them to struggle socially, often resulting in stigma and isolation. Social skills training improves social competence by providing skills, such as basic conversation, medication management , and community reintegration. Social skills interventions have been influential in reducing mental health symptoms, decreasing repeated hospitalizations, and improving social outcomes.

Cognitive Remediation

Cognitive symptoms of schizophrenia can result in deficits in processing, attention span, and memory. Cognitive training or remediation focuses on repetitive exercises designed to reorganize information, aid in learning, and provide behavioral prompts to assist in memory.

Family Education Groups

These groups focus on two interventions to assist clients, family members, and loved ones of those with schizophrenia. The first treatment approach emphasizes coping skills related to stress from living with the illness. The second approach highlights education on the diagnosis, symptoms, interventions, medications, side effects, and adverse events. Those engaging in family groups and interventions have seen positive outcomes, such as decreased relapse rates, fewer hospitalizations, and greater adherence to medications.

Cognitive Behavioral Therapy

Up to half of all clients with schizophrenia experience hallucinations and delusions. Using CBT to treat some of the positive symptoms of psychosis helps clients to challenge what they are experiencing and restructure what is happening to them. The cognitive model assumes that life events and experiences mold and shape core beliefs. It follows then that these beliefs influence everyday automatic thoughts. Automatic thoughts, like delusions and hallucinations, influence emotions, behaviors, and physiological responses. Therefore, the goal for CBT with respect to hallucinations and delusions is to facilitate a scenario with the client where they can challenge what they are experiencing:

“Is this a symptom, or is this actually happening to me?”

Nurse: Pam, advanced practice psychiatric nurse practitioner Years in Practice: Ten Clinical Setting: Outpatient treatment facility Geographic Location: Southeast United States

I was an advanced practice psychiatric nurse practitioner with ten years of experience and certified in CBT. I was doing a psychotherapy session with a client in the recovery stage of schizophrenia. The client was experiencing delusions that “people were looking at her and talking about her all the time.” This occurred daily as she went about managing her tasks in the community.

During the session, the client mentioned that she was walking to her therapy session and noticed a person who walked by her. She had a thought that he was “talking on the phone about her.” I asked the client if we could use this for their therapy session today, and the client said we could. I asked to identify what evidence, if any, that the person was talking about her. The client could not name any. I then asked to identify evidence that the person was not talking about her. The client then came up with several facts or scenarios as to why he was not talking about her.

I then asked her: What is more likely to be true?

• The thoughts that you are having are symptoms of your illness.
• The person was talking about you.

The client could use the evidence to identify that the thoughts were part of her symptoms. She was then able to use this method daily to challenge her delusions when walking in public.

Nursing Care for a Client Suffering from Schizophrenia

Nurses should develop a plan of care that is in accord with the client, their family, and other caretakers and that is relevant and culturally appropriate. It should involve evidence-based medical and psychosocial interventions that will assist the client in meeting their treatment goals in the least restrictive environment.

Nursing Assessment

Nursing interventions for those with schizophrenia begin with an assessment. For those experiencing psychosis, crowded, noisy, bright rooms can be very distracting during an interaction. Ensure that the assessment is done in a quiet room, with soft lighting, without interruptions. Allow access to the door for egress for both the nurse and the client, even if safety is not a concern.

Ensure the safety of self and client. If the client is acting aggressively, use a soft, soothing voice, move slowly, and approach with hands in front and palms open ( Table 15.6 ). Ask one question at a time, and allow the client time to answer questions. Observe their behavior. Are they looking at the interviewer or like they are responding to internal stimuli (hallucinations)? If they look like they are hallucinating, ask them if they see or hear things other than the interviewer’s voice. Have them describe what they see or hear. If the hallucinations are command in nature, ask about the content and keep them from acting on those commands. Assess for suicidal or homicidal content. Ask the client about delusions. Do not challenge their beliefs, but explore the nature of any expressed delusion. Assess any risk to self or others that may accompany the delusional thoughts.

Nursing Clinical Judgment

The goal for the client with schizophrenia is to maintain stability through adherence to medications, continued interaction with health-care providers, mitigation of adverse reactions and side effects, optimal nutritional status, and social and occupational functioning. The nursing clinical judgment measurement model assists the nurse in formulating clinical decisions based on critical thinking through client presentations to achieve optimal client outcomes. To prioritize clinical judgment, consider differing treatment and outcome goals through acute and maintenance phases of schizophrenia.

Schizophrenia: Part 3

See Schizophrenia: Part 2 for a review of the client data.

Following lab results, the UDS and CMP, it is confirmed that the client’s condition has not resulted from any underlying physical cause and is to be treated as a mental health problem. Which actions will be taken with this client? (Select answers from the appropriate lists.)

The nurse knows that the client will be prescribed   List 1   that may result in side effects such as   List 2   ,   List 2   , and   List 2   . The client will be evaluated for improvement in his condition as evidenced by the client   List 3   and   List 3   .

• lithium carbonate (Carbolith)
• benztropine (Cogentin)
• benzodiazepine (Alprazolam)
• risperidone (Risperdal)
• amitriptyline (Elavil)
• blurred vision
• urinary frequency
• constipation
• hyperactivity
• pacing only in the mornings
• engaging in therapeutic modalities
• seeing the FBI not in a helicopter
• only using tinfoil on windows when voices tell him to do so
• phones his mother to complain directly to her
• complying with his medication

Treatment and Outcome Goals

The client and the health-care team should identify realistic short- and long-term treatment goals. These can include taking medication as directed; mitigating side effects and adverse events associated with drugs; reducing positive, negative, and cognitive symptoms ; improving self-care deficits; improving social/occupational/educational functioning; and engaging in therapeutic modalities. Each stage of schizophrenia will have different outcome goals that require attention.

Outcomes Identification for the Acute Phase

Priority goals for clients in the acute phase of the illness include decreasing psychotic symptoms and maintaining the client’s and others’ safety. Utilize internal safety protocols to maintain a safe environment for both the client and staff. Use the least restrictive measures when managing aggression in violent and paranoid clients, and continuously assess and document carefully after any hands-on interventions. Other treatment goals in the acute phase include medication adherence, minimizing side effects and adverse effects of medications, establishing trust, and transitioning to lower levels of care in the community.

Outcomes for Stabilization and Maintenance Phase

During the stabilization and maintenance phases, preservation of stability and reestablishment into the community are optimal goals for outcomes. This is done through connecting the client with community resources, pharmacy assistance programs, crisis intervention and assertive community treatment teams (ACT), social workers, case managers, faith-based organizations, and the Schizophrenia and Psychosis Action Alliance, an organization for support, advocacy, and research. Best nursing outcomes are specific, measurable, achievable, relevant, and time-bound (SMART). Other outcomes include mitigating side effects, ensuring medication adherence, coping with diagnosis/symptoms, and managing stigma.

Implementation of Nursing Care

After assessment and setting treatment measures to meet goals, it is time to implement nursing care. Implementation strategies during the acute phase include:

• ensuring the least restrictive care environment and its safety, management of the safety of the client and others
• mitigating risks if present
• completing safety checks in the milieu and per unit safety protocols
• monitoring for changes to mental status, medication adherence, side effects, the effectiveness of medication management; and client data, such as vital signs, intake and output, and height and weight

Implementation during the stabilization and maintenance phase includes:

• safe transfers of care
• communication with other health-care providers
• transfer of health records according to HIPAA requirements
• coordination with other community care providers
• facilitating the use of cognitive interventions with clients to help challenge residual hallucinations
• establishing therapeutic communication and trust with clients experiencing delusions and then helping the client to focus on reality-based themes
• working with family, friends, and other supportive caregivers to develop a relapse prevention plan
• working with the client to identify warning signs of psychosis, stressors, side effects, or behaviors that lead to medication nonadherence, and things to do and people to call when concerned about relapse or safety

Implementation of treatment during this phase also includes family education about resources, medication, side effects, health, diet, and exercise. There are a number of issues pertaining to the recovery of the client that have to be shared with the client and the family. The information for the client relates to their personal recovery and ability to remain healthy. The information shared with the family is in the form of explaining the condition to them and giving advice on how to support the client and maintain their role within the family ( Table 15.7 ).

One notable type of philosophy for care of those diagnosed with schizophrenia is a therapeutic milieu, which is a holistic, safe, and structured environment that helps facilitate emotional well-being and recovery. The idea behind milieu therapy is that the environment affects how one feels or thinks. The optimal milieu therapy for an individual experiencing psychotic symptoms is a quiet, safe, and nonthreatening one. The milieu will help reduce aggression and violence in those with schizophrenia. Specific components of milieu therapy to support the client with psychosis include:

• Structure: Ensure predictable times, places, appointments, and schedules. Ensure that the client is in the same room, receives meals and medications in the same place, and has uninterrupted morning and evening routines.
• Containment: The client is maintained on specific safety protocols and levels according to their current level of risk. This limits access to things considered a risk to self-harm or harm to others. Communicate these limitations clearly and consistently to everyone on the treatment team, including the client and family members.
• Safety: The milieu must be safe for clients and staff. Ensure that it is emotionally safe by projecting empathy and consistency with staff.
• Flexibility: A healthy milieu is adaptable and supportive, not rigid or controlling.
• Socialization: The milieu provides an opportunity to apply social skills and to have others reciprocate.

A highly functioning milieu will help accelerate recovery from the psychotic process, establish trust, and develop social skills and communication with others. In addition, it will help to build a sense of safety and security and provide a supportive environment for the client to build new psychosocial skills. The nurse’s role is to manage the milieu, set and enforce healthy boundaries, establish routines, and provide a supportive environment.

Clinical Safety and Procedures (QSEN)

Safety during and after the restraint.

Definition: Minimizes risk of harm to clients and providers through both system effectiveness and individual performance (QSEN Institute, n.d.).

A psychiatric RN was involved in a behavioral restraint with a male client who attacked a staff member with the leg of a chair. The client was diagnosed with a psychotic disorder; the etiology had yet to be determined. The least restrictive interventions were not successful, including the option to take oral medications. Orders were given for restraint by the provider. A five-person team gathered, and the client was placed in four-point restraints in the room designated for that purpose. The client was given an injection of olanzapine 10 mg in the right buttock. The restraint room has a video camera, but the RN sat one to one with the client as per protocol. The RN documented information about what led up to the restraint, including all least restrictive efforts employed. As soon as the client was placed into restraints, vital signs were assessed along with neurovascular status on all four extremities. After seven minutes, the client became calm. One arm was released without incident. Vital signs and neurovascular status were assessed every fifteen minutes and they were allowed to use the restroom if needed. The client was monitored for pressure ulcers and signs and symptoms of rhabdomyolysis (muscle cramps, aches, or dark urine). Once the client was released from the restraints, vital signs were repeated, and a mental status evaluation was done. Assessments were documented on the standardized form used by the facility as per protocol. The client was continuously monitored for the remainder of the day. The staff completed a debrief that included evaluation of the situation, performance, and adherence to training requirements.

Evaluation of Nursing Care

Evaluating the effectiveness of treatment and the progression toward recovery is integral in client-centered care . This involves gathering information from all stages of care, and all sources of care and communicating the information with all care providers and team members, including the client, their family, and other care providers. Nurses should evaluate the following after implementing treatment for clients with schizophrenia:

• reduction of harm to clients and staff during restraints
• integration of safety practices that reduce harm to clients (medication reconciliation, five rights, falls prevention)
• assessment for risk of violence and suicide using evidenced-based tools
• assessment and monitoring of side effects and adverse events of psychotropic medications
• identification of client preferences, health literacy, and other client-centered outcomes in client records
• promotion and documentation of “warm handoffs” and communication between providers, systems, and clients during care transitions; warm handoffs are communications (over the phone or in person) between providers when a care transfer occurs
• involvement of case management services, social work, and other community transition services to ensure recovery-oriented practices (Mayo Clinic, 2020)

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• Authors: Rebecca Puchkors, Jeanne Saunders, David Sharp
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• Book title: Psychiatric-Mental Health Nursing
• Publication date: Jun 12, 2024
• Location: Houston, Texas
• Book URL: https://openstax.org/books/psychiatric-mental-health/pages/1-introduction
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Schizophrenia Case Study (45 min)

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A 21-year-old male is found outside of a gas station and according to bystanders, he was constantly talking for hours straight about the end of the world and the conspiracy of the government to control our minds. The patient appears to not have taken a shower in a long time; his hair is matted, his skin is dirty, he has a strong body odor and his nails are long with dirt under them. The patient is quoting the bible and asking everyone who enters the room if God has saved them yet. The nurse is assessing this patient and is asked if she could get Jesus a glass of water.

How should the nurse respond to the patient?

• Ask the patient if they can see Jesus and if Jesus is telling the patient to do something.
• Safety first! Assessing the reality of a patient is more important than re-orienting them.
• Re-orienting them happens after the nurse knows the patient doesn’t think Jesus is saying to kill everyone

The patient states, “Don’t you know who Jesus is? He will kill you if he wanted to. Don’t upset Jesus and get him a glass of water.” What should the nurse do at this point?

• Inform the patient that the only people you can see are the patient and yourself.
• Do not say you see the patient’s hallucination or validate the patient’s idea by getting ‘Jesus’ a glass of water.
• Try to divert the conversation back to the assessment and avoid getting stuck talking about the delusion.

The patient cooperates and is answering the nurse’s questions. Vital signs are stable and the patient tells the nurse that he has never been treated for any mental health problems before. He also tells the nurse that he is running away from home because people keep breaking into his apartment to laugh at him and steal his peanut butter and all of his writings because they will lead people to the secrets the government has been keeping. The nurse asks about medications the patient takes at home and the patient replies, “I don’t take that poison.” 

All of a sudden the patient starts to question the nurse and accuse the nurse of trying to trick the patient into taking poison and make him conform to the societal norms that the government wants us to do. The patient becomes very anxious and is staring at the door.

What is the nurse’s priority at this time?

• Confirm an exit plan for and make sure that the nurse is not in any danger of being trapped in the room with the patient and no way out.
• Do not let the patient get between you and the door

How should the nurse handle the new found mistrust with this patient?

• The nurse should make positive statements and then move the focus of the conversation such as, “I will not poison you, I promise. You seem nervous, do you want to take a break for a few minutes?”
• Allowing the patient a break can help interrupt the concerning thoughts the patient was having

What is the most important thing for the nurse to do at this time?

• Get out of the room and call security.
• Do NOT attempt to take the pencil away or question the patient about the drawing before making sure you the nurse are safe and secure.
• Do not go into the room without a security officer present.
• And chart Chart CHART everything that is happening.
• This patient will need to be with a sitter one and one as well as alarms and safety protocols implemented.

What kind of antipsychotic medication (Typical or Atypical) do you think this patient should be on?

• Typical antipsychotics because this patient is experiencing positive symptoms of schizophrenia .

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Nursing Case Studies

Schizophrenia case studies: putting theory into practice

This article considers how patients with schizophrenia should be managed when their condition or treatment changes.

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Treatments for schizophrenia are typically recommended by a mental health specialist; however, it is important that pharmacists recognise their role in the management and monitoring of this condition. In ‘ Schizophrenia: recognition and management ’, advice was provided that would help with identifying symptoms of the condition, and determining and monitoring treatment. In this article, hospital and community pharmacy-based case studies provide further context for the management of patients with schizophrenia who have concurrent conditions or factors that could impact their treatment.

Case study 1: A man who suddenly stops smoking

A man aged 35 years* has been admitted to a ward following a serious injury. He has been taking olanzapine 20mg at night for the past three years to treat his schizophrenia, without any problems, and does not take any other medicines. He smokes 25–30 cigarettes per day, but, because of his injury, he is unable to go outside and has opted to be started on nicotine replacement therapy (NRT) in the form of a patch.

When speaking to him about his medicines, he appears very drowsy and is barely able to speak. After checking his notes, it is found that the nurses are withholding his morphine because he appears over-sedated. The doctor asks the pharmacist if any of the patient’s prescribed therapies could be causing these symptoms.

What could be the cause?

Smoking is known to increase the metabolism of several antipsychotics, including olanzapine, haloperidol and clozapine. This increase is linked to a chemical found in cigarettes, but not nicotine itself. Tobacco smoke contains aromatic hydrocarbons that are inducers of CYP1A2, which are involved in the metabolism of several medicines [1] , [2] , [3] . Therefore, smoking cessation and starting NRT leads to a reduction in clearance of the patient’s olanzapine, leading to increased plasma levels of the antipsychotic olanzapine and potentially more adverse effects — sedation in this case.

Patients who want to stop, or who inadvertently stop, smoking while taking antipsychotics should be monitored for signs of increased adverse effects (e.g. extrapyramidal side effects, weight gain or confusion). Patients who take clozapine and who wish to stop smoking should be referred to their mental health team for review as clozapine levels can increase significantly when smoking is stopped [3] , [4] .

For this patient, olanzapine is reduced to 15mg at night; consequently, he seems much brighter and more responsive. After a period on the ward, he has successfully been treated for his injury and is ready to go home. The doctor has asked for him to be supplied with olanzapine 15mg for discharge along with his NRT.

What should be considered prior to discharge?

It is important to discuss with the patient why his dose was changed during his stay in hospital and to ask whether he intends to start smoking again or to continue with his NRT. Explain to him that if he wants to begin, or is at risk of, smoking again, his olanzapine levels may be impacted and he may be at risk of becoming unwell. It is necessary to warn him of the risk to his current therapy and to speak to his pharmacist or mental health team if he does decide to start smoking again. In addition, this should be used as an opportunity to reinforce the general risks of smoking to the patient and to encourage him to remain smoke-free.

It is also important to speak to the patient’s community team (e.g. doctors, nurses), who specialise in caring for patients with mental health disorders, about why the olanzapine dose was reduced during his stay, so that they can then monitor him in case he does begin smoking again.

Case 2: A woman with constipation

A woman aged 40 years* presents at the pharmacy. The pharmacist recognises her as she often comes in to collect medicine for her family. They are aware that she has a history of schizophrenia and that she was started on clozapine three months ago. She receives this from her mental health team on a weekly basis.

She has visited the pharmacy to discuss constipation that she is experiencing. She has noticed that since she was started on clozapine, her bowel movements have become less frequent. She is concerned as she is currently only able to go to the toilet about once per week. She explains that she feels uncomfortable and sick, and although she has been trying to change her diet to include more fibre, it does not seem to be helping. The patient asks for advice on a suitable laxative.

What needs to be considered?

Constipation is a very common side effect of clozapine . However, it has the potential to become serious and, in rare cases, even fatal [5] , [6] , [7] , [8] . While minor constipation can be managed using over-the-counter medicines (e.g. stimulant laxatives, such as senna, are normally recommended first-line with stool softeners, such as docusate, or osmotic laxatives, such as lactulose, as an alternative choice), severe constipation should be checked by a doctor to ensure there is no serious bowel obstruction as this can lead to paralytic ileus, which can be fatal [9] . Symptoms indicative of severe constipation include: no improvement or bowel movement following laxative use, fever, stomach pain, vomiting, loss of appetite and/or diarrhoea, which can be a sign of faecal impaction overflow.

As the patient has been experiencing this for some time and is only opening her bowels once per week, as well as having other symptoms (i.e. feeling uncomfortable and sick), she should be advised to see her GP as soon as possible.

The patient returns to the pharmacy again a few weeks later to collect a prescription for a member of their family and thanks the pharmacist for their advice. The patient was prescribed a laxative that has led to resolution of symptoms and she explains that she is feeling much better. Although she has a repeat prescription for lactulose 15ml twice per day, she says she is not sure whether she needs to continue to take it as she feels better.

What advice should be provided?

As she has already had an episode of constipation, despite dietary changes, it would be best for the patient to continue with the lactulose at the same dose (i.e. 15ml twice daily), to prevent the problem occurring again. Explain to the patient that as constipation is a common side effect of clozapine, it is reasonable for her to take laxatives before she gets constipation to prevent complications.

Pharmacists should encourage any patient who has previously had constipation to continue taking prescribed laxatives and explain why this is important. Pharmacists should also continue to ask patients about their bowel habits to help pick up any constipation that may be returning. Where pharmacists identify patients who have had problems with constipation prior to starting clozapine, they can recommend the use of a prophylactic laxative such as lactulose.

Case 3: A mother is concerned for her son who is talking to someone who is not there

A woman has been visiting the pharmacy for the past 3 months to collect a prescription for her son, aged 17 years*. In the past, the patient has collected his own medicine. Today the patient has presented with his mother; he looks dishevelled, preoccupied and does not speak to anyone in the pharmacy.

His mother beckons you to the side and expresses her concern for her son, explaining that she often hears him talking to someone who is not there. She adds that he is spending a lot of time in his room by himself and has accused her of tampering with his things. She is not sure what she should do and asks for advice.

What action can the pharmacist take?

It is important to reassure the mother that there is help available to review her son and identify if there are any problems that he is experiencing, but explain it is difficult to say at this point what he may be experiencing. Schizophrenia is a psychotic illness which has several symptoms that are classified as positive (e.g. hallucinations and delusions), negative (e.g. social withdrawal, self-neglect) and cognitive (e.g. poor memory and attention).

Many patients who go on to be diagnosed with schizophrenia will experience a prodromal period before schizophrenia is diagnosed. This may be a period where negative symptoms dominate and patients may become isolated and withdrawn. These symptoms can be confused with depression, particularly in younger people, though depression and anxiety disorders themselves may be prominent and treatment for these may also be needed. In this case, the patient’s mother is describing potential psychotic symptoms and it would be best for her son to be assessed. She should be encouraged to take her son to the GP for an assessment; however, if she is unable to do so, she can talk to the GP herself. It is usually the role of the doctor to refer patients for an assessment and to ensure that any other medical problems are assessed. 

Three months later, the patient comes into the pharmacy and seems to be much more like his usual self, having been started on an antipsychotic. He collects his prescription for risperidone and mentions that he is very worried about his weight, which has increased since he started taking the newly prescribed tablets. Although he does not keep track of his weight, he has noticed a physical change and that some of his clothes no longer fit him.

What advice can the pharmacist provide?

Weight gain is common with many antipsychotics [10] . Risperidone is usually associated with a moderate chance of weight gain, which can occur early on in treatment [6] , [11] , [12] . As such, the National Institute for Health and Care Excellence recommends weekly monitoring of weight initially [13] . As well as weight gain, risperidone can be associated with an increased risk of diabetes and dyslipidaemia, which must also be monitored [6] , [11] , [12] . For example, the lipid profile and glucose should be assessed at 12 weeks, 6 months and then annually [12] .

The pharmacist should encourage the patient to attend any appointments for monitoring, which may be provided by his GP or mental health team, and to speak to his mental health team about his weight gain. If he agrees, the pharmacist could inform the patient’s mental health team of his weight gain and concerns on his behalf. It is important to tackle weight gain early on in treatment, as weight loss can be difficult to achieve, even if the medicine is changed.

The pharmacist should provide the patient with advice on healthy eating (e.g. eating a balanced diet with at least five fruit and vegetables per day) and exercising regularly (e.g. doing at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity per week), and direct him to locally available services. The pharmacist can record the adverse effect on the patient’s medical record, which will help flag this in the future and thus help other pharmacists to intervene should he be prescribed risperidone again.

*All case studies are fictional.

Useful resources

• Mind — Schizophrenia
• Rethink Mental Illness — Schizophrenia
• Mental Health Foundation — Schizophrenia
• Royal College of Psychiatrists — Schizophrenia
• NICE guidance [CG178] — Psychosis and schizophrenia in adults: prevention and management
• NICE guidance [CG155] — Psychosis and schizophrenia in children and young people: recognition and management
• British Association for Psychopharmacology — Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology

About the author

Nicola Greenhalgh is lead pharmacist, Mental Health Services, North East London NHS Foundation Trust

[1] Chiu CC, Lu ML, Huang MC & Chen KP. Heavy smoking, reduced olanzapine levels, and treatment effects: a case report. Ther Drug Monit 2004;26(5):579–581. doi: 10.1097/00007691-200410000-00018

[2] de Leon J. Psychopharmacology: atypical antipsychotic dosing: the effect of smoking and caffeine. Psychiatr Serv 2004;55(5):491–493. doi: 10.1176/appi.ps.55.5.491

[3] Mayerova M, Ustohal L, Jarkovsky J et al . Influence of dose, gender, and cigarette smoking on clozapine plasma concentrations. Neuropsychiatr Dis Treat 2018;14:1535–1543. doi: 10.2147/NDT.S163839

[4] Ashir M & Petterson L. Smoking bans and clozapine levels. Adv Psychiatr Treat 2008;14(5):398–399. doi: 10.1192/apt.14.5.398b

[5] Young CR, Bowers MB & Mazure CM. Management of the adverse effects of clozapine. Schizophr Bull 1998;24(3):381–390. doi: 10.1093/oxfordjournals.schbul.a033333

[6] Taylor D, Barnes TRE & Young AH. The Maudsley Prescribing Guidelines in Psychiatry . 13th edn. London: Wiley Blackwell; 2018

[7] Oke V, Schmidt F, Bhattarai B et al . Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis — a case report. Int Med Case Rep J 2015;8:189–192. doi: 10.2147/IMCRJ.S86716

[8] Hibbard KR, Propst A, Frank DE & Wyse J. Fatalities associated with clozapine-related constipation and bowel obstruction: a literature review and two case reports. Psychosomatics 2009;50(4):416–419. doi: 10.1176/appi.psy.50.4.416

[9] Medicines and Healthcare products Regulatory Agency. Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus. 2020. Available from: https://www.gov.uk/drug-safety-update/clozapine-reminder-of-potentially-fatal-risk-of-intestinal-obstruction-faecal-impaction-and-paralytic-ileus (accessed April 2020)

[10] Leucht S, Cipriani A, Spineli L et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet 2013;382(9896):951–962. doi: 10.1016/S0140-6736(13)60733-3

[11] Bazire S. Psychotropic Drug Directory . Norwich: Lloyd-Reinhold Communications LLP; 2018

[12] Cooper SJ & Reynolds GP. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol 2016;30(8):717–748. doi: 10.1177/0269881116645254

[13] National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178]. 2014. Available from: https://www.nice.org.uk/guidance/cg178 (accessed April 2020)

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Perspectives of Nursing Students towards Schizophrenia Stigma: A Qualitative Study Protocol

1 School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China

Jingjing Su

2 World Health Organization Collaborating Centre for Community Health Services, School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China

Daniel Thomas Bressington

3 College of Nursing & Midwifery, Charles Darwin University, Casuarina, NT 0810, Australia

Sau Fong Leung

Associated data.

This statement can be excluded as the study did not report any data.

Aim: This study aims to explore fourth-year nursing students’ knowledge of schizophrenia and their attitudes, empathy, and intentional behaviours towards people with schizophrenia. Design: This will be a descriptive qualitative study using focus-group interviews. Methods: Fourth-year nursing students on clinical placement in a hospital in Hunan province will be invited for focus-group interviews. Snowball and purposive sampling will be used to recruit nursing students for this study. Five focus-group interviews, each including six participants, will be conducted to explore participants’ knowledge, attitudes, intentional behaviours, and empathy towards schizophrenia. The interview will be conducted through the online Tencent video conference platform and the interview data will be collected through the same platform. All interviews will be recorded and transcribed verbatim and analysed with the approach of the content analysis supported by NVivo 12. Simultaneous data collection and analysis will be performed, and the interviews will be continued until data saturation is met. The findings of this study will be helpful in developing effective interventions to decrease the stigma toward schizophrenia among nursing students and those who study healthcare disciplines.

1. Introduction

Mental illness is a highly frequent disorder in which an individual’s cognition, emotion regulation, or behaviour is clinically significantly disturbed [ 1 ]. Mental illness stigma is defined as social stereotyping of, or discrimination against, people with mental illness [ 2 ]. A study involving 16 countries showed that the public had a high level of stigma towards people with mental illness [ 3 ]. Mental illness-related stigma is extremely damaging to people with mental illness, their families, and the health care system [ 4 , 5 ], and those with severe mental illness often face severe stigma [ 6 ]. Typical severe mental illnesses include schizophrenia, bipolar disorder, and major depression [ 7 ], of which schizophrenia is the most stigmatized mental illness [ 8 , 9 , 10 ].

Schizophrenia results in individuals’ significant impairments in perceiving reality and changes all aspects of their lives; it affects approximately 24 million people globally [ 11 ]. In China, an epidemiological study reported that the lifetime prevalence of schizophrenia among Chinese people was 0.6% between 2013 and 2015 [ 12 ]. A recent study reported that the age-standardized incidence rate of schizophrenia in China was 18.47/100,000 in 2019 [ 13 ]. The incidence rate implies that almost 8.46 million people in China had schizophrenia [ 14 ]. However, a huge number of people with schizophrenia were undetected by the healthcare system, as only 0.29 million (95% UI = 0.26 to 0.33 million) newly diagnosed schizophrenia cases were reported in 2017 in China [ 15 ]. Stigma is the main barrier to health-seeking behaviours, and the exploration of schizophrenia stigma is urgent.

People with schizophrenia face stigma in different aspects of their daily lives, such as in employment [ 16 , 17 ], friendships [ 18 ], romantic relationships [ 16 , 18 ], rehabilitation [ 19 , 20 ], social integration [ 20 ], and receiving medical treatment [ 21 ], which affects their life quality [ 10 , 22 , 23 ] and reduces their willingness to confide in others or ask for help [ 16 , 24 , 25 , 26 , 27 ]. Such stigmatisation can make them lose their self-esteem and ignore their own symptoms [ 24 , 28 , 29 ]. The loss of social status and familial respect caused by stigma [ 16 ] can even lead to suicide [ 30 ]. Meanwhile, stigmatising views held by health professionals can decrease their willingness to work in psychiatric departments [ 31 , 32 ], leading to a shortage of doctors and nurses [ 33 ].

Nurses constitute the largest occupational group in the healthcare sector globally [ 7 ]. Some nursing students in Mainland China also hold negative attitudes towards people with mental illness [ 34 , 35 , 36 ]. Compared with their USA peers, they were found to have poor knowledge of schizophrenia [ 37 ]. Nurses play a major role in the rehabilitation and treatment of people with schizophrenia [ 38 ]. Thus, exploring the perspectives towards people with schizophrenia among nursing students, as future nurses, will be invaluable in designing anti-stigma interventions for these students and ultimately improving the conditions of people with schizophrenia. Many quantitative studies have investigated nursing students’ knowledge of mental illness and/or their stigmatised attitudes and/or intentional behaviours towards people with mental illness [ 39 , 40 , 41 , 42 , 43 ]. Mental illness stigma is influenced by multiple factors [ 44 ], especially cultural factors [ 45 ]. But little quantitative research considers the cultural factors of stigma. Previous quantitative research often used some form of scale to assess the attitudes and intentional behaviours of nursing students’ stigma towards schizophrenia [ 46 ]. To develop specific and targeted interventions in decreasing nursing students’ stigma towards schizophrenia, it is necessary to understand their real perspectives. However, our knowledge of this area is lacking. Hence, a qualitative study will be more suitable for such an investigation. A qualitative descriptive research study generates data of three dimensions—who, what, and where—of events or experiences from a subjective perspective [ 47 ]. Philosophically, reality exists within a certain context, which is continuously changing and is perceived differently by different subjects. Thus, reality is characteristic of diversity and subjectivity, and it is highly recommended that the approach of constructionism and critical theories that use interpretative and naturalistic methods should be adopted in this research [ 48 ]. This study aims to obtain straightforward descriptions of nursing students’ experiences and perceptions towards schizophrenia. The qualitative descriptive approach is frequently used to provide straightforward descriptions of experiences and perceptions within a unique context [ 49 ]. In this type of research, the research process is inductive and dynamic, and the data collected from this phenomenon will not be over-transformed [ 49 , 50 ]. The advantages of the qualitative descriptive approach are both the questions’ subjective nature and participants’ diverse experiences, which can be recognized. Moreover, the outcomes will be reported straightforwardly, or in a way using similar terminology to the initial research question [ 51 ].

Some qualitative studies have explored the knowledge, attitudes, and behaviours of health professional students [ 52 , 53 ], nursing students [ 54 , 55 ], and medical students [ 56 ] towards mental illness. There is a lack of qualitative research focusing on schizophrenia stigma, even though schizophrenia is the most stigmatized mental illness [ 8 , 9 , 10 ], and the relationship between culture and stigma is given little attention in qualitative studies. Thus, further studies could be centred around nursing students’ perceptions of schizophrenia stigma. Unlike Western countries, China is a developing country with a culture of face-saving that is deeply influenced by Confucianism, Taoism, and Buddhism [ 57 , 58 ].

In view of the relationship between culture and the stigma, the development of anti-stigma interventions should be tailored to the Chinese culture. The findings of such a qualitative study may help to develop Chinese culture-specific interventions to decrease schizophrenia-related stigma among nursing students, as well as students of other healthcare disciplines and health professionals in China.

2. Theoretical Framework

In 2006, Thornicroft put forward the idea that three domains have constructed the problem of stigma: “knowledge, leading to ignorance; attitudes, leading to prejudice; and behaviour, leading to discrimination” [ 59 ]. Although stigma has been conceptualized differently, attitudes and behaviours are two core elements in most conceptualizations [ 60 ]. Stigma can be recognized as a negative attitude towards people with mental illness, and public stigma consists of three base components: stereotypes, prejudice, and discrimination [ 61 , 62 ]. Empathy is recognized as how an individual perceives other people’s thinking and feeling, and figures out what makes someone give a response to other people’s suffering with sensitivity and care [ 63 ]. According to a meta-analysis report, empathy is a mediator of the relationship between intergroup contact and reduced prejudice [ 64 ]. A study reported that empathy is inversely related to stigma and can be used to predict stigma [ 65 ]. Some studies also reported that improving empathy could decrease negative attitudes towards people with mental illness or other specific populations, and function as a potential protective factor that can reduce stigma [ 65 , 66 , 67 ]. In different cultures, people have different understandings of stigma, treat it in different ways, and yield different results [ 68 ]. Culture and beliefs will affect people’s views towards mental illness [ 69 ]. “Notions of stigma are bound by culture” ([ 70 ] p. 1). Studies have shown that sociocultural and religious factors strongly influence stigmatising attitudes [ 71 , 72 , 73 , 74 , 75 ]. It is difficult to measure peoples’ real behaviours towards schizophrenia [ 76 ]. Thus, intentional behaviours will be measured instead. It is envisaged that understanding how nursing students’ knowledge, attitudes, intentional behaviours, empathy, and the cultural influence on them affect their perspectives of schizophrenia and support the future development of interventions to decrease schizophrenia-related stigma among nursing students.

This study will explore fourth-year nursing students’ knowledge of schizophrenia and their attitudes, empathy, and intentional behaviours towards people with schizophrenia.

4. Methods and Analysis

4.1. study design and setting.

This qualitative study will adopt a descriptive design focusing on fourth-year nursing students’ knowledge of schizophrenia and their attitudes, empathy, and intentional behaviours towards people with schizophrenia. The study will be conducted at a tertiary first-class hospital in mainland China that provides clinical training for more than 250 fourth-year nursing students from across the country each year. Data collection will be conducted through focus-group interviews based on an online interview platform (Tencent meeting, a very popular online interview platform in China).

It is recognized that focus-group interviews can help generate deeper and richer data in many scenarios, as they involve group interactions [ 77 ]. These data can help to construct the key components of the intervention [ 78 ]. Through focus-group interviews, data from the researcher and each participant can be collected, and new questions and answers can be generated through interactive verbal communication among the group members. Researchers can thus know their participants’ needs and feelings and explore the influence of cultural values and beliefs on them [ 79 ]. The consolidated criteria for reporting qualitative research [ 80 ] will be used to guide the reporting of the focus-group interviews and the writing of the qualitative protocol.

As mentioned above, it is widely recognized that cultural values influence the stigma surrounding mental illness. Focus groups involving in-depth interviews of a particular population group on a certain topic can be used to develop or modify relevant intervention protocols [ 77 ]. Thus, we chose focus-group interviews to collect the data from 25 July 2022 to 30 September 2022. Apart from the focus-group interviews, individual interviews will also be offered to any participant who does not feel comfortable discussing the sensitive topic of stigma in a group setting.

4.2. Participants, and Recruitment

All the participants of this study will be fourth-year nursing students. WeChat or emails will be used for recruitment purposes. The principal investigator will be responsible for recruiting eligible participants and collecting their written informed consent. The inclusion and exclusion criteria are as follows:

Inclusion Criteria:

Nursing students who (1) are on clinical placement at the hospital involved in this study; (2) are 18 years old or above; (3) can communicate in Mandarin; and (4) agree to participate in this study.

Exclusion Criteria:

Nursing students who (1) have no access to a computer, a smartphone, or any electronic device for joining the online interview.

4.3. Sampling

“In focus-group research, the strategy is to use purposeful sampling whereby the researcher selects participants based on the purpose of the study [ 79 ] p. 452.” To gain rich information and to achieve maximum variation sampling from the participant, we will enrol fourth-year nursing students who satisfy the criteria and, if possible: (1) have contact experience with people with schizophrenia or mental illness, (2) are of male gender (most nursing students are female; thus, we want to enrol some male nursing students), (3) come from different provinces (it would be best to include some from ethnic minority groups), and (4) are very interested in studying mental health and willing to discuss their perspectives on our research topic. However, due to the COVID-19 pandemic and without contact information for the potential participants, it will be challenging and difficult to recruit a purposeful sample. Thus, the initial participant recruitment will adopt the snowball sampling method. Interested nursing students will be recruited through the affiliation of the principal investigator with a nursing college which can promote the study.

If possible, we will also ask the participants to help us recruit their peers who can meet the inclusion criteria of the aforementioned purposeful sampling.

4.4. Sample Size

A sample size of 4–12 participants is recommended for focus-group interviews. However, as it will be challenging to manage more than 12 participants in online focus-group interviews, we will divide the participants into two or three independent focus groups [ 81 ], with six participants per group [ 79 ]. It is suggested that data collection should be controlled as data collection after data saturation leads to a waste of time and resources [ 82 ]; therefore, concurrent data analysis will be adopted. Data saturation determines the sample size; thus, an exact sample size cannot be determined before the focus-group interviews [ 83 ]. It is reported that the first 5–6 participants produce the majority of new information in the dataset, while little information is gained from the later participants, and 80–92% of early information is identified within the dataset from the first 10 participants [ 84 ]. Little new information will be collected when the sample size is close to 20 interviews [ 85 ]. Thus, we expect around 5 groups of focus-group interviews (about 30 participants) will achieve data saturation, (i.e., when no new codes or themes emerge). The focus-group interviews will be stopped upon reaching data saturation.

4.5. Data Collection

An interview guide will be prepared for focus-group interviews based on a literature review and a research-group discussion. To make the interview questions clearer and easier to understand for nursing students, pilot interviews were used to collect suggestions about the interview questions, and then the interview guide was adjusted. The details of the questions included in the interview guide are provided in Table 1 .

Interview guide of the focus groups.

Tencent Video Conference will be used to conduct and record the online focus-group interviews. A sociodemographic questionnaire will be used to collect participants’ demographic information. The principal researcher, who has received postgraduate research training, will conduct the focus-group interviews. Meanwhile, one research assistant will use field notes to record the non-verbal expressions and emotional states of all of the participants. Since this will be an online focus-group interview, all participants are free to choose a comfortable place for themselves during the interview. When the interview starts, some warm-up questions will be raised first to build rapport between all participants. Each focus group interview will last approximately 1–1.5 h. All of the interviews will be recorded and transcribed. A research assistant and the principal researcher will check the transcripts’ accuracy by comparing the transcripts word-by-word with the recorded videos independently. They will compare the difference between the two versions and check the video recording together before agreeing on a final version. The final version of the transcripts will be shared with the participants to correct any discrepancies and provide additional clarification that might improve data accuracy. Non-verbal responses will also be recorded in the transcripts [ 86 ].

4.6. Data Analysis

Data analysis will be conducted after completing the data transcripts and the coding will be done as early as possible. The principal researcher will read the transcription many times to ensure his familiarity with the data, which will be helpful for the subsequent data analysis. The dimensions of analysis will rely on the interview data and focus on the specific objectives to explore participants’ knowledge, attitudes, empathy, and intentional behaviours towards people with schizophrenia.

4.6.1. Descriptive Statistics

The demographic characteristics of the participants will be presented with descriptive statistics, including means, standard deviations, and percentages, where appropriate.

4.6.2. Qualitative Content Analysis

Content analysis is widely used in qualitative research to discover the underlying meaning of words by quantification [ 87 ]. An inductive approach will be used for content analysis in this study, as it involves detailed readings of the raw data to derive concepts and themes, which allows findings to emerge directly from the analysis of the raw data, rather than from a priori expectations or models [ 88 ]. Furthermore, in qualitative content analysis, systematic coding is used to describe the meaning of the qualitative data [ 89 ]; the two most common approaches are manifest content and latent content analyses [ 90 ]. Manifest content analysis involves examining the surface structure of the text, while latent content analysis involves exploring hidden meanings of the text [ 91 ]. Both manifest content and latent content analyses have advantages in text interpretation, and a combination of both may ensure more consistent and accurate findings than either approach alone [ 91 , 92 ]. Thus, both types of content analysis will be adopted in this study to understand participants’ true views about schizophrenia. Simultaneous qualitative data collection and analysis have been reported to enhance the depth and quality of data analysis [ 93 ]. Thus, concurrent data analysis will be used in the interviews, and the interviews will be stopped upon reaching data saturation.

The five steps of qualitative content analysis are described below: data preparing and organising, reading and memoing, data coding, generating categories, and presenting the description and themes [ 86 ].

NVivo 12, a qualitative data analysis software, will be used to manage the data. An experienced qualitative researcher will also be invited to code the transcripts independently, and the coding outcomes of the principal researcher and the qualitative researcher will be compared. If some disagreement occurs, the research team will discuss the themes and findings, and make modifications until a consensus is reached. An outline of this focus-group interview study is shown in Figure 1 .

Outline of the focus-group interview study.

4.7. Issues of Data Trustworthiness

Qualitative validity refers to the extent to which the study findings are accurate at every step of the analysis, while qualitative reliability refers to the extent to which the study findings are consistent between different researchers and projects [ 93 ]. Credibility, dependability, transferability, and confirmability are the four criteria that determine the trustworthiness of a rigorous qualitative study [ 94 ]. Peer-debriefing, member-checking, and all interview data will be transcribed into Chinese by a research assistant independently. Different categories and subcategories will be established after all data are analysed, and the research findings will be translated into English. This process will help to decrease the loss of meaning during translation and thus improve the credibility of the findings [ 95 ]. A sound audit trail and analytical memos will be maintained, and details of each step of the study will be recorded to ensure the dependability of this study. The information on the demographic and clinical characteristics and study context will be provided in detail, and the transferability of the findings will be increased in this study [ 96 ]. The researcher will reflect upon his actions to determine whether he has provided any misleading cues to the participants. Meanwhile, a research assistant will examine the video recordings of the interviews to identify any instances where the researcher might have manipulated the participants’ responses. Peer-debriefing will be used to examine the data-analysis process. Two trained research assistants will examine the processes of discussion and analysis to improve the confirmability of the data [ 97 ].

4.8. Ethical Issues and Data Safety

Ethical approval has been obtained from the Research Ethics Committee of The Hong Kong Polytechnic University (HSEARS20220127002 on 22 February 2022) and the Research Ethics Committee of the Hospital (KE202203129 on 18 March 2022) to conduct this study. Written informed consent will be obtained from eligible participants before data collection. Before filling in the information sheet, the participants will be reminded of the voluntary nature of their participation in the study, and their right to withdraw from the study at any time without any consequences for their clinical rotation. All information of the participants will be kept confidential and destroyed three years after completing the study.

5. Discussion

Exploring nursing students’ perspectives of schizophrenia stigma is a significant research topic, due to the lack of relevant knowledge. The findings of this qualitative study can inform the development of a Chinese culture-specific intervention to decrease schizophrenia-related stigma in China. Focus-group dynamic interaction is one of the methods to deal with sensitive, potential, and unpredictable questions within a group interview setting [ 98 ], whereas individual interviews may gain profound and accurate information of sensitive issues from participants. Most of our participants will be interviewed in focus groups as Chinese students might feel shy to express their opinions over a sensitive topic and would feel more at ease when accompanied by peers [ 99 ]. However, given the face-saving tendencies of some Chinese people [ 58 ], we will also consider offering individual interviews for students who feel uncomfortable with a focus-group interview. To ensure the data trustworthiness of this study, particular attention will be paid to data coding and data analysis, as highlighted in the earlier sessions. All interviews will be strictly transcribed by the principal researcher and a research assistant into written form to avoid the loss of information. Agreement on the codes and themes will be ensured among the research team members. More importantly, we will invite our participants to examine the findings of this data analysis and determine whether these findings reflect their real perspectives or opinions.

6. Limitations and Strengths

Nursing students with strong stigmatised views towards people with schizophrenia may be unwilling to participate in this study due to perceptions related to social desirability. This could lead to bias in participant recruitment. In addition, only fourth-year nursing students (from different universities) will be included in the focus-group interviews in view of the students’ theoretical knowledge of mental health. Thus, our sample may not be representative of the whole nursing student population spanning all degree years. However, the fourth year is the final year of the nursing degree, when nursing students’ stigma towards people with schizophrenia may affect their choice of nursing specialisation and their care for such patients in the years to come. Thus, we believe that exclusively including fourth-year nursing students is a potential strength of this study, as its results may guide the development of specific interventions to decrease these students’ stigma towards schizophrenia and encourage more graduating nurses to work in mental health departments.

7. Conclusions

To the best of our knowledge, this study will be the first to explore the perceived effect of Chinese culture on the stigma towards schizophrenia among nursing students. The study findings will inform the development of culture-specific interventions to decrease this stigma in Chinese nursing students and the nursing workforce. The findings may also stimulate the development of such interventions for decreasing the stigma towards other mental illnesses among nursing students, as well as students of other healthcare disciplines and health professionals in China.

Funding Statement

This research received no external funding.

Author Contributions

All the authors contributed to the design and methodology of this study. X.C. drafted the initial version of this manuscript and all the other authors were involved in the writing, reviewing, and editing. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of the Hong Kong Polytechnic University (protocol code HSEARS20220127002) and Xiang Ya Hospital (protocol code KE202203129) for studies involving humans.

Informed Consent Statement

Informed consent will be obtained from all participants involved in the study.

Data Availability Statement

Conflicts of interest.

The authors have no conflict of interest to declare.

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• [Observation and nursing care of female patients with schizophrenia during their menstrual period]. Xu L, Li BY, Yu HQ. Xu L, et al. Zhonghua Hu Li Za Zhi. 1996 Jun;31(6):333-5. Zhonghua Hu Li Za Zhi. 1996. PMID: 8945153 Chinese. No abstract available.
• Role of nurses in the community care of schizophrenia. [No authors listed] [No authors listed] J Adv Nurs. 1998 May;27(5):885. J Adv Nurs. 1998. PMID: 9637311 No abstract available.
• [Home care services in the psychiatric sector. Reflections of a nursing group]. Hellard-Flageul MF, Robert-Bronquard C, Blanc M. Hellard-Flageul MF, et al. Soins Psychiatr. 1985 Aug-Sep;(58-59):37-41. Soins Psychiatr. 1985. PMID: 3853305 French. No abstract available.
• Schizophrenia. Fox JC, Kane CF. Fox JC, et al. Annu Rev Nurs Res. 1998;16:287-322. Annu Rev Nurs Res. 1998. PMID: 9695895 Review.
• Empowering families to care for people with schizophrenia. Pack S. Pack S. Nurs Times. 2005 Jul 26-Aug 1;101(30):32-4. Nurs Times. 2005. PMID: 16092285 Review.
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Article Contents

Introduction, external influences, 1997–2003, conclusions, conflict of interest.

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National Institute of Mental Health Support for Cognitive Treatment Development in Schizophrenia: A Narrative Review

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Robert K Heinssen, Sarah E Morris, Joel T Sherrill, National Institute of Mental Health Support for Cognitive Treatment Development in Schizophrenia: A Narrative Review, Schizophrenia Bulletin , Volume 50, Issue 5, September 2024, Pages 972–983, https://doi.org/10.1093/schbul/sbae109

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For several decades the National Institute of Mental Health (NIMH) has supported basic and translational research into cognitive impairment in schizophrenia. This article describes the Institute’s ongoing commitment to cognitive assessment and intervention research, as reflected by three signature initiatives—Measurement and Treatment Research to Improve Cognition in Schizophrenia; Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia; and Research Domain Criteria—and related funding announcements that span basic experimental studies, efficacy and comparative effectiveness trials, and implementation research designed to promote cognitive healthcare in real-world treatment settings. We discuss how trends in science and public health policy since the early 2000s have influenced NIMH treatment development activities, resulting in greater attention to (1) inclusive teams that reflect end-user perspectives on the utility of proposed studies; (2) measurement of discrete neurocognitive processes to inform targeted interventions; (3) clinical trials that produce useful information about putative illness mechanisms, promising treatment targets, and downstream clinical effects; and (4) “productive urgency” in pursuing feasible and effective cognitive interventions for psychosis. Programs employing these principles have catalyzed cognitive measurement, drug development, and behavioral intervention approaches that aim to improve neurocognition and community functioning among persons with schizophrenia. NIMH will maintain support for innovative and impactful investigator-initiated research that advances patient-centered, clinically effective, and continuously improving cognitive health care for persons with psychotic disorders.

In 1992, the Schizophrenia Bulletin published several prescient articles and commentaries on the theme of cognitive therapy for schizophrenia. 1–7 These papers signaled fresh interest in interventions for improving attention, memory, learning, and problem-solving among persons with schizophrenia, and considered a variety of biobehavioral approaches to promote greater clinical, social, and vocational recovery. The authors’ perspectives on key questions about cognitive interventions (eg, cognitive targets, mechanisms of treatment effects, and implementation barriers); clinical research methods (eg, ecologically valid measures, trial designs, and mediation analyses); and alliances to promote uptake of effective practices (eg, partnerships between service users, family members, clinicians, and scientists) foreshadowed later efforts by the National Institute of Mental Health (NIMH) to promote cognitive treatment development in psychosis.

The present article summarizes NIMH initiatives since the early 2000s that aimed to facilitate cognitive intervention research for schizophrenia and related disorders. We first describe external developments between 1997 and 2003 that motivated NIMH to explore new tactics for stimulating treatment development research. We then examine specific NIMH initiatives between 2002 and 2012 that catalyzed cognitive measurement, drug development, and rehabilitation research aimed at improving neurocognition and community functioning in schizophrenia. Next, we consider recent science and policy developments intended to speed treatment development research along the discovery-translation-implementation pathway. We conclude by summarizing lessons that may benefit future efforts to advance patient-centered, clinically effective, and continuously improving cognitive health care for persons with psychotic disorders.

NIMH is the lead government agency in the United States for research on mental disorders. In setting its scientific priorities, the Institute considers input from diverse external sources, including other federal agencies, the extramural research community, advocacy and professional organizations, clinical providers and health system administrators, and persons who use mental health services. The period between 1997 and 2003 was a fertile time for interaction, with synergistic initiatives by the US Surgeon General, a Presidential Commission, and the Director of the National Institutes of Health (NIH) that convened diverse constituents to consider mental health and clinical research ecosystems and to recommend strategies for improving links between science and services.

The Surgeon General’s Report on Mental Health, 8 initiated in 1997, was an ambitious effort to summarize scientific evidence underlying the epidemiology, diagnosis, and treatment of mental disorders, and to describe gaps between what is known through research and application of advances in real-world settings. Based on an extensive review of the literature, the report conveyed optimism about the research supporting the efficacy and range of treatments available for many disorders. While the Surgeon General recommended strongly that people seek help for mental disorders, 9 the report highlighted important areas of scientific uncertainty. The Surgeon General called for continued investment in mental health research, emphasizing integrative neuroscience and molecular genetics studies to identify novel targets for pharmacologic and psychosocial interventions as well as new approaches to health services implementation research.

The President’s New Freedom Commission on Mental Health (2002–2003) extended the Surgeon General’s analysis to include a comprehensive study of the US mental health service delivery system across public and private sectors. 10 The Commission recognized enormous progress in the scientific study of interventions for mental disorders but noted an absence of cures and spotty implementation of evidence-based services in real-world settings. The Commission’s final report advocated a major, long-term commitment to basic research to promote recovery and resilience, and ultimately to cure and prevent mental illness. It also emphasized the need for applied research to study the dissemination, implementation, effectiveness, and sustainment of evidence-based interventions in communities, and to speed testing of emerging innovations in field settings. 11

The NIH Roadmap initiative, launched by the NIH Director in 2002–2003, reexamined the NIH research portfolio to identify scientific gaps and to consider novel methods, technologies, and large-scale projects to transform the process of medical research. 12 The Roadmap engaged hundreds of NIH staff, extramural scientists, and the lay public in a deliberative process of assessing scientific challenges, enumerating roadblocks to progress, and proposing bold ideas to increase the efficiency and impact of biomedical research. Three major themes—ie, new pathways to discovery, research teams of the future, and reengineering the clinical research enterprise—organized initiatives to promote state-of-the-art technologies, interdisciplinary team science, and clinical research via academic-community partnerships. Collectively, these programs aimed to speed the movement of research from the laboratory to the patient’s bedside within a decade. 13

Impact of External Initiatives on NIMH Treatment Development Activities

NIMH leaders and scientist administrators engaged actively in committees, work groups, and public meetings that supported the Surgeon General’s Report, the President’s New Freedom Commission, and the NIH Roadmap process. NIMH staff contributed to planning, convening, synthesizing, and reporting activities, learned new approaches from government and private sector partners, and adopted several best practices in subsequent cognitive treatment development efforts:

Include Key Partners.

All 3 external projects recognized the need for broad input and new partnerships to understand and address complex medical problems. 8 , 10 , 12 In addition to representatives from academia and government, nontraditional experts were included, such as persons with lived experience, professionals with practical experience in organizing, delivering, and financing mental health services, and representatives of private foundations and patient advocacy organizations. The Surgeon General’s report 8 and the NIH Roadmap 12 advocated stronger partnerships with biotechnology and pharmaceutical industries and greater collaboration between federal agencies with shared responsibilities for developing, regulating, and delivering evidence-based treatments.

Promote Transparency.

The New Freedom Commission utilized several tactics to increase transparency, including open meetings, regular opportunities for public input, and timely reports from subcommittees and the overall Commission. 11 For example, monthly working meetings included open deliberation and dedicated time for public testimony from advocacy groups, professional organizations, and members of the public. In addition, an interactive public website encouraged participation outside in-person meetings; over 2300 individuals submitted comments, concerns, and ideas for consideration. Finally, detailed reports from 15 subcommittees were made available, along with an interim progress report 14 that generated spirited commentary that influenced the final phase of the Commission’s work.

Encourage “Productive Urgency”.

The cadence, operations, and deliverables of the President’s New Freedom Commission and the NIH Roadmap set new standards for rapid policy analysis and strategic planning. Aggressive one-year timelines were established to direct effort to urgent problems in mental health delivery systems 11 as well as respond to heightened public expectations for NIH-supported research. 12 Subcommittees and working groups, comprised of government and private sector experts with relevant expertise, tackled key issues in parallel, with overall coordination of efforts by Commissioners and NIH leaders, respectively. This formula was successful in generating understandable goals, concrete recommendations, and performance benchmarks for assessing the impact of new initiatives. 13 , 15 The urgency, efficiency, and productivity that characterized these initiatives influenced NIMH’s ensuing efforts to spur cognitive treatment development research in schizophrenia.

NIMH Cognitive Treatment Development Initiatives, 2002–2012

The Surgeon General’s report identified cognitive dysfunction as a key feature of schizophrenia and noted a paucity of evidence-based treatments for cognitive symptoms. 8 Hyman and Fenton 16 echoed these observations and suggested cognitive impairment as a “test case” for new approaches to schizophrenia therapeutics. Specifically, they proposed a framework for drug and psychosocial intervention development that would (1) dissect schizophrenia into component symptom complexes such as cognitive deficits; (2) develop measures to define new clinical targets as endpoints in human clinical trials; (3) direct interventions at the narrower clinical targets; (4) employ novel experimental designs to evaluate efficacy and clinical significance; and (5) draw on cognitive neuroscience and neuroimaging research to clarify neural mechanisms involved in cognition and to develop objective biomarkers for cognitive deficits. Hyman’s and Fenton’s commentary signaled a new approach to assessment and treatment development in schizophrenia that influenced NIMH initiatives over a 10-year period.

Measurement and Treatment Research to Improve Cognition in Schizophrenia

In 2002, NIMH announced the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative, a multiyear effort to identify and remedy barriers to drug development and testing for cognition in schizophrenia. 17 Following a competitive selection process, a contract was awarded to UCLA (Stephen Marder and Michael Green, co-principal investigators) to engage the pharmaceutical industry, the academic community, and government agencies, including the US Food and Drug Administration (FDA), in a consensus-oriented process to identify cognitive targets for intervention; select reliable and valid neuropsychological measures to assess cognition as a dependent variable in treatment trials; propose experimental designs to establish the efficacy of agents to enhance cognition in schizophrenia; and identify potential molecular targets for new therapeutic agents. The contract mechanism allowed a high level of collaboration between NIMH staff and the MATRICS team to pursue these goals. Importantly, coordinated efforts between NIMH leaders and MATRICS investigators spurred conversations and new alliances among key actors in the drug development space, including psychopharmacologists, 18 the FDA, 19 and persons with lived experience. 20

The MATRICS team convened 6 interlocking conferences over a 2-year period, with timely reports that conveyed the focus, process, and outcomes of each meeting. 18 , 19 , 21–23 Concrete achievements that sprang from these activities include the following:

The MATRICS Consensus Cognitive Battery (MCCB) was developed using quantitative analyses and expert consensus methods and was field tested in a 5-site psychometric and validation study. 24 To facilitate interpretation of results using a common scaling across tests, the MCCB was co-normed using data obtained from a representative US community sample. 25

To meet the FDA’s requirement for functionally meaningful co-primary measures in cognitive intervention trials, 4 potential measures were evaluated alongside the MCCB for reliability, utility, practicality, and relationship to cognitive performance. 26

In 2005, the NIMH National Advisory Mental Health Council (NAMHC) and the FDA recommended the MCCB as the standard cognitive performance battery in clinical trials of potential cognition-enhancing interventions. 24

The MCCB has been translated into over 39 languages 27 and is now widely used to assess neurocognition in schizophrenia clinical studies. Since 2004, the MCCB has been cited in ~500 scientific publications and included as an outcome measure in ~170 clinical studies registered in ClinicalTrials.gov.

The FDA-NIMH-MATRICS workshop on clinical trial design for neurocognitive drugs for schizophrenia 19 developed guidelines for subject selection, co-primary outcome measures, and statistical approaches for clinical trials involving cognitive-enhancing drugs, which were later updated based on practical experience. 28

The MATRICS initiative was successful in catalyzing studies of procognitive drugs in schizophrenia, but new medications have proved elusive. 29 Green et al 30 , 31 reviewed cognitive intervention studies launched since MATRICS and identified several methodological factors that may hinder efforts to identify efficacious drugs. Those authors also noted broader scientific issues that impede drug discovery, including our incomplete understanding of the pathophysiology of cognitive impairment and error variance attributed to clinical and functional heterogeneity across schizophrenia spectrum disorders. 31 Two ensuing NIMH initiatives considered these important scientific considerations in turn.

Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia

The final meeting of the MATRICS program focused on new preclinical and clinical research approaches for assessing and improving cognition in schizophrenia. 23 A strong case was made for applying methods derived from experimental cognitive psychology and cognitive neuroscience to examine the integrity of specific cognitive systems implicated in schizophrenia and to directly measure the effects of drugs on cognition-related brain activity. 32 Responding to these recommendations, Cameron Carter and Deanna Barch proposed the Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia (CNTRICS) conference series 33 and were awarded consecutive research conference grants to articulate a neuroscience research agenda that would extend the work started by MATRICS.

Between 2007 and 2011 the CNTRICS steering committee organized 7 meetings that brought together experts from the basic and clinical sciences, researchers from academia and industry who use animal models, and individuals with experience in clinical trials, psychometrics, and cognitive rehabilitation in schizophrenia to explore potential benefits of using constructs, tasks, and tools from cognitive neuroscience to better understand and treat cognitive impairments in psychosis. 34 , 35 Interactive surveys, quantitative summaries, and consensus-building methods were employed across meetings to identify cognitive systems and component processes that could serve as targets for measurement and treatment development; to address psychometric issues relevant for adapting experimental cognitive tasks for use in clinical trials; to select candidate experimental tasks that measure key cognitive constructs implicated in schizophrenia; to consider promising imaging biomarkers for use in cognitive treatment development research; and to facilitate development of translational animal model paradigms for exploring cognitive and affective constructs. In addition, the steering committee introduced an innovative buddy system that paired prominent cognitive neuroscientists with well-known clinical researchers with schizophrenia expertise to maintain a patient-centered focus in CNTRICS deliberations.

Midway through the CNTRICS process, NIMH published a funding opportunity announcement to solicit proposals for research aimed at adapting and optimizing experimental cognitive measures for use in treatment trials of schizophrenia (RFA-MH-08-090). Among the studies selected for funding, a 5-site collaborative project came together as the “Cognitive Neuroscience Test Reliability and Clinical Applications for Schizophrenia (CNTRaCS) Consortium.” CNTRaCS investigators proposed a transdisciplinary approach for (1) cognitive task selection; (2) adaptation of validated paradigms for clinical research; (3) psychometric evaluation of new measures; and (4) maintaining construct validity of modified tasks. Since 2008, CNTRaCS has pursued translational measurement development for cognitive constructs identified in CNTRICS (ie, goal maintenance; relational encoding and retrieval in episodic memory; gain control; visual integration; working memory; and reinforcement learning) and produced a variety of cognitive neuroscience-based approaches for clinical research studies, including imaging biomarkers. 36

Together, CNTRICS and CNTRaCS achieved the respective goals of establishing a neuroscience research agenda for cognitive treatment development in schizophrenia and adapting validated laboratory tasks of cognitive operations for use in clinical trials. Over 60 scientific publications describe the scientific discourse that occurred during CNTRICS meetings as well as methods, results, and products from the CNTRaCS research program. Cognitive task paradigms developed by CNTRaCS are freely available to the field and industry ( https://cntracs.ucdavis.edu/ ), including tasks and associated computational models appropriate for clinical trials as well as research conducted within the NIMH Research Domain Criteria framework. 37

Research Domain Criteria

NIMH launched the Research Domain Criteria (RDoC) initiative in 2009 to provide a framework for research that explores novel ways of characterizing and classifying mental disorders. The rationale for this new approach was that the ecosystem of research funding, peer review of grant applications and scientific publications, and regulatory activities was over-focused on studies of highly heterogenous mental disorders as defined in longstanding diagnostic systems. The overarching RDoC hypothesis is that mental disorders may be better understood if the tools and concepts of modern behavioral neuroscience are used to dissect heterogeneity within psychopathology and assess functional domains that could be targeted for treatment in a more precise and individualized way.

The RDoC framework was informed by a series of workshops in 2010–2012—and an additional workshop in 2018—which closely modeled the MATRICS and CNTRICS meetings. These workshops engaged over 200 leading scientists and NIMH staff in discussions of the RDoC approach and the development of a set of exemplar constructs and associated elements that provide a shared vocabulary for this scientific endeavor. The first workshops focused on Working Memory 38 and Cognitive Systems, 39 built directly on the knowledge base created by CNTRICS. These workshops adopted CNTRICS’ focus on integrating knowledge from cognitive and affective neuroscience into novel approaches for translational research, a focus that persisted throughout the workshop series. In contrast to MATRICS, NIMH did not develop a formal battery of specified tasks for assessing RDoC domains but instead encouraged investigators to flexibly select measures that are fit for purpose. Participants in this series of formative RDoC workshops populated the RDoC matrix with exemplars of tasks and tools, including several CNTRaCS tasks, which could be used to assess constructs related to RDoC cognitive systems domains.

NIMH has published 19 RDoC-focused funding opportunity announcements since 2011. More than one hundred research projects adopting RDoC principles have been funded, along with many others awarded under other NIH funding mechanisms. Among these grants are several projects that examine cognitive constructs such as language 40 and perception 41 in psychosis which may lead to novel treatment targets or outcome measures. Most recently, the NIMH RDoC Unit launched the Individually Measured Phenotypes to Advance Computational Translation in Mental Health (IMPACT-MH) initiative (RFA-MH-23-105). Projects supported through IMPACT-MH will combine data from cognitive tasks and device-based behavioral measures with electronic health records information to derive novel clinical signatures that can be assessed at the individual level to improve clinical decision-making and predict clinical outcomes.

NIMH Workshop on Cognitive Training in Mental Disorders

During the period when MATRICS/CNTRICS/RDoC initiatives were being developed (2002–2012), NIMH observed growing interest among extramural scientists for nonpharmacologic cognitive training and rehabilitation interventions, with successful research proposals involving patients from diverse diagnostic categories and across developmental stages. In addition, an annual conference sponsored by the Columbia University Irving Medical Center brought together researchers, clinicians, and healthcare administrators to share experiences and perspectives on cognitive remediation in psychiatry and to focus attention on emerging translational, clinical, and implementation research questions. 42 To learn from the expanding cadre of cognitive interventionists, NIMH convened a state-of-the-science meeting in 2012 to review evidence for the efficacy of cognitive training approaches across psychiatric illnesses, including schizophrenia, and to identify knowledge gaps, new research opportunities, and examples of research-to-practice implementation. 43 The workshop included investigators from academia, military research agencies, and the NIMH Intramural Research Program; representatives of digital health companies, state mental health authorities, and community behavioral health systems; and health scientist administrators from several NIH institutes. Approximately one-quarter of participants were veterans of the MATRICS, CNTRICS, and/or RDoC initiatives, which provided valuable scientific continuity.

For purposes of the workshop, cognitive training (CT) was differentiated from other behavioral and psychosocial interventions that address problematic cognitions as part of a broader therapeutic approach, such as cognitive behavioral therapy or psychoeducation. CT was defined more precisely as “an intervention that uses specifically designed and behaviorally constrained cognitive or socio-affective learning events, delivered in a scalable and reproducible manner, to potentially improve neural system operations.” 44 The workshop addressed the current state of knowledge regarding (1) the neuroscience basis for cognitive, affective, and neural processes targeted by CT; (2) evidence of CT efficacy for improving neurocognitive processes and functioning; (3) hypothesized mechanisms of CT treatment effects; (4) approaches that combine CT with other treatment modalities; (5) predictors of treatment response; and (6) what has been learned from efforts to implement CT in clinical practice.

Keshavan et al. summarized the workshop’s presentations, discussions, and recommendations for future research. 44 The authors concluded that “overall, the evidence thus far supports the neurobiological rationale and the efficacy of cognitive training in schizophrenia, but replication of positive results is needed; many questions remain with regard to therapeutic mechanisms, key therapeutic ingredients, and approaches to dissemination in routine clinical settings.” Several considerations for the design of CT trials echo lessons from the MATRICS initiative 29 , 31 ; ie, the importance of detailed participant characterization, including baseline cognitive functioning; choosing appropriate inclusion/exclusion criteria; measuring specific (vs global) cognitive operations as treatment targets and outcomes; and accounting for mediators, moderators, and mechanisms of treatment effects. Other recommendations emphasized up-front attention to end-user perspectives, clinical workflows, and provider requirements in intended delivery settings, and including outcome measures that are meaningful to healthcare policymakers. Together, these recommendations encouraged best practices for advancing interventions that target core neurocognitive operations necessary for clinical, social, and educational/vocational recovery, and for positioning new interventions for rapid adoption in clinical practice.

Impact of NIMH Cognitive Treatment Development Initiatives

The MATRICS, CNTRICS, and RDoC initiatives were largely successful in replicating the inclusiveness, transparency, and productive urgency that characterized the Surgeon General’s Report, the President’s New Freedom Commission, and the NIH Roadmap. Each NIMH initiative brought together diverse constituents to work through complex scientific questions, and through progressive encounters, to establish a common framework and vocabulary for analyzing problems and imagining potential solutions. Frederick Frese, a respected mental health “prosumer,” contributed significantly to the MATRICS Neurocognition Committee 24 as a champion of recovery principles 20 and stigma-free, nonpejorative language about cognition in schizophrenia. 45 The unique value of this lived experience perspective prompted NIMH to encourage similar engagement with service users in subsequent research initiatives, as described below.

The cadence of MATRICS, CNTRICS, and RDoC meetings, the continuity of participants across initiatives, and new collaborations among diverse partners fostered interdisciplinary teams that later tackled translational research goals. The co-creation of new research concepts, methods, and products by such teams were essential factors in generating broad enthusiasm for cognitive treatment activities in schizophrenia. Indeed, ~750 scientific papers, review articles, and book chapters have been published since 2002 that are based on MATRICS, CNTRICS, or RDoC contributions to the assessment and treatment of cognitive symptoms in schizophrenia.

Science and Policy Trends, 2013–2023

Between 2002 and 2012, NIMH-supported initiatives created momentum for neuroscience-based studies in schizophrenia that focused on illness mechanisms and targeted interventions based on mechanistic insights. A small number of competitive funding opportunities incentivized the development of new assessment tools and clinical trial methods, but most funded studies used traditional grant mechanisms to support investigator-initiated projects. In the subsequent decade, new science and NIMH policy developments influenced trends in cognitive intervention research, including new expectations for clinical trials and implementation of science studies.

Experimental Therapeutics Paradigm for Clinical Trials

By 2010, major pharmaceutical companies had exited the field of psychiatry, citing poor understanding of disease mechanisms, a lack of biomarkers and valid animal models, and high failure rates in clinical trials. 46 , 47 The dramatic change in industry priorities prompted NIMH to seek guidance on how to better align basic, clinical, and intervention research to support pharmacologic treatment development. The NAMHC workgroup report, “From Discovery to Cure” 48 recommended several changes to the NIMH clinical trials portfolio to accelerate translational efforts, including a shift towards an experimental therapeutics model, “in which interventions are used as probes of disease mechanisms as well as tests of efficacy.” 49

Since 2014, NIMH has solicited clinical trial applications through a dedicated set of funding announcements that cover the intervention development pipeline, including first-in-human and early-stage clinical trials of novel investigational drugs or devices; pilot research to develop and test innovative psychosocial interventions; confirmatory efficacy trials; and comparative effectiveness trials. In each case, an experimental therapeutics approach is required, where projects (1) identify a mechanistic target or mediator for the intervention being tested; (2) measure the intervention’s impact on the hypothesized target; and (3) examine whether changes in targets are associated with changes in distal clinical or services outcomes. Trials designed in this manner are informative for basic, translational, and intervention research in that studies produce useful information about putative illness mechanisms, promising treatment targets, and downstream clinical effects.

Implementation and Sustainment of Evidence-Based Interventions

Reports from the Surgeon General, 8 the President’s New Freedom Commission, 10 the Institute of Medicine, 50 and a NAMHC workgroup on mental health services research 51 all noted long delays between the reporting of scientific findings and the translation of new knowledge into clinical practice. To address this “implementation gap,” NIMH began promoting deployment-focused approaches to intervention development, testing, and dissemination, 52 starting with the Recovery After an Initial Schizophrenia Episode (RAISE) initiative. 53 Subsequent deployment-focused studies have considered the perspective of end-users (eg, service users, clinicians, health care administrators, and payers) and characteristics of the ultimate delivery settings (eg, workforce capacity, training resources, clinical workflows) to help ensure that proposed interventions are feasible and scalable, and that research results are actionable for improving practice.

This approach is elaborated in current NIMH research initiatives aimed at accelerating the implementation and continuous improvement of new practices in diverse, real-world healthcare settings, including the ALACRITY Research Centers 54 program, EPINET Research Networks, 55 and funding announcements for comparative effectiveness trials (eg, PAR-21-130; PAR-21-131). Through these initiatives, NIMH strongly encourages meaningful involvement of mental health service users and family members in multiple roles throughout the research enterprise. For example, serving as a principal or co-principal investigator of a research project; membership in a project’s executive committee or external advisory group; as a practice-partner member of a transdisciplinary research team; or as a research participant whose lived experience perspectives are systematically assessed via qualitative and/or quantitative methods.

Impact of Experimental Therapeutics and Implementation of Science Funding Announcements

Extramural scientists have successfully pivoted to experimental therapeutics trials to test cognitive interventions for persons with psychotic disorders, as evidenced by research grant projects awarded across all stages of the intervention pipeline. Many funded projects are taking cognitive treatment in new directions, including (1) interventions that target social cognitive processes; (2) approaches that combine cognitive training with other therapies to improve neurocognitive outcomes or promote generalization of training effects (eg, procognitive medications, neuromodulation techniques, aerobic exercise, or behavioral skills training); (3) studies that integrate cognitive interventions into treatment programs for early psychosis; and (4) efforts to address heterogeneity in neurocognitive functioning through personalized cognitive training.

Several deployment-focused implementation projects are examining the adoption and sustainment of cognitive training interventions in real-world community settings. For example, one ALACRITY Center subproject focuses on improving the accessibility and personalization of cognitive remediation for schizophrenia in publicly funded outpatient mental health clinics (P50MH115843). An EPINET network project is testing the feasibility and real-world effectiveness of a neuroscience-informed cognitive training program that pairs social cognitive training with a research-supported mobile application to improve outcomes in first-episode psychosis (R01MH120589). A third implementation project is testing an environmental intervention to bypass cognitive and motivational difficulties associated with schizophrenia to increase adherence to medications and improve functional outcomes among persons receiving treatment in community mental health centers (R01MH11701).

Reflections and Considerations for Future Research

Cognitive treatment development in the United States has progressed substantially since 1992, when thought leaders debated whether cognitive intervention in schizophrenia was possible and if so, how clinical studies should proceed. 1–7 In the ensuing decades, NIMH has employed both top-down and bottom-up approaches to support basic, translational, and implementation research in cognitive treatment for psychosis. The MATRICS, CNTRICS, and RDoC initiatives illustrate the former tactic, where NIMH staff collaborated closely with extramural scientists and others to organize a neuroscience research agenda around cognitive therapeutics. These efforts over a 10-year period helped to cultivate a vibrant learning community that embraced the challenges of delineating cognitive systems implicated in schizophrenia and developing new animal models, clinical assessments, and intervention methods. Afterwards, NIMH shifted its focus to standing funding announcements designed to support innovative and impactful investigator-initiated research projects. Over the past decade, the science supporting cognitive treatment efficacy and implementation has advanced and evolved, propelled by the interests, creativity, and energy of the extramural research community.

Partnerships with other government agencies, industry, and persons with lived experience have grown over time and continue to benefit NIMH treatment development activities. For example, the Accelerating Medicines Partnership Program for Schizophrenia (AMP SCZ) 56 is a public-private endeavor between NIMH, the FDA, the European Medicines Agency, pharmaceutical companies, and other private-sector partners to generate tools that will aid the development of early-stage treatments for people who are at risk for schizophrenia. Persons with lived experience contribute to the leadership and operation of AMP SCZ, which has enriched both the science and real-world relevance of the project. 57 , 58 This aspect of AMP SCZ is consistent with NIMH’s expanded vision of team science, which includes individuals with lived experience, family members, frontline clinicians, and payers as colleagues in clinical research efforts. 54 , 55 It is also an Institute priority to include members of historically underrepresented groups in team science, ie, persons from racial, ethnic, and sexual and gender minority groups as well as individuals from lower socioeconomic strata.

Collectively, external influences and NIMH initiatives have helped set a direction for the next phase of science-to-service research in cognitive treatment for persons with psychotic disorders. The 2023 White House Report on Mental Health Research Priorities, 59 developed to address the mental health crisis exacerbated by the COVID-19 pandemic, provides additional guidance. For example, the White House Report calls for new scientific efforts to (1) support and expand the supply, capacity, and diversity of the mental health workforce; (2) increase the availability, quality, and impact of evidence-based services across a range of settings; (3) foster long-term engagement in care and recovery among persons receiving mental health treatments; and (4) develop and test strategies for provider training, supervision, and performance feedback to ensure sustained implementation of high-quality interventions. To reduce mental health disparities and advance equity, the Report encourages research that addresses social determinants of health, applies community-based participatory methods to ensure the responsiveness of interventions, and oversamples members of historically underrepresented groups in mental health studies.

These priorities are highly relevant to cognitive treatment of psychosis in the United States, where the cognitive intervention workforce is small, evidence-based programs are rarely available outside of academic research clinics, and few individuals with lived experience receive needed therapies. A forward-looking collaboration between the New York State Office of Mental Health (OMH) and Columbia University 60 addresses these limitations through a multiyear project to implement cognitive health services in state-operated outpatient clinics for persons with serious mental illness (SMI). In a series of richly detailed papers, 61–66 Medalia, Saperstein, and colleagues describe a systematic process for introducing cognitive remediation practices in large systems of psychiatric care. Their deployment-focused, phased, and data-driven approach stands out as a case study in implementation excellence.

Table 1 presents current views about the stages of successful implementation, as summarized in the National Implementation Research Network’s synthesis of implementation research and practice studies, 67 as well as best practices for promoting the adoption, installation, and sustainment of evidence-based programs, 68 per guidance provided by the Substance Abuse and Mental Health Services Administration regarding implementation of evidence-based programs. The New York State effort largely follows these recommendations, including (1) close collaboration between OMH officials, local facility personnel, and cognitive remediation experts on implementation choices, methods, and resources; (2) a standardized and sustainable staff training program that teaches evidence-based practices to busy clinicians and supports treatment fidelity; (3) program evaluation activities that support provision of high-quality care; and (4) treatment adaptations that meet the needs of a culturally diverse and multilingual SMI population. Several noteworthy features of the project include the following:

Stages of Implementation and Best Practices to Promote Adoption, Installation, and Continuity of Evidence-Based Programs

Note : Stages of implementation are based on the National Implementation Research Network’s synthesis of implementation research and practice studies. 67 Recommended actions are from guidance provided by the Substance Abuse and Mental Health Services Administration regarding implementation of evidence-based programs. 68 .

Cognitive remediation experts worked closely with OMH leaders and local clinic administrators to operationalize a public psychiatry model of cognitive health and to solve pragmatic questions about staffing models, clinical workflows, information technology needs, and billing practices.

Cognitive remediation services were implemented in a staggered manner, starting with outpatient clinics serving adults with SMI diagnoses 61 and later expanded to Coordinated Specialty Care (CSC) programs for first-episode psychosis. 62 , 63 The latter effort adopted recovery values, organizational principles, and implementation methods pioneered in the adult SMI programs, but modified them to address the needs and perspectives of younger service users. 64

Workforce development programs were created to build broad and enduring support for cognitive remediation interventions. All clinical and support staff received education about cognitive health and recovery; selected clinicians received targeted training and ongoing supervision in cognitive assessment, treatment planning, and intervention practices. Train-the-trainer classes were established to maintain a pool of competent instructors to teach these skills to new clinicians, as needed.

Clinicians collect program evaluation data as part of routine care; supervisors use these data to monitor treatment fidelity and troubleshoot implementation problems in real-time. Pragmatic measures of service utilization, dropout rates, and participant satisfaction confirm the fidelity, acceptability, and perceived effectiveness of cognitive remediation in state-operated clinics, 65 but also identify areas for further improvement. 66

The New York State implementation experiment responds to several research priorities outlined in the recent White House Report. 59 The initiative successfully expands the cognitive remediation workforce to include psychologists, nurses, physicians, social workers, and mental health counselors who work in community treatment settings. The public psychiatry model 61 assures that almost all persons served in state-operated clinics for adults, and CSC programs for youth, are eligible to receive cognitive health services. Integrating cognitive remediation into existing multidisciplinary rehabilitation programs furthers OMH’s commitment to person-centered, recovery-oriented treatment that fosters patients’ independence and community engagement. Innovative methods for training clinicians, tracking their performance, and maintaining treatment fidelity are sustaining the implementation of high-quality interventions over time. Finally, the extension of cognitive health services into CSC programs illustrates the importance of involving end-users, eg, CSC service providers 62 and persons with lived experience, 64 in developing interventions that are feasible to implement and responsive to the needs and preferences of the target population.

While these accomplishments are a clear step forward, further research in public sector settings is needed to (1) optimize the delivery of cognitive interventions (eg, increase referrals, participant enrollment, and service utilization); (2) eliminate potential inequalities in access, quality, or effectiveness of services for populations with health disparities 69 ; (3) evaluate the impact of cognitive interventions on objective measures of patients’ social, educational, and vocational functioning; and (4) determine the cost-effectiveness of combining cognitive remediation programs with traditional psychiatric rehabilitation services. These and similar practice-oriented research questions could be explored within a learning health care framework, where data collected as part of routine care are used to study the implementation, adaptation, and effectiveness of evidence-based interventions in public health clinics. 70 Such an approach ensures that research findings are directly relevant to representative sets of patients, clinicians, and health care system administrators, while clinical practice benefits from continuous data-driven improvement. 71

Throughout 2024, NIMH is celebrating 75 years of basic, translational, and health services research that has deepened our understanding of mental disorders and broadened the therapeutic armamentarium. Cognitive intervention research for schizophrenia has featured prominently in the Institute’s scientific portfolio, with sequential treatment development initiatives over the past 2 decades. A core set of principles guided these efforts, including convening diverse learning communities, using structured encounters to establish a common scientific framework and vocabulary for understanding complex challenges, and creating funding opportunities that encourage interdisciplinary, deployment-focused studies. Increasingly, teams that partner translational scientists, implementation researchers, and mental health shareholders, eg, service users, family members, clinicians, payers, and policymakers, are developing and testing interventions that align with conditions encountered in real-world treatment systems. This approach holds promise for speeding the introduction of evidence-based practices in these settings, thereby narrowing the typical research-to-implementation gap. 72 Going forward, science-to-service studies conducted within the learning health model will further accelerate progress toward clinically effective, continuously improving, and accessible cognitive health care for all persons with psychotic disorders.

The authors have no conflicts of interest to disclose. The views expressed in this article do not necessarily represent the views of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.

Bonnie J , Spring LR. Cognitive remediation in schizophrenia: Should we attempt it ? Schizophr Bull. 1992 ; 18 ( 1 ): 15 – 20 .

Google Scholar

Brenner HD , Hodel B , Roder V , Corrigan P. Treatment of cognitive dysfunctions and behavioral deficits in schizophrenia . Schizophr Bull. 1992 ; 18 ( 1 ): 21 – 26 .

Liberman RP , Green MF. Whither cognitive-behavioral therapy for schizophrenia ? Schizophr Bull. 1992 ; 18 ( 1 ): 27 – 35 .

Braff DL. Reply to cognitive therapy and schizophrenia . Schizophr Bull. 1992 ; 18 ( 1 ): 37 – 38 .

Spaulding WD. Design prerequisites for research on cognitive therapy for schizophrenia . Schizophr Bull. 1992 ; 18 ( 1 ): 39 – 42 .

Bellack AS. Cognitive rehabilitation for schizophrenia: Is it possible? Is it necessary ? Schizophr Bull. 1992 ; 18 ( 1 ): 43 – 50 .

Hogarty GE , Flesher S. Cognitive remediation in schizophrenia: proceed…with caution! Schizophr Bull. 1992 ; 18 ( 1 ): 51 – 57 .

U.S. Department of Health and Human Services . Mental Health: A Report of the Surgeon General . Rockville, MD : U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health ; 1999 . https://profiles.nlm.nih.gov/spotlight/nn/catalog/nlm:nlmuid-101584932X120-doc . Date accessed June 2, 2024 .

Google Preview

Satcher D. Mental health: a report of the Surgeon General—Executive summary . Professional Psychology: Research and Practice . 2000 ; 31 ( 1 ): 5 – 13 .

The President’s New Freedom Commission on Mental Health . Achieving the Promise: Transforming Mental Health Care in America. Final Report . U.S. Department of Health and Human Services, Pub. No. SMA-03-3832 ; 2003 . https://www.govinfo.gov/app/details/GOVPUB-PR-PURL-LPS36928 . Date accessed June 2, 2024 .

Hogan MF. The President’s new freedom commission: recommendations to transform mental health care in America . Psychiatr Serv. 2003 ; 54 ( 11 ): 1467 – 1474 .

Zerhouni E. The NIH roadmap . Science. 2003 ; 302 ( 5642 ): 63 – 72 .

National Institutes of Health Office of Strategic Coordination – The Common Fund . A Decade of Discovery: The NIH Roadmap and Common Fund . NIH Pub No. 14-8013 ; 2015 . https://commonfund.nih.gov/sites/default/files/ADecadeofDiscoveryNIHRoadmapCF.pdf . Date accessed June 2, 2024 .

The President’s New Freedom Commission on Mental Health . Interim Report to the President , 2002 . https://web.archive.org/web/20050310141415/http://www.mentalhealthcommission.gov/reports/interim_toc.htm . Date accessed June 2, 2024 .

Daly R. New freedom commission members assess report’s impact . Psychiatr News . 2006 ; 41 : 1 – 41 . doi: 10.1176/pn.41.9.0001a

Hyman SE , Fenton WS. What are the right targets for psychopharmacology ? Science. 2003 ; 299 ( 5605 ): 350 – 351 .

Fenton WS , Stover EL , Insel TR. Breaking the log-jam in treatment development for cognition in schizophrenia: NIMH perspective . Psychopharmacology (Berl). 2003 ; 169 ( 3-4 ): 365 – 366 .

Geyer MA , Tamminga CA. Measurement and treatment research to improve cognition in schizophrenia: neuropharmacological aspects . Psychopharmacology (Berl). 2004 ; 174 ( 1 ): 1 – 2 .

Buchanan RW , Davis M , Goff D , et al.  . A summary of the FDA-NIMH-MATRICS workshop on clinical trial design for neurocognitive drugs for schizophrenia . Schizophr Bull. 2005 ; 31 ( 1 ): 5 – 19 .

Frese FJ , Knight EL , Saks E. Recovery from schizophrenia: with views of psychiatrists, psychologists, and others diagnosed with this disorder . Schizophr Bull. 2009 ; 35 ( 2 ): 370 – 380 .

Nuechterlein KH , Barch DM , Gold JM , Goldberg TE , Green MF , Heaton RK. Identification of separable cognitive factors in schizophrenia . Schizophr Res. 2004 ; 72 ( 1 ): 29 – 39 .

Green MF , Nuechterlein KH , Gold JM , et al.  . Approaching a Consensus Cognitive Battery for clinical trials in schizophrenia: the NIMH-MATRICS conference to select cognitive domains and test criteria . Biol Psychiatry. 2004 ; 56 ( 5 ): 301 – 307 .

Geyer MA , Heinssen RK. New approaches to measurement and treatment research to improve cognition in schizophrenia . Schizophr Bull. 2005 ; 31 ( 4 ): 806 – 809 .

Nuechterlein KH , Green MF , Kern RS , et al.  . The MATRICS Consensus Cognitive Battery, Part 1: test selection, reliability, and validity . Am J Psychiatry. 2008 ; 165 ( 2 ): 203 – 213 .

Kern RS , Nuechterlein KH , Green MF , et al.  . The MATRICS consensus cognitive battery, Part 2: Co-norming and standardization . Am J Psychiatry. 2008 ; 165 ( 2 ): 214 – 220 .

Green MF , Nuechterlein KH , Kern RS , et al.  . Functional Co-primary measures for clinical trials in schizophrenia: results from the MATRICS psychometric and standardization study . Am J Psychiatry. 2008 ; 165 ( 2 ): 221 – 228 .

Nuechterlein KH , Green MF , Kern RS. The MATRICS consensus cognitive battery: an update . In: Barch DM , Young JW , eds. Cognitive Functioning in Schizophrenia: Leveraging the RDoC Framework . Cham, Switzerland : Springer Nature ; 2023 : 1 – 18 .

Buchanan RW , Keefe RSE , Umbricht D , Green MF , Laughren T , Marder SR. The FDA-NIMH-MATRICS guidelines for clinical trial design of cognitive-enhancing drugs: what do we know 5 years later ? Schizophr Bull. 2010 ; 37 ( 6 ): 1209 – 1217 .

Marder SR. Lessons from MATRICS . Schizophr Bull. 2011 ; 37 ( 2 ): 233 – 234 .

Green MF , Horan WP , Lee J. Nonsocial and social cognition in schizophrenia: current evidence and future directions . World Psychiatry . 2019 ; 18 ( 2 ): 146 – 161 .

Horan WP , Catalano LT , Green MF. An update on treatment of cognitive impairment associated with schizophrenia . In: Barch DM , Young JW , eds. Cognitive Functioning in Schizophrenia: Leveraging the RDoC Framework . Cham, Switzerland : Springer Nature ; 2023 : 407 – 436 .

Carter CS. Applying new approaches from cognitive neuroscience to enhance drug development for the treatment of impaired cognition in schizophrenia . Schizophr Bull. 2005 ; 31 ( 4 ): 810 – 815 .

Carter CS , Barch DM. Cognitive neuroscience-based approaches to measuring and improving treatment effects on cognition in schizophrenia: The CNTRICS Initiative . Schizophr Bull. 2007 ; 33 ( 5 ): 1131 – 1137 .

Cohen JD , Insel TR. Cognitive neuroscience and schizophrenia: translational research in need of a translator . Biol Psychiatry. 2008 ; 64 ( 1 ): 2 – 3 .

Carter CS , Barch DM , Buchanan RW , et al.  . Identifying cognitive mechanisms targeted for treatment development in schizophrenia: an overview of the first meeting of the cognitive neuroscience treatment research to improve cognition in schizophrenia initiative . Biol Psychiatry. 2008 ; 64 ( 1 ): 4 – 10 .

Barch DM , Boudewyn MA , Carter CS , et al.  . Cognitive [Computational] neuroscience test reliability and clinical applications for serious mental illness (CNTRaCS) Consortium: Progress and Future Directions . Curr Top Behav Neurosci . 2023 ; 63 : 19 – 60 .

Morris SE , Sanislow CA , Pacheco J , Vaidyanathan U , Gordon JA , Cuthbert BN. Revisiting the seven pillars of RDoC . BMC Med. 2022 ; 20 : 220 .

National Institute of Mental Health . Working Memory: Workshop Proceedings ; 2010 . https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/working-memory-workshop-proceedings. Date accessed June 2, 2024 .

National Institute of Mental Health . Cognitive Systems: Workshop Proceedings ; 2011 . https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/cognitive-systems-workshop-proceedings . Date accessed June 2, 2024 .

Bilgrami ZR , Sarac C , Srivastava A , et al.  . Construct validity for computational linguistic metrics in individuals at clinical risk for psychosis: associations with clinical ratings . Schizophr Res. 2022 ; 245 : 90 – 96 .

Bansal S , Bae G , Robinson BM , et al.  . Association between failures in perceptual updating and the severity of psychosis in schizophrenia . JAMA Psychiatry . 2022 ; 79 ( 2 ): 169 – 177 .

Columbia University Irving Medical Center . Cognitive Remediation in Psychiatry: New Directions in the 21st Century . 2024 . http://www.cognitive-remediation.org/ . Date accessed June 2, 2024 .

National Institute of Mental Health . Cognitive Training in Mental Disorders: Advancing the Science ; 2012 . https://web.archive.org/web/20120916071834/http://www.mentalhealth.gov/research-funding/scientific-meetings/2012/cognitive-training-in-mental-disorders-advancing-the-science/index.shtml . Date accessed June 2, 2024 .

Keshavan MS , Vinogradov S , Rumsey J , Sherrill J , Wagner A. Cognitive training in mental disorders: updated and future directions . Am J Psychiatry. 2014 ; 171 ( 5 ): 510 – 522 .

Bromley E. A Collaborative approach to targeted treatment development for schizophrenia: a qualitative evaluation of the NIMH-MATRICS Project . Schizophr Bull. 2005 ; 31 ( 4 ): 954 – 961 .

Miller G. Is pharma running out of brainy ideas ? Science. 2010 ; 329 ( 5991 ): 502 – 504 .

Hyman SE. Revolution stalled . Science Transl Med . 2012 ; 4 ( 155 ): 155cm111 .

National Advisory Mental Health Council Workgroup . From Discovery to Cure: Accelerating the Development of New and Personalized Interventions for Mental Illness ; 2010 . https://www.nimh.nih.gov/sites/default/files/documents/about/advisory-boards-and-groups/namhc/reports/fromdiscoverytocure.pdf . Date accessed June 2, 2024 .

Insel TR , Gogtay N. National Institute of Mental Health Clinical Trials: New Opportunities, New Expectations . JAMA Psychiatry . 2014 ; 71 ( 7 ): 745 – 746 .

Institute of Medicine . Crossing the Quality Chasm: A New Health System for the 21st Century . Washington, DC : National Academies Press ; 2001 .

National Advisory Mental Health Council Workgroup . The Road Ahead: Research Partnerships to Transform Services ; 2006 , https://www.nimh.nih.gov/sites/default/files/documents/about/advisory-boards-and-groups/namhc/reports/road-ahead.pdf . Date accessed June 2, 2024 .

Weisz JR. Bridging the research-practice divide in youth psychotherapy: the deployment-focused model and transdiagnostic treatment . Verhaltenstherapie . 2015 ; 25 : 129 – 132 .

National Institute of Mental Health . Recovery After an Initial Schizophrenia Episode (RAISE) . https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/recovery-after-an-initial-schizophrenia-episode-raise . Date accessed June 2, 2024 .

National Institute of Mental Health . Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness (ALACRITY) . https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/advanced-laboratories-for-accelerating-the-reach-and-impact-of-treatments-for-youth-and-adults-with-mental-illness-alacrity . Date accessed June 2, 2024 .

National Institute of Mental Health . Early Psychosis Intervention Network (EPINET) . https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/early-psychosis-intervention-network-epinet . Date accessed June 2, 2024 .

National Institute of Mental Health . Accelerating Medicines Partnership® Program for Schizophrenia (AMP® SCZ) . https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/accelerating-medicines-partnershipr-program-schizophrenia-ampr-scz . Date accessed June 2, 2024 .

Larrauri CA. He Who Has Hope, Has Everything . Psychiatr Serv. 2023 ; 74 ( 8 ): 892 – 893 .

Larrauri CA , Staglin B. Leading science with lived experience , Schizophr Bull . 2022 ; sbab147 , doi: 10.1093/schbul/sbab147

White House Office of Science & Technology Policy . White House Report on Mental Health Research Priorities ; 2023 . https://www.whitehouse.gov/wp-content/uploads/2023/02/White-House-Report-on-Mental-Health-Research-Priorities.pdf . Date accessed June 2, 2024 .

Medalia A , Erlich M. Why cognitive health matters . Am J Public Health . 2017 ; 107 ( 1 ): 45 – 47 .

Medalia A , Saperstein AM , Erlich MD , Sederer LI. Cognitive remediation in large systems of psychiatric care . CNS Spectr. 2019 ; 24 ( 1 ): 163 – 173 .

Saperstein AM , Medalia A , Bello I , Dixon LB. Addressing cognitive health in coordinated specialty care for early psychosis: real-world perspectives . Early Interv Psychiatry 2021 ; 15 ( 2 ): 374 – 379 .

Saperstein AM , Medalia A , Malinovsky I , Bello I , Dixon LB. Toolkit for assessing and addressing cognitive health in early psychosis: evaluation of feasibility and utility in a coordinated specialty care setting . Early Interv Psychiatry . 2021 ; 15 ( 5 ): 1376 – 1381 .

Saperstein AM , Bello I , Nossel I , Dixon LB , Medalia A. Implementation of cognitive health services in large systems of care: highlights from coordinated specialty care for first episode psychosis . Schizophr Bull . 2024 ; sbae030 , doi: 10.1093/schbul/sbae030 .

Soumet-Leman C , Medalia A , Erlich MD. Acceptability and perceived effectiveness of cognitive remediation in clinical practice . Psychiatr Serv. 2018 ; 69 ( 4 ): 493 – 494 .

Medalia A , Erlich MD , Soumet-Leman C , Saperstein AM. Translating cognitive behavioral interventions from bench to bedside: the feasibility and acceptability of cognitive remediation in research as compared to clinical settings . Schizophr Res. 2019 ; 203 : 49 – 54 .

Fixsen DL , Naoom SF , Blase KA , Friedman RM , Wallace F. Implementation Research: A Synthesis of the Literature . Tampa, FL : University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network (FMHI Publication #231) ; 2005 .

Substance Abuse and Mental Health Services Administration National Registry of Evidence-Based Programs and Practices (NREPP) . A Road Map to Implementing Evidence-Based Programs ; 2012 . https://web.archive.org/web/20130218035856/http://nrepp.samhsa.gov/Courses/Implementations/resources/imp_course.pdf . Date accessed June 2, 2024 .

National Institute on Minority Health and Health Disparities . Minority Health and Health Disparities Definitions . https://www.nimhd.nih.gov/resources/understanding-health-disparities/minority-health-and-health-disparities-definitions.html . Date accessed June 2, 2024 .

Heinssen RK , Azrin ST. A national learning health experiment in early psychosis research and care . Psychiatr Serv. 2022 ; 73 ( 9 ): 962 – 964 .

Blanco C , Heinssen RK , Tenhula WN. Public sector learning health care systems—improving patient experience, workforce well-being, and recovery outcomes . JAMA Psychiatry . 2024 ; 81 ( 1 ): 9 – 10 .

McGinty EE , Alegria M , Beidas RS , et al.  . The Lancet Psychiatry Commission: Transforming mental health implementation research . Lancet Psychiatry . 2024 ; 11 ( 5 ): 368 – 396 .

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