Regístrese
¿Aún no está registrado?
Información relevante

Consulte los artículos y contenidos publicados en éste medio, además de los e-sumarios de las revistas científicas en el mismo momento de publicación

Máxima actualización

Esté informado en todo momento gracias a las alertas y novedades

Promociones exclusivas

Acceda a promociones exclusivas en suscripciones, lanzamientos y cursos acreditados

Crear Mi cuenta
Buscar en
Revista de Psiquiatría y Salud Mental (English Edition)
Toda la web
Inicio Revista de Psiquiatría y Salud Mental (English Edition) Effectiveness, efficiency and efficacy in the multidimensional treatment of schi...
Journal Information
Vol. 10. Num. 1.January - March 2017
Pages 1-66
Visits
675
Vol. 10. Num. 1.January - March 2017
Pages 1-66
Original article
DOI: 10.1016/j.rpsmen.2016.09.002
Full text access
Effectiveness, efficiency and efficacy in the multidimensional treatment of schizophrenia: Rethinking project
Eficacia, eficiencia y efectividad en el tratamiento multidimensional de la esquizofrenia: proyecto Rethinking
Visits
675
Benedicto Crespo-Facorroa,
Corresponding author
crespob@unican.es

Corresponding author.
, Miguel Bernardob, Josep Maria Argimonc, Manuel Arrojod, Maria Fe Bravo-Ortize, Ana Cabrera-Cifuentesf, Julián Carretero-Románg, Manuel A. Franco-Martính, Paz García-Portillai, Josep Maria Haroj, José Manuel Olivaresk, Rafael Penadésl, Javier del Pino-Montesm, Julio Sanjuánn, Celso Arangoo
a Departamento de Medicina y Psiquiatría, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, IDIVAL, CIBERSAM, Santander, Spain
b Unidad de Esquizofrenia, Hospital Clínic de Barcelona, Universidad de Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
c Servicio Catalán de la Salud (CatSalut), Barcelona, Spain
d Servicio de Psiquiatría, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, La Coruña, Spain
e Área de Psiquiatría, Psicología Clínica y Salud Mental, Hospital Universitario La Paz, IdiPaz, Universidad Autónoma de Madrid, Madrid, Spain
f Asociación Madrileña de Amigos y Familiares de Personas con Esquizofrenia, Madrid, Spain
g Asociación Nacional de Enfermería de Salud, Spain
h Complejo Asistencial de Zamora, Zamora, Spain
i Área de Psiquiatría, Universidad de Oviedo, CIBERSAM, Oviedo, Spain
j Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, CIBERSAM, Sant Boi de Llobregat, Barcelona, Spain
k Unidad de Psiquiatría, Hospital Álvaro Cunqueiro, Vigo, Spain
l Unidad de Esquizofrenia, Hospital Clínic Barcelona, Universidad de Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
m Servicio de Reumatología, Hospital Universitario de Salamanca, Universidad de Salamanca, Salamanca, Spain
n Servicio de Psiquiatría, Hospital Clínico Universitario de Valencia, Valencia, Spain
o Servicio de Psiquiatría del Niño y Adolescente, Hospital General Universitario Gregorio Marañón, IiSGM, Facultad de Medicina, Universidad Complutense, CIBERSAM, Madrid, Spain
This item has received
675
Visits
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Tables (1)
Table 1. Relevant conclusions.
Abstract

Schizophrenia is a clinically heterogeneous syndrome affecting multiple dimensions of patients’ life. Therefore, its treatment might require a multidimensional approach that should take into account the efficacy (the ability of an intervention to get the desired result under ideal conditions), the effectiveness (the degree to which the intended effect is obtained under routine clinical practice conditions or settings) and the efficiency (value of the intervention as relative to its cost to the individual or society) of any therapeutic intervention. In a first step of the process, a group of 90 national experts from different areas of health-care and with a multidimensional and multidisciplinary perspective of the disease, defined the concepts of efficacy, effectiveness and efficiency of established therapeutic interventions within 7 key dimensions of the illness: symptomatology; comorbidity; relapse and adherence; insight and subjective experience; cognition; quality of life, autonomy and functional capacity; and social inclusion and associated factors. The main conclusions and recommendations of this stage of the work are presented herein.

Keywords:
Psychosis
Negative symptoms
Adherence
Insight
Antipsychotics
Resumen

La esquizofrenia es un síndrome clínicamente heterogéneo que afecta a múltiples dimensiones vitales del individuo. Su tratamiento requiere un abordaje multidimensional en el que se deberían tener en cuenta la eficacia (la capacidad de una intervención para obtener el resultado pretendido en condiciones ideales), la efectividad (el grado en que se obtiene el efecto pretendido en condiciones de la práctica clínica habitual) y la eficiencia (el valor de la intervención con respecto al coste para el individuo o la sociedad). En una primera fase, un grupo de 90 expertos nacionales de todos los ámbitos, desde una perspectiva multidimensional y multidisciplinar de la enfermedad, definieron los conceptos de eficacia, efectividad y eficiencia en torno a 7 dimensiones clave: síntomas; comorbilidades; recaídas y adherencia; conciencia de enfermedad y experiencia subjetiva; cognición; calidad de vida, autonomía y capacidad funcional, e inclusión. Las principales conclusiones de esta fase se presentan en este trabajo.

Palabras clave:
Síntomas negativos
Adherencia
Conciencia de enfermedad
Antipsicóticos
Full Text

Schizophrenia (schizophrenic spectrum disorders) is the most frequent psychotic disorder within non-affective psychotic syndromes, reported in DSM 5 under the heading “Schizophrenia and other psychotic disorders” and includes: schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, delusional disorder, substance-induced psychotic disorder, psychotic disorder secondary to a medical illness, catatonia associated with a medical illness, and unspecified psychotic disorder.

This is a clinically heterogeneous syndrome that usually affects multiple dimensions of the individual's life, beginning frequently at the end of adolescence or early adulthood, and is associated with progressive functional deterioration in a significant percentage of cases, especially in cases where the optimal required treatment is not provided. Annual prevalence is currently 0.3% and the annual incidence is 0.8 cases per 10,000 inhabitants, which represents approximately 4000 new cases of schizophrenia diagnosed per year in Spain.1

According to the Global Burden of Disease Study in 2010, mental disorders account for 7.4% of the global burden of disease in terms of disability adjusted life years (183.9 million DALY); schizophrenia is considered to be responsible for 7.4% of that burden of disease, associated with mental disorders.2 The economic cost is a parameter that is becoming increasingly recognised in health policies and planning in research. To achieve a reduction in indirect costs, which are the majority of the costs associated with mental disorders in social, employment, family and personal terms, it should be assessed whether direct costs must be increased or not, something which is essential in the medium and long term, regardless of whether or not there is more and better social and healthcare investment in the short term to reduce the high levels of disability associated with the disease.3

The mortality rate of people with schizophrenia is twice that of the general population.4–6 The life expectancy of men and women with schizophrenia is 15 and 12 years, respectively, which is shorter than for those without schizophrenia.7

Today there is growing agreement on the influence of intensive treatments from the initial phases over the prognosis of the disease. Beyond the choice of antipsychotics for initial treatment, these intensive treatments broadly address the different needs of patients and their families.8

Early and optimal diagnosis and treatment of schizophrenia can reduce the risk of disability and increase the chances of the patient's functional recovery. The treatment of schizophrenia requires a multidimensional approach which should take into account the following parameters: efficacy (the ability of an intervention to obtain the intended result under ideal conditions), effectiveness (the degree to which the intended effect is achieved with normal clinical practice), and efficiency (the value of the intervention with respect to the cost for the individual or society). It is in this context where evidence demonstrates the relevance of implementing and developing optimised treatment approaches to the progression of the disease,9,10 and where the Rethinking movement arises.

Objectives and methodology

Rethinking represents an initiative that, as its main objective, aims to draw up a number of expert recommendations on the fundamental treatment aspects of the best treatment and care in the real world for patients with schizophrenia and their caregivers. To this end, two specific objectives were proposed: 1) to assess the efficacy, effectiveness and efficiency of the treatment approaches currently adopted in our clinical environment; and 2) to identify needs which are not covered in the treatment of the disease and, therefore, propose specific action for improvement of the care and treatment of patients and caregivers. To achieve these objectives, a research methodology was designed that began with the formation of a multidisciplinary scientific committee (psychiatrists, managers, representatives of patient associations, representatives of scientific societies) from a selection of 90 recognised national experts with experience in the treatment of schizophrenia. These experts provided a multidimensional and multidisciplinary view of the disease, and committed themselves to sharing their experience in order to reach final recommendations on issues of interest.

This group of experts was selected on the basis of their professional recognition in the area of interest and the degree of experience and involvement in the treatment of those with schizophrenia in routine clinical settings. Considered and then included were professionals and groups from various different fields who were directly involved in the care and treatment of people with schizophrenia, and their caregivers: psychiatrists, psychologists, mental health nursing staff, health economics specialists, health managers, representatives of scientific societies, patient associations and patients’ relatives (Appendix A).

The scientific committee, in a first working meeting and through a reasoned group discussion, defined the overall working methodology to address the project, and posited 7 specific dimensions of the disease to work on the proposed objectives. These dimensions were as follows: symptoms; comorbidities; relapses and adherence to treatment; consciousness of illness and subjective experience; cognition; quality of life, autonomy and functional capacity, and inclusion.

The concepts of effectiveness and efficiency were specifically defined and analysed on the basis of these 7 key dimensions by the scientific committee. Working groups composed of experts from different disciplines were formed. Each working group was assigned a dimension and pairs were selected to evaluate, weight up and agree on the concepts of efficacy, effectiveness and efficiency in each dimension. In order to run this research, a critical and contrasted scientific review was undertaken to respond to the proposed topics. At a meeting where all the experts participated, the conclusions reached by each group were put together with the aim of producing a general document that would systematically record the evidence, suggestions for action and conclusions reached by the panel of experts on each of the clinical dimensions examined and analysed. The panellists, in their work, held interactive discussions, sharing their reasoned opinions and their commitment to reconsider some of these opinions by following the comments, arguments or suggestions of the other panellists in order to come to the final conclusions.

The Rethinking movement continued in a second phase in 2015, examining in greater depth the unmet needs identified by the professionals in their day-to-day work when dealing with the treatment of schizophrenia cases, and thus promote and implement areas for improvement. As a consequence of the analysis in this first part, it was considered necessary to include representatives of mental health nursing staff, due to their relevance in many of the treatment processes. The final document specifically highlights relevant and attainable intervention strategies that the experts’ group recommend by consensus, to improve the care of patients and caregivers. The results achieved were approved by the majority of the expert group, although there may have been some divergences on specific issues from a minority of the panel.

Results

In this article we thus present the main considerations and conclusions reached after the work done during these years by the panel of experts in order to define and describe a series of actions that would improve efficacy, efficiency and effectiveness in the current treatment of schizophrenia in our society.

Symptoms

Symptoms are the determinants of diagnosis and, along with functionality, the aspect that has greatest weight in the choice of treatment and in the prognosis of the patients.

Positive symptoms are of prime importance in the diagnosis of the disease,11 with the most frequent being hallucinations (68%), delusions (65%) and conceptual disorganisation (50%).12 For their assessment, we have a number of validated instruments, both general (e.g., Brief Psychiatric Assessment Scale [BPRS],13 Positive and Negative Symptoms Scale for Schizophrenia [PANSS],14,15 Scale for the Assessment of Positive Symptoms [SAPS])16 as specific for different symptoms (e.g. Auditory Hallucinations Assessment Scale [PSYRATS]17,18). The efficacy of first and second generation antipsychotics for these symptoms is similar, providing better results if good treatment compliance is assured.19 In addition to this, cognitive-behavioural therapy adapted for patients with persistent positive symptoms has been shown to be a useful intervention, although the scale of the effect observed in clinical trials is, at best, moderate.20

It is noteworthy that in clinical practice, despite the usefulness it may have for objectifying the clinical status of patients, the routine use of these scales is minimal, their use being restricted to research environments.

At present, there is some controversy as to whether the symptoms of disorganisation (thought, language, behaviour) should be included in the positive dimension,21 or, on the contrary, they should make up an independent dimension.22 From the point of view of their assessment, there are no specific psychometric instruments validated in Spanish. Their assessment therefore falls on the items on the positive symptom scales, such as the PANSS and the SAPS, and the clinician-assessed item from the severity scale of the symptoms for the dimensions of psychosis.23

Negative symptoms are present in 58% of patients during the first episode.24 They are better predictors of progression than positive symptoms25,26 and, along with cognitive symptoms, have a major impact on functioning, lifestyle and somatic health.27 Several batteries and scales have been drawn up for assessing the psychopathology of negative symptoms, including the following scales: Brief Scale for Negative Symptoms (BNSS),28 the Interview for the Clinical Assessment of Negative Symptoms (CAINS),29,30 the Inventory for Deficient Schizophrenia Syndrome (SDS)31,32 or the Scale for the Assessment of Negative Symptoms (SANS).33,34 There are also scales such as the PANSS, which, in some of their sections, measure negative symptoms, or others that assess secondary negative symptoms such as motor symptoms (e.g. with the modified Simpson-Angus Scale35).

Among the limitations we have in evaluating the efficacy of antipsychotics for these types of symptoms is the difficulty, in clinical trials, of distinguishing between primary negative symptoms–directly related to the pathophysiology of schizophrenia–and symptoms which are secondary to psychotic, affective symptomatology, concomitant diseases or the side effects of some drugs. The main reason is that the scales usually used in research and clinical settings do not have the capacity to adequately identify this symptomatology, resulting in an under- or over-inclusion of symptoms and behavioural assessment rather than experiential assessment.36 There are no drugs that have demonstrated efficacy for primary negative symptoms,26,37 furthermore, it seems that drugs that block dopaminergic receptors, such as antipsychotics, can produce negative symptoms in healthy people.38 Although psychosocial interventions have been more studied for the management of positive symptoms, there is some evidence that cognitive-behavioural therapy, social skills training, and combined interventions are associated with continued improved negative symptoms for more than 6 months. There are, however, many questions to be clarified regarding these interventions, such as whether or not combined treatments can produce greater and more lasting improvement.39–41 There is currently no approved pharmacological approach for the treatment of primary negative symptoms, revealing a key unmet need in this area of treatment.42 The efficacy results of some new treatments aimed at increasing glutamatergic neurotransmission and associated with antipsychotics were promising in phase II, although the Phase III studies did not confirm these results.43,44 Negative symptoms secondary to positive symptoms, depressive symptoms or antipsychotic treatment, would require specific treatments.

Affective symptoms of schizophrenia have received little attention, although 25%–30% of patients present post-psychotic depression.45 Diagnosis is difficult, especially differential diagnosis with negative symptoms. For its assessment, we have the Calgary Depression Assessment Scale.46,47 Data on efficacy and efficacy of antipsychotics for these symptoms is in short supply and suggests limited efficacy, although this is probably higher for some second generation antipsychotics.48 With regard to manic symptoms, it is known that their presence contributes to the prognosis of schizophrenia. Moreover, DSM-5, in its deconstruction of the disease, includes mania in its severity scale of symptoms of psychosis dimensions, as assessed by clinicians.23 Another instrument that has been used to evaluate manic symptoms in schizophrenia is the Young Mania Rating Scale,49 although its validity for assessment in patients with schizophrenia has been little researched.50

Up to two thirds of patients with untreated schizophrenia have motor symptoms.51 Motor symptoms are also frequent in patients receiving antipsychotic treatment, with differences between different drugs.52 Several scales, such as the Simpson Angus Scale (SAS)35 the Abnormal Involuntary Movement Scale (AIMS),53 and Barnes’ Scale for Assessment of Akathisia (BARS)54 are available for assessment. There are virtually no efficacy studies to guide the treatment of these symptoms. The two most serious situations are catatonia and tardive dyskinesia. Benzodiazepines and electroconvulsive therapy can be used for catatonia.55 For tardive dyskinesia the treatment alternatives provide very limited results.

The prevalence of consummate suicide in patients with schizophrenia is 4.9%56 and the highest proportion of suicides occur during the first 2 years from the onset of the disease57. The Beck Suicide Intent Scale (BSIS) 58 or the Columbia Suicide Severity Rating Scale (CSSRS) can be taken for suicide risk assessment.59 Preventive treatment for suicide risk has been little researched and currently only one pharmacological treatment, clozapine, is considered efficient and effective.60,61 Suicide risk management is also important in the treatment of comorbidities such as depression or substance use disorders.

Along with the risk of suicide, in some cases patients with schizophrenia may exhibit aggressive behaviour. It is important to note that people with psychopathologically stabilised schizophrenia do not present violent behaviour more frequently than the general population.62–64 Aggressive behaviour is more frequent prior to diagnosis and has as risk factors positive symptoms, comorbidity with substance abuse disorders, lack of adherence to treatment, recent exacerbation, vital stressors in childhood and psychopathic traits of personality.62,65 The most widely used validated assessment tool is the Manifest Aggressive Scale (OAS).66 The treatment approach will depend on the paths leading to this aggressive behaviour; If aggression is related to psychotic symptoms, clozapine is an effective treatment, but if this behaviour depends, for example, on the presence of comorbidity with a substance abuse disorder, it may require other drugs or psychosocial interventions.67 Regarding the treatment of aggressive behaviour, it is possible to indicate that both first and second generation antipsychotics are effective, and clozapine seems especially useful in the management of these patients.67

Multiple unmet needs have been detected in relation to the symptoms of schizophrenia that affect efficacy, effectiveness and efficiency. The persistence of symptoms, especially negative or cognitive symptoms, from many of these dimensions in a significant proportion of symptomatic patients after initiating treatment–or resistance to the treatment of positive symptoms–advocates the need for more effective treatments and the search for new treatment targets with different mechanisms of action.26,68,69 Cognitive-behavioural therapy may be effective for certain symptoms and can lead to a substantial reduction in relapses; it improves the patient's adaptation to his environment and his overall functioning, although recent meta-analyses do not demonstrate greater efficacy for this type of therapy than other less sophisticated and less demanding interventions.70.71 Thus, further studies on the effectiveness and efficiency of the combination of psychopharmacology with different psychosocial interventions are needed.

Most research on the results of pharmacological interventions in schizophrenia has focussed more on improving symptomatology (especially positive symptoms) and not on how this translates into an improvement in functionality and the quality of life of the patient. In addition, variable compliance has not received the necessary attention and this variable affects many of the symptoms assessed in the studies. More pragmatic clinical trials are needed that would respond to clinical questions that are more focussed on not only positive symptoms (the need to improve treatments for primary negative symptoms) and which would enable assessment of outcomes under real-life conditions. These studies should include cost-effectiveness measures.

Comorbidities in schizophrenia

Assuming remission and/or recovery as a treatment objective, the treatment of schizophrenia should go beyond the management of psychosis exclusively, also encompassing general health.

From the point of view of physical health, the most frequent comorbidities are those related to cardiovascular and metabolic risk factors.72–74 However, other medical co-morbidities such as oral problems, osteoporosis or pulmonary thromboembolism should be considered, to name but a few, which may also be present more frequently in these patients. Although this is associated with other comorbidities such as anxiety disorder or posttraumatic stress disorder, the most common comorbidities in patients with schizophrenia are obsessive compulsive disorder (prevalence 3.5–46%), substance abuse disorders (prevalence 47%), and depression (vital prevalence 81%).75

Diagnosis, especially early diagnosis, of physical comorbidities continues to be an important area of improvement in the management of these patients by all involved (patient, primary care physician and psychiatrist). The “Consensus on the physical health of the patient with schizophrenia on the part of the Spanish Societies of Psychiatry and Biological Psychiatry”76 has had a very limited impact on clinical practice77; unfortunately, this lack of follow-up of the guidelines for the management of psychotropic drugs extends to other specialties.78 Health promotion and prevention programmes require to be introduced for people with schizophrenia, and this entails greater coordination between health care networks and an assessment of their efficacy, effectiveness and efficiency, since the available information indicates a clear lack of evidence in this regard.72

The presence of physical comorbidities in patients with mental disorders increases costs. Specifically, schizophrenia is associated with higher costs per case than depression, in part because there is a higher risk of presenting physical comorbidities.79 This is a fundamental factor that has not been taken into account when assessing not only the efficiency but also the effectiveness and efficacy of the treatments of schizophrenia.

Just as we have indicated for diagnosis, the treatment of comorbidities, whether physical or mental, in some cases requires specific interventions (for example, treatment for cannabis abuse, smoking, guidance in healthy habits) and a prospective assessment of the usefulness and value of these interventions, all with a patient-centred approach. The initial results of some pragmatic clinical trials suggest that measures of that type could be effective and cost-efficient.80

In conclusion, the presence of comorbidities is one of the least developed fields of schizophrenia, and influences the efficacy, effectiveness and efficiency of the treatment of schizophrenia. It is therefore necessary to design education and awareness programmes for patients, primary care physicians and psychiatrists in order that all understand the importance of improving physical health, especially reducing cardiovascular and metabolic risk factors. Improving lifestyle and counteracting the side effects of treatments through specific intervention programmes are critical factors in this regard. Clinical practice and scientific evidence show the need to establish a comprehensive approach to health in patients as a way of achieving functional recovery.

Adherence to treatment and relapses

Adherence is defined as the extent to which a person's behaviour in terms of following prescribed treatment (pharmacological treatment, psychotherapy, lifestyle changes, etc.) corresponds to recommendations agreed with a healthcare provider. Partial adherence or complete withdrawal from treatment is often common in severe mental disorders; it is estimated that approximately half of the patients with schizophrenia usually stop taking 30% or more of the prescribed medication.81,82 Lack of adherence is associated with serious clinical consequences (increased risk of relapse, suicide or aggressive behaviour, among others) and high costs, both in monetary terms and psychosocial resources.83,84

In general, lack of adherence is of extraordinary relevance in all chronic diseases. It is estimated that between 33% and 69% of all hospital admissions in the U.S. are due to lack of adherence.85 The ability of clinicians and informal caregivers to address this problem is limited. Initiatives that improve adherence are key to progress towards more effective and comprehensive treatment plans.

Adherence assessment can be performed with direct methods, such as determining plasmatic levels of the drug or its metabolites, or indirect methods, such as medication count, patient interview or questionnaire use, although the only one validated in Spain is Morisky-Green's.86,87 The recommendation is to use both assessment methods as they provide complementary information. The most important factors associated with lack of adherence are lack of disease awareness, lack of adherence, presence of substance abuse disorder, lack of efficacy or poor tolerability of antipsychotic treatment, lack of family support, critical attitude and stigmatisation by the family.88–90 Possible strategies to improve adherence include: 1) pharmacological strategies, selecting the drug according to its profile of adverse effects, dosage and patient preferences, using long-acting intramuscular antipsychotics and avoiding combination therapy and 2) non-pharmacological strategies such as psychoeducation; strengthening the treatment alliance through decision-making techniques shared with the patient, and community assertive therapy, which have been shown to be efficacious, effective, and possibly efficient.91,92 In randomised clinical trials it has been observed that early intervention with family therapy reduces the severity of symptoms and improves access to treatment and compliance with it. Early intervention with cognitive-behavioural therapy reduces the severity of symptoms, with a low impact on relapses and hospital admissions.93

There is no universally accepted definition of relapse. The most frequently used in the literature is hospitalisation, although many others have been used that include scores on scales, subscales or items, behavioural changes or other operational criteria such as those of Csernansky and Andreasen.94 Among the factors that precipitate relapse are poor adherence to treatment, environmental stress, depression, substance abuse and history of relapse,94–96 and among protective factors: good adherence to treatment, duration of untreated psychosis less than 60 days and good response to treatment.97

Recent studies show the effectiveness of maintaining antipsychotic treatment with minimal effective doses for the prevention of relapses as a maintenance treatment.98,99 However, further maintenance treatment studies are required to compare with withdrawal of medication before it can be concluded that the best treatment strategy in patients with schizophrenia, following an acute psychotic episode, is indefinite maintenance treatment.

Relapses have relevant clinical and socioeconomic consequences. From the clinical point of view, it has been estimated that two-thirds of patients have a relapse and, of those who do, one in 6 does not recover from the episode.100 The costs of relapses, defined as hospitalisations, are high because they account for 38.5% of total costs of schizophrenia, only surpassed by the cost of informal care (47%) and well above the pharmaceutical cost (12.8%).101

Insight and subjective experience

Absence of insight of illness and subjective experience is a key aspect in the prognosis of psychosis.102 The lack of insight into the existence of a chronic disease that needs treatment is a non-specific manifestation but is a characteristic of psychosis. This is a complex and multidimensional phenomenon that includes recognition of having a illness (what has been called cognitive insight), and awareness of clinical symptoms and the need for treatment (so-called clinical insight).103 Disease insight is often an indicator of state and not of trait, and is therefore a modifiable factor, which is relevant since it is an important predictor of functioning after a first psychotic episode.104,105 Subjective experiences are those related to the identification of, strictly speaking, subjective aspects of the mental states of the patient and which require the subject himself to be identified. It is necessary to distinguish between subjective experiences with taking antipsychotics, on the one hand, and subjective experiences as a vital situation, on the other, the latter being closer to the dimension of quality of life.

The assessment of both insight and subjective experience with medication will depend on the type of treatment intervention. If the objective is to assess response to medication, insight can be assessed using the Birchwood Insight Scale (IS)106,107 or the Scale to Assess Unawareness of Mental Disorders (SUMD).108 If the objective is the assessment of psychosocial treatment, the recommendation is to use the Beck Cognitive Insight Scale (BCIS)109,110 or the Personal Beliefs about Illness Questionnaire-revised (PBIQ-R).111 Similarly, for the assessment of subjective experience with treatment, the recommendation would be to use the Drug Attitude Inventory (DAI-30 or the abbreviated version DAI-10)112–114 if the objective is to assess pharmacological treatment, or the Subjective Well-Being under Neuroleptics Scale (SWN-K)115,116 to evaluate psychosocial interventions.

There are few assessable studies on the effect of antipsychotic medication on insight and with inconclusive results.117 With regard to psychosocial interventions, the promotion of support and social relations has been assessed, along with vocational rehabilitation, cognitive-behavioural therapy, motivational intervention therapy aimed at increasing adherence, training in social skills, and self-observation through video and comprehensive interventions.117 In general, these interventions have a modest effect on the modification of insight, with very heterogeneous results.117 On the other hand, there is still insufficient evidence to show that improved insight is associated with better health outcomes for the individual, and studies on this are required.

Cognition

In schizophrenia basically 7 domains of cognition are affected from the early stages of the disease: processing speed, attention, working memory, verbal and visual learning, reasoning and problem solving. 11,118 As a consequence, the productivity of patients, their quality of life and social functioning is affected. Therefore, it is considered important to evaluate the cognitive functioning deficit in patients with schizophrenia, especially at debut, in patients with a recurrent or refractory progression, or in those who complain of amnestic discomfort or functional deterioration. There are multiple instruments119 for the assessment of cognitive function in patients with schizophrenia, which include complete neuropsychological batteries such as MATRICS, developed for use primarily in clinical trials, or instruments that have been validated in our setting, such as the Brief Scale to assess Cognitive Impairment In Psychiatric Patients (SCIP)120,121 or the Behavioural Assessment of the Designative Syndrome (BADS).122,123 Cognitive interview tools have also been developed, such as the Schizophrenia Cognition Rating Scale (SCoRS),124 which can help assess the level of cognitive impairment of the patient, and are being used in clinical trials for the assessment of interventions directed to this. However, more pragmatic tools are needed to allow screening of cognitive disorders in patients with schizophrenia.

The study of the variables that can mediate cognition, both in general cognitive functioning and social cognition, has been very limited, with small sample size in studies and with limitations when measuring the desired variables. So far it has only been possible to demonstrate that clinical factors and psychological treatments are mediators which are moderately related to cognition.70,125 Thus, patients with greater severity of symptoms present poorer neurocognitive performance, this being related to poorer social functioning. This last is influenced by the duration of unmasked psychosis126. Both cognitive therapy in the case of neurocognition, and intervention programmes on social cognition are the programmes that have yielded the most promising results to date.127

As with primary negative symptoms, most studies evaluating the efficacy of antipsychotic drugs to improve cognition in schizophrenia, when taking into account improvement, secondary to a reduction in positive symptomatology, do not find positive results in this domain.128 Moreover, in both animal models and healthy individuals, dopaminergic receptor blockers appear to worsen cognitive performance.129 Given the limitations of pharmacological treatments, neuropsychological rehabilitation therapies encompassed within the term “cognitive rehabilitation techniques” (CRT)70 have been proposed as an adjunctive treatment for cognitive disorders. They consist of applying specific techniques directed at exercising cognitive abilities and learning compensatory strategies, directed and supervised by a therapist.

There are different formats and programmes that can be presented in traditional pen and paper format or through computer programmes.130 The objective of the CRTs is to alter the level of individual functioning by improving the deficient cognitive area. For a CRT to be considered effective, it should be generalised to daily life. Overall, we can say that cognitive rehabilitation can become the critical factor for treatment success in at least one group of patients. It is important to note, in this regard, that cognitive impairment is present in the early stages of the disease and that cognitive rehabilitation shows moderate to major changes in these stages.131 The use of new technologies for cognitive training has succeeded in influencing the facilitation of mechanisms of cerebral plasticity132 and at the same time promoting improvements in functioning in the real world.133

In summary, clinicians should be aware that cognition is affected in most patients, even before the onset of the disease, and is therefore an important part of the clinical assessment of patients. It should be noted that alterations in cognition are associated with a greater degree of functional and social disability. This association has made cognition a relevant treatment target. The investigation of treatment strategies aimed at improving cognition is still at a very early stage, and there is still no suitable pharmacological treatment. Although this is an area that needs further development, cognitive rehabilitation is the most interesting option.

Quality of life, autonomy and functional capacity

The approach to treatment of people with schizophrenia requires a paradigm shift, which would lead to a greater degree of personal recovery, attempting to restore the premorbid situation and resume daily life.134 This implies focussing on three fundamental aspects: quality of life, personal autonomy and social functioning. Quality of life, as a subjective assessment of the person's life circumstances; personal autonomy, such as the capacity and right to make decisions that affect their personal life; and social functioning, such as the ability to function and develop in different areas of life.

Until now this dimension of recovery has been little considered in studies that assessed the efficacy and effectiveness of different treatments, especially psychopharmacological. There is more data on the efficacy, effectiveness and efficiency of psychosocial interventions and the organisation of services on outcomes in quality of life, personal autonomy and social functioning. In order to achieve this recovery, in addition to acute treatment of symptoms and maintenance of treatment to avoid relapses, all those affected require to be empowered: introducing the family as a fundamental element and ensuring better organisation in the care of persons with schizophrenia. Empowerment has to take place simultaneously at the patient population and individual level, as it consists of a multidimensional social process through which individuals and groups achieve better knowledge and control over their lives; As a consequence, they can transform their social and political environment to improve their circumstances of daily life which are related to health.135

The family dimension has begun to be considered in recent years, in the sense that the family and the patient form an indissoluble unit for treatment action with the aim of improving the progression and prognosis of the disease. It is necessary to detect homogenous groups of relatives and patients with schizophrenia to be able to intervene at family level with interventions based on the criteria of efficiency and effectiveness applied to the Spanish population and in our environment i.e. this would bear in mind our high-pressure healthcare situation; resource constraints, over-medicalisation, and lack of community resources. It is therefore necessary to provide healthcare and economic policies which are tailor-made for these circumstances.136

Improving the organisation of care for people with schizophrenia implies136: providing the required integrated, evidence-based care that will meet the needs of physical and mental healthcare; providing support for people with schizophrenia to live in their usual environment, and developing mechanisms to help them navigate complex employment and social benefits systems; providing specific support, information, and educational programmes for family members and caregivers in order that they can provide care for individuals with schizophrenia in a manner that minimises disruption to their lives; regularly reviewing and improving care procedures for people with schizophrenia, with all interested parties involved, including organisations that support people with schizophrenia; providing support which is equivalent to the impact of the disease, researching and seeking new treatments, and running adequately and regularly funded awareness campaigns that would form a permanent part of the action plans.

Regarding pharmacological treatment, in general terms, patients receiving this treatment have a better quality of life than those who do not receive it.137 Second-generation antipsychotics would have advantages in this regard compared to first-generation antipsychotics, 138 and long-term injectable antipsychotics appear to have advantages over oral antipsychotics in terms of better functioning, quality of life and patient satisfaction.139 However, some studies do not show any benefit for long-term injectable antipsychotics versus oral antipsychotics, in terms of reducing relapse.140

A related aspect that is increasingly relevant is the concept of “recovery from the patient's perspective”. This concept goes beyond the improvement in quality of life or subjective experience, and implies the patient's overall perception of feeling recovered as a person, in all senses. That is, it places the subject-patient and his own subjective perception at the centre. This aspect has been gaining importance in recent years, to become an essential aspect in the planning of mental healthcare services in many countries. In a recent qualitative study with Delphi groups on 381 patients diagnosed with schizophrenia,94 items were recorded which were related to the concept of recovery from the perspective of the patient. The first two most frequently cited items were: 1) to achieve an acceptable quality of life and 2) having a positive feeling towards oneself.141

In summary, this dimension needs to be incorporated as a fundamental measure of outcome, as regards both the preparation of individual care plans, and the treatments made available to those affected and their care provider organisation. To that end, their monitoring in usual clinical practice, and the use of this in research are key elements which require a prior critical and consensus-based assessment of the different scales existing.

Inclusion

According to biopsychosocial models, stigma is revealed in three aspects of social behaviour142: stereotypes, understood as general agreement as to what characterises a group of people; social prejudices, that is, the application or emotional experience of these stereotypes; and effective discrimination, that is, the behaviour of rejection towards those groups. The person with mental illness must face a threefold difficulty in recovering: the illness itself, the prejudices and discriminations he receives as a result of it (social stigma) and self-stigma (or internalised stigma), and the anticipated discrimination that the patient believes will occur before they have experienced it. The prevalence of internalised stigma is 41.7%,143 and 40–79% of the relatives of patients with severe mental disorders are considered stigmatised.144 The consequences of stigma are severe, ranging from inhibition when seeking help or treatment for their illness to a negative impact on the quality of life of the patient and their caregivers. The stigma assessment has so far focussed on internalised stigma, using scales such as the Internalised Stigma Scale (ISS)145 or the Internalised Stigma Inventory of Mental Illness (ISMI).146 However, it is also necessary to assess stigma within the general population with questionnaires such as the Mental Health Knowledge Scale (MAKS),147 the Community Attitudes towards the Mentally Ill (CAMI) scale148 or the Informed Behaviour Scale and Intended (RIBS).149

The fight against stigma should be a key element in mental healthcare plans in the coming years. This fight against stigma should include interventions on: 1) the patient: with strategies aimed at optimising pharmacological treatment, psychoeducational strategies to improve knowledge of the disease, managing stress, improving cognitive deficits, preventing relapses and consumption of substances, strategies to improve personal skills and promote autonomy, involving the patient in identifying discriminatory practices, and promoting access to and use of new technologies; 2) the family: with psychoeducational strategies aimed at improving knowledge and management of the disease, involving families in the treatment process; 3) health professionals: with training for social action as a model of tolerance and acceptance of people with mental disorders; 4) health authorities: promoting legislative and policy initiatives that favour the inclusion of mentally ill patients and developing management plans which would meet the expectations and needs of users; and 5) the media: through activities that promote the dissemination and implementation of existing guidelines for the treatment of mental health information and, among others, seeking to avoid transmitting a negative impression of mental illness.

Conclusions

What is required is a change in the paradigm of schizophrenia treatment, where the different dimensions reviewed in this article are considered, not only in terms of parameters of efficaciousness, but also of effectiveness and efficiency. There are numerous needs which are not covered in the healthcare received by persons with schizophrenia, but that they do require. The individual, family and social costs are very high. Studies are needed that would include key outcome variables which are ecological, pragmatic and relevant to the quality of life and functioning of persons with schizophrenia, their families and society.

The Rethinking working group, on an interdisciplinary basis, has contributed, through the collaboration of all parties involved (psychiatrists, clinical psychologists, nursing personnel, health economics specialists, health managers, representatives of scientific societies and patient associations, as well as family members and caregivers), a consideration and set of proposals to prioritise lines of action, including parameters of effectiveness and efficiency, that would address the unmet needs identified. Table 1 summarises the main conclusions of each of the dimensions analysed.

Table 1.

Relevant conclusions.

The need for pragmatic clinical trials focussed on the treatment of primary negative symptoms, to assess results in real-life conditions, including measures to achieve cost-effectiveness. 
Education and awareness programmes are required with a view to highlighting the importance of preserving and caring for the physical health of patients. 
Recent studies show the effectiveness of maintaining antipsychotic treatment with effective minimal doses for the prevention of relapses as maintenance treatment. 
Studies are also needed to demonstrate that improved insight, an indicator of state and not trait, and therefore a modifiable factor, is associated with better health outcomes for the individual 
The lack of effective and efficacious treatment strategies to improve cognition makes it necessary to further develop this area of research; cognitive rehabilitation would be the most advisable option. 
Functional recovery inevitably requires the empowerment of patients; the consideration of the family as a fundamental element; and better organisation of care. 
The fight against stigma should be a key element in mental healthcare plans, considering both self-stigma and social stigma at large. 

One relevant conclusion is highlighted for each of the 7 dimensions.

The growing scientific advances in the field of schizophrenia, improvements in treatment and care, and the greater information available to those affected and their caregivers, are leading us to a new stage characterised by growing optimism about the future of those who suffer from this condition.150 Our responsibility as experts must be to lead the movement to respond to the needs identified, effectively and efficiently. It is the desire of the Rethinking movement to implement concrete action plans over the next few years to continue to improve the lives of people with schizophrenia.

Ethical responsibilitiesProtection of people and animals

The authors state that no experiments have been performed on humans or animals for this research.

Confidentiality of data

The authors state that no patient data appears in this article.

Right to privacy and informed consent

The authors state that no patient data appears in this article.

Financing

Otsuka and Lundbeck have provided financial support to hold working meetings but have not participated in any way in the manuscript or in its design, content or conclusions.

Conflicts of interest

Benedicto Crespo-Facorro has received consulting and lecture fees from Janssen Johnson & Johnson, Lundbeck, Roche and Otsuka Pharmaceuticals.

Miguel Bernardo has received consulting fees or research grants from ABBiotics, Adamed, Almirall, Amgen, Boehringer, Eli Lilly, Ferrer, Forum Pharmaceuticals, Gedeon, Hersill, Janssen-Cilag, Lundbeck, Otsuka, Pfizer, Roche and Servier. He has obtained research grants from the Carlos III Health Institute, the Spanish Ministry of Science and Innovation, the Ministry of Economy and Competitiveness, the Spanish Centre for Biomedical Research in the Mental Health Network (CIBERSAM), the Government of Catalonia, the Department of Universities and Research Department D’Economia i Coneixement (2014SGR441), and the 7th Framework Programme of the European Union.

Josep Maria Argimon does not have any conflicts of interest.

Manuel Arrojo has been a consultant and/or has received fees/fees from the Otsuka-Lundbeck Alliance, Janssen-Cilag, Lilly, Lundbeck, Otsuka and Adamed.

Maria Fe Bravo has been a consultant and/or has received fees or grants from the Carlos III Health Institute, IdiPaz, AstraZeneca, Roche, Janssen-Cilag, Lundbeck, Otsuka and the Spanish Ministry of Health, Social Policy and Equality.

Ana Cabrera Cifuentes has been a consultant to and/or received fees/grants from Otsuka-Lundbeck Alliance, CIBERSAM, Otsuka and Janssen-Cilag.

Julián Carretero Román has been a consultant and/or has received fees or grants from Ferrer, Formannova, Lundbeck, Otsuka and the Spanish Ministry of Health, Social Policy and Equality.

Manuel A. Franco has received consulting fees or grants from Roche, Lilly, Lundbeck, Otsuka, Ferrer, Servier, Pfizer, Janssen, Astra-Zeneca, Castilla y León (health and education departments), FIS (Ministry of Health, Spain), Ministry of Economy and Competitiveness (CDTI), European Commission (Horizon2020/AAL/6th Framework Programme of the European Union).

Paz García-Portilla has been a consultant and/or has received fees/grants from Otsuka-Lundbeck Alliance, CIBERSAM, European Commission, the Spanish Health Institute Carlos III, Janssen-Cilag, Lilly, Lundbeck, Otsuka, Pfizer, Servier, Roche and Rovi.

Josep Maria Haro has received consultancy fees or grants from AstraZeneca, Caja Navarra, CIBERSAM, European Commission, GSK, Carlos III Health Institute, Lilly, Lundbeck, Ministry of Science and Innovation, Ministry of Health, Ministry of Economy and Competitiveness, Otsuka, Pfizer, Roche, and Takeda.

José Manuel Olivares has received consultancy fees or grants from Roche, Lilly, Lundbeck, Otsuka, Janssen, FIS (Spanish Ministry of Health), Pfizer, Glaxo, Xunta de Galicia (regional govt.) and the Biocaps Project.

Rafael Penadés has received aid for research and travel from Otsuka-Lundbeck.

Javier del Pino-Montes has received consulting fees from the Otsuka-Lundbeck Alliance.

Julio Sanjuán has participated in clinical trials on antipsychotics sponsored by Amgen and Roche laboratories. He has been an advisor at Lundbeck and Osuka Laboratories.

Celso Arango has received consultancy/advisory fees or grants from Abbot, Amgen, AstraZeneca, Bristol-Myers Squibb, Caja Navarra, CIBERSAM, Forum, Alicia Koplowitz Foundation, Carlos III Health Institute, Janssen-Cilag, Lundbeck, Merck, Ministry of Science and Innovation, Ministry of Health, Ministry of Economy and Competitiveness, Mutua Madrileña, Otsuka, Pfizer, Roche, Servier, Shire, Schering Plow and Takeda.

Appendix A
Rethinking Group

María José Acuña Oliva (USMC Dos Hermanas, UGC de Salud Mental del Hospital de Valme, Sevilla, España).

Luis Agüera Ortiz (Servicio de Psiquiatría, Hospital Universitario 12 de Octubre, Madrid, España).

Eduardo J. Aguilar (Universidad de Valencia, INCLIVA, CIBERSAM, Valencia, España).

Cristina del Álamo Jiménez (Sección de Psiquiatría, Hospital Universitario Infanta Cristina, Madrid, España).

Benedikt L Amann (FIDMAG Research Foundation Germanes Hospitalàries, CIBERSAM, Barcelona, España).

Nel Anxelu (Confederación de Salud Mental, Madrid, España).

Adolfo Benito Ruiz (Unidad de Hospitalización Breve, Hospital Provincial de Toledo, España).

Miquel Bioque (Hospital Clínic de Barcelona, CIBERSAM, Barcelona, España).

Pilar Caminero Luna (Oficina Regional de Salud Mental, Dirección General de Coordinación de la Asistencia Sanitaria, Servicio Madrileño de Salud, Madrid, España).

Mateo Campillo Agustí (Hospital Morales Meseguer, Murcia, España).

Ricardo Campos Ródenas (Sección de Psiquiatría, Hospital Clínico Universitario de Zaragoza, España).

Raquel Carmona Jurado (Hospital Comarcal Valle de los Pedroches, Pozoblanco, Córdoba, España).

Jorge Cervilla (Universidad de Granada, Servicio de Salud Mental, Complejo Hospitalario Universitario de Granada, España).

Jordi Cid (Programa de Salud Mental, Instituto de Asistencia Sanitaria, Girona, España).

Eugenio Ramón Chinea Cabello (Centro de Terapias Integradas para la Salud [CENTIS], Santa Cruz de Tenerife, Tenerife, España).

Iluminada Corripio Collado (Servicio de Psiquiatría, Hospital de Sant Pau, CIBERSAM, Barcelona, España).

Olga Delgado (Servicio de Medicina Preventiva, Hospital Universitario Son Dureta, Palma de Mallorca, España).

Olimpia Diaz-Mandado (Centro de Rehabilitación Psicosocial y Laboral de Toledo, Fundación Sociosanitaria de Castilla-La Mancha, Toledo, España).

Marina Díaz Marsá (Hospital Clínico San Carlos, Programa de Intervención Precoz en Psicosis de Inicio Reciente, Universidad Complutense, CIBERSAM, Madrid, España).

María Blanca Fernández-Abascal-Puente (Hospital Universitario Marqués de Valdecilla, Santander, España).

Juan José Fernández Miranda (Área de Gestión Clínica de Salud Mental-V, Servicio de Salud del Principado de Asturias [SESPA], Oviedo, España).

Alejandro Fernández Pellicer (Complejo Hospitalario Universitario de Pontevedra, España).

Julia Fraga (Servicio Gallego de Salud, Vigo, España).

David Fraguas (Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón [IiSGM], CIBERSAM, Madrid, España).

Jesús de la Gándara (Jefe del Servicio de Psiquiatría, Complejo Asistencial de Burgos, España).

Juan Carlos García Álvarez (Unidad de Salud Mental de Adultos de Los Ángeles, Hospital General Universitario de Alicante, España).

Ignacio García Cabeza (Hospital General Universitario Gregorio Marañón, Madrid, España).

Paz García López (Hospital Comarcal Vega Baja de Orihuela, Alicante, España).

Josep Gascón Barrachina (Servicio de Psiquiatría, Hospital Universitari de la Mutua de Terrassa, Barcelona, España).

Cristina Gisbert Aguilar (Servicio de Rehabilitación Psiquiátrica Hospitalaria, IAS, Girona, España).

José Carlos González (Universidad de Valencia, España).

Ana González-Pinto (Servicio de Psiquiatría, Hospital Universitario Araba, CIBERSAM, Universidad del País Vasco [UPV/EHU], Vitoria, España).

Delio Guerro Prado (Servicio de Psiquiatría, Complejo Asistencial de Ávila [SACYL], Ávila, España).

Rosa María Hernández Cifuentes (Hospital de Día de Psiquiatría, Hospital Clínico de Valladolid, Facultad de Enfermería, Universidad de Valladolid, España).

Álvaro Hidalgo (Área de Fundamentos de Análisis Económicos, Universidad de Castilla-La Mancha, España).

Javier Labad Arias (Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España).

Fernando Lana (Hospital de Día de Salud Mental, Instituto de Neuropsiquiatría y Adicciones [INAD], Hospital del Mar, Barcelona, España).

Anna Manné (Centro de Investigación en Red de Salud Mental [CIBERSAM], Hospital del Mar-Parc de Salut MAR, Barcelona, España).

Jesús Marín (Hospital La Paz, Madrid, España).

Demetrio Mármol Pérez (Unidad de Salud Comunitaria, Mairena del Aljarafe, Sevilla, España).

Manuel Martín Carrasco (Consejo Europeo de Sociedades Psiquiátricas [European Psychiatric Association], Clínica Padre Menni, Pamplona, España).

Jose Martinez-Raga (Unidad Docente de Psiquiatría y Psicología Médica, Hospital Universitario Dr. Peset, Valencia, España).

María Mayoral (Servicio de Psiquiatría del Niño y del Adolescente, Hospital General Universitario Gregorio Marañón, Madrid, España).

Fermín Mayoral Cleries (Hospital Regional de Málaga, Instituto de Investigación Médica de Málaga [IBIMA], España).

Gema Medina Ojeda (SACYL, Hospital Clínico Universitario de Valladolid, España).

Javier Min (Complejo Asistencial Universitario de León, España).

Salvador Miret Fallada (Hospital Universitari Santa Maria-Lleida, CIBERSAM, Lleida, España).

Fabiola Modrego Aznar (Unidad de Salud Mental-Consultas, Hospital Clínico Universitario, Zaragoza, España).

Juan D. Molina (Universidad Camilo José Cela, Hospital R. Lafora, Madrid, España).

Rosa Molina Ramos (Servicio de Psiquiatría, Área de Salud Mental de Llevant, Hospital de Manacor, Mallorca, España).

Fernando Mora (Hospital Universitario Infanta Leonor, Fundación Psiformación, Madrid, España).

Teresa Moreno-Calle (Programa de Primeros Episodios de Psicosis, Red de Salud Mental Bizkaia [RSMB], Osakidetza-Servicio Vasco de Salud, España).

Carlos Mur de Víu Bernad (Hospital Universitario de Fuenlabrada, Estrategia en Salud Mental del SNS, Madrid, España).

Santiago Navarro (Fundación Canaria de Investigación y Salud, Servicio de Evaluación del Servicio Canario de la Salud, España).

Mercedes Navio Acosta (Oficina Regional de Coordinación de Salud Mental, Consejería de Sanidad, Madrid, España).

Araceli Oltra Ponzoda (Conselleria de Sanitat Universal i Salut Púbica, València, España).

Miguel Angel Ortega Esteban (Departamento de Salud Mental, Servicio Riojano de Salud, España).

Mario Páramo Fernández (Hospital de Conxo, Universidad de Santiago, Santiago de Compostela, España).

Juan Manuel Pascual Paño (Universidad de Cádiz, Unidad Hospitalaria de Salud Mental, Jerez de la Frontera, España).

Salvador Peiró (Conselleria de Sanitat, Generalitat Valenciana, España).

José Pereira Miragaia (Servicio de Salud Mental, Servicio Canario de la Salud, Las Palmas de Gran Canaria, España).

Piedad Pérez Marín (Hospital Universitario Gregorio Marañón, Madrid, España).

Alfonso Pérez Poza (Universidad de Zaragoza, Hospital de Día, Hospital Universitario Miguel Servet [HUMS], Zaragoza, España).

Rafael del Pino López (Unidad de Gestión Clínica de Salud Mental, Hospital Universitario Virgen de la Victoria, Málaga, España).

Asunción Pino Pino (Centro Médico Asistencial La Vall d’Uixó, Castellón, España).

A.J. Ramírez-García.

Marta Rapado-Castro Romero (Departamento de Psiquiatría Infantil y Adolescencia, Hospital Universitario Gregorio Marañón, LiSGM, CIBERSAM, Madrid, España).

Carmen Rodríguez del Toro (Servicio de Psiquiatría, Hospital Álvaro Cunqueiro, Complejo Hospitalario Universitario de Vigo, España).

Gabriel Rubio (Universidad Complutense, Servicio de Psiquiatría, Hospital Universitario 12 de Octubre, Madrid, España).

Samuel Leopoldo Romero Guillena (UGC Salud Mental, Área Hospitalaria Virgen Macarena, Sevilla, España).

Alfredo de la Rubia Martínez (Hospital Psiquiátrico, Mérida, Badajoz, España).

Gemma Safont (Hospital Universitari Mútua de Terrassa, Barcelona, España).

Estrella Salvador Vadillo (Hospital Universitario Ramón y Cajal, Madrid, España).

Manuel Serrano Vázquez (Servicio de Psiquiatría, Xerencia de Xestion Integrada de A Coruña, España).

Raúl Vázquez-Noguerol Méndez (Unidad de Rehabilitación Psiquiátrica, Hospital Nicolás Peña, Servizo Galego de Saúde, EOXI de Vigo, España).

Eulalio Valmisa (UGC Salud Mental, Hospital Universitario de Puerto Real, Cádiz, España).

Miguel Vega (Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, España).

Diego de la Vega Sánchez (Área Psiquiátrica, Servicio Andaluz de Salud, Sevilla, España).

David Villavicencio (Consorcio Hospital General Universitario de Valencia, España).

José Luis Villegas Martínez (FEA Psiquiatría, Hospital Universitario de Salamanca, España).

Zafra Villena (Servicio de Psiquiatría, Hospital Arnau de Vilanova, Valencia, España).

M. Luisa Zamarro Arranz (Sección de Salud Mental-Alcobendas-San Sebastián de los Reyes, Hospital Infanta Sofía, Madrid, España).

Francisco Javier Zamora Rodríguez (Salud Mental, Área de Zafra-Llerena, Badajoz, España).

Conflicts of interest: Rethinking Group

María José Acuña Oliva has no conflicts of interest to declare.

Luis Agüera Ortiz has no conflicts of interests to declare.

Eduardo J. Aguilar has no conflicts of interest to declare.

Cristina del Álamo Jiménez has no conflicts of interests to declare.

Benedikt L Amann has been a rapporteur for Janssen, Lundbeck and Otsuka. He has received support through a stabilisation contract (CES12/024) and grants for research projects PI07/1278, PI10/02622 and PI/15/02242 from the Carlos III Health Institute - General Subdirectorate for Assessment and Promotion of Research, National Plan 2008–2011 and 2013–2016, and the European Regional Development Fund (ERDF).

Nel Anxelu has no conflicts of interest to declare.

Adolfo Benito Ruiz received payment from Janssen, Johnson & Jonhson and Otsuka in 2015.

Miquel Bioque has been a consultant for, received fees from and/or been rapporteur for Adamed, Ferrer, Janssen-Cilag, Lundbeck, Otsuka, and Pfizer.

Pilar Caminero Luna has no conflicts of interest to declare.

Mateo Campillo Agustí has received fees for scientific collaborations from Otsuka, Servier and Pfizer.

Ricardo Campos Ródenas has no conflicts of interest to declare.

Raquel Carmona Jurado has no conflicts of interest to declare.

Jorge Cervilla has no conflicts of interests to declare.

Jordi Cid has no conflicts of interest to declare.

Eugenio Ramón Chinea Cabello has received fees from the following pharmaceutical laboratories: Pfizer GEP, Pfizer, Lundbeck, Servier, Rovi, Janssen-Cilag, Janssen, Esteve, Lilly, Sanofi, Astrazeneca, Glaxo-Smithkline, Boehinger-Ingelheim and Bristol Myers Squibb.

Illuminada Corripio Collado has received consultancy fees or grants from Ferrer, Lilly, Otsuka and FIS (Ministry of Health, Spain).

Olga Delgado has no conflicts of interest to declare.

Olimpia Diaz-Mandado has received consulting fees from the Otsuka-Lundbeck Alliance.

Marina Díaz Marsá has received consulting fees from Janssen, as rapporteur for Servier and Esteve and collaborated with Alter and Ferrer projects.

Blanca Fernandez-Abascal Puente has received fees as a speaker from Lundbeck-Otsuka.

Juan José Fernández Miranda has received fees or grants from Janssen, Lundbeck, Otsuka and Pfizer, and the Government of the Principality of Asturias and the European Commission (G-V. European Union). He has received fees for lectures or grants from Janssen, Lundbeck, Otsuka, Pfizer Pharmaceuticals, and the regional government of Asturias and the European Commission.

Alejandro Fernández Pellicer has received fees for lectures from laboratories Jannssen, Pfizer, and Lilly. He has received fees from Lumbeck for participating in Rethinking project meetings.

Julia Fraga presents no conflicts of interest to declare.

David Fraguas has received consulting fees from Janssen, Lundbeck, and Otsuka; he has received fees for submissions from AstraZeneca; Bristol-Myers Squibb; Eisai; Janssen; Lundbeck; Otsuka; Pfizer, and has received research grants funded by the Carlos III Health Institute (Ministry of Economy and Competitiveness).

Jesus de la Gándara presents no conflicts of interest to declare.

Juan Carlos García Álvarez presents no conflicts of interests to declare.

Ignacio García Cabeza has been a consultant and has received fees or scholarships from Otsuka-Lundbeck, Janssen-Cilag, Eli Lilly, and Pfizer.

Paz García López presents no conflicts of interest to declare.

Dr. Josep Gascón Barrachina presents no conflicts of interest to declare.

Cristina Gisbert presents no conflicts of interest to declare.

José Carlos González presents no conflicts of interest to declare.

Ana González-Pinto has received consultancy fees from AstraZeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, Janssen-Cilag, Lundbeck, Merck, Otsuka, Pfizer, Sanofi-Aventis, Rovi, Roche, Ferrer, Ministry of Science and Innovation CIBERSAM), the Spanish Ministry of Science (Carlos III Health Institute), the Basque Government, the Stanley Medical Research Institute and the Wyeth Symposium: the Spanish Ministry of Science and Innovation (CIBERSAM), Ferrer, Lundbeck, Janssen-Cilag, Rovi, Roche, Astra Zeneca.

Delio Guerro Prado has no conflicts of interest to declare.

Rosa María Hernández has no conflicts of interest to declare.

Álvaro Hidalgo has no conflicts of interest to declare.

Javier Labad Arias has no conflicts of interest to declare.

Fernando Lana Moliner has received fees for attendance at Janssen-Cilag and Otsuka conferences, Janssen-Cilag and Otsuka travel grants, and fees for papers written by him from Janssen-Cilag.

Anna Manné has received lecture fees from Otsuka Pharmaceuticals and Janssen-Cilag.

Jesús Marín has no conflicts of interest to declare.

Demetrio Mármol Pérez has received lecture fees from Otsuka-Lundbeck, Janssen-Cylag, Pfizer and Esteve.

Manuel Martín Carrasco has no conflicts of interests to declare.

Jose Martinez-Raga has received consulting/consulting fees from Otsuka, Lundbeck, Janssen, Lilly and Astra Zeneca.

María Mayoral has no conflicts of interest to declare.

Fermin Mayoral Cleries has participated in training activities and scientific collaborations for the following companies: Jansen-Cilag, Astra Zeneca, Lilly, Ludbeck, Pfizer, and Roche.

Gema Medina Ojeda has no conflicts of interest to declare.

Javier Min has no conflicts of interest to declare.

Salvador Miret Fallada has no conflicts of interest to declare.

Fabiola Modrego Aznar has no conflicts of interest to declare.

Juan D. Molina has no conflicts of interests to declare.

Rosa Molina Ramos has no conflicts of interest to declare.

Fernando Mora has received fees for scientific collaborations from Janssen, GSK, Otsuka-Lundbeck, and Pfizer.

Teresa Moreno-Calle has received consulting/consultancy fees or research grants from Janssen-Cilag, Otsuka, Lundbeck and the Basque Government.

Carlos Mur de Víu Bernad has no conflicts of interest to declare.

Santiago Navarro has no conflicts of interest to declare.

Mercedes Ship Acosta has no conflicts of interest to declare.

Araceli Oltra Ponzoda has no conflicts of interest to declare.

Miguel Angel Ortega Esteban has no conflicts of interest to declare.

Mario Páramo Fernández has no conflicts of interest to declare.

Juan Manuel Pascual Paño has received fees for participation in conferences, clinical trials, as well as conference attendance coverage, from Otsuka, Janssen, Pfizer, Ferrer, Lilly, and Almirall.

Salvador Peiró has no conflicts of interest to declare.

José Pereira Miragaia has received fees from Lundbeck.

Piedad Pérez Marín has received fees as a speaker and adviser for Janssen-Cilag and Otsuka-Lundbeck.

Alfonso Pérez Poza has no conflicts of interest to declare.

Rafael del Pino López has no conflicts of interest to declare.

Asunción Pino has no conflicts of interest to declare.

Marta Rapado-Castro has no conflicts of interest to declare.

A.J. Ramírez-García has received consulting fees or grants from AstraZeneca, Janssen-Cilag, Lundbeck, and Otsuka.

Carmen Rodriguez del Toro has received fees from Otsuka-Lundbeck.

Gabriel Rubio has no conflicts of interest to declare.

Samuel Leopoldo Romero Guillena has received consulting fees or grants from: Janssen-Cilag, Lilly, Lundbeck, Otsuka, Pfizer, Servier, Sanofi and Rovi.

Alfredo de la Rubia Martínez has no conflicts of interest to declare.

Gemma Safont has received consultancy fees from the Otsuka-Lundbeck Alliance.

Estrella Salvador Vadillo has no conflicts of interest to declare.

Manuel Serrano Vázquez has no conflicts of interest to declare.

Raúl Vázquez-Noguerol Méndez has no conflicts of interest to declare.

Eulalio Valmisa has received consulting fees from Otsuka, and fees for submissions from Otsuka, Janssen, and Lundbeck.

Miguel Vega has received fees or grants from AB-Biotics, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen-Cilag, Juste, Lundbeck, Otsuka, Pfizer, and Sanofi.

Diego de la Vega Sánchez has received funding from the Jannsen and Lundbeck laboratories.

David Villavicencio has no conflicts of interest to declare.

José Luis Villegas Martínez has no conflicts of interest to declare.

Zafra Villena has no conflicts of interest to declare.

M. Luisa Zamarro Arranz has no conflicts of interest to declare.

Francisco Javier Zamora has received fees from Janssen-Cilag, Lilly, Lundbeck, Otsuka, Pfizer and Servier.

References
[1]
Martín García-Sancho J. (coord.). Guía de práctica clínica para el tratamiento de la esquizofrenia en centros de salud mental. Subdirección de Salud Mental. Servicio Murciano de Salud; 2009 [accessed 14.01.16]. Available from: http://www.guiasalud.es/GPC/GPC_443_Esquizofrenia_Murcia.pdf
[2]
H.A. Whiteford,L. Degenhardt,J. Rehm,A.J. Baxter,A.J. Ferrari,H.E. Erskine
Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010
[3]
M. Bernardo,G. Mezquida
Disease burden. Schizophrenia: a costly illness, in Insights in the management of Schizophrenia. Hospital Pharmacy Europe
Otsuka Pharmaceut, (2014),
[4]
C.H. Hennekens,A.R. Hennekens,D. Hollar,D.E. Casey
Schizophrenia and increased risks of cardiovascular disease
Am Heart J, 150 (2005), pp. 1115-1121 http://dx.doi.org/10.1016/j.ahj.2005.02.007
[5]
T.M. Laursen,K. Wahlbeck,J. Hallgren,J. Westman,U. Osby,H. Alinaghizadeh
Life expectancy and death by diseases of the circulatory system in patients with bipolar disorder or schizophrenia in the Nordic countries
[6]
S. Saha,D. Chant,J. McGrath
A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time?
Arch Gen Psychiatry, 64 (2007), pp. 1123-1131 http://dx.doi.org/10.1001/archpsyc.64.10.1123
[7]
C. Crump,M.A. Winkleby,K. Sundquist,J. Sundquist
Comorbidities and mortality in persons with schizophrenia: a Swedish national cohort study
Am J Psychiatry, 170 (2013), pp. 324-333 http://dx.doi.org/10.1176/appi.ajp.2012.12050599
[8]
I.E. Sommer,C.E. Bearden,E. van Dellen,E.J. Breetvelt,S.N. Duijff,K. Maijer
Early interventions in risk groups for schizophrenia: what are we waiting for?
NPJ Schizophr, 2 (2016), pp. 16003 http://dx.doi.org/10.1038/npjschz.2016.3
[9]
Grupo de trabajo de la Guía de práctica clínica sobre la esquizofrenia y el trastorno psicótico incipiente. Fòrum de Salut Mental c. Guía de práctica clínica sobre la esquizofrenia y el trastorno psicótico incipiente. Madrid: Plan de Calidad para el Sistema Nacional de Salud del Ministerio de Sanidad y Consumo. Agència d’Avaluació de Tecnologia i Recerca Mèdiques; 2009. Guía de Práctica Clínica: AATRM. No. 2006/05-2.
[10]
National Institute for Health and Care Excellence
Psychosis and schizophrenia in adults: prevention and management
Clin Guideline, (2014),
[11]
J. Van Os,S. Kapur
Schizophrenia
[12]
A. Breier,P.H. Berg
The psychosis of schizophrenia: prevalence, response to atypical antipsychotics, and prediction of outcome
Biol Psychiatry, 46 (1999), pp. 361-364
[13]
J.E. Overall,D.R. Gorham
The brief psychiatric rating scale
Psychol Rep, 10 (1962), pp. 790-812
[14]
V. Peralta,M.J. Cuesta
Psychometric properties of the positive and negative syndrome scale (PANSS) in schizophrenia
Psychiatry Res, 53 (1994), pp. 31-40
[15]
S.R. Kay,A. Fiszbein,L.A. Opler
The positive and negative syndrome scale (PANSS) for schizophrenia
Schizophr Bull, 13 (1987), pp. 261-276
[16]
N.C. Andreasen
Scale for the assessment of positive symptoms (SAPS)
University of Iowa, (1984)
[17]
J.C. Gonzalez,J. Sanjuan,C. Canete,M.J. Echanove,C. Leal
Evaluation of auditory hallucinations: the PSYRATS scale
Actas Esp Psiquiatr, 31 (2003), pp. 10-17
[18]
G. Haddock,J. McCarron,N. Tarrier,E.B. Faragher
Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS)
Psychol Med, 29 (1999), pp. 879-889
[19]
R. Tandon,H.A. Nasrallah,M.S. Keshavan
Schizophrenia, “just the facts”. 4. Clinical features and conceptualization
[20]
H.J. Sivec,V.L. Montesano
Cognitive behavioral therapy for psychosis in clinical practice
Psychotherapy (Chic), 49 (2012), pp. 258-270
[21]
W. Fleischhacker,C. Arango,P. Arteel,T.R.E. Barnes,W. Carpenter,K. Duckworth
Schizophrenia — Time to commit to policy change
Oxford PharmaGenesis Ltd, (2013)
[22]
J. Van Os
Are psychiatric diagnoses of psychosis scientific and useful? The case of schizophrenia
J Ment Health, 19 (2010), pp. 305-317 http://dx.doi.org/10.3109/09638237.2010.492417
[23]
American Psychiatric Association
Diagnostic and statistical manual of mental disorders
5th ed., American Psychiatric Association, (2013)
[24]
J. Bobes,C. Arango,M. Garcia-Garcia,J. Rejas
Prevalence of negative symptoms in outpatients with schizophrenia spectrum disorders treated with antipsychotics in routine clinical practice: findings from the CLAMORS study
J Clin Psychiatry, 71 (2010), pp. 280-286 http://dx.doi.org/10.4088/JCP.08m04250yel
[25]
J. Rabinowitz,S.Z. Levine,G. Garibaldi,D. Bugarski-Kirola,C.G. Berardo,S. Kapur
Negative symptoms have greater impact on functioning than positive symptoms in schizophrenia: analysis of CATIE data
Schizophr Res, 137 (2012), pp. 147-150 http://dx.doi.org/10.1016/j.schres.2012.01.015
[26]
C. Arango,R.W. Buchanan,B. Kirkpatrick,W.T. Carpenter
The deficit syndrome in schizophrenia: implications for the treatment of negative symptoms
Eur Psychiatry, 19 (2004), pp. 21-26 http://dx.doi.org/10.1016/j.eurpsy.2003.10.004
[27]
M.P. García-Portilla,J. Bobes
The new challenge in identifying the negative syndrome of schizophrenia
Rev Psiquiatr Salud Ment (Barc), 6 (2013), pp. 141-143
[28]
B. Kirkpatrick,G.P. Strauss,L. Nguyen,B.A. Fischer,D.G. Daniel,A. Cienfuegos
The brief negative symptom scale: psychometric properties
Schizophr Bull, 37 (2011), pp. 300-305 http://dx.doi.org/10.1093/schbul/sbq059
[29]
A. Valiente-Gomez,G. Mezquida,A. Romaguera,I. Vilardebo,H. Andres,B. Granados
Validation of the Spanish version of the Clinical Assessment for Negative Symptoms (CAINS)
Schizophr Res, 166 (2015), pp. 104-109 http://dx.doi.org/10.1016/j.schres.2015.06.006
[30]
A.M. Kring,R.E. Gur,J.J. Blanchard,W.P. Horan,S.P. Reise
The Clinical Assessment Interview for Negative Symptoms (CAINS): final development and validation
Am J Psychiatry, 170 (2013), pp. 165-172 http://dx.doi.org/10.1176/appi.ajp.2012.12010109
[31]
M. Bernardo,E. Fernandez-Egea,A. Torras,F. Gutierrez,M. Ahuir,C. Arango
Adaptation and validation into Spanish of Schedule for the Deficit Syndrome
Med Clin (Barc), 129 (2007), pp. 91-93
[32]
B. Kirkpatrick,R.W. Buchanan,P.D. McKenney,L.D. Alphs,W.T. Carpenter Jr.
The Schedule for the Deficit syndrome: an instrument for research in schizophrenia
Psychiatry Res, 30 (1989), pp. 119-123
[33]
J.E. Obiols,J. Salvador,M. Humbert,J. Obiols
Evaluación de los síntomas negativos de la esquizofrenia
Rev Psiquiatr Fac Med Barc, 12 (1985), pp. 85-91
[34]
N.C. Andreasen
Scale for the Assessment of Negative Symptoms (SANS)
University of Iowa, (1984)
[35]
G.M. Simpson,J.W. Angus
A rating scale for extrapyramidal side effects
Acta Psychiatr Scand Suppl, 212 (1970), pp. 11-19
[36]
M.P. Garcia-Portilla,L. Garcia-Alvarez,P.A. Saiz,S. Al-Halabi,M.T. Bobes-Bascaran,M.T. Bascaran
Psychometric evaluation of the negative syndrome of schizophrenia
Eur Arch Psychiatry Clin Neurosci, 265 (2015), pp. 559-566 http://dx.doi.org/10.1007/s00406-015-0595-z
[37]
C. Arango,G. Garibaldi,S.R. Marder
Pharmacological approaches to treating negative symptoms: a review of clinical trials
Schizophr Res, 150 (2013), pp. 346-352 http://dx.doi.org/10.1016/j.schres.2013.07.026
[38]
J.F. Artaloytia,C. Arango,A. Lahti,J. Sanz,A. Pascual,P. Cubero
Negative signs and symptoms secondary to antipsychotics: a double-blind, randomized trial of a single dose of placebo, haloperidol, and risperidone in healthy volunteers
Am J Psychiatry, 163 (2006), pp. 488-493 http://dx.doi.org/10.1176/appi.ajp.163.3.488
[39]
O. Elis,J.M. Caponigro,A.M. Kring
Psychosocial treatments for negative symptoms in schizophrenia: current practices and future directions
Clin Psychol Rev, 33 (2013), pp. 914-928 http://dx.doi.org/10.1016/j.cpr.2013.07.001
[40]
R.J. Drake,M. Nordentoft,G. Haddock,C. Arango,W.W. Fleischhacker,B. Glenthoj
Modeling determinants of medication attitudes and poor adherence in early nonaffective psychosis: implications for intervention
Schizophr Bull, 41 (2015), pp. 584-596 http://dx.doi.org/10.1093/schbul/sbv015
[41]
S. Jauhar,P.J. McKenna,J. Radua,E. Fung,R. Salvador,K.R. Laws
Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias
Br J Psychiatry, 204 (2014), pp. 20-29 http://dx.doi.org/10.1192/bjp.bp.112.116285
[42]
S. Sarkar,K. Hillner,D.I. Velligan
Conceptualization and treatment of negative symptoms in schizophrenia
World J Psychiatry, 5 (2015), pp. 352-361 http://dx.doi.org/10.5498/wjp.v5.i4.352
[43]
D. Umbricht,D. Alberati,M. Martin-Facklam,E. Borroni,E.A. Youssef,M. Ostland
Effect of bitopertin, a glycine reuptake inhibitor, on negative symptoms of schizophrenia: a randomized, double-blind, proof-of-concept study
JAMA Psychiatry, 71 (2014), pp. 637-646 http://dx.doi.org/10.1001/jamapsychiatry.2014.163
[44]
D.C. Goff
Bitopertin: the good news and bad news
JAMA Psychiatry, 71 (2014), pp. 621-622 http://dx.doi.org/10.1001/jamapsychiatry.2014.257
[45]
S.G. Siris,C. Bench
Depresión and schizophrenia
Schizophrenia, 2nd ed.,
[46]
S. Sarro,R.M. Duenas,N. Ramirez,B. Arranz,R. Martinez,J.M. Sanchez
Cross-cultural adaptation and validation of the Spanish version of the Calgary Depression Scale for Schizophrenia
Schizophr Res, 68 (2004), pp. 349-356 http://dx.doi.org/10.1016/S0920-9964(02)00490-5
[47]
D. Addington,J. Addington,B. Schissel
A depression rating scale for schizophrenics
Schizophr Res, 3 (1990), pp. 247-251
[48]
S. Leucht,C. Corves,D. Arbter,R.R. Engel,C. Li,J.M. Davis
Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis
[49]
R.C. Young,T. Biggs,V.E. Ziegler,D.A. Meyer
A rating scale for mania: reliability, validity and sensitivity
Br J Psychiatry, 133 (1978), pp. 429-435
[50]
S.C. Park,J. Choi
Using the Young Mania Rating Scale for identifying manic symptoms in patients with schizophrenia
Yonsei Med J, 57 (2016), pp. 1298-1299 http://dx.doi.org/10.3349/ymj.2016.57.5.1298
[51]
V. Peralta,M.S. Campos,E.G. de Jalon,M.J. Cuesta
Motor behavior abnormalities in drug-naive patients with schizophrenia spectrum disorders
Mov Disord, 25 (2010), pp. 1068-1076 http://dx.doi.org/10.1002/mds.23050
[52]
C. Rummel-Kluge,K. Komossa,S. Schwarz,H. Hunger,F. Schmid,W. Kissling
Second-generation antipsychotic drugs and extrapyramidal side effects: a systematic review and meta-analysis of head-to-head comparisons
Schizophr Bull, 38 (2012), pp. 167-177 http://dx.doi.org/10.1093/schbul/sbq042
[53]
W. Guy
ECDEU assessment manual for psychopharmacology
revised ed., US Department of Health, Education, and Welfare, (1976)
[54]
T.R. Barnes
A rating scale for drug-induced akathisia
Br J Psychiatry, 154 (1989), pp. 672-676
[55]
M. Belaizi,A. Yahia,J. Mehssani,M.L. Bouchikhi Idrissi,M.Z. Bichra
Acute catatonia: questions, diagnosis and prognostics, and the place of atypical antipsychotics
[56]
B.A. Palmer,V.S. Pankratz,J.M. Bostwick
The lifetime risk of suicide in schizophrenia: a reexamination
Arch Gen Psychiatry, 62 (2005), pp. 247-253 http://dx.doi.org/10.1001/archpsyc.62.3.247
[57]
R. Tandon
Suicidal behavior in schizophrenia
Expert Rev Neurother, 5 (2005), pp. 95-99 http://dx.doi.org/10.1586/14737175.5.1.95
[58]
A.T. Beck,D. Schuyler,I. Herman
Development of suicidal intent scales
The prediction of suicide, pp. 45-56
[59]
K. Posner,G.K. Brown,B. Stanley,D.A. Brent,K.V. Yershova,M.A. Oquendo
The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults
Am J Psychiatry, 168 (2011), pp. 1266-1277 http://dx.doi.org/10.1176/appi.ajp.2011.10111704
[60]
H. Meltzer
Clozapine and suicide
Am J Psychiatry, 159 (2002), pp. 323-324 http://dx.doi.org/10.1176/appi.ajp.159.2.323
[61]
H.Y. Meltzer,L. Alphs,A.I. Green,A.C. Altamura,R. Anand,A. Bertoldi
Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT)
Arch Gen Psychiatry, 60 (2003), pp. 82-91
[62]
C. Arango,I. Bombin,T. Gonzalez-Salvador,I. Garcia-Cabeza,J. Bobes
Randomised clinical trial comparing oral versus depot formulations of zuclopenthixol in patients with schizophrenia and previous violence
Eur Psychiatry, 21 (2006), pp. 34-40 http://dx.doi.org/10.1016/j.eurpsy.2005.07.006
[63]
C. Arango,A. Calcedo Barba,S. González,A. Calcedo Ordóñez
Violence in inpatients with schizophrenia: a prospective study
Schizophr Bull, 25 (1999), pp. 493-503
[64]
J. Bobes,O. Fillat,C. Arango
Violence among schizophrenia out-patients compliant with medication: prevalence and associated factors
Acta Psychiatr Scand, 119 (2009), pp. 218-225 http://dx.doi.org/10.1111/j.1600-0447.2008.01302.x
[65]
K. Witt,R. van Dorn,S. Fazel
Risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies
[66]
S.C. Yudofsky,J.M. Silver,W. Jackson,J. Endicott,D. Williams
The Overt Aggression Scale for the objective rating of verbal and physical aggression
Am J Psychiatry, 143 (1986), pp. 35-39 http://dx.doi.org/10.1176/ajp.143.1.35
[67]
J. Volavka,L. Citrome
Pathways to aggression in schizophrenia affect results of treatment
Schizophr Bull, 37 (2011), pp. 921-929 http://dx.doi.org/10.1093/schbul/sbr041
[68]
S.R. Marder
Perspective: retreat from the radical
Nature, 508 (2014), pp. S18 http://dx.doi.org/10.1038/508S18a
[69]
P. Chue,J.K. Lalonde
Addressing the unmet needs of patients with persistent negative symptoms of schizophrenia: emerging pharmacological treatment options
Neuropsychiatr Dis Treat, 10 (2014), pp. 777-789 http://dx.doi.org/10.2147/NDT.S43404
[70]
T. Wykes,V. Huddy,C. Cellard,S.R. McGurk,P. Czobor
A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes
Am J Psychiatry, 168 (2011), pp. 472-485 http://dx.doi.org/10.1176/appi.ajp.2010.10060855
[71]
C. Jones,D. Hacker,I. Cormac,A. Meaden,C.B. Irving
Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia
Cochrane Database Syst Rev, 4 (2012), pp. CD008712
[72]
M. De Hert,D. Cohen,J. Bobes,M. Cetkovich-Bakmas,S. Leucht,D.M. Ndetei
Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level
World Psychiatry, 10 (2011), pp. 138-151
[73]
M.A. De Hert,R. van Winkel,D. van Eyck,L. Hanssens,M. Wampers,A. Scheen
Prevalence of the metabolic syndrome in patients with schizophrenia treated with antipsychotic medication
Schizophr Res, 83 (2006), pp. 87-93 http://dx.doi.org/10.1016/j.schres.2005.12.855
[74]
M. De Hert,C.U. Correll,J. Bobes,M. Cetkovich-Bakmas,D. Cohen,I. Asai
Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care
World Psychiatry, 10 (2011), pp. 52-77
[75]
A.I. Green,C.M. Canuso,M.J. Brenner,J.D. Wojcik
Detection and management of comorbidity in patients with schizophrenia
Psychiatr Clin North Am, 26 (2003), pp. 115-139
[76]
J. Sáiz Ruiz,J. Bobes García,J. Vallejo Ruiloba,J. Giner Ubago,M.P. García-Portilla González
Consensus on physical health of patients with schizophrenia from the Spanish Societies of Psychiatry and Biological Psychiatry
Actas Esp Psiquiatr, 36 (2008), pp. 251-264
[77]
J. Saiz-Ruiz,M.D. Saiz-Gonzalez,A.A. Alegria,E. Mena,J. Luque,J. Bobes
Impact of the Spanish consensus on physical health of patients with schizophrenia
Rev Psiquiatr Salud Ment (Barc), 3 (2010), pp. 119-127
[78]
E.M. Moreno,J.A. Moriana
Clinical guideline implementation strategies for common mental health disorders
Rev Psiquiatr Salud Ment (Barc), 9 (2016), pp. 51-62
[79]
D. McDaid,A.L. Park
Counting all the costs: the economic impact of comorbidity
pp. 23-32
[80]
E. Peckham,M.S. Man,N. Mitchell,J. Li,T. Becque,S. Knowles
Smoking Cessation Intervention for severe Mental Ill Health Trial (SCIMITAR): a pilot randomised control trial of the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation service
Health Technol Assess, 19 (2015), pp. 1-148 http://dx.doi.org/10.3310/hta191020
v–vi
[81]
D.I. Velligan,Y.W. Lam,D.C. Glahn,J.A. Barrett,N.J. Maples,L. Ereshefsky
Defining and assessing adherence to oral antipsychotics: a review of the literature
Schizophr Bull, 32 (2006), pp. 724-742 http://dx.doi.org/10.1093/schbul/sbj075
[82]
D.C. Goff,M. Hill,O. Freudenreich
Strategies for improving treatment adherence in schizophrenia and schizoaffective disorder
J Clin Psychiatry, 71 (2010), pp. 20-26 http://dx.doi.org/10.4088/JCP.9096su1cc.04
[83]
F.J. Acosta,J.L. Hernandez,J. Pereira,J. Herrera,C.J. Rodriguez
Medication adherence in schizophrenia
World J Psychiatry, 2 (2012), pp. 74-82 http://dx.doi.org/10.5498/wjp.v2.i5.74
[84]
M. Sajatovic,D.I. Velligan,P.J. Weiden,M.A. Valenstein,G. Ogedegbe
Measurement of psychiatric treatment adherence
J Psychosom Res, 69 (2010), pp. 591-599 http://dx.doi.org/10.1016/j.jpsychores.2009.05.007
[85]
L. Osterberg,T. Blaschke
Adherence to medication
N Engl J Med, 353 (2005), pp. 487-497 http://dx.doi.org/10.1056/NEJMra050100
[86]
A. Val Jiménez,G. Amorós Ballestero,P. Martínez Visa,M.L. Fernández Ferré,M. León Sanromà
Descriptive study of patient compliance in pharmacologic antihypertensive treatment and validation of the Morisky and Green test
Aten Primaria, 10 (1992), pp. 767-770
[87]
D.E. Morisky,L.W. Green,D.M. Levine
Concurrent and predictive validity of a self-reported measure of medication adherence
Med Care, 24 (1986), pp. 67-74
[88]
J.P. Lacro,L.B. Dunn,C.R. Dolder,S.G. Leckband,D.V. Jeste
Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature
J Clin Psychiatry, 63 (2002), pp. 892-909
[89]
T.J. Hudson,R.R. Owen,C.R. Thrush,X. Han,J.M. Pyne,P. Thapa
A pilot study of barriers to medication adherence in schizophrenia
J Clin Psychiatry, 65 (2004), pp. 211-216
[90]
J.M. Kane,T. Kishimoto,C.U. Correll
Non-adherence to medication in patients with psychotic disorders: epidemiology, contributing factors and management strategies
World Psychiatry, 12 (2013), pp. 216-226 http://dx.doi.org/10.1002/wps.20060
[91]
R.W. Buchanan,J. Kreyenbuhl,D.L. Kelly,J.M. Noel,D.L. Boggs,B.A. Fischer
The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements
Schizophr Bull, 36 (2010), pp. 71-93 http://dx.doi.org/10.1093/schbul/sbp116
[92]
W.R. Keller,B.A. Fischer,R. McMahon,W. Meyer,M. Blake,R.W. Buchanan
Community adherence to schizophrenia treatment and safety monitoring guidelines
J Nerv Ment Dis, 202 (2014), pp. 6-12 http://dx.doi.org/10.1097/NMD.0000000000000093
[93]
V. Bird,P. Premkumar,T. Kendall,C. Whittington,J. Mitchell,E. Kuipers
Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review
Br J Psychiatry, 197 (2010), pp. 350-356 http://dx.doi.org/10.1192/bjp.bp.109.074526
[94]
J.M. Olivares,J. Sermon,M. Hemels,A. Schreiner
Definitions and drivers of relapse in patients with schizophrenia: a systematic literature review
Ann Gen Psychiatry, 12 (2013), pp. 32 http://dx.doi.org/10.1186/1744-859X-12-32
[95]
O. Caseiro,R. Perez-Iglesias,I. Mata,O. Martinez-Garcia,J.M. Pelayo-Teran,R. Tabares-Seisdedos
Predicting relapse after a first episode of non-affective psychosis: a three-year follow-up study
J Psychiatr Res, 46 (2012), pp. 1099-1105 http://dx.doi.org/10.1016/j.jpsychires.2012.05.001
[96]
M. Alvarez-Jimenez,A. Priede,S.E. Hetrick,S. Bendall,E. Killackey,A.G. Parker
Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies
Schizophr Res, 139 (2012), pp. 116-128 http://dx.doi.org/10.1016/j.schres.2012.05.007
[97]
M. Alvarez-Jimenez,J.F. Gleeson,L.P. Henry,S.M. Harrigan,M.G. Harris,G.P. Amminger
Prediction of a single psychotic episode: a 7.5-year, prospective study in first-episode psychosis
Schizophr Res, 125 (2011), pp. 236-246 http://dx.doi.org/10.1016/j.schres.2010.10.020
[98]
L. Wunderink,F.J. Nienhuis,S. Sytema,C.J. Slooff,R. Knegtering,D. Wiersma
Guided discontinuation versus maintenance treatment in remitted first-episode psychosis: relapse rates and functional outcome
J Clin Psychiatry, 68 (2007), pp. 654-661
[99]
J. Mayoral-van Son,V. Ortiz-Garcia de la Foz,O. Martinez-Garcia,T. Moreno,M. Parrilla-Escobar,E.M. Valdizan
Clinical outcome after antipsychotic treatment discontinuation in functionally recovered first-episode nonaffective psychosis individuals: a 3-year naturalistic follow-up study
J Clin Psychiatry, 77 (2016), pp. 492-500 http://dx.doi.org/10.4088/JCP.14m09540
[100]
D. Wiersma,F.J. Nienhuis,C.J. Slooff,R. Giel
Natural course of schizophrenic disorders: a 15-year followup of a Dutch incidence cohort
Schizophr Bull, 24 (1998), pp. 75-85
[101]
J. Oliva-Moreno,J. Lopez-Bastida,R. Osuna-Guerrero,A.L. Montejo-Gonzalez,B. Duque-Gonzalez
The costs of schizophrenia in Spain
Eur J Health Econ, 7 (2006), pp. 182-188 http://dx.doi.org/10.1007/s10198-006-0350-5
[102]
C. Arango,X. Amador
Lessons learned about poor insight
Schizophr Bull, 37 (2011), pp. 27-28 http://dx.doi.org/10.1093/schbul/sbq143
[103]
R. Ayesa-Arriola,J.M. Rodriguez-Sanchez,C. Morelli,J.M. Pelayo-Teran,R. Perez-Iglesias,I. Mata
Insight dimensions in first-episode psychosis patients: clinical, cognitive, pre-morbid and socio-demographic correlates
Early Interv Psychiatry, 5 (2011), pp. 140-149 http://dx.doi.org/10.1111/j.1751-7893.2010.00249.x
[104]
M. Parellada,L. Boada,D. Fraguas,S. Reig,J. Castro-Fornieles,D. Moreno
Trait and state attributes of insight in first episodes of early-onset schizophrenia and other psychoses: a 2-year longitudinal study
Schizophr Bull, 37 (2011), pp. 38-51 http://dx.doi.org/10.1093/schbul/sbq109
[105]
L. Pina-Camacho,J. Garcia-Prieto,M. Parellada,J. Castro-Fornieles,A.M. Gonzalez-Pinto,I. Bombin
Predictors of schizophrenia spectrum disorders in early-onset first episodes of psychosis: a support vector machine model
Eur Child Adolesc Psychiatry, 24 (2015), pp. 427-440 http://dx.doi.org/10.1007/s00787-014-0593-0
[106]
N. Camprubi,A. Almela,J. Garre-Olmo
Psychometric properties of the Spanish validation of the Insight Scale
Actas Esp Psiquiatr, 36 (2008), pp. 323-330
[107]
M. Birchwood,J. Smith,V. Drury,J. Healy,F. Macmillan,M. Slade
A self-report Insight Scale for psychosis: reliability, validity and sensitivity to change
Acta Psychiatr Scand, 89 (1994), pp. 62-67
[108]
A. Ruiz,E. Pousa,R. Duno,J. Crosas,S. Cuppa,C. Garcia
Spanish adaptation of the Scale to Asses Unawareness of Mental Disorder (SUMD)
Actas Esp Psiquiatr, 36 (2008), pp. 111-1198
[109]
J.A. Gutierrez-Zotes,J. Valero,M.J. Cortes,A. Labad,S. Ochoa,M. Ahuir
Spanish adaptation of the Beck Cognitive Insight Scale (BCIS) for schizophrenia
Actas Esp Psiquiatr, 40 (2012), pp. 2-9
[110]
A.T. Beck,E. Baruch,J.M. Balter,R.A. Steer,D.M. Warman
A new instrument for measuring insight: the Beck Cognitive Insight Scale
Schizophr Res, 68 (2004), pp. 319-329 http://dx.doi.org/10.1016/S0920-9964(03)00189-0
[111]
M. Birchwood,C. Jackson,K. Brunet,J. Holden,K. Barton
Personal beliefs about illness questionnaire-revised (PBIQ-R): reliability and validation in a first episode sample
Br J Clin Psychol, 51 (2012), pp. 448-458 http://dx.doi.org/10.1111/j.2044-8260.2012.02040.x
[112]
R. Robles García,V. Salazar Alvarado,F. Páez Agraz,F. Ramírez Barreto
Evaluación de actitudes al medicamento en pacientes con esquizofrenia: propiedades psicométricas de la versión en español del DAI
Actas Esp Psiquiatr, 32 (2004), pp. 138-142
[113]
T.P. Hogan,A.G. Awad,R. Eastwood
A self-report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity
Psychol Med, 13 (1983), pp. 177-183
[114]
A.G. Awad
Subjective response to neuroleptics in schizophrenia
Schizophr Bull, 19 (1993), pp. 609-618
[115]
J. Sanjuan,J.M. Haro,J. Maurino,T. Diez,J. Ballesteros
Validation of the Spanish version of the Subjective Well-being under Neuroleptic Scale (SWN-K) in patients with schizophrenia
Med Clin (Barc), 138 (2012), pp. 151-154
[116]
D. Naber
A self-rating to measure subjective effects of neuroleptic drugs, relationships to objective psychopathology, quality of life, compliance and other clinical variables
Int Clin Psychopharmacol, 10 (1995), pp. 133-138
[117]
G.H. Pijnenborg,R.J. van Donkersgoed,A.S. David,A. Aleman
Changes in insight during treatment for psychotic disorders: a meta-analysis
Schizophr Res, 144 (2013), pp. 109-117 http://dx.doi.org/10.1016/j.schres.2012.11.018
[118]
M.J. Cuesta,A.M. Sanchez-Torres,B. Cabrera,M. Bioque,J. Merchan-Naranjo,I. Corripio
Premorbid adjustment and clinical correlates of cognitive impairment in first-episode psychosis. The PEPsCog Study
Schizophr Res, 164 (2015), pp. 65-73 http://dx.doi.org/10.1016/j.schres.2015.02.022
[119]
N. Bakkour,J. Samp,K. Akhras,E. El Hammi,I. Soussi,F. Zahra
Systematic review of appropriate cognitive assessment instruments used in clinical trials of schizophrenia, major depressive disorder and bipolar disorder
Psychiatry Res, 216 (2014), pp. 291-302 http://dx.doi.org/10.1016/j.psychres.2014.02.014
[120]
O. Pino,G. Guilera,J.E. Rojo,J. Gómez-Benito,S.E. Purdon
SCIP-S, screening del deterioro cognitivo en psiquiatría
TEA Ediciones, (2014)
[121]
Purdon SE. The Screen for Cognitive Impairment in Psychiatry (SCIP): instructions and three alternate forms. Edmonton, AB: PNL, Inc.
[122]
M.L. Vargas,J.C. Sanz,J.J. Marin
Behavioral assessment of the dysexecutive syndrome battery (BADS) in schizophrenia: a pilot study in the Spanish population
Cogn Behav Neurol, 22 (2009), pp. 95-100 http://dx.doi.org/10.1097/WNN.0b013e318192cd08
[123]
N. Alderman,P.W. Burgess,H. Emslie,J.J. Evans,B. Wilson
BADS – behavioral assessment of dysexecutive syndrome
Thames Valley, (1996)
[124]
R.S. Keefe,M. Poe,T.M. Walker,J.W. Kang,P.D. Harvey
The Schizophrenia Cognition Rating Scale: an interview-based assessment and its relationship to cognition, real-world functioning, and functional capacity
Am J Psychiatry, 163 (2006), pp. 426-432 http://dx.doi.org/10.1176/appi.ajp.163.3.426
[125]
K.H. Choi,T. Wykes,M.M. Kurtz
Adjunctive pharmacotherapy for cognitive deficits in schizophrenia: meta-analytical investigation of efficacy
Br J Psychiatry, 203 (2013), pp. 172-178 http://dx.doi.org/10.1192/bjp.bp.111.107359
[126]
D. Fraguas,J. Merchan-Naranjo,A. del Rey-Mejias,J. Castro-Fornieles,A. Gonzalez-Pinto,M. Rapado-Castro
A longitudinal study on the relationship between duration of untreated psychosis and executive function in early-onset first-episode psychosis
Schizophr Res, 158 (2014), pp. 126-133 http://dx.doi.org/10.1016/j.schres.2014.06.038
[127]
D.C. Goff,M. Hill,D. Barch
The treatment of cognitive impairment in schizophrenia
Pharmacol Biochem Behav, 99 (2011), pp. 245-253 http://dx.doi.org/10.1016/j.pbb.2010.11.009
[128]
R.E. Nielsen,S. Levander,G. Kjaersdam Telleus,S.O. Jensen,T. Ostergaard Christensen,S. Leucht
Second-generation antipsychotic effect on cognition in patients with schizophrenia — a meta-analysis of randomized clinical trials
Acta Psychiatr Scand, 131 (2015), pp. 185-196 http://dx.doi.org/10.1111/acps.12374
[129]
S. Moritz,C. Andreou,S. Klingberg,T. Thoering,M.J. Peters
Assessment of subjective cognitive and emotional effects of antipsychotic drugs. Effect by defect?
Neuropharmacology, 72 (2013), pp. 179-186 http://dx.doi.org/10.1016/j.neuropharm.2013.04.039
[130]
S. Vinogradov,M. Fisher,E. de Villers-Sidani
Cognitive training for impaired neural systems in neuropsychiatric illness
Neuropsychopharmacology, 37 (2012), pp. 43-76 http://dx.doi.org/10.1038/npp.2011.251
[131]
P.D. Harvey
What is the evidence for changes in cognition and functioning over the lifespan in patients with schizophrenia?
J Clin Psychiatry, 75 (2014), pp. 34-38 http://dx.doi.org/10.4088/JCP.13065su1.08
[132]
R. Penades,N. Pujol,R. Catalan,G. Massana,G. Rametti,C. Garcia-Rizo
Brain effects of cognitive remediation therapy in schizophrenia: a structural and functional neuroimaging study
Biol Psychiatry, 73 (2013), pp. 1015-1023 http://dx.doi.org/10.1016/j.biopsych.2013.01.017
[133]
K. Subramaniam,S. Vinogradov
Cognitive training for psychiatric disorders
Neuropsychopharmacology, 38 (2013), pp. 242-243 http://dx.doi.org/10.1038/npp.2012.177
[134]
G Shepherd,J Boardman,M. Slade
Hacer de la recuperación una realidad
(2007)
Available from: http://www.juntadeandalucia.es/salud/servicios/contenidos/andaluciaessalud/docs/42/Hacer_Realidad_la_Recuperaci%C3%B3n.pdf [accessed 14.01.16]
[135]
J. Loss,M. Wiese
Evaluation von Empowerment–Perspektiven und Konzepte von Gesundheitsförderern. Ergebnisse einer qualitativen Studie in Australien
Gesundheitswesen, 70 (2008), pp. 755-763 http://dx.doi.org/10.1055/s-0028-1103260
[136]
W.W. Fleischhacker,C. Arango,P. Arteel,T.R. Barnes,W. Carpenter,K. Duckworth
Schizophrenia — time to commit to policy change
Schizophr Bull, 40 (2014), pp. S165-S194 http://dx.doi.org/10.1093/schbul/sbu006
[137]
S. Leucht,M. Tardy,K. Komossa,S. Heres,W. Kissling,G. Salanti
Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis
[138]
A.G. Awad,L.N. Voruganti
Impact of atypical antipsychotics on quality of life in patients with schizophrenia
CNS Drugs, 18 (2004), pp. 877-893
[139]
G. Kaplan,J. Casoy,J. Zummo
Impact of long-acting injectable antipsychotics on medication adherence and clinical, functional, and economic outcomes of schizophrenia
Patient Prefer Adherence, 7 (2013), pp. 1171-1180 http://dx.doi.org/10.2147/PPA.S53795
[140]
T. Kishimoto,A. Robenzadeh,C. Leucht,S. Leucht,K. Watanabe,M. Mimura
Long-acting injectable vs oral antipsychotics for relapse prevention in schizophrenia: a meta-analysis of randomized trials
Schizophr Bull, 40 (2014), pp. 192-213 http://dx.doi.org/10.1093/schbul/sbs150
[141]
D. Jose,Ramachandra,K. Lalitha,S. Gandhi,G. Desai,Nagarajaiah
Consumer perspectives on the concept of recovery in schizophrenia: a systematic review
Asian J Psychiatr, 14 (2015), pp. 13-18 http://dx.doi.org/10.1016/j.ajp.2015.01.006
[142]
M. Muñoz,E. Pérez,M. Crespo,A.I. Guillén
El estigma de la enfermedad mental
Consejería de Familia y Asuntos Sociales de la Comunidad de Madrid-Obra Social de Caja Madrid-Universidad Complutense de Madrid, (2009)
[143]
E. Brohan,R. Elgie,N. Sartorius,G. Thornicroft
Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: the GAMIAN-Europe study
Schizophr Res, 122 (2010), pp. 232-238 http://dx.doi.org/10.1016/j.schres.2010.02.1065
[144]
E.L. Struening,D.A. Perlick,B.G. Link,F. Hellman,D. Herman,J.A. Sirey
Stigma as a barrier to recovery: the extent to which caregivers believe most people devalue consumers and their families
Psychiatr Serv, 52 (2001), pp. 1633-1638 http://dx.doi.org/10.1176/appi.ps.52.12.1633
[145]
M. King,S. Dinos,J. Shaw,R. Watson,S. Stevens,F. Passetti
The Stigma Scale: development of a standardised measure of the stigma of mental illness
Br J Psychiatry, 190 (2007), pp. 248-254 http://dx.doi.org/10.1192/bjp.bp.106.024638
[146]
J.B. Ritsher,P.G. Otilingam,M. Grajales
Internalized stigma of mental illness: psychometric properties of a new measure
Psychiatry Res, 121 (2003), pp. 31-49
[147]
S. Evans-Lacko,K. Little,H. Meltzer,D. Rose,D. Rhydderch,C. Henderson
Development and psychometric properties of the Mental Health Knowledge Schedule
Can J Psychiatry, 55 (2010), pp. 440-448 http://dx.doi.org/10.1177/070674371005500707
[148]
S.M. Taylor,M.J. Dear
Scaling community attitudes toward the mentally ill
Schizophr Bull, 7 (1981), pp. 225-240
[149]
S. Evans-Lacko,D. Rose,K. Little,C. Flach,D. Rhydderch,C. Henderson
Development and psychometric properties of the reported and intended behaviour scale (RIBS): a stigma-related behaviour measure
Epidemiol Psychiatr Sci, 20 (2011), pp. 263-271
[150]
M. Bernardo,M. Bioque
What have we learned from research into first-episode psychosis?
Rev Psiquiatr Salud Ment (Barc), 7 (2014), pp. 61-63

Please cite this article as: Crespo-Facorro B, Bernardo M, Argimon JM, Arrojo M, Bravo-Ortiz MF, Cabrera-Cifuentes A, et al. Eficacia, eficiencia y efectividad en el tratamiento multidimensional de la esquizofrenia: proyecto Rethinking. Rev Psiquiatr Salud Ment (Barc). 2017;10:4–20.

Copyright © 2016. SEP y SEPB
es en pt
Política de cookies Cookies policy Política de cookies
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos