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National Guidelines for Psychosocial Interventions for Schizophrenia or Schizophrenia-type Conditions – summary

The National Guidelines for Psychosocial Interventions for Schizophrenia or Schizophrenia-type Conditions 2011 contain 43 recommendations. The National Board of Health and Welfare highlights recommendations on co-ordinated measures, family interventions, psychological treatment and vocational rehabilitation.

Central recommendations with economic and organisational consequences

The Swedish National Board of Health and Welfare adjudges that the recommendations concerning co-ordinated measures (Assertive Community Treatment – ACT model), family interventions, psychological treatment and vocational rehabilitation are those with the greatest efficacy. In the Condition and Remedy list (tillstånds- och åtgärdslista), all the conditions and remedies are presented.

The assessments made by the National Board of Health and Welfare concerning the economic and organisational consequences of the recommendations are based on the activities conducted by Health Care and Social Services at the present time. The information concerning which measures are implemented and to what extent they are implemented is, however, frequently inadequate. This makes such assessments difficult to make.

A number of measures recommended by the National Board of Health and Welfare have been developed internationally and are new for the psychiatric and social services in Sweden. During the work on the formulation of the national guidelines for psychosocial interventions for schizophrenia or schizophrenia spectrum disorders it has become clear that there is a need to develop an organisation and models for how new knowledge shall be effectively implemented.

Co-ordinated measures earlier – and also later

The National Board of Health and Welfare recommends early intervention measures in accordance with the ACT model (Assertive Community Treatment) including family interventions and social skills training. This approach centers on the early detection and treatment of early symptoms of persons with first time episode psychosis. These measures yield positive effects in terms of the possibility of independent living arrangements and the person concerned spending fewer days in hospital.

The National Board of Health and Welfare also recommends intensive case management in accordance with the ACT model for persons with schizophrenia or schizophrenia spectrum disorders who are high consumers of care and treatment, who risk being frequently admitted to psychiatric wards or who break off care contacts. Compared with treatment as usual, these measures reduce the number of hospitalizations, days in hospital, the risk of homelessness and unemployment as well as delivering greater stability in living arrangements.

The recommendations demand increased collaboration between the health care services (psychiatry) and the social services. In the short term, the recommendation implies increased costs for both health care services and social services, above all in terms of training, instruction/supervision and possible additional human resources. In the longer term, however, the National Board of Health and Welfare adjudges that the costs will be unchanged or lower compared with the situation today, inter alia owing to reduced costs for hospital care and treatment.

Family interventions

The National Board of Health and Welfare recommends family interventions for persons with schizophrenia or schizophrenia spectrum disorders who maintain contact with their family or close relatives. Such an intervention reduces the risk of relapse and hospitalisation and is considered to improve the person’s social functions and life quality as well as the emotional climate in the family.

The recommendation entails increased initial costs for the competence development of the personnel and a possible increased demand for human resources. In the longer term, however, the National Board of Health and Welfare adjudges that the costs will be unchanged or lower compared with today as a consequence of a more co-ordinated and flexible programme and as a result of a reduced number of relapses and hospitalisations.

Access to psychological treatment with cognitive behavioural therapy

The National Board of Health and Welfare recommends that health care services offer individualised cognitive behavioural therapy (CBT) to persons with schizophrenia or schizophrenia spectrum disorders with enduring symptoms. The main reason for the recommendation is that the treatment demonstrates positive effects on enduring symptoms and on central problems for the individual concerned. Health care services can also offer music therapy where persons have a need for so-called non-verbal therapy forms.

The National Board of Health and Welfare is aware that there exists a great shortage of personnel with appropriate competence within CBT. The recommendation requires that each county council (landsting) and region carry out an analysis of the current position as regards the availability of human resources with the right competence and how effective treatments are devised. The National Board of Health and Welfare adjudges that the costs for the health care services will increase in the short term but the costs are then expected to return to existing levels or even to a lower level.

Vocational rehabilitation through collaboration

The National Board of Health and Welfare recommends the Individual Placement and Support (IPS) model for persons with schizophrenia or schizophrenia spectrum disorders. Current evidence indicates that IPS supported employment is a more effective approach for helping people with psychiatric disorders to find and maintain competitive employment than traditional, stepwise approaches to vocational rehabilitation.

The responsibility for vocational rehabilitation lies at present with several different authorities in Sweden. It is not clear how the recommended measure shall find a place in the Swedish care and support system. There is consequently a need to continue with the trial activities on the basis of collaboration between the different authorities concerned. The implementation of the recommendation requires that the health care and social services collaborate with one another and also have contact with the Swedish Public Employment Service (Arbetsförmedlingen) and the Social Insurance Agency (Försäkringskassan).

The National Board of Health and Welfare adjudges that there will be an initial cost increase for health care and social services associated with the requirement for further training and supervision as well as the organisational change. In the longer term, however, the costs for health care services, social services and other parts of society will decline.

Lack of data sources impedes follow-up

The National Board of Health and Welfare has prepared 22 follow-up indicators within the psychosocial area for persons with schizophrenia or schizophrenia spectrum disorders.

The fact that data sources at present are lacking is a major problem for the follow-up of results within the psychosocial area. This lack of data sources means that the monitoring of the measures recommended in the guidelines is largely limited by whether the health care and social services are in a position to offer these data inputs at present. A development of data sources is continuing and, in the longer term, such indicators will be so formulated as to provide knowledge concerning the procedures applied in the psychosocial area and the results they deliver.

It is not possible to monitor certain indicators proposed at the national level at the present time. These indicators, however, should start to be used in the local follow-up of health care and social services for persons with mental impairment. A total of 15 national indicators have been prepared for the follow-up of the health care (psychiatric) inputs and 12 national indicators for social service inputs for persons with mental impairment. In addition, four more general indicators are proposed in order to reflect the results of the responsible authority’s measures in the psychosocial area.