December 16, 2005

New Canadian Treatment Guidelines for Schizophrenia

Marvin Ross sends us these links to the new Canadian Treatment Guidelines for schizophrenia published in the Canadian Journal of Psychiatry. This is the guide for Canadian psychiatrists for the treatment of schizophrenia. Its somewhat "technical" in nature - but we think most people who have been visiting and reading at this web site for a while can handle the terminology. Its highly recommended reading. Canada is arguably much faster in implementing new approaches, treatments and therapies for schizophrenia than many other countries, including the US, and already has a strong network of early diagnosis and treatment centers across the country. Some drugs are different in Canada, compared to the USA. Of particular interest to many families are the recommended "Psychosocial" interventions and therapies. Click on the Table of Contents link below to start reading from the beginning of the document.

Note that PDF files of the Canadian Schizophrenia Treatment Guidelines are also available here - see the left side of the page where it says "PDF" to download and print out these files. You may want to send them to family members or friends or NAMI members who might benefit. The last USA Schizophrenia treatment guidelines was published in 1999, we believe, and is only available for a fee (though a short summary is available for families).

The Canadian Journal of Psychiatry
November 2005
Treatment of Schizophrenia

Table of Contents - listing of all Contents
7S Rationale
8S Guideline Development Process
8S Table 1 Criteria for rating quality of published evidence in individual articles reviewed
9S Literature Search
9S Screening Process
9S Table 2 Evidence level summary for rating evidence
10S Quality-Rating Process
11S General Principles
11S Acute Phase
12S Table 3 Assessments for patients with schizophrenia
13S Stabilization Phase
13S Stable Phase
14S Relapse and Adherence to Treatment
14S Table 4 Recommendation
15S Specific Clinical Situations and Assessments
15S First Episode
15S Neuropsychological Assessment
15S Genetic Assessment
16S Neuroimaging
16S Poorly Responsive or “Refractory” Illness
16S Comorbid Conditions
16S Physical Health Monitoring
17S Dual Diagnosis (Mental Retardation)
19S Medications
19S General Principles
19S Second-Generation Antipsychotics
20S Pharmacologic Strategies for Phase-Specific Treatment
20S Acute Phase
21S Table 5 Second-generation antipsychotic dosages and titration
22S Stabilization Phase
22S Stable Phase
25S Management of Side Effects
25S Weight Gain and Abdominal Obesity
25S Impairment in Glucose Regulation and Diabetes
25S Dyslipidemia
25S QT Prolongation
25S Endocrine and Sexual Side Effects
26S Cognitive Side Effects and Sedation
26S Extrapyramidal Side Effects
26S Neuroleptic Dysphoria
26S Neuroleptic Malignant Syndrome
27S Clozapine Side Effect Profile
27S Table 6 Recommendations
28S Drug–Drug Interactions
29S General Principles
29S Medication Adherence and Psychoeducation
30S Vocational Interventions
30S Skills Training
30S Cognitive-Behavioural Interventions
31S Family Interventions
32S Cognitive Remediation
32S Peer Support, Self-Help, and Recovery
33S Stigma
33S Associated Features and Special Situations
33S Treatment of Comorbid Symptoms
33S Substance Use
33S Prenatal Planning
34S Psychosocial Interventions Across Illness Phases
34S Acute Phase
34S Stabilization Phase
34S Stable Phase
35S Table 7 Recommendations
37S Service Delivery and the Treatment System
37S General Principles
37S Access
38S Availability
38S Coordination and Continuity of Care
38S Service Delivery Components
38S Early Psychosis Treatment Services
38S Acute Inpatient Care
38S Day Hospitals
39S Home-Based Acute Care
39S Mobile Crisis Service
39S Outpatient and Community Mental Health Services
39S Case Management
40S Residential Care
41S Table 8 Recommendations
43S The Prodromal Phase of Schizophrenia
43S Table 9 Recommendations
53S Appendix I Jadad Scale for Rating Clinical Trials
54S Appendix II Algorithm A. Pharmacotherapy. Acute Emergent Phase: The Severely Aggressive and (or) Agitated Patient
55S Appendix III Algorithm B. Pharmacotherapy: Stabilization and Stable Phase
56S Appendix IV Schema of Psychosocial Interventions: Stabilization and Stable Phase


This article is excellent. I have printed it, and am encouraged how the therapeutic interventions are seen as essential to treatment as well.

Thank you.

Posted by: hopeformydolly at December 17, 2005 01:08 PM

I notice that the development, printing and distribution of these new Canadian guidelines were paid for entirely by four leading Canadian drug companies.

It is therefore not surprising that the authors, aware of and beholden to such drug companies, make no mention anywhere of nutritional therapy of schizophrenia, not even mentioning Fishoil.

Over in England, Dr Malcolm Peet has done excellent work on high-dose Fishoil fatty acid treatment of schizophrenia, .... [Edited for brevity by editors]

Posted by: Dr Robert Peers at December 18, 2005 05:51 AM

Mr. Peers,

Yes - I see that you are correct on this point, the drug companies provided funding in the way of a non-restricted grant, and that payment is fully explained in the new guidelines issued by the Canadians. Please also note that they cover a broad array of different treatments (e.g. psycho-social, etc.) that do not have anything to do with the medications. It seems to us to be a reasonably well-balanced publication.

We certainly hope to see Dr. Peet's research replicated by independent groups and ultimately shown to be effective - but thats not the case yet. Like you - we hope to more effective treatments of any time for schizophrenia, and we don't care where they come from.

Its interesting that you don't note that Dr. Peet also gets funding from a Fish Oil company (he is on the scientific board of advisors for Minami Nutrition which provides the OmegaBrite fish oils) - perhaps you just haven't been aware of this, but you seem to think that there is no possible conflict of interest there - for some reason you think that only funding that comes from certain corporations is relevant to disclose, and not others, or that the biases of some people or corporations may be important and others not.

Please stop posting what we believe are your obviously heavily biased view on our site. We work very hard to provide a fully balanced view on all possible treatments for schizophrenia - and we are an evidence-based site. The plain fact is that the research on all of the treatments you've been pushing so hard are all in their very early stages, and not nearly as well researched as other treatments that we cover. In fact the recent Cochrane review of fish oil suggests that nothing is really proven yet - and since that is the gold standard of reference points, we're going with that.

Until that research is done that provides greater proof of efficacy, please stop posting what we feel are largely off-topic, or not well substantiated messages.


Posted by: Sz Administrator at December 18, 2005 02:46 PM

I thank you for pointing out Malcolm Peet's links with a fishoil nutrition company, which I did not know about before. Of course, we cannot judge whether this commercial connection adversely affects his fishoil research, which your science writer should investigate, if it worries you, and Fishoil reminds you of Pig Pills!

Please note that Malcolm has also made the priceless observation, unique in psychiatry, that the fatty, Omega-3 deficient Western diet is a major risk factor for both schizophrenia and chronic physical diseases, especially obesity, diabetes and heart disease, which are all much more common in schiz patients and in their families, than in other families.

His recent review paper, Nutrition And Schizophrenia (Wrld Rev Nutr Dietet, 2005) is about much more than fishoil, so I believe his heart is in the right place after all, that he wants his patients to have a healthy diet and lose weight, as well as take fishoil.

I do not see my posts as unbalanced, because although there will always be a place for (accidentally-discovered!)drugs in treatment of scz--I have prescribed them since 1970 myself--but it is now time, after 55 years of partially effective drug treatment, to put nutrition first, including Fishoil.

Scz patients are known to eat an unbalanced fatty diet, while low dietary intake of EPA correlates directly with increased scz severity (J E Mellor, Hum Psychopharmacol 1996; 11:39-46). Is it "unbalanced" of me to suggest that low-fat diet and a capsule or two of fishoil will help the brain, and also reduce diabetes and heart risk!

I was once an admitting officer at a major psychiatric hospital, so I know my drugs--but surely we can now prescribe diet and fishoil as well, hoping to reduce the dose of drugs, which cause tiredness, diabetes and unemployability, as we all know.

Regarding my posts, I realize that is tedious for everybody to be reading my diet stuff, and perhaps I have said enough already, but may I suggest an alternative? Since you state that your web site welcomes new treatment ideas for scz, provided they are evidence-based, why not set aside a special section on Nutrition And Schizophrenia, where diet promoters and skeptics (like yourselves!) can present evidence for and against?

Many of your readers would surely like to see up-to-date reliable info on brain nutrition (as on the new British site,, as new research results appear in this small but growing field, which may yet revolutionize psychiatry.

Is that a reasonable suggestion?

PS I notice that your own science writer, Mr Marvin Ross, states on his web site that he writes mostly for pharmaceutical companies--so in the interests of transparency, should this commercial tie not be stated also on this web site?

Posted by: Dr Robert Peers at December 18, 2005 10:59 PM

I for one (a caregiver of someone with sz)prefer waiting for evidence on fish oil and the Cochrane review would be a good authority.

I disagree that meds make people with sz unemployable. My loved one certainly is unemployable without meds. It can be symptoms of the illness that may make some people with illness unemployable. But, even on meds some people are not employable.

I guess what I don't like are blanket statements such as, meds make those with the illness unemployable.

I think there may be a role of nutririon, but EVIDENCE is necessary. The causes and triggers of sz seem to be variable and the illness doesn't effect everyone in the same way.

My loved one takes fishoil and medication and follows a very good diet. He also gets exercise every day. My experience with him is that the meds make him more motivated and less withdrawn. But, his meds have been finely tuned over quite a period of time. Maybe, some people with sz get frustrated with the meds and give up on them. It really is quite a process to stick with the meds and work with pdocs to get the right mix.

In the past, my loved one with sz completely bought into the idea that fish oil could be a cure. He cut back his meds drastically and then stopped taking them altogether. He relapsed and was jailed and then spent 2 months in hospital.

I feel very strongly that there needs to be evidence that fish oil works, if indeed it does.

If it works for some and then not for others, how will this be determined. In my loved ones' case, I feel his trial of fish oil only, came at far too great a cost as he relapsed in order to find out that it didn't work for him.

Evidence is the only way.

Posted by: Catherine at December 20, 2005 06:40 AM


Seven blind people touched various parts of the elephant and opined it to be a pillar,fan,snake etc.Schizophrenia is just like that and all brain disceases seem to have one thing common;that 30% donot respond to any treatment known to mankind at that time.A very functional schizophernic has reduced her dosage but compensated it with YOGA which has significantly helped her.i work undeer her and so i know.this trick will not work for 30%.why?god only knows.Fishoil may again help some in adjunct with normal medication.Chinese have found strong help in reducing sideffects with GINGOBILBOA.Let all Blindmen including neurologists,neurosurgeons,neurochemists,aneasthesists,immunologists etc and ofcourse psychiatrists work together in focussed manner and find the BIG PICTURE.

Posted by: captain johann at December 21, 2005 07:33 AM

the statements about fish oil above are fictitious and have already been debunked by cochrane. there is no proof for any of the statements given in its favor, and no evidence that taking fish oil does anything to improve the disease. nor is there any evidence that fish oil or any oil or any fatty acid compounds are deficient and cause schizophrenia. until the cause of the disease is known, claiming a substance will cure it is utterly facetious.

it's like seeing someone wearing high heeled shoes and saying high heeled shoes cause schizophrenia, or fuller saying it's caused by cats.

it is completely false that 30 per cent of schiz. cases don't respond to any medication. actually the percentage of cases that are completely non-med responsive is far lower, under 5 per cent. in every case of 'non response' i have ever seen, the person was either not taking his medication or was not being given the right medication.

too, it depends on how 'treatment response' is measured, though. not all people see all symptoms disappear, however that has never been and never will be the goal of treatment.

medication is a starting point. a doctor has to take that medication and use it as a tool, and learn which medication (s) help each individual, and which ones they tolerate. i'd like there to be more medications to choose from, better quality control, better research, and many things, but if i had to lay the blame at one door right now, i would blame it on the overall quality of the health care and legal/community health system in our country, which leaves people to deteriorate until nothing can help them.

schizophrenia is a brain disease. medication is not a miracle cure, it is a TREATMENT. early treatment is the key. if treatment is sporadic, insufficient or with the wrong medication, this allows this disease to progress. i see the end product in people fully disabled in nursing homes.


Posted by: slc at January 17, 2006 08:45 AM

excellent website , however heavy bias in favor of genetic and chemical theories and poor research into depth therapies.
I am a physician and psychologist, practicing both. I wish to remain anonymous to avoid peer harassment, but I assure you that under the right conditions the disease can be beaten to the point of minimal or even no medication. and this is over and above the percentage of natural remissions

Posted by: shrink psych at April 10, 2006 05:12 PM

actually no two scz person react the same to abilify, let alone seroquel.

yet for some bipolars with psychotic symptoms, an anti-psychotic may be prescribed for temporary relief.

i object to the statement that schizophrenia is a brain disease, when the meds used are mainly for the behavior disorder(s) arising from that disease, not the disease itself.

and sometimes they even use anti-depressants.

to call the theories about fish oil fiction is an opinion.

most of what is known about schizophrenia can be detected through expensive brain scans now.

the theory as to why not all meds work the same on all schizophrenic may too be "fiction".

heck, overuse of one medication could cause MOST of the symptoms for one patient while another patient could be tolerant to it.

but overall, diet is important, especially for predromal schizophrenics.

and no, not all schizophrenics will have a psychotic episode.

the highly functional just become eccentric.

Posted by: sageb1 at February 21, 2007 02:13 AM

I need your advice for my cousin. He is sick with schizophrania as doctors said but he refuses to take medicine . he doesnot trust anyone and even his parents. he doesnot get out of his room and feels that there are people watching him all the time. his situation is getting worse day after day what can we do. please if you have any suggestions answer me on my

Posted by: Manal at March 23, 2007 12:56 AM


I would like to take bifeprunox when it will be on the market. But at the moment I'm taking risperdal consta. I wonder if will take long before bifeprunox also will exist with injection. There must be a lot of people with the same problem. I don't know whether my doctor will think it is a good idea to change to bifeprunox if it is not as injection as I can not be sick again with a baby. However the company that is behind bifeprunox must be aware of the problem that many people have to take their medication with injection so I wonder why does it take so long time before it is injection?

Best regards,


Posted by: Helena at June 1, 2007 07:07 AM

Hello, this is a question for the doctor who wrote in and said that it can be cured to the point of little to no medication. Id love to know how because I want to help my sister, who they are ready to give up on and ship her off to a nursing home forvere, and she's only 39! If you cant tell me, can you give me a clue? Or can you email me directly at Id love to try anything to help my dear old sister!

Posted by: christina at January 1, 2008 02:53 AM

my 21 yr old daughter has an undetermind mental illness i want to try fish oil pills she is 5'4 110 lbs how many mg shoud i give to her. western medications have not helped they have hurt her please help

Posted by: SANDY at February 28, 2008 10:28 AM

I think that this is a really neat place even though I am trying to find some pages for my reasearch paper for art.

Posted by: lolita at June 19, 2008 09:11 AM

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