This is the current release of the guideline.

Severe mental illness, including:

• Schizophrenic disorders
• Schizotypal disorders
• Persistent delirious disorders
• Induced delirious disorders
• Schizoaffective disorders
• Other non-organic psychotic disorders
• Bipolar disorder
• Serious depressive episode with psychotic symptoms
• Recurrent serious depressive disorders
• Compulsive obsessive disorder

Adults with severe mental illness

Note: The following cases are excluded from the target population group of this clinical practice guideline:

• People with mental disorders in childhood and adolescence (under 18 years old)
• People over the age of 65, as they are subject to receiving treatment in different services other than the Mental Health Service
• People affected by mental disorders that are secondary to medical illnesses
• People who have organic psychoses
• People whose disorder is included in psychotic categories but has a transitory or episodic nature
• People whose main diagnosis is substance abuse, moderate-serious intellectual impairment, general development disorders, who reach adult age or organic mental disorder
• People with personality disorders. This does not mean that personality disorders that present a psychotic symptomatology are excluded, but that this diagnosis per se does not mean that it is included.

Management/Nonpharmacological Treatment

1. Psychological interventions
   • Cognitive-behavioural therapy
   • Interpersonal therapy
   • Family interventions
   • Psychoeducational programmes
   • Cognitive rehabilitation
2. Social interventions
   • Daily living skills programmes
   • Residential programmes in the community
   • Programmes aimed at leisure and spare time
   • Programmes aimed at employment
   • Art and music therapy
3. Service level interventions
   • Continuity of assistance from care centres (e.g., day centres, psychosocial rehabilitation centres, community mental health centres, etc.)
   • Case management
4. Interventions with specific subpopulations
   • Dual diagnoses
   • Homelessness
   • Low intelligent quotient (IQ)/mental retardation

The search strategy started by identifying the most relevant clinical practice guidelines (CPGs) (local, national, and international) in different databases and information sources, prepared by other groups that could be relevant for this CPG: National Guideline Clearinghouse (NGC), Tripdatabase, GuíaSalud, National Institute for Health and Clinical Excellence (NICE), and Guidelines International Network (G-I-N).

26 CPGs were identified on some of the diagnoses that were included within the criterion of severe mental illness (SMI). Of these 26 guidelines, those in which the population, topics, interventions, development date, or methodology did not comply with the objectives and scope of this CPG were rejected. Finally, 5 guidelines were selected. The cut-off value to accept the guidelines following the Appraisal of Guidelines Research and Evaluation (AGREE) instrument was set at 60%, except for the methodology section, area 3: rigour and preparation, where the cut-off had to be over 75%. Each one of the 5 CPGs selected was assessed by 4 independent reviewers. Finally, only 3 CPG passed established cut-off values: the CPGs on schizophrenia, bipolar disorder and compulsive obsessive disorder developed by NICE of the United Kingdom, and it was decided to use them as a secondary source of evidence that would help answer some specific aspects.

Once the part corresponding to the identification and analysis of published CPGs had ended, in order to make the bibliographic search for relevant evidence that might respond to the questions of the CPG formulated previously, it was established that the following general databases would be consulted: Medline, Cochrane Library, Embase and PsycINFO. Furthermore, different web sites, entities, and associations were consulted, such as the Centre for Reviews and Dissemination (CRD), NICE, American Psychiatric Association (APA), and ClinicalTrials.gov. Medical Subject Heading (MeSH) terms and free language were used for the search strategy in order to improve the sensitivity and specificity of the search. The search was restricted to systematic reviews of randomised control trials and original studies of randomised and non-randomised control trials and to English, French, Portuguese, and Spanish languages. A hand search was also carried out to review the references of the identified, included or excluded studies. A hand search was carried out in scientific magazines to obtain information on some aspects of the CPG.

Due to the lack of quality evidence relating to some specific aspects of the questions, an extended search for original observational studies and case series was carried out, and grey literature (conferences, unpublished reports, etc.) at national and international levels was consulted. Before finishing the CPG, a final search was carried out for recently published articles (until December 2008) that might help answer some of the questions of the CPG. The articles were then critically appraised to assess the quality of the article and determine if it could be included in the evidence used to formulate the recommendations. No articles published after that date were included as a source of evidence for the CPG.

Prior to the publication of this guideline, a preliminary draft was brought out with the update of the Schizophrenia CPG prepared by NICE. This document was reviewed by this guideline development group to analyse the possible contributions and/or changes that had arisen in this new update and that might modify the recommendations of the previous schizophrenia guideline published by NICE.

1802 articles were identified, from which 113 were selected to make the recommendations.

26 clinical guidelines were identified, from which 3 were selected to make the recommendations.

Levels of Evidence

1++ - High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs) or RCTs with a very low risk of bias.

1+ - Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias.

1- - Meta-analyses, systematic reviews or RCTs with a high risk of bias.

2++ - High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with very low risk of confounding or bias and a high probability that the relationship is causal.

2+ - Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal.

2- - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal.

3 - Non-analytical studies, e.g., case reports and case series.

4 - Expert opinion.

Note: Studies classified as 1- and 2- should not be used in the process of developing recommendations due to their high possibility of bias.

Once the bibliographic search had finalised, a first screening of the articles found was carried out. Articles were rejected if, according to the title or abstract, they could not respond to the questions. With the remaining articles, those whose title and abstract appeared to be useful, a second screening was carried out and a first reading was done to see if they could answer some of the questions of the clinical practice guideline (CPG).

Afterwards, the quality of those articles that had passed the two screenings was assessed, using the Servicio de Evaluacíon de Tecnologías Sanitarías (OSTEBA) (OST FLCritica) critical appraisal tool.

To classify the evidence of the effectiveness of the interventions selected, the modified hierarchic classification system of the Scottish Intercollegiate Guidelines Network (SIGN) was used (see the "Rating Scheme for the Strength of the Evidence" field), and the data obtained from the selected articles were dumped onto a grid for assessment and subsequent development of the guideline recommendations (see Appendix 3 in the original guideline document).

The highest evidence level found was selected for each intervention question. When there was a systematic review (SR) or meta-analysis in relation to the question, these were used as a source of evidence, and the less solid and worst quality studies were rejected. When SR or meta-analyses could not be found, observational studies or case series were used.

The evidence level of the information obtained from other sources, such as the aforementioned CPGs, was maintained, so long as the original source that the evidence came from was clearly specified. In those cases where this was not clear, that information was used, but the evidence level was lowered to a lower level, and subsequently, the degree of recommendation.

Following the critical appraisal of the available evidence, the recommendations were formulated. A discussion group was made up with the entire clinical practice guideline (CPG) development group. Using a well-reasoned opinion, and bearing in mind the quality of the evidence found and the clinical experience of the CPG development group, the recommendations were gradually developed with their relative classification.

Several recommendations were prepared for each answer, indicating the level of evidence and degree of recommendation. When the recommendations were controversial or there was no evidence, it was solved by consensus of the development group. In those questions with respect to which there was no clear evidence about a particular topic, the group proposed research recommendations.

Grades of Recommendation

A: At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++, and directly applicable to the target population; or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+.

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++.

D: Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+.

Good Practice Point (GPP)*: Recommended best practice based on the clinical experience of the guideline development group.

*Sometimes the guideline development group becomes aware that there are some significant practical aspects they wish to emphasise and for which there is probably no supporting scientific evidence available. Generally, these cases are related to some aspect of the treatment, considered to be a good clinical practice and that nobody would normally question. These aspects are considered good clinical practice points. These messages are not an alternative to evidence based recommendations, but must be only considered when there is not another way to highlight the aspect mentioned above.

A formal cost analysis was not performed and published cost analyses were not reviewed.

The guidelines established in the Methodology Manual for the Preparation of Clinical Practice Guidelines in the (Spanish) National Health System include the participation of expert collaborators and external reviewers. The expert collaborators participated in the review of the questions and the recommendations of the clinical practice guidelines (CPGs) and the external reviewers contributed to the review of the draft. Before sending the draft CPGs to the external reviewers, the clinical leaders of the CPG also carried out a review of the text. The guideline development group meticulously took into consideration all the comments and contributions made during the consultation period with the CPG collaborators and reviewers and introduced any changes they deemed appropriate derived from their comments. The recommendations made in this CPG do not necessarily have to coincide or be in agreement with the contributions of the reviewers and collaborators. The final responsibility for the recommendations lies in the CPG development group.

The informative document for people with severe mental illness (SMI) and their families, prepared by the CPG development group, was anonymously reviewed by people who suffer from SMI and their family members, introducing appropriate changes as a result of their comments.

The following scientific associations collaborated in the preparation of this CPG: Aragonese Mental Health Association-Spanish Neuropsychiatry Association, National Mental Health Nursing Association, Spanish Psychiatry Society, Aragonese Psychosocial Rehabilitation Association, Aragon and La Rioja Psychiatry Society, represented by members of the development group, expert collaborators, and external reviewers. The invaluable contribution of the Aragonese Pro Mental Health Association (ASAPME) and the Federation of Aragonese Pro Mental Health Associations (FEAFES-ARAGON) must also be mentioned.

Levels of evidence (1++ to 4) and grades of recommendation (A to D, and GPP) are defined at the end of the "Major Recommendations" field.

Psychological Interventions

Cognitive-behavioural Therapies

Question to Be Answered: Is cognitive behavioural therapy-based psychological intervention effective in the treatment of people with severe mental illness (SMI)?

C - In people with SMI, cognitive behavioural treatment can used combined with standard treatment to reduce positive symptomatology, mainly hallucinations.

C - People with SMI and persistent positive symptomatology can be offered a specific cognitive behavioural-orientated psychological intervention for this pathology, lasting for a prolonged period of time (more than one year), in order to improve the persistent symptomatology.

C - Incorporate cognitive therapy into the strategies aimed at preventing relapses of depressive symptomatology in people with SMI and diagnosis of bipolar disorder.

B - When the main objective of the intervention in people with SMI is to improve their social functioning, it is advisable to incorporate social skills training.

There is not sufficient evidence to make recommendations in the problem-solving area for people with SMI and a diagnosis of schizophrenia and related disorders.

Interpersonal Therapy

Question to Be Answered: Is interpersonal therapy effective in the treatment of people with SMI?

C - The strategies aimed at preventing relapses in people with SMI and a diagnosis of bipolar disorder should evaluate the incorporation of interpersonal and social rhythm therapy (IPSRT) into the treatment.

Family Interventions

Questions to Be Answered:

• Do family interventions in their different formats present benefits compared with nonintervention, or other types of psychosocial intervention, in people with SMI?
• At what time, during the course of the illness, is it best to start family intervention for people with SMI and their families?
• What is the most appropriate time framework for the family intervention programmes and/or sessions for people with SMI and their families?

B - For people with SMI and a diagnosis of schizophrenia and related disorders, and their families, family intervention should be offered as an integral part of the treatment.

B - In family interventions that are carried out with people with SMI and diagnosis of schizophrenia and related disorders, the intervention should be done in a single-family format.

B - The recommended duration in family interventions aimed at people with SMI and diagnosis of schizophrenia and related disorders must be at least 6 months and/or 10 or more sessions.

A - Psychosocial intervention programmes must be offered that include family intervention with a psychoeducational component and coping and social skills training techniques, added to the standard treatment for people with SMI and diagnosis of non-affective psychosis.

B - Family members and caregivers of people with SMI and a diagnosis of bipolar disorder must be offered group psychoeducational programmes that include information and coping strategies that permit discussions within a friendly emotional climate.

Psychoeducational Interventions

Questions to Be Answered:

• Are psychoeducational interventions effective in people with SMI?
• What are the key components in psychoeducational interventions in people with SMI?
• What is the most adequate level of psychoeducational intervention: individual, group or family?

A - Quality information must be provided about the diagnosis and the treatment, giving support and handling strategies to people with SMI and diagnosis of schizophrenia and related disorders, to family members and to the people with whom they live.

A - Psychoeducational programmes that are offered to people with SMI and diagnosis of schizophrenia and related disorders, must incorporate the family.

B - Group psychoeducational programmes aimed at people with SMI and a diagnosis of bipolar disorder must incorporate specific psychological techniques, carrying them out in a relatively stable period of their disorder and always as a supplement to the psychopharmacological treatment.

GPP - The psychoeducational programmes for people with SMI must be integrated as an additional intervention in an individualised treatment plan, whose duration will be proportional to the objectives proposed, considering a minimum of 9 months' intensive programme and the need for undefined refresher sessions.

Cognitive Rehabilitation

Questions to Be Answered:

• Are cognitive rehabilitation interventions efficient in people with SMI and cognitive impairment?
• Which is the most adequate format of these interventions for people with SMI and cognitive impairment?

B - People with SMI and diagnosis of schizophrenia and related disorders that have cognitive impairment must be offered cognitive rehabilitation programmes.

B - Cognitive rehabilitation programmes aimed at people with SMI and cognitive impairment must be integrated into more extensive psychosocial rehabilitation programmes.

C - From the cognitive rehabilitation interventions or programmes aimed at people with SMI, it is advisable to choose those that include or are accompanied by "compensatory" interventions, in other words, changes in strategy, and training in coping skills or techniques.

Social Interventions

Question to Be Answered: Do social insertion programmes — daily living skills programmes, residential programmes in the community, or programmes directed to leisure and spare time — improve the evolution of the illness and the quality of life of people with SMI?

GPP - Daily living skills training programmes could be offered to people with SMI in order to improve their personal independence and their quality of life.

D - For people with SMI who require support to remain in their accommodation, it is advisable that the community residential offers include more extensive psychosocial programmes.

D - People with SMI and deficiencies perceived in their social relations should follow community leisure and spare time programmes.

GPP - During the monitoring of the individualised therapeutic programme, it is advisable to systematically assess the need to use the spare time programmes and offer them to people with SMI who require them.

Programmes Aimed at Employment

Question to Be Answered: Which employment-related intervention format improves labour market insertion of people with SMI?

A - Sheltered employment programmes are necessary for people with SMI who express their desire to return to work or get a first job. Programmes based on placement models are recommended, with a short preliminary training period, immediate placement, and with frequent individual support.

C - Sheltered employment programmes aimed at searching for normalised employment must not be the only programmes related to labour activity that are offered to people with SMI.

D - It would be recommendable for the psychosocial rehabilitation centres that look after people with SMI and diagnosis of schizophrenia and related disorders, to include employment integration programmes.

B - When employment insertion programmes are offered to people with SMI, the preferences on the type of job to be carried out must be assessed and taken into account.

B - For people with SMI and diagnosis of schizophrenia and related disorders, who has a history of previous job failure, it would be advisable to incorporate cognitive rehabilitation as a part of the employment programmes they are going to participate in.

GPP - The mental health teams, in coordination with the institutions and other social agents involved, must advise about all types of employment resources, aimed at gainful occupation and production, and adapted to the local employment opportunities. Likewise, they must be orientated towards interventions that put into motion different devices adapted to the needs and to the ability level of people with SMI, to increase stable and productive occupation expectations.

Other Therapeutic Interventions: Art Therapy and Music Therapy

Question to Be Answered: Do therapeutic interventions, such as art therapy and music therapy, improve the evolution of the illness and the quality of life of people with SMI?

C - Music therapy and art therapy could be offered to people with SMI and schizophrenia and related disorders as a therapeutic complement to other types of interventions.

Service Level Interventions

Question to Be Answered: Which service supply system — day centres and/or psychosocial rehabilitation centres, community Mental Health centres, Assertive Community Treatment, Intensive Case Management (ICM), non-acute day hospitals or Case management (CM) — is more effective in people with SMI?

B - When people with SMI need to be readmitted several times into acute units, and/or there is a past history of difficulties to engage with the services with the subsequent risk of relapse or social crisis (as, for example, becoming a "homeless" person) it is advisable to provide assertive community treatment teams.

GPP - The continuity of the treatment must be favoured via the integration and coordination of the use of the different resources by the people with SMI, maintaining continuity of care and interventions, and in the psychotherapeutic relations established.

GPP - Care must be maintained from the perspective of the Community Mental Health Centres (CMHC) as a configuration of the most commonly implemented services in our context, based on teamwork, on service integration and not losing the perspective of being able to integrate other ways of configuring the services that might be developed.

GPP - When the needs of the people with SMI cannot be covered from the CMHC, continuity of assistance must be given from units that provide day care, and whose activity is organised around the principles of psychosocial rehabilitation, whatever the name of the resource are (Day Centres, Psychosocial Rehabilitation Centres, etc.).

GPP - A certain level of care can be offered to people with SMI whose needs cannot be satisfied by resources that provide day-care in rehabilitation orientated residential resources whatever the names of the resources are (hospital rehabilitation units, medium stay units, therapeutic communities, etc.).

Interventions with Specific Subpopulations

SMI with Dual Diagnosis

Question to Be Answered: What type of treatment has proven to be most effective in people with SMI and substance abuse: integral or parallel treatment?

B - People with SMI with dual diagnosis must follow psychosocial intervention programmes and drug-dependent treatment programmes, both in an integrated manner and parallel.

B - The treatment programmes offered to people with SMI with dual diagnosis must have a multi-component nature, be intensive and prolonged.

C - For people with SMI and dual diagnosis and in a homeless situation, the treatment programmes should incorporate sheltered housing as a service.

GPP - When the care for people with SMI and dual diagnosis is provided in parallel, it is necessary to guarantee continuity in the care and coordination among the different health and social levels.

"Homeless" with SMI

Question to Be Answered: Which intervention is more efficient in people with SMI and "homeless"?

A - For homeless people with SMI who require psychiatric care and psychosocial intervention, it is advisable for both to be supplied together via integral programmes where residential programme/housing is offered.

C - When there is no active substance abuse, it would be advisable to provide grouped accommodation to homeless people with SMI included in integral intervention programmes.

C - When it is not possible to use accommodation and support programmes in the integral psychosocial intervention of homeless people with SMI, the intervention of assertive community treatment team should be offered.

SMI and Low Intelligence Quotient (IQ)/Mental Retardation

Question to Be Answered: Which psychosocial treatment is more effective in people with SMI and a low IQ?

B - For people with SMI and a low IQ, and when there is a presence of persistent productive symptoms, it is recommendable to indicate cognitive behaviour therapy adapted to that condition.

GPP - To improve the diagnosis of psychiatric disorders included within the concept of SMI in people with a low IQ, adapted criteria and specific and validated instruments must be used.

Definitions:

Levels of Evidence

1++ - High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs) or RCTs with a very low risk of bias.

1+ - Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias.

1- - Meta-analyses, systematic reviews or RCTs with a high risk of bias.

2++ - High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with very low risk of confounding or bias and a high probability that the relationship is causal.

2+ - Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal.

2- - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal.

3 - Non-analytical studies, e.g., case reports and case series.

4 - Expert opinion.

Note: Studies classified as 1- and 2- should not be used in the process of developing recommendations due to their high possibility of bias.

Grades of Recommendation

A: At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+.

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++.

D: Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+.

Good Practice Point (GPP)*: Recommended best practice based on the clinical experience of the guideline development group.

*Sometimes the guideline development group becomes aware that there are some significant practical aspects they wish to emphasise and for which there is probably no supporting scientific evidence available. Generally, these cases are related to some aspect of the treatment, considered to be a good clinical practice and that nobody would normally question. These aspects are considered good clinical practice points. These messages are not an alternative to evidence based recommendations, but must be only considered when there is not another way to highlight the aspect mentioned above.

None provided

The type of supporting evidence is specifically stated for each recommendation (see the "Major Recommendations" field).

Appropriate intervention for patients with severe mental illness

Not stated

Classical psychoanalytical framing is contraindicated.

This clinical practice guideline (CPG) is an aid for decision making in health care. It is not mandatory, and it is not a substitute for the clinical judgement of healthcare personnel.

Clinical practice guidelines (CPGs) aim to help professionals and users to take decisions on the most appropriate healthcare. Their development means investing effort and resources, which are sometimes not appropriately used, because they are not sufficiently used by the health professionals and because they do not represent an improvement in the care quality and results in health of the population they are aimed at.

To improve the implementation of a CPG, in other words, introduce it into a clinical setting, it is advisable to design a series of strategies aimed at overcoming the possible barriers for its adoption.

The plan to implement this CPG for psychosocial interventions in severe mental illnesses includes the following interventions:

• Presentation of the CPG by the health authorities to the media.
• Collaboration with scientific societies that have participated in the preparation of this CPG to review and disseminate it.
• Forwarding the CPG to different databases that compile CPGs for its evaluation and inclusion therein.
• Contact with the Spanish Federation of Associations of Family Members with Mental Illness and other associations of stakeholders to show them the guide.
• Free access to the different versions of this CPG on the GuíaSalud Web site (http://www. guiasalud.es ).
• Dissemination of information about the CPG in scientific activities (congresses, conferences, meetings) related to psychiatry, psychology, nursing, social work, occupational therapy.
• Forwarding by post of a three-page information leaflet about the CPG to professional associations, health administration care centres, local associations of health professionals, etc.
• Information about the CPG in magazines and medical daily newspapers of the specialties involved.
• Dissemination of the existence and the objectives of the CPG by means of distribution lists for professionals who are potentially interested in it.

Not applicable: The guideline was not adapted from another source.

Collaborating societies:

• Aragonese Mental Health Association-Spanish Neuropsychiatry Association
• National Mental Health Nursing Association
• Spanish Society of Psychiatry
• Aragonese Psychosocial Rehabilitation Association
• Aragon and La Rioja Society of Psychiatry

Members of these societies have participated as authors, expert collaborators, or external reviewers of the clinical practice guideline (CPG).

This clinical practice guideline (CPG) has been funded through the agreement signed by the Carlos III Health Institute, an independent body of the Ministry of Science and Innovation, and the Aragon Health Sciences Institute (I+CS), within the framework of collaboration provided for in the Quality Plan for the National Healthcare System of the Ministry of Health and Social Policy.

Clinical Practice Guideline (CPG) Development Group for Psychosocial Interventions in Severe Mental Illness

Group Members: Concepción de la Cámara Izquierdo, Specialist Physician in Psychiatry, Hospital Clínico Universitario "Lozano Blesa", Zaragoza; Francisco José Caro Rebollo, Specialist Physician in Psychiatry, Hospital Universitario "Miguel Servet", Zaragoza; Milagros Escusa Julián, Nurse, Acute Psychiatry Unit, Hospital "Obispo Polanco", Teruel; Francisco José Galán Calvo, Social Worker, Fundación Ramón Rey Ardid, Zaragoza; Laura Gracia López, Psychologist, Care Centre for Psychically Disabled, Instituto Aragonés de Servicios Sociales, Zaragoza; Andrés Martín Gracia, Specialist Physician in Psychiatry, Centro de Rehabilitación Psicosocial Nª Sra. del Pilar, Zaragoza; Miguel Martínez Roig, Specialist Physician in Psychiatry, Centro de Salud Mental Actur Sur, Zaragoza; Pedro Pibernat Deulofeu, Employment Therapist, Fundación Agustín Serrate, Huesca; Mª Esther Samaniego Díaz de Corcuera, Mental Health Nurse, Fundación Ramón Rey Ardid, Zaragoza; Ana Vallespí Cantabrana, Clinical Psychologist, Centro de Salud Mental Actur-Sur, Zaragoza; María José Vicente Edo, Mental Health Nurse, Instituto Aragonés de Ciencias de la Salud, Zaragoza

Coordination - Clinical Area: Francisco José Caro Rebollo, Specialist Physician in Psychiatry, Hospital Universitario "Miguel Servet" Zaragoza; Miguel Martínez Roig, Specialist Physician in Psychiatry, Centro de Salud Mental Actur Sur, Zaragoza

Coordination - Methodological Area: Juan Ignacio Martín Sánchez, Specialist Physician in Preventive Medicine and Public Health, Instituto Aragonés de Ciencias de la Salud, Zaragoza; María José Vicente Edo, Mental Health Nurse, Instituto Aragonés de Ciencias de la Salud, Zaragoza

Collaborators - Documentalist: Irene Muñoz Guajardo, Instituto Aragonés de Ciencias de la Salud, Zaragoza

Other Collaborations: Carlos Albiñana Rodríguez, Documentalist, Zaragoza; José Mª Mengual Gil, Specialist Physician in Paediatrics, Instituto Aragonés de Ciencias de la Salud, Zaragoza, Coordinación logística; Asociación Aragonesa Pro Salud Mental (ASAPME) Federación de Asociaciones; Aragonesas Pro Salud Mental (FEAFES-ARAGON), Zaragoza

Expert Collaboration: José Mª Álvarez Martínez, Clinical Psychologist, Hospital Universitario "Río Hortega", Valladolid; Fernando Cañas de Paz, Specialist Physician in Psychiatry, Hospital "Dr. R. Lafora", Madrid; Mª Consuelo Carballal Balsa, Nurse, Subdirección Xeral de Saúde Mental y Drogodependencias, Santiago de Compostela, A Coruña; Alberto Fernández Liria, Specialist Physician in Psychiatry, Hospital Universitario "Príncipe de Asturias", Alcalá de Henares, Madrid; Daniel Navarro Bayón, Psychologist, Fundación Socio-Sanitaria de Castilla-La Mancha para la Integración Socio-Laboral del Enfermo Mental (FISLEM), Toledo; Antonio Lobo Satué, Specialist Physician in Psychiatry, Hospital Clínico Universitario "Lozano Blesa", Zaragoza; Lilisbeth Perestelo Pérez, Clinical Psychologist, Servicio de Evaluación y Planificación de la Dirección del Servicio Canario de la Salud, Santa Cruz de Tenerife

External Review: Miguel Bernardo Arroyo, Specialist Physician in Psychiatry, Hospital Clínic, Barcelona; Manuel Camacho Laraña, Specialist Physician in Psychiatry, Universidad de Sevilla, Sevilla; Julián Carretero Román, Mental Health Nurse, Hospital "Infanta Leonor", Madrid; Carlos Cuevas Yust, Clinical Psychologist, Hospital "Virgen del Rocío", Sevilla; Begoña Iriarte Campo, Clinical Psychologist, Asociación Bizitegi, Bilbao; Juan Fco. Jiménez Estévez, Clinical Psychologist, Hospital Universitario "San Cecilio", Granada; José Manuel Lalana Cuenca, Specialist Physician in Psychiatry, Centro de Salud Mental Pirineos, Huesca; Marcelino López Álvarez, Specialist Physician in Psychiatry, Fundación Pública, Andaluza para la Integración Social de Personas con Enfermedad Mental (FAISEM), Sevilla; Mercedes Serrano Miguel, Social Worker, Centre d'Higiene Mental Les Corts, Barcelona; Catalina Sureda García, Nurse, Unitat Comunitària de Rehabilitació, Palma de Mallorca; José Juan Uriarte Uriarte, Specialist Physician in Psychiatry, Hospital de Zamudio, Zamudio, Bizkaia; Oscar Vallina Fernández, Clinical Psychologist, Hospital Sierrallana, Torrelavega, Cantabria

All the members of the guideline development group, as well as the people who have participated in the expert collaboration and in the external review, have made the declarations of interests that are presented in Appendix 7 of the original guideline document.

This is the current release of the guideline.

Electronic copies: Available in Portable Document Format (PDF) from the GuíaSalud Web site .

A Spanish version of the original guideline document is available in Portable Document Format (PDF) from the GuíaSalud Web site .

Additional clinical practice guideline tools are available in Spanish only from the GuíaSalud Web site .

Patient information can be found in the appendices of the original guideline document . A Spanish version is also available from the GuíaSalud Web site .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI Institute on September 6, 2011. The information was verified by the guideline developer on September 16, 2011.

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.