Commentary on Galletly et al. (2016),The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

An important feature of the guidelines by Galletly et al. (2016) highlights the best practice principles for clinicians working with people with schizophrenia and trauma histories. While there is some debate in the literature regarding the causal link between trauma and psychosis, meta-analyses have reported childhood adversity and trauma substantially increases the risk of psychosis up to 2.8 times (Varese et al., 2012). The guidelines provide a comprehensive suite of practice principles for the clinical management of this population including recommendations for the assessment of trauma as integral to the diagnosis of people with schizophrenia and related disorders. The guidelines specifically address a number of the clinical challenges inherent in the treatment and medical management of this population. Most significantly, it provides a valuable tool for the assessment, diagnosis and the treatment of people whose trauma histories can be under-acknowledged in clinical mental health settings. Given this, recognising the psychiatric and health implications of trauma should be a clinical imperative.

Psychiatric assessments, clinical foci and challenges

Because psychosis symptomology dominates clinical presentations in mental health settings, clinical interventions assessing the links between trauma and psychosis are therefore limited. Thus, practice paradigms such as trauma informed care should provide the theoretical framework underpinning treatment approaches in this population. The identification of trauma in psychosis populations should be included as part of routine clinical assessment and in the development of appropriate mental health treatment plans. Measures of trauma, such as the Childhood Trauma Questionnaire (Bernstein et al., 2003), can be effective tools that can provide clinical insight into trauma experiences and can inform clinical care decisions. While these types of measures tend to focus on familial abuse/neglect, the importance and influence of peer relationships is also critical. Nonetheless, further research is needed to ascertain the appropriate treatment methods. While recent research has delivered promising results using several cognitive behavioural therapy (CBT) techniques, unfortunately these studies are underpowered and in some cases lack control groups (Bendall et al., 2013).

However, several challenges integral to ensuring quality clinical outcomes for this population are evident. For example, how best to address trauma and schizophrenia simultaneously in clinical settings remains a medical and psychosocial challenge for mental health clinicians. Restricted access to clinical resources necessitates a clinical focus that remains primarily on clinically addressing illness symptomology. This in turn can limit a clinician’s capacity to address other underlying psychosocial issues related to schizophrenia and trauma. Although health and psychiatric comorbidities related to schizophrenia and trauma can be a significant clinical concern, they remain an underexplored area for both mental health research and psychiatric clinical practice. Thus, determining trauma histories of people with psychiatric disorders can be significant in determining clinical pathways for recovery. However, there remain significant challenges in assessing trauma. For example, there is a need for safe interview environments, access to appropriate trauma measurement tools and the provision of well-trained and experienced clinicians. Most significantly, it is imperative to minimise re-traumatisation and to provide psychosocial supports on discharge from the service for consumers.

Conclusion

As such the guidelines by Galletly et al. (2016) address an important practice gap in the field of psychiatric clinical practice. As more research linking schizophrenia and trauma is conducted, evidence based interventions should be developed that aim to improve our clinical understanding of trauma and enhance illness recovery for consumers. However, this will only occur if the focus of research extends to examining and comparing the efficacy of diagnostic and treatment approaches.

People with schizophrenia and the experience of trauma is a topic that requires deeper discussion. We encourage readers to continue this discussion in the Letters section of this journal and to provide additional insights about working with this clinically complex population.

See Guideline by Galletly et al., 50: 410–472.