Treatment Recommendations for Tardive Dyskinesia.

BACKGROUND: Tardive dyskinesia is a movement disorder characterised by irregular, stereotyped, and choreiform movements associated with the use of antipsychotic medication. We aim to provide recommendations on the treatment of tardive dyskinesia. METHODS: We performed a systematic review of studies of the treatment of tardive dyskinesia. Studies were rated for methodological quality using the American Academy of Neurology Risk of Bias Classification system. Overall level of evidence classifications and grades of recommendation were made using the Scottish Intercollegiate Guidelines Network framework. RESULTS: Preventing tardive dyskinesia is of primary importance, and clinicians should follow best practice for prescribing antipsychotic medication, including limiting the prescription for specific indications, using the minimum effective dose, and minimising the duration of therapy. The first-line management of tardive dyskinesia is the withdrawal of antipsychotic medication if clinically feasible. Yet, for many patients with serious mental illness, the discontinuation of antipsychotics is not possible due to disease relapse. Switching from a first-generation to a second-generation antipsychotic with a lower D2 affinity, such as clozapine or quetiapine, may be effective in reducing tardive dyskinesia symptoms. The strongest evidence for a suitable co-intervention to treat tardive dyskinesia comes from tests with the new VMAT inhibitors, deutetrabenazine and valbenazine. These medications have not been approved for use in Canada. CONCLUSION: Data on tardive dyskinesia treatment are limited, and the best management strategy remains prevention. More long-term safety and efficacy data are needed for deutetrabenazine and valbenazine, and their routine availability to patients outside of the USA remains in question.

The Assessment and Treatment of Antipsychotic-Induced Akathisia.

BACKGROUND: Akathisia is a common and distressing neuropsychiatric syndrome associated with antipsychotic medication, characterised by subjective and objective psychomotor restlessness. The goal of this guideline is to provide clinicians with recommendations on the assessment and treatment of akathisia. METHODS: We performed a systematic review of therapeutic studies assessing the treatment of antipsychotic-induced extrapyramidal symptoms. Forty studies on akathisia and 4 systematic reviews evaluating the adverse effects of antipsychotics were used in the formulation of recommendations. Studies were rated for methodological quality using the American Academy of Neurology Risk of Bias Classification system. The overall level of evidence classifications and grades of recommendation were made using the Scottish Intercollegiate Guidelines Network framework. RESULTS: As a good practice point, clinicians should systematically assess akathisia with a validated scale before starting antipsychotics and during antipsychotic dosage titration. For the management of akathisia, there was adequate evidence to allow recommendations regarding antipsychotic dose reduction, antipsychotic polypharmacy, switching antipsychotic medication, and the use of adjuvant medications including beta-blockers, anticholinergics, 5HT2A antagonists, benzodiazepines, and vitamin B6. CONCLUSION: The treatment of antipsychotic-induced akathisia should be personalised, with consideration of antipsychotic dose reduction, cessation of antipsychotic polypharmacy, and switching to an antipsychotic with a perceived lower liability for akathisia, before the use of adjuvant medications. The choice of adjuvant medications should favour the more established treatments, with careful consideration of contraindications and side effects. Limitations in the evidence should be acknowledged and prompt cautious prescribing, particularly with respect to the duration of use of adjuvant medications, is warranted.

Canadian Schizophrenia Guidelines: Schizophrenia and Other Psychotic Disorders with Coexisting Substance Use Disorders.

OBJECTIVE: Persons with schizophrenia and other psychotic disorders frequently have coexisting substance use disorders that require modifications to treatment approaches for best outcomes. The objectives of this review were to identify evidence-based practices best practices that improve outcomes for individuals with schizophrenia and substance used disorders. METHOD: We reviewed guidelines that were published in the last 5 years and that included systematic reviews or meta-analyses. Most of our recommendations came from 2 publications from the National Institute for Health and Care Excellence (NICE): the 2011 guidance titled Coexisting Severe Mental Illness (Psychosis) and Substance Misuse: Assessment and Management in Healthcare Settings and the 2014 guidance titled Psychosis and Schizophrenia in Adults: Prevention and Management. We placed these recommendations into the Canadian context to create this guideline. RESULTS: Evidence supports the inclusion of individuals with coexisting substance use disorders in first-episode psychosis programs. The programs should integrate psychosis and substance use treatments, emphasizing ongoing monitoring of both substance use and patterns and symptoms. The best outcomes are achieved with combined use of antipsychotic medications and addiction-based psychosocial interventions. However, limited evidence is available to recommend using one antipsychotic medication over another or one psychosocial intervention over another for persons with schizophrenia and other psychotic disorders with coexisting substance use disorders. CONCLUSIONS: Treating persons who have schizophrenia and other psychotic disorders with coexisting substance use disorders can present clinical challenges, but modifications in practice can help engage and retain people in treatment, where significant improvements over time can be expected.

Canadian Schizophrenia Guidelines: Introduction and Guideline Development Process.

INTRODUCTION: The aim of the Canadian Schizophrenia Guidelines is to provide evidence-based recommendations for the treatment of schizophrenia and schizophrenia spectrum disorders. The target users are health care professionals. Recommendations are provided as guidance to physicians and patients, with the goal of improving the overall standard of care of individuals with schizophrenia. METHODS: The guidelines were developed using the ADAPTE process, a systematic approach and alternative to de novo guideline development, in which an existing guideline is customised to suit the local context. We assembled a multidisciplinary team of experts, patients, and family carers from across Canada with the goal of involving individuals with diverse areas of expertise and offering different perspectives. RESULTS: We identified 6 guidelines that were suitable for adaptation. Recommendations from each guideline were extracted and, based on content, were reviewed by the relevant working group. Each working group examined the evidence from which the recommendation was derived and the acceptability and applicability of the recommendation to the Canadian context. Working groups also made decisions on modifications to recommendations when language or terms differed between the source guideline and the Canadian context. Each working group presented selected recommendations to the guideline panel at an in-person consensus meeting. Once the consensus process was completed, each working group created a manuscript with the recommendations adapted from the included guidelines, with the rationale for each recommendation. CONCLUSIONS: The process yielded an up-to-date list of evidence-based recommendations that are relevant and applicable in Canada.

Canadian Treatment Guidelines for Individuals at Clinical High Risk of Psychosis.

OBJECTIVE: Young people who are at clinical high risk (CHR) of developing psychosis are often help seeking and have significant distress and dysfunction. There are limited guidelines for the assessment and treatment for this population. The aim of this guideline was to develop treatment recommendations for this at-risk group. METHOD: A systematic search was conducted for published guidelines for CHR. All current guidelines for schizophrenia were reviewed for treatment guidelines on individuals at CHR. The recommendations adopted were primarily drawn from the European Psychiatric Association (EPA) guidance on the early intervention in clinical high-risk states of psychoses and the 2014 National Institute for Health and Care Excellence (NICE) guidelines on the treatment and management of those at CHR for psychosis. RESULTS: After the guideline development process described, 9 recommendations were developed based on the quality of evidence, appropriateness for the Canadian health care system, and clinical expert consensus. CONCLUSIONS: Assessment by an expert in the field was the first recommendation. It was recommended that treatment follow a staged approach with psychological treatments being the first-line treatment and pharmacotherapy reserved for adults, those who did not respond to psychological interventions, and those who had more severe symptoms.

Canadian Practice Guidelines for Comprehensive Community Treatment for Schizophrenia and Schizophrenia Spectrum Disorders.

OBJECTIVE: The objective of this review is to identify the features and components of a comprehensive system of services for people living with schizophrenia. A comprehensive system was conceived as one that served the full range of people with schizophrenia and was designed with consideration of the incidence and prevalence of schizophrenia. The system should provide access to the full range of evidence-based services, should be recovery oriented, and should provide patient-centred care. METHOD: A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum disorders. The guidelines were rated by at least 2 raters, and recommendations adopted were primarily drawn from the National Institute for Clinical Excellence (2014) Guideline on Psychosis and Schizophrenia in adults and the Scottish Intercollegiate Guidelines Network guidelines on management of schizophrenia. RESULTS: The recommendations adapted for Canada cover the range of services required to provide comprehensive services. CONCLUSIONS: Comprehensive services for people with schizophrenia can be organized and delivered to improve the quality of life of people with schizophrenia and their carers. The services need to be organized in a system that provides access to those who need them.

Canadian Treatment Guidelines on Psychosocial Treatment of Schizophrenia in Adults.

OBJECTIVE: It is generally recognised that psychosocial interventions are essential components of the effective treatment of schizophrenia in adults. A considerable body of research is being published regarding the effectiveness of such interventions. In the current article, we derive recommendations reflecting the current state of evidence for their effectiveness. METHODS: Recommendations were formulated on the basis of a review of relevant guidelines, particularly those formulated by the Scottish Intercollegiate Guideline Network (SIGN) and National Institute for Health and Care Excellence (NICE). RESULTS: There is evidence strongly supporting the use of family interventions, supported employment programs, and cognitive-behavioural therapy. There are also reasons to recommend the use of cognitive remediation, social skills training, and life skills training under specified circumstances. It is important that all patients and families be provided with education about the nature of schizophrenia and its treatment. Several recent innovative psychosocial approaches to treatment are awaiting more thorough evaluation. CONCLUSIONS: There continues to be strong evidence for the effectiveness of several psychosocial interventions in improving outcomes for adults with schizophrenia. In the past decade, innovative interventions have been described, several of which are the subject of ongoing evaluative research.

Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum and Other Psychotic Disorders.

OBJECTIVE: The objective of this article is to identify best practices in the diagnosis and assessment of patients with schizophrenia spectrum and other psychotic disorders. The diagnosis and assessment may occur in a range of situations from the emergency room to the outpatient clinic and at different stages of the disorder. The focus may be on acute exacerbations of illness, residual symptoms, levels of function, or changes in the response to treatment. METHODS: A systematic search was conducted for guidelines published in the last 5 years for schizophrenia and schizophrenia spectrum disorders. The guidelines were rated by at least 2 raters, and recommendations adopted on the diagnosis and assessment were primarily drawn from the American Psychiatric Association practice guidelines for the psychiatric evaluation of adults and the National Institute for Health and Care Excellence guideline on psychosis and schizophrenia in adults. A number of de novo recommendations were also developed. RESULTS: Eleven recommendations were identified that cover a range of assessment situations from diagnosis to the involvement of families in assessments. CONCLUSIONS: An accurate assessment establishes the baseline for treatment planning based on clinical decision making for both pharmacotherapy and psychosocial treatments.

Guidelines for the Pharmacotherapy of Schizophrenia in Adults.

OBJECTIVE: The present guidelines address the pharmacotherapy of schizophrenia in adults across different stages, phases, and symptom domains. METHOD: Guidelines were developed using the ADAPTE process, which takes advantage of existing guidelines. Six guidelines were identified for adaptation, with recommendations extracted from each. For those specific to the pharmacotherapy of schizophrenia in adults, a working group selected between guidelines and recommendations to create an adapted guideline. RESULTS: Recommendations can be categorized into 6 areas that include 1) first-episode schizophrenia, 2) acute exacerbation, 3) relapse prevention and maintenance treatment, 4) treatment-resistant schizophrenia, 5) clozapine-resistant schizophrenia, and 6) specific symptom domains. For each category, recommendations are made based on the available evidence, which is discussed and linked to other established guidelines. CONCLUSIONS: In most cases, evidence-based recommendations are made that can be used to guide current clinical treatment and decision making. Notably, however, there is a paucity of established evidence to guide treatment decision making in the case of clozapine-resistant schizophrenia, a subsample that represents a sizable proportion of those with schizophrenia.

Canadian Guidelines for the Pharmacological Treatment of Schizophrenia Spectrum and Other Psychotic Disorders in Children and Youth.

OBJECTIVE: Schizophrenia spectrum and other psychotic disorders often have their onset in adolescence. The sequelae of these illnesses can negatively alter the trajectory of emotional, cognitive, and social development in children and youth if left untreated. Early and appropriate interventions can improve outcomes. This article aims to identify best practices in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders. METHODS: A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum disorders in children and youth (under age 18 years). Recommendations were drawn from the National Institute for Health and Care Excellence guidelines on psychosis and schizophrenia in children and youth (2013 and 2015 updates). Current guidelines were adopted using the ADAPTE process, which includes consensus ratings by a panel of experts. RESULTS: Recommendations identified covered a range of issues in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders. Further work in this area is warranted as we continue to further understand their presentation in the developing brain. CONCLUSIONS: Canadian guidelines for the pharmacotherapy management of children and youth with schizophrenia spectrum disorders are essential to assist clinicians in treating this vulnerable population. Ongoing work in this area is recommended.

Standardizing Fidelity to Evidence-Based Practice in the Early Psychosis Intervention Network.

OBJECTIVE: This study investigated variations in the measurement of fidelity to coordinated specialty care (CSC) within the Early Psychosis Intervention Network (EPINET), a learning health system that consists of 101 CSC programs within eight hubs. The study investigated the degree to which five fidelity scales could be mapped onto a standard scale. METHODS: The investigators identified six fidelity scales in use by EPINET participants; examined their item content, scoring, and data sources; and mapped five scales onto the First Episode Psychosis Services Fidelity Scale (FEPS-FS), which is the most widely used scale. RESULTS: Mapping five fidelity scales onto the FEPS-FS showed that the percentage of FEPS-FS components successfully mapped ranged from 42% to 81%. CONCLUSIONS: Mapping five scales onto one that uses dichotomous scoring identified the degree of variation in measures and reduced the amount and quality of usable fidelity data. Identifying variations in fidelity measurement is a core function of a learning health system.

Development and implementation of fidelity assessment in first episode psychosis services in Czechia: A pilot study.

AIM: The aim of the study was to evaluate fidelity in first episode psychosis (FEP) teams in Czechia and to gage the feasibility and utility of the process in a mental health system that is undergoing a transformation. METHODS: Fidelity assessment was conducted using The First Episode Psychosis Services Fidelity Scale (FEPS-FS). Fidelity assessment was based on a review of data abstracted from the health records of active clients, program documents, administrative data, and interviews with members of staff. The mean scores were compared across the teams. Feasibility and utility were assessed by program response to their fidelity results. RESULTS: Three FEP teams were involved in the fidelity assessment. Across the 35 items, the mean fidelity score ranged from 2.5 to 3.1. Across the FEP teams, the percentage of the 35 items rated as 4 or 5 (satisfactory or exemplary) ranged from 34.3% to 51.4%. CONCLUSIONS: This study provided an opportunity to implement FEPS-FS and assess fidelity in FEP teams in Czechia. The fidelity assessment also provided a baseline for measuring change.

Psychosis literacy in a Canadian health region: results from a general population sample.

OBJECTIVE: To assess the public's level of mental health literacy for psychosis. METHOD: A cross-sectional telephone survey using a random phone number selection procedure was conducted to identify a sample of 1685 participants comprised of youth at risk (aged 15 to 39 [corrected] years) and parents of youth at risk of psychosis (aged 35 to 59 years). The Canadian Journal of Psychiatry regrets the error and any inconvenience it might have caused. [corrected]. Participants were asked about their awareness of symptoms and causes of schizophrenia and psychosis, treatment options, and preferred channels for obtaining information about health and mental health. RESULTS: The response rate was 73%. There was a high reported knowledge of the term schizophrenia (76%), but a low reported knowledge of the term psychosis (23%). Ninety-one per cent of participants agreed that medications can control symptoms of schizophrenia. Significant barriers to getting help included not knowing the early signs of psychosis, concerns about being labelled mentally ill or psychotic, and not knowing where to go for help. Preferred communication elements to reach at-risk youth and their families were pamphlets at family physicians' and school counsellors' offices, posters on buses, television and radio advertisements, and information on websites. CONCLUSIONS: Whereas there is good knowledge about recognition and treatment of schizophrenia, there is less awareness of the broader concept of psychosis. Barriers to accessing care included recognition of early signs of psychosis and stigma. Public education programs aimed at promoting earlier intervention would need to address information about both psychosis and stigma.

A comparison of the National Clinical Audit of Psychosis 2019/2020 standards and First Episode Psychosis Services Fidelity Scale 1.0.

AIM: The authors compare two approaches to assessment of the quality of early psychosis intervention services, the National Clinical Audit of Psychosis used in the United Kingdom and the First Episode Psychosis Services Fidelity Scale used in North America and Europe. METHODS: We compare the two approaches on the source of standards, measurement type, data collection, time requirements, scoring and reliability. Finally, we review their strengths and limitations. RESULTS: Both measures are based on standards derived from the same research evidence base. Both methods rely on data from health records and administrative data. The audit is supplemented with user survey data, the fidelity scale with clinician interviews. The audit requires more time. The audit is based on quality indicators rated as present or absent which yields a statistical benchmark. The Fidelity Scale is based on quality indicators that are rated on a five-point scale yielding a standards-based measure. The two methods cover similar service components, but the FEPS-FS has a broader coverage of team functioning. The National audit also collects data on the user experience directly from patients. The fidelity scale has achieved good to excellent inter-rater reliability, the reliability of the audit has not been tested. CONCLUSIONS: Both methods have face validity and provide reliable and useful measures of quality of care. The NCAP works in the context of a single provider health system, the FEPS-FS works in a more variable health system. Comparing the two systems in the field would support international comparison of standards of care.

Developing an International Standard Set of Patient-Reported Outcome Measures for Psychotic Disorders.

OBJECTIVE: The objective of this project was to develop a set of patient-reported outcome measures for adolescents and adults who meet criteria for a psychotic disorder. METHODS: A research team and an international consensus working group, including service users, clinicians, and researchers, worked together in an iterative process by using a modified Delphi consensus technique that included videoconferencing calls, online surveys, and focus groups. The research team conducted systematic literature searches to identify outcomes, outcome measures, and risk adjustment factors. After identifying outcomes important to service users, the consensus working group selected outcome measures, risk adjustment factors, and the final set of outcome measures. International stakeholder groups consisting of >100 professionals and service users reviewed and commented on the final set. RESULTS: The consensus working group identified four outcome domains: symptoms, recovery, functioning, and treatment. The domains encompassed 14 outcomes of importance to service users. The research team identified 131 measures from the literature. The consensus working group selected nine measures in an outcome set that takes approximately 35 minutes to complete. CONCLUSIONS: A set of patient-reported outcome measures for use in routine clinical practice was identified. The set is free to service users, is available in at least two languages, and reflects outcomes important to users. Clinicians can use the set to improve clinical decision making, and administrators and researchers can use it to learn from comparing program outcomes.

Feasibility and acceptability of a volunteer peer fidelity assessment model in early psychosis intervention programmes in Ontario: Results from a pilot study.

AIM: Fidelity monitoring can support high-quality service delivery but is resource-intensive to implement. A fidelity assessment model utilizing volunteer assessors was trialled as a low-cost strategy for conducting fidelity assessments. This article reports on the acceptability and feasibility of this model. METHODS: Twenty volunteer assessors were trained to conduct fidelity assessments in nine Early Psychosis Intervention programmes across Ontario, Canada. Assessments were conducted using the First-Episode Psychosis Services Fidelity Scale based on a 2-day site visit, during which assessors interviewed staff, clients and families; reviewed charts; observed a team meeting and reviewed programme materials. The model was evaluated based on assessor focus groups, programme interviews, consensus meeting data and time-tracking logs. General inductive analysis was used to code and synthesize qualitative data. Quantitative data were aggregated and summarized. RESULTS: Participant feedback was positive and indicated that use of peer assessors and the in-person site visit added value to the process. The model was perceived to provide valuable information to support internal quality improvement efforts. Assessors reported direct benefits from participating, including networking and learning opportunities. Key challenges were the high time demand on assessors and turnover in the assessor team. CONCLUSIONS: The volunteer peer fidelity model was perceived to be a valuable improvement process by participants, but the high cost and reliance on ongoing volunteerism makes its sustainability uncertain. Next steps may include exploring remote assessment strategies or direct payments, although these strategies risk reducing the acceptability, and therefore uptake, of the assessment.

International application of standards for health care quality, access and evaluation of services for early intervention in psychotic disorders.

AIM: Standards for health care quality, access and evaluation of early intervention in psychosis services are required to assess implementation, provide accountability to service users and funders and support quality assurance. The aim of this article is to review the application of standards in Europe and North America. METHODS: Descriptive methods will be used to illustrate the organizational context in which standards are being applied and used, specific measures being applied and results so far. RESULTS: Both fidelity scales and quality indicators of health care are being used. Fidelity scales are being applied in Australia, Canada, Denmark, Italy and United States. In England, quality indicators derived from the National Institute for Health and Care Excellence guidance are being used. CONCLUSION: In the last 4 years, significant progress has been made in the development and application of measures that assess quality and access to evidence-based practices for early intervention in psychosis services. This represents an important step towards providing accountability, improving outcomes and service user experience. The methods used allow for comparison between the services that are assessed with the same methods, but there is a need to compare the different methods. Further research is also required to explore links between quality of care and outcomes for community mental health services that deliver early intervention in psychotic disorders.

Adapting Evidence-Based Early Psychosis Intervention Services for Virtual Delivery: Protocol for a Pragmatic Mixed Methods Implementation and Evaluation Study.

BACKGROUND: Timely and comprehensive treatment in the form of early psychosis intervention (EPI) has become the standard of care for youth with psychosis. While EPI services were designed to be delivered in person, the COVID-19 pandemic required many EPI programs to rapidly transition to virtual delivery, with little evidence to guide intervention adaptations or to support the effectiveness and satisfaction with virtual EPI services. OBJECTIVE: This study aims to explore the adaptations required to deliver NAVIGATE, a model of coordinated specialty care used in EPI, in a virtual format. This study will evaluate implementation of the NAVIGATE model delivered virtually by describing the nature of the adaptations to the intervention, assessing fidelity to the EPI model and the satisfaction of clients, family members, and care providers. We will investigate barriers and facilitators to virtual NAVIGATE implementation, service engagement, and health equity impacts of this work. METHODS: The Centre for Addiction and Mental Health (Toronto, Ontario, Canada) transitioned to delivering NAVIGATE virtually early in the COVID-19 pandemic. The Framework for Reporting Adaptations and Modifications for Evidence-Based Interventions will be used to describe the adaptations required to deliver NAVIGATE virtually. Fidelity to the EPI model will be measured using the First Episode Psychosis Services Fidelity Scale and fidelity to NAVIGATE will be assessed by investigating adherence to its core components. Implementation facilitators and barriers will be explored using semistructured interviews with providers informed by the Consolidated Framework for Implementation Research. Satisfaction with virtually delivered NAVIGATE will be assessed with virtual client and provider experience surveys and qualitative interviews with clients, family members, and providers. Service engagement data will be collected through review of medical records, and potential impacts of virtually delivered NAVIGATE on different population groups will be assessed with the Health Equity Impact Assessment. RESULTS: Virtual clinical delivery of NAVIGATE started in March 2020 with additional adaptations and data collection is ongoing. Data will be analyzed using descriptive statistics and survival analysis for quantitative data. Qualitative data will be analyzed using thematic content analysis. Integration of qualitative and quantitative data will occur at the data collection, interpretation, and reporting levels following a convergent design. CONCLUSIONS: This study will provide information regarding the type of intervention adaptations required for virtual delivery of NAVIGATE for youth with early psychosis, ensuring access to high-quality care for this population during the pandemic and beyond by guiding future implementation in similar contexts. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34591.

Social cognition mediates illness-related and cognitive influences on social function in patients with schizophrenia-spectrum disorders.

BACKGROUND: Although cognition has been studied extensively among patients with schizophrenia, social cognition has only recently emerged as an area of interest. The objective of the current study was to use structural equation modelling to test the hypothesis that the relation between cognitive performance and social function is mediated by patients' social cognitive abilities. METHODS: We assessed participants who met criteria for a schizophrenia-spectrum disorder, with equal distribution among first- and multi-episode participants, and nonpsychiatric controls on a range of measures within each of the domains of cognition, social cognition and social function. RESULTS: Using structural equation modelling, we derived a model that explained 79.7% of the variance in social function and demonstrated that the link between cognition and social function was fully mediated by social cognition. LIMITATIONS: A limitation of this study is that the measures contributing to the structural equation modelling analysis were obtained at the same point in time. Thus, the temporal order of causation suggested by Model 2 remains theoretically specified. CONCLUSION: This study provides some first steps in understanding the complex relation between cognition and social function. Such a relation has potential implications for the design of remediation strategies.

Facilitators and barriers to implementing quality measurement in primary mental health care: Systematic review.

OBJECTIVE To identify facilitators and barriers to implementing quality measurement in primary mental healthcare as part of a large Canadian study (Continuous Enhancement of Quality Measurement) to identify and select key performances measures for quality improvement in primary mental health care.DATA SOURCES CINAHL, EMBASE, MEDLINE, and PsycINFO were searched, using various terms that represented the main concepts, for articles published in English between 1996 and 2005.STUDY SELECTION In consultation with a health sciences research librarian, the initial list of identified references was reduced to 702 abstracts, which were assessed for relevance by 2 coders using predetermined selection criteria. Following a consensus process, 34 articles were selected for inclusion in the analysis. An additional 106 citations were identified in the references of these articles, 14 of which were deemed relevant to this study, for a total of 57 empirical articles identified for review. Most articles described implementation of health care innovations and clinical practice guidelines, 5 focused on quality indicators, and 1 examined mental health indicators.SYNTHESIS Content analysis of the 57 articles identified 7 common categories of facilitators and barriers for implementing innovations, guidelines, and quality indicators: indicator characteristics, promotional strategies,implementation strategies, resources, individual-level factors, organizational-level factors, and external factors.Implementation studies in which these factors were addressed were more likely to achieve successful outcomes.CONCLUSION The overlap in facilitators and barriers across implementation of mental health indicators, healthcare innovations, and practice guidelines is not surprising, as they are often related. The overlap strengthens the findings of the limited number of studies of quality indicators. The Continuous Enhancement of Quality Measurement process for identification and selection of indicators has attended to some of these issues by using a rigorous scientific approach and by engaging a range of stakeholders in selecting and prioritizing the indicators.