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"a narrative summary and evaluation of the findings or theories within a literature base.  Also known as 'narrative literature review'. "

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How to Write an Abstract in APA Format

3-minute read

• 2nd November 2023

If you’re writing an in-depth research paper following APA guidelines, you most likely need to include an abstract . If you’re confused about where to start – don’t be. We’ve got you covered! In this post, we’ll walk you through the steps of formatting and writing an abstract in APA format.

What Is an Abstract?

An abstract is a brief summary of a larger academic text, such as a thesis, dissertation, or research paper, typically located at the very beginning of the paper before the introduction. Its main purpose is to give readers a clear and concise overview of your key points, objectives, results, and conclusion. Essentially, it lets the reader know the purpose and premise of your study and what to expect from your paper.

How to Write an Abstract Using APA Style

If you’re following APA guidelines, your abstract should include:

●  Your clearly stated hypothesis or hypotheses

●  The key takeaways of the literature review

●  Your research questions and/or objectives

●  The methods used in your study

●  The research design and sample/sample size

●  Your results and key findings

●  The significance of your study and the implications of your findings

Note that you should provide a short overview of these points and not an in-depth analysis (which will come later in your paper) – each should be around one to two sentences long. The total length will vary depending on a variety of factors, such as your university/journal specifications, topic, and the length of your paper, but APA guidelines recommend that abstracts shouldn’t exceed 250 words.

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How to Format an Abstract in APA Format

How should you format your abstract if you’re using APA style? To start, the abstract should be located on the second page of your paper, after the title page. To format your abstract:

●  Set one-inch margins on all sides.

●  Label the section “Abstract” on the first line of the page, centered, and using bold font.

●  Use a clear, readable, widely available font, such as Times New Roman (12 pt.) or Calibri (11 pt.).

●  Begin writing the text one line below the “Abstract” label.

●  Do not indent and write text as a single paragraph.

APA guidelines state that three to five keywords can be included at the end of your abstract, which makes your paper searchable in a database. Be sure to choose brief, relevant keywords or phrases that reflect the most important aspects of your study. Keywords should be written one line below the text of the abstract immediately following the label “Keywords” in italics . Keywords can be listed in any order and should be separated using commas.

For example, for a journal article titled Biodiversity and Environmental Resilience: Strategies for Sustainability , the keywords section could look like this:

Note that keywords should be written in lowercase (unless they’re proper nouns) and no end punctuation is necessary after the final keyword.

If you want to ensure your abstract grabs your reader’s attention and leaves a lasting impression, then have it professionally proofread by our expert team. Our editors are skilled at editing a wide range of academic subjects – from astronomy to zoology. Send in your free sample to get started today!

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Writing Abstracts for a Literature Review in APA Format

While developing your APA style school research paper, follow the specific formatting guidelines to finalize your paper. This citation example focuses on writing  abstracts for an APA style paper. Learning how to write abstracts is a good skill to have, as it helps you develop the ability to summarize the important points in your paper. A busy student can read abstracts to determine if it’s worth the time to read the full paper.

Sectioning Your APA Research Paper

In APA style, a research paper has four sections:

Types of Research Papers

You may be asked to prepare several types of research papers  as a student, including:

• Empirical Study
• Theory-Oriented
• Methodological

A literature review paper is one you’ll be asked to write frequently, as many times there is not enough time in a class setting to complete extensive research.

Formatting an APA Abstract

The abstract page is the second page of your report, right after the title page. This page is numbered 2 on your report.

On the first line of the page, center the word Abstract . *Do not underline, bold, italicize or otherwise format the title.

On the second line, start your abstract. *Do not indent.

Inserting Keywords into an APA Abstract

In today’s digital world, it is important to think about ways readers can find your work online. Adding keywords at the end of your abstract guides online searches. After the abstract paragraph, type Keywords:  italicized and indented.

Keywords:  digital print, online sources

Abstract Word Limits

The maximum word count for an APA abstract is 250 words. However, your instructor may ask for fewer words or provide you with additional guidance. In fact, some instructors or publications  may restrict the word count to 150.

Writing the Abstract

The abstract is a concise summary of your paper. Write it after you have finished your paper, so you have a clear idea of what to include in this short paragraph.

Examples of APA Abstracts

Following your instructor’s guidance, include these elements in your APA abstract:

• First, briefly state the research topic  and questions.
• Then, using the primary studies in the literature you reviewed, include the participants in the studies and the main results.
• Remember to include the conclusion of your literature review.
• Finally, finish with a sentence about any implications or future research that developed from the research presented in your paper.

APA Abstract Example

This article is an examination of the history of gender demographics in the field of librarianship. The historic development and subsequent “feminization” of librarianship continues to influence the gender wage gap and the disproportionate leadership bias in the field today. This article examines the stereotyping of librarians and the cyclical effect of genderizing the profession. Consideration of current trends and data in librarian demographics demonstrates a consistent decrease in gender diversity, accompanied by a troubling lack of women leaders and executives. Additionally, this article explores options for combating the gender perceptions that negatively impact women in library and information science fields, including management and negotiation training in graduate programs, increased emphasis on technological skills, and professional organization advocacy.

Mars, P. (2018). Gender demographics and perceptions in librarianship.  School of Information Student Research Journal 7 (2). Retrieved from http://scholarworks.sjsu.edu/slissrj/vol7/iss2/3

Abstract Example With Keywords

The future of books and libraries is put into question by the increasing popularity of e-books and the use of computers as text platforms. In an effort to anticipate which reading platform—print, e-readers, or computers displays—will dominate in the coming years, recent research and experimental data on the suitability of each reading platform for reading comprehension will be considered, from the perspectives of optical issues, cognition, and metacognition. It will be shown that, while printed books are most conducive to learning from longer, more difficult texts, e-readers and computer displays offer convenience and some distinct advantages to readers in particular situations. This synthesis of current research will be helpful to librarians working in digital and print book purchasing and collection development, as well as those making long-range planning decisions.

Keywords : books, digital books, e-paper, reading comprehension, cognition

Tanner, M. J. (2014). Digital vs. print: Reading comprehension and the future of the book.  SLIS Student Research Journal, 4 (2). Retrieved from http://scholarworks.sjsu.edu/slissrj/vol4/iss2/6

A Crucial Element

Your APA abstract is a critical part of your school research paper. Thus, you should put a lot of thought into creating your abstract and make sure it includes all the required elements. As always, be sure to follow your teacher’s guidance for length and format.

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Understanding APA Literature Reviews

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How do I Write a Literature Review?: #5 Writing the Review

• Step #1: Choosing a Topic
• Step #2: Finding Information
• Step #3: Evaluating Content
• Step #4: Synthesizing Content
• #5 Writing the Review
• Citing Your Sources

WRITING THE REVIEW 

You've done the research and now you're ready to put your findings down on paper. When preparing to write your review, first consider how will you organize your review.

The actual review generally has 5 components:

Abstract  -  An abstract is a summary of your literature review. It is made up of the following parts:

• A contextual sentence about your motivation behind your research topic
• Your thesis statement
• A descriptive statement about the types of literature used in the review
• Summarize your findings
• Conclusion(s) based upon your findings

Introduction :   Like a typical research paper introduction, provide the reader with a quick idea of the topic of the literature review:

• Define or identify the general topic, issue, or area of concern. This provides the reader with context for reviewing the literature.
• Identify related trends in what has already been published about the topic; or conflicts in theory, methodology, evidence, and conclusions; or gaps in research and scholarship; or a single problem or new perspective of immediate interest.
• Establish your reason (point of view) for reviewing the literature; explain the criteria to be used in analyzing and comparing literature and the organization of the review (sequence); and, when necessary, state why certain literature is or is not included (scope)  - 

Body :  The body of a literature review contains your discussion of sources and can be organized in 3 ways-

• Chronological -  by publication or by trend
• Thematic -  organized around a topic or issue, rather than the progression of time
• Methodical -  the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the "methods" of the literature's researcher or writer that you are reviewing

You may also want to include a section on "questions for further research" and discuss what questions the review has sparked about the topic/field or offer suggestions for future studies/examinations that build on your current findings.

Conclusion :  In the conclusion, you should:

Conclude your paper by providing your reader with some perspective on the relationship between your literature review's specific topic and how it's related to it's parent discipline, scientific endeavor, or profession.

Bibliography :   Since a literature review is composed of pieces of research, it is very important that your correctly cite the literature you are reviewing, both in the reviews body as well as in a bibliography/works cited. To learn more about different citation styles, visit the " Citing Your Sources " tab.

• Writing a Literature Review: Wesleyan University
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How to craft an APA abstract

Last updated

16 December 2023

Reviewed by

An APA abstract is a brief but thorough summary of a scientific paper. It gives readers a clear overview of what the paper is about and what it intends to prove.

The purpose of an abstract is to allow researchers to quickly understand the paper's topic and purpose so they can decide whether it will be useful to them.

• What is the APA style?

APA style is a method of formatting and documentation used by the American Psychological Association. This style is used primarily for papers in the field of education and in the social sciences, including:

Anthropology

What is an abstract in APA format?

Writing an abstract in APA format requires you to conform to the writing rules for APA-style papers, including the following guidelines:

The abstract should be 150–250 words

It should be brief but concise, containing all the paper's main points

The abstract is a separate page that comes after the title page and before the paper's main content

• Key elements of an APA abstract 

While the rules for constructing an APA abstract are straightforward, the process can be challenging. You need to pack a great deal of relevant content into a short piece.

The essential elements of an APA abstract are:

Running header containing the title of the paper and page number

Section label, centered and in bold, containing the word "abstract"

The main content of the abstract, 150–250 words in length and double-spaced

A list of keywords, indented and introduced with the word "keywords" in italics

Essential points to cover in an APA abstract  

When you’re creating your APA abstract, consider the following questions.

What is the main topic the paper is addressing?

People searching for research on your topic will probably be browsing many papers and studies. The way your abstract is crafted will help to determine whether they feel your paper is worth reading.

Are your research methods quantitative or qualitative?

Quantitative research is focused on numbers and statistics, typically gathered from studies and polls where the questions are in yes/no or multiple-choice format.

Qualitative research is based on language and gathered using methods such as interviews and focus groups. It is more detailed and time-consuming to gather than quantitative research but can yield more complex and nuanced results.

Did you use primary or secondary sources?

Another key element is whether your research is based on primary or secondary sources. 

Primary research is data that you or your research team gathered. Secondary research is gathered from existing sources, such as databases or previously published studies.

Is your research descriptive or experimental?

Your research may be descriptive, experimental, or both.

With descriptive research , you’re describing or analyzing existing studies or theories on the topic. You may be using surveys, case studies, or observation to study the topic.

Experimental research studies variables using the scientific method. With an experiment, your objective is to establish a cause-and-effect relationship between two variables (or show the lack of one).

What conclusion did you reach?

Readers will want to know upfront what your paper is claiming or proving. Your APA abstract should give them a condensed version of your conclusions. Summarize your most significant findings.

It's customary to place your findings and conclusion in the final sentence of the abstract. This should be directly related to the main topic of the paper.

What is the relevance of your findings?

Show readers that your paper is a significant contribution to the field. While staying accurate and not overstating your case, boast a bit about why people need to read your paper.

Briefly describe the implications and importance of your findings. You can also point out any further research that is needed concerning this topic.

Did you choose the most appropriate keywords?

Including keywords is useful for indexing if your paper is eventually included in a database. Choose keywords that are relevant to the paper and as specific as possible.

For example, if your paper is about signs of learning disabilities in elementary-age children, your keyword list might include:

Learning disability symptoms

Elementary education

Language-based learning disabilities

Any other terms discussed in the paper

• How to format an APA abstract

Use standard APA formatting with double spacing, 12pt Times New Roman font, and one-inch margins.

Place a running head at the top left-hand side of the page. This is an abbreviated version of the paper's title. Use all capital letters for the running header. This is not usually required for academic papers but is essential if you are submitting the paper for publication. The page number “2” should follow the running header (Page 1 is the title page).

Just under the running head, in the center, place the word "abstract."

Place your list of keywords at the end. The list should be indented and, according to APA guidelines, contain three to five keywords.

• What are the 3 types of abstracts?

There are certain variations in different types of APA abstracts. Here are three of the most common ones.

Experimental or lab report abstracts

An abstract for an experimental or lab report needs to communicate the key purpose and findings of the experiment. Include the following:

Purpose and importance of the experiment

Hypothesis of the experiment

Methods used to test the hypothesis

Summary of the results of the experiment, including whether you proved or rejected the hypothesis

Literature review abstracts

A literature review is a survey of published work on a work of literature. It may be part of a thesis, dissertation, or research paper .

The abstract for a literature review should contain:

A description of your purpose for covering the research topic

Your thesis statement

A description of the sources used in the review

Your conclusions based on the findings

Psychology lab reports

Psychology lab reports are part of the experiment report category. Psychology experiments, however, may contain distinctive elements.

Describe the goal or purpose of the experiment

If the experiment includes human subjects, describe them. Mention the number of participants and what demographic they fit

Describe any tools, equipment, or apparatus you used for the experiment. For example, some experiments use electroencephalography (EEG) to measure brain waves. You may have also used tools such as questionnaires , case studies , or naturalistic observation. Describe the procedure and parameters of the experiment.

Summarize your conclusions

• What not to include in an APA abstract

As this section is 250 words maximum, it's important to know what should not be included.

Avoid the following in an APA abstract:

Jargon, acronyms, or abbreviations

Citations. These should appear in the body of the paper.

Lengthy or secondary information. Keep it brief and stick to the main points. Readers should want to read your paper for more detailed information.

Opinions or subjective comments

Anything not covered in the paper

• Guidelines for writing an APA abstract

While an abstract is the shortest section of your paper, it is nevertheless one of the most important parts. It determines whether or not someone decides that the paper is worth reading or not. What follows are some guidelines to keep in mind when creating your APA abstract. 

Focus on your main point. Don't try to fit in multiple conclusions. The idea is to give readers a clear idea of what your main point or conclusion is. On a similar note, be explicit about the implications and significance of your findings. This is what will motivate people to read your paper.

Write the abstract last. Ensure the abstract accurately conveys the content and conclusions of your paper. You may want to start with a rough draft of the abstract, which you can use as an outline to guide you when writing your paper. If you do this, make sure you edit and update the abstract after the full paper is complete.

Proofread your abstract. As the abstract is short and the first part of the paper people will read, it's especially important to make it clear and free of spelling, grammatical, or factual errors. Ask someone in your field to read through it.

Write the abstract for a general audience. While the paper may be aimed at academics, scientists, or specialists in your field, the abstract should be accessible to a broad audience. Minimize jargon and acronyms. This will make the paper easier to find by people looking for information on the topic.

Choose your keywords with care. The more relevant keywords you include, the more searchable your paper will be. Look up papers on comparable topics for guidance.

Follow any specific guidelines that apply to your paper. Requirements for the abstract may differ slightly depending on the topic or guidelines set by a particular instructor or publication.

APA style is commonly used in the fields of psychology, sociology, anthropology, economics, and education.

If you’re writing an abstract in APA style, there are certain conventions to follow. Your readers and people in your industry will expect you to adhere to particular elements of layout, content, and structure.

Follow our advice in this article, and you will be confident that your APA abstract complies with the expected standards and will encourage people to read your full paper.

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How to Write an APA Abstract

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Emily is a board-certified science editor who has worked with top digital publishing brands like Voices for Biodiversity, Study.com, GoodTherapy, Vox, and Verywell.

Verywell / Nusha Ashjaee 

• Writing Your Abstract
• How to Use Keywords

An APA abstract is a concise but comprehensive summary of a scientific paper. It is typically a paragraph long, or about 150 to 250 words. The goal of the abstract is to provide the reader with a brief and accurate idea of what a paper is about.

The APA abstract should appear on a separate page immediately after the title page and before the main content of your paper. While professional papers that appear in scientific journals and other publications require an APA abstract, they may not be required for student papers. However, you should always check with your instructor for specific requirements.

What Is APA Format?

APA format is the official style of the American Psychological Association. It is used in writing for psychology and other social sciences. These style guidelines specify different aspects of a document's presentation and layout, including how pages are structured, how references are organized, and how sources are cited.

This article explains how to create an abstract in APA format for your psychology papers or other types of scientific writing. It covers the basic rules you should follow as well as specific guidelines for writing abstracts for experimental reports, literature reviews, and other articles.

What Is an Abstract in APA Format?

In addition to providing guidance for the general style and organization of a paper, APA format also stipulates using an abstract designed to briefly summarize the key details in a paper.

While it is sometimes overlooked or only an afterthought, an abstract is an integral part of any academic or professional paper. The abstract is a critical component of an APA-formatted paper. This brief overview summarizes what your paper contains. It should succinctly and accurately represent what your paper is about and what the reader can expect to find.

Following a few simple guidelines, you can create an abstract following the format. Done well, an abstract generates interest in your work and helps readers learn if the paper will interest them.

APA Format Abstract Basics

The abstract is the second page of a lab report or APA-format paper and should immediately follow the title page . Think of an abstract as a highly condensed summary of your entire paper.

The purpose of your abstract is to provide a brief yet thorough overview of your paper. It should function much like your title page—it should allow the person reading it to quickly determine what your paper is all about. Your abstract is the first thing that most people will read, and it is usually what informs their decision to read the rest of your paper.

The abstract is the single most important paragraph in your entire paper, according to the APA Publication Manual. A good abstract lets the reader know that your paper is worth reading.

According to the official guidelines of the American Psychological Association, an abstract should be brief but packed with information. Each sentence must be written with maximum impact in mind. To keep your abstract short, focus on including just four or five of the essential points, concepts, or findings.

An abstract must also be objective and accurate. The abstract's purpose is to report rather than provide commentary. It should accurately reflect what your paper is about. Only include information that is also included in the body of your paper.

Key Elements of an APA Abstract

Your abstract page should include:

• A running head , which is a shortened version of your title that appears in all caps at the top left of each page of your paper
• A section label , which should be the word "Abstract" centered and bolded at the top of the page
• A page number , which should be the second page of your paper (the title page should be page 1)
• A double-spaced paragraph of about 150 to 250 words
• An indented list of keywords related to your paper's content. Include the label "Keywords:" in italics and list three to five keywords that are separated by commas

How to Write an Abstract in APA Format

Before you write your abstract, you first need to write your paper in its entirety. In order to write a good abstract, you need to have a finished draft of your paper so you can summarize it accurately.

While the abstract will be at the beginning of your paper, it should be the last section you write.

Once you have completed the final draft of your psychology paper , use it as a guide for writing your abstract.

• Begin your abstract on a new page . Place your running head and page number 2 in the top right-hand corner. Center the word "Abstract" at the top of the page.
• Know your target word count . An abstract should be between 150 and 250 words. Exact word counts vary from journal to journal . If you are writing your paper for a psychology course, your professor may have specific word requirements, so be sure to ask. The abstract should be written as only one paragraph with no indentation.
• Structure the abstract in the same order as your paper . Begin with a brief summary of the introduction , and then continue on with a summary of the method , results , and discussion sections of your paper.
• Look at other abstracts in professional journals for examples of how to summarize your paper . Notice the main points that the authors chose to mention in the abstract. Use these examples as a guide when choosing the main ideas in your own paper.
• Write a rough draft of your abstract . Use the format required for your type of paper (see next sections). While you should aim for brevity, be careful not to make your summary too short. Try to write one to two sentences summarizing each section of your paper. Once you have a rough draft, you can edit for length and clarity.
• Ask a friend to read over the abstract . Sometimes, having someone look at your abstract with fresh eyes can provide perspective and help you spot possible typos and other errors.

The abstract is vital to your paper, so it should not be overlooked or treated as an afterthought. Spend time writing this section carefully to ensure maximum readability and clarity.

It is important to remember that while the abstract is the last thing you write, it is often the most read part of your paper.

Experimental Report Abstracts

The format of your abstract also depends on the type of paper you are writing. For example, an abstract summarizing an experimental paper will differ from that of a meta-analysis or case study . For an experimental report, your abstract should:

• Identify the problem . In many cases, you should begin by stating the question you sought to investigate and your hypothesis .
• Describe the participants in the study . State how many participants took part and how they were selected. For example: "In this study, 215 undergraduate student participants were randomly assigned to [the experimental condition] or [the control condition]."
• Describe the study method . For example, identify whether you used a within-subjects, between-subjects, or mixed design.
• Give the basic findings . This is essentially a brief preview of the results of your paper. 
• Provide any conclusions or implications of the study . What might your results indicate, and what directions does it point to for future research?

Literature Review Abstracts

If your paper is a meta-analysis or literature review, your abstract should:

• Describe the problem of interest . In other words, what is it that you set out to investigate in your analysis or review?
• Explain the criteria used to select the studies included in the paper . There may be many different studies devoted to your topic. Your analysis or review probably only looks at a portion of these studies. For what reason did you select these specific studies to include in your research?
• Identify the participants in the studies . Inform the reader about who the participants were in the studies. Were they college students? Older adults? How were they selected and assigned?
• Provide the main results . Again, this is essentially a quick peek at what readers will find when they read your results section. Don't try to include everything. Just provide a very brief summary of your main findings. 
• Describe any conclusions or implications . What might these results mean and what do they reveal about the body of research that exists on this particular topic?

Lab Reports and Articles

Psychology papers such as lab reports and APA format articles also often require an abstract. In these cases as well, the abstract should include all of the major elements of your paper, including an introduction, hypothesis, methods, results, and discussion.

Remember, although the abstract should be placed at the beginning of your paper (right after the title page), you will write the abstract last after you have completed a final draft of your paper.

To ensure that all of your APA formatting is correct, consider consulting a copy of the  Publication Manual of the American Psychological Association .

Keywords in an APA Abstract

After the paragraph containing the main elements of your abstract, you can also include keywords related to your paper. Such keywords are used when indexing your paper in databases and can help researchers and students locate your paper when searching for information about those topics.

Because keywords help people find your paper, it is essential to choose the right ones. The APA suggests including between three and five keywords.

You can identify keywords by thinking about what your paper is about. For example, if your paper focuses on how social media use is related to depression in teenagers, you might include the keywords: social media, mood, depression, adolescents, social networking sites 

A Word From Verywell

The abstract may be very brief, but it is so important that the official APA style manual identifies it as the most important paragraph in your entire paper. Careful attention to detail can ensure that your abstract does a good job representing the contents of your paper. If possible, take your paper to your school's writing lab for assistance.

Nagda S. How to write a scientific abstract. J Indian Prosthodont Soc. 2013;13(3):382–383. doi:10.1007/s13191-013-0299-x

Kumar A. Writing an abstract: Revealing the essence with eloquence .  J Indian Soc Periodontol . 2022;26(1):1-2. doi:10.4103/jisp.jisp_634_21

American Psychological Association. APA Style Journal Article Reporting Standards: Reporting Standards for Studies With an Experimental Manipulation .

American Psychological Association. APA Style Journal Article Reporting Standards: Quantitative Meta-Analysis Article Reporting Standards .

Tullu MS. Writing the title and abstract for a research paper: Being concise, precise, and meticulous is the key .  Saudi J Anaesth . 2019;13(Suppl 1):S12-S17. doi:10.4103/sja.SJA_685_18

American Psychological Association. Publication Manual of the American Psychological Association (7th ed.). American Psychological Association; 2019.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Write Abstracts, Literature Reviews, and Annotated Bibliographies: Home

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What is an Abstract?

An abstract is a summary of points (as of a writing) usually presented in skeletal form ; also : something that summarizes or concentrates the essentials of a larger thing or several things. (Merriam-Webster Dictionary Online)  

An abstract is a brief summary of a research article, thesis, review, conference proceeding or any in-depth analysis of a particular subject or discipline, and is often used to help the reader quickly ascertain the paper's purpose. When used, an abstract always appears at the beginning of a manuscript, acting as the point-of-entry for any given scientific paper or patent application. Abstraction and indexing services are available for a number of academic disciplines, aimed at compiling a body of literature for that particular subject. (Wikipedia)

An abstract is a brief, comprehensive summary of the contents of an article. It allows readers to survey the contents of an article quickly. Readers often decide on the basis of the abstract whether to read the entire article. A good abstract should be: ACCURATE --it should reflect the purpose and content of the manuscript. COHERENT --write in clear and concise language. Use the active rather than the passive voice (e.g., investigated instead of investigation of). CONCISE --be brief but make each sentence maximally informative, especially the lead sentence. Begin the abstract with the most important points. The abstract should be dense with information. ( Publication Manual of the American Psychological Association)

Abstract Guidelines

An abstract of a report of an empirical study should describe: (1) the problem under investigation (2) the participants with specific characteristics such as age, sex, ethnic group (3) essential features of the study method (4) basic findings (5) conclusions and implications or applications. An abstract for a literature review or meta-analysis should describe: (1) the problem or relations under investigation (2) study eligibility criteria (3) types of participants (4) main results, including the most important effect sizes, and any important moderators of these effect sizes (5) conclusions, including limitations (6) implications for theory, policy, and practice. An abstract for a theory-oriented paper should describe (1) how the theory or model works and the principles on which it is based and (2) what phenomena the theory or model accounts for and linkages to empirical results. An abstract for a methodological paper should describe (1) the general class of methods being discussed (2) the essential features of the proposed method (3) the range of application of the proposed method (4) in the case of statistical procedures, some of its essential features such as robustness or power efficiency. An abstract for a case study should describe (1) the subject and relevant characteristics of the individual, group, community, or organization presented (2) the nature of or solution to a problem illustrated by the case example (3) questions raised for additional research or theory.

• What is a Literature Review?

A literature review is a body of text that aims to review the critical points of current knowledge including substantive findings as well as theoretical and methodological contributions to a particular topic. Literature reviews are secondary sources, and as such, do not report any new or original experimental work.Most often associated with academic-oriented literature, such as a thesis, a literature review usually precedes a research proposal and results section. Its ultimate goal is to bring the reader up to date with current literature on a topic and forms the basis for another goal, such as future research that may be needed in the area.A well-structured literature review is characterized by a logical flow of ideas; current and relevant references with consistent, appropriate referencing style; proper use of terminology; and an unbiased and comprehensive view of the previous research on the topic. (Wikipedia)

Literature Review: An extensive search of the information available on a topic which results in a list of references to books, periodicals, and other materials on the topic. ( Online Library Learning Center Glossary )

"... a literature review uses as its database reports of primary or original scholarship, and does not report new primary scholarship itself. The primary reports used in the literature may be verbal, but in the vast majority of cases reports are written documents. The types of scholarship may be empirical, theoretical, critical/analytic, or methodological in nature. Second a literature review seeks to describe, summarize, evaluate, clarify and/or integrate the content of primary reports."

Cooper, H. M. (1988), "The structure of knowledge synthesis", Knowledge in Society , Vol. 1, pp. 104-126

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APA 7th edition Reference Guide  

St Patrick's College uses APA 7th edition to reference information sources. There are some subjects where APA Referencing is not used, so it is important to clarify with your teacher regarding the reference style required.    

This guide provides the rules for the  APA  7th Edition Reference style  and its application across a range of source material, including print, online, audio/visual, images and graphs, social media and personal communication. Each source has its own page within the guide, with in-text citation and reference listing examples.

The Library Team are available to help you get your head around referencing, and can check your reference lists prior to assignment submission. A Library Helpdesk ticket needs to be raised to action this request.

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• Schizophrenia (Heidelb)
• v.8(1); 2022

Systematic literature review of schizophrenia clinical practice guidelines on acute and maintenance management with antipsychotics

Christoph u. correll.

1 The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY USA

2 Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY USA

3 Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany

Amber Martin

4 Evidera, Waltham, MA USA

Charmi Patel

5 Janssen Scientific Affairs, LLC, Titusville, NJ USA

Carmela Benson

Rebecca goulding.

6 Goulding HEOR Consulting Inc., Vancouver, BC Canada

Jennifer Kern-Sliwa

Kruti joshi, emma schiller.

7 Biohaven Pharmaceuticals, New Haven, CT USA

Associated Data

The data that support the findings of the SLR are available from the corresponding author upon request.

Clinical practice guidelines (CPGs) translate evidence into recommendations to improve patient care and outcomes. To provide an overview of schizophrenia CPGs, we conducted a systematic literature review of English-language CPGs and synthesized current recommendations for the acute and maintenance management with antipsychotics. Searches for schizophrenia CPGs were conducted in MEDLINE/Embase from 1/1/2004–12/19/2019 and in guideline websites until 06/01/2020. Of 19 CPGs, 17 (89.5%) commented on first-episode schizophrenia (FES), with all recommending antipsychotic monotherapy, but without agreement on preferred antipsychotic. Of 18 CPGs commenting on maintenance therapy, 10 (55.6%) made no recommendations on the appropriate maximum duration of maintenance therapy, noting instead individualization of care. Eighteen (94.7%) CPGs commented on long-acting injectable antipsychotics (LAIs), mainly in cases of nonadherence (77.8%), maintenance care (72.2%), or patient preference (66.7%), with 5 (27.8%) CPGs recommending LAIs for FES. For treatment-resistant schizophrenia, 15/15 CPGs recommended clozapine. Only 7/19 (38.8%) CPGs included a treatment algorithm.

Introduction

Schizophrenia is an often debilitating, chronic, and relapsing mental disorder with complex symptomology that manifests as a combination of positive, negative, and/or cognitive features 1 – 3 . Standard management of schizophrenia includes the use of antipsychotic medications to help control acute psychotic episodes 4 and prevent relapses 5 , 6 , whereas maintenance therapy is used in the long term after patients have been stabilized 7 – 9 . Two main classes of drugs—first- and second-generation antipsychotics (FGA and SGA)—are used to treat schizophrenia 10 . SGAs are favored due to the lower rates of adverse effects, such as extrapyramidal effects, tardive dyskinesia, and relapse 11 . However, pharmacologic treatment for schizophrenia is complicated because nonadherence is prevalent, and is a major risk factor for relapse 9 and poor overall outcomes 12 . The use of long-acting injectable (LAI) versions of antipsychotics aims to limit nonadherence-related relapses and poor outcomes 13 .

Patient treatment pathways and treatment choices are determined based on illness acuity/severity, past treatment response and tolerability, as well as balancing medication efficacy and adverse effect profiles in the context of patient preferences and adherence patterns 14 , 15 . Clinical practice guidelines (CPG) serve to inform clinicians with recommendations that reflect current evidence from meta-analyses of randomized controlled trials (RCTs), individual RCTs and, less so, epidemiologic studies, as well as clinical experience, with the goal of providing a framework and road-map for treatment decisions that will improve quality of care and achieve better patients outcomes. The use of clinical algorithms or other decision trees in CPGs may improve the ease of implementation of the evidence in clinical practice 16 . While CPGs are an important tool for mental health professionals, they have not been updated on a regular basis like they have been in other areas of medicine, such as in oncology. In the absence of current information, other governing bodies, healthcare systems, and hospitals have developed their own CPGs regarding the treatment of schizophrenia, and many of these have been recently updated 17 – 19 . As such, it is important to assess the latest guidelines to be aware of the changes resulting from consideration of updated evidence that informed the treatment recommendations. Since CPGs are comprehensive and include the diagnosis as well as the pharmacological and non-pharmacological management of individuals with schizophrenia, a detailed comparative review of all aspects of CPGs for schizophrenia would have been too broad a review topic. Further, despite ongoing efforts to broaden the pharmacologic tools for the treatment of schizophrenia 20 , antipsychotics remain the cornerstone of schizophrenia management 8 , 21 . Therefore, a focused review of guideline recommendations for the management of schizophrenia with antipsychotics would serve to provide clinicians with relevant information for treatment decisions.

To provide an updated overview of United States (US) national and English language international guidelines for the management of schizophrenia, we conducted a systematic literature review (SLR) to identify CPGs and synthesize current recommendations for pharmacological management with antipsychotics in the acute and maintenance phases of schizophrenia.

Systematic searches for the SLR yielded 1253 hits from the electronic literature databases. After removal of duplicate references, 1127 individual articles were screened at the title and abstract level. Of these, 58 publications were deemed eligible for screening at the full-text level, from which 19 were ultimately included in the SLR. Website searches of relevant organizations yielded 10 additional records, and an additional three records were identified by the state-by-state searches. Altogether, this process resulted in 32 records identified for inclusion in the SLR. Of the 32 sources, 19 primary CPGs, published/issued between 2004 and 2020, were selected for extraction, as illustrated in the PRISMA diagram (Fig. ​ (Fig.1). 1 ). While the most recent APA guideline was identified and available for download in 2020, the reference to cite in the document indicates a publication date of 2021.

SLR systematic literature review.

Of the 19 included CPGs (Table ​ (Table1), 1 ), three had an international focus (from the following organizations: International College of Neuropsychopharmacology [CINP] 22 , United Nations High Commissioner for Refugees [UNHCR] 23 , and World Federation of Societies of Biological Psychiatry [WFSBP] 24 – 26 ); seven originated from the US; 17 – 19 , 27 – 32 three were from the United Kingdom (British Association for Psychopharmacology [BAP] 33 , the National Institute for Health and Care Excellence [NICE] 34 , and the Scottish Intercollegiate Guidelines Network [SIGN] 35 ); and one guideline each was from Singapore 36 , the Polish Psychiatric Association (PPA) 37 , 38 , the Canadian Psychiatric Association (CPA) 14 , the Royal Australia/New Zealand College of Psychiatrists (RANZCP) 39 , the Association Française de Psychiatrie Biologique et de Neuropsychopharmacologie (AFPBN) from France 40 , and Italy 41 . Fourteen CPGs (74%) recommended treatment with specific antipsychotics and 18 (95%) included recommendations for the use of LAIs, while just seven included a treatment algorithm Table ​ Table2). 2 ). The AGREE II assessment resulted in the highest score across the CPGs domains for NICE 34 followed by the American Psychiatric Association (APA) guidelines 17 . The CPA 14 , BAP 33 , and SIGN 35 CPGs also scored well across domains.

Guidelines included in the review.

Characteristics of schizophrenia guidelines.

AACP American Association of Community Psychiatrists, AFPBN Association Française de Psychiatrie Biologique et Neuropsychopharmacologie, AP antipsychotic, APA American Psychiatric Association, BAP British Association of Psychopharmacology, CINP International College of Neuropsychopharmacology, CPA Canadian Psychiatric Association, LAI long-acting injectable, no not recommended, NA not applicable, NICE National Institute for Health and Care Excellence, NJDMHS New Jersey Division of Mental Health Services, NR not reported, PPA Polish Psychiatric Association, PORT Patient Outcomes Research Team, RANZCP Royal Australian/New Zealand College of Psychiatrists, SIGN Scottish Intercollegiate Guidelines Network, TMAP Texas Medication Algorithm Project, UNHCR United Nations High Commissioner for Refugees, WFSBP World Federation of Societies of Biological Psychiatry, yes recommended.

Acute therapy

Seventeen CPGs (89.5%) provided treatment recommendations for patients experiencing a first schizophrenia episode 14 , 17 – 19 , 22 – 24 , 28 , 30 – 36 , 39 – 41 , but the depth and focus of the information varied greatly (Supplementary Table 1 ). In some CPGs, information on treatment of a first schizophrenia episode was limited or grouped with information on treating any acute episode, such as in the CPGs from CINP 22 , AFPBN 40 , New Jersey Division of Mental Health Services (NJDMHS) 32 , the APA 17 , and the PPA 37 , 38 , while the others provided more detailed information specific to patients experiencing a first schizophrenia episode 14 , 18 , 19 , 23 , 24 , 28 , 33 – 36 , 39 , 41 . The American Association of Community Psychiatrists (AACP) Clinical Tips did not provide any information on the treatment of schizophrenia patients with a first episode 29 .

There was little agreement among CPGs regarding the preferred antipsychotic for a first schizophrenia episode. However, there was strong consensus on antipsychotic monotherapy and that lower doses are generally recommended due to better treatment response and greater adverse effect sensitivity. Some guidelines recommended SGAs over FGAs when treating a first-episode schizophrenia patient (RANZCP 39 , Texas Medication Algorithm Project [TMAP] 28 , Oregon Health Authority 19 ), one recommended starting patients on an FGA (UNHCR 23 ), and others stated specifically that there was no evidence of any difference in efficacy between FGAs and SGAs (WFSBP 24 , CPA 14 , SIGN 35 , APA 17 , Singapore guidelines 36 ), or did not make any recommendation (CINP 22 , Italian guidelines 41 , NICE 34 , NJDMHS 32 , Schizophrenia Patient Outcomes Research Team [PORT] 30 , 31 ). The BAP 33 and WFBSP 24 noted that while there was probably no difference between FGAs and SGAs in efficacy, some SGAs (olanzapine, amisulpride, and risperidone) may perform better than some FGAs. The Schizophrenia PORT recommendations noted that while there seemed to be no differences between SGAs and FGAs in short-term studies (≤12 weeks), longer studies (one to two years) suggested that SGAs may provide benefits in terms of longer times to relapse and discontinuation rates 30 , 31 . The AFPBN guidelines 40 and Florida Medicaid Program guidelines 18 , which both focus on use of LAI antipsychotics, both recommended an SGA-LAI for patients experiencing a first schizophrenia episode. A caveat in most CPGs was that physicians and their patients should discuss decisions about the choice of antipsychotic and that the choice should consider individual patient factors/preferences, risk of adverse and metabolic effects, and symptom patterns 17 – 19 , 22 , 24 , 28 , 30 – 36 , 39 , 41 .

Most CPGs recommended switching to a different monotherapy if the initial antipsychotic was not effective or not well tolerated after an adequate antipsychotic trial at an appropriate dose 14 , 17 – 19 , 22 – 24 , 28 , 32 , 33 , 35 , 36 , 39 . For patients initially treated with an FGA, the UNHCR recommended switching to an SGA (olanzapine or risperidone) 23 . Guidance on response to treatment varied in the measures used but typically required at least a 20% improvement in symptoms (i.e. reduction in Positive and Negative Syndrome Scale or Brief Psychiatric Rating Scale scores) from pre-treatment levels.

Several CPGs contained recommendations on the duration of antipsychotic therapy after a first schizophrenia episode. The NJDMHS guidelines 32 recommended nine to 12 months; CINP 22 recommended at least one year; CPA 14 recommended at least 18 months; WFSBP 25 , the Italian guidelines 41 , and NICE 34 recommended 1 to 2 years; and the RANZCP 39 , BAP 33 , and SIGN 35 recommended at least 2 years. The APA 17 and TMAP 28 recommended continuing antipsychotic treatment after resolution of first-episode symptoms but did not recommend a specific length of therapy.

Twelve guidelines 14 , 18 , 22 , 24 , 28 , 30 , 31 , 33 – 36 , 39 , 40 (63.2%) discussed the treatment of subsequent/multiple episodes of schizophrenia (i.e., following relapse). These CPGs noted that the considerations guiding the choice of antipsychotic for subsequent/multiple episodes were similar to those for a first episode, factoring in prior patient treatment response, adverse effect patterns and adherence. The CPGs also noted that response to treatment may be lower and require higher doses to achieve a response than for first-episode schizophrenia, that a different antipsychotic than used to treat the first episode may be needed, and that a switch to an LAI is an option.

Several CPGs provided recommendations for patients with specific clinical features (Supplementary Table 1 ). The most frequently discussed group of clinical features was negative symptoms, with recommendations provided in the CINP 22 , UNHCR 23 , WFSBP 24 , AFPBN 40 , SIGN 35 , BAP 33 , APA 17 , and NJDMHS guidelines; 32 negative symptoms were the sole focus of the guidelines from the PPA 37 , 38 . The guidelines noted that due to limited evidence in patients with predominantly negative symptoms, there was no clear benefit for any strategy, but that options included SGAs (especially amisulpride) rather than FGAs (WFSBP 24 , CINP 22 , AFPBN 40 , SIGN 35 , NJDMHS 32 , PPA 37 , 38 ), and addition of an antidepressant (WFSBP 24 , UNHCR 23 , SIGN 35 , NJDMHS 32 ) or lamotrigine (SIGN 35 ), or switching to another SGA (NJDMHS 32 ) or clozapine (NJDMHS 32 ). The PPA guidelines 37 , 38 stated that the use of clozapine or adding an antidepressant or other medication class was not supported by evidence, but recommended the SGA cariprazine for patients with predominant and persistent negative symptoms, and other SGAs for those with full-spectrum negative symptoms. However, the BAP 33 stated that no recommendations can be made for any of these strategies because of the quality and paucity of the available evidence.

Some of the CPGs also discussed treatment of other clinical features to a limited degree, including depressive symptoms (CINP 22 , UNHCR 23 , CPA 14 , APA 17 , and NJDMHS 32 ), cognitive dysfunction (CINP 22 , UNHCR 23 , WFSBP 24 , AFPBN 40 , SIGN 35 , BAP 33 , and NJDMHS 32 ), persistent aggression (CINP 22 , WFSBP 24 , CPA 14 , AFPBN 40 , NICE 34 , SIGN 35 , BAP 33 , and NJDMHS 32 ), and comorbid psychiatric diagnoses (CINP 22 , RANZCP 39 , BAP 33 , APA 17 , and NJDMHS 32 ).

Fifteen CPGs (78.9%) discussed treatment-resistant schizophrenia (TRS); all defined it as persistent, predominantly positive symptoms after two adequate antipsychotic trials; clozapine was the unanimous first choice 14 , 17 – 19 , 22 – 24 , 28 , 30 – 36 , 39 . However, the UNHCR guidelines 23 , which included recommendations for treatment of refugees, noted that clozapine is only a reasonable choice in regions where white blood cell monitoring and specialist supervision are available, otherwise, risperidone or olanzapine are alternatives if they had not been used in the previous treatment regimen.

There were few options for patients who are resistant to clozapine therapy, and evidence supporting these options was limited. The CPA guidelines 14 therefore stated that no recommendation can be given due to inadequate evidence. Other CPGs discussed options (but noted there was limited supporting evidence), such as switching to olanzapine or risperidone (WFSBP 24 , TMAP 28 ), adding a second antipsychotic to clozapine (CINP 22 , NICE 34 , TMAP 28 , BAP 33 , Florida Medicaid Program 18 , Oregon Health Authority 19 , RANZCP 39 ), adding lamotrigine or topiramate to clozapine (CINP 22 , Florida Medicaid Program 18 ), combination therapy with two non-clozapine antipsychotics (Florida Medicaid Program 18 , NJDMHS 32 ), and high-dose non-clozapine antipsychotic therapy (BAP 33 , SIGN 35 ). Electroconvulsive therapy was noted as a last resort for patients who did not respond to any pharmacologic therapy, including clozapine, by 10 CPGs 17 – 19 , 22 , 24 , 28 , 32 , 35 , 36 , 39 .

Maintenance therapy

Fifteen CPGs (78.9%) discussed maintenance therapy to various degrees via dedicated sections or statements, while three others referred only to maintenance doses by antipsychotic agent 18 , 23 , 29 without accompanying recommendations (Supplementary Table 2 ). Only the Italian guideline provided no reference or comments on maintenance treatment. The CINP 22 , WFSBP 25 , RANZCP 39 , and Schizophrenia PORT 30 , 31 recommended keeping patients on the same antipsychotic and at the same dose on which they had achieved remission. Several CPGs recommended maintenance therapy at the lowest effective dose (NJDMHS 32 , APA 17 , Singapore guidelines 36 , and TMAP 28 ). The CPA 14 and SIGN 35 defined the lower dose as 300–400 mg chlorpromazine equivalents or 4–6 mg risperidone equivalents, and the Singapore guidelines 36 stated that the lower dose should not be less than half the original dose. TMAP 28 stated that given the relapsing nature of schizophrenia, the maintenance dose should often be close to the original dose. While SIGN 35 recommended that patients remain on the same antipsychotic that provided remission, these guidelines also stated that maintenance with amisulpride, olanzapine, or risperidone was preferred, and that chlorpromazine and other low-potency FGAs were also suitable. The BAP 33 recommended that the current regimen be optimized before any dose reduction or switch to another antipsychotic occurs. Several CPGs recommended LAIs as an option for maintenance therapy (see next section).

Altogether, 10/18 (55.5%) CPGs made no recommendations on the appropriate duration of maintenance therapy, noting instead that each patient should be considered individually. Other CPGs made specific recommendations: Both the Both BAP 33 and SIGN 35 guidelines suggested a minimum of 2 years, the NJDMHS guidelines 32 recommended 2–3 years; the WFSBP 25 recommended 2–5 years for patients who have had one relapse and more than 5 years for those who have had multiple relapses; the RANZCP 39 and the CPA 14 recommended 2–5 years; and the CINP 22 recommended that maintenance therapy last at least 6 years for patients who have had multiple episodes. The TMAP was the only CPG to recommend that maintenance therapy be continued indefinitely 28 .

Recommendations on the use of LAIs

All CPGs except the one from Italy (94.7%) discussed the use of LAIs for patients with schizophrenia to some extent. As shown in Table ​ Table3, 3 , among the 18 CPGs, LAIs were primarily recommended in 14 CPGs (77.8%) for patients who are non-adherent to other antipsychotic administration routes (CINP 22 , UNHCR 23 , RANZCP 39 , PPA 37 , 38 , Singapore guidelines 36 , NICE 34 , SIGN 35 , BAP 33 , APA 17 , TMAP 28 , NJDMHS 32 , AACP 29 , Oregon Health Authority 19 , Florida Medicaid Program 18 ). Twelve CPGs (66.7%) also noted that LAIs should be prescribed based on patient preference (RANZCP 39 , CPA 14 , AFPBN 40 , Singapore guidelines 36 , NICE 34 , SIGN 35 , BAP 33 , APA 17 , Schizophrenia PORT 30 , 31 , AACP 29 , Oregon Health Authority 19 , Florida Medicaid Program 18 ).

Recommendations for LAI antipsychotics in the treatment of schizophrenia.

AACP American Association of Community Psychiatrists, AFPBN Association Française de Psychiatrie Biologique et Neuropsychopharmacologie, APA American Psychiatric Association, BAP British Association of Psychopharmacology, CINP International College of Neuropsychopharmacology, CPA Canadian Psychiatric Association, LAI long-acting injectable, no not recommended, NA not applicable, NICE National Institute for Health and Care Excellence, NJDMHS New Jersey Division of Mental Health Services, PPA Polish Psychiatric Association, PORT Patient Outcomes Research Team, RANZCP Royal Australian/New Zealand College of Psychiatrists, SIGN Scottish Intercollegiate Guidelines Network, TMAP Texas Medication Algorithm Project, UNHCR United Nations High Commissioner for Refugees, WFSBP World Federation of Societies of Biological Psychiatry, yes recommended.

Thirteen CPGs (72.2%) recommended LAIs as maintenance therapy 18 , 19 , 24 , 28 – 36 , 39 , 40 . While five CPGs (27.8%), i.e., AFPBN 40 , RANZCP 39 , TMAP 28 , NJDMHS 32 , and the Florida Medicaid Program 18 recommended LAIs specifically for patients experiencing a first episode. While the CPA 14 did not make any recommendations regarding when LAIs should be used, they discussed recent evidence supporting their use earlier in treatment. Five guidelines (27.8%, i.e., Singapore 36 , NICE 34 , SIGN 35 , BAP 33 , and Schizophrenia PORT 30 , 31 ) noted that evidence around LAIs was not sufficient to support recommending their use for first-episode patients. The AFPBN guidelines 40 also stated that LAIs (SGAs as first-line and FGAs as second-line treatment) should be more frequently considered for maintenance treatment of schizophrenia. Four CPGs (22.2%, i.e., CINP 22 , UNHCR 23 , Italian guidelines 41 , PPA guidelines 37 , 38 ) did not specify when LAIs should be used. The AACP guidelines 29 , which evaluated only LAIs, recommended expanding their use beyond treatment for nonadherence, suggesting that LAIs may offer a more convenient mode of administration or potentially address other clinical and social challenges, as well as provide more consistent plasma levels.

Treatment algorithms

Only Seven CPGs (36.8%) included an algorithm as part of the treatment recommendations. These included decision trees or flow diagrams that map out initial therapy, durations for assessing response, and treatment options in cases of non-response. However, none of these guidelines defined how to measure response, a theme that also extended to guidelines that did not include treatment algorithms. Four of the seven guidelines with algorithms recommended specific antipsychotic agents, while the remaining three referred only to the antipsychotic class.

LAIs were not consistently incorporated in treatment algorithms and in six CPGs were treated as a separate category of medicine reserved for patients with adherence issues or a preference for the route of administration. The only exception was the Florida Medicaid Program 18 , which recommended offering LAIs after oral antipsychotic stabilization even to patients who are at that point adherent to oral antipsychotics.

Benefits and harms

The need to balance the efficacy and safety of antipsychotics was mentioned by all CPGs as a basic treatment paradigm.

Ten CPGs provided conclusions on benefits of antipsychotic therapy. The APA 17 and the BAP 33 guidelines stated that antipsychotic treatment can improve the positive and negative symptoms of psychosis and leads to remission of symptoms. These CPGs 17 , 33 as well as those from NICE 34 and CPA 14 stated that these treatment effects can also lead to improvements in quality of life (including quality-adjusted life years), improved functioning, and reduction in disability. The CPA 14 and APA 17 guidelines noted decreases in hospitalizations with antipsychotic therapy, and the APA guidelines 17 stated that long-term antipsychotic treatment can also reduce mortality. The UNHCR 23 and the Italian 41 guidelines noted that early intervention increased positive outcomes. The WFSBP 24 , AFPBN 40 , CPA 14 , BAP 33 , APA 17 , and NJDMHS 32 affirmed that relapse prevention is a benefit of continued/maintenance treatment.

Some CPGs (WFSBP 24 , Italian 41 , CPA 14 , and SIGN 35 ) noted that reduced risk for extrapyramidal adverse effects and treatment discontinuation were potential benefits of SGAs vs. FGAs.

The risk of adverse effects (e.g., extrapyramidal, metabolic, cardiovascular, and hormonal adverse effects, sedation, and neuroleptic malignant syndrome) was noted by all CPGs as the major potential harm of antipsychotic therapy 14 , 17 – 19 , 22 – 24 , 28 – 32 , 34 – 37 , 39 – 42 . These adverse effects are known to limit long-term treatment and adherence 24 .

This SLR of CPGs for the treatment of schizophrenia yielded 19 most updated versions of individual CPGs, published/issued between 2004 and 2020. Structuring our comparative review according to illness phase, antipsychotic type and formulation, response to antipsychotic treatment as well as benefits and harms, several areas of consistent recommendations emerged from this review (e.g., balancing risk and benefits of antipsychotics, preferring antipsychotic monotherapy; using clozapine for treatment-resistant schizophrenia). On the other hand, other recommendations regarding other areas of antipsychotic treatment were mostly consistent (e.g., maintenance antipsychotic treatment for some time), somewhat inconsistent (e.g., differences in the management of first- vs multi-episode patients, type of antipsychotic, dose of antipsychotic maintenance treatment), or even contradictory (e.g., role of LAIs in first-episode schizophrenia patients).

Consistent with RCT evidence 43 , 44 , antipsychotic monotherapy was the treatment of choice for patients with first-episode schizophrenia in all CPGs, and all guidelines stated that a different single antipsychotic should be tried if the first is ineffective or intolerable. Recommendations were similar for multi-episode patients, but factored in prior patient treatment response, adverse effect patterns, and adherence. There was also broad consensus that the side-effect profile of antipsychotics is the most important consideration when making a decision on pharmacologic treatment, also reflecting meta-analytic evidence 4 , 5 , 10 . The risk of extrapyramidal symptoms (especially with FGAs) and metabolic effects (especially with SGAs) were noted as key considerations, which are also reflected in the literature as relevant concerns 4 , 45 , 46 , including for quality of life and treatment nonadherence 47 – 50 .

Largely consistent with the comparative meta-analytic evidence regarding the acute 4 , 51 , 52 and maintenance antipsychotic treatment 5 effects of schizophrenia, the majority of CPGs stated there was no difference in efficacy between SGAs and FGAs (WFSBP 24 , CPA 14 , SIGN 35 , APA 17 , and Singapore guidelines 36 ), or did not make any recommendations (CINP 22 , Italian guidelines 41 , NICE 34 , NJDMHS 32 , and Schizophrenia PORT 30 , 31 ); three CPGs (BAP 33 , WFBSP 24 , and Schizophrenia PORT 30 , 31 ) noted that SGAs may perform better than FGAs over the long term, consistent with a meta-analysis on this topic 53 .

The 12 CPGs that discussed treatment of subsequent/multiple episodes generally agreed on the factors guiding the choices of an antipsychotic, including that the decision may be more complicated and response may be lower than with a first episode, as described before 7 , 54 – 56 .

There was little consensus regarding maintenance therapy. Some CPGs recommended the same antipsychotic and dose that achieved remission (CINP 22 , WFSBP 25 , RANZCP 39 , and Schizophrenia PORT 30 , 31 ) and others recommended the lowest effective dose (NJDMHS 32 , APA 17 , Singapore guidelines 36 , TMAP 28 , CPA 14 , and SIGN 35 ). This inconsistency is likely based on insufficient data as well as conflicting results in existing meta-analyses on this topic 57 – 59 .

The 15 CPGs that discussed TRS all used the same definition for this condition, consistent with recent commendations 60 , and agreed that clozapine is the primary evidence-based treatment choice 14 , 17 – 19 , 22 – 24 , 28 , 30 – 36 , 39 , reflecting the evidence base 61 – 63 . These CPGs also agreed that there are few options well supported by evidence for patients who do not respond to clozapine, with a recent meta-analysis of RCTs showing that electroconvulsive therapy augmentation may be the most evidence-based treatment option 64 .

One key gap in the treatment recommendations was how long patients should remain on antipsychotic therapy after a first episode or during maintenance therapy. While nine of the 17 CPGs discussing treatment of a first episode provided a recommended timeframe (varying from 1 to 2 years) 14 , 22 , 24 , 32 – 35 , 39 , 41 , the APA 17 and TMAP 28 recommended continuing antipsychotic treatment after resolution of first-episode symptoms but did not recommend a specific length of therapy. Similarly, six of the 18 CPGs discussing maintenance treatment recommended a specific duration of therapy (ranging from two to six years) 14 , 22 , 25 , 32 , 39 , while as many as 10 CPGs did not point to a firm end of the maintenance treatment, instead recommending individualized decisions. The CPGs not stating a definite endpoint or period of maintenance treatment after repeated schizophrenia episodes or even after a first episode of schizophrenia, reflects the different evidence types on which the recommendation is based. The RCT evidence ends after several years of maintenance treatment vs. discontinuation supporting ongoing antipsychotic treatment; however, naturalistic database studies do not indicate any time period after which one can safely discontinue maintenance antipsychotic care, even after a first schizophrenia episode 8 , 65 . In fact, stopping antipsychotics is associated not only with a substantially increased risk of hospitalization but also mortality 65 – 67 . In this sense, not stating an endpoint for antipsychotic maintenance therapy should not be taken as an implicit statement that antipsychotics should be discontinued at any time; data suggest the contrary.

A further gap exists regarding the most appropriate treatment of negative symptoms, such as anhedonia, amotivation, asociality, affective flattening, and alogia 1 , a long-standing challenge in the management of patients with schizophrenia. Negative symptoms often persist in patients after positive symptoms have resolved, or are the presenting feature in a substantial minority of patients 22 , 35 . Negative symptoms can also be secondary to pharmacotherapy 22 , 68 . Antipsychotics have been most successful in treating positive symptoms, and while eight of the CPGs provided some information on treatment of negative symptoms, the recommendations were generally limited 17 , 22 – 24 , 32 , 33 , 35 , 40 . Negative symptom management was a focus of the PPA guidelines, but the guidelines acknowledged that supporting evidence was limited, often due to the low number of patients with predominantly negative symptoms in clinical trials 37 , 38 . The Polish guidelines are also one of the more recently developed and included the newer antipsychotic cariprazine as a first-line option, which although being a point of differentiation from the other guidelines, this recommendation was based on RCT data 69 .

Another area in which more direction is needed is on the use of LAIs. While all but one of the 19 CPGs discussed this topic, the extent of information and recommendations for LAI use varied considerably. All CPGs categorized LAIs as an option to improve adherence to therapy or based on patient preference. However, 5/18 CPGs (27.8%) recommended the use of LAI early in treatment (at first episode: AFPBN 40 , RANZCP 39 , TMAP 28 , NJDMHS 32 , and Florida Medicaid Program 18 ) or across the entire illness course, while five others stated there was not sufficient evidence to recommend LAIs for these patients (Singapore 36 , NICE 34 , SIGN 35 , BAP 33 , and Schizophrenia PORT 30 , 31 ). The role of LAIs in first-episode schizophrenia was the only point where opposing recommendations were found across CPGs. This contradictory stance was not due to the incorporation of newer data suggesting benefits of LAIs in first episode and early-phase patients with schizophrenia 70 – 74 in the CPGs recommending LAI use in first-episode patients, as CPGs recommending LAI use were published between 2005 and 2020, while those opposing LAI use were published between 2011 and 2020. Only the Florida Medicaid CPG recommended LAIs as a first step equivalent to oral antipsychotics (OAP) after initial OAP response and tolerability, independent of nonadherence or other clinical variables. This guideline was also the only CPG to fully integrate LAI use in their clinical algorithm. The remaining six CPGs that included decision tress or treatment algorithms regarded LAIs as a separate paradigm of treatment reserved for nonadherence or patients preference rather than a routine treatment option to consider. While some CPGs provided fairly detailed information on the use of LAIs (AFPBN 40 , AACP 29 , Oregon Health Authority 19 , and Florida Medicaid Program 18 ), others mentioned them only in the context of adherence issues or patient preference. Notably, definitions of and means to determine nonadherence were not reported. One reason for this wide range of recommendations regarding the placement of LAIs in the treatment algorithm and clinical situations that prompt LAI use might be due to the fact that CPGs generally favor RCT evidence over evidence from other study designs. In the case of LAIs, there was a notable dissociation between consistent meta-analytic evidence of statistically significant superiority of LAIs vs OAPs in mirror-image 75 and cohort study designs 76 and non-significant advantages in RCTs 77 . Although patients in RCTs comparing LAIs vs OAPs were less severely ill and more adherent to OAPs 77 than in clinical care and although mirror-image and cohort studies arguably have greater external validity than RCTs 78 , CPGs generally disregard evidence from other study designs when RCT evidence exits. This narrow focus can lead to disregarding important additional data. Nevertheless, a most updated meta-analysis of all 3 study designs comparing LAIs with OAPs demonstrated consistent superiority of LAIs vs OAPs for hospitalization or relapse across all 3 designs 79 , which should lead to more uniform recommendations across CPGs in the future.

Only seven CPGs included treatment algorithms or flow charts to guide LAI treatment selection for patients with schizophrenia 17 – 19 , 24 , 29 , 35 , 40 . However, there was little commonality across algorithms beyond the guidance on LAIs mentioned above, as some listed specific treatments and conditions for antipsychotic switches, while others indicated that medication choice should be based on a patient’s preferences and responses, side effects, and in some cases, cost effectiveness. Since algorithms and flow charts facilitate the reception, adoption and implementation of guidelines, future CPGs should include them as dissemination tools, but they need to reflect the data and detailed text and be sufficiently specific to be actionable.

The systematic nature in the identification, summarization, and assessment of the CPGs is a strength of this review. This process removed any potential bias associated with subjective selection of evidence, which is not reproducible. However, only CPGs published in English were included and regardless of their quality and differing timeframes of development and publication, complicating a direct comparison of consensus and disagreement. Finally, based on the focus of this SLR, we only reviewed pharmacologic management with antipsychotics. Clearly, the assessment, other pharmacologic and, especially, psychosocial interventions are important in the management of individuals with schizophrenia, but these topics that were covered to varying degrees by the evaluated CPGs were outside of the scope of this review.

Numerous guidelines have recently updated their recommendations on the pharmacological treatment of patients with schizophrenia, which we have summarized in this review. Consistent recommendations were observed across CPGs in the areas of balancing risk and benefits of antipsychotics when selecting treatment, a preference for antipsychotic monotherapy, especially for patients with a first episode of schizophrenia, and the use of clozapine for treatment-resistant schizophrenia. By contrast, there were inconsistencies with regards to recommendations on maintenance antipsychotic treatment, with differences existing on type and dose of antipsychotic, as well as the duration of therapy. However, LAIs were consistently recommended, but mainly suggested in cases of nonadherence or patient preference, despite their established efficacy in broader patient populations and clinical scenarios in clinical trials. Guidelines were sometimes contradictory, with some recommending LAI use earlier in the disease course (e.g., first episode) and others suggesting they only be reserved for later in the disease. This inconsistency was not due to lack of evidence on the efficacy of LAIs in first-episode schizophrenia or the timing of the CPG, so that other reasons might be responsible, including possibly bias and stigma associated with this route of treatment administration. Lastly, gaps existed in the guidelines for recommendations on the duration of maintenance treatment, treatment of negative symptoms, and the development/use of treatment algorithms whenever evidence is sufficient to provide a simplified summary of the data and indicate their relevance for clinical decision making, all of which should be considered in future guideline development/revisions.

The SLR followed established best methods used in systematic review research to identify and assess the available CPGs for pharmacologic treatment of schizophrenia with antipsychotics in the acute and maintenance phases 80 , 81 . The SLR was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including use of a prespecified protocol to outline methods for conducting the review. The protocol for this review was approved by all authors prior to implementation but was not submitted to an external registry.

Data sources and search algorithms

Searches were conducted by two independent investigators in the MEDLINE and Embase databases via OvidSP to identify CPGs published in English. Articles were identified using search algorithms that paired terms for schizophrenia with keywords for CPGs. Articles indexed as case reports, reviews, letters, or news were excluded from the searches. The database search was limited to CPGs published from January 1, 2004, through December 19, 2019, without limit to geographic location. In addition to the database sources, guideline body websites and state-level health departments from the US were also searched for relevant CPGs published through June 2020. A manual check of the references of recent (i.e., published in the past three years), relevant SLRs and relevant practice CPGs was conducted to supplement the above searches and ensure and the most complete CPG retrieval.

This study did not involve human subjects as only published evidence was included in the review; ethical approval from an institution was therefore not required.

Selection of CPGs for inclusion

Each title and abstract identified from the database searches was screened and selected for inclusion or exclusion in the SLR by two independent investigators based on the populations, interventions/comparators, outcomes, study design, time period, language, and geographic criteria shown in Table ​ Table4. 4 . During both rounds of the screening process, discrepancies between the two independent reviewers were resolved through discussion, and a third investigator resolved any disagreement. Articles/documents identified by the manual search of organizational websites were screened using the same criteria. All accepted studies were required to meet all inclusion criteria and none of the exclusion criteria. Only the most recent version of organizational CPGs was included for data extraction.

Study selection criteria.

CPG clinical practice guideline, RCT randomized controlled trial, SLR systematic literature review.

a The draft of the third version of the APA guideline became available on their website in December of 2019, but the final version was not published until late 2020 and the final copyright reflects a 2021 date.

Data extraction and synthesis

Information on the recommendations regarding the antipsychotic management in the acute and maintenance phases of schizophrenia and related benefits and harms was captured from the included CPGs. Each guideline was reviewed and extracted by a single researcher and the data were validated by a senior team member to ensure accuracy and completeness. Additionally, each included CPG was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Following extraction and validation, results were qualitatively summarized across CPGs.

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Supplementary information

Acknowledgements.

This study received financial funding from Janssen Scientific Affairs.

Author contributions

C.C., A.M., R.G., C.P., C.B., K.J., J.K.S., E.S. and E.K. contributed to the conception and the design of the study. A.M., R.G. and E.S. conducted the literature review, including screening, and extraction of the included guidelines. All authors contributed to the interpretations of the results for the review; A.M. and C.C. drafted the manuscript and all authors revised it critically for intellectual content. All authors gave their final approval of the completed manuscript.

Open Access funding enabled and organized by Projekt DEAL.

Data availability

Competing interests.

C.C. has received personal fees from Alkermes plc, Allergan plc, Angelini Pharma, Gedeon Richter, Gerson Lehrman Group, Intra-Cellular Therapies, Inc, Janssen Pharmaceutica/Johnson & Johnson, LB Pharma International BV, H Lundbeck A/S, MedAvante-ProPhase, Medscape, Neurocrine Biosciences, Noven Pharmaceuticals, Inc, Otsuka Pharmaceutical Co, Inc, Pfizer, Inc, Recordati, Rovi, Sumitomo Dainippon Pharma, Sunovion Pharmaceuticals, Inc, Supernus Pharmaceuticals, Inc, Takeda Pharmaceutical Company Limited, Teva Pharmaceuticals, Acadia Pharmaceuticals, Inc, Axsome Therapeutics, Inc, Indivior, Merck & Co, Mylan NV, MedInCell, and Karuna Therapeutics and grants from Janssen Pharmaceutica, Takeda Pharmaceutical Company Limited, Berlin Institute of Health, the National Institute of Mental Health, Patient Centered Outcomes Research Institute, and the Thrasher Foundation outside the submitted work; receiving royalties from UpToDate; and holding stock options in LB Pharma. A.M., R.G., and E.S. were all employees of Evidera at the time the study was conducted on which the manuscript was based. C.P., C.B., K.J., J.K.S., and E.K. were all employees of Janssen Scientific Affairs, who hold stock/shares, at the time the study was conducted.

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The online version contains supplementary material available at 10.1038/s41537-021-00192-x.

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An In-Depth Literature Review of E-Portfolio Implementation in Higher Education: Processes, Barriers, and Strategies

Authors: Hongyan Yang (The University of Tennessee, Knoxville) , Rachel Wong (The University of Tennessee, Knoxville)

Literature Review

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This is an accepted article with a DOI pre-assigned that is not yet published.

This literature review examines the implementation of e-portfolios in higher education, with a focus on the implementation process, potential barriers, and strategies for overcoming challenges. This review seeks to provide instructional designers and higher education instructors with design strategies to effectively implement e-portfolios. Through an analysis of seventeen studies, we identified six common steps in the implementation process, including identifying a purpose, stakeholders, and platform, conducting workshops, creating e-portfolios, and evaluating the project. The implementation process also raised eight concerns, including concerns related to technology, policy, pedagogy, artifact quality, privacy, student motivation, academic integrity, and teacher workload. To address these concerns, existing strategies suggest that successful implementation requires training and policy support, student-centered pedagogy, criteria for assessing artifacts, privacy and data protection, feedback, anti-plagiarism measures, and shared successful models.

Keywords: literature review, e-Portfolio, implementation, higher education

Accepted on 20 Apr 2024

Peer reviewed, creative commons attribution-noncommercial-sharealike 4.0, harvard-style citation.

Yang, H & Wong, R. () 'An In-Depth Literature Review of E-Portfolio Implementation in Higher Education: Processes, Barriers, and Strategies', Issues and Trends in Learning Technologies . doi: 10.2458/itlt.5809

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Yang, H & Wong, R. An In-Depth Literature Review of E-Portfolio Implementation in Higher Education: Processes, Barriers, and Strategies. Issues and Trends in Learning Technologies. ; doi: 10.2458/itlt.5809

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Yang, H & Wong, R. (, ). An In-Depth Literature Review of E-Portfolio Implementation in Higher Education: Processes, Barriers, and Strategies. Issues and Trends in Learning Technologies doi: 10.2458/itlt.5809

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