Community Therapeutic Space for Women with Schizophrenia: A New Innovative Approach for Health and Social Recovery

Abstract

Women with schizophrenia have distinct health and social needs compared to men. The Mutua Terrassa Functional Unit for Women with Schizophrenia has designed a new intervention called the Community Therapeutic Space (CTS), which is based on individual and group interventions focused on physical and mental health, and social factors. We carried out a narrative review focusing on green and blue spaces, climate change, light, digitalization and health, and gynecological screening in women with schizophrenia, to propose content for seven topics of the CTS. The personalized space offers individual appointments with mental health professionals with particular attention to pharmacological and social issues. The health space focuses mainly on groups of healthy habits, and links women to community activities. The interaction space focuses mainly on social connections, and the connection with nature. The content of these three spaces has been divided into seven colors: green and blue corners (related to green and blue spaces), red corner (climate change), yellow corner (light and health), white corner (mainly focused on mindfulness), black corner (digitalization in healthcare), and purple corner (related to gynecological screening). In the future, peer-to-peer and volunteer programs may help our healthcare unit to ensure and maintain the positive effects of these interventions.

1. Introduction

Men and women with schizophrenia have many differences in their health and social needs. Several authors have reported that women with schizophrenia have a later age of onset and often have more positive and depressive symptoms and require lower doses of antipsychotic medication than men [1]. In addition, social determinants of mental health appear to have a more negative impact on women than men [1]. In recent decades, a large amount of research has focused on the need to design and implement gender-specific programs for people with severe mental illness, particularly for those diagnosed with schizophrenia [2]. Due to the lack of gender-specific clinical guidelines for schizophrenia treatment, clinicians and researchers have actively worked to develop dedicated units for women with psychosis [3]. Mental health is the main focus of treatment in these units. However, many of them have included endocrinological aspects in their treatment goals. For example, the Basel early-detection-of-psychosis (FEPSY) program regularly monitored prolactin levels in people at very early stages of the disorder in a gender-specific approach [4]. This is because there is growing evidence that the dysfunction of the hypothalamic–pituitary–gonadal axis affects clinical outcomes in both sexes [5]. In 1995, a specialized program for women with schizophrenia was established at the Clarke Institute of Psychiatry at the University of Toronto [6]. Women referred to the clinics presented with psychotic symptoms that required accurate diagnosis, fluctuating symptoms during menstruation or menopause, and were also referred for clinical advice on social issues by their case managers. Pregnancy planning and genetic counseling were also reasons for referral. Physical problems or medical comorbidities related to the use of psychotropic medication were also considered. The women’s clinic received many referrals to switch from antipsychotics to clozapine or to monitor weight gain associated with antipsychotic use. Women with schizophrenia were seen at the clinic for mental health, physical, and social issues, all of which had a high impact on their clinical outcomes.

Gender differences in the occurrence of medical comorbidities, and the specificity of obstetric and gynecological problems in women, point to the physical domain as an important target for improving the health of women with schizophrenia [7,8]. Metabolic syndrome is prevalent in women with schizophrenia, and many gender differences in its prevalence have been reported [9]. In addition, side effects of antipsychotics, such as hyperprolactinemia, are relatively more common in women of reproductive age than in men [10].

Obstructive sleep apnea, which can result from antipsychotic-induced obesity, is also a treatment target that requires special attention [11]. Globally, the physical aspects of women with schizophrenia have received more attention in specialized programs.

Schizophrenia is negatively affected by the social determinants of health, particularly in women. These social determinants include discrimination, immigration, urbanicity, social isolation, low socioeconomic status, inadequate housing, childhood and adult trauma, and many other social risk factors [12]. Interventions against gender stigma, as well as protective measures and parenting support, are effective therapies to improve women’s mental and physical health and social risks. In particular, migration has been reported as a risk factor for schizophrenia, and migration-related factors have been associated with clinical and social outcomes. Trabsa and co-workers found gender differences in clinical outcomes [13]. Stress in women was associated with age at first migration and being a racialized person. Stress in men was related to language barriers and the presence of physical comorbidities. Gender roles and social expectations influence stress levels in people with psychosis disorders.

To improve clinical outcomes and promote social recovery and community integration, women with schizophrenia sometimes require a specific intervention in partial hospitalization programs. These programs have received different names and are defined by different treatment goals [14]. In general, the concept of empowerment has reflected a new approach to the treatment of mental illness, particularly in a gender-specific approach. Indeed, the WHO Regional Office for Europe has defined empowerment as “a multidimensional process through which individuals and groups gain greater knowledge and control over their lives’” [15]. This means that the concept of “empowerment” is very relevant for women with schizophrenia when focusing on mental health, physical health, and social needs. Recommendations to support the empowerment of women in partial hospitalization programs have been described previously [16]. Some of these recommendations promote women’s self-help and support through their social networks, supporting the development of activities and community-based strategies to improve health, and providing sufficient information to support women in making informed decisions.

Evans and collaborators have discussed the transformation of partial hospitalization programs into recovery-oriented community programs [16]. Initially, partial hospitalization programs or day hospitals were designed to manage and monitor psychotropic medication, develop therapy groups and activity groups, and provide integrated family-based care. However, these treatment approaches are not sufficient to develop core strategies based on mental health promotion and prevention for women with severe mental illness. Previous work has reported on gender-specific approaches to treat women with psychosis in community settings.

Social engagement has been found to be relevant for people with schizophrenia, and social support is one of the most important determinants of mental health. In line with these clinical and social needs, several authors highlighted the need to develop therapeutic interventions aimed at improving social and personal functioning. Mental health prevention and promotion based on patients’ connection to green and blue spaces has been widely reported, as has been the need to adapt mental health plans to climate crises. Stress reduction and sleep hygiene have been found to be relevant, and an important target for mindfulness strategies. Furthermore, despite the clinical relevance of the interaction of light and health, and the relevance of gynecological screening, these aspects have not been specifically addressed in these specific programs [6].

There is still a lack of programs that provide information and work toward social integration and participation in community-based programs for women. In the Mutua Terrassa Functional Unit for Women with Schizophrenia, we have programmed a new intervention and community-based program with the main aim of filling this gap.

Aims

The main aim of this work is to describe a new innovative approach for the social and health recovery of women with schizophrenia. Our objective was to describe the community therapeutic space and its components: personalized space, health space, and interaction (social) space and their implications in the social and health recovery of women attending the Mutua Terrassa Functional Unit for Women with Schizophrenia.

We conducted a narrative review on the impact of green and blue spaces, climate change, light exposure, mindfulness, digitalization in healthcare, and gynecological screening to inform the development of our women’s clinic program.

2. Results of the Narrative Review: Grouping of Color Contents

The content of this innovative program, called Community Therapeutic Space (CTS), was developed according to several themes that were the main targets of the narrative review (green spaces, blue spaces, climate change, light exposure, mindfulness, digitalization in healthcare, and gynecological screening). The findings from the narrative review have been grouped into color corners. The methods of the narrative review are detailed in the Methods Section.

A total of 1284 records were screened of which 33 were included. Five studies reporting on the association between green spaces and schizophrenia (coded as Green Corner) were included. Two studies reported associations between blue spaces and schizophrenia (Blue Corner). Four additional studies were found that reported on the effects of climate change on health outcomes in people with schizophrenia (Red Corner). The association between light exposure and health was examined in four studies (Yellow Corner). The effects of mindfulness-based therapies and schizophrenia were reported in 11 studies from the retrieved records (White Corner). The association between digitalization for access and participation of women in mental health services was reported in three papers (Black Corner). Four studies reported findings on gynecological screening for schizophrenia, specifically for breast and cervical cancer screening (Purple Corner).

2.1. Green Corner

The green corner focuses mainly on the benefits of green spaces for the well-being of people with schizophrenia.

2.1.1. Mental Health

Recent research reports that cumulative exposure to green spaces in childhood is associated with a lower risk of schizophrenia in adolescence and adulthood, highlighting the positive effects of exposure to natural environments [17]. A more recent population-based cohort of people aged 14–40 living in neighborhoods in Toronto found similar results [18]. The authors reported that living in an area with little green space was associated with an increased risk of developing schizophrenia, independent of other social and environmental factors. A recent systematic review has replicated these earlier findings. Marcham and Ellet found 12 studies reporting an association between exposure to green space and mental health [19]. Seven studies found that exposure to green space was associated with a reduced risk of schizophrenia and five studies reported a dose–response correlation.

2.1.2. Physical Health

Wei and collaborators investigated whether there were differences in the effects of greenspace types on the microbiome of patients with schizophrenia [20]. The taxonomic composition of the gut microbiome was examined with green space types. The relationship between green space and gut microbiome in schizophrenia differed by greenspace type. Tree coverage was found to influence taxonomic composition, suggesting that urban green spaces may be useful to improve well-being in schizophrenia [20].

2.1.3. Social Issues

Nature-based therapies are mainly based on the link between connectedness to nature and mental and physical well-being [21]. Green spaces have been associated with higher levels of physical activity, which has been linked to better outcomes in cognitive function [22].

The evidence for the effectiveness of nature-based therapies involving green spaces in schizophrenia is low to moderate. However, the recommendation to visit and interact with green spaces has been found to be safe and socially oriented.

2.2. Blue Corner

The blue corner focuses mainly on the relationship between blue spaces and health outcomes. Blue spaces are defined as outdoor spaces where water is the central characteristic. They have been shown to have positive effects on physical and mental health [23]. These spaces can be divided into three types: real- or nature-based spaces, artificial blue spaces, and virtual reality experiences.

2.2.1. Mental Health

The effects of exposure to blue spaces have been studied in recent years. One study showed that both blue-space views and blue-space visits have a positive effect on mental health. Visiting blue spaces was found to have stronger effects than viewing blue spaces [24]. More recently, Wright and collaborators investigated the impact of blue spaces on the well-being of people with severe mental illness [23]. Nineteen adults were enrolled and underwent a semi-structured online and telephone interview to report on their experiences of blue spaces. Inductive thematic analysis of their experiences concluded that patients were able to develop a blue identity based on a sense of attachment to these blue places. The concept of blue care for people with schizophrenia, bipolar disorder, and other mental health illnesses was discussed, based on the need to bring the benefits of blue spaces to people who live near them.

2.2.2. Physical Health

A recent systematic review and meta-analysis examined the association between blue spaces and health outcomes [25]. The authors found that living closer to a blue space was associated with higher levels of physical activity. Larger geographical areas of blue space were significantly associated with higher levels of restoration. Sustainable strategies that include access to blue natural environments were widely recommended [26].

2.2.3. Social Interaction

The meta-analysis carried out by Georgiou and colleagues found no significant association between distance to blue spaces and restoration and social interaction [25]. However, higher levels of contact with blue spaces were significantly associated with higher levels of restoration.

Research on the positive effects of access to blue spaces for people with schizophrenia is scarce and the level of evidence appears to be low. The social benefits of blue spaces have been limited to increased rates of physical activity and improved mood.

2.3. Red Corner

The red corner focuses on climate change and its impact on mental health, physical health, and social issues.

2.3.1. Mental Health

A recent umbrella review described and classified for the first time the global impacts of air pollution and climate change on mental health outcomes and suggested some targets for public health interventions [27]. Strongly suggestive evidence was found for an association between increased temperatures and higher rates of suicide or mortality related to mental health disorders. Air pollution has been associated with an increased incidence of cognitive impairment and dementia. In particular, short-term exposure to sulfur dioxide has been associated with relapses of schizophrenia [27]. An interesting study added that future hospitalizations for exacerbation of schizophrenia were more strongly associated with temperature changes in low-temperature environments [28]. To reduce the increasing impact of climate change-related health inequalities, adaptation of mental health plans and clinical guidelines for people with severe mental disorders is recommended [29].

2.3.2. Physical Health

People with schizophrenia experience higher mortality rates during extreme heat events [30]. A recent qualitative interview-based study examined the experiences of 35 patients with schizophrenia who suffered the 2021 Heat Dome in Canada, and its impact on physical, cognitive, and emotional outcomes. Patients reported mild-to-severe physical symptoms and an exacerbation of schizophrenia-related symptoms and emotional symptoms that negatively impacted daily functioning. The authors recommended a community-level response and individualized initiatives for people with schizophrenia [30].

2.3.3. Social Issues

Climate change has direct, indirect, and intersectional impacts on mental health. A recent paper discusses these effects on the incidence of mental health disorders such as affective and psychotic disorders, posttraumatic stress disorder, and substance use [31]. Direct effects are the consequences of direct exposure to heat, cyclones, floods, and other climatic events. Indirect effects refer to malnutrition, hunger, forced migration, and displacement, while intersectional effects are defined as social inequality, social exclusion, social isolation, and discrimination. Several studies have shown that women with schizophrenia suffer more negatively from the effects of psychosocial risk factors, which are likely to include the social consequences of climate change.

Very few studies focus on the impact of the climate crisis on mental health in schizophrenia. The vast majority of studies report mainly on the effects of high temperatures and air pollution on mortality and mental health.

2.4. Yellow Corner

The yellow corner focuses mainly on the effects of light on the mental and physical health of women with schizophrenia. Different types of light exposure are considered: (1) natural light exposure and (2) bright light therapy.

2.4.1. Mental Health

Lack of light exposure has been associated with circadian disruption and weak disrupted patterns. Light exposure is often reduced in people with schizophrenia, with a significant increase in this reduction in later life [32]. A recent study of 20 schizophrenia patients and 21 healthy controls found that those with schizophrenia were exposed to significantly fewer hours of bright light, which was associated with differences in sleep patterns. In a more recent study of 20 schizophrenia patients admitted to a psychiatric ward, circadian lighting was found to improve psychopathological symptoms, suggesting that it would be a promising intervention focusing on chronotherapy for both sexes [33]. A previous study investigated the potential effects of light therapy on negative symptoms in 20 patients with schizophrenia admitted to a psychiatric ward [34]. Patients did not experience a positive effect on clinical symptoms. In particular, negative and positive symptoms did not improve, and general psychopathological symptoms increased. Bright light therapy could not be recommended.

2.4.2. Physical Health

Exposure to light increases vitamin D production, which is a factor associated with mineral bone density. Antipsychotic-induced hyperprolactinemia reduces bone density and increases the risk of fracture [35]. Both factors should be considered, especially when treating postmenopausal women with schizophrenia.

2.4.3. Social Issues

Light exposure is indirectly related to social connectedness and social networks.

Although the evidence for increasing social and cultural activities on physical and mental health in schizophrenia has been poorly investigated and the evidence is small, several papers have linked quality of life with the social relationship domain. Interventions focusing on social life have been found to be effective and safe.

2.5. White Corner

The white corner focuses mainly on mindfulness-based strategies that can be guided by mental health professionals, and other informal mindfulness interventions [36,37]. Formal and informal strategies are based on the practice of consciously attending to the present moment without any judgment [38]. Formal practice refers to engaging in mindfulness meditation, and informal practice refers to being mindful of daily life activities.

2.5.1. Mental Health

A systematic review and meta-analysis examined the effectiveness of mindfulness-based interventions in patients with schizophrenia [38]. Patients who received the intervention showed reductions in psychotic symptoms, insight, functioning, and mindfulness. A more recent randomized controlled trial investigated the beneficial effects of mindfulness-based interventions in patients with remitted psychosis compared with psychoeducational strategies [39]. Global functioning was higher in the psychoeducation group, with no differences in relapse rates between groups. Other studies found that residual and cognitive symptoms may be a relevant target for mindfulness-based strategies [40]. Further studies are needed to replicate the effectiveness of these strategies on cognitive symptoms [41]. Recent studies have investigated the potential effects of mindfulness training in virtual reality [42]. Plencler and co-workers assessed its efficacy on psychotic, affective, and cognitive symptoms in a sample consisting of 25 patients with schizophrenia or schizoaffective disorders [42]. Negative and positive symptoms were improved, as was cognitive functioning.

2.5.2. Physical Health

Mindfulness-based stress reduction programs have been reported to reduce perceived stress and heart rate variability, and improve well-being and functional recovery in people with schizophrenia [43,44]. A more recent systematic review and meta-analysis by Rißmayer and collaborators confirmed the benefits of exercise, and mindfulness components on psychopathological symptoms and functioning [45].

2.5.3. Social Issues

Mindfulness-based cognitive therapies have also been reported to reduce the stigma in people with schizophrenia. Tang and collaborators found positive effects of mindfulness-based interventions on stigma in 62 inpatients with schizophrenia [46]. Social functioning may improve indirectly.

Evidence from meta-analyses and randomized clinical trials supports that mindfulness-based strategies have been found to be comparable with cognitive–behavioral therapies in psychosis.

2.6. Black Corner

The black corner focuses on the relationship between digitalization or digital alliance and access and participation of women with schizophrenia in mental health services.

2.6.1. Mental and Physical Health

Barriers and facilitators to the access of digital tools have been widely identified in scientific literature. Digital technologies have been reported to have beneficial effects on mental health in patients suffering from severe mental illness; however, several gaps are still under discussion [47]. Recent studies highlight that smartphone apps are promising tools for improving access to mental health care [48]. Access to laboratory results, documents, and scheduled mental health appointments increases the access of patients to adequate healthcare and improves adherence rates.

2.6.2. Social Issues

A randomized controlled trial investigated the effect of a digital tool to support patient activation and shared decision making in patients diagnosed with schizophrenia, schizotypal, and delusional disorder [49]. Communication with healthcare providers and patient activation improved.

The digital divide is one of the main factors explaining the poor access and participation of women with schizophrenia in mental health centers. Although there are few studies that focus on mental health outcomes for women with schizophrenia, evidence suggests that digital tools increase adherence to mental health services.

2.7. Purple Corner

Breast cancer screening has been reported to be lower in women with schizophrenia compared with women without schizophrenia at age 50 years or older. O’Neill and collaborators compared breast cancer screening completion in 11,631 women with schizophrenia (cases) and 115,959 women without schizophrenia (controls) at age 50 years during a two-year follow-up period [50]. The role of primary care payment models was included in the analysis. Women with schizophrenia had lower rates of mammography screening than women without schizophrenia. Cases in a family health team model had higher screening rates than those in a fee-for-service model. More recently, Den and collaborators examined the incidence of breast cancer and clinical outcomes in a group of 1,398,475 women with schizophrenia aged 18 years or older [51]. The incidence of breast cancer was 0.53% in 2011 and 2022. A peak in incidence was found in 2017 (1.29%). Hispanic women had lower rates of breast cancer than non-Hispanic women. Antipsychotic use was reported to be associated with worse clinical outcomes.

Adherence to cervical cancer screening is lower in women diagnosed with psychosis compared with the general population. Vázquez-Bourgon and co-workers examined cancer screening completion in women with psychosis (including schizophrenia) and without mental illness, who are aged around 25 years [52]. Women with psychosis entered the cervical cancer screening protocol later than the control group.

In the same line, Hwong and colleagues examined cervical cancer screening rates in women with and without schizophrenia [53]. The authors found that cervical screening rates were lower among Medicaid beneficiaries with schizophrenia than among controls. Younger age, non-white population, substance use, and comorbid depressive and anxiety symptoms were associated with higher screening rates.

Despite low rates of adherence to screening programs for breast and cervical cancer, case management strategies to encourage participation in gynecological screening in schizophrenia have been poorly investigated.

Table 1. Content of corners and proposed interventions.

Corners	Rationale	Proposed Interventions
Green	Positive effects of green spaces on mental and physical health [22].	Nature-based therapies and connectedness with nature [21].
Blue	Physical and mental health benefits of contact with blue spaces [25]. Increased sense of attachment when exposed to blue spaces [23].	Possibility of contact with blue spaces [25]. Blue prescribing (how to link blue space activities with particular health needs).
Red	Air pollution and climate change associated with poor mental health outcomes [27].	Reducing the impact of climate change-related health inequalities. Adapting mental health plans and clinical guidelines to climate changes [29].
Yellow	Lack of light exposure is associated with circadian disruption and reduction in vitamin D [32,35].	Promoting natural light exposure [32].
White	Mindfulness-based strategies may reduce psychotic symptoms and improve social functioning and reduce stigma [44,45,46].	Mindfulness-based stress reduction programs [43]. Mindfulness-based interventions.
Black	Digital tools may have a positive impact on mental and physical health of patients through increased access and participation in services [47].	Discussion about barriers to access to the Internet or technology to reduce health inequalities [49].
Purple	Mortality rates attributed to gynecological cancer are increased in women with schizophrenia [50,51].	Promoting the connection of patients with screening for gynecological cancers is crucial [50,51].

summarizes the main content of each color corner, and the proposed interventions found in the narrative review. Furthermore,

Table 2. Health and social domains and their grouping into the 7 color-coded corners.

Domain	Outcomes	Corner
Physical health domain	Nutrition	Green/Blue Corner
	Physical activity	Green/Blue and Yellow Corner
	Bone health	Yellow Corner
	Prevention and promotion of health in the climate crisis.	Red Corner
	Gynecological screening	Purple Corner
Mental health domain	Prevention and promotion of mental well-being	White Corner/Green and Blue Corner
	Accessibility and Participation	Black Corner
Social domain	Connectedness and social network	Yellow Corner

shows key health (physical and mental health) and social outcomes, which provides the rationale for grouping these outcomes into the seven color-coded corners. The outcomes are classified into three groups: Physical Health Domain, Mental Health Domain, and Social Domain, and reclassified into seven color-coded corners.

3. Description of the Project

The Community Therapeutic Space (CTS) is a new, innovative approach developed within the Mutua Terrassa Functional Unit for Women with Schizophrenia. It consists of specialized individual appointments and group sessions. The seven main themes of the health and interaction groups are the impact of green and blue spaces, climate change, light exposure, mindfulness, digitalization, and gynecological screening on health outcomes.

The results of the narrative review were the content suggestions for these groups and for the development of our women’s clinic programs, particularly the health and interaction groups.

In this Section, we describe the program staff, the reasons for referrals, the programming of activities, the timetable, and a brief description of the protocol.

3.1. Phase 1: Community Therapeutic Space in the Context of the Functional Unit for Women with Schizophrenia

3.1.1. Program Staff

The main staff of the Community Therapeutic Space are mental health professionals and training personnel who attend at least one group and individual follow-up session.

• Psychiatrists, psychologists, nurses, and social workers (no occupational therapists).
• Psychiatric, psychologist, and nursing residents.
• General physicians (GPs) and nutritionists.
• Fellows: from other countries (Chile, Belgium, etc.) who stay for at least 2 to 3 months.

All members of the unit are involved in the learning project of the functional unit for women with schizophrenia. This project includes clinical rounds, workshops, seminars, and clinical discussions. The themes of the narrative review described above are included in the learning objectives developed for the unit’s professionals.

3.1.2. Referrals

Women with schizophrenia and related disorders who attend our Functional Unit for Women with Schizophrenia are the target population for this Community Therapeutic Space (CTS). The three main reasons for referral are mental health problems affecting global functioning, physical health problems or risk of medical comorbidities, and social difficulties or the presence of social exclusion or risk of discrimination factors.

More specific reasons for referral are detailed below:

• Persistence of psychotic symptoms with impact on social and personal functioning.
• Differential diagnosis of psychosis: schizophrenia, schizoaffective disorder, and delusional disorder.
• Social issues. Women are referred for social counseling. Social exclusion and discrimination and migrant status are the main reasons for referrals, especially for the interaction group.
• Health issues: side-effects of antipsychotic drugs, medical comorbidity requiring collaboration with other health professionals, and prevention and promotion of physical health.

Young people with schizophrenia are included in the functional unit for women with schizophrenia. By implication, they are also a target population for the CTS. In the case of recruiting enough young people, we are planning to divide the target sample into two groups: (a) young people, and (b) middle-aged, old people.

3.1.3. Programing the Community Therapeutic Space in the Women’s Clinic

The main purpose of the Community Therapeutic Space is the individual assessment, treatment, rehabilitation, and recovery of women diagnosed with schizophrenia and related disorders. Recovery has been defined as a construct that integrates components of connectedness, hope, identity, meaning in life, and empowerment, as well as the integration of women in the community [54]. On the other hand, rehabilitation processes integrate aspects of physical care, involvement in social and cultural activities, and maintenance of social and personal functioning (social relationships, etc.) [55].

The three main health and social areas that are developed in this project are (1) the mental health domain, (2) the physical health domain, and (3) the social needs or social domain of these women. The interventions are mainly designed to cover these three areas. First-person experiences will be considered in the future to build a community transformational model that integrates the voice of patients in the programming of the CTS [56].

Three specific spaces are designed to personalize the clinical care of women with schizophrenia: (1) personalized space, (2) health space, and (3) interaction space.

The personalized space consists of individual appointments with psychiatrists, psychologists, nurses, or social workers, depending on the main reason for referral and their specific needs. The health space consists of groups focused on prevention and promotion of a healthy lifestyle. Psychoeducation is the main method used in health groups, with an emphasis on lifestyle recommendations. The interaction space aims to improve and promote social interaction and includes social counseling. Reducing stigma and discrimination and empowering women with schizophrenia is an important aim of this interaction space. Women are encouraged to participate in social clubs, community programs, and activity classes.

The Community Therapeutic Space opens at 9.30 a.m. and closes at 2.00 p.m. It is located in both the Community Mental Health Unit (CMHU) in Terrassa and in Sant Cugat. In the CMHU Terrassa, the Community Therapeutic Space is programmed for Thursdays. In the CMHU of Sant Cugat, it is programmed on Mondays.

Participants, and Inclusion and Exclusion Criteria

Approximately 8 to 10 women with schizophrenia and related disorders will be enrolled in the CTS.

Women will be included if they meet the following criteria: (1) they are included in the functional unit for women with schizophrenia and related disorders; (2) they have physical health, mental health, and psychosocial risk factor needs that require more intensive interventions than can be offered in adult mental health centers; (3) they require behavioral activation; and (4) they agree to group activities.

The possibility of negative effects attributed to the intervention should be anticipated. Some of the relative contraindications or potential risks of the interventions refer to the possibility that women may have an acute exacerbation of psychotic symptoms that may make it difficult for them to relate to other group members, or that may make it difficult for them to interact with therapists in a group setting. In these cases, the CTS intervention should be contraindicated, and patients should be offered alternatives such as intensive individual visits and other partial hospitalization services when necessary. On the other hand, patients with schizophrenia may also be present with the onset or relapse of affective symptoms and/or suicidal risk. In case these symptoms interfere with their group functioning or are a relevant stress factor, patients will be offered alternatives such as those mentioned above. To assess patient satisfaction, and to improve patient adherence to the intervention, weekly phone calls will be made by administrative staff to remind them of the sessions and to ensure their participation.

Assessment Measures

The following measures will be assessed at baseline, at the end of the 8-week intervention, and annually thereafter. These assessments will include patient satisfaction and information on occupational, social, and relational functioning: walking, participation in social and cultural activities, increase in healthy habits, perception of improvement in mindfulness strategies, adherence to gynecological screening, and access to and participation in health services through technology and applications.

Patients will be asked at baseline, and after the intervention, about the following: how often they walk, how many times a month they visit green and blue spaces and participate in socio-cultural activities programed in the community, and how they perceive changes in their healthy habits (diet, physical activity). They will also be asked about their weekly use of mindfulness-based strategies and their integration into their daily lives, their use of digital tools to access health services, and their association-recommended gynecological screening programs.

Changes will be evaluated to plan other future strategies and to re-evaluate the content of the groups.

Several works have pointed out that Assertive community treatment (ACT), intensive case management (ICM), and crisis intervention are cost-effective interventions for women with schizophrenia [57]. Combining health and recovery approaches can improve the overall health and functioning of these populations.

Table 3. Daily program of the Community Therapeutic Space (CTS) for Women with Schizophrenia.

Timeline	Activity	Therapeutic Team
9.30 a.m.–10.00 a.m.	Start and Welcome.	Social Worker or psychologist
10.00 a.m.–11.00 a.m.	Interaction Space (Group).	Psychologist/social worker (Social Skills, Meta-cognition/Link to Social Activities/Leisure)
11.00 a.m.	Break.
11.30 a.m.–12.00 a.m.	Personalized Space (Individual appointments: psychiatrist, psychologist, nurses, social worker).	Individualized therapeutic plan: Psychologist (different from the group leader). Social Work Nurses Psychiatrist
12.00 a.m.–12.30 a.m.	Personalized Space (Individual appointments: psychiatrist, psychologist, nurses, social worker).	Psychologist (different from the group leader) Social Work Nurses Psychiatrist
12.30 a.m.–13.30 a.m.	Physical or Mental Health Space (Group).	Psychiatrists, psychologists, nurses. General Physicians (GPs), Nutritionists.
13.30 a.m.–14.00 a.m.	Closing Summary.	Feedback. Evaluation of Individualized Therapeutic Plan

summarizes the schedule and daily program of this intervention. For each activity, the schedule, the activities, and the therapeutic team involved are described.

3.1.4. Description of the Personalized Space

(1)

Patient and family assessment [6]. Differential diagnosis is offered. Women with schizophrenia are diagnosed later in life than men [58]. Furthermore, recent literature reports that migrant women with schizophrenia have less access to health services [59], both of which are strong reasons to offer this personalized assessment in an intensive approach. This personalized space will identify barriers and facilitators to women’s access and participation in mental health services and take action to intervene in these factors.

(2)

Case management. Different clinical scenarios can be identified in women with schizophrenia. They have specific clinical and social needs. Some women have more severe physical health problems, others report severe social needs, and still others have both. In addition, about 50% of women with schizophrenia are mothers [60]. This clinical scenario merits an individual approach to women and their children.

(3)

Individual counseling and pharmacotherapy. The treatment of women with schizophrenia presents different clinical challenges when compared with men. For women of reproductive age, menstruation should be targeted. Second-generation antipsychotics, especially prolactin-sparing antipsychotics should be considered during this period of a woman’s life. Gynecological screening and hormone replacement therapy are often considered for menopausal women with schizophrenia. This personalized space provides a link to gynecological services. In the case of hyperprolactinemia, a consultation with a neuroendocrinologist can be offered, which is a specific intervention derived from the Observatories of the Functional Unit for Women with Schizophrenia [61]. The model of care based on the observatories—vigilance teams and specific interventions—is described elsewhere [61].

(4)

Psychoeducation of patients and families. Clinic staff maintain contact with family members and other members of the women’s ecosystem. Support and psychoeducation are the main activities of family intervention.

(5)

Assessment of substance use disorders. The therapeutic space is linked to addiction experts through the Observatory of Substance Use Disorders. This personalized approach is a very good opportunity for prevention and early detection of comorbid substance use disorders.

3.1.5. Description of the Interaction Space

Leisure groups. The woman’s clinic aims to establish links with community services such as leisure activities, fitness programs, dance, and swimming classes for women. One of the main goals of the clinic staff is to help women to become part of a social network. Leisure groups are designed to promote social relationships, and activities to increase belonging to a social group. For example, social prescribing is one of the main interventions of the interaction space. Social prescribing connects women to community groups and activities to improve their mental health and well-being. This activity is closely related to the health space because it can also include links to exercise groups, art groups, and activities involving nature [62]. Connections with community activities based on horticultural therapy and therapeutic gardening are suggested in the context of this group [63,64,65].

3.1.6. Description of the Health Space

Diet and exercise groups. Women with schizophrenia have specific health needs that vary according to their reproductive stage: premenopausal, menopausal transition, menopausal, and postmenopausal. Cardiovascular, respiratory, and bone health are specific targets for these groups. This health space connects women to community health programs, nutrition programs, and fitness programs. All women are linked to their general practitioner, and the clinic staff pay particular attention to the potential side effects of antipsychotic medication [61]. Special attention is given to comorbidities with respiratory conditions, such as obstructive sleep apnea.

3.2. Phase II: Volunteer Program

After the eight sessions of the Community Therapeutic Space, the benefits of the interventions should be maintained. A second phase of the project will be designed for the future to ensure that the community activities with a health or social dimension are maintained. This second phase of the project will involve a volunteer program for women with schizophrenia.

Recent studies have investigated the potential effects of a one-year befriending program or just receiving information about social community activities in 124 patients with schizophrenia [66]. Patients were followed up after one year, 63 in the intervention group and 61 in the control group. As a result of the intervention, the first group of patients had significantly more social contacts than the control group after one year. Several benefits have been reported in patients with severe mental illness who participate in voluntary group befriending interventions [67]. Interviews with 23 patients revealed that patients experienced a reduction in stigma, an increase in relationships and personal growth, continuity of befriending, and acceptance and sustainability of befriending. The authors highlight the low cost of this intervention, which has been shown to be useful and effective in schizophrenia.

3.3. Protocol of the Intervention

The CTS is an eight-week intervention. This once-a-week intervention consists of health and interaction groups and individual appointments. This means that women with schizophrenia who participate in the program receive a total of two group sessions and two individual sessions per week for 8 weeks. Each group session lasts 1 h, and each individual session lasts 30 min. Several studies evaluating the effectiveness of group therapy for severe mental illness have not found greater effects of a 12-week intervention compared with an 8-week group intervention [68]. During this eight-week period, women with schizophrenia receive the health and interaction group intervention for a total of 16 sessions. Personalized individual appointments are also offered.

The main content of the seven corners is programmed according to the results of the narrative review. The objectives and main tasks of the seven color-coded corners applied to the health and interaction groups are described below.

3.3.1. Green Corner

In the green corner of the CTS, we help our women with schizophrenia to identify green spaces in their communities and neighborhoods. The positive effects of green spaces on mental and physical health are also discussed, as well as the barriers and facilitators to accessing these places. To increase opportunities to connect with nature, the interaction/social group promotes social activities. In the health group, the association of nature with the consumption of fruit and vegetables is discussed.

3.3.2. Blue Corner

In the blue corner of the CTS, we discuss with patients the potential positive effects of exposure to blue spaces on mental health and the variety of activities associated with these blue spaces: walking, running, and cycling, together with relatives, friends, or alone. Touching the water, reading, and swimming are also discussed in these groups. The sensory, social, and emotional qualities of blue spaces are discussed in depth in the blue corner of our CTS. Visits to natural blue spaces are also recommended and may be planned in the future.

3.3.3. Red Corner

Women with schizophrenia are encouraged to plan their health care according to changes in temperature and other consequences of the climate crisis. In the health and interaction groups (spaces) of the CTS, the influence of climate change on social risk factors is discussed, as well as different options to reduce these negative consequences.

3.3.4. Yellow Corner

The yellow corner of the CTS focuses on the potential benefits of light exposure on mental and physical health, and social connectedness.

As natural light exposure is recommended for schizophrenia, and some potential barriers can be identified, social groups and activities are recommended for this population in the health and social groups.

3.3.5. White Corner

As training in mindfulness techniques seems to be beneficial for women with schizophrenia, we have included in the white corner of the CTS informal mindfulness practices to reduce stress and sleep-wake rhythm disturbances.

3.3.6. Black Corner

In the black corner of the ECT, women with schizophrenia are linked to digital literacy training in the community, with the main aim of reducing the digital divide in this population.

The health and interaction groups discuss some examples of the potential use of health apps to increase patient accessibility and interaction with the health system. Digital mental health interventions are not fully discussed in the black corner.

3.3.7. Purple Corner

As linkage to primary care services has been shown to be critical for gynecological cancer screening, health groups in the purple corner encourage women with schizophrenia to participate in these screening programs and promote linkage to primary care and gynecological services.

A brief description of each of the sessions of the health and interaction space is described in

Table 4. Protocol of the intervention: the health and interaction space and the 7 color-coded colors.

	Sessions of the Health Group	Sessions of the Interaction Group
Week 1	Session: Green Corner—Healthy lifestyles. Objective: To connect women to nature and healthy lifestyles. Proposed tasks: To promote interaction with urban and non-urban green spaces.	Session: Green Corner—Social interaction. Objective: To promote social activities in urban and non-urban green spaces. Proposed tasks: To promote social interactions and development of social activities.
Week 2	Session: Purple Corner—Gynecological screening. Objective: To promote adherence to gynecological screening programs. Proposed tasks: To connect women with primary care programs.	Session: White Corner—Mindfulness in the community. Objective: To promote development of activities involving techniques of mindfulness (exercise, etc.). Proposed tasks: To connect women with natural spaces and activate mindfulness techniques.
Week 3	Session: Yellow Corner—Light exposure and health. Objective: To promote light exposure and outdoor activities. Proposed tasks: To connect women with social and cultural activities.	Session: Blue Corner—social interactions. Objective: To connect women with blue spaces. Proposed tasks: To develop social activities involving blue spaces.
Week 4	Session: White Corner—mindfulness and health. Objective: To promote stress-reduction strategies. Proposed tasks: To connect women with natural spaces and cultural activities by applying mindfulness techniques.	Session: Red Corner—climate crisis and social activities. Objective: To reduce the impact of climate change-related health inequalities. Proposed tasks: To promote outdoor activities in safe spaces (during heat waves).
Week 5	Session: Green Corner—nutrition. Objective: To promote the consumption of fruits and vegetables. Proposed tasks: To increase consumption of vegetables/fruits.	Session: White Corner—Mindfulness in the community. Objectives: To promote the development of activities involving techniques of mindfulness. Proposed tasks: To connect women with natural spaces (mindfulness techniques).
Week 6	Session: Black Corner—access. Objective: To increase and facilitate the access of women to mental health services. Proposed tasks: To use digital tools to access mental health services.	Session: Black Corner—participation with mental health services. Objective: To promote participation in mental health services. Proposed tasks: To connect women to services and to increase participation.
Week 7	Session: Red Corner—health and safety. Objective: To adapt mental health plans to climate change. Proposed tasks: To connect women with safe outdoor spaces.	Session: Yellow Corner—cultural activities. Objective: To promote the participation of women in cultural activities. Proposed tasks: To connect women with community sources and services.
Week 8	Session: Blue/Yellow Corner—nutrition and healthy styles. Objective: To promote healthy nutrition habits. Proposed tasks: To discuss the consumption of fish and other healthy habits related to blue spaces.	Session: Green Corner—social interaction. Objective: To promote interaction with urban and non-urban green spaces. Proposed tasks: To promote social interaction and development of social activities in green spaces.

. This table mainly focuses on how the green, blue, red, yellow, white, black, and purple corners are applied to the health and interaction groups.

4. Methods

4.1. Screening and Selection Process

We conducted a narrative review by searching the PubMed and the Clinicaltrials.gov databases from 2021 to inception in the area of health and social care for women with schizophrenia. Relevant papers published in the last years were included to analyze the content of recent evidence on schizophrenia to improve the healthcare and recovery of these women, and to implement the content of the Community Therapeutic Space intervention.

We decided to include papers from the last 3–4 years because this innovative intervention aims to include the most relevant evidence on the impact of green and blue spaces, climate change, light exposure, digitalization, and gynecological screening. In recent years, a large body of research has pointed to the protective and therapeutic effects of green and blue spaces on mental and physical health. Incorporating recent work in this area provides the latest ideas for developing interventions to improve mental and physical health. Evidence of the impact of climate change on mental health has increased substantially in recent years. The latest evidence on recommendations to protect people from the mental and physical health impacts of the climate crisis provides useful and safe planning for climate-adapted interventions. Recent evidence from climate change literature is needed to recommend safe exposure to light. Mindfulness-based strategies have been extensively investigated in recent years, as has the use of digital tools to connect patients with health services. Recent recommendations on gynecological screening in women should be implemented in health-related interventions.

Other authors have also included recent work in reviewing the health and social care needs of women with schizophrenia [69].

This narrative review aimed to identify scientific evidence in the fields of green and blue spaces, climate change, light and health, digitalization and health, and gynecological screening in women with schizophrenia, in order to plan the health and interaction spaces that focus mainly on health and social issues.

For that purpose, we used the following search terms: “green space”, “blue space”, “climate change”, “light”, “mindfulness”, “digitalization” and “gynecological screening”, and schizophrenia.

4.2. Inclusion/Exclusion Criteria

Papers were included if they were considered relevant to the field and were clinically important and included samples formed by patients with schizophrenia. With regard to the study design, preference was given to systematic reviews and meta-analyses, and randomized controlled trials. However, large longitudinal designs and population-based cohort studies were also included. Additional classic papers were included if they provided relevant information on topics (green and blue spaces, climate change, light exposure, mindfulness, digitalization, and gynecological screening) that were not the focus of the most recent papers.

The following specific inclusion criteria were applied for each of the 7 topics of review: (1) Green Corner. Papers on green spaces were only included if they reported an association between green spaces, mental health, or mental well-being in schizophrenia. The impact of exposure to green spaces on mental and physical health, and social connectedness were the focus of interest. (2) Blue Corner. Studies were included if they reported an association between mental health or mental well-being and blue spaces in schizophrenia. The effects of exposure to blue spaces on physical health and the social domain were also considered. (3) Red Corner. Studies were included if they reported an association of climate change on mental and physical health in schizophrenia. (4) Yellow corner. Papers reporting the association between light and health in schizophrenia were eligible. (5) White Corner. Papers on the effects of mindfulness-based strategies to improve mental and physical health in schizophrenia were included. Studies that included descriptions of mindfulness strategies during social activities were also included. (6) Black Corner. Studies reporting the effectiveness of digital tools to improve patient access and participation were included. (7) Purple Corner. Studies were included if they reported on gynecological screening in women with schizophrenia.

The inclusion and exclusion of papers was carried out by two senior authors (M.N. and A.G.-R.). Any disagreements were resolved by consensus with the participation of a third author.

In the second step, the evidence was classified according to the main “color content” (green, blue, red, yellow, white, black, and purple). Results were grouped and described into the following three sections for each of the corners: (1) mental health, (2) physical health, and (3) social issues, in order to plan new intervention strategies.

5. Discussion

The Community Therapeutic Space (CTS) of the Mutua Terrassa Functional Unit for Women with Schizophrenia is a new innovative intervention that consists mainly of three spaces: the personalized space, the health space, and the interaction space during an 8-week package of daily sessions. The first step of the project, namely, the Functional Unit for Women with Schizophrenia, was inaugurated in January 2023 with the main aim of improving the mental and physical health of women with schizophrenia and reducing the impact of social risk factors [61].

The main aim of the CTS is to offer personalized interventions that focus on mental and physical health, and social needs of women with schizophrenia and related disorders [56,61]. Several topics of concern have been identified to carry out a narrative review to design the main contents of this innovative intervention. The seven selected topics are the impact of (1) green spaces, (2) blue spaces, (3) climate crisis, (4) light, (5) mindfulness, (6) digitalization (in terms of access and participation to mental health services), and (7) gynecological screening.

The personalized space of the CTS offers individual appointments with psychiatrists, psychologists, nurses, or social workers according to the woman’s needs. Particular attention is paid to pharmacological issues according to the reproductive and post-reproductive phases of women [6]. The health space focuses mainly on groups of healthy habits (diet/nutrition, sleep, physical activity), and aims to link women to community activities, associations, or social foundations. The interaction space is mainly focused on social connections and is mainly based on the connection with nature and community resources and its positive benefits.

The content of these potential three spaces has been grouped into seven color-coded corners that define health and social interventions: green, blue, red, yellow, white, black, and purple.

The green and blue corners focus on the beneficial effects of green and blue spaces on people’s mental and physical health. In fact, cumulative exposure to green spaces has been associated with a reduced risk of schizophrenia [17], higher levels of physical activity, and better cognitive outcomes [22]. Exposure to green and blue spaces is promoted by green and blue corners to increase the connectedness to nature and a social group. A recent study from the UK Biobank confirmed that green spaces, blue spaces, and the natural environment were associated with a reduced risk of psychiatric disorders in middle-aged and older adults [70]. Potential confounders should be included in the effectiveness analysis of future studies in that field [71].

The red corner focuses on the effects of climate change and air pollution on mental and physical health and social interactions [27,28,29]. The Red Corner health and social groups focus mainly on how to prevent the physical and mental health impacts of climate change and air pollution, and how to adapt mental health plans to these impacts. Recent work in bipolar disorder populations confirms the negative impact of the climate crisis, and the need to develop preventive strategies, and intervention programs to reduce its negative effects [72].

The yellow corner focuses on the effects of light on mental and physical health and social connectedness. Lack of light exposure has been linked to sleep disturbances and other circadian disruptions [32]. A reduction in vitamin D levels has been frequently reported in schizophrenia as a result of reduced light exposure [39]. The health and interaction spaces (groups) of the CTS promote light exposure according to individual health and social needs. Potential health risks are considered and discussed with patients. Social interactions may overlap with increased light exposure. Recent studies have confirmed the role of light exposure as an environmental risk factor for psychiatric disorders. Longer exposure to light at night was associated with an increased risk of major depressive disorder, psychosis, and bipolar disorder [73]. Greater daylight exposure was associated with a reduced risk, suggesting that light-dependent interventions may be effective in improving mental health [73].

The white corner focuses on formal and informal mindfulness strategies that are mainly based on the practice of consciously attending to the present [43,45]. We found a recent systematic review and meta-analysis confirming the reduction in psychotic symptoms by mindfulness-based interventions. Mindfulness components of exercise are also considered and discussed in the white corner. Mindfulness interventions have been associated with greater effects in younger populations, and modest positive effects have been reported in older adults [65,74]. Modified interventions according to age or reproductive stage should be further investigated.

Digital tools have been shown to have a positive impact on the mental and physical health of patients with severe mental illness [47]. Access to appropriate healthcare is also a target for digital technologies. Patient activation has been reported to be improved through the use of digital tools [49]. While extensive research has explored digital markers for mental health symptoms in individuals with severe mental illness, their application to physical health, and access and participation of patients with mental health services, remains underexamined [75]. The digital divide is one of the main targets of the black corner health and interaction groups. Aspects for discussion include access to the Internet and technology or process improvements to reduce health inequalities due to the digital divide [76].

The purple corner of the CTS focuses on breast and cervical cancer screening, both of which have been reported to be lower in women with schizophrenia [50,53]. Recent studies in this area have discussed the potential role of primary care models and screening rates in schizophrenia populations. In our health groups, professionals and patients discuss the benefits, barriers, and facilitators of adequate cancer screening. Links to primary care and gynecological services are facilitated through the group. Campaigns and other interventions to encourage women to take up gynecological screening have been extensively researched [77].

In terms of mental health, the personalized space of the CTS may be a good opportunity to reconsider the use of alternative antipsychotic medications. People with schizophrenia often suffer from comorbidity of depressive symptoms, obsessive thoughts and compulsive behaviors, suicidal ideation, and substance use disorders. In this clinical scenario, several authors have emphasized the need to consider the use of long-acting injectable antipsychotics, which have been shown to be effective in treating non-core clinical symptoms of schizophrenia [78]. In the specific context of first-episode psychosis, several papers highlight the need to identify predictors of readmission and effective interventions to reduce the risk of hospitalization and its clinical consequences. Once again, substance use has been identified as a potential risk factor for readmission at one year, and long-acting antipsychotics have been reported to have positive effects on clinical outcomes compared with oral medications [79]. In the personalized space, the use of antipsychotic medications is discussed with women and the mental health team, according to predictors of exacerbation and other safety issues [80].

The core content of the CTS promotes personal recovery and is linked to established models of psychiatric rehabilitation. For example, connecting with nature and socializing with other women helps participants improve their personal and social functioning (see green corner). Another example is the blue corner, which is mainly designed to promote physical activity in areas close to blue spaces. The yellow corner focuses on the benefits of walking and social activities and is based on vitamin D production and bone health. The black corner, in particular, helps women to access health services and increase their participation in the health care process. Mindfulness-based therapies, mainly addressed in the white corner, focus on stress-related strategies that improve overall personal recovery. Physical health also influences recovery. This is why the purple corner focuses on screening for gynecological cancers.

One of the main strengths of the CTS is that the intervention promotes the use of and exposure to healing environments. In fact, for many decades, nature has been described as a relevant element for healing and recovery in the mental health field [81]. This concept of healing architecture refers to how mental health recovery is linked to nature through the built environment. It has been applied in the field of community mental health interventions as well as in the design of spaces in inpatient psychiatric wards [82,83,84].

Healthy architecture focuses mainly on the design of spaces and structures; however, the broader definition of architecture and design that incorporates nature focuses on the biophilic concept [85,86] that links humans, nature, and mental health. Recently, several papers have reported the association between natural landscapes and positive effects on mental health, and the effects of exposure to greenery on physical and mental health [87,88].

However, CTS has several limitations that should be taken into account. Firstly, it should be noted that there are limitations to the accessibility of other rehabilitation services or community facilities that can be proposed in the CTS process. Secondly, there is a need for clinical expertise and supervision from other clinicians who are experts in the areas proposed in the health and social interaction groups. However, this can also be an opportunity to broaden the working group and motivate the whole community team. Another limitation is that women with schizophrenia have different medical and social needs, depending on the complexity of the illness. Interventions should be tailored to psychosocial difficulties and health needs. CTS also needs expert clinicians to work on maintaining the effects of the group. The role of volunteers and first-person experience can improve long-term outcomes.

6. Conclusions

Women with schizophrenia have different health and social needs compared to men. The Mutua Terrassa Functional Unit for Women with Schizophrenia has designed a new intervention called the Community Therapeutic Space, which is mainly based on individual and group interventions focused on physical and mental health and social risk factors. Three main intervention spaces are defined: the personalized space (individual appointments), the health space (groups of healthy habits), and the interaction space (social connections).

The content of these three spaces has been designed according to a recent review on seven important topics coded into seven color corners: green and blue corners (related to green and blue spaces), red corner (climate change), yellow corner (light and health), white corner (mainly focused on mindfulness), black corner (digitalization in healthcare), and purple corner (related to gynecological screening). In the future, peer-to-peer and volunteer programs may help our healthcare unit to ensure and maintain the positive effects of these personalized interventions. Furthermore, future transformative innovative approaches should include the patient’s perspective. Focus groups will be designed at the end of the CTS to adapt the intervention to the individual needs of women with schizophrenia. Qualitative assessment will be based on such patient perspectives.