BACKGROUND: We aimed to identify therapeutic approaches for managing schizophrenia in different phases and clinical situations - the prodromal phase, first-episode psychosis, cognitive and negative symptoms, pregnancy, treatment resistance, and antipsychotic-induced metabolic side effects - while assessing clinicians' adherence to guidelines.

METHODS: A cross-sectional online survey was conducted in 2023 as part of the Ambassador project among psychiatrists and trainees from 35 European countries, based on a questionnaire that included six clinical vignettes (cases A-F). Additionally, a review of multiple guidelines/guidance papers was performed.

RESULTS: The final analysis included 454 participants. Our findings revealed a moderate to high level of agreement among European psychiatrists regarding pharmacological treatment preferences for first-episode psychosis and cognitive and negative symptoms, prodromal symptoms and pregnancy, with moderate adherence to clinical guidelines. There was substantial similarity in treatment preferences for antipsychotic-induced metabolic side effects and treatment resistance; however, adherence to guidelines in these areas was only partial. Despite guideline recommendations, non-pharmacological treatments, including psychotherapy and recovery-oriented care, were generally underutilized, except for psychoeducation and lifestyle recommendations, and cognitive behavioural therapy for treatment of the prodromal phase. Contrary to guidelines, cognitive remediation and physical exercise for cognitive symptoms were significantly neglected.

CONCLUSIONS: These discrepancies highlight the need for effective implementation strategies to bridge the gap between research evidence, clinical guidelines/guidance papers, and real-world clinical practice. Clinicians' unique combination of knowledge and experience positions them to shape future guidelines, especially where real-world practice diverges from recommendations, reinforcing the need to integrate both research evidence and clinical consensus.