Schizophrenia in Dogs

Front Psychiatry
. 2023 Jun 23;14:1192075. doi: 10.3389/fpsyt.2023.1192075
Dog-assisted interventions for adults

diagnosed with schizophrenia and related
disorders: a systematic review
Malene Kalsnes Tyssedal 1,*, Erik Johnsen 1,2,3, Aurora Brønstad 1, Silje Skrede 4,5
  PMCID: PMC10326428 PMID: 37426092
Abstract
Background
Many individuals diagnosed with schizophrenia and related disorders experience insufficient
symptom relief from currently available treatment options. Researching additional venues should
be prioritized. This systematic review, designed in accordance with PRISMA, examined the
effect of targeted and structured dog-assisted interventions as a supplementary treatment.
Methods
Randomized as well as non-randomized studies were included. Systematic searches were

conducted in APA PsycInfo, AMED, CENTRAL, Cinahl, Embase, Medline, Web of Science,
and in several sources covering “gray” (unpublished) literature. In addition, forward and
backward citation searches were performed. A narrative synthesis was conducted. Quality of
evidence and risk of bias were assessed in accordance with GRADE and RoB2/ROBINS-I
criteria.
Results
12 publications from 11 different studies met eligibility criteria. Overall, studies showed
diverging results. General psychopathology, positive and negative symptoms of psychosis,
anxiety, stress, self-esteem, self-determination, lower body strength, social function, and quality
of life were among the outcome measures with significant improvement. Most documentation for
significant improvement was found for positive symptoms. One study indicated significant
deterioration of non-personal social behavior. The risk of bias was high or serious for most of the
outcome measures. Three outcome measures were associated with some concerns regarding risk
of bias, and three with low risk of bias. Quality of evidence was graded low or very low for all
outcome measures.
Conclusions
The included studies indicate potential effects of dog-assisted interventions for adults diagnosed
with schizophrenia and related disorders, mostly beneficial. Nevertheless, low number of
participants, heterogeneity, and risk of bias complicate the interpretation of results. Carefully
designed randomized controlled trials are needed to determine causality between interventions
and treatment effects.
Keywords: animal-assisted interventions, therapy dog, PANSS, psychosocial outcomes,

psychosis, severe mental illness
1. Introduction
Schizophrenia and related psychotic disorders are characterized by positive symptoms, negative
symptoms, and cognitive difficulties. Hallucinations, delusions, and disorganized speech are
examples of positive symptoms, while amotivation, anhedonia, and affective flattening are
examples of negative symptoms. Genetic predisposition, substance use, trauma, and acute stress
are among the risk factors for development of severe psychotic disorders. In addition,
neurobiological factors, such as dopamine dysfunction, are associated with presence of positive
symptoms and negative symptoms, as well as cognitive difficulties (1, 2). Overall lifetime
prevalence for schizophrenia and related disorders is stated as 7.49 per 1,000 (3). The prognosis
varies among individuals and extends between recovery and a chronic, lifelong course (4). Life
expectancy is reduced by several years, with somatic comorbidity as one of the major causes (5).
Overall, severe psychotic disorders are associated with a high burden of disease (6).
Treatment recommendations consist of a combination of pharmacological and non-

pharmacological interventions (7). Current antipsychotic medications are shown to be more
effective for positive symptoms than for negative and cognitive symptoms (1), and the latter two
symptom groups are important determinants of disability (8). Numerous non-pharmacological
interventions are considered in the guidelines by the Norwegian Directorate of Health (7), in
accordance with international standards. Psychoeducation, family interventions, cognitive
therapy, physical activity, and music therapy are among the included options. However, a
substantial group of individuals diagnosed with schizophrenia and related disorders do not
experience sufficient symptom relief (9). The heterogenous pathophysiology and phenotypes of
severe psychotic disorders underpin the need for varied treatment options (10). Direct
interpersonal engagement can be too demanding in some individuals. Interaction with therapeutic
animals might theoretically be a less stressful alternative.
Animals have been included in the treatment for several disorders through centuries (11).
Currently, there has been a development where anecdotal evidence to a larger extent is replaced
by scientific research (12). The International Association of Human-Animal Interaction
Organizations (IAHAIO) (13) has published specific guidelines for animal-assisted interventions
(AAI). These guidelines are stating that AAI must be targeted and structured, with therapeutic
benefits as purpose. Animal-assisted therapy (AAT) and animal-assisted activity (AAA) are two
examples of AAI relevant to health care. While AAT must be planned, measurable, and
documented, AAA signifies informal interaction. The guidelines are further stating that AAT is
targeted toward physical, cognitive, behavioral, and/or socio-emotional functioning, while AAA
is targeted toward motivation, education, and/or recreation. Knowledge related to health and
behavior of included animals is required for providers of both AAT and AAA. Professional
expertise, for example within health care, is in addition required for providers of AAT.
Studies have suggested treatment effects related to AAI for a range of health conditions and
diseases (14). Biophilia, stress buffering, and distraction are elements in some theories and
hypotheses that may explain potential effects (15). The biophilia hypothesis describes the affinity
of humans to other living species (16). Effects related to the biophilia hypothesis may involve
feelings of safety and facilitation of interpersonal interactions where animals may serve as social
catalysators (17). In addition, decreased levels of cortisol and increased levels of oxytocin, β-
endorphin, prolactin, phenyl acetic acid, and dopamine have been detected after interaction with
dogs (18). These changes may be associated with physiological and psychosocial benefits, such
as stress relief and improvement of social bonding and learning (18–21). Summarized, AAI are
aimed at a wide range of symptoms and features, including those presented in severe psychotic
disorders. Increased motivation for therapeutic activities due to interaction with animals has been
described, for example in a study including individuals with acquired brain injury (22).
Treatment effects of AAI will be highly relevant to investigate further for individuals with severe
psychotic disorders. This is particularly justified by the fact that lack of motivation, which affects
adherence to treatment, is a core feature among the negative symptoms (23).
A systematic review (SR) from 2018 on equine-assisted interventions indicated potential effects
for individuals diagnosed with schizophrenia and related disorders. Significant improvement was
shown for several outcome measures, such as negative symptoms, social functioning,
pharmacological compliance, and risk of violence. The authors stated that further research is
needed (24). A SR from 2019, including randomized controlled trials (RCTs) on AAI with
several animal species, found inconclusive results regarding treatment effects for individuals
diagnosed with schizophrenia and related disorders. However, potential benefits were found for
some outcome measures, such as positive symptoms, negative symptoms, emotional symptoms,
and self-view (25).
As different animal species have different properties, we sought to investigate effects of dog-
assisted interventions (DAI) specifically to increase directness and complement previous SRs.
An investigation of therapeutic effects of DAI is also relevant due to findings in a survey among
individuals diagnosed with schizophrenia, indicating that the dog was a preferred animal (26). A
meta-analysis found that dogs were the most commonly involved animal in AAT (27). Beneficial
therapeutic effects may be related to the cognitive and emotional capacities in dogs, in addition
to an evolutionary connection with humans (28). Feasibility is also an important issue as dogs
can thrive in same environments as humans. We sought to evaluate effects of targeted and
structured interventions with therapeutic benefits as purpose. Therefore, both AAT and AAA
were included.
Due to an existing knowledge gap, in addition to an extension of the field by four articles
published during 2021–2023 (29–32), we found it relevant to perform a modified and updated
SR on the topic. Summarized, modifications consisted of broader inclusion regarding study
designs, and a narrower approach regarding the objective. The aim of the SR was to investigate
effect of DAI for adults diagnosed with shizophrenia and related disorders. To our knowledge,
this isolated topic has not been specifically covered by previous SRs.
2. Methods
The SR was designed in accordance with PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) guidelines (33). In addition, a document with examples from the
guidelines was used (34). Two handbooks, by Cochrane (35) and by the Norwegian Institute of
Public Health (NIPH) (36), were also used as references.
2.1. Eligibility criteria
Eligibility criteria are presented in Table 1.
Table 1.
Eligibility criteria.
Inclusion criteria Exclusion criteria

Population Participants aged 18 years or older diagnosed Lack of distinguishing between
with schizophrenia or related disorders (37 )a measurements from participants
Ongoing treatment in a psychiatric ward, with other diagnoses than
outpatient clinic or residential institution schizophrenia and related disorders
Intervention Dog-assisted interventions with aim of Lack of distinguishing between
therapeutic benefits measurements from interventions
with different animal species
Outcome Outcomes measured with validated N/A
instruments on at least two time points
throughout the study
Study design Quantitative studies of all designs N/A
Report Both published articles and gray literature Articles written in other languages
properties No restrictions regarding year of publication than English or Scandinavian
Risk of bias N/A Critical risk of bias
Open in a new tab
N/A, Not applicable.

a
Schizophrenia and related disorders: Schizophrenia, schizotypal and delusional disorders (F20-
F29) in International Classification of Diseases, ICD-10, and corresponding diagnoses in
Diagnostic Statistical Manual, DSM-IV and DSM-V, assessed using a tool from New Zealand
Health Information Service. Nevertheless, studies were not excluded due to missing diagnosis
codes.
2.2. Search strategies, information sources and study selection
A detailed description of the search strategies can be found in Supplementary Tables 2–13.
Briefly, the search strategy was developed in accordance with chapter 4 in Cochrane's method
book (38) and chapter 4 in the method book by NIPH (36). Furthermore, two SRs (24, 25) on
related topics, in addition to IAHAIOs definition of animal-assisted interventions (13), were used
as references. Relevant articles detected through initial, non-systematic searches in Google
Scholar and PubMed were reviewed for additional search terms and used for validation of the
search strategy (29, 39–45).
The main searches were conducted 21.05.22 in APA PsycInfo (Ovid), AMED (Ovid),
CENTRAL (Cochrane), Cinahl (Ebsco), Embase (Ovid), Medline (Ovid) and Web of Science.
Automatic alerts regarding new publications until submission were set up. Duplicates from the
main search were initially removed by automatic duplicate detection in EndNote version 20.
Remaining duplicates were removed manually. Title and abstracts of all the remaining articles
were screened by two reviewers working independently (by AB and EJ from A to K, and by MT
and SS from L to AA, sorted by authors last name). Articles were initially excluded if the title or
abstract did not include DAI or AAI not further specified, and schizophrenia, other psychotic
disorders or mental disorders not specified.
The assessments of which articles to read in full text version and which to include in the SR,
were also made independently by two reviewers for each study. The supplementary searches
were conducted in the period from 30.04.22 to 28.05.23. For supplementary sources, please refer
to the detailed description found in the Supplementary material. These searches consisted of both
forward and backward reference searching, in addition to searches in databases, registers, and in
websites of organizations. Backward citation searches in relevant reviews were conducted by EJ
from A to K, and by MT from L to AA, sorted by authors last name. Beyond this, the
supplementary searches were conducted by one reviewer (MT).
2.3. Data collection and synthesis of results
Study properties were collected in accordance with the PICO (population, intervention,
comparison, outcome) model (46). Report properties were also collected, in addition to
information regarding study design. Measurements regarding overall change, final values and/or
follow-up for all outcomes related to effects were sought for extraction. Some of the elements
were not documented in all articles. The data elements presented in Tables 2–4 were collected by
one reviewer (MT) and controlled by one reviewer (EJ). Supplementary Table 15 provides an
overview over data elements sought for extraction.
Table 2.
Study characteristics.
Population Intervention Comparison Outcome Study design
measure
Barker Schizophrenia, n = 34 n = 45 participants STAI (anxiety) Crossover
and schizoaffective participants (39 included in design
Dawson, disorder and (26 included analyses)
1998 other psychotic in analyses) Therapeutic
(47) disorders, acute Dog-assisted recreation group
Inpatients Sexa: therapy 30 session (music and
F 174, M 139 min x1 art activities,
b
Age : Mean 37 education about
years, SD 12 leisure time and
resources) x1
(duration not
specified)
Calvo et Schizophrenia, n = 16 n = 8 participants Primary RCT (non-
al., 2016 chronic (DSM- participants (8 included in outcomes: blinded)
(39) IV-TR) (14 included analyses) One PANSS (positive,
Inpatients Sex: F in analyses) activity from the negative, general
7, M 17 Age: Dog-assisted functional program symptoms) EQ-
Mean 47.8 therapy in (art therapy, group 5D (quality of
years, SD 6.7 addition to sports, dynamic life) Secondary
Age at psychosocial psycho-stimulation outcomes:
diagnosis: Mean rehabilitation or gymnastics) in Adherence
20.5 years, SD program 6 addition to other (patient
5.0 months, 60 programs of the experience)
min x2 per psychosocial Salivary cortisol,
week rehabilitation alpha-amylase
program 6 months, (stress relief)
60 min x2 per week
Chen et Schizophrenia, n = 20 n = 20 participants Primary RCT (non-
al., 2021 chronic (DSM- participants (20 included in outcomes: blinded)
(29) 5) Inpatients and (20 included analyses) Addition PANSS (negative
day care patients in analyses) of nursing and general
Sex: F 22, M 18 Dog-assisted intervention and symptoms)
Age ≥ 40 years therapy in occupational DASS-21
(mean 54.7) addition to therapy from the (depression,
usual usual treatment anxiety, stress)
treatment program 12 weeks, Secondary
programs 12 60 min x1 per week outcomes:
weeks, 60–65 PANSS (positive
min x1 per symptoms) CHI
week (well-being)
Chen et Same population Same Same comparison MoCa (global Same design
al., 2022 as Chen et al., intervention as as Chen et al., 2021 cognitive as Chen et
(30) 2021 (29) (29) function) CST al., 2021 (29)
measure
Chen et al., (lower body
2021 (29) strength) TUG
(agility) 5MWT
(mobility) ACIS
(communication
and interaction
skills)
Chu et Schizophrenia n = 15 n = 15 participants Questionnaire: RCT
al., 2009 Inpatients Sex:? participants (15 included in Self-esteem Self- (assessment
(45) (authors state no (12 included analyses) determination blinded)
significant in analyses) Treatment as usual Extent of social
difference Dog-assisted support Adverse
between groups) activity 8 psychiatric
Age < 60 years weeks, 50 min symptoms
Duration of x 1 per week (positive,
illness >10 years negative and
emotional)
Kovacs Schizophrenia, n=7 N/A ILSS (living Pilot study
et al., chronic (DSM- participants (7 skills) (pre-post)
2004 IV) Inpatients included in
(40) Sex: F 4, M 3 analyses)
Age 29–58 years Dog-assisted
(mean 43.6) therapy 9
Duration of months, 50
illness >10 years min x 1 per
week
Kovacs Schizophrenia, n=5 N/A BGRS (non- Exploratory
et al., chronic (DSM- participants (3 verbal study (pre-
2006 IV) Day-care included in the communication) post)
(41) Sex: F 3, M 2 analyses)
Age: 32–71 Dog-assisted
years therapy 6
months, 50
min x1 per
week
Lang et Schizophrenia, n = 14 n = 14 participants STAI (anxiety) Crossover
al., 2010 acute (DSM-IV) participants (14 included in design
(42) Inpatients? Sex: (14 included analyses) Interview
F 7, M 7 Age: in analyses) without dog 30 min
Mean 37.3 Dog-assisted x1
years, SD 13.8 interview 30
Duration of min x 1
measure
illness: Mean 6
years, SD 9
Monfort Schizophrenia- n = 18 n = 13 participants LSP-20 (life Quasi-
et al., spectrum participants (10 included in skills) PANSS experimental
2022 disorders and (13 included analyses)d Standard (positive, prospective
(31) substance-use in analyses)c treatment negative, and study
disorders (dual Dog-assisted (antipsychotics, general
pathology) therapy in psychotherapy, symptoms) (Lack
Residential addition to psychoeducation, of baseline
treatment Age: standard cognitive therapy) recordingse)
Mean 40.3 treatment
years, SD 6.1 Maximum of
Sex: F: 13.9%, 12 weeks (10
M: 86.1% sessions), 45
min per week
Nathans Schizophrenia, n = 10 n = 10 participantsPrimary outcome Controlled
Barel et chronic (DSM- participants (lost to follow-up SHAPS pilot study
al., 2005 IV) Inpatients (lost to not specified) (anhedonia)
(43) Sex: F 8, M 12 follow-up not Learning about Secondary
Age: Mean 39.9 specified) caring for animals,outcomes SANS
years, SD 11.67 Dog-assisted going for walks and(negative
Duration of therapy in participating in symptoms)
illness: Mean addition to discussions in PANSS (total)
18.1 years, SD psychosocial addition to PANSS (positive
11.2 treatment 10 psychosocial symptoms) SQLS
weeks x 60 treatment 10 weeks (quality of life in
min per week x 60 min per week relation to
treatment)
QLESQ (quality
of life)
Shih et Schizophrenia, n = 45 n = 45 participants MHSFS (Social Longitudinal,
al., 2023 chronic (DSM- participants (45 included in competence and single-blind
(32) 5)Inpatients Sex: (45 included analyses) abilities in daily experimental
F 45, M 45 Age: in analyses) Discussion groups, life) SAFS (day- study
Mean 50.2, SD Dog-assisted including films to-day living
9.6 Age of therapy 12 about animals 12 abilities, social
morbidity: Mean weeks, 60 min weeks, 60 min x1 functioning,
30.6, SD 11.0 x1 per week per week occupational
abilities)
WHOQOL-BREF
(quality of life)
measure
Villalta- Schizophrenia, n = 12 n = 9 participants LSP (social RCT
Gil et (DSM-IV) participants (7 included in the competence) (assessment
al., 2009 Inpatients, long (11 included analyses) IPT 12.5 PANSS (positive, blinded)
(44) term Sex: F 3, in the weeks, 45 min, x2 negative and
M:18 Age in analyses) per week general
intervention Modified IPT symptoms)
group: Mean with dog- WHOQOL-BREF
49.1 years, SD assisted (quality of life)
9.4 Age in therapy 12.5
control group: weeks, 45 min
Mean 48.9, SD x2 per week
8.6 Duration of
illness: >10
years (mean
28.79)
Open in a new tab
5MWT, 5-Meter Walk Test; ACIS, Assessment of Communication and Interaction Skills;
BGRS, Budapest Gesture Rating Scale; CHI, Chinese Happiness Inventory; CST, Chair Stand
Test; DASS-21, Depression Anxiety Stress Scales Assessment; EQ-5D, EuroQoL-5 Dimensions
questionnaire; ILSS, Independent Living Scale Survey; LSP, Living Skills Profile; MHSFS,
Mental health-social functioning scale; MoCA, Montreal Cognitive Assessment; PANSS,
Positive and Negative Syndrome Scale; QLESQ, Quality of Life Enjoyment and Satisfaction
Questionnaire; SAFS, Social adaptive function scale; SANS, Schedule for the Assessment of
Negative Symptoms; SHAPS, Snaith-Hamilton Pleasure Scale; SQLS, Subjective Quality of Life
Scale; STAI, State-Trait Anxiety Inventory; TUG, Timed Up-and-Go; WHOQOL-BREF, Brief
World Health Organization Quality of Life Assessment.
DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders-IV-text revision; F,

Females; IPT, Integrated psychological treatment; M, Males; N/A, Not applicable; RCT,
Randomized controlled trial; SD, Standard deviation.
a, b
Subgroup data not available. The numbers refer to the whole group, including mood disorders,
psychotic disorders, substance use disorders and other disorders.
c
Reviewer's interpretation based on the following information: 21 took part in the intervention
group, 5 dropped out and 3 did not meet eligibility criteria. Nevertheless, Tables 1, 2 in the
article are showing n = 21 in the intervention group.
d
Reviewer's interpretation based on the following information: 15 took part in the control group,
3 dropped out and 2 did not meet eligibility criteria. Nevertheless, Tables 1, 2 in the article are
showing n = 15 in the control group.
e
Measured after session 3, 6 and 10.
The results were presented as significant or non-significant. Significant results were presented
with p-values and associated statistics, most commonly averages and standard deviations. As
statistical methods varied among the studies and confidence intervals were not stated, it was not
possible to select a common effect measure across studies. Substantial heterogeneity regarding
interventions and outcomes prohibited meta-analysis. Studies were grouped for narrative
synthesis based on outcome measures. Effect sizes were presented in the synthesis for the
outcomes where effect size was calculated.
Effect sizes measured by Cohen's d were categorized as small for values from 0.2 to 0.49, as
medium for values from 0.50 to 0.79, and as large for values above 0.79 (49). Effect sizes
measured by SRD were categorized as small for values from 0.11 to 0.27, as medium for values
from 0.28 to 0.43, and as large for values above 0.43 (50). The categorization corresponded to
the presentation of effect sizes in one of the studies (29). In another study, effect sizes were
described by percentage and not presented as small, medium, or large (44). In this SR, the
descriptive presentations of effect sizes from the abovementioned study (44) were therefore
based on recommendations by Cohen (49).
2.4. Risk of bias and quality of evidence
Risk of bias was assessed independently by two reviewers (MT and SS) for each outcome using
RoB2 (Risk of Bias 2) tool (51) for RCTs, a specialized version of RoB2 for cluster-randomized
trials (52), and ROBINS-I (Risk Of Bias In Non-randomized Studies—of Interventions) (53) for
the remaining studies. In addition to assessments related to reporting bias covered under RoB2
and ROBINS-I (bias due to missing data), correlation between trial registers (ClinicalTrials.gov)
and published studies were considered with regard to publication bias.
The quality of evidence was assessed independently by two reviewers (EJ and MT) based on
guidelines from GRADE (Grading of Recommendations Assessment, Development and
Evaluation) handbook (54) and an article regarding imprecision (55). In addition, an article with
guidelines regarding quality of evidence in SRs without meta-analyses was used (56). In
accordance with GRADE (54), the evidence across studies was graded as high, moderate, low, or
very low for each outcome. Risk of bias, publication bias, inconsistency, indirectness, and
imprecision were assessed for potential downgrading of the certainty of evidence. While serious
limitations may lead to downgrading by one level, very serious limitations may lead to
downgrading by two levels. On the other hand, large magnitude of effect may lead to upgrading
by one or two levels, while large dose-response gradient and effect-reducing confounders may
lead to upgrading by one level.
3. Results
3.1. Selection of studies
The main searches retrieved a total of 2,296 records. The total number of identified records was
2,329 after supplementary searches in additional databases. Searches in Google Scholar, in
websites of organizations, and citation searches additionally expanded the number of records to
5,587. Details are presented in Figure 1. Nine of the articles from the main database searches met
eligibility criteria. Three additional articles published during 2022 and 2023 were included after
updated searches in Google Scholar. These articles were also detected through automatic
database alerts. No additional articles were included after searches for unpublished literature or
through citation searches. At the time of the most updated search, performed 28.05.23 in Google
Scholar, no new publications were discovered. This was consistent with simultaneous
assessments of the automatic database alerts from the main searches. Summarized, 12 articles,
based on 11 studies, met eligibility criteria. An overview of studies excluded after review in full
text version, or due to lack of access to full text version, is presented in Supplementary Table 14.
Figure 1.
Open in a new tab
PRISMA flow diagram. Overview of the selection process. The flow diagram was created via a
tool in accordance with the PRISMA statement (57).
3.2. Study characteristics
References and details regarding study characteristics are presented in Table 2. In the 11 eligible
studies, a total of 196 participants were included in intervention groups and 179 were included in
control groups. The phase of disorder was described as chronic in six of the studies, as acute in
two, and not specified in the remaining. All studies included both females and males. The
participants were recruited from inpatient settings in eight of the studies, from a residential
treatment center in one, from a day-care unit in one, and from both a psychiatric rehabilitation
ward and a day-care ward in one. Baseline treatment, which was not stated in all studies,
consisted of antipsychotic medications and different psychosocial treatments. In some of the
studies, it was stated that all participants received stable antipsychotic treatment (29, 30, 43, 44).
Where analyzed, no significant differences were found between the intervention group and the
control group regarding antipsychotics (31).
The interventions were described as therapy in nine of the studies, as activity in one, and as
interview in one. Four studies were designed as RCTs, one as a controlled pilot study, two as
crossover studies, two as pilot/exploratory studies, one as longitudinal, single-blind experimental
study, and one as quasi-experimental prospective study. Outcome measures were overall positive
and negative symptoms, anhedonia, general psychopathology including isolated measurements
of depression, emotional symptoms and anxiety, living skills, social function, social adaptive
function, stress, extent of social support, self-determination, self-esteem, global cognitive
function, lower body strength, agility, mobility, communication and interaction skills including
isolated measurements of non-verbal communication, quality of life, well-being, and patient
experience (adherence).
3.2.1. Intervention details
References and further details regarding the interventions are presented in Table 3. The extent of
interventions ranged from a single session consisting of 30 minutes to sessions of 50 minutes per
week for nine months. Although there was no standardized program across the studies, elements
such as physical activity, cognitive activities, and interaction with other participants were
common across several of the studies. Specific information regarding certification of therapy
dogs was provided in two studies, and information regarding veterinary examinations was
provided in three. It was stated that the intervention providers were both educated in psychiatry
and had experience or training within AAI in four of the studies. In two of the studies, the
intervention was led by a psychiatrist and a social worker, and by a psychologist without further
information given. In one of the studies, the intervention was led by researchers, social workers
and professional AAT therapists. In four of the studies, it was stated that the intervention
providers were researchers and/or handlers without further information given.
Table 3.
Intervention details, modified version of TIDieR (template for intervention description and
replication) (48).
Study Descript Aim Descripti Key elements Interventio Modes Location Durati
ion of on of the of n provider of on
the dogs intervention deliver
interven y
tion
Barke Animal- Investigate Two Handler Dog Group Hospital 30 min
r and assisted effect on therapy talked handlers session setting, x1 (one
Daws therapy anxiety dogs generally USA single
on, levels meeting about dog and
interven y
tion
1998 hospital encouraged session
(47) policy for discussion )
AAT about pets;
(including dog moved
vaccinatio freely around
n, interacting/ca
controllab rrying out
ility and basic
temperam obedience
ent) commands.
Calvo Animal- Analyze Five Establish Researcher Group Outdoors 6
et al., assisted impact of therapy emotional (unspecifie session , hospital months
2016 therapy AAT on dogs bond between d with setting, , 1 h x2
(39) symptomato experienc participant education) eight Spain per
logy and ed in and dogs; particip week
quality of AAT. walk the ants in
life; Physical dogs; train each
Evaluate the and and play with group,
patient's behaviora the dogs four of
experience l Participants the five
of AAT examinati worked in dogs
sessions; on by pairs at the present
Assess specialists start of each
stress relief in session
during AAT veterinary
sessions. behaviora
l
medicine
Chen Animal- Evaluate Four Warm-up Certified Group Spacious 12
et al., assisted effect of therapy (establishing animal- sessions and quiet weeks,
2021 therapy AAT for dogs contact); assisted with 10 classroo 60–65
(29) middle- certified therapeutic therapist particip m, min x1
aged and by the activities Occupation ants in rehabilita per
older Professio (activity for al therapist each tion week
patients nal positive (specialized group ward/day
with Animal- emotions, in care
schizophren Assisted social psychiatric ward,
ia, on Therapy activity, rehabilitatio Taiwan
psychotic Associati cognitive n) Certified
symptoms, on of activity, dog handler
negative Taiwan physical
interven y
tion
emotions, activity);
and well- grooming and
being. feeding;
feedback
Chen Same Evaluate the Same Same Same Same Same Same
et al., intervent efficacy of dogs as intervention intervention modes location duratio
2022 ion as AAT for Chen et as Chen et al., providers as of as Chen n as
(30) Chen et middle- al., 2021 2021 (29) Chen et al., delivery et al., Chen
al., 2021 aged (29) 2021 (29) as Chen 2021 et al.,
(29) patients et al., (29) 2021
with 2021 (29)
schizophren (29)
ia on
cognition,
physical
and social
functions
Chu Animal- Examine a Two Dogs led in Researchers Group Garden 8
et al., assisted program for dogs, circle around (unspecifie sessions and weeks,
2009 activity pet-assisted unspecifie the d with 15 activity 50 min
(45) activity to d training participants; education) particip hall, x1 per
determine participants ants hospital week
whether encouraged to setting,
such interact with Taiwan
interactions dogs and
can other
positively participants;
influence physical
the activity
physiologic
al and
psychologic
al aspects of
patients
with
schizophren
ia
Kovac Animal- Evaluate One dog Establish Psychiatrist Group Garden 9
s et assisted effects of (no contact as dog Social sessions and months
al., therapy AAT in further went around with occupatio , 50
interven y
tion
2004 institutional
descriptio participants; worker Dog seven nal room, min x1
(40) ized ns) simple or handler particip social per
middle- complex ants institute, week
aged exercises Hungary
patients including
with interaction
schizophren with other
ia with participants;
regards to physical
adaptive activity;
functioning. grooming and
feeding
Kovac Animal- Examine Two dogs Warm-up Psychiatrist Group Day- 6
s et assisted effects of (one (establishing , sessions care-unit, months
al., therapy AAT in participat contact); goal experienced with Hungary , 50
2006 chronic ed in the oriented with group five min x1
(41) schizophren majority phase with therapy and particip per
ia to of grooming and AAT for ants week
increase sessions), feeding the patients
non-verbal well- dog; specific with
communicat trained, exercises and schizophren
ion examined interaction ia Co-
by a with therapy therapist
veterinari staff and (psycholog
an other y student)
participants Dog
handler
(psycholog
y student)
Lang Dog- Evaluate Two Level of Research Group Quiet 30 min
et al., assisted effect of therapy interaction assistant session room, x1
2010 interview dog assisted dogs that with dog (unspecifie with hospital
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Natha Animal- Examine One dog Participants Psychology Group Hospital 10
ns- assisted beneficial approved could choose student sessions setting, weeks,
Barel therapy effects of by a from different qualified as with 10 Israel 60 min
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2005 assisted an the dog trainer and ants week
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feeding,
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teaching,
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taking the dog
for a walk
Shih Animal- Evaluate Two Building Researchers Group The 12
et al., assisted effectivenes service relationships Social sessions reception weeks,
2023 therapy s of AAT dogs, with dogs and workers hall, 1 h x1
(32) on social minimum other Two hospital per
interactions 3 months participants; professional setting, week
and quality of brief AAT- Taiwan
of life for training interaction therapists
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Open in a new tab
AAT, Animal-assisted therapy.
3.3. Results of individual studies
Significant results were defined as p ≤ 0.05 or p < 0.05 by the included studies. The results from
each study are presented in Table 4.
Table 4.
Results of individual studies.
Between groups Within intervention Within control groups

groups
Barker STAI (change) Anxiety: I = C Stated as mean (SD) STAI STAI Anxiety: NS
and (change) Anxiety: 5.77
Dawson, (13.72), p < 0.006
1998
(47)
Calvo et Stated as mean (SD) PANSS Stated as mean (SD) Stated as mean (SD)
al., 2016 (change/posttreatment) PANSS (change) Positive: PANSS (change) Positive:
(39) Positive: I = C Negative: I = C 5.28 (4.78), p = 0.001 7.87 (4.29), p = 0.001
General: I = C EQ-5D Negative: 5.64 (8.19), p = Negative: NS General:
(change/posttreatment) Total 0.022 General: 10.00 12.63 (13.57), p = 0.033
score: I = C Health today (8.70), p = 0.001 EQ-5D EQ-5D Total score: NS
12m: I = C Mobility: I = C Total score: NS Health Health today 12m: NS
a
Pain/discomfort: I = C Health today 12m : NS Mobility: Mobility: NS
state today: I = C NS Pain/discomfort: NS Pain/discomfort: NS
Anxiety/depression: I = C Health state today: NS Health state today: NS
Daily activities: I = C Anxiety/depression: NS Anxiety/depression: NS
Personal care: I = C Daily activities: NS Daily activities: NS
Adherence Overall: I > C: Personal care: NS Stress Personal care: NS
92.9% (4.7) vs. 61.2% (24.8), relief Salivary cortisolb:
p = 0.001 Specific functional Decrease, p < 0.05
rehabilitation Salivary alpha-amylasea:
interventions: AAT vs. art Change, NS
therapy: I > C, p = 0.01 AAT
vs. gymnastics: I > C, p =
0.01 AAT vs. psychodynamic
therapy: N/A AAT vs. group
sport: N/A
Chen et Stated as median PANSS N/A N/A
al., 2021 Total (change): I > C: −1.0 vs.
(29) 0, p = 0.001, SRD 0.15 Total
(posttreatment): I = C Positive
(change): I > C: −3 vs. 0, p <
0.001 Positive
(posttreatment): I = C
Negative (change): I > C: −3
vs. 0, p < 0.001, SRD 0.50
Negative (posttreatment): I =
C General (change): I > C: −7
vs. 0, p < 0.001, SRD 0.20
General (posttreatment): I = C
groups
DASS-21 Total
(change/posttreatment): I = C
Stress (change): I > C, −1.0
vs. 1.5, p = 0.012, SRD 0.15
Stress (posttreatment): I = C
Anxiety
Depression
CHI Well-being
Chen et Stated as median MoCa N/A N/A
al., 2022 Global cognitive function
(30) (change): I = C Global
cognitive function
(posttreatment): I = C CST
Lower body strength (change)
I > C, 0.50 vs. −1.00, p =
0.007 Lower body strength
(posttreatment): I = C
TUG Agility (change): I = C
Agility (posttreatment): I = C
5MWT Mobility (change): I =
C Mobility (posttreatment): I
= C ACIS Communication
and interaction skills
(change): I > C, 5.00 vs. 0.50,
p < 0.001 Communication
and interaction skills
(posttreatment): I > C, 71.50
vs. 65.00, p = 0.003
Chu et Stated as mean N/A N/A
al., 2009 Questionnaire (change) Self-
(45) esteem: I > C 6.03 vs. −0.19,
p = 0.025 Self-determination:
I > C: 5.87 vs. −0.21, p =
0.020 Social support: I = C
Positive symptoms: I > C:
−6.42 vs. 0.69, p = 0.005
Negative symptoms: I = C
Emotional symptoms: I > C:
−5.62 vs. 0.13, p = 0.048
groups
Kovacs N/A Stated as mean (SD) ILSS, N/A
et al., degree of behavioral
2004 problems Domestic
(40) activities: 0.97 (0.93) to
0.37 (0.58), p = 0.01
Health: 0.90 (0.77) to 0.33
(0.66), p = 0.02 Leisure:
NS Money management:
NS Transportation: NS
Eating: NS Grooming: NS
ILSS, frequency of
occurrence of behaviors
Domestic activities: 2.06
(1.18) to 3.26 (0.74), p =
0.01 Health: 2.71 (0.48) to
3.40 (0.24), p = 0.01
Leisure: NS Money
management: NS
Transportation: NS Eating:
NS Grooming: NS
Kovacs N/A BGRS Nonverbal N/A
et al., communication:
2006 Significance was not
(41) investigated
Lang et Stated as mean (SD) STAI N/A N/A
al., 2010 (change) Anxiety: I > C: 45.9
(42) (11.8) to 35.6 (11.0) vs. 42.4
(11.1) to 40.1 (10.5), p <
0.0001
Monfort Stated as mean PANSS N/A N/A
et al., (posttreatment) Positive: I >
2022 C, 27.81, p = 0.002 Negative:
(31) I = C General: I = C LSP-20
(posttreatment) Life skills
(total): I > C, 20.44, p = 0.001
Nathans- Stated as mean (SD) SHAPS N/A N/A
Barel et (posttreatment) Hedonic tone:
al., 2005 I > C, 3.44 (0.40) vs. 3.12
(43) (0.34), p = 0.02 QLESQ
(posttreatment) Leisure time
activities: I > C: 3.75 (0.91)
vs. 3.47 (0.71), p = 0.01
Physical health: I =
groups
CSubjective feelings: I = C
Social relationships: I = C
General activities: I = C
Work: I = C Household
duties: I = C Medication
satisfaction: I = C
School/course work: I = C
Life satisfaction and
enjoyment: I = C SQLS
(posttreatment) Psychological:
I = C Motivation: I = C Side
effects: I = C PANSS
(posttreatment) Total: I = C
Positive: I = C SANS
(posttreatment) Negative
symptoms: I = C
Shih et Stated as B (SE) group x time Stated as mean (SD) Stated as mean (SD)
al., 2023 (reference control group x MHSFS Social function MHSFS Social function
(32) baseline) MHSFS Social (change t1): 50.56 (11.89) (change, t1): 54.09 (13.80)
function (T2): I > C, B (SE) = to 52.80 (11.93), p < 0.01 to 55.18 (14.34), p <
1.16, p = 0.043 Social Social function (change, 0.05Social function
function (T3): I < C, B (SE) = t2): NS SAFS Social (change, t2): NS SAFS
−5.37, p = 0.037 SAFS Social adaptive function (change Social adaptive function
adaptive function (T2): I = C t1): 11.56 (7.66) to 9.87 (change t1): 11.87 (7.67) to
Social adaptive function (T3): (7.69), p < 0.01 Social 10.51 (8.21), p < 0.05
I = C WHOQOL Quality of adaptive function (change, Social adaptive function
life (T2): I > C, B (SE) = 4.44, t2): NS WHOQOL (change, t2): 11.87 (7.67)
p = 0.044Quality of life (T3): Quality of life (change t1): to 10.16 (7.46), p < 0.05
I > C, B (SE) = 11.06, p = 79.33 (13.40) to 86.42 WHOQOL Quality of life
0.007 (17.98), p < 0.01 Quality (change t1): NS Quality of
of life (change, t2): 79.33 life (change, t2): NS
(13.40) to 86.64 (15.92), p
< 0.01
Villalta- LSP (posttreatment) Self- Stated as mean (SD) LSP Stated as mean (SD) LSP
Gil et al., care: I = C Social behavior: I Self-care: NS Social Self-care: NSSocial
2009 = C Social contact: I = C Non- behavior: NS Social behavior: NS Social
(44) personal social behavior: I = contact: 13.67 (2.67) to contact: NS Non-personal
C Autonomous life: I = C 18.00 (4.40), p < 0.05, social behavior: NS
PANSS (posttreatment) Total: Cohen's d -1.19 Non- Autonomous life: NS
I = C Positive: I = C Negative: personal social behavior: PANSS Total: 86.22
I = CGeneral: I = C 22.50 (1.38) to 20.55 (10.03) to 61.83 (12.69), p
WHOQOL-BREF (2.94), p < 0.05, Cohen's d < 0.05 Positive: 22.67
(posttreatment) Physical 0.85 Autonomous life: NS (7.71) to 17.00 (6.07), p <
groups
health: I = C Psychological: I PANSS Total: 88.25 0.05, Cohen's d 0.82
= C Social relationships: I = C (12.17) to 73.64 (18.69), p Negative: NS General:
Environment: I = C < 0.05 Positive: 20.83 38.11 (5.82) to 28.50
(5.46) to 15.64 (4.03), p < (5.58), p < 0.05, Cohen's d
0.01, Cohen's d 1.08 1.69 WHOQOL-BREF
Negative: 28.92 (5.25) to Physical health: NS
19.36 (6.34), p < 0.01, Psychological: NS Social
Cohen's d 1.64 General: relationships: NS
NS WHOQOL-BREF Environment: NS
Physical health: NS
Psychological: NS Social
relationships: 2.08 (0.79)
to 2.85 (0.56), p < 0.05,
Cohen's d −1.12
Environment: NS
Open in a new tab
5MWT, 5-Meter Walk Test; ACIS, Assessment of Communication and Interaction Skills;
BGRS, Budapest Gesture Rating Scale; CHI, Chinese Happiness Inventory; CST, Chair Stand
Test; DASS-21, Depression Anxiety Stress Scales Assessment; EQ-5D, EuroQoL-5 Dimensions
questionnaire; ILSS, Independent Living Scale Survey; LSP, Living Skills Profile; MHSFS,
Mental health-social functioning scale; MoCA, Montreal Cognitive Assessment; PANSS,
Positive and Negative Syndrome Scale; QLESQ, Quality of Life Enjoyment and Satisfaction
Questionnaire; SAFS, Social adaptive function scale; SANS, Schedule for the Assessment of
Negative Symptoms; SHAPS, Snaith-Hamilton Pleasure Scale; SQLS, Subjective Quality of Life
Scale; STAI, State-Trait Anxiety Inventory; TUG, Timed Up-and-Go; WHOQOL-BREF, Brief
World Health Organization Quality of Life Assessment.
AAT, Animal assisted therapy; C, Control group; I, Intervention group; N/A, Not applicable; NS,
Not significant; SD, standard deviation; SE, standard Error; SRD, Success rate difference; t1,
Change from baseline to posttreatment; t2, Change from baseline to follow-up 3 months after
intervention; T2, Posttreatment; T3, 5 months follow-up; v.s., Vs.
a
Significant before Bonferroni correction, non-significant after Bonferroni correction.
b
Only measured within the intervention group.
3.4. Synthesis
3.4.1. Positive and negative symptoms
Three studies showed significant improvement for the intervention group compared with the
control group for positive symptoms (29, 31, 45). The effect size in one of the studies was small
(29). Two studies showed significant improvement both within the intervention group and within
the control group, and no significant differences were found between the groups (39, 44). The
effect sizes within both groups in one of the studies were large (44). One study found no
significant difference between the groups, and significance within the groups was not stated (43).
With regard to negative symptoms in general, one study showed significant improvement, with
large effect size for the intervention group compared with the control group (29). One study
showed significant improvement for the intervention group compared with the control group for
anhedonia (43). Two studies showed significant improvement within the intervention groups,
and not within the control groups, for negative symptoms in general (39, 44). The effect size was
large in one of the studies (44). The differences between the groups were not significant. Two
studies found no significant differences between the groups. Significance within the groups were
not stated (43, 45). In one of the studies, the groups were described as “not comparable” due to
significant pre-intervention differences. There were no significant differences at the end of the
intervention (31).
3.4.2. General psychopathology including isolated assessments of emotional symptoms,

anxiety and depressive symptoms
With regard to general psychopathology, one study showed significant improvement, with small
effect size, for the intervention group compared with the control group (29). One study showed
significant improvement both within the intervention group and within the control group. No
significant difference was found between the groups (39). One study showed significant
improvement, with large effect size, within the control group, and no significant change within
the intervention group. The difference between the groups was not significant (44). One study
showed no significant differences between the intervention group and the control group.
Significance within the groups was not stated (31).
One study showed significant improvement for the intervention group compared with the control
group for emotional symptoms (45). With regard to anxiety, one study showed significant
improvement for the intervention group compared with the control group (42). Furthermore, one
study showed significant improvement within the intervention group, and not within the control
group. There was no significant difference between the groups (47). One study found no
significant improvement for anxiety and depressive symptoms. Significance within the groups
was not stated (29).
3.4.3. Living skills, stress, self-esteem, self-determination, social contact and cognition
One study showed significant improvement for living skills for the intervention group compared
with the control group (31). One study, not including a control group, showed significant
improvement within the intervention group for independent living skills related to domestic
activities and health. There were no significant changes for several other aspects of living skills
in the same study (40). Another study showed significant improvement within the intervention
group, with large effect size, for living skills related to social contact. No significant
improvement was observed within the control group. The difference between the groups was not
significant. Furthermore, the study showed a significant deterioration, with large effect size, for
non-personal social behavior within the intervention group. There was no significant change in
non-personal social behavior within the control group. The difference between the groups was
not significant. The same study found no significant change for other domains of living skills
(44).
One study showed significant improvement, with small effect size, for the intervention group
compared with the control group for stress (29). Another study showed significant improvement
within the intervention group for change in cortisol levels. No significance was found for change
in alpha-amylase. These markers were not investigated within the control group (39). With
regard to self-esteem and self-determination, one study showed significant improvement for the
intervention group compared with the control group. The same study found no significant
difference between the groups for extent of social support. Significance within the groups was
not stated (45). One study showed significant improvement for the intervention group compared
with the control group for social function measured at the end of the intervention period.
However, at 3 months follow-up, results were opposite, with significant improvement for the
control group compared with the intervention group. Regarding social adaptive function, the
same study showed no significant change between the groups. There were significant
improvements both within the intervention group and within the control group at post-
intervention. Nevertheless, only the control group had significant improvement at 3 months
follow-up
group for communication and interaction skills (30). One study, without a control group,
indicated improvement within the intervention group for use of space during communication and
partial improvement for anatomy of movement, dynamics of movements and regulating
movements. Calculation of significance was not performed (41). One study found no significant
difference between the intervention group and the control group in global cognitive function
(30).
3.4.4. Physical performance
group for lower body strength. No significant changes between the groups were found for agility
and mobility measured by the same study. Significance within the groups was not stated (30).
3.4.5. Quality of life and wellbeing
group for quality of life in general, both with regard to post-treatment and 3 months follow-up
compared with baseline (32). One study showed significant improvement for the intervention
group compared with the control group for quality of life related to utilization of leisure time.
There was no significant difference between the groups for a range of other factors of quality of
life. Significance within the groups was not stated (43). Another study showed significant
improvement, with large effect size, within the intervention group for quality of life related to
social relationships. There was no significant findings within the control group. The difference
between the groups was not significant. Further, there were no significant findings in this study
for quality of life related to other factors (44). One study showed significant improvement before
Bonferroni correction within the intervention group, and not within the control group, for quality
of life related to general health. The difference between the groups was not significant. There
were no significant findings for other domains of quality of life in this study (39). With regard to
well-being, one study found no significant difference between the intervention group and the
control group. Significance within the groups were not stated (29).
3.4.6. Adherence
One study showed significantly higher adherence, 93% compared with 61%, for the intervention
group compared with the control group (39). The reasons for non-adherence within the
intervention group were mostly related to family or health issues. Adherence, measured as
proportion of attended sessions, was not stated as an outcome measure in the other studies.
However, lost to follow-up was documented in most of the studies (presented in Table 2).
3.5. Risk of bias
The overall risk of bias was associated with some concerns for all outcomes in the cluster-
randomized trial (32) and with high risk for most of the outcomes in the RCTs (29, 30, 39, 44,
45). Agility, lower body strength, and mobility measured by Chen et al. (30) were outcome
measures with low risk of bias. For the non-randomized studies (NRS) (31, 40–43, 47), the
overall risk of bias was categorized as serious for all outcomes. An overview is presented in
Figures 2–5. One NRS was excluded due to critical risk of bias (59). The material included both
studies with significant and non-significant results. No findings were made of studies reported in
trial registers not published. Consequently, the risk of publication bias on the field was
considered low. Nevertheless, most of the included studies lacked protocols.
Figure 2.
Open in a new tab
Risk of bias in RCTs and cluster-randomized trials. The highest overall risk for each study is
presented as most of the outcomes within each study were associated with the same risk. An
exception applied to domain 4. For this domain, alpha-amylase, cortisol and adherence measured
by Calvo et al. (39) were associated with low risk. The same applied to agility, lower body
strength, and mobility measured by Chen et al., (30), which resulted in overall low risk of bias
for these three outcomes. Social competence measued by Villalta-Gil et al. (44) was associated
with some concerns for the abovementioned domain. The figure was created via “Risk-of-bias
VISualization”-tool (58).
Figure 5.
Open in a new tab
Summarized risk of bias in NRSs. Summarized risk of bias across studies. The figure was
created via “Risk-of-bias VISualization”-tool (58).
Figure 3.
Open in a new tab
Summarized risk of bias in RCTs and cluster-randomized trials. Summarized risk of bias across
studies. The figure was created via “Risk-of-bias VISualization”-tool (58).
Figure 4.
Open in a new tab
Risk of bias in NRSs. The highest overall risk for each study is presented as most of the
outcomes within each study were associated with the same risk. An exception applied to domain
6. For this domain, life skills measured by Monfort et al. (31) were associated with low risk. The
figure was created via “Risk-of-bias VISualization”-tool (58).
3.6. Certainty of evidence
Inconsistency, indirectness, imprecision, and risk of bias were factors that led to downgrading of
the quality. It was not possible to upgrade the quality due to serious and very serious limitations.
The quality of evidence was considered low for agility, lower body strength, and mobility. For
the rest of the outcomes, the quality of evidence was considered very low. Details concerning the
assessments are presented in Supplementary Tables 16–38.
4. Discussion
In this SR, exclusively including studies with isolated results for adults diagnosed with
schizophrenia and related disorders, numerous outcomes of DAI were examined. Both
significant improvement and non-significant findings for the intervention groups compared with
the control groups were reported for general symptoms, positive symptoms, negative symptoms,
anxiety, living skills and quality of life. Significant improvement in the intervention groups
compared with the control groups was also described for emotional symptoms, stress, self-
esteem, self-determination, social function, communication and interaction skills, lower body
strength, and adherence, but each of these outcome measures was only examined in single
studies.
Within intervention groups, significant improvement was in addition described for salivary
cortisol and social adaptive function, also examined in single studies. One study indicated
significant deterioration of non-personal social behavior within the intervention group. Specific
investigation of wellbeing, depression, agility, mobility, global cognitive function, alpha-
amylase, and extent of social support was performed in single studies, and these outcome
measures had no significant changes. Significance for non-verbal communication was not stated.
Heterogeneity in study design and lack of statistical calculations complicated the assessment of
study outcomes. Therefore, we considered the findings in relation to factors that may have
influenced results. Positive symptom score was the outcome measure with the most convincing
findings. Significant improvement was demonstrated in several studies, but it should be noted
that this was the outcome measure investigated by most studies. Findings concerning negative
symptoms, the second most investigated outcome measure, were more divergent. Overall,
inconsistent results were reported for the majority of outcome measures examined by more than
one study. In the following sections, we highlight some potential explanations.
Importantly, a substantial difference across the studies was related to the content of the control
groups. As an example, the studies by Villalta-Gil et al. (44) and Calvo et al. (39) included
specific treatment programs focusing on psychosocial aspects with and without DAT. On the
other hand, Chu et al. (45) compared AAA with treatment as usual. While significant
improvement for several outcomes occurred within the groups in the first two studies, results
from the latter contrasted the two abovementioned studies with a substantially larger degree of
significant effects of active treatment. Active intervention also occurred in control groups in
other studies—e.g. therapeutic recreation (music, art and education) as comparator in the study
by Barker et al. (47). No significant changes for anxiety were seen between the groups in this
study. The findings were contrasted by results in the study by Lang et al. (42) where the presence
of a dog seemed to be the only difference between the groups (42). The findings suggest that the
content in the control group may contribute largely to the heterogeneity of results across studies.
As there are many uncertainties related to the effects of components only presented in DAI, a
specific recommendation for future research is to conduct component studies. This suggestion is
in accordance with a SR regarding factors of AAI (60) and a study on the role of common factors
in psychotherapy (61).
A second issue contributing to lack of significant results may be related to other aspects of study
design: low numbers of participants or short duration of interventions. As an example, the study
by Shih et al. (32) showed significant improvement for quality of life between the groups.
Increased overall quality of life was not shown in the other studies, neither between the groups or
within the groups. The study by Shih et al. (32) stood out with a higher number of participants.
Similarly, in one study showing significant improvement for the intervention group compared
with the control group for both positive and negative symptoms, the population consisted of 40
participants (29). For the four studies with non-significant changes for negative symptoms, the
samples were smaller with 18 to 23 participants included in analyses (31, 39, 43, 44).
Finally, study participant heterogeneity is likely to influence results on many levels. It is
conceivable that treatment effects of different psychosocial interventions will vary based on
individual characteristics such as symptom burden and preferences. Conditions reflecting
symptom burden and level of functioning are reflected in the included trials: participants in the
studies with significant changes between the groups for positive symptoms measured by PANSS,
were recruited from a psychiatric rehabilitation ward (29), from a day care center (29) and from a
residential center (31), whereas participants in the studies with non-significant changes were
hospitalized (39, 43, 44). Nevertheless, analyses of 27 hospitalized participants showed
significant changes between the groups for positive symptoms, and not for negative symptoms,
measured by a questionnaire (45). Recommendations for further research include dividing
participants into subpopulations as well as investigating whether the effectiveness of AAI varies
based on severity of symptoms, demanding a relatively high number of participants.
Diverging results have also been documented in previous SRs on related topics. As an example,
a SR on dog presence and therapeutic alliance stated that half of the studies showed effect.
Heterogeneity in study characteristics was described as an important limitation (62). Some of the
results in our SR, however, contrasted earlier findings. In the SR by Hawkins et al. (25)
including RCTs on AAI in general for individuals diagnosed with schizophrenia and related
disorders, no improvement regarding quality of life was reported. One of the studies included in
our SR indicated the opposite (32). This underpins that the field is under continuous
development.
One of the purposes of this SR was to examine somatic effects, which were directly assessed in
some of the studies through examination of physical skills and measurements of biochemical
markers (30, 39). However, heart rate, blood pressure, HbA1c and lipid levels have not yet been
investigated for adults diagnosed with schizophrenia and related disorders participating in DAI.
This will be of importance as the population is at high risk of metabolic syndrome (63).
Beneficial effects on cardiovascular risk factors have been associated with dog companionship or
therapy for varied populations, but it is stated that further research is needed (64).
Another outcome measure especially relevant for further investigation is motivation. No

significant changes were found for motivation related to treatment as a measure of quality of life,
but this was only investigated in one study (43). Adherence can also function as an indicator of
motivation. The adherence was significantly higher in the intervention group compared with the
control group in one study (39). However, the results remain inconclusive. In addition to stating
of reasons for non-adherence and lost to follow-up, validated instruments such as IMI-SR (65)
may provide valuable information in further studies.
Significant worsening of non-personal social behavior within the intervention group was
reported in one study (44). According to the authors, the intervention was not directed at these
aspects and a similar trend was seen within the control group. Overall, prevention of negative
consequences should have high priority. Examination by specialists in veterinary behavioral
medicine was one of the preventive interventions described in one of the studies (39). Another
example was inclusion of another dog in the later stages to reduce anxiety and grief due to
removal of the dog at the end of the study (41). In a SR specifically addressing the benefits and
risks associated with AAI, allergies, infections and accidents were described as the major risk
factors. It was stated that these factors were outweighed by benefits (14). Animal welfare was
only mentioned specifically by one of the included studies in our SR (39). Methods for overall
safety, prevention of negative consequences and welfare for both participants and animals are of
importance to describe in further articles. Development of interventions must be performed in
accordance with guidelines for safety and welfare, for example from IAHAIO (13). A specific
recommendation for further research is to describe evaluations regarding signs of stress in the
participating dogs. In addition, a predetermined plan of action in case of negative consequences
is of importance to include.
In addition to abovementioned limitations regarding consistency, a low number of participants

led to imprecision. Furthermore, three outcome measures were associated with indirectness due
to surrogate measures or use of inappropriate measurement methods. Risk of bias was
categorized as high or serious for most of the included studies. Some factors that entailed the risk
were missing outcome data, deficient blinding of personnel who assessed the measurements and
risk of confounding. However, some of the factors causing risk of bias could not be avoided due
to the nature of the interventions.
Exclusion of articles written in other languages than English and Scandinavian led to risk of
selection bias in the review process. Lack of access to potentially relevant studies may also have
caused bias. Due to lack of variables, such as confidence intervals, findings were reported as
significant or non-significant. Such reporting is against the principles of Cochrane, and it must be
emphasized that lack of evidence is not the same as lack of effect (66). Therefore, both
significant and non-significant findings must be interpreted with caution.
Although inclusion of other designs than RCTs led to lower quality of evidence, these studies
proved valuable in this SR through presentation of outcome measures not synthesized in a
previous SR (25). Furthermore, inclusion of recent published studies led to novel insight on the
topic. Isolated assessments of anhedonia, social function (including social adaptive function),
communication and interaction skills (including non-verbal communication), lower body
strength, mobility, agility and cognitive function, were among the outcome measures that
expanded the knowledge. Specific examination of dog-assisted interventions increased the
directness and complemented more general reviews on related topics.
Summarized, the findings suggest that DAI may have an effect on a range of symptoms and
features associated with severe psychotic disorders. However, the findings must be interpreted
with caution. Due to several knowledge gaps, it is challenging to state specific implications for
policy and practice. The trade-off regarding potential benefits and potential harms are important.
Based on available data, we consider the potential benefits of DAI to outweigh risk of harmful
effects, given that all required precautions are taken. A potential negative consequence was
described by only one of the included studies, and the causality of the finding remained uncertain
(44). A specific implication for practice, which must be emphasized, is the necessity of
development and implementation of interventions in accordance with guidelines for safety and
welfare. The lack of data regarding animal welfare assessments is considerable, and the area is
overall described as under-researched (67). In addition to the specific recommendations for
further research presented in the paragraphs above and in Supplementary Table 39, reduction of
bias and increase of quality will be essential. Accordingly, there is a specific need for carefully
designed RCTs. This is particularly justified by the risk of confounding associated with NRS.
5. Conclusion
The included studies indicate potential effects of dog-assisted interventions for adults diagnosed
with schizophrenia and related disorders, mostly beneficial. However, the results must be
interpreted with caution due to methodological limitations such as low number of participants,
heterogeneity among study design and included participants, and risk of bias. Findings of both
significant and non-significant results are in accordance with reviews on animal-assisted
interventions in general. Importantly, inclusion of several study designs and novel trials enabled
synthesizing of outcome measures not covered by previous reviews. Some of the results, such as
significant improvement for quality of life, contrast earlier findings. This underpins that the field
is under continuous development, and further examination of causality is warranted.
Recommendations for future research include factors such as calculation of effect sizes,
development of more standardized programs, and investigation of effects related to motivation
and somatic effects.
Data availability statement

The original contributions presented in the study are included in the article/Supplementary
material, further inquiries can be directed to the corresponding author.
Author contributions
MT designed this systematic review with contributions from all co-authors, wrote the original
draft, and all authors participated in revision. EJ and MT extracted data and graded the quality.
MT and SS assessed risk of bias. All authors participated in screening and selection of articles
and approved the final manuscript.
Acknowledgments
We would like to thank Elisabeth Ebner, Hilde Wedvich, Ida Sofie Karslen Sletten, and Randi
Bolstad at the Medical Library at University of Bergen for valuable advice regarding search
strategy.
Abbreviations
5MWT, 5-Meter Walk Test; AAA, Animal-assisted activity; AAI, Animal-assisted interventions;
AAT, Animal-assisted therapy; ACIS, Assessment of Communication and Interaction Skills;
BGRS, Budapest Gesture Rating Scale; C, Control group; CHI, Chinese Happiness Inventory;
CST, Chair Stand Test; DAI, Dog-assisted interventions; DANS, Data Archiving and Networked
Services; DASS-21, Depression Anxiety Stress Scales Assessment; DSM-IV-TR, Diagnostic and
Statistical Manual of Mental Disorders-IV-text revision; EQ-5D, EuroQoL-5 Dimensions
questionnaire; F, Females; GRADE, Grading of Recommendations Assessment, Development
and Evaluation; I, Intervention group; IAHAIO, The International Association of Human-Animal
Interaction Organizations; ICD, International Classification of Diseases; ILSS, Independent
Living Scale Survey; IPT, Integrated psychological treatment; LSP, Living Skills Profile; M,
Males; MHSFS, Mental health-social functioning scale; MoCA, Montreal Cognitive Assessment;
N/A, Not applicable; NIPH, Norwegian Institute of Public Health; NORA, Norwegian Open
Research Archives; NRS, Non-randomized studies; NS, Not significant; PANSS, Positive and
Negative Syndrome Scale; PICO, Population, intervention, comparison, outcome; PRESS, Peer
Review Of Electronic Search Strategies; PRISMA, Preferred Reporting Items for Systematic
Reviews and Meta-Analyses; QLESQ, Quality of Life Enjoyment and Satisfaction
Questionnaire; RCT, Randomized controlled trial; RoB2, Risk of Bias 2; ROBINS-I, Risk Of
Bias In Non-randomized Studies - of Interventions; SAFS, Social adaptive function scale; SANS,
Schedule for the Assessment of Negative Symptoms; SD, Standard deviation; SE, Standard
error; SHAPS, Snaith-Hamilton Pleasure Scale; SQLS, Subjective Quality of Life Scale; SR,
Systematic review; SRD, Success rate difference; STAI, State-Trait Anxiety Inventory; TUG,
Timed Up-and-Go; V.s, Versus; WHOQOL-BREF, The World Health Organization Quality of
Life Brief Version.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or
financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily
represent those of their affiliated organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or claim that may be made by its
manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at:
https://www.frontiersin.org/articles/10.3389/fpsyt.2023.1192075/full#supplementary-material
Click here for additional data file. (572.4KB, PDF)
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials
included in this article.
Supplementary Materials
Click here for additional data file. (572.4KB, PDF)
Data Availability Statement
The original contributions presented in the study are included in the article/Supplementary
material, further inquiries can be directed to the corresponding author.
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Front Psychiatry

. 2023 Jun 23;14:1192075. doi: 10.3389/fpsyt.2023.1192075

Dog-assisted interventions for adults

  PMCID: PMC10326428 PMID: 37426092

Randomized as well as non-randomized studies were included. Systematic searches were

Keywords: animal-assisted interventions, therapy dog, PANSS, psychosocial outcomes,

Treatment recommendations consist of a combination of pharmacological and non-

2.1. Eligibility criteria

Eligibility criteria are presented in Table 1.

Inclusion criteria Exclusion criteria

N/A, Not applicable.

2.2. Search strategies, information sources and study selection

2.3. Data collection and synthesis of results

DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders-IV-text revision; F,

2.4. Risk of bias and quality of evidence

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3.2. Study characteristics

3.2.1. Intervention details

AAT, Animal-assisted therapy.

3.3. Results of individual studies

Results of individual studies.

Between groups Within intervention Within control groups

3.4.1. Positive and negative symptoms

3.4.2. General psychopathology including isolated assessments of emotional symptoms,

3.4.4. Physical performance

3.4.5. Quality of life and wellbeing

3.5. Risk of bias

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3.6. Certainty of evidence

Another outcome measure especially relevant for further investigation is motivation. No

In addition to abovementioned limitations regarding consistency, a low number of participants

Data availability statement

Click here for additional data file. (572.4KB, PDF)

Click here for additional data file. (572.4KB, PDF)

Data Availability Statement

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