Recognition and management of psychosis and schizophrenia in children and young people: summary of NICE guidance
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f150 (Published 23 January 2013) Cite this as: BMJ 2013;346:f150
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The publication of NICE guidelines relating to the Recognition and management of Psychosis and Schizophrenia in children and young people 1 is to be welcomed given the lack of published guidance in this area, especially concerning the management of young people deemed to be at high risk of psychosis 2,3. However, we feel that the working group may have missed an opportunity to incorporate the views of current adolescent service users. The guideline development process included service-user representation at all stages. However, there was a dearth of published literature in relation to the experiences and treatment preferences of child and adolescent service users with psychosis to draw on 4 although we note the guidelines did not reference our recently published study in this area 5. Indeed, this is a patient group rarely consulted, possibly due to a perception that young people may find it difficult to articulate hallucinatory experiences or have inaccurate recall of events 6,7. However, there is a growing acceptance that eliciting and learning from service users' views is an important means of improving the quality of future health care and research within the NHS 8,9. Indeed, where the evidence base is uncertain, as in the present case, patient preferences may play a more significant role in treatment selection 10.
In response to our concerns we are working with our local Early Intervention in Psychosis service to address this issue by offering information to young people describing possible therapeutic options and asking them to state their preferences.
Patrick Welsh
Post-Doctoral Research Associate, Durham University
Honorary Assistant Psychologist, South Durham Early Intervention in Psychosis Service
Thomas Dormer
Honorary Service-User Researcher, Durham University
Paul A. Tiffin
Clinical Senior Lecturer & Honorary Consultant in the Psychiatry of Adolescence
References
1. Kendall T, Hollis C, Stafford M, Taylor C. Recognition and management of psychosis and schizophrenia in children and young people: summary of NICE guidance. BMJ 2013; 346.
2.RANZCP Clinical Practice Guidlines Team. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. Aust N Z J Psychiatry 2005; 39:1-30.
3.International Early Psychosis Association Writing Group. International clinical practice guidelines for early psychosis. Br J Psychiatry Suppl 2005; 187:120-124.
4. Byrne R, Davies L, Morrison AP. Priorities and preferences for the outcomes of treatment of psychosis: A service user persspective. Psychosis 2010; 2(3):210-17.
5. Welsh P, Tiffin PA. Observations of a small sample of adolescents experiencing an at-risk mental state (ARMS) for psychosis. Schizophr Bull 2012; 38(2):215-8.
6.Schimmelmann BG, Schultze-Lutter F. Early detection and intervention of psychosis in children and adolescents: urgent need for studies. Eur Child Adolesc Psychiatry 2012; 21:239-241.
7. Booth T, Booth W. Sounds of silence: narrative research with inarticulate subjects. Disability and Society 1996; 11(1):55-69.
8. Black N, Jenkinson C. How can patients' views of their care enhance quality improvement? BMJ 2009: 339:202–205.
9. Staley K. Exploring Impact: Public involvement in NHS, public health and social care research. INVOLVE: Eastleigh, 2009.
10. Rozmovits L, Rose P, Ziebland S. In the absence of evidence, who chooses? A qualitative study of patients' needs after treatment for colorectal cancer. J Health Serv Res Policy 2004; 9(3):159-64.
Competing interests: No competing interests
The RCGP Adolescent Health Group welcomes the newly published Guidelines (1) recognized as the most recent publication addressing youth mental health - one of the latest clinical priority areas identified by the RCGP. The capacity of general practice to respond to early manifestations of psychiatric illness has been found to be wanting (2,3) and there are often unacceptable delays in identification and diagnosis of early signs of illness (4).
The imminent appointment by the RCGP of a Youth Mental Health Clinical Champion aims to raise the awareness of GPs, and the primary health care team, to the importance of responding effectively and therapeutically to signs of emotional distress and early mental health symptoms in young people. The champion will be supported by the Adolescent Health Group, who wish to comment on the following caveats to the NICE Guidelines.
1. The guidelines assume young people and their families are ready to disclose symptoms suggestive of possible psychosis to their GP. Whilst this is essential if prompt referral is to happen but the current paucity of training for GPs in adolescent mental health often leads to superficial consultations and missed opportunities (5).
2. We are concerned that advising a wait of four weeks before the first, albeit urgent referral , does not account for the high risk to health and safeguarding of some young people who describe possible first rank symptoms and feel clinical judgement regarding timing of referral should be exercised .
3. CAMHS services vary in their responsiveness to requests for urgent referrals and we would encourage all GPs to ensure that the young person had been seen, and local arrangements were in place ,to assure of an early prompt assessment. The Early Intervention in Psychosis Services has transformed access in many areas but it is not uniform. We would urge Commissioners of children and young people’s services to insist on mechanisms to assure prompt assessment is guaranteed.
4. We recommend best practice is for GPs to arrange to see all young people who are given a diagnosis of a psychotic illness within the first six months and not to wait until they may be transferred to primary care at 12m for continued prescribing, under a shared care agreement. A good relationship between GP, young person, and ideally family, may promote the uptake of and sustained engagement with psychological therapies.
5. GPs need to be adequately supported in the care of young people with psychoses, including awareness of the side – effects of antipsychotic medication and the importance of spotting early debilitating adverse responses such as tardive dyskinesia.
6. Although this point lies outside of the remit of the GDG, GP work carried out under ‘shared care’ arrangements, needs to be adequately resourced.
Jane H Roberts,
Clinical Senior Lecturer , University of Sunderland. GP.
Chair of RCGP Adolescent Health Group,
Response submitted on behalf of the Adolescent Health Group members
jane.roberts@sunderland.ac.uk
References
1. Kendall T, Hollis C, Stafford M, Taylor C. Recognition and management of psychosis and schizophrenia in children and young people: summary of NICE guidance. BMJ 2013;346.
2. Kramer T, Garralda M. Child and adolescent mental health problems in primary care. Advances in Psychiatric Treatment 2000;6:287-94.
3. Hickie I, Fogarty A, Davenport T, Luscombe G, Burns J. Responding to experiences of young people with common mental health problems attending Australian general practice. Medical Journal of Australia 2007;187:S47-S52.
4. Kessler R, Berglund P, Demler O, Jin R, Merikangas K, Walters E. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry 2005;62(6):593-602.
5. Roberts JH. Challenging clinical encounters: an investigation into the experiences of GPs consulting with young people experiencing emotional distress and an exploration of the GP’s role. University of Sunderland, 2012.
Competing interests: No competing interests
Re: Recognition and management of psychosis and schizophrenia in children and young people: summary of NICE guidance
Cardiovascular disease and shortened life span are only 2 of the physical effects of neuroleptics and are part of iatrogenic metabolic syndrome, with movement disorders as further evidence of the neurotoxic effects of neuroleptics on the brain.1,2
Neuroleptics have many physiological. physical and psychological adverse effects, not least akathisia which is a known precursor to suicidal ideation and completed suicide.3,4 Akathisia is also known to induce violence and aggression.5,6 One patient described the unremitting symptoms of neuroleptic induced akathisia to me “like having your brain sand-papered all the time”.
My point is the guidelines state, “There is a worse prognosis for schizophrenia when onset is in childhood or adolescence”. I wonder is this really true or could it be an artefact because of treatment with neuroleptics?
The cost effectiveness of early treatment does not take into account the further costs of prolonged drug prescribing and the known possible long term physical side effects; tardive dyskinesia, EPS etc. that incur expensive hospitalisation and long-term care.
The younger the person, “treated,” the more likely these effects will occur. Therefore we have to question whether or not early drug intervention is more cost effective than talk therapies.
Is a diagnosis of ‘schizophrenia’ relevant or useful at such an early age.
In first episode psychosis the guideline states “There is little evidence that psychological interventions are effective without antipsychotic medication”. It is my opinion that antipsychotic medications’ physiological effects and psychological interference in a young brain are more likely to hinder psychological interventions.
There is evidence for psychological therapies in psychosis.7 - 21 An opportunity has been lost in early intervention services where a child or young person could be treated with Open Dialogue/Needs Adapted Approach as used in Finland, which has an 80% success rate using a bare minimum of meds. 22-26 or they could be referred to a Hearing Voices Network group for young people. 27
There is a wealth of evidence for non-neuroleptic and minimal medication approaches for psychosis.
Adherence poses problems. Will withdrawal effects be recognized as
such or be mistaken for return of symptoms of a disease; “treatment
resistant schizophrenia” or a relapse? Drug initiation or changes in dose
are known to be connected with a physiological reaction to
neurotransmitter disruption and resultant symptoms.28
If neuroleptics are to be used the metabolising ability of the individual
child must be taken into account to avoid unnecessary drug/gene
interactions.29 - 33 where drug toxicities can build up in Poor and Intermediate
Metabolisers causing ADR.
Those who have single nucleotide polymorphisms (SNP) for Cytochrome
P450 2D634 and 2C19, two of the most variant drug metabolising liver isoenzymes,
are the most likely to suffer ADR. Note that 75% of psychotropic drugs are
metabolized through CYP450 2D6.35
Finally, is fully informed consent possible without pharmacogenetic
information for metabolising neuroleptics or other psychiatric drugs
particularly in a child? I hope the GMC can see the point of genotype
testing in MH purely for the safety of the patient if not for the peace of
mind of the prescriber.
The one-third of children and young people with ‘schizophrenia’ who
have severe impairment may be those who are Poor and Intermediate
Metabolisers of psychotropic drugs.
To make a fully informed choice is almost impossible because it is difficult for young people and their carers to know the full information about psychosis, schizophrenia and drugs when there are so few independent sources. The influence the Pharmaceutical Industry has in the NHS36 and in doctor’s training is another cause for concern. NHS sources do not seem to recognise antidepressant-induced psychosis37 - 40 or include pharmacogentic information.
Having to measure for all the possible neuroleptic physical ADRs as the
guideline suggests, should warn consumers and their carers of the risks.
Health and Social Care workers are therefore left with having to try and explain ‘treatment’ when they themselves are not fully informed. How does one explain the drugs are going to help your child and there is a 5% increased risk of involuntary movement disorders occurring for every year they are taken. In my opinion it does not matter how rare this may be – if it happens to your child it is inexcusable. If similar “side effects” were caused by other medications on the market they would have been banned long ago and certainly not prescribed to children..
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Competing interests: No competing interests