Management of psychosis and schizophrenia in adults: summary of updated NICE guidanceBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1173 (Published 12 February 2014) Cite this as: BMJ 2014;348:g1173
- Elizabeth Kuipers, professor, head and NIHR senior investigator12,
- Amina Yesufu-Udechuku, systematic reviewer3,
- Clare Taylor, senior editor4,
- Tim Kendall, director, consultant psychiatrist and medical director, professor456
- 1Department of Psychology, Institute of Psychiatry, King’s College London, London SE5 8AF, UK
- 2NIHR Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London SE5 8AF
- 3National Collaborating Centre for Mental Health, University College London (Clinical, Educational and Health Psychology), London WC1E 7HB
- 4National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London E1 8BB
- 5Sheffield Health and Social Care NHS Foundation Trust, Sheffield S10 3TH, UK
- 6University College London (Clinical, Educational and Health Psychology), London WC1E 7HB
- Correspondence to: T Kendall
Psychosis is relatively common, with schizophrenia being the most prevalent form of psychotic disorder, affecting about seven in 1000 adults, with onset typically occurring between the ages of 15 and 35.1 These disorders, which are characterised by distressing hallucinations and delusions, disturbed behaviour, and memory and motivation problems, present a major personal,2 social,3 clinical,4 and financial5 challenge. Moreover, poor physical health is strongly associated with schizophrenia, with men dying 20 years earlier than the general population and women dying 15 years earlier,6 7 mainly from illnesses such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease, HIV infection, hepatitis C, and tuberculosis.8 Difficulties in people with severe mental illness accessing general medical services in primary and secondary care contribute to reduced life expectancy.9
Although many people with psychosis and schizophrenia respond to antipsychotic drugs initially, around 80% relapse within five years, partly because they discontinue medication,10 which for many people has unacceptable side effects. However, although around 75% of people with schizophrenia recurrently relapse and have continued disability,10 there is a moderately good long term global outcome in over half.11
This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on managing psychosis and schizophrenia in adults.12
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
Care across all phases—physical health
People with psychosis or schizophrenia, especially those taking antipsychotics, should be offered a combined programme of healthy eating and physical activity by their mental healthcare provider. (New recommendation.) [Based on very low to high quality evidence from randomised controlled trials]
Offer people with psychosis or schizophrenia who smoke help to stop smoking, even if previous attempts have been unsuccessful. Be aware of the potential impact of reducing nicotine on the metabolism of other drugs, particularly clozapine and olanzapine. (New recommendation.) [Based on the experience and opinion of the Guideline Development Group (GDG)]
Consider one of the following to help people stop smoking:
- Nicotine replacement therapy (usually a combination of transdermal patches with a short acting product such as an inhalator, gum, lozenges, or spray) for people with psychosis or schizophrenia
- Bupropion for people with a diagnosis of schizophrenia
- Varenicline for people with psychosis or schizophrenia.
[Based on very low to moderate quality evidence from randomised controlled trials]
Warn people taking bupropion or varenicline that there is an increased risk of adverse neuropsychiatric symptoms and monitor them regularly, particularly in the first two to three weeks of treatment. (New recommendation.) [Based on the experience and opinion of the GDG]
Support for carers
As early as possible negotiate with service users and carers about how information about the service user will be shared. When discussing rights to confidentiality, emphasise the importance of sharing information about risks and the need for carers to understand the service user’s perspective. Foster a collaborative approach that supports both service users and carers, and respects their individual needs and interdependence. (New recommendation.) [Based on the experience and opinion of the GDG]
Offer carers an assessment (provided by mental health services) of their own needs and discuss with them their strengths and views. Develop a care plan to address any identified needs, give a copy to the carer and to their general practitioner, and ensure it is reviewed annually. (New recommendation.) [Based on the experience and opinion of the GDG]
Offer a carer focused education and support programme, which may be part of a family intervention for psychosis and schizophrenia, as early as possible to all carers. The intervention should
- Be available as needed
- Have a positive message about recovery.
(New recommendation.) [Based on qualitative studies and very low to moderate quality evidence from randomised controlled trials]
Refer a person without delay to a specialist mental health service or an early intervention in psychosis service for assessment of risk of developing psychosis if the person is distressed, has a decline in social functioning, and has any of the following:
- Psychotic symptoms that are transient (of short duration) or attenuated (of lower intensity)
- Other experiences or behaviour suggestive of possible psychosis
- A first degree relative with psychosis or schizophrenia.
(New recommendation.) [Based on the experience and opinion of the GDG]
If a person is considered to be at increased risk of developing psychosis:
- Offer individual cognitive behavioural therapy, with or without family intervention
(New recommendation.) [Based on very low to moderate quality evidence from randomised controlled trials and the experience and opinion of the GDG]
First episode psychosis
Early intervention in psychosis services should be accessible to all people with a first episode or first presentation of psychosis, irrespective of the person’s age or the duration of untreated psychosis. (New recommendation.) [Based on the experience and opinion of the GDG]
Assess for post-traumatic stress disorder and other reactions to trauma because people with psychosis or schizophrenia are likely to have experienced adverse events or trauma associated with the development of the psychosis or as a result of the psychosis itself. For people who show signs of post-traumatic stress, follow the recommendations in the NICE clinical guideline on post-traumatic stress disorder.15 (New recommendation.) [Based on the experience and opinion of the GDG]
Offer oral antipsychotic medication in conjunction with family intervention and individual cognitive behavioural therapy. (New recommendation.) [Based on low to high quality evidence from randomised controlled trials]
Do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist. (Amended recommendation.) [Based on the experience and opinion of the GDG]
Before starting antipsychotic medication
Undertake and record the following baseline investigations:
- Weight (plotted on a chart)
- Waist circumference
- Pulse and blood pressure
- Fasting blood glucose, glycated haemoglobin (HbA1c), blood lipid profile, and prolactin levels
- Assessment of any movement disorders
- Assessment of nutritional status, diet, and level of physical activity.
(New recommendation.) [Based on the experience and opinion of the GDG]
Choice of antipsychotic medication
The choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the carer if the service user agrees. Provide information and discuss the likely benefits and possible side effects of each drug, including:
- Metabolic (including weight gain and diabetes)
- Extrapyramidal (including akathisia, dyskinesia, and dystonia)
- Cardiovascular (including prolonging the QT interval)
- Hormonal (including increasing plasma prolactin)
- Other (including unpleasant subjective experiences).
(Amended recommendation.) [Based on the experience and opinion of the GDG]
Do not initiate regular combined antipsychotic medication except for short periods (such as when changing medication). [Based on the experience and opinion of the GDG]
Monitoring antipsychotic medication
Monitor and record the following regularly and systematically throughout treatment, but especially during titration:
- Response to treatment, including changes in symptoms and behaviour
- Side effects of treatment, taking into account overlap between certain side effects and clinical features of schizophrenia (such as the overlap between akathisia and agitation or anxiety) and impact on functioning
- Emergence of movement disorders
- Weight, weekly for the first six weeks, then at 12 weeks, at one year, and then annually (plotted on a chart)
- Waist circumference annually (plotted on a chart)
- Pulse and blood pressure at 12 weeks, at one year, and then annually
- Fasting blood glucose, HbA1c, and blood lipid levels at 12 weeks, at one year, and then annually
- Adherence to treatment
- Overall physical health.
(New recommendation.) [Based on the experience and opinion of the GDG]
The secondary care team should maintain responsibility for monitoring service users’ physical health and the effects of antipsychotic medication for at least the first 12 months or until the person’s condition has stabilised, whichever is longer. Thereafter, the responsibility for this monitoring may be transferred to primary care under shared care arrangements. (New recommendation.) [Based on the experience and opinion of the GDG]
Subsequent acute episodes of psychosis or schizophrenia
Offer oral antipsychotic medication in conjunction with a psychological intervention. (New recommendation.) [Based on low to high quality evidence from randomised controlled trials]
- Cognitive behavioural therapy to all people with psychosis or schizophrenia
- Family intervention to all families of people with psychosis or schizophrenia who live with or are in close contact with the service user.
These can be started either during the acute phase or later, including in inpatient settings.
[Based on low to moderate quality evidence from randomised controlled trials]
Promoting recovery and possible future care
General practitioners and other primary care professionals should monitor the physical health of people with psychosis or schizophrenia when responsibility for monitoring is transferred from secondary care, and then at least annually. The health check should be comprehensive, focusing on physical health problems that are common in people with psychosis and schizophrenia. Include all the checks above (section “Before starting antipsychotic medication”) and refer to relevant NICE guidelines on monitoring for cardiovascular disease, diabetes, obesity, and respiratory disease. A copy of the results should be sent to the care coordinator and psychiatrist and put in the secondary care notes. (New recommendation.) [Based on the experience and opinion of the GDG]
Identify people with psychosis or schizophrenia who have high blood pressure, have abnormal lipid levels, are obese or at risk of obesity, have diabetes or are at risk of diabetes (indicated by abnormal blood glucose levels), or are physically inactive at the earliest opportunity following relevant NICE guidance.23 24 25 26 27 28 (New recommendation.) [Based on the experience and opinion of the GDG]
Offer supported employment programmes to people with psychosis or schizophrenia who wish to find or return to work. Consider other occupational or educational activities, including pre-vocational training, for people who are unable to work or unsuccessful in finding employment. (New recommendation.) [Based on very low to high quality evidence from randomised controlled trials]
Accessing psychological interventions (cognitive behavioural therapy and family intervention) to prevent and treat psychosis, and to treat schizophrenia in the longer term, requires a shift in emphasis for community based services away from the overly bureaucratic case and risk management practices of the current system for organising care from secondary mental health services, namely the care programme approach.29 This can be achieved, in part, by establishing therapeutic teams to facilitate access to evidence based interventions at the point of need.
The longstanding dependence of services on antipsychotic drugs as the sole treatment for people with psychosis and schizophrenia has led to polypharmacy and inappropriate use, including as a means to prevent psychosis. Services should audit their use of antipsychotics to align prescribing with the best evidence.30 31
To overcome barriers to achieving good physical healthcare, there needs to be greater emphasis on incentive schemes for general practitioners (Quality and Outcomes Framework32), for healthcare providers (Commissioning for Quality and Innovation33), and for service users.34 However, primary and secondary care need to collaborate because key physical health monitoring performance indicators have been removed from the Quality and Outcomes Framework.
Further information on the guidance
In the past decade there have been great changes in the way the care of people with psychosis and schizophrenia in the community is organised between primary and secondary care, leading to some local inconsistencies and much less contact with primary care,35 which is likely to be exacerbated by the removal of key physical health indicators from the Quality and Outcomes Framework this year. Access to psychological interventions for people with schizophrenia remains variable across primary and secondary care.36
The updated guideline reviews the areas of service level interventions that were not updated in the 2009 guideline such as peer support and self management interventions, vocational rehabilitation and teams, and service level interventions that encompass community based interventions and alternatives to acute admission. In addition, the 2014 guideline provides new reviews of interventions for at risk mental states, carers’ experience, and physical healthcare.
Brief methodology for this guideline
This guideline, which is a partial update of NICE clinical guideline 82,37 was developed by the National Collaborating Centre for Mental Health using NICE’s guideline methods for updates (http://publications.nice.org.uk/the-guidelines-manual-pmg6). The guideline review process involved comprehensive and systematic literature searches to identify relevant evidence for the updated clinical and economic reviews, with critical appraisal of the quality of the identified evidence. A multidisciplinary team of health and social care professionals from psychiatry, psychology, occupational therapy, general practice, nursing, and social work, as well as representatives of service users and carers (the Guideline Development Group (GDG)), was established to review the evidence and develop the subsequent recommendations. The guideline then went through an external consultation with stakeholders. The GDG considered the stakeholders’ comments, reanalysed the data where necessary, and modified the guideline as appropriate.
NICE has produced three different versions of the guideline: a full version; a summary version known as the “NICE guideline”; and a version for people with psychosis and schizophrenia, their families and carers, and the public. All these versions, as well as a pathway, are available from the NICE website (http://guidance.nice.org.uk/178). Further updates of the guideline will be produced as part of NICE’s guideline development programme.
Future research and remaining uncertainties
The clinical and cost effectiveness of
- Peer support interventions in people with psychosis and schizophrenia
- Psychological intervention alone, compared with treatment as usual, in people with psychosis or schizophrenia who choose not to take antipsychotic drugs
The short and long term benefits to physical health of guided medication discontinuation or reduction in first episode psychosis and whether this can be achieved without major risks
How the benefits of early intervention in psychosis services can be maintained once service users are discharged after three years
The benefit of a trauma reprocessing intervention based on cognitive behavioural therapy for post-traumatic stress disorder symptoms in people with psychosis and schizophrenia
Cite this as: BMJ 2014;348:g1173
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the Guideline Development Group were Elizabeth Kuipers (chair), Tim Kendall (facilitator), Amina Yesufu-Udechuku (systematic reviewer), Max Birchwood, Alison Brabban, Nadir Cheema (health economist), Debbie Green, Bronwyn Harrison (research assistant), Zaffer Iqbal, Sonia Johnson, Tom Lochhead, Max Marshall, Evan Mayo-Wilson (senior systematic reviewer), Jonathan Mitchell, Tony Morrison, Maryla Moulin (project manager), David Shiers, Eric Slade (health economist), Sarah Stockton (senior information scientist), Clare Taylor (senior editor), Clive Travis, Rachel Waddingham, Peter Woodhams, and Norman Young.
Contributors: All authors contributed to the conception and drafting of this article and revising it critically. They have all approved the final version. TK is the guarantor.
Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: TK, CT, and AYU had support from the National Collaborating Centre for Mental Health (NCCMH) for the submitted work; TK receives funding from NICE to support guideline development work at the NCCMH.
Provenance and peer review: Commissioned; not externally peer reviewed.