Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care

National Institute for Health and Clinical Excellence

Introduction

• This guideline covers the treatment and management of schizophrenia and related disorders in adults (18 years and older) with an established diagnosis of schizophrenia (with onset before age 60). The guideline does not address the specific treatment of young people under the age of 18, except those who are receiving treatment and support from early intervention services

• Schizophrenia is a major psychiatric disorder, or cluster of disorders, characterised by psychotic symptoms that alter a person’s perception, thoughts, affect and behaviour. Each person with the disorder will have a unique combination of symptoms and experiences
• A diagnosis of schizophrenia is still associated with considerable stigma, fear and limited public understanding. The first few years after onset can be particularly upsetting and chaotic, and there is a higher risk of suicide. Once an acute episode is over, there are often other problems such as social exclusion, with fewer opportunities to return to work or study and problems forming new relationships

• There is now a new emphasis on services for early detection and intervention, a focus on long-term recovery and promoting people’s choices about their management. Most people will recover, although some will have persisting difficulties or remain vulnerable to future episodes. Most people find ways to manage acute problems, and compensate for any remaining difficulties

• Carers, relatives and friends of people with schizophrenia are important during the assessment process and in the long-term successful delivery of effective treatments

Key priorities for implementation

Access and engagement

• Healthcare professionals working with people with schizophrenia should ensure they are competent in:
  • assessment skills for people from diverse ethnic and cultural backgrounds
  • using explanatory models of illness for people from diverse ethnic and cultural backgrounds
  • explaining the causes of schizophrenia and treatment options
  • addressing cultural and ethnic differences in treatment expectations and adherence
  • addressing cultural and ethnic differences in beliefs regarding biological, social and family
  • influences on the causes of abnormal mental states
  • negotiating skills for working with families of people with schizophrenia
  • conflict management and conflict resolution

• Mental health services should work in partnership with local stakeholders, including those representing black and minority ethnic (BME) groups, to enable people with mental health problems, including schizophrenia, to access local employment and educational opportunities. This should be sensitive to the person’s needs and skill level and is likely to involve working with agencies such as Jobcentre Plus, disability employment advisers and non-statutory providers

• Healthcare teams working with people with schizophrenia should identify a lead healthcare professional within the team whose responsibility is to monitor and review:
  • access to and engagement with psychological interventions
  • decisions to offer psychological interventions and equality of access across different ethnic groups

Primary care and physical health

• GPs and other primary healthcare professionals should monitor the physical health of people with schizophrenia at least once a year. Focus on cardiovascular disease risk assessment as described in ‘Lipid modification’ (NICE clinical guideline 67) but bear in mind that people with schizophrenia are at higher risk of cardiovascular disease than the general population. A copy of the results should be sent to the care coordinator and/or psychiatrist, and put in the secondary care notes

Psychological interventions

• Offer cognitive behavioural therapy (CBT) to all people with schizophrenia. This can be started either during the acute phase or later, including in inpatient settings

• Offer family intervention to all families of people with schizophrenia who live with or are in close contact with the service user. This can be started either during the acute phase or later, including in inpatient settings

Pharmacological interventions

• For people with newly diagnosed schizophrenia, offer oral antipsychotic medication. Provide information and discuss the benefits and side-effect profile of each drug with the service user. The choice of drug should be made by the service user and healthcare professional together, considering:
  • the relative potential of individual antipsychotic drugs to cause extrapyramidal side effects (including akathisia), metabolic side effects (including weight gain) and other side effects (including unpleasant subjective experiences)
  • the views of the carer where the service user agrees

• Do not initiate regular combined antipsychotic medication, except for short periods (for example, when changing medication)

Interventions for people with schizophrenia whose illness has not responded adequately to treatment

• For people with schizophrenia whose illness has not responded adequately to pharmacological or psychological treatment:
  • review the diagnosis
  • establish that there has been adherence to antipsychotic medication, prescribed at an adequate dose and for the correct duration
  • review engagement with and use of psychological treatments and ensure that these have been offered according to this guideline. If family intervention has been undertaken suggest CBT; if CBT has been undertaken suggest family intervention for people in close contact with their families
  • consider other causes of non-response, such as comorbid substance misuse (including alcohol), the concurrent use of other prescribed medication or physical illness

• Offer clozapine to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs. At least one of the drugs should be a non-clozapine second-generation antipsychotic

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG82

National Institute for Health and Clinical Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. March 2009