Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care (update) NICE guideline Draft for consultation, September 2008 If you wish to comment on this version of the guideline, please be aware that all the supporting information and evidence is contained in the full version. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 1 of 39
Contents Introduction...3 Person-centred care...5 Key priorities for implementation...6 1 Guidance...9 1.1 Care across all phases...9 1.2 Initiation of treatment (first episode)...13 1.3 Treatment of acute episode...16 1.4 Promoting recovery...22 2 Notes on the scope of the guidance...27 3 Implementation...28 4 Research recommendations...29 4.1 Clozapine augmentation...29 4.2 Family intervention...29 4.3 Cultural competence training for staff...30 5 Other versions of this guideline...31 5.1 Full guideline...31 5.2 Quick reference guide...31 5.3 Understanding NICE guidance...31 6 Related NICE guidance...32 7 Updating the guideline...33 Appendix A: The Guideline Development Groups...34 Appendix B: The Guideline Review Panel...39 Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 2 of 39
This guidance is an update of NICE clinical guideline 1 (published December 2002) and will replace it. Recommendations shaded in grey are from clinical guideline 1 and are not included in the consultation. The original NICE guideline and supporting documents are available from www.nice.org.uk/cg1 Introduction This guideline relates to a range of difficulties which are typically given a diagnosis of schizophrenia but may also be called psychosis and schizoaffective disorder. It is characterised by distress related to hearing voices or having unusual experiences, and by uncommon, sometimes bizarre beliefs, that are not shared by others. Thinking can become jumbled and difficult to follow. Accompanying these are other features which include losing interest and lacking drive and motivation: typically activities reduce, relationships are put under strain and the person often withdraws into themself. Concentration, attention and memory can alter, and self care can become less of a priority. Over a lifetime, between 1-2% of the population will have these kinds of problems, which tend to come on during young adulthood (but can occur at any age), often at a time when people are trying to make the transition into independent life styles. The difficulties frequently have a distressing impact on family and friends. These diagnoses are still associated with 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; reduced opportunities to get back to work or study and make new relationships. Recently, there has been a new emphasis in services on early detection, early intervention and recovery, and on individuals being able to make choices about their management. There is evidence now that most people will recover, Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 3 of 39
although some will have persisting difficulties or remain vulnerable to future episodes. Not everyone will accept help from statutory services. Longer term, most people will find ways to manage acute problems, and compensate for any remaining difficulties. Optimal treatment usually includes pharmacological and specific psychological interventions, plus a range of other support provided in the community. Carers, relatives and friends of individuals with schizophrenia are important both in the process of assessment and engagement and in the long term successful delivery of effective interventions. This guideline uses the term carer to apply to all people who have regular close contact with the person, including advocates, friends or family members, although some family members may choose not to be carers. Schizophrenia is commonly associated with a number of other conditions, such as depression, anxiety, post-traumatic stress disorder, personality disorder and substance misuse. This guideline does not cover the separate management of these conditions. The guideline will cover those with an established diagnosis of schizophrenia (with onset before age 60) who require treatment beyond age 60. It will also cover the use of early intervention services in the early treatment of people with schizophrenia (this includes people with psychosis who are younger than 18). The guideline will assume that prescribers will use a drug s summary of product characteristics to inform their decisions for individual patients. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 4 of 39
Person-centred care This guideline offers best practice advice on the care of people with schizophrenia. Treatment and care should take into account service users' needs and preferences. People with schizophrenia should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If service users do not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines Reference guide to consent for examination or treatment (2001) (available from www.dh.gov.uk). Healthcare professionals should also follow the code of practice that accompanies the Mental Capacity Act (summary available from www.publicguardian.gov.uk). Good communication between healthcare professionals and service users is essential. It should be supported by evidence-based written information tailored to the service user's needs. Treatment and care, and the information service users are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. If the service user agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 5 of 39
Key priorities for implementation Access and engagement Healthcare professionals working with people with schizophrenia should ensure they are competent (including in assessment skills) to address: explanatory models of illness for different ethnic groups cultural and ethnic differences in treatment expectations and adherence cultural and ethnic differences in beliefs regarding biological, social and family influences on the aetiology of abnormal mental states negotiating skills for working with families from different cultures when one member (or more) has schizophrenia conflict management and conflict resolution. [1.1.2.3] Mental health services should work in partnership with local stakeholders, including those representing BME groups, to enable people with mental health problems, including schizophrenia, to access local employment and educational opportunities. This should be sensitive to the different needs and level of skill of individuals and is likely to involve working with agencies such as Jobcentre Plus, Disability Employment Advisors and non-statutory providers. [1.4.7.2] Healthcare teams working with people with schizophrenia should identify a lead healthcare professional for psychological interventions to monitor and review: access to and engagement with psychological interventions decisions to offer psychological interventions and equality of access across different ethnic groups. [1.3.4.8] Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 6 of 39
Primary care and physical health GPs and other primary healthcare professionals should monitor the physical health of people with schizophrenia. Physical health checks should: focus on monitoring: weight gain and obesity (waist hip ratio or waist circumference); blood pressure; dietary intake; activity levels and exercise; use of tobacco and alcohol or other substances; blood levels of glucose; lipids (including cholesterol, HDL, LDL and triglycerides); prolactin levels (if indicated) be done at a minimum once a year have results clearly documented by the primary care clinician have results communicated to the care coordinator and/or psychiatrist, and recorded in the secondary care notes. [1.4.1.2] Psychological interventions Offer cognitive behavioural therapy (CBT) to people with schizophrenia. This can be started during the acute phase 1. [1.3.4.1] Offer family intervention to families of people with schizophrenia who are living with or who are in close contact with the service user. This can be started during the acute phase 2. [1.3.4.2] Pharmacological interventions For people with newly diagnosed schizophrenia, offer oral antipsychotic medication. Following discussion and provision of relevant information on the benefits and side effect profile of each available drug with the service user, the choice of drug should be determined in partnership between the service user and healthcare professional by consideration of the following factors: preference of the service user not to experience specific side effects, paying particular attention to the relative liability of individual antipsychotic drugs for extrapyramidal side effects 1 CBT should be delivered in accordance with recommendation 1.3.4.12 2 Family intervention should be delivered in accordance with recommendation 1.3.4.13 Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 7 of 39
(including akathisia), metabolic side effects (including weight gain) and other serious side effects views of the carer where service users agree to this. [1.2.4.1] Do not prescribe regular combined antipsychotic medication, except for short periods of overlap when changing medication. [1.2.4.8] Interventions for people who have an inadequate or no response to treatment Offer clozapine to people with schizophrenia who have an inadequate or no response to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs, at least one of which should be a non-clozapine second-generation antipsychotic. [1.4.6.2] For people with schizophrenia whose illness appears to have an inadequate or no response to pharmacological or psychological treatment and for whom the diagnosis is confirmed as schizophrenia at review, healthcare professionals should: establish that service users have adhered to antipsychotic medication as prescribed at an adequate dose and for the correct duration review the use of psychological treatments and ensure that these have been offered in accordance with this guideline; if family intervention has been undertaken suggest CBT; if CBT has been undertaken suggest family intervention for those who are 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 medicines and physical illness. [1.4.6.1] Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 8 of 39
1 Guidance The following guidance is based on the best available evidence and applies to all healthcare professionals working with people with schizophrenia and, where appropriate, to their carers, unless otherwise stated. The full guideline ([add hyperlink]) gives details of the methods and the evidence used to develop the guidance. 1.1 Care across all phases 1.1.1 Optimism 1.1.1.1 Healthcare professionals should work in partnership with people with schizophrenia and their carers, offering help, treatment and care in an atmosphere of hope and optimism, taking time to build supportive and empathic relationships as an essential part of care. 1.1.2 Race, culture and ethnicity The following recommendations apply to all people with schizophrenia and their carers. However, people from black and minority ethnic (BME) groups with schizophrenia are more likely than other groups to be disadvantaged or have impaired access and/or engagement with mental health services and have therefore been identified as having particular needs that may be addressed by the following recommendations. 1.1.2.1 All healthcare professionals working with people with schizophrenia and their carers should: avoid using clinical language, or at least keep it to a minimum be culturally competent to explain the causes and treatment options to people from diverse backgrounds ensure comprehensive written information is available in the appropriate language provide and work proficiently with interpreters where needed Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 9 of 39
provide a list of local education providers who can provide English language teaching for people who have difficulties speaking and understanding English. 1.1.2.2 Healthcare professionals who are inexperienced in working with people with schizophrenia with different cultural backgrounds to themselves should seek consultation and supervision from healthcare professionals who are experienced in working transculturally. 1.1.2.3 Healthcare professionals working with people with schizophrenia should ensure they are competent (including in assessment skills) to address: explanatory models of illness for different ethnic groups cultural and ethnic differences in treatment expectations and adherence cultural and ethnic differences in beliefs regarding biological, social and family influences on the aetiology of abnormal mental states negotiating skills for working with families from different cultures when one member (or more) has schizophrenia conflict management and conflict resolution. 1.1.2.4 Mental health services should work with local voluntary sector BME stakeholder groups to jointly ensure the provision of culturally appropriate psychological and psychosocial treatment, including the provision of therapies by voluntary organisations if this will improve access to the treatments recommended in this guideline for service users from different cultural backgrounds. 1.1.3 Getting help early 1.1.3.1 Healthcare professionals should facilitate access as soon as possible to assessment and treatment and promote early access throughout all phases of care. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 10 of 39
1.1.4 Assessment 1.1.4.1 Ensure that people with schizophrenia receive a comprehensive multidisciplinary assessment. The assessment should include the following domains: accommodation cultural economic ethnic occupational physical health psychiatric psychological pharmacological quality of life sexual health social. 1.1.4.2 Healthcare professionals should routinely monitor for other coexisting conditions, including depression and anxiety, particularly in the early phases of treatment. 1.1.5 Working in partnership with carers 1.1.5.1 Healthcare professionals working with carers of people with schizophrenia should: provide written and verbal information on schizophrenia and its management, including how families and carers can help through all phases of treatment offer a Carer's Assessment of their caring, physical and mental health needs provide information about and facilitate access to local carer and family support groups and relevant voluntary organisations Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 11 of 39
be able to negotiate confidentiality and the sharing of information between the service user and their carers. 1.1.6 Consent, capacity and treatment decisions 1.1.6.1 Before each treatment decision is taken, healthcare professionals should ensure that they: understand and apply the principles underpinning the Mental Capacity Act provide service users and carers with information, both verbal and written, regarding schizophrenia and its management, so as to ensure properly informed consent prior to initiating treatment. This should apply whether or not people are being detained or treated under the Mental Health Act and is especially important for people from BME groups. 1.1.6.2 When the Mental Health Act is used, healthcare professionals should inform service users of their rights to appeal to a Mental Health Review Tribunal (MHRT) and support service users who choose to exercise those rights. 1.1.7 Advance agreements 1.1.7.1 Advance agreements (statements and decisions) should be developed collaboratively with people with schizophrenia, especially for those who have more severe illnesses and for those who have been treated under the Mental Health Act. These should be formally recorded and copies should be placed in primary-care and secondary-care care plans, and copies given to the service user and his or her care coordinator. A copy should also be given to his or her carer subject to agreement with the service user. 1.1.7.2 Advance agreements should be honoured in accordance with the Mental Capacity Act irrespective of whether the person with schizophrenia is held under the Mental Health Act. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 12 of 39
1.1.8 Second opinion 1.1.8.1 A decision by the service user, and carer where appropriate, to seek a second opinion on the diagnosis should be supported, particularly in view of the considerable personal and social consequences of being diagnosed with schizophrenia. 1.1.9 Transfer between services 1.1.9.1 Transition from one service to another should be discussed in advance with the service user (and carers if appropriate), and should be undertaken using the Care Programme Approach (CPA). The care plan should ensure effective collaboration with other care providers during transitions, and includes the opportunity to access services in times of crisis. 1.2 Initiation of treatment (first episode) 1.2.1 Early referral 1.2.1.1 Primary care clinicians should urgently refer all people with first presentation of psychotic symptoms to a local community based secondary mental health service (for example, early intervention service, crisis resolution and home treatment team, community mental health team). 1.2.1.2 After referral from primary care, healthcare professionals working in secondary care should undertake a full assessment, including an assessment by a consultant psychiatrist, and develop a care plan at the earliest opportunity. A copy of the care plan should be sent to the primary healthcare professional who made the referral. 1.2.1.3 Every care plan should include a crisis plan that defines the role of primary and secondary care identifying the key clinical contacts in the event of an emergency or impending crisis. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 13 of 39
1.2.2 Early intervention services 1.2.2.1 Early intervention services should be offered to all people with a first episode or first presentation of psychosis, irrespective of the person's age or the duration of untreated psychosis. 1.2.2.2 Early intervention services should aim to provide a full range of relevant pharmacological, psychological, social, and occupational interventions for people with psychosis, consistent with this guideline. 1.2.3 Early treatment 1.2.3.1 If a GP is going to initiate antipsychotic medication, it should be undertaken only by those with experience in the treatment and management of schizophrenia. This should be done in accordance with this guideline (see recommendation 1.2.4.3 on how to prescribe antipsychotic medication). 1.2.4 Pharmacological interventions 1.2.4.1 For people with newly diagnosed schizophrenia, offer oral antipsychotic medication. Following discussion and provision of relevant information on the benefits and side effect profile of each available drug with the service user, the choice of drug should be determined in partnership between the service user and healthcare professional by consideration of the following factors: preference of the service user not to experience specific side effects, paying particular attention to the relative liability of individual antipsychotic drugs for extrapyramidal side effects (including akathisia), metabolic side effects (including weight gain) and other serious side effects views of the carer where service users agree to this. How to use oral antipsychotic medication 1.2.4.2 Before initiating antipsychotic medication, give the person with schizophrenia an electrocardiogram (ECG) when: Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 14 of 39
the Summary of Product Characteristics (SPC) for a particular drug indicates the need for an ECG a physical examination has identified any specific cardiovascular risks (for example, hypertension) there is personal history of cardiovascular disease, or the service user is entering an inpatient unit. 1.2.4.3 Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial, and include the following: document the indications for oral antipsychotic medication, the expected benefits and risks and the anticipated timeframe for change of symptoms and emergence of side effects the dose prescribed at the start should be at the lower end of the licensed/recommended range and slowly titrated upwards within the dose range identified in the British National Formulary (BNF) or SPC justify and document reasons for dosage outside the range identified in the BNF or SPC monitor regularly and systematically throughout treatment, but especially during the titration phase for: efficacy, including symptom and behaviour change adverse effects of treatment, taking account of the potential overlap between certain side effects and some of the clinical features of schizophrenia (for example the overlap between akathisia and agitation or anxiety) physical health document results of all monitoring clearly in the notes with rationale for changes in medication, stopping medication or persisting with the same medication, and the effects of such changes an adequate trial at optimum dosage of 4-6 weeks Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 15 of 39
1.2.4.4 Healthcare professionals should discuss the use of other nonprescribed therapies, including complementary and alternative therapies, with the service user and carer where appropriate, including discussion of possible interference with therapeutic effects of prescribed medication and psychological treatments. 1.2.4.5 Healthcare professionals should discuss the use of alcohol and drugs (prescribed and non prescribed; legal and illicit) with the service user and carers where appropriate, including discussion of possible interference with therapeutic effects of prescribed medication and psychological treatments. 1.2.4.6 As required ( p.r.n. ) prescriptions of antipsychotic medication should be made in accordance with recommendation 1.2.4.3. Specifically, it should be reviewed weekly in terms of the clinical indications, frequency of administration, therapeutic gains and side effects, and whether it has led to high-dose prescribing for the service user. 1.2.4.7 Do not use a loading dose of antipsychotic medication (often referred to as rapid neuroleptisation ). 1.2.4.8 Do not prescribe regular combined antipsychotic medication, except for short periods of overlap when changing medication. 1.2.4.9 If prescribing chlorpromazine, warn of a potential photosensitive skin response and advise to use sunscreen if necessary. 1.3 Treatment of the acute episode 1.3.1 Service-level interventions 1.3.1.1 All teams providing services for people with schizophrenia should offer a comprehensive range of interventions consistent with this guideline. 1.3.1.2 Community mental health teams are an acceptable way of organising community care and may have the potential for Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 16 of 39
effectively coordinating and integrating other community-based teams providing services for people with schizophrenia. However, there is insufficient evidence of their advantages to support a recommendation which precludes or inhibits the development of alternative service configurations. 1.3.1.3 Crisis resolution and home treatment teams should be used as a means to manage crises for service users, and as a means of delivering high-quality acute care. In this context, teams should pay particular attention to risk monitoring as a high-priority routine activity. 1.3.1.4 Crisis resolution and home treatment teams should be considered for people with schizophrenia who are in crisis to augment the services provided by early intervention services and assertive outreach teams. 1.3.1.5 Crisis resolution and home treatment teams should be considered for people with schizophrenia who may benefit from early discharge from hospital following a period of inpatient care. 1.3.1.6 Acute day hospitals should be considered as a clinical and costeffective option for the provision of acute care, both as an alternative to acute admission to inpatient care and to facilitate early discharge from inpatient care. 1.3.1.7 Offer social, group and physical activities to people with schizophrenia, and record arrangements in their care plan. 1.3.2 Pharmacological interventions 1.3.2.1 For people with an acute exacerbation or recurrence of schizophrenia, offer oral antipsychotic medication. Choice of drug should be influenced by the same criteria recommended for the initiation of treatment (see section 1.2.4), taking account of the clinical response and side effects of the service user's current and previous medication. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 17 of 39
1.3.3 Rapid tranquillisation 1.3.3.1 Uncommonly people with schizophrenia may pose an immediate risk to themselves or others during an acute episode and may need to be considered for rapid tranquillisation. The management of immediate risk to self or others should follow the relevant NICE guidelines. 1.3.3.2 Healthcare professionals should follow Violence (NICE clinical guideline 25) when faced with the threat of imminent violence or when considering the use of rapid tranquillisation. 1.3.3.3 Following the use of rapid tranquillisation, the person with schizophrenia should be offered the opportunity to discuss their experiences and should be provided with a clear explanation of the decision to use urgent sedation. This should be documented in their notes. 1.3.3.4 The person with schizophrenia should also be given the opportunity to write their account of their experience of rapid tranquillisation in the notes. 1.3.3.5 Healthcare professionals should follow 'Self-harm' (NICE clinical guideline 16) when managing acts of self-harm in people with schizophrenia. 1.3.4 Psychological and psychosocial interventions 1.3.4.1 Offer cognitive behavioural therapy (CBT) to people with schizophrenia. This can be started during the acute phase 3. 1.3.4.2 Offer family intervention to families of people with schizophrenia who are living with or who are in close contact with the service user. This can be started during the acute phase 4. 3 CBT should be delivered in accordance with recommendation 1.3.4.12 4 Family intervention should be delivered in accordance with recommendation 1.3.4.13 Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 18 of 39
1.3.4.3 Consider offering arts therapies to people with schizophrenia (including in the inpatient setting), particularly for the alleviation of negative symptoms. This can be started during the acute phase. 1.3.4.4 Counselling and supportive psychotherapy (as discrete interventions) should not routinely be offered to people with schizophrenia. However, service user preferences should be taken into account, especially if other more efficacious psychological treatments are not locally available. 1.3.4.5 Adherence therapy (as a discrete intervention) should not be offered to people with schizophrenia. 1.3.4.6 Social skills training (as a discrete intervention) should not routinely be offered to people with schizophrenia. Principles in the provision of psychological therapies 1.3.4.7 Healthcare professionals providing psychological interventions should routinely and systematically monitor a range of outcomes across relevant domains, including service user satisfaction and, if appropriate, carer satisfaction. 1.3.4.8 Healthcare teams working with people with schizophrenia should identify a lead healthcare professional for psychological interventions to monitor and review: access to and engagement with psychological interventions decisions to offer psychological interventions and equality of access across different ethnic groups. 1.3.4.9 Healthcare professionals providing psychological interventions should: have an appropriate level of competence in delivering the intervention for people with schizophrenia have regular psychological therapy supervision from a competent therapist and supervisor. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 19 of 39
1.3.4.10 Trusts should provide access to training which equips healthcare professionals with the competencies required to deliver the psychological therapy interventions recommended in this guideline. 1.3.4.11 When psychological treatments, including arts therapies, are initiated in the acute phase (including during admission), the full course should be continued after discharge without unnecessary interruption. How to deliver psychological interventions 1.3.4.12 Cognitive behavioural therapy should be delivered as an individual treatment, including more than 16 planned sessions and should: follow a treatment manual so that: recipients establish links between their thoughts, feelings or actions with respect to the current or past symptoms, and/or functioning the re-evaluation of their perceptions, beliefs or reasoning relates to the target symptoms involve a further component within the intervention with at least one of the following: recipients monitor their own thoughts, feelings or behaviours with respect to the symptom or recurrence of symptoms the promotion of alternative ways of coping with the target symptom the reduction of distress the improvement of functioning. 1.3.4.13 Family intervention should: include the person with schizophrenia where practicable be between three months and one year in duration include more than 10 planned sessions take account of the whole family's potential preference for singlefamily interventions rather than multi-family group interventions Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 20 of 39
have a specific supportive, educational or treatment function and contain negotiated problem solving/crisis management work. 1.3.4.14 Arts therapies should be provided by a Health Professions Council (HPC) registered arts therapist, with previous experience of working with people with schizophrenia. The intervention should be provided in small groups or individual sessions and should combine psychotherapeutic techniques with activities aimed at promoting creative expression while containing and giving meaning to the service user's experiences. It should also include: a creative process that is used to facilitate self-expression within a specific therapeutic framework an artistic medium that is used as a bridge to verbal dialogue and insight-based psychological development if appropriate the aim of enabling the patient to experience him/herself differently and develop new ways of relating to others. 1.3.5 Early post-acute period In the early period of recovery following an acute episode, service users and healthcare professionals will need to jointly reflect upon the acute episode and its impact and make plans for future care. 1.3.5.1 Encourage people with schizophrenia to write an account of their illness in their notes. 1.3.5.2 Psychoanalytic and psychodynamic principles may be considered to help healthcare professionals to understand the experience of people with schizophrenia and their interpersonal relationships. 1.3.5.3 Inform the service user that there is a high risk of relapse if they discontinue medication within the next 1 to 2 years. 1.3.5.4 Withdrawal from antipsychotic medication should be undertaken gradually whilst regularly monitoring signs and symptoms for evidence of relapse. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 21 of 39
1.3.5.5 Following withdrawal from antipsychotic medication, monitoring for signs and symptoms of potential relapse should continue for at least 2 years. 1.4 Promoting recovery 1.4.1 Primary care 1.4.1.1 The organisation and development of practice case registers should be used as an essential step in monitoring the physical and mental health of people with schizophrenia in primary care. 1.4.1.2 GPs and other primary healthcare professionals should monitor the physical health of people with schizophrenia. Physical health checks should: focus on monitoring: weight gain and obesity (waist hip ratio or waist circumference); blood pressure; dietary intake; activity levels and exercise; use of tobacco and alcohol or other substances; blood levels of glucose; lipids (including cholesterol, HDL, LDL and triglycerides); prolactin levels (if indicated) be done at a minimum once a year have results clearly documented by the primary care clinician have results communicated to the care coordinator and/or psychiatrist, and recorded in the secondary care notes. 1.4.1.3 People with schizophrenia who have been identified to be at risk of developing cardiovascular disease and/or diabetes (for example, elevated blood pressure, raised lipid levels, smokers, and increased waist measurement) should be managed using the appropriate NICE guidance for prevention of these conditions. 1.4.1.4 People with schizophrenia who have established diabetes and/or cardiovascular diseases should be treated in primary care in accordance with the appropriate NICE guidance on management of diabetes and cardiovascular disease. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 22 of 39
1.4.1.5 Healthcare professionals in secondary care working with people with schizophrenia should ensure, as part of the CPA process, that individuals with schizophrenia are receiving physical healthcare from primary care described in this guideline. 1.4.1.6 When a person with an established diagnosis of schizophrenia presents with a suspected relapse (for example with increased psychotic symptoms or a significant increase in the use of alcohol or other substances), primary care physicians should refer to the crisis section of the care plan and consider referral to the key clinician or care coordinator identified in the crisis plan. 1.4.1.7 When a person with schizophrenia is no longer being cared for in secondary care, consider re-referral from primary care if there is: poor response to treatments non-adherence with medication comorbid substance misuse level of risk to self or others intolerable side effects from medication. 1.4.1.8 Referral to mental health services should take account of service user and carer requests, especially for: review of the side effects of existing treatments psychological treatments or other interventions. 1.4.1.9 When a person with schizophrenia is planning on moving to the catchment area of a different NHS trust, their current secondary care provider should contact the new secondary care and primary care providers, and provide them with the current care plan. 1.4.2 Service interventions 1.4.2.1 Assertive outreach teams should be provided for people with serious mental disorders including people with schizophrenia. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 23 of 39
1.4.2.2 Assertive outreach teams should be provided for people with serious mental disorders, including for people with schizophrenia, who make high use of inpatient services and who have a history of poor engagement with services leading to frequent relapse and/or social breakdown (as manifest by homelessness or seriously inadequate accommodation). 1.4.2.3 Assertive outreach teams should be provided for people with schizophrenia who are homeless. 1.4.2.4 Crisis resolution and home treatment teams should be considered for people with schizophrenia who are in crisis to augment the services provided by early intervention services and assertive outreach teams. 1.4.2.5 Integrating the care of people with schizophrenia who receive services from community mental health teams, assertive outreach teams, early intervention services and crisis resolution and home treatment teams should be carefully considered. The care programme approach should be the main mechanism by which the care of individuals across services is properly managed and integrated. 1.4.3 Psychological interventions 1.4.3.1 Offer CBT to people with schizophrenia to assist in promoting recovery, both for those with persisting positive and negative symptoms and for those in remission. The intervention should be delivered as described in recommendation 1.3.4.12. 1.4.3.2 Offer family intervention to families of people with schizophrenia who are living with or who are in close contact with the service user. The intervention should be delivered as described in recommendation 1.3.4.13. 1.4.3.3 Family intervention may be particularly useful for families of people with schizophrenia who have: Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 24 of 39
recently relapsed or who are considered at risk of relapse persisting symptoms. 1.4.3.4 Consider offering arts therapies to people to assist in promoting recovery, in particular those with negative symptoms. 1.4.4 Pharmacological interventions 1.4.4.1 Choice of drug should be influenced by the same criteria recommended for treatment of the acute episode (see section 1.3.2.1). 1.4.4.2 Targeted, intermittent dosage maintenance strategies should not be used routinely. However, these strategies may be considered for people with schizophrenia who are unwilling to accept a continuous maintenance regimen or for whom some other contraindication to maintenance therapy exists, such as side effect sensitivity. 1.4.4.3 Consider offering depot/long-acting injectable antipsychotic medication to people with schizophrenia: who express a preference for such treatment after an acute episode for whom the avoidance of covert non-adherence with antipsychotic drugs is a clinical priority within the treatment plan. 1.4.5 How to prescribe depot/long-acting injectable antipsychotic medication 1.4.5.1 When initiating depot/long-acting injectable antipsychotic medication: take into account the preferences and attitudes of the service user towards the mode of administration and organisational procedures (for example, home visits and location of clinics) related to the delivery of regular intramuscular injections Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 25 of 39
take into account the same criteria recommended for the use of oral antipsychotic medication (see section 1.2.4), particularly in relation to the risks and benefits of the drug regimen initially use a small test-dose, as set out in the BNF or SPC. 1.4.6 Interventions for people with schizophrenia who have an inadequate or no response to pharmacological or psychological treatment 1.4.6.1 For people with schizophrenia whose illness appears to have an inadequate or no response to pharmacological or psychological treatment and for whom the diagnosis is confirmed as schizophrenia at review, healthcare professionals should: establish that service users have adhered to antipsychotic medication as prescribed at an adequate dose and for the correct duration review the use of psychological treatments and ensure that these have been offered in accordance with this guideline; if family intervention has been undertaken suggest CBT; if CBT has been undertaken suggest family intervention for those who are 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 medicines and physical illness. 1.4.6.2 Offer clozapine to people with schizophrenia who have an inadequate or no response to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs, at least one of which should be a non-clozapine second-generation antipsychotic. 1.4.6.3 For people with schizophrenia who appear to have an inadequate or no response to treatment despite an adequate trial of clozapine, consider offering a second antipsychotic in addition to clozapine. An adequate trial of such an augmentation may need to be up to 8 Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 26 of 39
to 10 weeks. The choice of drug should avoid compounding the common side effects of clozapine. 1.4.7 Employment, education and occupational activities 1.4.7.1 Supported employment programmes should be provided for those people with schizophrenia who wish to return to work or gain employment. However, it should not be the only work-related activity offered when individuals are unable to work or are unsuccessful in their attempts to find employment. 1.4.7.2 Mental health services should work in partnership with local stakeholders, including those representing BME groups, to enable people with mental health problems, including schizophrenia, to access local employment and educational opportunities. This should be sensitive to the different needs and level of skill of individuals and is likely to involve working with agencies such as Jobcentre Plus, Disability Employment Advisors and non-statutory providers. 1.4.7.3 Healthcare professionals should routinely document the daytime activities of people with schizophrenia within their care plans, including documentation of occupational outcomes. 1.4.8 Return to primary care 1.4.8.1 Service users who have responded effectively to treatment and remain stable should be given the option to continue with their care within primary care. When a service user wishes to take up this offer this should be recorded in writing and transfer of responsibilities should be coordinated through the CPA. 2 Notes on the scope of the guidance NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover. The scope of this guideline is available from www.nice.org.uk/38756. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 27 of 39
How this guideline was developed NICE commissioned the National Collaborating Centre for Mental Health to develop this guideline. The Centre established a Guideline Development Group (see appendix A), which reviewed the evidence and developed the recommendations. An independent Guideline Review Panel oversaw the development of the guideline (see appendix B). There is more information in the booklet: The guideline development process: an overview for stakeholders, the public and the NHS (third edition, published April 2007), which is available from www.nice.org.uk/guidelinesprocess or from NICE publications (phone 0845 003 7783 or email publications@nice.org.uk and quote reference N1233). 3 Implementation The Healthcare Commission assesses how well NHS organisations meet core and developmental standards set by the Department of Health in Standards for better health (available from www.dh.gov.uk). Implementation of clinical guidelines forms part of the developmental standard D2. Core standard C5 says that NHS organisations should take into account national agreed guuidance when planning and delivering care. NICE has developed tools to help organisations implement this guidance (listed below). These are available on our website (www.nice.org.uk/cgxxx). [NICE to amend list as needed at time of publication] Slides highlighting key messages for local discussion. Costing tools: costing report to estimate the national savings and costs associated with implementation costing template to estimate the local costs and savings involved. Implementation advice on how to put the guidance into practice and national initiatives that support this locally. Audit criteria to monitor local practice. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 28 of 39
4 Research recommendations The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group s full set of research recommendations is detailed in the full guideline (see section 5). 4.1 Clozapine augmentation For people with treatment-resistant schizophrenia who have shown only a partial response to clozapine, is augmentation of clozapine monotherapy with an appropriate second antipsychotic clinically and cost-effective? Why this is important Clinicians commonly use a second antipsychotic to augment clozapine where the response has been unsatisfactory, but the findings from clinical trials thus far are inconclusive. There is some indication that an adequate trial of such a strategy may be longer than the 6-8 weeks usually considered adequate for a treatment study of an acute psychotic episode. The pharmacological rationale for choice of second antipsychotic should be tested. That is: 1) potent dopamine D2 receptor blockade, as a hypothesised mechanism of pharmacodynamic synergy, and 2) a low liability for compounding the characteristic side effects of clozapine. 4.2 Family intervention For people with schizophrenia from BME groups living in the UK, does ethnically adapted family intervention for schizophrenia (adapted in consultation with BME groups to better suit different cultural and ethnic needs) enable more people in BME groups to engage with this therapy, and show concomitant reductions in patient relapse rates and carer distress? Why is this important? Family intervention has a well established evidence base from the last 30 years, and proven efficacy for reducing relapse rates in schizophrenia. However most recent studies applying cultural modification to the intervention Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 29 of 39
have been conducted in non-uk service settings and set against relatively undeveloped treatment as usual services. Thus, the efficacy of culturally adapted family intervention has not been established within UK NHS settings. BME groups are over-represented in schizophrenia diagnoses, and in some inner city settings make up at least 50% of admissions and crisis care. They are also less likely to be offered psychological interventions and may thus remain more vulnerable to relapses, despite larger networks and potentially more family support, in those that are living with family carers. Engaging BME families in suitable adaptations of family intervention would expand the evidence base for family intervention in the UK and be an important way to improve their experiences and outcomes, for both carers and service users. 4.3 Cultural competence training for staff For people with schizophrenia from BME groups living in the UK, does staff training in cultural competence at an individual level and at an organisational level (delivered as a learning and training process embedded in routine clinical care and service provision) improve the service user's experience of care and chance of recovery, and reduce staff burnout? Why is this important? Culture is known to influence the content and some would argue the form and intensity of presentation of symptoms; it also determines what is considered illness and the remedies people seek. Cultural practices and customs may well create contexts in which distress is generated, for example, where conformity to gender, age, and cultural roles is challenged. It is important that professionals are careful and considerate, but clear and thorough in their use of clinical language and in the explanations they provide, not just to service users and carers, but also to other health professionals. Services should also ensure that all clinicians are skilled in working with people from diverse linguistic and ethnic backgrounds, and have a process by which they can assess cultural influences and address cumulative inequalities through their routine clinical practice (Bhui et al., 2007). Addressing organisational aspects of cultural competence and capability is necessary alongside individual Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 30 of 39
practice improvements. However, the effect of the cultural competence of mental health professionals on service user experience and recovery has not been adequately investigated. 5 Other versions of this guideline 5.1 Full guideline The full guideline, 'Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care (update)' contains details of the methods and evidence used to develop the guideline. It is published by the National Collaborating Centre for Mental Health, and is available from www.nccmh.org.uk, our website (www.nice.org.uk/cgxxxfullguideline) and the National Library for Health (www.library.nhs.uk). [Note: these details will apply to the published full guideline.] 5.2 Quick reference guide A quick reference guide for healthcare professionals is available from www.nice.org.uk/cgxxxquickrefguide For printed copies, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk (quote reference number N1XXX). [Note: these details will apply when the guideline is published.] 5.3 Understanding NICE guidance Information for patients and carers ( Understanding NICE guidance ) is available from www.nice.org.uk/cgxxxpublicinfo For printed copies, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk (quote reference number N1XXX). [Note: these details will apply when the guideline is published.] We encourage NHS and voluntary sector organisations to use text from this booklet in their own information about schizophrenia. Schizophrenia (update): NICE guideline DRAFT (September 2008) Page 31 of 39