Schizophrenia

Implementing NICE guidance

2009

NICE clinical guideline 82

Updated guidance

This guideline updates and replaces:

‘Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care’ (NICE clinical guideline 1 [2002])

‘Guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia’ (NICE technology appraisal guidance 43 [2002])

What this presentation covers

Background

Scope

Key priorities for implementation

Costs and savings

Discussion

Find out more

Background (1)

• Schizophrenia is a major psychiatric disorder or cluster of disorders, characterised by psychotic symptoms.

• About 1% of the population will develop schizophrenia.

• The first symptoms tend to start in young adulthood.

• A diagnosis of schizophrenia is associated with stigma, fear and limited public understanding.

• There is a higher risk of suicide.

Background (2)

• Recent emphasis on early detection and intervention services.

• After an acute episode there are often problems such as: - social exclusion - fewer opportunities to return to work or study - problems forming new relationships

• Most people recover, although some have persisting difficulties or remain vulnerable to future episodes.

• Carers, relatives and friends are important during assessment and delivery of effective treatments.

Scope

Treatment and management of schizophrenia and related disorders.

Adults with an established diagnosis (with onset before age 60).

Does not address the specific treatment of people under 18, except those receiving treatment and support from early intervention services.

Healthcare professionals should ensure competence in:

•Working with people from diverse ethnic and cultural backgrounds:- Assessment skills- Using explanatory models of illness

• Addressing cultural and ethnic differences:- In treatment expectations and adherence- In beliefs regarding biological, social and family influences

on the causes of abnormal mental states

Access and engagement (1)

Healthcare professionals should ensure competence in:

• Explaining the causes of schizophrenia and treatment options

• Negotiating skills for working with families of people with schizophrenia

• Conflict management and conflict resolution

Access and engagement (2)

• Mental health services should work in partnership with local stakeholders (including those representing BME groups) to enable access to local employment and educational opportunities.

• Work with agencies, such as Jobcentre Plus, disability employment advisers and non-statutory providers should be sensitive to the person’s needs and skill level.

Access and engagement (3)

Identify a lead healthcare professional to monitor and review:

• access to and engagement with psychological interventions

• decisions to offer psychological interventions

• equality of access across different ethnic groups.

 

Access and engagement (4)

GPs and other primary healthcare professionals should:

- Monitor physical health at least once a year

- Focus on cardiovascular disease risk monitoring

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

- Put in the secondary care notes

 

Primary care and physical health

• Offer cognitive behavioural therapy (CBT) to all people with schizophrenia.

• Offer family intervention to all families who live with or are in close contact with the service user.

• Both can be started either during the acute phase or later, including in inpatient settings.

Psychological interventions

•For people with newly diagnosed schizophrenia offer oral antipsychotic medication

• Provide information and discuss the benefits and side-effect profile of each drug offered with the service user

• The choice of particular antipsychotic drug should be made by the service user and healthcare professional together, considering:

– the relative potential to cause extrapyramidal,

metabolic and other side effects

– the views of the carer (if the service user agrees).

Pharmacological interventions

Do not initiate regular combined antipsychotic medication except for short periods, for example, when changing medication.

Pharmacological interventions

• Review the diagnosis.

• Check adherence to antipsychotic medication, and the dose and duration.

• Review engagement with and use of psychological treatments.

• If family intervention undertaken suggest CBT.

• If CBT undertaken suggest family intervention for people in close contact with their families.

• Consider other causes of non-response.

Interventions for people with schizophrenia whose illness has not

responded adequately to treatment

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.

Interventions for people with schizophrenia whose illness has not

responded adequately to treatment

Consider offering arts therapies to all people with schizophrenia, particularly for the alleviation of negative symptoms. This can be started either during the acute phase or later, including in inpatient settings.

Arts therapy

Costs and savings

The guideline on schizophrenia is unlikely to result in a significant change in resource use in the NHS. However, recommendations in the following areas may result in additional costs/savings depending on local circumstances:

•race, culture and ethnicity

•pharmacological interventions

•psychological and psychosocial interventions.

Discussion• How do current staff competencies match those described in the

recommendations? How are cultural aspects addressed?

• How well do current links with stakeholder organisations support employment and educational links?

• How can the quality and number of annual health checks carried out on people with schizophrenia be improved?

• How do we measure access to, uptake of and outcomes for CBT and family-based interventions?

• How well does current prescribing practice match the new recommendations?

Find out more

Visit www.nice.org.uk/CG82 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing template and costing statement•audit support•guide to resources