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The content on this page is not current guidance and is only for the purposes of the consultation process.

2021 surveillance of psychosis and schizophrenia in children and young people: recognition and management

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Overview of 2021 surveillance methods

NICE's surveillance team checked whether recommendations in psychosis and schizophrenia in children and young people: recognition and management (NICE guideline CG155) remain up to date.

Intelligence gathering

Initial intelligence gathering (IIG) was used to gather new evidence relevant to all sections of the guideline, this comprised of:

  • Feedback from topic experts via a questionnaire.

  • A search for new or updated Cochrane reviews and national policy.

  • Consideration of evidence from previous surveillance.

  • Examining related NICE guidance and quality standards and NIHR signals.

  • A search for ongoing research.

  • Examining the NICE event tracker for relevant ongoing and published events.

  • Assessing the new evidence against current recommendations to determine whether or not to update sections of the guideline.

  • Consulting on the proposal with stakeholders, except if we propose to update and replace the whole guideline (this document).

For further details about the process and the possible update proposals that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.

Evidence considered in surveillance

IIG was used to gather new evidence relevant to all sections of the guideline. For most areas sufficient evidence was identified through IIG to enable us to make a proposal about the need to update guideline sections without the need for literature searches. Intelligence gathering included new evidence published or updated between 01 June 2016 and 31 October 2021. We included:

  • 10 relevant studies from a total of 25 identified by topic experts

  • 13 studies from trials that have now completed that were identified as ongoing during the previous surveillance review in 2016.

IIG suggested searches for more evidence about weight management interventions for children and young people using antipsychotics were warranted and we carried out focused literature searches in this area. We found 2 studies in a search for randomised controlled trials and systematic reviews published between 01 June 2016 and 31 October 2021.

From all sources, we considered 25 studies in total to be relevant to the guideline.

See the summary of evidence from surveillance for details of all evidence considered, and references.

Selecting relevant studies

Studies were considered for inclusion using criteria defined by the guideline review protocols. Evidence from populations of children and young people (less than 18 years) was prioritised for inclusion. Where this was not possible, studies that included people under and over 18 years, but with a mean age of under 25 are used, as per the guideline review protocols (full guideline p.163 and p. 219). The original guideline contains recommendations adapted from adult populations (p.79 and p.101 of CG155 full guideline). Where we have included studies with data exclusively from adults in the evidence summary is clearly stated.

Ongoing research

We checked for relevant ongoing research; of the ongoing studies identified, 3 studies were assessed as having the potential to change recommendations. Therefore, we plan to regularly check whether these studies have published results and evaluate the impact of the results on current recommendations as quickly as possible. These studies are:

Intelligence gathered during surveillance

Views of topic experts

We considered the views of topic experts who were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their specialty. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to the guideline.

We received 6 questionnaire responses from topic experts, including: a general practitioner with a special interest in children and young people's health and mental health commissioning in primary care; an academic with a special interest in psychological interventions and schizophrenia spectrum disorders; a consultant psychiatrist and associate medical director; a professor of child and adolescent psychiatry; an academic and health economist with a special interest in children and young people's mental health; and a consultant mental health pharmacist.

Four topic experts thought guideline recommendations reflected current practice; 3 highlighted that ensuring the currency of recommendations about suspected psychosis remained up to date was a high priority. One topic expert noted that in some circumstances antipsychotics can reduce symptom severity in some children at high risk of transition when psychological therapies have failed. Topic experts raised issues about principles of practice including strengthening recommendations about supporting patient decision making to better enable shared decision making. Topic experts also raised several equalities issues which are discussed below in the equalities section. Topic experts also highlighted new evidence about individual CBT versus group CBT; brief versus longer duration CBT; and the antipsychotics lurasidone, quetiapine and aripiprazole.

Views of stakeholders

Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance proposal was to not update the guideline, we are consulting with stakeholders.

Implementation of the guideline

We identified the Royal College of Psychiatrists and the Healthcare Quality Improvement partnership's National Clinical Audit of Psychosis (NCAP) which includes data about children and young people. It concludes that there is 'pervasive evidence of wide variations and inequities in provision…and wait times, early intervention programmes (EIP), in provision for children and young people under 18 and…at-risk mental state service provision across England….There is also wide variation in offer, take-up and refusal rates of NICE interventions across EIP teams nationally.'

We did not identify any evidence that CG155's recommendations are contributing to this implementation issue and the NCAP notes (p.56): 'more needs to be done to ensure equitable…provision of evidence-based EIP care across England in line with NICE quality standards.' NHS England and NICE have produced guidance called Implementing the Early Intervention in Psychosis Access and Waiting Time Standard which is based on recommendations and metrics in the NICE guidelines and quality standards about psychosis and schizophrenia for children (CG155 and QS102) and adults (CG178, and QS80).

Equalities

One topic expert commented that there is stigma attached to the recognition of serious mental illness and that most screening tools are devised for the 'western' British patient. CG155-1.1.18 recommends people working with those with schizophrenia should take into account the stigma associated with schizophrenia and CG155-1.1.20 recommends that health and social care professionals should be competent to assess people from diverse backgrounds.

Another topic expert commented there are inequalities around deprivation, and stigma about recognising mental health problems in some groups of people leading to delays in engaging with talking therapies. The guideline equality impact assessment (EIA) notes: 'The scope identified that children, young people and adults with schizophrenia from black and minority ethnic (BAME) backgrounds tend to present late to services.' Recommendations 1.1.18 to 1.1.23 encourage services to work collaboratively with BAME and other minority groups, to ensure culturally appropriate psychosocial interventions. CG155-1.1.18 encourages practitioners working with children with psychosis to respect their socioeconomic status.

Overall proposal

After considering all evidence and other intelligence and the impact on current recommendations, we decided that no update is necessary at this time. We identified 4 areas described in the surveillance proposal section where evidence and practice are developing at a rate that suggests recommendations may need amending in the near future. We will monitor these areas for new evidence to assess its impact on recommendations as it publishes.