Psychosis and schizophrenia in adults: prevention and management

Healthcare professionals working with people with psychosis or 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 psychosis or 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 psychosis or schizophrenia

• conflict management and conflict resolution. [2009]

People with psychosis or schizophrenia, especially those taking antipsychotics, should be offered a combined healthy eating and physical activity programme by their mental healthcare provider.

Our 2019 review of the STEPWISE trial did not change this recommendation. [2019]

If a person has rapid or excessive weight gain, abnormal lipid levels or problems with blood glucose management, offer interventions in line with relevant NICE guidance (see the NICE guidelines on obesity, cardiovascular disease: risk assessment and reduction, including lipid modification and preventing type 2 diabetes). [2014]

Offer people with psychosis or schizophrenia who smoke help to stop smoking, even if previous attempts have been unsuccessful. Be aware of the potential significant impact of reducing cigarette smoking on the metabolism of other drugs, particularly clozapine and olanzapine. [2014]

Follow the recommendations on stop-smoking interventions in the NICE guideline on tobacco, with the following exceptions:

• do not offer bupropion to people with psychosis to help them stop smoking

• warn people with psychosis or schizophrenia who are taking bupropion or varenicline that there is an increased risk of adverse neuropsychiatric symptoms and monitor them regularly, particularly in the first 2 to 3 weeks. [2014]

Routinely monitor weight, and cardiovascular and metabolic indicators of morbidity in people with psychosis and schizophrenia. These should be audited in the annual team report. [2014]

Trusts should ensure compliance with quality standards on the monitoring and treatment of cardiovascular and metabolic disease in people with psychosis or schizophrenia through board-level performance indicators. [2014]

All teams providing services for people with psychosis or schizophrenia should offer a comprehensive range of interventions consistent with this guideline. [2009]

Give carers written and verbal information in an accessible format about:

• diagnosis and management of psychosis and schizophrenia

• positive outcomes and recovery

• types of support for carers

• role of teams and services

• getting help in a crisis. [2014]

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. [2014]

Review regularly how information is shared, especially if there are communication and collaboration difficulties between the service user and carer. [2014]

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. [2014]

Consider peer support for people with psychosis or schizophrenia to help improve service user experience and quality of life. Peer support should be delivered by a trained peer support worker who has recovered from psychosis or schizophrenia and remains stable. Peer support workers should receive support from their whole team, and support and mentorship from experienced peer workers. [2014]

Consider a manualised self-management programme delivered face-to-face with service users, as part of the treatment and management of psychosis or schizophrenia. [2014]

Peer support and self-management programmes should include information and advice about:

• psychosis and schizophrenia

• effective use of medication

• identifying and managing symptoms

• accessing mental health and other support services

• coping with stress and other problems

• what to do in a crisis

• building a social support network

• preventing relapse and setting personal recovery goals. [2014]

If a person is distressed, has a decline in social functioning and has:

• transient or attenuated psychotic symptoms or

• other experiences or behaviour suggestive of possible psychosis or

• a first-degree relative with psychosis or schizophrenia
  
  refer them for assessment without delay to a specialist mental health service or an early intervention in psychosis service because they may be at increased risk of developing psychosis. [2014]

A consultant psychiatrist or a trained specialist with experience in at-risk mental states should carry out the assessment. [2014]

If a person is considered to be at increased risk of developing psychosis (as described in recommendation 1.2.1.1):

• offer individual cognitive behavioural therapy (CBT) with or without family intervention (delivered as described in the section on how to deliver psychological interventions) and

• offer interventions recommended in NICE guidance for people with any of the anxiety disorders, depression, emerging personality disorder or substance misuse. [2014]

Do not offer antipsychotic medication:

• to people considered to be at increased risk of developing psychosis (as described in recommendation 1.2.1.1) or

• with the aim of decreasing the risk of or preventing psychosis. [2014]

If, after treatment (as described in recommendation 1.2.3.1), the person continues to have symptoms, impaired functioning or is distressed, but a clear diagnosis of psychosis cannot be made, monitor the person regularly for changes in symptoms and functioning for up to 3 years using a structured and validated assessment tool. Determine the frequency and duration of monitoring by the:

• severity and frequency of symptoms

• level of impairment and/or distress and

• degree of family disruption or concern. [2014]

If a person asks to be discharged from the service, offer follow-up appointments and the option to self-refer in the future. Ask the person's GP to continue monitoring changes in their mental state. [2014]

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. [2014]

People presenting to early intervention in psychosis services should be assessed without delay. If the service cannot provide urgent intervention for people in a crisis, refer the person to a crisis resolution and home treatment team (with support from early intervention in psychosis services). Referral may be from primary or secondary care (including other community services) or a self- or carer-referral. [2014]

Early intervention in psychosis services should aim to provide a full range of pharmacological, psychological, social, occupational and educational interventions for people with psychosis, consistent with this guideline. [2014]

Consider extending the availability of early intervention in psychosis services beyond 3 years if the person has not made a stable recovery from psychosis or schizophrenia. [2014]

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. [2009, amended 2014]

Carry out a comprehensive multidisciplinary assessment of people with psychotic symptoms in secondary care. This should include assessment by a psychiatrist, a psychologist or a professional with expertise in the psychological treatment of people with psychosis or schizophrenia. The assessment should address the following domains:

• psychiatric (mental health problems, risk of harm to self or others, alcohol consumption and prescribed and non-prescribed drug history)

• medical, including medical history and full physical examination to identify physical illness (including organic brain disorders) and prescribed drug treatments that may result in psychosis

• physical health and wellbeing (including weight, smoking, nutrition, physical activity and sexual health)

• psychological and psychosocial, including social networks, relationships and history of trauma

• developmental (social, cognitive and motor development and skills, including coexisting neurodevelopmental conditions)

• social (accommodation, culture and ethnicity, leisure activities and recreation, and responsibilities for children or as a carer)

• occupational and educational (attendance at college, educational attainment, employment and activities of daily living)

• quality of life

• economic status. [2009, amended 2014]

Structural neuroimaging techniques are not recommended in NICE technology appraisal guidance as a routine part of initial investigations for managing first-episode psychosis. For full details, see the guidance on structural neuroimaging in first-episode psychosis (TA136, 2008).

Assess for post-traumatic stress disorder and other reactions to trauma because people with psychosis or schizophrenia are likely to have experienced previous 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 guideline on post-traumatic stress disorder. [2014]

Routinely monitor for other coexisting conditions, including depression, anxiety and substance misuse particularly in the early phases of treatment. [2009, amended 2014]

Write a care plan in collaboration with the service user as soon as possible following assessment, based on a psychiatric and psychological formulation, and a full assessment of their physical health. Send a copy of the care plan to the primary healthcare professional who made the referral and the service user. [2009, amended 2014]

For people who are unable to attend mainstream education, training or work, facilitate alternative educational or occupational activities according to their individual needs and capacity to engage with such activities, with an ultimate goal of returning to mainstream education, training or employment. [2014]

For people with first episode psychosis offer:

• oral antipsychotic medication (see the section on how to use antipsychotic medication) in conjunction with

• psychological interventions (family intervention and individual CBT, delivered as described in the section on how to deliver psychological interventions). [2014]

Advise people who want to try psychological interventions alone that these are more effective when delivered in conjunction with antipsychotic medication. If the person still wants to try psychological interventions alone:

• offer family intervention and CBT

• agree a time (1 month or less) to review treatment options, including introducing antipsychotic medication

• continue to monitor symptoms, distress, impairment and level of functioning (including education, training and employment) regularly. [2014]

If the person's symptoms and behaviour suggest an affective psychosis or disorder, including bipolar disorder and unipolar psychotic depression, follow the recommendations in the NICE guidelines on bipolar disorder or depression. [2014]

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). [2009, amended 2014]

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 or glycosylated haemoglobin (HbA1c)

• blood lipid profile and prolactin levels

• assessment of any movement disorders

• assessment of nutritional status, diet and level of physical activity. [2014, amended 2021]

Before starting antipsychotic medication, offer the person with psychosis or schizophrenia an electrocardiogram (ECG) if:

• specified in the summary of product characteristics (SPC)

• a physical examination has identified specific cardiovascular risk (such as diagnosis of high blood pressure)

• there is a personal history of cardiovascular disease or

• the service user is being admitted as an inpatient. [2009]

Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial. Include the following:

• Discuss and record the side effects that the person is most willing to tolerate.

• Record the indications and expected benefits and risks of oral antipsychotic medication, and the expected time for a change in symptoms and appearance of side effects.

• At the start of treatment give a dose at the lower end of the licensed range and slowly titrate upwards within the dose range given in the British national formulary (BNF) or SPC.

• Justify and record reasons for dosages outside the range given in the BNF or SPC.

• Record the rationale for continuing, changing or stopping medication, and the effects of such changes.

• Carry out a trial of the medication at optimum dosage for 4 to 6 weeks. [2009, amended 2014]

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 (for example, the overlap between akathisia and agitation or anxiety) and impact on functioning

• the emergence of movement disorders

• weight, weekly for the first 6 weeks, then at 12 weeks, at 1 year and then annually (plotted on a chart)

• waist circumference annually (plotted on a chart)

• pulse and blood pressure at 12 weeks, at 1 year and then annually

• fasting blood glucose or HbA1c, and blood lipid levels at 12 weeks, at 1 year and then annually

• adherence

• overall physical health. [2014, amended 2021]

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. [2014]

Discuss any non-prescribed therapies the service user wishes to use (including complementary therapies) with the service user, and carer if appropriate. Discuss the safety and efficacy of the therapies, and possible interference with the therapeutic effects of prescribed medication and psychological treatments. [2009]

Discuss the use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs with the service user, and carer if appropriate. Discuss their possible interference with the therapeutic effects of prescribed medication and psychological treatments. [2009]

'As required' (p.r.n.) prescriptions of antipsychotic medication should be made as described in recommendation 1.3.6.3. Review clinical indications, frequency of administration, therapeutic benefits and side effects each week or as appropriate. Check whether 'p.r.n.' prescriptions have led to a dosage above the maximum specified in the BNF or SPC. [2009]

Do not use a loading dose of antipsychotic medication (often referred to as 'rapid neuroleptisation'). [2009]

Do not initiate regular combined antipsychotic medication, except for short periods (for example, when changing medication). [2009]

If prescribing chlorpromazine, warn of its potential to cause skin photosensitivity. Advise using sunscreen if necessary. [2009]

CBT should be delivered on a one-to-one basis over at least 16 planned sessions and:

• follow a treatment manual (with evidence of efficacy from a clinical trial, if possible) so that:

  • people can establish links between their thoughts, feelings or actions and their current or past symptoms, and/or functioning

  • the re-evaluation of people's perceptions, beliefs or reasoning relates to the target symptoms

• also include at least one of the following components:

  • people monitoring their own thoughts, feelings or behaviours with respect to their symptoms or recurrence of symptoms

  • promoting alternative ways of coping with the target symptom

  • reducing distress

  • improving functioning. [2009]

Family intervention should:

• include the person with psychosis or schizophrenia if practical

• be carried out for between 3 months and 1 year

• include at least 10 planned sessions

• take account of the whole family's preference for either single-family intervention or multi-family group intervention

• take account of the relationship between the main carer and the person with psychosis or schizophrenia

• have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work. [2009]

When providing psychological interventions, routinely and systematically monitor a range of outcomes across relevant areas, including service user satisfaction and, if appropriate, carer satisfaction. [2009]

Healthcare teams working with people with psychosis or 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. [2009]

Healthcare professionals providing psychological interventions should:

• have an appropriate level of competence in delivering the intervention to people with psychosis or schizophrenia

• be regularly supervised during psychological therapy by a competent therapist and supervisor. [2009]

Trusts should provide access to training that equips healthcare professionals with the competencies required to deliver the psychological therapy interventions recommended in this guideline. [2009]

Offer crisis resolution and home treatment teams as a first-line service to support people with psychosis or schizophrenia during an acute episode in the community if the severity of the episode, or the level of risk to self or others, exceeds the capacity of the early intervention in psychosis services or other community teams to effectively manage it. [2014]

Crisis resolution and home treatment teams should be the single point of entry to all other acute services in the community and in hospitals. [2014]

Consider acute community treatment within crisis resolution and home treatment teams before admission to an inpatient unit and as a means to enable timely discharge from inpatient units. Crisis houses or acute day facilities may be considered in addition to crisis resolution and home treatment teams depending on the person's preference and need. [2014]

If a person with psychosis or schizophrenia needs hospital care, think about the impact on the person, their carers and other family members, especially if the inpatient unit is a long way from where they live. If hospital admission is unavoidable, ensure that the setting is suitable for the person's age, gender and level of vulnerability, support their carers and follow the recommendations in the NICE guideline on service user experience in adult mental health. [2014]

For people with an acute exacerbation or recurrence of psychosis or schizophrenia, offer:

• oral antipsychotic medication (see the section on how to use antipsychotic medication) in conjunction with

• psychological interventions (family intervention and individual CBT, delivered as described in the section on how to deliver psychological interventions). [2014]

For people with an acute exacerbation or recurrence of psychosis or schizophrenia, offer oral antipsychotic medication or review existing medication. The choice of drug should be influenced by the same criteria recommended for starting treatment (see the section on how to use antipsychotic medication). Take into account the clinical response and side effects of the service user's current and previous medication. [2009, amended 2014]

Offer CBT to all people with psychosis or schizophrenia (delivered as described in recommendation 1.3.7.1). This can be started either during the acute phase or later, including in inpatient settings. [2009]

Offer family intervention to all families of people with psychosis or schizophrenia who live with or are in close contact with the service user (delivered as described in recommendation 1.3.7.2). This can be started either during the acute phase or later, including in inpatient settings. [2009]

Consider offering arts therapies to all people with psychosis or schizophrenia, particularly for the alleviation of negative symptoms. This can be started either during the acute phase or later, including in inpatient settings. [2009]

Arts therapies should be provided by a Health and Care Professions Council registered arts therapist with previous experience of working with people with psychosis or schizophrenia. The intervention should be provided in groups unless difficulties with acceptability and access and engagement indicate otherwise. Arts therapies should combine psychotherapeutic techniques with activity aimed at promoting creative expression, which is often unstructured and led by the service user. Aims of arts therapies should include:

• enabling people with psychosis or schizophrenia to experience themselves differently and to develop new ways of relating to others

• helping people to express themselves and to organise their experience into a satisfying aesthetic form

• helping people to accept and understand feelings that may have emerged during the creative process (including, in some cases, how they came to have these feelings) at a pace suited to the person. [2009]

When psychological treatments, including arts therapies, are started in the acute phase (including in inpatient settings), the full course should be continued after discharge without unnecessary interruption. [2009]

Do not routinely offer counselling and supportive psychotherapy (as specific interventions) to people with psychosis or schizophrenia. However, take service user preferences into account, especially if other more efficacious psychological treatments, such as CBT, family intervention and arts therapies, are not available locally. [2009]

Do not offer adherence therapy (as a specific intervention) to people with psychosis or schizophrenia. [2009]

Do not routinely offer social skills training (as a specific intervention) to people with psychosis or schizophrenia. [2009]

Occasionally people with psychosis or schizophrenia pose an immediate risk to themselves or others during an acute episode and may need rapid tranquillisation. The management of immediate risk should follow the NICE guideline on violence and aggression, and the NICE guideline on self-harm. [2009]

After rapid tranquillisation, offer the person with psychosis or schizophrenia the opportunity to discuss their experiences. Provide them with a clear explanation of the decision to use urgent sedation. Record this in their notes. [2009]

After each acute episode, encourage people with psychosis or schizophrenia to write an account of their illness in their notes. [2009]

Healthcare professionals may consider using psychoanalytic and psychodynamic principles to help them understand the experiences of people with psychosis or schizophrenia and their interpersonal relationships. [2009]

Inform the service user that there is a high risk of relapse if they stop medication in the next 1 to 2 years. [2009]

If withdrawing antipsychotic medication, undertake gradually and monitor regularly for signs and symptoms of relapse. [2009]

After withdrawal from antipsychotic medication, continue monitoring for signs and symptoms of relapse for at least 2 years. [2009]

Continue treatment and care in early intervention in psychosis services or refer the person to a specialist integrated community-based team. This team should:

• offer the full range of psychological, pharmacological, social and occupational interventions recommended in this guideline

• be competent to provide all interventions offered

• place emphasis on engagement rather than risk management. [2014]

Consider intensive case management for people with psychosis or schizophrenia who are likely to disengage from treatment or services. [2014]

Review antipsychotic medication annually, including observed benefits and any side effects. [2014]

Offer people with psychosis or schizophrenia whose symptoms have responded effectively to treatment and remain stable the option to return to primary care for further management. If a service user wishes to do this, record this in their notes and coordinate transfer of responsibilities through the care programme approach. [2009]

Offer CBT to assist in promoting recovery in people with persisting positive and negative symptoms and for people in remission. Deliver CBT as described in recommendation 1.3.7.1. [2009]

Offer family intervention to families of people with psychosis or schizophrenia who live with or are in close contact with the service user. Deliver family intervention as described in recommendation 1.3.7.2. [2009]

Family intervention may be particularly useful for families of people with psychosis or schizophrenia who have:

• recently relapsed or are at risk of relapse

• persisting symptoms. [2009]

Consider offering arts therapies to assist in promoting recovery, particularly in people with negative symptoms. [2009]

The choice of drug should be influenced by the same criteria recommended for starting treatment (see the section on how to use antipsychotic medication). [2009]

Do not use targeted, intermittent dosage maintenance strategies (use of antipsychotic medication only during periods of incipient relapse or symptom exacerbation) routinely. However, consider them for people with psychosis or schizophrenia who are unwilling to accept a continuous maintenance regimen or if there is another contraindication to maintenance therapy, such as side-effect sensitivity. [2009]

Consider offering depot/long-acting injectable antipsychotic medication to people with psychosis or schizophrenia:

• who would prefer such treatment after an acute episode

• where avoiding covert non-adherence (either intentional or unintentional) to antipsychotic medication is a clinical priority within the treatment plan. [2009]

When initiating depot/long-acting injectable antipsychotic medication:

• take into account the service user's preferences and attitudes towards the mode of administration (regular intramuscular injections) and organisational procedures (for example, home visits and location of clinics)

• take into account the same criteria recommended for the use of oral antipsychotic medication (see the section on how to use antipsychotic medication), particularly in relation to the risks and benefits of the drug regimen

• prescribe according to the procedures set out in the BNF or SPC. [2009, amended 2022]

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. [2009]

Offer clozapine to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least 2 different antipsychotic drugs. At least 1 of the drugs should be a non-clozapine second-generation antipsychotic. [2009]

For people with schizophrenia whose illness has not responded adequately to clozapine at an optimised dose, healthcare professionals should consider recommendation 1.5.7.1 (including measuring therapeutic drug levels) before adding a second antipsychotic to augment treatment with clozapine. An adequate trial of such an augmentation may need to be up to 8 to 10 weeks. Choose a drug that does not compound the common side effects of clozapine. [2009]

Electroconvulsive therapy (ECT) is recommended in NICE technology appraisal guidance as an option for rapid short-term treatment of severe symptoms of catatonia when other treatments have not worked or the condition is life-threatening. It is not recommended for general use in managing schizophrenia. For full details, see the guidance on the use of electroconvulsive therapy (TA59, 2009).

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. [2014]

Routinely record the daytime activities of people with psychosis or schizophrenia in their care plans, including occupational outcomes. [2009]