Psychosis and schizophrenia in adults: prevention and management

Evidence

We found 223 studies in a search for systematic reviews and randomised controlled trials published between 1 November 2008 and 13 March 2017. We also included 6 relevant studies identified by members of the guideline committee who originally worked on this guideline. Five further studies were identified through post-publication communications.

From all sources, we considered 234 studies to be relevant to the guideline.

We also checked for relevant ongoing research, which will be evaluated again at the next surveillance review of the guideline.

See appendix A: summary of evidence from surveillance for details of all evidence considered and references.

Views of topic experts

We considered the views of topic experts, including those who helped to develop the guideline and other correspondence we have received since the publication of the guideline.

Views of stakeholders

Stakeholders commented on the decision not to update the guideline. Overall, 9 stakeholders commented. See appendix B for stakeholders' comments and our responses.

Five stakeholders agreed with the decision not to update the guideline, while 4 stakeholders disagreed with this decision. A number of issues were raised during consultation relevant to areas across the guideline.

Two stakeholders discussed the recommendations regarding the use of long acting injectable antipsychotics. It has been acknowledged that there have been a number of new long acting injectable formulations licenced since the last update of the pharmacological intervention section of this guideline, which have not specifically been considered. However, the body of evidence in this area is not likely to be sufficient to recommend a specific antipsychotic treatment over another. Therefore, it is considered that the current recommendation, which suggests considering the use of long acting injectable antipsychotics for the promotion of recovery in certain people, is unlikely to be impacted by this evidence.

One stakeholder raised that promising research has been conducted on an open-dialogue approach to treatment of psychosis and that new research is currently being conducted in this area. The limited evidence available for this intervention means that impact on the guideline at this time is unlikely. However, the ongoing trial highlighted will be monitored in order to consider the results at the next surveillance review, alongside other evidence in this area.

One stakeholder highlighted that consideration should be made to updating NICE guideline CG178 to include a recommendation on the risks associated with olanzapine and weight gain. Evidence was identified during the surveillance review that olanzapine causes weight gain, in support of this view. However, recommendations in NICE guideline CG178 describe that the choice of antipsychotic medication should be made between the service user and the healthcare professional together, and include a discussion of the side effects, including metabolic side effects. It is considered that this recommendation is sufficient to suggest that the metabolic side effects of olanzapine should be considered as part of the choice to prescribe it. Therefore, this evidence is not likely to have an impact on the current recommendations.

Two stakeholders commented on areas which are outside the current scope of the guideline. It was raised that a test for vitamin B12 deficiency should be included as part of the diagnosis procedure for schizophrenia. The remit provided to NICE for the development of CG178 specifically considers the prevention and management of psychosis and schizophrenia and therefore, the guideline does not consider diagnosis. It was also raised that the current recommendations do not cover any socio-cultural interventions for the treatment of schizophrenia. However, no evidence in this area was identified and therefore it is not likely there would be an impact on the guideline at this time.

Three stakeholders commented on equality issues. It was raised that diagnosis can be biased with respect to gender, race and culture, however, diagnosis falls outside the remit for NICE guideline CG178. It was also raised that measuring cardiovascular disease risk should be performed using a tool which takes account of deprivation and ethnicity. Such a tool has been considered during the 2017 surveillance review of NICE guideline CG181 and therefore will not be included in this guideline. The gap in the parity of esteem regarding mental and physical health was highlighted, alongside the low uptake of services for people with schizophrenia and psychosis. It was suggested that NICE could strengthen recommendations for effective treatments focusing on medicines optimisation, and promote further shared and informed decision making to address this issue. NICE bases its recommendations on the best available evidence and the strength of the recommendations reflects the strength of this evidence. NICE views mental and physical health with equal importance, and issues with parity of esteem in this area are due to implementation of the guideline. No new evidence was identified during this surveillance review to prompt an update in this area, and the current recommendations on promoting shared decision making were supported. As well as this, other NICE guidelines have been published which focus on promoting these areas across both physical and mental health services, such as medicines optimisation, service user experience in adult mental health and patient experience in adult NHS services.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

NICE Surveillance programme project team

Kay Nolan
Associate Director

Jeremy Wight
Consultant Clinical Adviser

Emma McFarlane
Technical Adviser

Albany Meikle
Technical Analyst

The NICE project team would like to thank the topic experts who participated in the surveillance process.

ISBN: 978-1-4731-1383-1