Psychosis and schizophrenia in adults: prevention and management

Assessing the evidence

We found 234 studies through surveillance of this guideline.

This included evidence which supports the current recommendations on team and service-level interventions; carers' experience; prevention of psychosis; behavioural interventions to promote physical health and vocational rehabilitation.

There was a large volume of newly identified evidence, especially in the areas of psychological and pharmacological interventions. This evidence was mixed with some studies supporting current recommendations and other evidence being inconsistent with current recommendations. However, due to the large range of specific intervention types and outcomes reported, there was only a small volume of corroborating evidence in each area. Where there was evidence which reported on similar interventions, the outcomes were often contradictory and/or from studies including small sample sizes. Overall, it is due to the lack of consistency across the volume of the evidence that the decision not to update NICE guideline CG178 has been taken.

We asked topic experts whether this evidence would affect current recommendations. Generally, the topic experts agreed that the new evidence was not sufficient to impact the current recommendations.

Through consultation with topic experts, it was highlighted that with the introduction of new long acting injectable antipsychotics, it is no longer appropriate to only recommend that an initial small test dose of such medication is used. Some newer long acting injectables require stabilisation on the equivalent oral formulation prior to initiation, making the use of an additional small test dose unnecessary, according to their licence. Therefore, it was concluded that an amendment would be made to recommendation 1.5.6.1 to remove 'initially use a small test dose as set out in the BNF or SPC' and replace this bullet point with 'prescribe according to the procedures set out in the BNF or SPC'.

We found evidence on questions which were not covered during guideline development on the benefits and harms of non-antipsychotic pharmacological interventions; intermittent drug techniques; pharmacological interventions for the promotion of physical health; treatment with transcranial stimulation; the effect of changes to the environment; acupuncture as treatment and the effect of augmentation of antipsychotics with non-antipsychotics.

This evidence was considered to be insufficient to prompt the addition of new recommendations in these areas at this time. This was in the main due to a small volume of evidence being identified in each area. Where larger volumes of evidence were identified, such as evidence for the augmentation of antipsychotics with non-antipsychotics, a lack of consistency in the specific interventions and outcomes reported resulted in little corroborating evidence being available.

We did not find any evidence related to access and engagement.

For any evidence relating to published or ongoing NICE technology appraisals, the guideline surveillance review deferred to the technology appraisal decision as review of technology appraisals is outside the remit of the surveillance process. This included guidance on the use of electroconvulsive therapy.

Equalities

It was raised by topic experts that inequalities persist in the access and experience of services, however, it was recognised that these issues are addressed in the guideline. It was also highlighted that a gap in the level of esteem between physical and mental health still exists, however, this is considered to be an implementation issue beyond the remit of the guideline. Physical health risk assessment tools for people with severe mental health conditions which consider deprivation and ethnicity were highlighted, however these tools have been considered during the 2017 surveillance review of NICE guideline CG181. Issues regarding bias in diagnosis with regard to culture, race and gender were raised, however this falls outside the remit of this guideline. No other equality issues were identified.

Overall decision

After considering all the evidence and views of topic experts and stakeholders, we decided that no update is necessary for this guideline.

See how we made the decision for further information.