Rehabilitation for adults with complex psychosis

Organising the rehabilitation pathway (recommendations 1.3.1 to 1.3.7)

The evidence supported each locality having a defined rehabilitation pathway with access to a range of service components in different settings to provide the appropriate treatment and support that people need. The committee agreed that different levels of support, and usually both inpatient and community services, are needed to support people's full recovery. They noted it was important that these services were provided as locally as possible. The committee agreed that this would:

In the committee's view, the commissioning of rehabilitation services needs to take into account the mental health services that are already available and how services will work together to meet the population's needs. Currently, there is a lack of integration between services and a lack of clarity about who should be funding and commissioning them. The committee considered it essential that health and social care commissioners work together to commission services, to address people's overlapping health and social care needs. They acknowledged that to provide a full range of inpatient rehabilitation services, independent sector providers as well as those in the NHS may need to be involved.

Local authorities are required under the Health and Social Care Act (2012) to perform a joint strategic needs assessment to identify the health and social care needs of their population. The committee identified key groups that need to be included through a complementary local rehabilitation service needs assessment – people who are most likely to need local rehabilitation services, and those who might need highly specialist or longer-term rehabilitation services – to ensure services can be planned to help meet their needs.

The committee was aware that commissioning highly specialist services at the local level might not be feasible because there may not be enough people with very complex needs to warrant a dedicated unit. Therefore, they recommended local areas could work together to commission these services at a regional level.

The committee highlighted the need for flexibility within the rehabilitation pathway. People with complex psychosis do not always have a linear progression to recovery from needing high support to independence; some people may need continued support in the long term and some people may need more than 1 period of rehabilitation. It should be possible to accommodate this in the pathway.

The lead commissioner (recommendations 1.3.8 and 1.3.9)

Qualitative evidence showed that integration and collaborative working across teams and services was facilitated by a lead champion. This model of a lead commissioner is also recommended by NICE for people with learning disabilities and behaviour that challenges, who similarly have overlapping health and social care needs. Qualitative evidence, along with the experience of the committee, provided a number of attributes that would enable the lead commissioner to perform their role effectively.

Organising the rehabilitation pathway (recommendations 1.3.1 to 1.3.7)

These recommendations largely reflect current practice in terms of joint commissioning. However, greater emphasis on an integrated rehabilitation pathway will likely see fewer people being referred to out-of-area placements and discharged from inpatient rehabilitation to community rehabilitation settings at a faster rate.

Economic evidence from a wider NHS and Personal Social Perspective shows that there may be a large cost saving from faster discharge rates that are appropriate to a person's illness and reduce inappropriate out-of-area placements. However, there may be a high resource impact for local authorities who are responsible for commissioning the provision of housing for people discharged from inpatient units. To some degree, this resource impact felt by local authorities would be offset by faster transitions to supported housing and floating support.

Providing more local inpatient facilities could potentially increase capital costs for some commissioners in the short term if those facilities do not currently exist. In the longer term, this would involve replacing costs incurred out of area with those incurred locally, so the move to more locally available services is expected to be cost neutral over time. Overall, the health benefits of people spending more time in contact with community-based services, and less in inpatient facilities, would offset any initial additional resource impact.

The lead commissioner (recommendations 1.3.8 and 1.3.9)

An appropriately skilled lead commissioner would facilitate local authorities working together with health and social care commissioners, which is current practice in some areas.

Return to recommendations

Integrated rehabilitation pathway (recommendation 1.3.10)

The qualitative evidence identified barriers to integrating rehabilitation care pathways, which resonated with the committee's own experience. 'Siloes' of resources were discussed as a key barrier, and the committee noted that collaborations among services are hard to sustain unless they are underpinned by sufficient shared budgets. They also agreed that competitive funding among services is often not in the best interest of people in rehabilitation because it can discourage services from supporting a person to progress through the pathway. The committee agreed additional areas to highlight in the recommendation where the lead commissioner could help to address barriers to integration.

Transitions (recommendations 1.3.11 to 1.3.13)

The committee agreed that because people with complex psychosis have a fluctuating illness, they need to be able to move seamlessly between services in the pathway depending on their needs. Based on consensus, the committee recommended measures to achieve this.

There was some qualitative evidence that some service users come to services passively because it is simply where they are 'sent to' next. Being able to visit a service before a placement begins helps people to make their own decisions and to feel more at ease about making the transition.

One study showed benefit of an integrated system to support transitions. The integrated system was a team of health and social care practitioners and informal carers for each person who met weekly to coordinate care, were able to communicate through a shared IT environment, and were trained to collaborate. Because the evidence was limited to 1 randomised controlled trial and there was no detail about what aspects of the intervention were effective, the committee could only recommend exploring ways to improve the sharing of information and IT systems.

To find out more about whether an integrated system involving a multidisciplinary team might help improve transitions and people's progress through the rehabilitation pathway towards greater independence, the committee also made a recommendation for research on integrated care systems.

Multidisciplinary teams (recommendations 1.5.1 and 1.5.2)

There was some evidence to support providing community rehabilitation through a multidisciplinary team and this was in line with the committee's experience. The committee also considered multidisciplinary working to be effective in inpatient rehabilitation services, so they recommended it for both inpatient and community settings. They used their own experience to recommend some of the core roles that would need to be included in the team. They also recommended other health professionals the team should have access to in order to meet the mental and physical healthcare needs of people with complex psychosis during rehabilitation. Input from welfare rights specialists was also thought to be important because people with complex psychosis will be on welfare benefits and are likely to need advice on their income. Speech and language therapist input would be needed to deal with the additional communication needs that can be experienced by this group. Physiotherapists would be needed to help people with mobility issues to engage in more physical activity to mitigate the physical health impact of a more sedentary lifestyle.

Size of accommodation (recommendation 1.5.3)

The evidence suggested that for every additional bed in an inpatient rehabilitation unit, there was an associated small decline in people's quality of care (as rated by Quality Indicator for Rehabilitative Care [QuIRC] on living environment, therapeutic environment, promotion of self-management and autonomy and promotion of social integration). The committee agreed this finding was also relevant to supported accommodation. The committee could not specify the optimal size of inpatient units or supported accommodation because no absolute optimal size was indicated in the evidence, and units of varying size may be appropriate for different areas.

Service quality improvement (recommendations 1.5.4 and 1.5.5)

There was evidence that the quality of rehabilitative care (as measured using QuIRC for inpatient units and QuIRC‑SA for supported accommodation) was associated with better outcomes of rehabilitation, autonomy, experience of care and satisfaction for people using the service. This evidence came from inpatient units, community units and supported accommodation. The committee agreed that measuring the quality of rehabilitative care using currently available tools would help rehabilitation units to identify areas for improvement and ultimately lead to better rehabilitation services. They also recommended services consider joining a peer accreditation or quality improvement forum because rehabilitation services often exist in isolation, so it is important for them to share good practice with other practitioners.

Rehabilitation in the community (recommendations 1.5.6 to 1.5.8)

There was evidence that multidisciplinary community team management increased participation in activities of daily living. The committee used their experience to extrapolate from this to recommend how community mental health rehabilitation teams should provide care and work together to support people in community rehabilitation. However, they acknowledged that this team's remit may vary in different areas depending on how other community-based services are organised.

Supported accommodation (recommendation 1.5.9)

The committee used qualitative evidence to highlight features of supported accommodation that are valued by people, The committee discussed the importance of supporting people to have autonomy, including to make potentially risky decisions, while still maintaining reasonable safety and helping people to avoid exploitation. The committee believed that in the long term, these recommendations would allow service users to live more sustainably and independently in the community, with fewer stressors and mental health relapses that lead to hospitalisation.

Rehabilitation in inpatient settings (recommendations 1.5.10 and 1.5.11)

Evidence showed that rehabilitation units with an expected maximum length of stay were associated with better quality of care. The committee agreed that having an expected maximum length of stay could help prevent delays when people are ready to move on through the rehabilitation pathway. However, they also agreed this should not be treated as absolute; services need to be flexible and provide appropriate treatment and support tailored to each person's needs.

The committee noted that accepting a placement in inpatient rehabilitation could affect people's eligibility to receive particular benefits (for example housing benefit) and could affect people's existing tenancies with local authorities. The committee wanted providers to be aware of and advise people about these issues.

There was a lack of evidence about the characteristics of effective highly specialist or longer-term high-dependency inpatient services. People with particularly complex comorbid conditions whose care cannot be managed in less specialised settings often spend very long periods of time (sometimes many years) in highly specialist or longer-term inpatient rehabilitation services. The Care Quality Commission has raised concerns about quality of life for people in this group. It is important to understand the characteristics of services and service users that support successful progress through rehabilitation, so the committee made a recommendation for research on highly specialist and longer-term high-dependency rehabilitation units.

Out-of-area placements (recommendations 1.5.12 to 1.5.15)

Health economic modelling showed that providing rehabilitation locally was less costly than using out-of-area placements, which are often provided by the independent sector. Although no clinical outcomes were found in the accompanying systematic review, the model included data from the Care Quality Commission, which showed that people placed in out-of-area inpatient wards have a longer average stay on such wards than those placed in local wards. There is a large hypothetical overall cost saving from a wider NHS and Personal Social Services perspective which, in the model, is driven by a reduction in the rate of out-of-area placements and faster discharge rates to supported accommodation that enable more independent living.

The committee acknowledged that there were no relevant clinical outcomes or utility data to compute quality-adjusted life years, although it was their view that a person in supported accommodation would typically have improved activities of daily living. Reducing out-of-area placements would therefore lead to more people being appropriately discharged to supported accommodation, which would reduce costs and improve quality of life.

The committee was aware of evidence suggesting that for many people in out-of-area placements, it could be appropriate to offer rehabilitation in local inpatient units. Being in a local unit also makes it easier for people to maintain contact with their families, communities and local support networks or activities, such as peer support groups.

The committee shared anecdotal reports of people being in out-of-area placements for many years, without clinical oversight from the person's local area. To avoid this, they made recommendations with the aim of reducing out-of-area placements wherever possible, providing better support while people are in these placements and bringing them back to their local area as soon as possible. This included recommending time frames for reviewing out-of-area placements, which were based on committee consensus.

There was a lack of comparative evidence between services provided by the independent sector and the NHS. The committee acknowledged that the independent sector is an important provider of rehabilitation services; however, the services they provide are often a long way from where people live, and from the local area that funds their placement. Many independent units are locked, and lengths of stay are considerably longer (and therefore costlier) than in equivalent NHS services. There is little systematic and reliable evidence on the characteristics of users of these services or the effectiveness of these units, to establish if the longer stays are necessary. Given the potential for significant cost savings if the effectiveness in the 2 sectors were found to be the same, the committee made a recommendation for research on inpatient rehabilitation provided by the independent sector.

Recommendation 1.6.1

Qualitative evidence showed that service users value a recovery-orientated approach to their care. This means helping people to work towards their aspirations and make the most of their abilities, while giving them support and encouragement wherever needed. The evidence suggested several key areas including activities of daily living, hobbies and interests, and vocational goals, where service users believed that services could help them work towards recovery.

Supporting people to make decisions (recommendations 1.6.2 and 1.6.3)

Working collaboratively with people with complex psychosis to produce a care plan can be challenging because of diminished communication and mental capacity. Despite these challenges, planning care in collaboration with the service user is expected practice in UK mental health services. Guidance on mental capacity and communication needs is already provided in other NICE guidelines but the committee also agreed it was relevant to highlight the legal obligation to follow the NHS Accessible Information Standard when working with people in rehabilitation.

Universal staff competencies (recommendations 1.6.4 to 1.6.8)

The committee considered staff training in recovery orientation to be essential to deliver an effective rehabilitation service. There was qualitative evidence that staff sometimes lack optimism or are overly risk-averse about the prospect of rehabilitation for some people, which can negatively affect a person's recovery. To address this, the committee recommended ways to encourage positive attitude changes to help staff retain hope and optimism, while acknowledging that not everyone will achieve full independence.

The committee made the recommendation on supporting structured activities based on limited evidence combined with consensus. They saw structured group activities as a key aspect of rehabilitation (see recommendation 1.8.4) and agreed that all staff, not just certain staff such as occupational therapists, should be able to support these activities.

The committee also discussed safeguarding and risk, and agreed that all staff need to be trained to deal with risks relevant to the setting they are working in.

There is a high prevalence of substance misuse among the rehabilitation population. The committee thought it was essential that all staff are able to identify these problems and provide the right support.

Maintaining and supporting social networks (recommendation 1.6.9)

Involving family members and carers in decision making can reduce isolation and increase support for people having rehabilitation. However, this can be complex for people with severe mental illness. Relationships may have broken down during the person's illness or the person may find it difficult to form new relationships and they may need additional support with this. A person's capacity or their wishes about other people's involvement can also change during their illness.

Laws and established NICE guidelines are already in place that cover involving family members and sharing information, as well as supporting families and helping people keep in contact with their home communities.

Assessment (recommendations 1.7.1 to 1.7.6)

The committee used evidence about rates of physical and mental health conditions and substance misuse in this population to recommend what to consider as part of the initial assessment when people enter the rehabilitation service. The committee also drew on their experience to provide details about what a structured comprehensive biopsychosocial needs assessment should cover to assess people's complex needs and comorbidities.

The committee agreed that baseline investigations before starting antipsychotic medicines recommended in the NICE guidelines on psychosis and schizophrenia in adults and bipolar disorder should form the core of the initial physical health check for people in rehabilitation services because most would be receiving antipsychotic medicines.

The committee also drew on the evidence identifying the most common physical and mental health comorbidities to highlight conditions that staff need to be alert for because these may contribute to higher mortality or complexity in rehabilitation in this population. The committee also agreed that more understanding is needed about the likely impact of physical comorbidities on mortality among people with complex psychosis, so they made a recommendation for research on coexisting physical health conditions.

Care planning and review (recommendations 1.7.7 to 1.7.12)

The committee agreed that the comorbid health conditions and other needs identified in the needs assessment could be used along with people's recovery goals to contribute to a healthcare plan that would reduce morbidity and mortality, and improve people's function and quality of life.

Quantitative evidence suggested that detailed and regularly updated care plans lead to better service user outcomes, especially when developed within a multidisciplinary team. The committee used this evidence, their own experience and other NICE guidelines to make further recommendations on good care planning. They decided that monthly reviews in inpatient rehabilitation, and 6-monthly reviews for people in community rehabilitation, would keep care plans relevant without being overly invasive.

Daily living skills (recommendations 1.8.1 to 1.8.3)

Based on evidence suggesting that interventions could improve daily living skills and, given the importance of these skills in recovery and quality of life, the committee recommended promoting interventions to improve these activities as highly as other types of interventions. In the committee's experience, this does not always happen in practice.

Based on their experience, the committee agreed that individualised support could improve daily living skills, for example by choosing activities that people enjoy and that motivate them. If a person is motivated, they might be more likely to engage in activities of daily living such as personal care or going out on public transport. Having access to areas such as kitchens and laundry was also agreed to be important so that people can practise their skills.

Interpersonal and social skills (recommendations 1.8.4 to 1.8.6)

There was qualitative evidence that people in rehabilitation value structured group activities, and a randomised controlled trial found that taking part in them improves interpersonal functioning. This was in line with the committee's views, so they recommended these activities in both inpatient and community settings.

Based on the committee's experience, structured group activities need to be offered daily in inpatient settings and at least weekly in community settings to be effective, and people should have choice in what they do. Although there was no evidence on peer-supported activities, committee members had found these to be effective and agreed they could be an option.

Structured group activities are routinely provided by rehabilitation services, but the evidence base is fairly limited. The committee thought that more specific detail on the structured activities, and their efficacy, could help further inform practice. They therefore made a recommendation for research on structured group activities.

Engagement in community activities, including leisure, education and work (recommendations 1.8.7 to 1.8.14)

The committee wanted to emphasise the importance of meaningful occupation and work in promoting recovery and helping to promote community inclusion, based on their own experience and the preferences expressed in the qualitative evidence. The committee highlighted a number of aims of community activities, and recommended a range of hobbies and leisure activities, as well as skill development opportunities.

Evidence from randomised controlled trials showed that Individual Placement and Support (IPS) increases engagement in employment for those interested in work, and this was supported by cost-effectiveness evidence from a health economic model. There was also evidence that adding cognitive remediation can increase the effectiveness of vocational rehabilitation. The committee recommended considering both of these interventions. They agreed, however, that some people may not be ready for mainstream employment and would benefit from alternatives to IPS such as transitional employment schemes.

The committee also discussed the role of partnerships with other organisations such as voluntary organisations and employment advice schemes. They agreed these could be an important route to engagement with employment or education.

The committee discussed peer-support interventions for engaging in community activities. Although these were widely valued by the committee, there was no directly relevant research to guide the development of peer support for community activities in complex psychosis and rehabilitation services. The committee therefore made a recommendation for research on peer-support interventions.

The committee also discussed staff training interventions to mediate improvements in daily living skills, interpersonal skills and engagement in community activities, which are key areas of personal recovery in rehabilitation. However, no trials were found that assessed these interventions, so they made a recommendation for research on staff training interventions.

Substance misuse (recommendations 1.8.15 to 1.8.19)

There is a high prevalence of alcohol and substance misuse among the rehabilitation population. Because of limited evidence, the committee made recommendations based mainly on consensus and existing NICE guidance. They wanted to prevent a situation where substance misuse was occurring but rehabilitation staff viewed it as being outside their remit. The committee agreed that questions about substance use should be routine when people enter the rehabilitation service and that rehabilitation staff needed to know what their role should be in supporting people and providing substance misuse interventions.

Recommendations 1.9.1 to 1.9.3

The committee focused this section on people with symptoms of psychosis that are resistant to standard treatment because this population represents people using rehabilitation services. The committee recommended adjustments to standard treatments for psychosis described in other NICE guidance.

The committee were aware that comorbidities, including other mental health conditions and autism spectrum disorder, can affect outcomes in people with complex psychosis. These comorbidities need to be identified and treated in line with NICE guidance.

Psychological therapies (recommendations 1.9.4 to 1.9.6)

There was some evidence from randomised controlled trials that for people with treatment-resistant psychosis, cognitive behavioural therapy (CBT) decreased positive psychosis symptoms compared with pharmacological therapy alone. Based on this evidence and their experience that people with complex psychosis are often too unwell to engage with CBT at earlier contacts with the rehabilitation service, the committee recommended that it should be continued in this treatment-resistant population.

In the committee's experience, some people in rehabilitation are not ready to engage with CBT. The committee discussed the importance of providing additional psychological interventions but could not recommend a specific intervention because of the lack of evidence. Instead they recommended interventions to consider and emphasised that these should be based on psychological assessment, formulation and consideration of each person's preferences.

The committee also wanted to acknowledge the importance of low-intensity psychological interventions. Despite the lack of evidence from trials, the committee decided that the option of providing all staff with skills in delivering these interventions should be considered in rehabilitation settings.

Pharmacological treatments (recommendations 1.9.7 to 1.9.17)

There was some evidence from randomised controlled trials supporting augmentation with the agents in recommendation 1.9.7 for reducing psychosis symptoms in people with schizophrenia refractory to clozapine. The evidence was limited by small sample sizes and information on adverse events was very sparse. However, given the lack of treatment options, and considering that current prescribing for this population is inconsistent, the committee decided that augmentation should be considered an option.

In general, the committee recommended classes of drug rather than individual drugs, but they specifically mentioned aripiprazole as an example when recommending augmentation with antipsychotics. The committee noted that amisulpride is more commonly prescribed than aripiprazole, but the evidence did not show a change in psychosis symptoms following amisulpride, while there was some evidence on the effectiveness of aripiprazole in reducing total psychosis symptoms. Although the evidence also showed that ziprasidone decreased psychosis symptoms, this drug is not licensed or available in the UK.

Given the safety profiles of these drugs and their potential interactions when combined, the committee recommended seeking advice from a psychiatrist specialising in treatment resistance or a specialist mental health pharmacist if needed.

The committee made recommendations on dosing and interactions with other substances based on their experience and knowledge about the safety of various therapeutic options. They recommended therapeutic plasma levels because this may be useful in checking non-adherence or to confirm toxicity or pharmacokinetic drug interactions.

The committee agreed it was important to measure drug levels regularly to assess adherence and guide dosing. There was a lack of evidence on how frequently this should be done, so the committee used their own knowledge and experience, as well as drawing on NICE's guideline on bipolar disorder for monitoring of people taking lithium.

The committee also agreed it was important to monitor the effects of specific medicines. However, again there was no evidence on how frequently to do this. Some antipsychotics increase prolactin, raising the risk of hyperprolactinaemia, and the committee discussed whether prolactin should be measured: before starting treatment with a drug that raises prolactin (as is common practice, and recommended in NICE's guideline on psychosis and schizophrenia in adults); only if a person has symptoms for hyperprolactinaemia; or at regular intervals. The consensus was to consider monitoring prolactin annually and more regularly if the person is symptomatic.

The committee also wanted to highlight the importance of electrocardiogram (ECG) monitoring. Antipsychotic medicines can cause cardiac abnormalities, for example lengthened QT interval on electrocardiography. Although the NICE guidelines on psychosis and schizophrenia in adults and bipolar disorder recommend ECGs only when starting antipsychotic medicines, the committee recommended considering ECGs annually (and more frequently for people with complex antipsychotic regimens or doses above BNF levels). They agreed this consideration was warranted for this population, many of whom have been on medicines long term, or combinations of medicines that may alter cardiac rhythm, or both. It is already common practice to perform ECGs if exceeding BNF limits for antipsychotics.

Adherence to medicines and helping people to manage their own medicines (recommendations 1.9.18 to 1.9.20)

Evidence showed that medicines adherence was associated with successful progression in the rehabilitation pathway to more independent living. However, there was no evidence on specific interventions to improve adherence in people using rehabilitation services. The committee noted that people with a severe mental illness may find polypharmacy and complex regimens difficult to manage and so recommended avoiding these if possible.

Acknowledging the importance of self-management of medicines in people's recovery, the committee recommended opportunities to do this for those assessed as able to take part. Because of the lack of evidence on specific interventions to improve medicines adherence, they also made a recommendation for research on medicine adherence for people in supported accommodation. They agreed that people in supported accommodation are likely to receive less support with taking medication than those in inpatient rehabilitation.

Interventions tailored to people in rehabilitation

The committee noted that having psychological and pharmacological interventions specifically for people in rehabilitation, could improve their ability to live in the community. However, the existing evidence was not specific to rehabilitation settings and did not include all relevant outcomes, so the committee made a recommendation for research on tailored interventions.

Electroconvulsive therapy (recommendation 1.9.21)

The committee was aware of other NICE guidance on electroconvulsive therapy and agreed it was appropriate to cross-refer to this.

Responsibilities for healthcare providers (recommendations 1.10.1 to 1.10.3)

In the committee's experience, access to physical healthcare services is variable depending on the rehabilitation setting and they agreed it was crucial that people did not miss out on monitoring or treatment of their physical health. So the committee outlined the role that inpatient rehabilitation teams should play in physical healthcare, and also adapted existing recommendations on GP responsibilities (recommendations 1.10.1 and 1.10.2) from the NICE guideline on psychosis and schizophrenia in adults. These adapted recommendations were consistent with the evidence about physical comorbidities that the committee looked at.

Coordinating physical healthcare (recommendations 1.10.4 to 1.10.5)

Combining the limited evidence with their experiences of health promotion in rehabilitation services, the committee agreed that a single professional should coordinate people's physical healthcare. The committee did not specify the role of the professional (for example, a doctor, nurse, healthcare assistant or care coordinator) but the key point was to have a named person to maintain continuity.

The committee recommended the items that should be considered in physical healthcare plans based on their experience, and the evidence on comorbidities in people with severe mental illness.

Healthy living (recommendations 1.10.6 to 1.10.13)

The committee agreed that smoking was one of the most important modifiable risk factors in this population. They noted that people with complex psychosis using rehabilitation services may find accessing standard smoking cessation programmes difficult. Given the lack of evidence for a specific intervention in rehabilitation, and the need to be mindful of potential drug interactions, the committee agreed that the smoking cessation guidance in the NICE guideline on psychosis and schizophrenia in adults was applicable to the rehabilitation population.

Adverse lifestyle factors may be more prevalent in people with complex psychosis, for example they may be less physically active, which could place them at a higher risk of physical health problems such as obesity, cardiovascular disease, metabolic syndrome and diabetes. They therefore agreed that recommendation 1.1.3.1 about a combined healthy eating and physical activity programme from the NICE guideline on psychosis and schizophrenia in adults was also relevant to include for this population and was broadly supported by the evidence they looked at.

Given that adverse lifestyle factors may be more prevalent in people with complex psychosis, the committee made the recommendation about providing information on physical health risks based on both their knowledge and experience and evidence of the prevalence of comorbidities. The committee also noted that people with complex psychosis may have difficulty maintaining oral hygiene due to poor self‑care and may be at higher risk of substance misuse and sexual and reproductive health problems.

The committee also discussed the importance of good sleep for overall physical health and recovery. Although there was no evidence of specific interventions to improve sleep in the evidence or other NICE guidance, the committee agreed it would be good practice to provide advice and support for maintaining sleep hygiene, and practitioners should avoid environmental barriers that may hinder sleep.

Monitoring physical health (recommendations 1.10.14 to 1.10.16)

The committee recommended an annual physical health check for people in rehabilitation services based on the physical health checks in NICE's guidelines on psychosis and schizophrenia in adults and bipolar disorder. They added assessments of sexual health, vision, hearing and podiatry, substance use and thyroid function. These additions were based on both their clinical experience and the evidence on comorbidities.

To increase uptake of this health check, the committee agreed it could be done either at the rehabilitation service by a nominated professional, or at the person's GP practice. Adapting recommendations from NICE's guideline on psychosis and schizophrenia in adults, the committee recommended discussing the results of the physical health check with the person and relevant practitioners.

Care and treatment for physical health conditions (recommendations 1.10.17 and 1.10.18)

The committee agreed that risk factors and physical or mental health conditions identified during the initial health check should be managed according to existing NICE guidance. For the treatment recommendation, the committee listed the same conditions as NICE's guideline on psychosis and schizophrenia but added chronic obstructive pulmonary disease (COPD) because of the high proportion of COPD in the population.

The recommendation to be alert to possible blood-borne diseases was based on evidence about the relatively high prevalence of hepatitis and HIV in people with severe mental illness. The committee agreed this may be related to homelessness, intravenous drug use or a history of sexually transmitted disease. They also agreed that more understanding is needed about the risks predicting blood-borne virus infection in this population so that strategies can be developed to address these, so they made a recommendation for research on the risk of blood-borne virus infections.