The U.K.’s National Institute for Health and Care Excellence has issued its new clinical guidelines for “Psychosis and Schizophrenia in Adults: Treatment and Management.” For those considered to be at risk of psychosis, CBT (with or without family intervention), assessment for trauma, and help for anxiety, depression, personality disorder or substance abuse are suggested. For first episode psychosis, the guidelines recommend trauma assessment and informed choice of limited antipsychotics.
From the Guidelines:
The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.
Preventing psychosis
-
If a person is considered to be at increased risk of developing psychosis (as described inrecommendation 1.2.1.1):
- offer individual cognitive behavioural therapy (CBT) with or without family intervention (delivered as described in section 1.3.7) and
- offer interventions recommended in NICE guidance for people with any of the anxiety disorders, depression, emerging personality disorder or substance misuse. [new 2014]
First episode psychosis
- 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. [new 2014]
- 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 Post-traumatic stress disorder (NICE clinical guideline 26). [new 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]
- Do not initiate regular combined antipsychotic medication, except for short periods (for example, when changing medication).
Subsequent acute episodes of psychosis or schizophrenia and referral in crisis
- Offer CBT to all people with psychosis or schizophrenia (delivered as described inrecommendation 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 inrecommendation 1.3.7.2). This can be started either during the acute phase or later, including in inpatient settings. [2009]
Promoting recovery and possible future care
- GPs and other primary healthcare professionals should monitor the physical health of people with psychosis or schizophrenia when responsibility for monitoring is transferred from secondary care, and then at least annually. The health check should be comprehensive, focusing on physical health problems that are common in people with psychosis and schizophrenia. Include all the checks recommended in 1.3.6.1 and refer to relevant NICE guidance on monitoring for cardiovascular disease, diabetes, obesity and respiratory disease. A copy of the results should be sent to the care coordinator and psychiatrist, and put in the secondary care notes. [new 2014]
- 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]
- 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. [new 2014]
Of further interest:
NICE says stop prescribing drugs to prevent schizophrenia (OnMedica)
From the article:
“Elizabeth Kuipers, professor of clinical psychology at the Institute of Psychiatry, King’s College London and chair of the guideline development group, said: “There have been many developments since the original recommendations were published – we now know a lot more about successfully reducing the risk or preventing the development of psychosis.
“The newly updated guideline recommends the use of CBT, rather than antipsychotics, for people at risk of developing psychosis, along with interventions in line with NICE guidance on anxiety disorders, depression, and emerging personality disorder or substance misuse if they have coexisting problems.”
For people with a first episode of psychosis, NICE recommends offering an oral antipsychotic medication in conjunction with a psychological intervention. People who want to try psychological interventions alone should be advised that these are more effective when delivered in conjunction with antipsychotic medication.
NICE: Updated schizophrenia and psychosis guidelines (Nursing in Practice)
From the article:
“Clive Travis, representing service users on the guideline development group, said:”There seemed little science in my care until the latter part of that decade [2000] beyond random attempts to get a drug that suited me and other aspects of the care seemed more traditional than scientifically well founded. My carers were left with a bitter taste due to lack of support.
“I was not alone among users to lose my employment, almost as though to do so was part and parcel of the condition. The new schizophrenia guideline makes the possibility of employment part of the recovery and also better recognises the role of the carer.
“The newly updated guideline is a major stride in the long walk which is the history and science of recovery from schizophrenia and psychosis and will enable much of what happened to me to happen less often, less damagingly, in a less costly way or not at all. People with schizophrenia and psychosis can and do get better, get their life back and enjoy it again and this guideline will give them their best chance yet of doing that.”
This is a positive step but the actual NICE guidelines only covers “psychosis” for schizophrenia, schizoaffective disorder, schizophreniform disorder and delusional disorder. However, it says that psychosis for “affective disorders” (including Bipolar type 1) is different.
It makes it sound that they can really distinguish one disorder from another, despite having no objective clinical test to classify people.
Diagnosis is not verifiable, and a subjective classification often depends on the psychiatrist you see.
Not only do they draw such an invalid distinction, but they are now claiming that treatment should differ.
Psychiatry is an ass!
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I personally believe that now that the proof exists that the antipsychotics cause long run outcomes, even in “bipolar” patients, exactly as seen in long run medicated schizophrenics. The antipsychotics should officially be know as “chemically lobotomy drugs.”
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Hi, there’s lots and lots of evidence to say that the chemical treatment approach creates a permanent chemical imbalance.
(The word ‘psychotogenic’ might be the word?)
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I agree there with you, it does seem to be a positive step.
Psychotherapy definitely does work for ‘schizophrenia’. But non genuine approachs don’t work, and can give Psychotherapy a bad name.
Being disturbed,for me, is like being lost in a forest and on your own. If you have a friend on a mountain with a pair of binoculars and can phone them, they can guide you out.
But the friend has to be genuine and available and know what they are doing to guide you. Its the same with psychotherapy.
‘Anti Psychotics’ and Heart Rhythm also gets mentioned but I don’t think enough:
‘Anti Psychotics’ like Seroquel are among the most dangerous drugs that can be prescribed to middle aged men.
Besides weight gain cholesterol and diabetes these drugs can disrupt heart rhythm (even at very low doses) and cause death.
Irregular Heart Rhythm: From my own experience, does not get investigated much. This is because its a lot of trouble. Dealing with it is problematic and time consuming, and most of the deaths get hidden anyway.
Heart rhythm problems can come and go. When they subside they can be forgotten about.
I think a quick independent investigation into heart rhythm and middle aged Seroquel/Quietiapine usage could identify an epidemic.
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Promoting recovery seems to mean drugging up for life in most cases, if I read these guidelines correctly.
Most practitioners do not read the full guidelines, they read the short version. The long one contains caveats and general discussion, so are open to interpretation. The short ones read like a strongly recommended treatment programmes with no room for interpretation or mediation from the recommendations.
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Hi John
You mean the NICE is for show, and on the ground they can do whatever they like?
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I remember reading a critique of NICE guidlines from a member of the critical psychiatry network. The long ones were all: on the one hand this, on the other that, which reflects scientific studies. The short ones go, Durgs, CBT, This, And That, And The Other. So all the nuanced discussion is taken out.
This is nonsense. We do not have a universal mental health system in the UK. There are typical treatments, but what you get can vary from area to area.
Also, anyone who has spent any time with people who are mentally distressed realizes quite quickly that what helps people is a whole variety of things that have an underlying pattern of forming trusting relationships, understanding the person and offering encouragement. CBT is a fashion. Just because the day center helper who you really like, who listens intently to your moans and buys you coffee occasionally has no training in CBT does not mean they are not helpful.
I think that changes in the mental health system will come as a result of many actions from many different people. Changing guild lines like this to have CBT and family work is a small change but it does undermine what is the mainstream treatment. Anything that does that is worthwhile, although it doesn’t look like what happens at the moment in most places I know.
Time for a few banner drops outside a few hospitals me thinks. How about – LEGALIZED DRUG PUSHERS WORK HERE?
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I have seen what ‘Token’ psychotherapy looks like and its more of a gimmick. The UK ‘Times’ newspaper today’s (Monday’s) front page covers a NICE recommendation on the rationing of medical treatment away from the elderly for financially expediant reasons. A recovered ‘Severely Mentally Ill’ person saves the UK £36,000 per year or at least £1 million in their lives: Most people can recover with basic suitable treatment.
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Whether most people can recover I do not know, althogh Open Dialogue and Soteria House had similar outcomes in very different social situations. One in rural Finland and the other in suburban California.
What I do know is that given appropriate care most people can improve to some degree and that most places do not offer appropriate care. Wards are well furnished warehouses and staff in the community do drug checks with almost no time to get to know patients.
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I think what Soteria House and Open Dialogue (with 80% Recovery Rates) demonstrate is that most of the chronic mental illness is due to the unsuitable psychiatric treatment.
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That ‘Schizophrenia’ as its known is only a lifelong condition due to Psychiatry. And there’s no such thing as a ‘Schizophrenic’.
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