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.
If a person is considered to be at increased risk of developing psychosis (as described inrecommendation 188.8.131.52):
- 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]
- 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 184.108.40.206). This can be started either during the acute phase or later, including in inpatient settings. 
- 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 220.127.116.11). This can be started either during the acute phase or later, including in inpatient settings. 
- 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 18.104.22.168 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. 
- 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:
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  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.”