Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Definitions of depression and severity

Depression refers to a wide range of mental health problems characterised by the absence of a positive affect (a loss of interest and enjoyment in ordinary things and experiences), low mood and a range of associated emotional, cognitive, physical and behavioural symptoms. For more detail, see the International Classification of Diseases-11 (ICD-11) or the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria for depression.

Depression severity exists along a continuum and is essentially composed of 3 elements:

Severity of depression is therefore a consequence of the contribution of all of these elements.

Traditionally, depression severity has been grouped under 4 categories (subthreshold, mild, moderate and severe) but in the development of this guideline the committee wanted to develop a way of representing the severity of depression which best represents the available evidence on the classification and would help the uptake of the recommendations in routine clinical practice. This guideline has therefore defined new episodes of depression as less severe or more severe depression.

Less severe depression encompasses subthreshold and mild depression, and more severe depression encompasses moderate and severe depression. Thresholds on validated scales were used in this guideline as an indicator of severity. For example, a score 16 on the PHQ-9 scale was used, with scores less than 16 defined as less severe depression, and scores of 16 or more defined as more severe depression.

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

1.1 Principles of care

Working with adults and young people with psychosis and coexisting substance misuse

1.1.1 When working with adults and young people with known or suspected psychosis and coexisting substance misuse, take time to engage the person from the start, and build a respectful, trusting, non-judgemental relationship in an atmosphere of hope and optimism. Be direct in your communications, use a flexible and motivational approach, and take into account that:

  • stigma and discrimination are associated with both psychosis and substance misuse

  • some people will try to conceal either one or both of their conditions

  • many people with psychosis and coexisting substance misuse fear being detained or imprisoned, being given psychiatric medication forcibly or having their children taken into care, and some fear that they may be 'mad'.

1.1.2 When working with adults and young people with known or suspected psychosis and coexisting substance misuse:

  • ensure that discussions take place in settings in which confidentiality, privacy and dignity can be maintained

  • avoid clinical language without adequate explanation

  • provide independent interpreters (who are not related to the person) if needed

  • aim to preserve continuity of care and minimise changes of key workers in order to foster a therapeutic relationship.

Race and culture

1.1.3 Healthcare professionals working with adults and young people with psychosis and coexisting substance misuse should ensure that they are competent to engage, assess, and negotiate with service users from diverse cultural and ethnic backgrounds and their families, carers or significant others.

'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.

1.1.4 Work with local black and minority ethnic organisations and groups to help support and engage adults and young people with psychosis and coexisting substance misuse. Offer organisations and groups information and training about how to recognise psychosis with coexisting substance misuse and access treatment and care locally.

Providing information

1.1.5 Offer written and verbal information to adults and young people appropriate to their level of understanding about the nature and treatment of both their psychosis and substance misuse. Written information should:

1.1.6 All healthcare professionals in primary, secondary or specialist substance misuse services working with adults and young people with psychosis should offer information and advice about the risks associated with substance misuse and the negative impact that it can have on the experience and management of psychosis.

Working with and supporting families, carers and significant others

1.1.7 Encourage families, carers or significant others to be involved in the treatment of adults and young people with psychosis and coexisting substance misuse to help support treatment and care and promote recovery.

1.1.8 When families, carers or significant others live or are in close contact with the person with psychosis and coexisting substance misuse, offer family intervention as recommended in NICE guideline on psychosis and schizophrenia in adults.

1.1.9 When families, carers or significant others are involved in supporting the person with psychosis and coexisting substance misuse, discuss with them any concerns about the impact of these conditions on them and on other family members.

1.1.10 Offer families, carers or significant others a carer's assessment of their caring, physical, social, and mental health needs. Where needs are identified, develop a care plan for the family member or carer.

1.1.11 Offer written and verbal information to families, carers or significant others appropriate to their level of understanding about the nature and treatment of psychosis and substance misuse, including how they can help to support the person. Written information should be available in the appropriate language or, for those who cannot use written text, in an accessible format (audio or video).

1.1.12 Offer information to families, carers or significant others about local family or carer support groups and voluntary organisations, including those for psychosis and for substance misuse, and help families, carers or significant others to access these.

1.1.13 Negotiate confidentiality and sharing of information between the person with psychosis and coexisting substance misuse and their family, carer or a significant other.

'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.

1.1.14 Ensure the needs of young carers or dependent adults of the person with psychosis and coexisting substance misuse are assessed. Initiate safeguarding procedures where appropriate (see recommendations 1.1.16 to 1.1.20 on safeguarding issues).

Support for healthcare professionals

1.1.15 Working with people with psychosis and coexisting substance misuse can be challenging and healthcare professionals should seek effective support – for example, through professional supervision or staff support groups.

Safeguarding issues

1.1.16 If people with psychosis and coexisting substance misuse are parents or carers of children or young people, ensure that the child's or young person's needs are assessed according to local safeguarding procedures.

See also, safeguarding children on the Gov.uk website.

1.1.17 If children or young people being cared for by people with psychosis and coexisting substance misuse are referred to CAMHS under local safeguarding procedures:

  • use a multi-agency approach, including social care and education, to ensure that various perspectives on the child's life are considered

  • consider using the Common Assessment Framework (CAF); advice on this can be sought from the local named lead for safeguarding.

1.1.18 If serious concerns are identified, health or social care professionals working with the child or young person (see recommendation 1.1.17) should develop a child protection plan.

1.1.19 When working with people with psychosis and coexisting substance misuse who are responsible for vulnerable adults, ensure that the home situation is risk assessed and that safeguarding procedures are in place for the vulnerable adult. Advice on safeguarding vulnerable adults can be sought from the local named lead for safeguarding.

1.1.20 Consider adults with psychosis and coexisting substance misuse for assessment according to local safeguarding procedures for vulnerable adults if there are concerns regarding exploitation or self-care, or if they have been in contact with the criminal justice system.

Advance decisions and statements

1.1.22 Develop advance decisions and advance statements in collaboration with adults with psychosis and coexisting substance misuse, especially if their condition is severe and they have been treated under the Mental Health Act (1983; amended 1995 and 2007). Record the decisions and statements and include copies in the care plan in primary and secondary care. Give copies to the person, their care coordinator, and their family, carer or a significant other if the person agrees.

'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.

1.1.23 Take advance decisions and advance statements into account in accordance with the Mental Capacity Act (2005). Although advance decisions and advance statements can be overridden using the Mental Health Act (1983; amended 1995 and 2007), try to honour them wherever possible.

Working with the voluntary sector

1.1.24 Healthcare professionals in primary care and secondary care mental health services, and in specialist substance misuse services, should work collaboratively with voluntary sector organisations that provide help and support for adults and young people with psychosis and coexisting substance misuse. Ensure that advocates from such organisations are included in the care planning and care programming process wherever this is possible and agreed by the person with psychosis and coexisting substance misuse.

1.1.25 Healthcare professionals in primary care and secondary care mental health services, and in specialist substance misuse services, should work collaboratively with voluntary sector organisations providing services for adults and young people with psychosis and coexisting substance misuse to develop agreed protocols for routine and crisis care.

1.2 Recognition of psychosis with coexisting substance misuse

1.2.1 Healthcare professionals in all settings, including primary care, secondary care mental health services, CAMHS and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely ask adults and young people with known or suspected psychosis about their use of alcohol and/or prescribed and non-prescribed (including illicit) drugs. If the person has used substances ask them about all of the following:

1.2.2 Healthcare professionals in all settings, including primary care, secondary care mental health services, CAMHS and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely assess adults and young people with known or suspected substance misuse for possible psychosis. Seek corroborative evidence from families, carers or significant others, where this is possible and permission is given.

'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.

1.3 Primary care

Referral from primary care

1.3.1 Refer all adults and young people with psychosis or suspected psychosis, including those who are suspected of coexisting substance misuse, to either secondary care mental health services or CAMHS for assessment and further management.

1.3.2 Refer all adults and young people with substance misuse or suspected substance misuse who are suspected of having coexisting psychosis to secondary care mental health services or CAMHS for assessment and further management.

Physical healthcare

1.3.3 Monitor the physical health of adults and young people with psychosis and coexisting substance misuse, as described in the NICE guideline on psychosis and schizophrenia in adults. Pay particular attention to the impact of alcohol and drugs (prescribed and non-prescribed) on physical health. Monitoring should be conducted at least once a year or more frequently if the person has a significant physical illness or there is a risk of physical illness because of substance misuse.

1.4 Secondary care mental health services

Competence

1.4.1 Healthcare professionals working within secondary care mental health services should ensure they are competent in the recognition, treatment and care of adults and young people with psychosis and coexisting substance misuse.

1.4.2 Healthcare professionals working within secondary care mental health services with adults and young people with psychosis and coexisting substance misuse should consider having supervision, advice, consultation and/or training from specialists in substance misuse services. This is to aid in the development and implementation of treatment plans for substance misuse within CAMHS or adult community mental health services.

Pathways into care

1.4.3 Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate mental healthcare because of their substance misuse.

1.4.4 Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate substance misuse services because of a diagnosis of psychosis.

1.4.5 For most adults with psychosis and coexisting substance misuse, treatment for both conditions should be provided by healthcare professionals in secondary care mental health services such as community-based mental health teams.

Coordinating care

1.4.6 Consider seeking specialist advice and initiating joint working arrangements with specialist substance misuse services for adults and young people with psychosis being treated by community mental health teams, and known to be:

  • severely dependent on alcohol or

  • dependent on both alcohol and benzodiazepines or

  • dependent on opioids and/or cocaine or crack cocaine.

    Adult community mental health services or CAMHS should continue to provide care coordination and treatment for the psychosis within joint working arrangements.

1.4.7 Consider seeking specialist advice and initiate joint working arrangements with specialist substance misuse services if the person's substance misuse:

  • is difficult to control and/or

  • leads to significant impairment of functioning, family breakdown or significant social disruption such as homelessness.

1.4.8 If a person with psychosis and coexisting substance misuse requires planned detoxification from either drugs or alcohol, this should take place in an inpatient setting (see section 1.6).

1.4.9 Delivery of care and transfer between services for adults and young people with psychosis and coexisting substance misuse should include a care coordinator and use the Care Programme Approach.

Assessment

1.4.10 Adults and young people with psychosis and coexisting substance misuse attending secondary care mental health services should be offered a comprehensive, multidisciplinary assessment, including assessment of all of the following:

  • personal history

  • mental, physical and sexual health

  • social, family and economic situation

  • accommodation, including history of homelessness and stability of current living arrangements

  • current and past substance misuse and its impact upon their life, health and response to treatment

  • criminal justice history and current status

  • personal strengths and weaknesses and readiness to change their substance use and other aspects of their lives.

    The assessment may need to take place over several meetings to gain a full understanding of the person and the range of problems they experience, and to promote engagement.

1.4.11 When assessing adults and young people with psychosis and coexisting substance misuse, seek corroborative evidence from families, carers or significant others where this is possible and permission is given. Summarise the findings, share this with the person and record it in their care plan.

'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.

1.4.12 Review any changes in the person's use of substances. This should include changes in:

  • the way the use of substances affects the person over time

  • patterns of use

  • mental and physical state

  • circumstances and treatment.

    Share the summary with the person and record it in their care plan.

1.4.13 When assessing adults and young people with psychosis and coexisting substance misuse, be aware that low levels of substance use that would not usually be considered harmful or problematic in people without psychosis, can have a significant impact on the mental health of people with psychosis.

1.4.14 Regularly assess and monitor risk of harm to self and/or others and develop and implement a risk management plan to be reviewed when the service users' circumstances or levels of risk change. Specifically consider additional risks associated with substance misuse, including:

  • physical health risks (for example, withdrawal seizures, delirium tremens, blood-borne viruses, accidental overdose, and interactions with prescribed medication) and

  • the impact that substance use may have on other risks such as self-harm, suicide, self-neglect, violence, abuse of or by others, exploitation, accidental injury and offending behaviour.

Biological/physical testing

1.4.15 Biological or physical tests for substance use (such as blood and urine tests or hair analysis) may be useful in the assessment, treatment and management of substance misuse for adults and young people with psychosis. However, this should be agreed with the person first as part of their care plan. Do not use biological or physical tests in routine screening for substance misuse in adults and young people with psychosis.

Treatment

1.4.16 Before starting treatment for adults and young people with psychosis and coexisting substance misuse, review:

  • the diagnosis of psychosis and of the coexisting substance misuse, especially if either diagnosis has been made during a crisis or emergency presentation and

  • the effectiveness of previous and current treatments and their acceptability to the person; discontinue ineffective treatments.

1.4.17 When developing a care plan for an adult or young person with psychosis and coexisting substance misuse, take account of the complex and individual relationships between substance misuse, psychotic symptoms, emotional state, behaviour and the person's social context.

1.4.18 Ensure that adults and young people with psychosis and coexisting substance misuse are offered evidence-based treatments for both conditions (see recommendations 1.4.19 and 1.4.20).

1.4.19 For the treatment of psychosis, see NICE guideline on bipolar disorder or the guideline on NICE guideline on psychosis and schizophrenia in adults.

1.4.20 For the treatment of substance misuse, see:

1.4.21 When developing a treatment plan for a person with psychosis and coexisting substance misuse, tailor the plan and the sequencing of treatments to the person and take account of:

  • the relative severity of both the psychosis and the substance misuse at different times and

  • the person's social and treatment context and

  • the person's readiness for change.

1.4.22 Do not exclude adults and young people with psychosis and coexisting substance misuse from contingency management programmes because of their psychosis.

1.4.23 Use antipsychotics according to the guideline on NICE guidelines on psychosis and schizophrenia in adults or bipolar disorder because there is no evidence for any differential benefit for one antipsychotic over another for people with psychosis and coexisting substance misuse.

1.4.24 Use depot/long-acting injectable antipsychotics according to the NICE guideline on psychosis and schizophrenia in managing covert non-adherence with treatment for psychosis and not as a specific treatment for psychosis and coexisting substance misuse.

1.4.25 When prescribing medication for adults and young people with psychosis and coexisting substance misuse:

  • take into account the level and type of substance misuse, especially of alcohol, as this may alter the metabolism of prescribed medication, decrease its effectiveness and/or increase the risk of side effects

  • warn the person about potential interactions between substances of misuse and prescribed medication

  • discuss the problems and potential dangers of using non-prescribed substances and alcohol to counteract the effects or side effects of prescribed medication.

1.5 Substance misuse services

Competence

1.5.1 Healthcare professionals in substance misuse services should be competent to:

  • recognise the signs and symptoms of psychosis

  • undertake a mental health needs and risk assessment sufficient to know how and when to refer to secondary care mental health services.

Assessment

1.5.2 Adults and young people with psychosis and coexisting substance misuse attending substance misuse services should be offered a comprehensive, multidisciplinary mental health assessment in addition to an assessment of their substance misuse.

Joint working

1.5.3 Healthcare professionals in substance misuse services should be present at Care Programme Approach meetings for adults and young people with psychosis and coexisting substance misuse within their service who are also receiving treatment and support in other health services.

1.5.4 Specialist substance misuse services should provide advice, consultation, and training for healthcare professionals in adult mental health services and CAMHS regarding the assessment and treatment of substance misuse, and of substance misuse with coexisting psychosis.

1.5.5 Specialist substance misuse services should work closely with secondary care mental health services to develop local protocols derived from this guideline for adults and young people with psychosis and coexisting substance misuse. The agreed local protocols should set out responsibilities and processes for assessment, referral, treatment and shared care across the whole care pathway.

1.6 Inpatient mental health services

Substance misuse

1.6.1 All inpatient mental health services should ensure that they have policies and procedures for promoting a therapeutic environment free from drugs and alcohol that have been developed together with service users and their families, carers or significant others. These should include: search procedures, visiting arrangements, planning and reviewing leave, drug and alcohol testing, disposal of legal and illicit substances, and other security measures. Soon after admission, provide all service users, and their families, carers or significant others, with information about the policies and procedures.

'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.

1.6.2 When carrying out a comprehensive assessment for all adults and young people admitted to inpatient mental health services, ensure that they are assessed for current substance misuse and evidence of withdrawal symptoms at the point of admission.

1.6.3 Biological or physical tests for substance use should only be considered in inpatient services as part of the assessment and treatment planning for adults and young people with psychosis and coexisting substance misuse. Obtain consent for these tests and inform the person of the results as part of an agreed treatment plan. Where mental capacity is lacking, refer to the Mental Capacity Act (2005).

1.6.4 Ensure that planned detoxification from either drugs or alcohol is undertaken only:

Discharge

1.6.5 Do not discharge adults and young people with psychosis and coexisting substance misuse from an inpatient mental health service solely because of their substance misuse.

1.6.6 When adults and young people with psychosis and coexisting substance misuse are discharged from an inpatient mental health service, ensure that they have:

  • an identified care coordinator and

  • a care plan that includes a consideration of needs associated with both their psychosis and their substance misuse and

  • been informed of the risks of overdose if they start reusing substances, especially opioids, that have been reduced or discontinued during the inpatient stay.

1.7 Staffed accommodation

Exclusion from services

1.7.1 Do not exclude people with psychosis and coexisting substance misuse from staffed accommodation (such as supported or residential care) solely because of their substance misuse

1.7.2 Do not exclude people with psychosis and coexisting substance misuse from staffed accommodation aimed at addressing substance misuse solely because of their diagnosis of psychosis.

Aims of treatment

1.7.3 Ensure that people with psychosis and coexisting substance misuse who live in staffed accommodation receive treatment for both their psychosis and their substance misuse with the explicit aim of helping the person remain in stable accommodation.

1.8 Specific issues for young people with psychosis and coexisting substance misuse

Competence

1.8.1 Professionals in Tier 1 (primary care and educational settings) should be competent to recognise early signs of psychosis and substance misuse in young people.

1.8.2 Healthcare professionals in Tier 3 (community mental health teams) and Tier 4 (specialist inpatient and regional services) CAMHS, and in early intervention in psychosis services, should be competent in the management of psychosis and substance misuse in young people.

Identification and referral

1.8.3 Professionals in Tier 1 (primary care and educational settings) should seek advice or consultation from Tier 2 CAMHS (primary care) when signs of psychosis are detected in young people. If healthcare professionals in Tier 2 CAMHS detect signs of psychosis in young people, a referral to Tier 3 CAMHS or early intervention in psychosis services for young people should be made according to local protocols.

1.8.4 Ask all young people seen in Tier 3 and Tier 4 CAMHS and in early intervention in psychosis services who have psychosis or suspected psychosis about substance misuse (see recommendation 1.2.1).

1.8.5 Children and young people who, after comprehensive assessment, are considered to be at high risk of harm to themselves or others, should be referred directly to Tier 4 CAMHS including inpatient services where necessary.

Assessment and treatment

1.8.6 Healthcare professionals working with young people with psychosis and coexisting substance misuse should ensure they are familiar with the legal framework that applies to young people including the Mental Health Act (1983; amended 1995 and 2007), the Mental Capacity Act (2005), and the Children Act (2004).

1.8.7 For psychological, psychosocial, family and medical interventions for young people, follow the recommendations for adults in this guideline; they may need to be adapted according to the young person's circumstances and age. In addition, other agencies, including children's services, should be involved to ensure that the young person's educational, employment, family and housing needs are met.

1.8.8 When prescribing medication, take into account the young person's age and weight when determining the dose. If it is appropriate to prescribe unlicensed medication, explain to the young person and/or their parents or carers the reasons for doing this.

1.8.9 Those providing and commissioning services should ensure that:

  • age-appropriate mental health services are available for young people with psychosis and coexisting substance misuse and

  • transition arrangements to adult mental health services are in place where appropriate.

  • National Institute for Health and Care Excellence (NICE)