Shared Learning Awards 2020 winner - Prescribing guidelines for patients with a first episode of psychosis

It is very important that anyone with a first episode of psychosis receives the most effective and appropriate treatment as early on as possible.

Mental health workers at Avon and Wiltshire Mental Health Partnership NHS Trust established that there was no clear guidance for prescribing antipsychotics during a first episode of psychosis.

They wanted to change this and aimed to improve their prescribing practice and ensuring the right medication is provided at the right time.

This project started in 2016 with non-medical practitioners (NMPs) who became aware that prescribing practice for patients with a first episode of psychosis varied greatly. At this time only 2 of the 5 teams had Consultants and NMPs were responsible for the prescribing.

Over the last 4 years the project has grown to include junior doctors, medical students and the whole multidisciplinary team, working together to develop prescribing guidelines. This provides evidence based guidance to all prescribers initiating treatment to clients experiencing a first episode of psychosis.

Elena Ely, team manager and NMP for Bath & North East Somerset Early Intervention team, Avon and Wiltshire Mental Health Partnership NHS Trust
Dr Liz Ewins
consultant psychiatrist, early intervention in psychosis
Avon and Wiltshire Partnership Mental Health Trust

What was done and why

Psychosis affects 1 to 3% of the population, which is higher than the incidences of diabetes in young people. If a person suffers side effects during the first stage of psychosis due to their medication, they are more likely to stop treatment. This can lead to a relapse of symptoms, which are harder to treat, and can lead to time spent in hospital.

People's experience of medication in the first stages of treatment can have a lasting effect on how they feel towards it in the future and how likely they are to stick to a treatment. 

Our guidelines CG178and CG155 state that antipsychotic medication should be chosen by the user and healthcare professional together. This allows them to consider the likely benefits and possible side effects of each drug. The guidelines also provide the information required for prescribing medication to people at the first stage of psychosis.

This includes

  • baseline investigations
  • reviews of treatment including side effects
  • physical health monitoring.

Outcomes and impact

Now that more patients are involved in prescribing decisions, compliance has increased. The stopping of medication due to side effects has also reduced.

As a result, it is likely that this will have an impact on reducing rates of relapse, and a reduction in time spent in hospital.

Patients have welcomed more choice in their treatment and are satisfied with the information provided about the different medication options available. 

The trust set up a working group to develop and improve guidelines to help make the best decisions for their patients. Teaching and education sessions were presented about the new guidelines. This raised awareness and promoted good prescribing practice by following our guidance.  

What was learnt

To ensure the guidelines are adopted all prescribers need to be made aware of the benefits to patients and the latest evidence-based treatments. The involvement of the trust’s medicines optimisation group, their medical advisory group and endorsement of the medical director was key.

Close working relationships with inpatient colleagues and prescribers across other mental health teams have also been essential.

This really helped take the initiative forward as they are often responsible for prescribing.

A prescribing guideline for all patients with a first episode psychosis cannot be too prescriptive. A fine balance can be achieved to ensure the best possible outcomes for this vulnerable group of patients.

See the full example