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Psychosis and schizophrenia in adults: treatment and management [CG178]

Measuring the use of this guidance

Recommendation: 1.1.3.1

People with psychosis or schizophrenia, especially those taking antipsychotics, should be offered a combined healthy eating and physical activity programme by their mental healthcare provider. [new 2014]

What was measured: Proportion of NHS mental health trusts that offered programmes on healthy eating and physical activity to people with psychosis or schizophrenia.
Data collection end: October 2015
80%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.


Recommendation: 1.1.3.3

Offer people with psychosis or schizophrenia who smoke help to stop smoking, even if previous attempts have been unsuccessful. Be aware of the potential significant impact of reducing cigarette smoking on the metabolism of other drugs, particularly clozapine and olanzapine. [new 2014]

What was measured: Proportion of NHS mental health trusts that offered help to stop smoking some or all of the time to people with psychosis or schizophrenia.
Data collection end: October 2015
90%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.


Recommendation: 1.1.3.6

Routinely monitor weight, and cardiovascular and metabolic indicators of morbidity in people with psychosis and schizophrenia. These should be audited in the annual team report.

What was measured: Proportion of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 12 months
Data collection end: July 2015
81.5%
Area covered: England
Source: Health and Social Care Information Centre. Quality Outcomes Framework.


Recommendation: 1.1.5.7

Offer a carer-focused education and support programme, which may be part of a family intervention for psychosis and schizophrenia, as early as possible to all carers. The intervention should: be available as needed have a positive message about recovery. [new 2014]

What was measured: The percentage of patients aged 17 years or over with an identified carer whose carer were offered a carer-focused education and support programme.
Data collection end: June 2015
50%
Number that met the criteria: 915 / 1828
Area covered: England
Source: Royal College of Psychiatrists. Early Intervention in Psychosis Audit.


Recommendation: 1.2.3.1

If a person is considered to be at increased risk of developing psychosis (as described in recommendation 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.

What was measured: Proportion of early intervention in psychosis services that provide cognitive behavioural therapy.
Data collection end: August 2014
50%
Area covered: England
Source: Stain H J, Mawn L, Common S, Pilton M, and Thompson A. (2017). Research and practice for ultra-high risk for psychosis: A national survey of early intervention in psychosis services in England. Early Intervention in Psychiatry.

What was measured: Proportion of early intervention in psychosis services that provide family intervention.
Data collection end: August 2014
42%
Area covered: England
Source: Stain H J, Mawn L, Common S, Pilton M, and Thompson A. (2017). Research and practice for ultra-high risk for psychosis: A national survey of early intervention in psychosis services in England. Early Intervention in Psychiatry.


Recommendation: 1.3.3.1

Carry out a comprehensive multidisciplinary assessment of people with psychotic symptoms in secondary care. This should include assessment by a psychiatrist, a psychologist or a professional with expertise in the psychological treatment of people with psychosis or schizophrenia. The assessment should address the following domains: psychiatric (mental health problems, risk of harm to self or others, alcohol consumption and prescribed and non-prescribed drug history) medical, including medical history and full physical examination to identify physical illness (including organic brain disorders) and prescribed drug treatments that may result in psychosis physical health and wellbeing (including weight, smoking, nutrition, physical activity and sexual health) psychological and psychosocial, including social networks, relationships and history of trauma developmental (social, cognitive and motor development and skills, including coexisting neurodevelopmental conditions) social (accommodation, culture and ethnicity, leisure activities and recreation, and responsibilities for children or as a carer) occupational and educational (attendance at college, educational attainment, employment and activities of daily living) quality of life economic status.

What was measured: Proportion of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 12 months.
Data collection end: July 2015
80.3%
Area covered: England
Source: Health and Social Care Information Centre. Quality Outcomes Framework.


Recommendation: 1.3.3.4

Write a care plan in collaboration with the service user as soon as possible following assessment, based on a psychiatric and psychological formulation, and a full assessment of their physical health. Send a copy of the care plan to the primary healthcare professional who made the referral and the service user.

What was measured: Proportion of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive care plan documented in the record, in the preceding 12 months, agreed between individuals, their family and/or carers as appropriate.
Data collection end: July 2015
77.2%
Area covered: England
Source: Health and Social Care Information Centre. Quality Outcomes Framework.


Recommendation: 1.3.5.1

"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]"

What was measured: Proportion of NHS mental health trusts that 'always' discussed antipsychotic treatment and its likely benefits when deciding on antipsychotic treatment with people with psychosis or schizophrenia.
Data collection end: October 2015
70%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that 'always' discussed antipsychotic treatment and its weight gain side effects when deciding on antipsychotic treatment with people with psychosis or schizophrenia.
Data collection end: October 2015
50%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that 'always' discussed antipsychotic treatment and its diabetes and metabolic side effects when deciding on antipsychotic treatment with people with psychosis or schizophrenia.
Data collection end: October 2015
30%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.


Recommendation: 1.3.6.1

"Before starting antipsychotic medication, undertake and record the following baseline investigations: - weight (plotted on a chart) - waist circumference - pulse and blood pressure - fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile and prolactin levels - assessment of any movement disorders - assessment of nutritional status, diet and level of physical activity. [new 2014]"

What was measured: Proportion of NHS mental health trusts that were very likely or likely to record weight plotted on a chart prior to antipsychotic treatment initiation with people with psychosis and schizophrenia.
Data collection end: October 2015
40%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that were very likely or likely to record waist circumference prior to antipsychotic treatment initiation with people with psychosis and schizophrenia.
Data collection end: October 2015
20%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that were very likely or likely to record pulse prior to antipsychotic treatment initiation with people with psychosis and schizophrenia.
Data collection end: October 2015
70%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that were very likely or likely to record blood pressure prior to antipsychotic treatment initiation with people with psychosis and schizophrenia.
Data collection end: October 2015
60%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that were very likely or likely to record fasting blood glusose prior to antipsychotic treatment initiation with people with psychosis and schizophrenia.
Data collection end: October 2015
50%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that were very likely or likely to record HbA1c prior to antipsychotic treatment initiation with people with psychosis and schizophrenia.
Data collection end: October 2015
40%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that were very likely or likely to record blood lipid profile prior to antipsychotic treatment initiation with people with psychosis and schizophrenia.
Data collection end: October 2015
60%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that were very likely or likely to record assessment of any movement disorders prior to antipsychotic treatment initiation with people with psychosis and schizophrenia.
Data collection end: October 2015
60%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that were very likely or likely to record assessment of nutritional status, diet and level of physical activity prior to antipsychotic treatment initiation with people with psychosis and schizophrenia.
Data collection end: October 2015
60%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.


Recommendation: 1.3.6.4

Monitor and record the following regularly and systematically throughout treatment, but especially during titration: • response to treatment, including changes in symptoms and behaviour • side effects of treatment, taking into account overlap between certain side effects and clinical features of schizophrenia (for example, the overlap between akathisia and agitation or anxiety) and impact on functioning • the emergence of movement disorders • weight, weekly for the first 6 weeks, then at 12 weeks, at 1 year and then annually (plotted on a chart) • waist circumference annually (plotted on a chart) • pulse and blood pressure at 12 weeks, at 1 year and then annually • fasting blood glucose, HbA1c and blood lipid levels at 12 weeks, at 1 year and then annually • adherence • overall physical health. [new 2014]

What was measured: Proportion of patients registered with active clozapine treatment who had annual weight monitoring.
Data collection end: February 2013
92%
Number that met the criteria: 65 / 71
Area covered: Local
Source: Sakenyte K & Stark J (2013) Evaluation of clozapine prescribing practice. International Journal of Pharmacy Practice: 21 (suppl 2), pp 30-137.

What was measured: Proportion of patients registered with active clozapine treatment who had annual blood pressure monitoring.
Data collection end: February 2013
90%
Number that met the criteria: 64 / 71
Area covered: Local
Source: Sakenyte K & Stark J (2013) Evaluation of clozapine prescribing practice. International Journal of Pharmacy Practice: 21 (suppl 2), pp 30-137.

What was measured: Proportion of patients registered with active clozapine treatment who had annual waist measurement monitoring.
Data collection end: February 2013
8%
Number that met the criteria: 6 / 71
Area covered: Local
Source: Sakenyte K & Stark J (2013) Evaluation of clozapine prescribing practice. International Journal of Pharmacy Practice: 21 (suppl 2), pp 30-137.

What was measured: Proportion of patients registered with active clozapine treatment who had annual blood glucose monitoring.
Data collection end: February 2013
70%
Number that met the criteria: 50 / 71
Area covered: Local
Source: Sakenyte K & Stark J (2013) Evaluation of clozapine prescribing practice. International Journal of Pharmacy Practice: 21 (suppl 2), pp 30-137.

What was measured: Proportion of patients registered with active clozapine treatment who had annual lipid level monitoring.
Data collection end: February 2013
41%
Number that met the criteria: 29 / 71
Area covered: Local
Source: Sakenyte K & Stark J (2013) Evaluation of clozapine prescribing practice. International Journal of Pharmacy Practice: 21 (suppl 2), pp 30-137.

What was measured: The number of people taking antipsychotics who had their weight recorded.
Data collection end: June 2014
46%
Number that met the criteria: 12 / 26
Area covered: Local
Source: Hall I, Shah, A and Thomson, H (2016) Improving physical health for people taking antipsychotic medication in the Community Learning Disabilities Service.[Erratum appears in BMJ Qual Improv Rep. 2016;5(1).

What was measured: The number of people taking antipsychotics who had a recorded blood test.
Data collection end: June 2014
73%
Number that met the criteria: 19 / 26
Area covered: Local
Source: Hall I, Shah, A and Thomson, H (2016) Improving physical health for people taking antipsychotic medication in the Community Learning Disabilities Service.[Erratum appears in BMJ Qual Improv Rep. 2016;5(1).


Recommendation: 1.3.6.7

Discuss the use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs with the service user, and carer if appropriate. Discuss their possible interference with the therapeutic effects of prescribed medication and psychological treatments. [2009]

What was measured: Proportion of NHS mental health trusts that 'always' discussed antipsychotic treatment and the use of alcohol when deciding on antipsychotic treatment with people with psychosis or schizophrenia.
Data collection end: October 2015
50%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that 'always' discussed antipsychotic treatment and the use of tobacco when deciding on antipsychotic treatment with people with psychosis or schizophrenia.
Data collection end: October 2015
20%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that 'always' discussed antipsychotic treatment and the use of other prescribed medications when deciding on antipsychotic treatment with people with psychosis or schizophrenia.
Data collection end: October 2015
30%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that 'always' discussed antipsychotic treatment and the use of non-prescribed medications when deciding on antipsychotic treatment with people with psychosis or schizophrenia.
Data collection end: October 2015
0%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.

What was measured: Proportion of NHS mental health trusts that 'always' discussed antipsychotic treatment and the use of illicit drugs when deciding on antipsychotic treatment with people with psychosis or schizophrenia.
Data collection end: October 2015
30%
Area covered: England
Source: Swaby L, et al. (2016). Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey. BJPsych Bulletin.


Recommendation: 1.4.4.1

Offer CBT to all people with psychosis or schizophrenia (delivered as described in recommendation 1.3.7.1). This can be started either during the acute phase or later, including in inpatient settings. [2009]

What was measured: Proportion of people with schizophrenia who were offered individual CBT.
Data collection end: November 2010
6.9%
Number that met the criteria: 13 / 187
Area covered: Local
Source: Haddock G. et al (2014) An investigation of the implementation of NICE-recommended CBT interventions for people with schizophrenia. Journal of Mental Health 2014; 23 (4): 162-165

What was measured: The proportion of patients with a first episode of psychosis or suspected psychosis who were offered Cognitive Behavioural Therapy for psychosis (CBTp).
Data collection end: June 2015
41%
Number that met the criteria: 1000 / 2465
Area covered: England
Source: Royal College of Psychiatrists. Early Intervention in Psychosis Audit.


Recommendation: 1.4.4.2

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 in recommendation 1.3.7.2). This can be started either during the acute phase or later, including in inpatient settings. [2009]

What was measured: Proportion of people with schizophrenia who were recorded as having high or moderate family contact that were offered family intervention therapy.
Data collection end: November 2010
2.5%
Number that met the criteria: 3 / 118
Area covered: Local
Source: Haddock G. et al (2014) An investigation of the implementation of NICE-recommended CBT interventions for people with schizophrenia. Journal of Mental Health 2014; 23 (4): 162-165

What was measured: The percentage of psychosis or schizophrenia patients whose families were offered family intervention.
Data collection end: June 2015
31%
Number that met the criteria: 582 / 1901
Area covered: England
Source: Royal College of Psychiatrists. Early Intervention in Psychosis Audit.


Recommendation: 1.5.7.2

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]

What was measured: The proportion of people having a first episode or suspected psychosis who did not have an adequate response to a full trial of two antipsychotic drugs and were prescribed clozapine.
Data collection end: June 2015
36%
Number that met the criteria: 39 / 109
Area covered: England
Source: Royal College of Psychiatrists. Early Intervention in Psychosis Audit.


Recommendation: 1.5.8.1

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]

What was measured: The percentage of psychosis or schizophrenia patients recorded as unemployed and seeking work who were offered one or more supported employment or education programmes.
Data collection end: June 2015
63%
Number that met the criteria: 286 / 456
Area covered: England
Source: Royal College of Psychiatrists. Early Intervention in Psychosis Audit.



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