About this guideline

NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions.

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.

This guideline was developed by the National Collaborating Centre for Mental Health, which is based at the Royal College of Psychiatrists. The Collaborating Centre worked with a Guideline Development Group, comprising healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, which reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation.

The methods and processes for developing NICE clinical guidelines are described in The guidelines manual.

NICE produces guidance, standards and information on commissioning and providing high-quality healthcare, social care, and public health services. We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland. Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.

Update information

This guideline updates and replaces NICE clinical guideline 82 (published March 2009).

Recommendations are marked as [2009], [2009, amended 2014], [2014] or [new 2014].

  • [2009] indicates that the evidence has not been reviewed since 2009.

  • [2009, amended 2014] indicates that the evidence has not been reviewed since 2009 but changes have been made to the recommendation wording that change the meaning (see below).

  • [2014] indicates that the evidence has been reviewed but no changes have been made to the recommendation.

  • [new 2014] indicates that the evidence has been reviewed and the recommendation has been updated or added.

Recommendations from NICE clinical guideline 82 that have been amended

Recommendations are labelled [2009, amended 2014] if the evidence has not been reviewed since 2009 but changes have been made to the recommendation wording that change the meaning.

Recommendation in 2009 guideline

Recommendation in current guideline

Reason for change

Work in partnership with people with schizophrenia and their carers. Offer help, treatment and care in an atmosphere of hope and optimism. Take time to build supportive and empathic relationships as an essential part of care. [1.1.1.1]

Use this guideline in conjunction with Service user experience in adult mental health (NICE clinical guidance 136) to improve the experience of care for people with psychosis or schizophrenia using mental health services, and:

• work in partnership with people with schizophrenia and their carers

• offer help, treatment and care in an atmosphere of hope and optimism

• take time to build supportive and empathic relationships as an essential part of care. [2009; amended 2014] [1.1.1.1]

The GDG amended this recommendation to direct readers to the NICE guidance on service user experience, which replaces some of the recommendations from the 2009 schizophrenia guideline.

Ensure that people with schizophrenia receive a comprehensive multidisciplinary assessment, including a psychiatric, psychological and physical health assessment. The assessment should also address the following:

• accommodation

• culture and ethnicity

• economic status

• occupation and education (including employment and functional activity)

• prescribed and non-prescribed drug history

• quality of life

• responsibility for children

• risk of harm to self and others

• sexual health

• social networks. [1.1.4.1]

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. [2009; amended 2014] [1.3.3.1]

The GDG amended the recommendation in line with 'Psychosis and schizophrenia in children and young people' (NICE clinical guideline 155) to ensure that the comprehensive assessment is better tailored to the needs of people with psychosis or schizophrenia and better designed for developing a care plan.

The GDG considered it important to align this guideline and 'Psychosis and schizophrenia in children and young people' because the latter promotes early intervention in psychosis services (as an alternative to child and adolescent mental health services) for people aged 15 and older, some of whom (over 18) will be covered by this guideline. The GDG therefore wished to ensure that both guidelines were consistent in their key aspects.

Routinely monitor for other coexisting conditions, including depression and anxiety, particularly in the early phases of treatment.[1.1.4.2]

Routinely monitor for other coexisting conditions, including depression, anxiety and substance misuse particularly in the early phases of treatment. [2009; amended 2014] [1.3.3.3]

The GDG judged that substance misuse should be added to the recommendation because of its prevalence in people with psychosis and schizophrenia.

Carry out a full assessment of people with psychotic symptoms in secondary care, including an assessment by a psychiatrist. Write a care plan in collaboration with the service user as soon as possible. Send a copy to the primary healthcare professional who made the referral and the service user.[1.2.1.2]

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. [2009; amended 2014] [1.3.3.4]

The first sentence has been deleted because it was replaced by the assessment recommendations in sections 1.2.2 and 1.3.3. The second sentence was amended to reflect best practice as defined by the GDG.

If it is necessary for a GP to start antipsychotic medication, they should have experience in treating and managing schizophrenia. Antipsychotic medication should be given as described in section 1.2.4. [1.2.3.1]

Antipsychotic medication for a first presentation of sustained psychotic symptoms should not be started in primary care unless it is done in consultation with a consultant psychiatrist. [2009; amended 2014] [1.3.2.1]

The GDG judged that the context in which the 2009 recommendation had been made had changed, and that it was important to emphasise that antipsychotics should not be initiated in primary care unless done with supervision from a consultant.

The GDG considered it important to align this guideline and 'Psychosis and schizophrenia in children and young people' because the latter promotes early intervention in psychosis services (as an alternative to child and adolescent mental health services) for people aged 15 and older, some of whom (over 18) will be covered by this guideline. The GDG therefore wished to ensure that both guidelines were consistent in their key aspects.

For people with newly diagnosed schizophrenia, offer oral antipsychotic medication. Provide information and discuss the benefits and side-effect profile of each drug with the service user. The choice of drug should be made by the service user and healthcare professional together, considering:

• the relative potential of individual antipsychotic drugs to cause extrapyramidal side effects (including akathisia), metabolic side effects (including weight gain) and other side effects (including unpleasant subjective experiences)

• the views of the carer if the service user agrees.

[1.2.4.1]

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; updated 2014] [1.3.5.1]

This recommendation was amended in line with 'Psychosis and schizophrenia in children and young people' (NICE clinical guideline 155).

The GDG considered it important to align this guideline and 'Psychosis and schizophrenia in children and young people' because the latter promotes early intervention in psychosis services (as an alternative to child and adolescent mental health services) for people aged 15 and older, some of whom (over 18) will be covered by this guideline. The GDG therefore wished to ensure that both guidelines were consistent in their key aspects.

Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial. Include the following:

• Record the indications and expected benefits and risks of oral antipsychotic medication, and the expected time for a change in symptoms and appearance of side effects.

• At the start of treatment give a dose at the lower end of the licensed range and slowly titrate upwards within the dose range given in the British National Formulary (BNF) or SPC.

• Justify and record reasons for dosages outside the range given in the BNF or SPC.

• Monitor and record the following regularly and systematically throughout treatment, but especially during titration:

− efficacy, 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

− adherence

− physical health.

• Record the rationale for continuing, changing or stopping medication, and the effects of such changes.

• Carry out a trial of the medication at optimum dosage for 4–6 weeks.

[1.2.4.3]

Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial. Include the following:

• Discuss and record the side effects that the person is most willing to tolerate.

• Record the indications and expected benefits and risks of oral antipsychotic medication, and the expected time for a change in symptoms and appearance of side effects.

• At the start of treatment give a dose at the lower end of the licensed range and slowly titrate upwards within the dose range given in the British national formulary (BNF) or SPC.

• Justify and record reasons for dosages outside the range given in the BNF or SPC.

• Record the rationale for continuing, changing or stopping medication, and the effects of such changes.

• Carry out a trial of the medication at optimum dosage for 4–6 weeks.

[2009; amended 2014] [1.3.6.3]

This recommendation was amended because the GDG wished to make a separate recommendation about monitoring, in line with 'Psychosis and schizophrenia in children and young people' (NICE clinical guideline 155). Therefore the 4th bullet point of the original recommendation was used as the basis of a new recommendation (see 1.3.6.4).

The GDG considered it important to align this guideline and 'Psychosis and schizophrenia in children and young people' because the latter promotes early intervention in psychosis services (as an alternative to child and adolescent mental health services) for people aged 15 and older, some of whom (over 18) will be covered by this guideline. The GDG therefore wished to ensure that both guidelines were consistent in their key aspects.

For people with an acute exacerbation or recurrence of schizophrenia, offer oral antipsychotic medication. The choice of drug should be influenced by the same criteria recommended for starting treatment (see section 1.2.4). Take into account the clinical response and side effects of the service user's current and previous medication.[1.3.2.1]

For people with an acute exacerbation or recurrence of psychosis or schizophrenia, offer oral antipsychotic medication or review existing medication. The choice of drug should be influenced by the same criteria recommended for starting treatment (see sections 1.3.5 and 1.3.6). Take into account the clinical response and side effects of the service user's current and previous medication. [2009; amended 2014] [1.4.3.1]

This recommendation was amended in line with 'Psychosis and schizophrenia in children and young people' (NICE clinical guideline 155), to state that existing medication should be reviewed.

The GDG considered it important to align this guideline and 'Psychosis and schizophrenia in children and young people' because the latter promotes early intervention in psychosis services (as an alternative to child and adolescent mental health services) for people aged 15 and older, some of whom (over 18) will be covered by this guideline. The GDG therefore wished to ensure that both guidelines were consistent in their key aspects.

Mental health services should work in partnership with local stakeholders, including those representing BME groups, to enable people with mental health problems, including schizophrenia, to access local employment and educational opportunities. This should be sensitive to the person's needs and skill level and is likely to involve working with agencies such as Jobcentre Plus, disability employment advisers and non-statutory providers. [1.4.7.2]

Mental health services should work in partnership with local stakeholders, including those representing black, Asian and minority ethnic groups, to enable people with mental health problems, including psychosis or schizophrenia, to stay in work or education and to access new employment (including self-employment), volunteering and educational opportunities. [2009; amended 2014] [1.5.8.2]

The recommendation has been amended to reflect recent terminology relating to ethnic groups and to remove reference to specific agencies in order to ensure that the recommendation remains current for as long as possible. The GDG also wished to challenge the assumption that people with psychosis and schizophrenia are not already in employment by stating that they should be enabled to 'stay in work or education'.

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also Patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

For updates, also include the following (delete if not applicable):

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of 'The guidelines manual' (January 2009). This does not apply to any recommendations ending [2009] (see Update information above for details about how recommendations are labelled). In particular, for recommendations labelled [2009] the word 'consider' may not necessarily be used to denote the strength of the recommendation.

Other versions of this guideline

The full guideline, Psychosis and schizophrenia in adults contains details of the methods and evidence used to develop the guideline. It is published by the National Collaborating Centre for Mental Health.

The recommendations from this guideline have been incorporated into a NICE Pathway.

We have produced information for the public about this guideline.

Implementation

Implementation tools and resources to help you put the guideline into practice are also available.

Your responsibility

This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summaries of product characteristics of any drugs.

Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Copyright

© National Institute for Health and Care Excellence 2014. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.

ISBN: 978-1-4731-0428-0

  • National Institute for Health and Care Excellence (NICE)