Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

Preventing psychosis

  • 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. [new 2014]

First episode psychosis

  • 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). [2009]

Subsequent acute episodes of psychosis or schizophrenia and referral in crisis

  • 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]

  • 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]

Promoting recovery and possible future care

  • 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 1.3.6.1 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. [2009]

  • 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]

  • National Institute for Health and Care Excellence (NICE)