Psychosis and schizophrenia in adults: prevention and management

Overview

This example describes the Avon and Wiltshire Mental Health Partnership (AWP)'s approach to improving prescribing practice to ensure patients with a first episode of psychosis are offered the right treatment. This draws upon psychosis and schizophrenia in adults: prevention and management (NICE clinical guideline 178).

A critical component of optimal early treatment for people with a first episode psychosis includes appropriate and effective use of medications.

There are no clear guidelines for prescribing antipsychotics for people with a first episode of psychosis, however. We wanted to develop clear guidance for prescribers to show when treatment should be started, what should be prescribed, and for how long. NICE guidance clearly states that the antipsychotic medication should be chosen by the service user and healthcare professional together, taking into account the likely benefits and possible side effects of each drug.

The NICE guidance also provides clear information on baseline investigations, reviews of treatment including side effects, and physical health monitoring needed. But there is no specific guidance about what medication choices are best, or in what order medication should be trialled. We wanted to provide prescribers with clear advice to ensure that NICE guidance was adhered to, and minimise side effects for this vulnerable group of patients.

Before the project started there were no prescribing guidelines for the first episode psychosis across the AWP. The AWP serves a population of approximately 1.8 million people.

Psychosis affects 1% to 3% of the population, which is higher than diabetes in young people. A person's experience of medication in the first stages of treatment can have a lasting impact on future attitudes towards medication, adherence and outcomes. People experiencing a first episode psychosis are more likely to have side effects from antipsychotics.

If a person experiences side effects, they are more likely to stop treatment, leading to a potential relapse of symptoms, which are harder to treat, possibly leading to an inpatient stay. This is detrimental to the person's care and quality of life. Prescribing for a first episode psychosis is therefore a critical time to optimise medical treatments and maximise the chance of a positive outcome for the person. We set up a working group to develop and improve prescribing guidelines.

An initial baseline trust-wide audit showed that practice around first episode prescribing varied greatly. We found that patients were not being included in prescribing decisions, first-generation antipsychotics were sometimes used (with detrimental side effects), medication was not being trialled for an adequate period of time, and clozapine was not being offered when it was clinically appropriate to do so. Looking at the most up-to-date research, we put together a prescribing guideline to help prescribers make the best decisions for their patients.

We sought feedback from prescribers across the trust, including our inpatient colleagues, developing the guidelines with the help of our trust quality improvement team, pharmacists and AWP's medicines optimisation group. We presented this to the trust-wide medical advisory group, and to the Southwest Regional Early Intervention in Psychosis Network.

We were keen to develop guidelines that would be appropriate for all people presenting with a first episode psychosis, whether that be in the community or in an inpatient setting. We therefore spent time presenting our work around the trust, and consulting colleagues across the Southwest Regional Early Intervention in Psychosis Network, and the Royal College of Psychiatrists Early Intervention Network.

At each step, we collected feedback and refined the guidelines so they would reflect best clinical practice. One particular challenge was engaging our inpatient colleagues. There is invariably pressure to stabilise a patient's mental state, treat quickly, and discharge back to the community as quickly as possible because of bed pressures within mental health. We presented our work to the trust medical director who endorsed our project, taking steps to ensure that bed pressures did not get in the way of our treatment guidelines.

As well as working closely with inpatient colleagues to develop the guidelines, we also produced teaching sessions and presented the guidelines and rationale at each locality across the trust to raise awareness and promote good prescribing practice that followed NICE guidance. The project did not incur any costs and actually proved to be cost saving for the trust; our first-line recommended treatment, aripiprazole, was shown to save the trust nearly £3,000 over the course of the person's treatment.