Dr David Shiers (left), Dr Clare Taylor, and Prof Tim Kendall summarise key aspects for primary care in updated NICE guidance on psychosis and schizophrenia in adults
P sychosis, and the specific diagnosis of schizophrenia, affects around 7 out of 1000 adults.1 Onset tends to occur between the ages of 15 and 35 years,1 which is also the time at which other major mental disorders first present.2 These disorders are characterised by acute episodes of distressing hallucinations (perception in the absence of any stimulus) and delusions (fixed or falsely held beliefs), disturbed behaviour, and memory and concentration difficulties. The acute episodes are usually preceded by a ‘prodromal period’ involving some deterioration in personal functioning and the emergence of psychotic symptoms that are briefer and less intense than those of an actual psychosis. The main challenge for general practitioners (GPs) in detecting psychosis promptly is to be able to distinguish its presentation during the early phases from other mental health problems, in patients who are of an age when psychological difficulties often first present.
People with psychosis and schizophrenia experience high rates of multiple comorbid physical health problems;3 cardiovascular disease (CVD) is the most common cause of premature mortality in this population.4 Lifestyle (poor diet, physical inactivity, smoking, and social exclusion) and potentially adverse effects of antipsychotic medication (including weight gain and disturbances of glucose and lipid metabolism) are contributory factors to CVD5 and other long-term physical health problems, such as diabetes6. Furthermore, some of the key risks for premature mortality in people with psychosis and schizophrenia may emerge and become established early, perhaps even before the first acute episode, especially if the person is already a heavy smoker.7
This article summarises the key recommendations that are relevant for GPs and other primary care professionals in NICE Clinical Guideline (CG) 178 on Psychosis and schizophrenia in adults: treatment and management,8 which was developed by the National Collaborating Centre for Mental Health (see Box 1, below). The guideline, issued in February 2014, updates and replaces the 2009 edition (NICE CG82).
|Box 1: NICE Accreditation Mark|
NICE Clinical Guideline 178 on Psychosis and schizophrenia in adults: treatment and management has been awarded the NICE Accreditation Mark.
This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.
The role of primary care
eople with severe mental illness, including psychosis and schizophrenia, view primary care as having a specific and important role to play in coordinating their mental and physical healthcare.9 Some primary care healthcare professionals, however, may hold negative opinions about providing care for this population10 and many see themselves as being involved only in the monitoring and treatment of physical illness.11 From 2006, the quality and outcomes framework (QOF) instituted a pay-for-performance scheme to encourage annual review of the physical health of people with severe mental illness.12 Nevertheless, average rates of GP consultation with people who are severely mentally ill have markedly diminished in the last 10 years,13 with CVD (and risk of CVD) being under-recognised and under-treated.14
The 2014 guideline update heralds a significant shift in direction for the management of psychosis and schizophrenia in adults from the previous (2009) guideline.8 While primary care is involved across the care pathway, healthcare professionals in this setting can make a critical contribution in three main ways, by:8
- improving the early clinical pathway for people experiencing an emerging psychosis (including its prodrome)
- providing better support for carers, particularly during their early experience of care
- reducing risk for physical health problems (e.g. CVD, obesity, and diabetes).
Although first presentations of psychotic disorders are uncommon in general practice (an individual GP will usually see about one case every 1–2 years), GPs are frequently consulted along the developing illness pathway15 and are the most likely practitioners to refer to specialist services. Moreover, GP involvement can lead to fewer detentions under the Mental Health Act16 and can reduce distress.15,17
NICE CG178 distinguishes between those people at increased risk of developing psychosis and those with a first episode of psychosis.8 In terms of identification in primary care, the differences between ‘prodromal’ and ‘definite’ symptoms of psychosis may be subtle and more a question of degree and progression. Recognising changes in an individual over time, being responsive to the family’s concerns, and being able to work with diagnostic uncertainty underpin the GP’s contribution to early identification and the initiation of a timely pathway to specialist services to facilitate proactive engagement and avoid crisis.
Where the presentation suggests the patient has the potential for developing psychosis (but without yet clear evidence of it), NICE CG178 promotes identification of individuals at increased risk and interventions to prevent transition to psychosis. An individual presenting with a high-risk state will typically appear distressed, have experienced a recent decline in social functioning, and will have any of the following:8
- psychotic symptoms that are transient (i.e. of short duration) or attenuated (i.e. of lower intensity)
- other experiences or behaviour suggestive of possible psychosis
- a first-degree relative with psychosis or schizophrenia.
In this situation, the GP should refer the person without delay to a specialist mental health service or early intervention in psychosis service, where individuals at increased risk of developing psychosis should receive:8
- individual cognitive behavioural therapy (CBT) that can be delivered with or without family intervention and
- treatments recommended in NICE guidance for any anxiety disorders,18-20 depression,21,22 emerging personality disorder,23,24 or substance misuse.25-27
NICE CG178 cautions that antipsychotic medication should not be offered to decrease the risk of, or to prevent, psychosis.8
First episode psychosis
Management and treatment
Where the diagnosis of psychosis is more certain, the contribution of the GP is again critical. Early detection and initiation of a rapid specialist assessment, with the emphasis on proactive engagement with the service user, can avoid hospital admission in crisis, which can often be traumatic for the person and their family. NICE CG178 makes it clear that an early intervention in psychosis service should be accessible to all people with a first episode, or first presentation, of psychosis, regardless of their age or of how long their psychosis has remained untreated.8
The recommended treatment for first-episode psychosis and for subsequent episodes is oral antipsychotic medication in conjunction with psychological treatment (CBT together with family intervention). The choice of antipsychotic medication should be made by the person and the professional working together, taking into account the likely benefits and possible side-effects.8 Antipsychotic medication for a first presentation of sustained psychotic symptoms should not be initiated by GPs and other primary healthcare professionals unless it is done in consultation with a consultant psychiatrist.8
The first experience of psychosis may not only be bewildering for the individual but can also have a significant impact on their family or carer.28 It is important that both primary care and specialist services support carers at this difficult time. NICE recommends that, as early as possible after diagnosis, professionals discuss with the individual and their family or carer how information about the person’s treatment and care will be shared; this should be reviewed regularly, especially if the person and their carer are having difficulties communicating or collaborating with each other. The importance of sharing information about risks, and the need for carers to understand the service user’s perspective, should be highlighted, while respecting the individual’s confidentiality. Carers should be included in decision-making if the service user agrees.8
To enable carers to support people with psychosis and schizophrenia, they should be given written and verbal information in an accessible format about:8
- diagnosis and management of psychosis and schizophrenia
- positive outcomes and recovery
- types of support for carers
- role of teams and services
- getting help in a crisis.
Carers should be offered an assessment of their own needs, provided by mental health services. A care plan should be developed for them and a copy given to the GP. This care plan should be reviewed annually. Carers should also be advised of their right to a formal carer’s assessment provided by social care services, and told how to access it.8
Carers should be offered a carer-focused education and support programme, which may be part of a family intervention for psychosis and schizophrenia. The intervention should be available as needed and have a positive message about recovery.8
Monitoring physical health and annual health-check
NICE CG178 outlines a key role for GPs and other primary healthcare professionals in monitoring the physical health of people with psychosis and schizophrenia. While the secondary care team should maintain responsibility for monitoring a person’s physical health and the effects of antipsychotic medication for at least the first 12 months or until the person’s condition has stabilised (whichever is longer), after that the responsibility for this monitoring may be transferred to primary care, under shared-care arrangements.8 Primary care should place these individuals on the practice case register within 12 months of diagnosis to ensure that systematic monitoring of physical health commences from this point of transfer of responsibility.
The contribution of primary care to the shared-care arrangement should include an annual physical health-check for the person, covering:8
- weight (plotted on a chart)
- waist circumference
- pulse and blood pressure
- fasting blood glucose, glycated haemoglobin (HbA1c), blood lipid profile, and prolactin levels
- assessment of:
- any movement disorders
- nutritional status, diet, and level of physical activity.
General practitioners should also consult the relevant NICE guidance for the monitoring of CVD, diabetes, obesity, and respiratory disease.29-32 A copy of the results should be sent to the care coordinator and psychiatrist and put in the secondary care notes.
People with psychosis or schizophrenia who are physically inactive or who have the following conditions need to be identified at the earliest opportunity:8
- high blood pressure
- abnormal lipid levels
- obesity or risk of obesity
- diabetes or risk of diabetes (as indicated by abnormal blood glucose levels).
Relevant NICE guidance should be followed for managing risks for new presentations of, and established, diabetes or CVD.29-36
Healthy eating and physical activity
All 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, and primary care can help support this intervention by making sure that people with rapid or excessive weight gain, abnormal lipid levels, or problems with blood glucose management are offered treatment in line with relevant NICE guidance.29-31
Given that smoking is a contributory factor in many chronic physical health problems in people with psychosis and schizophrenia, help with stopping smoking should be offered, even if previous attempts have been unsuccessful. The NICE guideline cautions that professionals need to be aware of the potential rapid and significant impact of reducing cigarette smoking on the metabolism of psychotropic medication, particularly clozapine and olanzapine. Interventions to consider include:8
- nicotine replacement therapy (usually a combination of transdermal patches with a short-acting product such as an inhalator, gum, lozenges, or spray) for people with psychosis or schizophrenia
- bupropion for people with a diagnosis of schizophrenia, or
- varenicline for people with psychosis or schizophrenia.
People taking bupropion or varenicline should be warned that there is an increased risk of adverse neuropsychiatric symptoms. They should be monitored regularly, particularly in the first 2–3 weeks of treatment. At the time of publication of NICE CG178 (February 2014), bupropion was contraindicated in people with bipolar disorder. Therefore, it is not recommended for people with psychosis unless they have a diagnosis of schizophrenia.
Returning to primary care
People whose symptoms have responded effectively to treatment and remain stable should be given the option of returning to primary care for further management and support. If a person decides to do this, the decision should be recorded in their notes and the transfer of responsibilities should be coordinated using the care programme approach.8
Where care has completely transferred to primary care, the annual review should include response to treatment, including changes in symptoms and behaviour and treatment adherence, in addition to a physical health review.8
It is particularly important that these individuals are actively reviewed from the practice register of people with severe mental illness. This is a key step in ensuring that people with psychoses receive appropriate mental and physical healthcare within primary care. Reasonable adjustments may be needed to facilitate review for those who struggle to keep appointments.
Ongoing support for carers, as described in the Key points, should be included in the planning and delivery of care.
Primary care professionals need to be alert to increased psychotic symptoms or a significant increase in the use of alcohol or other substances in people with an established diagnosis of psychosis or schizophrenia, because these may signal a relapse. They should consult the crisis section of the care plan and consider referring the person to the key clinician or care coordinator identified in the crisis plan.
Primary care professionals should also consider re-referral to secondary care if there is:8
- poor response to treatment
- non-adherence to medication
- intolerable side-effects from medication
- risk to self or others.
When re-referring people with psychosis or schizophrenia to mental health services, any requests that the person or their carer makes should be taken into account; this includes asking for the side-effects of existing treatments to be reviewed, or requests for accessing psychological therapies or other interventions.
When a person with psychosis or schizophrenia is planning to move to the catchment area of a different NHS trust, a meeting should be arranged between the services and the person involved to agree a transition plan before transfer. The person’s current care plan should be sent to the new secondary care and primary care providers.
Cardiovascular disease, rather than suicide, is the main contributor to the 15–20 years’ reduced life expectancy in people with psychosis and schizophrenia.37 Early age of onset, high rates of smoking, and accelerating weight gain and cardiometabolic risks within weeks of starting antipsychotic medication combine to expose these people to high risk of CVD and diabetes in their twenties and thirties—at a time of life before primary care usually considers active primary or secondary prevention of these conditions. In tackling these issues, NICE CG178 emphasises the need for systematic prevention (including promotion of physical activity, healthy nutrition, and support for smoking cessation), risk detection, and early intervention.8
Collaborative care will remain critical to successful implementation. New recommendations clarify clinical responsibilities, which are allocated specifically to secondary care for at least the first 12 months, and transfer to primary care thereafter.8
Challenges to implementation
A key challenge to successful implementation will be to encourage a positive approach. The late Professor Helen Lester concluded in her last public lecture, ‘Bothering about Billy’,38 that primary care is ideally placed to improve the health outcomes of this population. Professor Lester challenged her GP colleagues to embrace prevention, highlighting the strapline of the Lester Cardiometabolic Health Resource:39 ‘Don’t just screen, intervene’; she also reminded colleagues of the poor access and discrimination that ‘Billy’ and others often face in primary care.
NICE CG178 recognises the crucial contribution primary care makes to the care and management of people with psychosis and schizophrenia. Working collaboratively with secondary mental health services, GPs are very well placed to recognise the early warning signs of psychosis, expedite referral for assessment and treatment, and provide support to families and carers. They can also identify and treat a range of physical health problems that often coexist with psychotic disorders.
NICE implementation tools
NICE has developed the following tools to support implementation of Clinical Guideline 178 (CG178) on Psychosis and schizophrenia in adults: treatment and management. The tools are now available to download from the NICE website: www.nice.org.uk/CG178
NICE support for improvement systems and audit
Baseline assessment tool
The baseline assessment is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
NICE support for service improvement systems and audit
A costing statement has been produced because of wide variation in practice, therefore a national resource impact would be challenging to estimate. The statement has been prepared in consultation with experts working in this area and has been approved for publication by NICE.
Other sources of support
Healthy Active Lives (HeAL) consensus statement—International Physical Health in Youth working group
Available at: www.nice.org.uk/nicemedia/live/14382/66642/66642.pdf
A competence framework for psychological interventions with people with psychosis and bipolar disorder
An intervention framework for patients with psychosis on antipsychotic medication35
Available at: www.nice.org.uk/nicemedia/live/14382/66557/66557.pdf
- Commissioners should:
- ensure that they commission an early intervention service in line with NICE CG178 for rapid identification of people who are developing psychosis
- Commissioners could:
- by working with care providers and primary care, design a local care pathway that clearly sets out referral routes for people presenting with suspected psychosis and re-referral routes for people with relapsing psychosis
- by analysing QOF data, check how well GP practices are completing physical health checks for people with psychosis and addressing risk factors for CVD and metabolic disease
- consider commissioning specialist community health support workers for people with psychosis, to ensure that they attend for regular physical and mental health checks and comply with medication (both for their psychosis and for physical health needs)
- Local formularies should clearly identify:
- which antipsychotic drugs are to be used
- who should initiate these drugs
- any shared care arrangements for drugs that require close monitoring (e.g. clozapine).
- World Health Organization website. Mental health: schizophrenia. 2014. www.who.int/mental_health/management/schizophrenia/en/
- Kessler R, Amminger G, Aguilar-Gaxiola S et al. Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry 2007; 20: 359–364.
- Langan J, Mercer S, Smith D. Multimorbidity and mental health: can psychiatry rise to the challenge? Br J Psychiatry 2013; 202: 391–393.
- Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry 2007; 64 (10): 1123–1131.
- De Hert M, Dekker J, Wood D et al. Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC). Eur Psychiatry 2009; 24 (6): 412–424.
- Manu P, Correll C, van Winkel R et al. Prediabetes in patients treated with antipsychotic drugs. J Clin Psychiatry 2012; 73 (4): 460–466.
- Myles N, Newall H, Curtis J et al. Tobacco use before, at, and after first-episode psychosis: a systematic meta-analysis. J Clin Psychiatry 2012; 73 (4): 468–475.
- NICE. Psychosis and schizophrenia in adults: treatment and management. NICE Clinical Guideline 178. NICE, 2014. Available at: www.nice.org.uk/guidance/CG178
- Lester H, Tritter J, Sorohan H. Patients’ and health professionals’ views on primary care for people with serious mental illness: focus group study.BMJ 2005;330 (7500): 1122.
- Brown J, Weich S, Downes-Grainger E, Goldberg D. Attitudes of inner-city GPs to shared care for psychiatric patients in the community. Br J Gen Pract 1999; 49 (445): 643–644.
- Bindman J, Johnson S, Wright S et al. Integration between primary and secondary services in the care of the severely mentally ill: patients’ and general practitioners’ views. Br J Psychiatry 1997; 171: 169–174.
- NHS Employers website. Quality and outcomes framework. www.nhsemployers.org/your-workforce/primary-care-contacts/general-medical-services/quality-and-outcomes-framework (accessed 8 May 2014).
- Reilly S, Planner C, Hann M et al. The role of primary care in service provision for people with severe mental illness in the United Kingdom. PLoS One 2012; 7 (5): e36468.
- Royal College of Psychiatrists. Report of the National Audit of Schizophrenia (NAS) 2012. London: Healthcare Quality Improvement Partnership, 2012. Available at: www.rcpsych.ac.uk/pdf/NAS%20National%20report%20FINAL.pdf
- Cole E, Levy G, King M et al. Pathways to care for patients with a first episode of psychosis. A comparison of ethnic groups.Br J Psychiatry 1995; 167 (6): 770–776.
- Mental Health Act 1983 (as amended). Available at: www.legislation.gov.uk/ukpga/1983/20/section/20A (accessed 16 April 2014).
- Burnett R, Mallett R, Bhugra D et al. The first contact of patients with schizophrenia with psychiatric services: social factors and pathways to care in a multi-ethnic population. Psychol Med 1999; 29 (2): 475–483.
- NICE. Social anxiety disorder: recognition, assessment and treatment. Clinical Guideline 159. NICE, 2013. Available at: www.nice.org.uk/guidance/CG159
- NICE. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: management in primary, secondary and community care. Clinical Guideline 113. NICE, 2011. Available at: www.nice.org.uk/guidance/CG113
- NICE. Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. Clinical Guideline 26. NICE, 2005. Available at: www.nice.org.uk/guidance/CG26
- NICE. Depression with a chronic physical health problem: treatment and management. Clinical Guideline 91. NICE, 2009. Available at: www.nice.org.uk/guidance/CG91
- NICE. Depression: the treatment and management of depression in adults (update). Clinical Guideline 90. NICE, 2009. Available at: www.nice.org.uk/guidance/CG90
- NICE. Borderline personality disorder: treatment and management. Clinical Guideline 78. NICE, 2009. Available at: www.nice.org.uk/guidance/CG78
- NICE. Antisocial personality disorder: treatment, management and prevention. Clinical Guideline 77. NICE, 2009. Available at: www.nice.org.uk/guidance/CG77
- NICE. Drug misuse: opioid detoxification. Clinical Guideline 52. NICE, 2007. Available at: www.nice.org.uk/guidance/CG52
- NICE. Drug misuse: psychological interventions. Clinical Guideline 51. NICE, 2007. Available at: www.nice.org.uk/guidance/CG51
- NICE. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Clinical Guideline 115. NICE, 2011. Available at: www.nice.org.uk/guidance/CG115
- Awad A, Voruganti L. The burden of schizophrenia on caregivers: a review. Pharmacoeconomics. 2008; 26 (2): 149–162.
- NICE. Preventing type 2 diabetes: population and community-level interventions. Public Health Guidance 35. NICE, 2011. Available at: www.nice.org.uk/guidance/PH35
- NICE. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Clinical Guideline 67. NICE, 2008. Available at: www.nice.org.uk/guidance/CG67
- NICE. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline 43. NICE, 2006. Available at: www.nice.org.uk/guidance/CG43
- NICE. Prevention of cardiovascular disease. Public Health Guidance 25. NICE, 2010. Available at: www.nice.org.uk/guidance/PH25
- NICE. Hypertension: clinical management of primary hypertension in adults. Clinical Guideline 127. NICE, 2011. Available at: www.nice.org.uk/guidance/CG127
- NICE. Physical activity: brief advice for adults in primary care. Public Health Guidance 44. NICE, 2010. Available at: www.nice.org.uk/guidance/PH44
- NICE. Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. Clinical Guideline 15. NICE, 2004. Available at: www.nice.org.uk/guidance/CG15
- NICE. Type 2 diabetes: the management of type 2 diabetes. Clinical Guideline 87. NICE, 2009. Available at: www.nice.org.uk/guidance/CG87
- Wahlbeck K, Westman J, Nordentoft M et al. Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. Br J Psychiatry 2011; 199: 453–458.
- Lester H. Bothering about Billy. Royal College of General Practitioners James McKenzie Lecture 2012. Brit J Gen Pract 2013; 63 (608); e232–e234. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3582983/
- Lester H, Shiers D, Rafi I et al. Positive cardiometabolic health resource: an intervention framework for patients with psychosis on antipsychotic medication. London: Royal College of Psychiatrists, 2012. Available at: www.nice.org.uk/nicemedia/live/14021/62388/62388.pdf G