Dr Jonathan Mitchell explains why the NICE quality standard for psychosis and schizophrenia in adults was needed and how it could improve outcomes for patients and carers

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Read this article to learn more about:

  • how to recognise people who may be at risk of developing psychosis
  • why early referral and treatment of people at risk of psychosis is important
  • why regular physical health checks and treatment should be offered to people with psychosis.

Key points

Audit points

GP commissioning messages

 

 Psychosis is a general term used to describe a group of disorders including schizophrenia in which people experience hallucinations, delusions, and changes in mood and behaviour. The use of the generic term 'psychosis' rather than specific diagnoses (such as schizophrenia) has become more common, in part due to stigma associated with more specific diagnoses, and in part to recognise that diagnostic uncertainty is common early in the course of psychotic illness.

Background

The overall incidence of psychosis is 32 per 100,000 individuals in England and appears to have been stable over time, but varies dramatically by age, sex, place, and migration status/ethnicity. The peak age of onset is in individuals in their 20s and incidence generally declines with age, although there is a second peak in women in their mid to late 40s.1

The duration of untreated psychosis (DUP), defined as the time from onset of persistent psychotic symptoms to treatment with an antipsychotic, is associated with long-term outcomes. A longer DUP is associated with worse outcomes in terms of symptoms and social function.2 Although most people improve following a first episode of psychosis, relapse rates are high and up to 80% have a further episode within 5 years.3

Diagnosis

It is often difficult to establish a firm diagnosis when people first present with psychotic symptoms, as symptom patterns may change over time. Mood disturbance is very common, with up to 80% of people reporting depression before, during, or in the year after a first episode of psychosis.4

It has long been recognised that many people who developed psychosis or schizophrenia had a prodromal period with changes in their thoughts, mood, and behaviour prior to the start of their psychotic illness. Over the last two decades, research has shown that it may be possible to identify people who have an 'at risk mental state' and are at a much higher risk of developing psychosis than the general population, with up to one-third of people presenting in this way going on to develop psychosis.5

People who are at increased risk of developing psychosis may present to primary care as distressed and/or have a decline in their social functioning in conjunction with transient or attenuated psychotic symptoms, other changes in experience or behaviour suggestive of psychosis, or a first-degree relative with psychosis.6 Patients presenting with these symptoms should be referred to specialist mental health services, or an early intervention in psychosis service, without delay.

Prevention in people who are at high risk

A recent systematic review and meta-analysis has shown that it may be possible to prevent psychosis in people who are at high risk.7 Antipsychotic drugs have not been shown to be effective in those who are at risk of developing psychosis and are known to be associated with side-effects and long-term physical health problems and so are best avoided; cognitive behavioural therapy (CBT) is the treatment of choice for those who are at increased risk of developing psychosis.6

The need for a quality standard

NICE Clinical Guideline (CG) 1 on the management of schizophrenia was the first guideline to be published by NICE (in 2002) and there have been two updates since, the latest (CG178) in 2014.6 The quality of care for people with psychosis and schizophrenia, however, remains variable: evidence-based psychological interventions are often not readily accessible, social outcomes for people with psychosis remain poor, and people with psychosis have a reduced life expectancy.6,8

Quality standard for psychosis and schizophrenia in adults

NICE Quality Standard (QS) 80 on Psychosis and schizophrenia in adults was published in February 2015.9 It covers the treatment and management of psychosis and schizophrenia in adults aged 18–60 years in primary, secondary, and community care. Its eight quality statements (see Table 1, below) should bring about improvements in treatment and better outcomes, including to:9

  • reduce excess premature mortality
  • increase employment and vocational rates
  • increase the use of crisis resolution and home treatment teams and reduce hospital admissions, including those under the Mental Health Act10
  • improve service user experience of mental health services.

Although most of the statements relate primarily to specialist mental health services, GPs and primary care services play a key role in the recognition and referral of people developing psychosis and in improving the physical health of people with psychosis and schizophrenia.

Referral to early intervention in psychosis services—statement 1

Early intervention in psychosis services have been shown to improve outcome following a first episode of psychosis;11 however, even in areas where there are well established early intervention in psychosis teams, there can be a long delay from referral to a mental health service and starting both antipsychotic medication and a comprehensive treatment package.12

Many people with a first episode of psychosis (or their families) initially seek help by going to their GP. It can be difficult to distinguish between people who have an 'at risk mental state' and are at increased risk of developing psychosis in the future, and those who have already developed psychosis. Although the distinction between these two groups is important (as the treatment required is different),6 the distinction in primary care may not be essential as both groups of people will benefit from a specialist assessment and treatment in a mental health team.

If GPs recognise psychosis early and urgently refer to a specialist mental health service highlighting the possibility of psychosis, then delays in assessment and treatment may be reduced. Referral in this way may also lead to improved pathways to care, reduced rates of hospitalisation, lower levels of Mental Health Act10 use, and improve longer-term outcomes.

Cognitive behavioural therapy—statement 2

Cognitive behavioural therapy for psychosis (CBTp) is a specific form of CBT for the treatment of psychosis. It has been shown to reduce rates of rehospitalisation, length of hospital stay, symptom severity, and depression.6 Although CBTp is recommended for all people with psychosis and at all phases of the illness, access to treatment is limited in many areas.8

Family intervention—statement 3

Family intervention (FI) is a psychological treatment for people with psychosis and their families and carers. There is a strong evidence base dating back to the 1960s and FI is known to reduce relapse and readmission rates; however, despite this evidence and recommendations in NICE guidelines since 2002, it is often not available.6,8 Family intervention should include at least 10 planned sessions, carried out over 3–12 months.9

Table 1: NICE quality standard for psychosis and schizophrenia in adults— list of quality statements9
No.Quality statement
1 Adults with a first episode of psychosis start treatment in early intervention in psychosis services within 2 weeks of referral.
2 Adults with psychosis or schizophrenia are offered cognitive behavioural therapy for psychosis (CBTp).
3 Family members of adults with psychosis or schizophrenia are offered family intervention.
4 Adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs are offered clozapine.
5 Adults with psychosis or schizophrenia who wish to find or return to work are offered supported employment programmes.
6 Adults with psychosis or schizophrenia have specific comprehensive physical health assessments.
7 Adults with psychosis or schizophrenia are offered combined healthy eating and physical activity programmes, and help to stop smoking.
8 Carers of adults with psychosis or schizophrenia are offered carer-focused education and support programmes.

NICE (2014) QS80. Quality standard for psychosis and schizophrenia in adults. Available at: www.nice.org.uk/guidance/qs80 Reproduced with permission.

Treatment with clozapine—statement 4

Although GPs are advised not to initiate antipsychotic treatment without the involvement of a psychiatrist, there is a well-established evidence base that antipsychotic drugs are effective in the treatment of acute psychotic episodes and prevention of relapse.6 Conventional antipsychotics are beneficial for most people with psychosis, however, a significant proportion of people with schizophrenia do not respond well or are unable to tolerate these.6 There is good evidence that clozapine is the most effective drug for people with treatment-resistant schizophrenia (schizophrenia that has not responded to trials of two different antipsychotics), but there is often a delay between the development of treatment resistance and a trial of clozapine.13

Treatment with clozapine can be associated with agranulocytosis and therefore it can only be prescribed by registered specialists; patients taking clozapine require regular monitoring of full blood count.14 Patients who develop neutropenia need to stop taking clozapine, although in some circumstances it may be possible for them to start taking it again.15

Supported employment programmes—statement 5

Employment rates among people with psychosis and schizophrenia are very low. For people wishing to find work, supported employment schemes have been found to lead to higher rates of employment than other interventions;6 however, as with talking treatments, the availability of supported employment programmes is limited.

Assessing physical health—statement 6

People with psychosis have a life expectancy up to 20 years less than the general population, with much of the excess mortality due to cardiovascular disease.6,8,9 About 10% of people with schizophrenia have type 2 diabetes (i.e. at least double the risk compared with the general population).16

Annual physical health reviews have been recommended to try and reduce excess mortality; however, a national audit of the treatment of people with schizophrenia found that although most patients reported they were happy with their physical healthcare, abnormal findings in health checks were not always acted upon: for example, only 54% of people with raised blood glucose and 20% of those with dyslipidaemia had received an appropriate intervention.17

The latest NICE guideline6 and quality standard9 recommend that mental health services conduct specific monitoring for people starting treatment with antipsychotic drugs and that people with psychosis have an annual physical health review conducted in primary care.

The annual physical health review conducted in primary care should include assessment of lifestyle and include:6

  • weight
  • waist circumference
  • pulse and blood pressure
  • fasting blood glucose, HbA1c, and blood lipid levels
  • overall physical health.

Intervention should be offered for any abnormal findings and results should be shared between the GP surgery and mental health team.

Promoting healthy eating, physical activity, and smoking cessation—statement 7

The rates of obesity and type 2 diabetes are higher in people with psychosis or schizophrenia than in the general population and this, together with a higher rate of smoking, is likely to contribute to reduced life expectancy. Although some of the increase in obesity may be associated with antipsychotic drug treatment, lifestyle factors play a significant role. People with psychosis often have a more sedentary lifestyle and poor diet. Combined healthy eating and physical activity programmes can help promote weight loss.6,9

About 60% of people with psychosis smoke and most want to stop or cut down. Nicotine replacement and treatment with bupropion and varenicline have been shown to be effective for people with psychosis. Although stopping smoking is not associated with an increase in psychotic symptoms, neuropsychiatric symptoms have been reported with the use of bupropion and varenicline and so their use should be accompanied by appropriate monitoring.18 Healthcare and social care practitioners should also be aware that smoking increases the metabolism of some medications.18

Carer-focused education and support—statement 8

Caring for a person with psychosis can be a source of stress and can have a significant impact on the carer's quality of life. Carer-focused education and support programmes have been shown to improve outcomes for carers.6 These programmes differ from FI as they are focused on the carer's needs and are intended to improve outcomes for carers rather than the person with psychosis; they may also help carers to be able to identify symptoms of concern.

Conclusion

Antipsychotic drug and psychological treatments are effective for psychosis, although availability of psychological treatments has been limited. The physical healthcare of people with psychosis requires improvement, and in some cases, closer liaison between primary and secondary care may help to achieve this.

The proportion of people with psychosis:

  • who are on the practice SMI register
  • who are on the SMI register and who have had a comprehensive annual physical health review including assessment of lifestyle, smoking status, BMI, blood pressure, blood glucose, and lipids in the last 12 months
  • who smoke and who have been offered support to stop smoking
  • who are overweight or obese and who have been offered an intervention to lose weight
  • who, on the basis of blood tests results, are at high risk of or who have diabetes, and have been offered treatment.

SMI=severe mental illness; BMI=body mass index

Key points

  • Early recognition of emerging psychotic symptoms may enable psychosis to be prevented
  • Early treatment of psychosis is associated with better long-term outcomes
  • People treated with a comprehensive treatment package in an early intervention in psychosis team have better outcomes
  • Physical health problems are very common in individuals with psychosis. Screening may improve outcomes, but only if abnormal findings are recognised and intervention offered
  • Joint working and good communication links between primary care and mental health services is essential to improving care and treatment of people with psychosis.

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Audit points

The proportion of people with psychosis:

  • who are on the practice SMI register
  • who are on the SMI register and who have had a comprehensive annual physical health review including assessment of lifestyle, smoking status, BMI, blood pressure, blood glucose, and lipids in the last 12 months
  • who smoke and who have been offered support to stop smoking
  • who are overweight or obese and who have been offered an intervention to lose weight
  • who, on the basis of blood tests results, are at high risk of or who have diabetes, and have been offered treatment.

SMI=severe mental illness; BMI=body mass index

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GP commissioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • CCG mental health commissioning leads should review their local portfolio of commissioned services against the recommendations in NICE QS80 and identify any gaps in service provision
  • CBTp and family intervention are evidence based and are often not freely available to patients with schizophrenia and other psychoses. Such services should specifically be identified as a priority for provision
  • Early identification of psychoses and prompt intervention is linked to better outcomes:
    • CCGs should work with primary care services to set clear referral criteria and pathways for specialist assessment even if the initial diagnosis is not clear
  • Regular physical health checks and preventative health programmes are important in this patient group and are incentivised in general practice through the QOF (domains MH003–MH010):
    • CCGs could audit practice achievement against these QOF domains (to include exception reporting) and commission proactive healthcare programmes to reach those patients who fail to have regular health checks.

CCG=clinical commissioning group; QS=quality standard; CBTp=cognitive behavioural therapy for psychosis; QOF=quality and outcomes framework

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References

  1. Kirkbride J, Errazuriz A, Croudace T et al. Incidence of schizophrenia and other psychoses in England, 1950–2009: a systematic review and meta-analyses. PLoS One 2012; 7: e31660.
  2. Penttilä M, Jääskeläinen E, Hirvonen N et al. Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br J Psychiatry 2014; 205 (2): 88–94.
  3. Robinson D, Woerner M, Alvir J et al. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 1999; 56: 241–247.
  4. Upthegrove R, Birchwood M, Ross K et al. The evolution of depression and suicidality in first episode psychosis. Acta Psychiatr Scand 2010; 122 (3): 211–218.
  5. Fusar-Poli P, Bonoldi I, Yung A et al. Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Arch Gen Psychiatry 2012; 69 (3): 220–229.
  6. National Collaborating Centre for Mental Health, NICE. Psychosis and schizophrenia in adults: treatment and management. Clinical Guideline 178. NICE, 2014. Available at:www.nice.org.uk/guidance/cg178
  7. Stafford M, Jackson H, Mayo-Wilson E et al. Early interventions to prevent psychosis. BMJ 2013; 346: f185.
  8. The Schizophrenia Commission. The abandoned illness: a report from the schizophrenia commission. London: Rethink Mental Illness, 2012. Available at: www.rethink.org/media/514093/TSC_main_report_14_nov.pdf
  9. NICE. Psychosis and schizophrenia in adults. Quality Standard 80. NICE, 2015. Available at: www.nice.org.uk/guidance/qs80 (accessed 8 June 2015)
  10. Mental Health Act 2007, as amended. Available at: www.legislation.gov.uk/ukpga/2007/12/contents
  11. Bird V, Premkumar P, Kendall T et al. Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. Br J Psychiatry 2010; 197 (5): 350–356.
  12. Birchwood M, Connor C, Lester H et al. Reducing duration of untreated psychosis: care pathways to early intervention in psychosis services. Br J Psychiatry 2013; 203 (1): 58–64.
  13. Howes O, Vergunst F, Gee S et al. Adherence to treatment guidelines in clinical practice: study of antipsychotic treatment prior to clozapine initiation. Br J Psychiatry 2012; 201 (6) 481–485.
  14. NICE BNF website. Clozapine. Formulary.www.evidence.nhs.uk/formulary/bnf/current (accessed 1 June 2015).
  15. Dunk L, Annan L, Andrews C. Rechallenge with clozapine following leucopenia or neutropenia during previous therapy. Br J Psychiatry 2006; 188 (3): 255–263.
  16. Stubbs B, Vancampfort D, De Hert M et al. The prevalence and predictors of type two diabetes mellitus in people with schizophrenia: a systematic review and comparative meta analysis. Acta Psychiatr Scand 2015: 1–14 doi: 10.1111/acps.12439 [Epub ahead of print].
  17. Crawford M, Jayakumar S, Lemmey S et al. Assessment and treatment of physical health problems among people with schizophrenia: national cross-sectional study. Brit J Psychiatry 2014; 205 (6): 473–477.
  18. Campion J, Shiers D, Britton J et al. Primary care guidance on smoking and mental disorders. London: Royal College of General Practitioners & Royal College of Psychiatrists, 2014. Available at: www.rcpsych.ac.uk/pdf/PrimaryCareGuidanceonSmokingandMental Disorders2014update.pdf