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Psychosis and schizophrenia in adults: prevention and management

  • This Guidelines summary includes recommendations on Preventing psychosis, First episode psychosis, and Promoting recovery and possible future care that are relevant to the primary care setting. Please refer to the full guideline for the complete set of recommendations

Preventing psychosis

Referral from primary care

  • If a person is distressed, has a decline in social functioning and has:
    • transient or attenuated psychotic symptoms or
    • other experiences or behaviour suggestive of possible psychosis or
    • a first-degree relative with psychosis or schizophrenia
  • Refer them for assessment without delay to a specialist mental health service or an early intervention in psychosis service because they may be at increased risk of developing psychosis

Specialist assessment

  • A consultant psychiatrist or a trained specialist with experience in at-risk mental states should carry out the assessment

Monitoring and follow-up

  • If, after treatment, the person continues to have symptoms, impaired functioning or is distressed, but a clear diagnosis of psychosis cannot be made, monitor the person regularly for changes in symptoms and functioning for up to 3 years using a structured and validated assessment tool. Determine the frequency and duration of monitoring by the:
    • severity and frequency of symptoms
    • level of impairment and/or distressand
    • degree of family disruption or concern
  • If a person asks to be discharged from the service, offer follow-up appointments and the option to self-refer in the future. Ask the person’s GP to continue monitoring changes in their mental state

First episode psychosis

Primary care

  • Do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist

How to use antipsychotic medication

  • Before starting antipsychotic medication, undertake and record the following baseline investigations:
    • weight (plotted on a chart)
    • waist circumference
    • pulse and blood pressure
    • fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile, and prolactin levels
    • assessment of any movement disorders
    • assessment of nutritional status, diet and level of physical activity

Return to primary care

  • Offer people with psychosis or schizophrenia whose symptoms have responded effectively to treatment and remain stable the option to return to primary care for further management. If a service user wishes to do this, record this in their notes and coordinate transfer of responsibilities through the care programme approach

Primary care

Monitoring physical health in primary care

  • Develop and use practice case registers to monitor the physical and mental health of people with psychosis or schizophrenia in primary 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 How to use antipsychotic medication 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
  • Identify people with psychosis or schizophrenia who have high blood pressure, have abnormal lipid levels, are obese or at risk of obesity, have diabetes or are at risk of diabetes (as indicated by abnormal blood glucose levels), or are physically inactive, at the earliest opportunity following relevant NICE guidance in Monitoring physical health in primary care
  • Treat people with psychosis or schizophrenia who have diabetes and/or cardiovascular disease in primary care according to the appropriate NICE guidance
  • Healthcare professionals in secondary care should ensure, as part of the care programme approach, that people with psychosis or schizophrenia receive physical healthcare from primary care as described in recommendations

Relapse and re-referral to secondary care

  • When a person with an established diagnosis of psychosis or schizophrenia presents with a suspected relapse (for example, with increased psychotic symptoms or a significant increase in the use of alcohol or other substances), primary healthcare professionals should refer to the crisis section of the care plan. Consider referral to the key clinician or care coordinator identified in the crisis plan
  • For a person with psychosis or schizophrenia being cared for in primary care, consider referral to secondary care again if there is:
    • poor response to treatment
    • non-adherence to medication
    • intolerable side-effects from medication
    • comorbid substance misuse
    • risk to self or others
  • When re-referring people with psychosis or schizophrenia to mental health services, take account of service user and carer requests, especially for:
    • review of the side-effects of existing treatments
    • psychological treatments or other interventions

Transfer

  • 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 involved and the service user 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

© NICE 2014. Psychosis and schizophrenia in adults: prevention and management. Available from: www.nice.org.uk/guidance/CG178. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: June 2014.