older psychiatryPeople considered to be at increased risk of developing psychosis should be offered cognitive behavioural therapy (CBT) as opposed to antipsychotic medication, according to the National Institute for Health and Care Excellence (NICE).

In its updated guidance on psychosis and schizophrenia, NICE says that individual CBT should be offered for prevention with or without family intervention, and that interventions should be offered as recommended in NICE's guidance for people with any of the anxiety disorders, depression, emerging personality disorder or substance misuse.

For people with a first episode of psychosis, NICE recommends offering an oral antipsychotic medication in conjunction with a psychological intervention.

In addition, people who want to try psychological interventions alone should be advised that these are more effective when delivered in conjunction with antipsychotic medication.

NICE adds that the choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the care if the service user agrees. Doctors should provide information and discuss each drug's likely benefits and possible side effects.

Monitor physical health

Elsewhere in the updated recommendations NICE says that GPs and other primary healthcare professionals should monitor the physical health of people with psychosis and schizophrenia when responsibility for monitoring is transferred from secondary care.

The health check should be comprehensive, focusing on physical health problems that are common in people with psychosis and schizophrenia. They should include the investigations offered before starting antipsychotic medication.

NICE has also sought to address other areas where people who have a psychotic episode may need help. For instance, many people who have a psychotic episode often experience social exclusion, or reduced opportunities to return to work or study afterwards.

As a result, NICE has called for supported employment programmes to be offered to people with psychosis or schizophrenia who wish to find or return to work. Occupational or educational activities, including pre-vocational training should be considered for those who are unable to work or unsuccessful in finding employment.

The updated guideline also calls for more support for carers, and recommends that those caring for people with psychosis or schizophrenia should be offered an assessment provided by mental health services of their own needs, which should be discussed with them.

Also, a care plan should be developed to address any identified needs which should be reviewed annually, and a copy should be given to the carer and their GP.

Welcome acknowledgement

Mental health charities have welcomed NICE’s guidelines. Naomi Phillips, head of policy and campaigns at Mind, said: “We are pleased that NICE has acknowledged CBT can help not just those with a diagnosis, but that it could also play a preventative role and its use should be extended to those who may be prone to developing schizophrenia. We know that talking therapies can be effective and don’t have the unpleasant side effects that many drugs bring. 

“The Improving Access to Psychological Therapies (IAPT) scheme has allowed many more people to be referred for talking therapies, but we know there are still huge variations in waiting times across the country. For early intervention to work, its vital people are able to access the services they need within 28 days.

“Even though schizophrenia is fairly common, affecting about 1 in 100 people, there is still a huge stigma surrounding it which can prevent people seeking help. That’s why it’s so vital that healthcare professionals monitor individuals and look out for symptoms early, particularly those identified as being more susceptible. With the right support, it is possible to recover.”

Dr Felix Davies, managing director for mental health services at Turning Point, added: “The emphasis on early intervention is hugely important as is the focus on person-centred care. People with schizophrenia often face stigma and inequalities within the health system which are unacceptable. It is imperative, therefore, that there is adequate funding for mental health services, that the support available is suited to each person’s specific needs and that all services consult with individuals about their own care. This is essential to successful treatment. 

“Progress is being made but we must work together as providers of mental health services to ensure that we continue to improve the services and care available, including making parity of esteem a reality. We cannot afford to stand still.”