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Published on 1 July 2004

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NICE clinical guideline for schizophrenia

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The effects of schizophrenia on a person’s life experience and opportunities are considerable, and service users and carers need help and support to deal with their future and cope with the changes the illness brings.

Health professionals should work in partnership with service users and carers, offering help, treatment and care in an atmosphere of hope and optimism. Service users and their relatives seeking help should be assessed and receive treatment at the earliest possible opportunity. The assessment of needs for health and social care should be comprehensive and address medical, social, psychological, occupational, economic, physical and cultural issues.

Health professionals involved in the routine treatment and management of schizophrenia should take time to build a supportive and empathic relationship with service users and carers; this should be regarded as an essential element of the routine care offered.

Clear and intelligible information should be made available to service users and their families about schizophrenia and its possible causes, and about the possible role families can have in promoting recovery and reducing relapse.

Health professionals should make all efforts necessary to ensure that a service user can give meaningful and properly informed consent before treatment is initiated, giving adequate time for discussion and the provision of written information. They should also provide accessible information about the disease and its treatments to service users, carers and families; this should be considered an essential part of the routine treatment and management of schizophrenia.

Finally, it is recommended that the choice of treatment is developed and documented in individuals’ care programmes whenever possible.

Initiation of treatment at the first episode

Early referral
In primary care, all people with suspected or newly diagnosed schizophrenia should be referred urgently to secondary mental health services for assessment and development of a care plan. If there is a presumed diagnosis of schizophrenia, then part of the urgent assessment should include an early assessment by a consultant psychiatrist.

Early intervention services
As many people with actual or possible schizophrenia have difficulty in getting help, treatment and care at an early stage, early intervention services should be developed to provide the correct mix of specialist pharmacological, psychological, social, occupational and educational interventions at the earliest opportunity. When the needs of the service user and/or carer exceed the capacity of early intervention services, referral to crisis resolution and home treatment teams, acute day hospitals or inpatient services should be considered.

Early treatment
For acute symptoms, the GP should consider starting atypical antipsychotic drugs at the earliest opportunity. Wherever possible, this should be following discussion with a psychiatrist, and referral should be a matter of urgency.

Pharmacological intervention
Oral atypical antipsychotics (amisulpride, olanzapine, quetiapine, risperidone and zotepine) are considered in the choice of first-line treatments for newly diagnosed schizophrenia, with drugs at the lower end of the standard dose range being the preferred treatments.

Treatment of the acute episode

Service-level interventions
Community mental health teams are an acceptable way of organising community care. However, there is insufficient evidence of their advantages to support a recommendation that precludes or inhibits the development of alternative service configurations.

Crisis resolution and home treatment teams should be used to manage crises for service users and to deliver high-quality acute care. Teams should pay particular attention to risk monitoring as a high-priority routine activity. This type of intervention should be considered for people who may benefit from early discharge from hospital following inpatient care.

Acute day hospitals should be considered as a clinical, cost-effective option for provision of acute care, as an alternative to acute admission to inpatient care and to facilitate early discharge from inpatient care.

Finally, social, group and physical activities are an important aspect of comprehensive service provision as the acute phase recedes, and afterwards.

Pharmacological interventions
The choice of antipsychotic drug should be made jointly by the individual and the clinician responsible for treatment, based on an informed discussion of the relative benefits of the drugs and their side-effect profiles. The individual’s advocate or carer should be consulted where appropriate.

Antipsychotic therapy should be initiated as part of a comprehensive package of care that addresses the individual’s clinical, emotional and social needs. The clinician responsible for treatment and key worker should monitor both therapeutic progress and tolerability of the drug on an ongoing basis. Monitoring is particularly important when individuals have just changed from one antipsychotic agent  to another.

Dosage of conventional medication should be in the range of 300–1000mg chlorpromazine equivalents per day for a minimum of six weeks. The minimum effective dose should be used. Massive loading doses (“rapid neuroleptisation”) should not be used.

Oral atypical antipsychotic drugs should be considered as treatment options for individuals currently receiving conventional antipsychotic drugs who, despite adequate symptom control, are experiencing unsatisfactory management or unacceptable side-effects, and for those in relapse who have previously experienced unsatisfactory management or unacceptable side-effects with conventional antipsychotic drugs. The decision as to what are unacceptable side-effects should be taken following discussion between the patient and the clinician responsible for treatment. When discussion is not possible (in particular in the management of an acute schizophrenic episode), oral atypical drugs should be considered the treatment of choice because of the lower potential risk of extrapyramidal symptoms.

It is not recommended that, in routine clinical practice, individuals change to one of the oral atypical antipsychotic drugs if they are currently achieving good control of their condition without unacceptable side-effects with conventional antipsychotic drugs.

Antipsychotic drugs, atypical or conventional, should not be prescribed concurrently, except for short periods to cover changeover.

Early postacute period
Towards the end of an acute episode, service users should be offered help to understand the period of illness better. Carers may also need help in understanding the experience. Assessment for further help to minimise disability, reduce risk and improve quality of life should be routinely undertaken during recovery from the acute phase. In particular, psychological and family help, contingency planning and identifying local resources/services are important. Advice about drug treatments to maintain recovery is also important.

Promoting recovery

Primary care
Primary care professionals have an important part to play in the physical and mental healthcare of people with schizophrenia. They are best placed to monitor the physical health of people with schizophrenia and should do so regularly.

Secondary care
Secondary services should undertake regular and full assessment of the mental and physical health of their service users, addressing all issues relevant to a person’s quality of life and wellbeing.

Psychological interventions
Psychological treatments should be an indispensable part of the treatment options available for service users and their families in the effort to promote recovery.

Pharmacological interventions
The main aim is to prevent relapse and help keep a person stable enough to live as normal a life as possible.

Oral atypical antipsychotics are a treatment option for individuals currently receiving conventional antipsychotic drugs who, despite adequate symptom control, are experiencing unsatisfactory management or unacceptable side-effects, and for those in relapse who have previously experienced unsatisfactory management or unacceptable side-effects with conventional antipsychotic drugs.

Depot antipsychotic preparations should be a treatment option where a service user expresses a preference for such treatment because of its convenience, or as part of a treatment plan in which the avoidance of covert nonadherence with antipsychotic drugs is a clinical priority. These preparations should be prescribed within the standard recommended dosage and interval range for optimum effectiveness.

In the case of treatment-resistant schizophrenia, the clinician should consider olanzapine or risperidone. In individuals with evidence of resistance, clozapine should be introduced at the earliest opportunity. Although antipsychotics should not be prescribed concurrently, the addition of a second antipsychotic to clozapine may be considered in this case.

Rapid tranquillisation
Occasionally, during acute illness, some service users can become behaviourally disturbed and may need help to calm down. Thus it is important to ensure that the environment is properly adapted for the needs of the acutely ill and that communication between staff and service users is clear and therapeutic, in order to minimise frustration and misunderstandings.

Staff at psychiatric inpatient units should be trained in methods to assess and manage potential and actual violence using de-escalation techniques, restraint, seclusion and rapid tranquillisation.

Drug treatment
If drugs are needed to calm an individual, an oral preparation should be offered first. If intramuscular injection proves necessary, lorazepam, haloperidol or olanzapine are the preferred drugs. Wherever possible, a single agent is preferred to a combination. If two drugs are needed, lorazepam and haloperidol should be considered. If haloperidol is used, anticholinergics should be administered to reduce the risk of dystonia and other extrapyramidal side-effects. Vital signs and side-effects should be regularly monitored, and full physical and mental health tranquillisation may be traumatic, in which case patients will need debriefing with full explanation, discussion and support.

The aim of drug treatment is to calm the patient and reduce the risk of violence and harm, rather than to treat the underlying psychiatric condition. An optimal response would be a reduction in agitation or aggression without sedation, allowing the service user to participate in further assessment and treatment. Ideally, the drug should have a rapid onset of action and a low level of side-effects.
Drugs for rapid tranquillisation, particularly in the context of restraint, should be used with caution, particularly because of the risks of loss of consciousness and the possible damage to the therapeutic partnership between the service user and the clinician.

NICE
National Institute for Clinical Excellence
London, UK
E:nice@nice.nhs.uk
W:www.nice.org.uk
The National Institute for Clinical Excellence is a part of the National Health Service.
It makes recommendations on treatments and care using the best available evidence.
This article presents key information from the NICE guideline “Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and
secondary care” December 2002.
W:www.nice.org.uk/page.aspx?o=42461
This abridged version is published with permission from NICE.



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