Two members of the NICE guideline development group highlight important issues from the latest evidence-based guideline for readers of Nursing Times
Keywords: Schizophrenia, Mental health, Antipsychotics
NICE (2009) has recently launched an updated guideline on treating and managing schizophrenia in adults in primary and acute care. This replaces its very first guideline produced in 2002.
The guidance is organised into four major areas: care across all phases; initiating treatment for first episodes; treating acute episodes; and promoting recovery. The key areas that have been updated or are new are:
- Access and engagement for minority ethnic groups;
- Evidence for early intervention services;
- Evidence about using some psychological and psychosocial interventions;
- Evidence about antipsychotic drugs and advice on information-giving, benefits and side-effects, and collaborative decision-making;
- Reviews of primary care and treatment for physical health problems.
Mental health nurses play a key role in all aspects of care and the phases of treating schizophrenia. The NICE guideline, which identifies interventions for people with this condition based on updated evidence, is vitally important for nurses.
The guidance emphasises early detection and intervention. Early intervention services are vital for people presenting with first-episode or early psychosis. These should be irrespective of age or for how long the person has been experiencing symptoms.
Mental health nurses often play a key liaison and advisory role with their colleagues in primary care and other community agencies, and/or initiate referral to acute care specialist mental health services.
The NICE guideline strongly advocates early access to assessment and treatment. People with schizophrenia should receive a comprehensive multidisciplinary assessment in acute care, including a psychiatric, psychological and physical health assessment.
Other factors to address include: accommodation; culture and ethnicity; economic status; occupation and education; history of drug (both prescribed and non-prescribed) use; quality of life; responsibility for children; risk of harm to self and others; sexual health and social networks; and any co-morbid conditions.
Mental health nurses, as key members of multidisciplinary mental health services, are well placed to conduct comprehensive assessments and to devise care plans, especially in their role as care coordinators in the care programme approach. This approach aims to ensure that coordinated care meets users’ needs.
Following assessment, a care plan should be developed with clients and a copy should be sent to the primary care professional who made the referral, other agencies or services providing significant care and families or carers, if appropriate.
Families and carers can play an important part in supporting people with schizophrenia. Clients must consent to them being involved. Mental health nurses, in their role as care coordinators, should oversee carers’ assessments.
Pharmacological treatment remains the cornerstone for people with schizophrenia. This usually starts in acute care where psychiatrists and independent nurse prescribers are well placed to oversee its initiation and ongoing management.
Furthermore, nurses have an important role in giving information on medication, discussing and exploring the risk-benefit profile, and monitoring tolerance and side-effects collaboratively with clients. Such medication-management strategies are crucial in optimising the benefits of the medication regimen and adherence.
Important evidence-based treatments for schizophrenia also include specific psychological interventions, namely cognitive behavioural therapy (CBT), family intervention and arts therapies.
Mental health nurses working as care coordinators for clients are ideally placed to promote access to such interventions, identify indications for treatment, make referrals to appropriate services and promote engagement with interventions. Specialist mental health nurses with appropriate training and supervision can also provide interventions on a one-to-one basis.
Clients’ physical health should be monitored at least once a year in primary care. Nurses in primary care will be involved in carrying out physical health checks, while their counterparts in acute care should ensure, as part of planning within the care programme approach that clients receive physical health care from primary care.
To promote and optimise recovery, clients also need support in – and access to – employment, education and occupational activities to help integrate them into their usual social context and role, and realise their aspirations. Mental health nurses should take a leading role, working alongside clients, and seek out opportunities beyond statutory service settings.
Jacqueline Sin, MSc, BSc, BN, BGS, PGCert CPN, RMN, is education and practice lead for psychosocial interventions, Berkshire Healthcare NHS Foundation Trust and Thames Valley University; Clare Taylor, DPhil, MPhil, BA, is editor, National Collaborating Centre for Mental Health.
NICE (2009)Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults inPrimary and Secondary Care (Update). London: NICE.