New and updated aspects in NICE guidance on managing schizophrenia in adults include early intervention, medication and cultural sensitivity
Sin, J. et al (2009) Schizophrenia in adults 1: NICE guidance on detection, assessment and initial management. Nursing Times; 105: 20, early online publication..
This first in a two-part unit on updated NICE guidance on schizophrenia looks at early detection, assessment and initial treatment of the condition. It also examines issues around working with people from diverse ethnic and cultural groups.
Keywords: Mental health, Psychosis, Schizophrenia
- This article has been double-blind peer reviewed
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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; Tim Kendall, FRCPsych, MBChB, BMedSci, is joint director, National Collaborating Centre for Mental Health; deputy director, Royal College of Psychiatrists’ Research and Training Unit; and consultant psychiatrist and medical director, Sheffield Health and Social Care NHS Foundation Trust.
- Understand the implications of the updated NICE guideline on promoting access for and engagement of people from black and minority ethnic groups.
- Be familiar with the main principles of promoting early detection, comprehensive assessment and starting drug treatment in schizophrenia.
The National Collaborating Centre for Mental Health recently developed a national guideline on treating and managing schizophrenia in adults in primary and acute care (NICE, 2009). The guideline is an update of the very first guideline produced by NICE in 2002. The key areas that have been updated or are new are outlined in Box 1.
Box 1. Updated or new areas
- Access for and engagement of minority ethnic groups.
- Evidence for early intervention services.
- Evidence about the use of some psychological and psychosocial interventions (there is more detail about the purpose, principles and delivery of psychological interventions and a new review of arts therapies).
- Evidence about antipsychotic drugs and advice on information-giving, benefits and side-effect profiles, and collaborative decision-making.
- Reviews of primary care and treatment for physical health problems (there is more explicit detail on how to carry out physical health checks).
The guidance identifies the main interventions for people with schizophrenia and emphasises early detection and intervention. There is also a focus on long-term recovery and promoting clients’ choices about managing their condition.
Nursing staff can play a key role in the detection and the different phases of treating schizophrenia. Nurses in primary care and mental health nurses specialising in various areas of acute care – for example, acute inpatient, community mental health services and early intervention services for psychosis – often work with clients, their families and carers, and other agencies involved in caring for them.
Nurses are involved in all aspects of care for this group, including assessment, care coordination and promoting engagement. They also work with the wider multidisciplinary team and other health and social care professionals, helping to develop a comprehensive care plan using the care programme approach (Department of Health, 2008).
The guideline is organised according to four major areas: care across all phases; starting treatment for the first episode; treating the acute episode; and promoting recovery.
Key features of schizophrenia
Schizophrenia is a major psychiatric disorder (or cluster of disorders), and the most common form of psychotic disorder, which alters a person’s perception, thoughts and behaviour.
Over a lifetime, about 1% of the population will develop schizophrenia. The UK National Survey of Psychiatric Morbidity found a population prevalence of five per 1,000 of psychotic disorder in people aged 16-74 years (Singleton et al, 2000). Average rates for men and women are similar, although there is a lower female rate in late adolescence and early adulthood (because the mean age of onset is about five years later in women).
People who develop schizophrenia will have their own unique combination of symptoms and experiences, the precise pattern of which will be influenced by their particular circumstances.
Common initial or so-called ‘prodromal’ symptoms and difficulties include: social withdrawal; unusual and uncharacteristic behaviour; disturbed communication and affect; bizarre ideas and perceptual experiences; and reduced interest in and motivation for doing day-to-day activities (these symptoms are sometimes called ‘negative’ symptoms).
Such symptoms are usually exacerbated in an acute phase, which is marked by characteristic ‘positive’ symptoms of hallucinations, delusions and behavioural disturbances. The acute phase is usually resolved with some treatment, and most people will gradually recover, although some will continue to experience residual symptoms and relapses.
Early detection and assessment
The guideline says that people presenting with psychotic symptoms (hallucinations and/or delusions) in primary care should be referred to a local community-based acute mental health service such as an early intervention service, crisis resolution and home treatment team or a community mental health team, depending on the stage and severity of the illness and local service resources.
Mental health nurses are the core members of multidisciplinary community mental health services. They play a key liaison and advisory role with their primary care colleagues and other community agencies.
Where concerns for people presenting with suspected symptoms of psychosis are raised, mental health nurses provide specialist advice for further assessment in primary care and/or initiate referral to acute care specialist mental health services.
Mental health nurses often conduct the initial assessment and engage with people with psychotic symptoms in community settings. Family members and/or carers will also be involved if the person with psychotic symptoms agrees.
The NICE guideline emphasises 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 (including employment and functional activity); history of prescribed and non-prescribed drugs; quality of life; responsibility for children; risk of harm to self and others; sexual health; and social networks.
Clients commonly have other mental health problems, especially depression and anxiety, so it is important to monitor for these in the early phases.
Following assessment, a care plan should be developed with clients and a copy should be sent to the professional in primary care who made the referral, other agencies or services that provide significant care and families or carers, if appropriate.
The care plan should include a plan of what should happen in a crisis and the roles of both primary and acute care should be defined.
Partnership working with clients and carers
Before each decision about a particular treatment or intervention is made, it is important that clients are provided with appropriate and detailed information so they can give meaningful consent.
Healthcare professionals should understand the Mental Capacity Act 2005 and be able to apply its principles. It is important also to be aware that mental capacity is specific to each decision; therefore, capacity needs to be assessed when each decision is taken.
These principles are applicable whether or not the person is being treated under the Mental Health Act and are particularly important for people from black and minority ethnic groups (see below).
Within the care-planning process, nurses should support people with schizophrenia to prepare advance statements (of preferred treatments) and advance decisions (to refuse treatment); this is especially important for those whose illness is severe and those who have been treated under the Mental Health Act. Healthcare professionals should honour advance decisions and take advance statements into consideration wherever possible.
Families and carers can play an important part in supporting clients, and, if clients consent to them being involved, they should be given information about the condition and its treatment and supported in their role as a carer.
Families and carers should be given information about local support groups and other voluntary organisations aimed at them, and should be offered a carer’s assessment. Any needs of children in the family, including young carers, should also be assessed.
Working with people from diverse ethnic and cultural groups
Part of promoting early detection and intervention is ensuring that people from diverse ethnic and cultural backgrounds, developing psychotic symptoms for the first time, do not encounter barriers in accessing care and are offered effective interventions.
Studies have shown, for instance, that African-Caribbean people in the UK have a higher incidence of schizophrenia than the general population, but treatments and services are not adapted to meet their needs (Kirkbride et al, 2006).
The guideline recommends that healthcare professionals working with people with schizophrenia should be competent in assessing people from diverse ethnic and cultural backgrounds and explaining the diagnosis and treatment options in a way that is culturally appropriate.
To help this process, mental health services should ideally work with local voluntary BME groups to ensure that culturally appropriate psychological treatment is provided.
Nurses inexperienced in working with clients from diverse ethnic and cultural backgrounds should seek advice and supervision from healthcare professionals who are experienced in working transculturally.
To enhance engagement with clients and their families from diverse backgrounds, nurses should explore and understand the cultural and ethnic differences in belief about biological, social and family influences on the causes of abnormal mental states. They should also address their differences in treatment expectations and adherence.
Early intervention services are vital for people presenting with first-episode or early psychosis. This should be irrespective of age or for how long they have had symptoms.
Early intervention services should provide the full range of interventions recommended in this guideline for people with psychosis. Nurses are an essential part of the early intervention service and should be involved in providing some of these interventions.
Drug treatment is usually started in acute care where psychiatrists and independent nurse prescribers are well placed to oversee its initiation and ongoing management.
If it is necessary for a GP to start medication, they should be experienced in treating people with schizophrenia. Nurse prescribers should maintain their advisory role for GPs who provide treatment for this group.
In addition to providing supplementary or independent prescribing, nurses are important 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.
Decisions about which antipsychotic to use should be made in partnership with clients, and their carer if the client agrees, taking into account relative potential of individual drugs to cause extrapyramidal side-effects (such as akathisia), metabolic side-effects (such as weight gain) and other ones (including unpleasant subjective experiences).
Combinations of antipsychotics should not usually be started except for short periods, for example when changing medication.
If the client has specific cardiovascular risk (such as high blood pressure), a history of cardiovascular disease or is being admitted as an inpatient, then an ECG should be carried out before starting an antipsychotic. The summary of product characteristics for the drug may also indicate the need to have an ECG.
- Part 2, to be published next week, discusses interventions for acute episodes and promoting recovery.
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Department of Health (2008) Refocusing the Care Programme Approach: Policy and Positive Practice Guidance. London: DH.
Kirkbride, J.B. et al (2006) Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AeSOP study. Archives of General Psychiatry; 63: 250–258.
NICE (2009) Schizophrenia (Update).Core Interventions in the Treatment and Management of Schizophrenia inAdults in Primary andSecondary Care (Update). London: NICE.
Singleton, N. et al (2000) Psychiatric Morbidity Among Adults Living in Private Households, 2000. London: HMSO.