National Institute for Health and Clinical Excellence (NICE)
Printable version E-mail this to a friend

GPs should refer young people with psychosis or schizophrenia "without delay"

GPs should refer children and young people up to the age of 18 who present with psychotic symptoms or other experiences suggestive of possible psychosis without delay to a specialist mental health services, latest NICE guidance suggests.

Specialist services include Child and Adolescent Mental Health Services (CAMHS) for those up to 17 years of age, or an early intervention in psychosis service for those 14 years or over, which includes a consultant psychiatrist with training in child and adolescent mental health.

Children and young people with a first presentation of sustained psychotic symptoms lasting 4 weeks or more should also be referred urgently to a CAMHS or an early intervention in psychosisservice, says NICE,

In the UK, the prevalence of psychotic disorders in children aged between 5 and 18 years has been estimated to be 0.4 per cent. Schizophrenia accounts for 24.5 per cent of all psychiatric admissions in young people aged 10-18 years with an exponential rise across the adolescent years. The rise in incidence increases most from age 15 onwards.

For this guidance, the term ‘psychosis' is used to refer to the group of psychotic disorders that includes schizophrenia, schizoaffective disorder, schizophreniform disorder and delusional disorder.

The guideline also addresses those children and young people considered clinically to be at high risk or prodromal for psychosis and schizophrenia.

NICE recommends that antipsychotic medication in children and young people with a first presentation of sustained psychotic symptoms should not be started in primary care unless it is done in consultation with a consultant psychiatrist with training in child and adolescent mental health.

The secondary care team should maintain responsibility for monitoring physical health and the effects of antipsychotic medication in children and young people for at least the first 12 months or until their condition has stabilised.

Thereafter, the responsibility for this monitoring may be transferred to primary care under shared care arrangements.

GPs can play a key role in promoting recovery and providing possible future care.

NICE recommends that practice case registers are developed and used to monitor the physical and mental health of children and young people with psychosis or schizophrenia in primary care.

GPs should monitor the physical health of children and young people with psychosis or schizophrenia at least once a year. Bear in mind that people with schizophrenia are at higher risk of cardiovascular disease than the general population.

Identify children and young people with psychosis or schizophrenia who smoke or who have high blood pressure, raised lipid levels or increased waist measurement at the earliest opportunity and monitor for the emergence of cardiovascular disease and diabetes.

Treat children and young people with psychosis or schizophrenia who have diabetes and/or cardiovascular disease in primary care, using the appropriate NICE guidance for children and young people where available.

When a child or young person with a 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) and is still receiving treatment, primary healthcare professionals should refer to the crisis section of the patient's care plan. Consider referral to the key clinician or care coordinator identified in the crisis plan.

GPs should also consider making a referral to secondary care again if there is:

  • poor response to treatment
  • non-adherence to medication
  • intolerable side effects from medication or the child or young person or their parents or carers request a review of side effects
  • the child or young person or their parents or carers request psychological interventions not available in primary care
  • comorbid substance misuse
  • risk to self or others.

Dr David Shiers, a GP who advises the National Audit of Schizophrenia (The Royal College of Psychiatrists), and member of the Guideline Development Group said: "The effect of psychosis and schizophrenia on a child cannot be underestimated. Nor can the heavy burden placed on their parents and carers.

"As well as recommendation of effective treatments and care, the guidance also places a strong emphasis on ensuring children and their families or carers have all the information and support they need, encouraging practitioners to consider the impact of the diagnosis and treatment; in particular this needs psychiatrists and general practitioners to work collaboratively and to be clear about their respective roles and responsibilities.”

Free, Secure, Compliant UK Public Sector IT Recycling Service