National Institute for Health and Clinical Excellence (NICE)
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Offer talking therapies to people at risk of psychosis and schizophrenia

People considered to be at increased risk of developing psychosis should be offered cognitive behavioural therapy (CBT) as opposed to antipsychotic medication, according to updated guidelines from NICE.

Around 1 in 100 people will develop psychosis and schizophrenia over the course of a lifetime. In most cases a first episode of psychosis is preceded by a ‘prodromal period', where a person may exhibit a range of behavioural and psychological symptom. These include shortened attention spans, short periods of low intensity psychotic symptoms, withdrawal, and displays unusual behaviour and ideas.

Antipsychotic drugs are often used to prevent the development of psychosis and to treat the disorder, though these can have certain side effects. Cognitive behavioural therapy is another measure often used, where therapists work collaboratively with a patient to talk through psychotic experiences and modify unhelpful thought patterns and behaviours.

In its updated guidance on psychosis and schizophrenia, NICE recommends that CBT should be offered to a person considered to be at increased risk of developing psychosis. Furthermore, antipsychotic medication should not be offered to anyone at increased risk of developing psychosis, or with the aim of decreasing the risk of psychosis.

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.

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.

Further updated recommendations cover recovery and possible future care. NICE recommends 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.

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 also calls 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.

Elsewhere, the updated guideline 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.

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.

Elizabeth Kuipers, Professor of Clinical Psychology at the Institute of Psychiatry, King's College London and chair of the guideline development group, said: "There have been many developments since the original recommendations were published - we now know a lot more about successfully reducing the risk or preventing the development of psychosis.

"The newly updated guideline recommends the use of CBT, rather than antipsychotics, for people at risk of developing psychosis, along with interventions in line with NICE guidance on anxiety disorders, depression, and emerging personality disorder or substance misuse if they have coexisting problems."

Professor Mark Baker, Director of the Centre for Clinical Practice, NICE, said: "This is the second update of NICE's very first clinical guideline. Since the original was published in 2002 there has been a new emphasis on how to detect and treat this condition earlier and also an increased focus on long-term recovery.

"This guideline sets out how best to treat and manage people with schizophrenia, from the first episode through to management of further acute episodes and longer term care."

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