This updated guideline from NICE looks at psychosis and schizophrenia in adults. Although there is quite a lot that is 'new' in here, the changes really reflect what we have been doing for a while through QOF (and some of which is now disappearing from QOF).
This link takes you to access details for Adult Mental Health Services in Hampshire.
Here is a summary of what is 'new'.
We should be promoting a 'healthy' lifestyle in patients. Consider smoking, weight, exercise levels, diabetes and lipids.
Encourage smoking cessation, but beware that reducing nicotine levels can alter the metabolism of antipsychotic drugs, especially clozapine and olanzapine. Beware neuro-psychiatric side-effects with Zyban and Champix. They suggest the following:
- Nicotine replacement - for any condition
- Bupropion - schizophrenia
- Champix - with psychosis or schizophrenia
Psychological support to patients and carers
Carers should be offered an assessment of their needs through the mental health team (MHT), but should also be advised that they can have a formal carer's assessment through Adult Services.
Peer-support and self-management programmes should also be available through the MHT.
Prevention of psychosis
Many patients will have symptoms for quite a long time before they present with frank psychosis. This may include a deterioration in personal functioning, low grade psychotic symptoms, memory and concentration problems, unusual ideas and behaviour and apathy and social withdrawal. If there is concern that a patient may be in a 'prodrome' state, then they should be referred 'without delay' to the MHT. NICE suggests the following criteria:
- Patient is distressed AND
- Has a decline in social functioning AND
- One of the below:
- Transient or attenuated psychotic symptoms
- Other experiences or behaviour suggestive of psychosis
- First degree relative with psychosis or schizophrenia
Initial management by the MHT would generally by CBT, rather than medication. Patients should be followed up by the MHT for 3 years, though this can be done with the GP if the patient prefers.
First episode of psychosis
Refer to an 'Early Intervention in Psychosis Team'
Do not start an antipsychotic in primary care, without first discussing it with a consultant psychiatrist
Ask about co-morbid mental health problems (eg PTSD, depression and anxiety) which often go alongside a psychotic illness.
Before use, certain checks should be made. These are listed in the guideline if you are starting a medication in general practice.
During treatment, the following checks should be done. After 12 months, these will be our responsibility and should be done annually:
- Weight and waist circumference
- Pulse and Blood Pressure
- Bloods (including glucose, HbA1c, lipids)
- Response, adherence, side-effects (including movement disorders)