Psychosis and

schizophrenia in adults:
prevention and
management

Clinical guideline
Published: 12 February 2014
Last updated: 1 March 2014

[Link]/guidance/cg178

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conditions#notice-of-rights).
Psychosis and schizophrenia in adults: prevention and management (CG178)

Your responsibility
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals
and practitioners are expected to take this guideline fully into account, alongside the
individual needs, preferences and values of their patients or the people using their service.
It is not mandatory to apply the recommendations, and the guideline does not override the
responsibility to make decisions appropriate to the circumstances of the individual, in
consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment
or in a procedure should be reported to the Medicines and Healthcare products Regulatory
Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the

guideline to be applied when individual professionals and people using services wish to
use it. They should do so in the context of local and national priorities for funding and
developing services, and in light of their duties to have due regard to the need to eliminate
unlawful discrimination, to advance equality of opportunity and to reduce health
inequalities. Nothing in this guideline should be interpreted in a way that would be
inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally

sustainable health and care system and should assess and reduce the environmental
impact of implementing NICE recommendations wherever possible.

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Psychosis and schizophrenia in adults: prevention and management (CG178)

Contents
Overview ..................................................................................................................................... 4

Who is it for? .......................................................................................................................................... 4

Recommendations ...................................................................................................................... 5

1.1 Care across all phases ..................................................................................................................... 5

1.2 Preventing psychosis ...................................................................................................................... 9

1.3 First episode psychosis .................................................................................................................. 11

1.4 Subsequent acute episodes of psychosis or schizophrenia and referral in crisis .................... 19

1.5 Promoting recovery and possible future care .............................................................................. 22

Recommendations for research ................................................................................................ 29

1 Peer support interventions ................................................................................................................ 29

2 People who choose not to take antipsychotic medication ............................................................ 30

3 The physical health benefits of discontinuing antipsychotic medication .................................... 30

4 Maintaining the benefits of early intervention in psychosis services after discharge ................ 31

5 Interventions for PTSD symptoms in people with psychosis and schizophrenia ........................ 32

Context ........................................................................................................................................ 33

Finding more information and committee details .................................................................... 35

Update information .................................................................................................................... 36

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Psychosis and schizophrenia in adults: prevention and management (CG178)

This guideline replaces CG82 and ESNM39.

This guideline is the basis of QS80 and QS167.

Overview
This guideline covers recognising and managing psychosis and schizophrenia in adults. It
aims to improve care through early recognition and treatment, and by focusing on long-
term recovery. It also recommends checking for coexisting health problems and providing
support for family members and carers.

Who is it for?
• Healthcare professionals

• People with psychosis or schizophrenia, their families and carers

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Psychosis and schizophrenia in adults: prevention and management (CG178)

Recommendations
People have the right to be involved in discussions and make informed decisions
about their care, as described in making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the
strength (or certainty) of our recommendations, and has information about
prescribing medicines (including off-label use), professional guidelines, standards
and laws (including on consent and mental capacity), and safeguarding.

Health and care professionals should follow our general guidelines for people
delivering care:

• decision making and mental capacity

• medicines adherence

• medicines optimisation

• multimorbidity

• service user experience in adult mental health

• shared decision making

• supporting adult carers.

1.1 Care across all phases

1.1.1 Race, culture and ethnicity

[Link] Healthcare professionals working with people with psychosis or schizophrenia
should ensure they are competent in:

• assessment skills for people from diverse ethnic and cultural backgrounds

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Psychosis and schizophrenia in adults: prevention and management (CG178)

• using explanatory models of illness for people from diverse ethnic and
cultural backgrounds

• explaining the causes of psychosis or schizophrenia and treatment options

• addressing cultural and ethnic differences in treatment expectations and

adherence

• addressing cultural and ethnic differences in beliefs regarding biological,

social and family influences on the causes of abnormal mental states

• negotiating skills for working with families of people with psychosis or

schizophrenia

• conflict management and conflict resolution. [2009]

1.1.2 Physical health

[Link] People with psychosis or schizophrenia, especially those taking antipsychotics,
should be offered a combined healthy eating and physical activity programme by
their mental healthcare provider.

Our 2019 review of the STEPWISE trial did not change this recommendation.
[2019]

[Link] If a person has rapid or excessive weight gain, abnormal lipid levels or problems
with blood glucose management, offer interventions in line with relevant NICE
guidance (see the NICE guidelines on obesity, cardiovascular disease: risk
assessment and reduction, including lipid modification and preventing type 2
diabetes). [2014]

[Link] Offer people with psychosis or schizophrenia who smoke help to stop smoking,
even if previous attempts have been unsuccessful. Be aware of the potential
significant impact of reducing cigarette smoking on the metabolism of other
drugs, particularly clozapine and olanzapine. [2014]

[Link] Follow the recommendations on stop-smoking interventions in the NICE guideline

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Psychosis and schizophrenia in adults: prevention and management (CG178)

on tobacco, with the following exceptions:

• do not offer bupropion to people with psychosis to help them stop smoking

• warn people with psychosis or schizophrenia who are taking bupropion or

varenicline that there is an increased risk of adverse neuropsychiatric
symptoms and monitor them regularly, particularly in the first 2 to 3 weeks.
[2014]

[Link] Routinely monitor weight, and cardiovascular and metabolic indicators of

morbidity in people with psychosis and schizophrenia. These should be audited in
the annual team report. [2014]

[Link] Trusts should ensure compliance with quality standards on the monitoring and
treatment of cardiovascular and metabolic disease in people with psychosis or
schizophrenia through board-level performance indicators. [2014]

1.1.3 Comprehensive services provision

[Link] All teams providing services for people with psychosis or schizophrenia should
offer a comprehensive range of interventions consistent with this guideline.
[2009]

1.1.4 Support for carers

[Link] Give carers written and verbal information in an accessible format about:

• diagnosis and management of psychosis and schizophrenia

• positive outcomes and recovery

• types of support for carers

• role of teams and services

• getting help in a crisis. [2014]

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Psychosis and schizophrenia in adults: prevention and management (CG178)

[Link] As early as possible negotiate with service users and carers about how
information about the service user will be shared. When discussing rights to
confidentiality, emphasise the importance of sharing information about risks and
the need for carers to understand the service user's perspective. Foster a
collaborative approach that supports both service users and carers, and respects
their individual needs and interdependence. [2014]

[Link] Review regularly how information is shared, especially if there are communication
and collaboration difficulties between the service user and carer. [2014]

[Link] Offer a carer-focused education and support programme, which may be part of a
family intervention for psychosis and schizophrenia, as early as possible to all
carers. The intervention should:

• be available as needed

• have a positive message about recovery. [2014]

1.1.5 Peer support and self-management

[Link] Consider peer support for people with psychosis or schizophrenia to help
improve service user experience and quality of life. Peer support should be
delivered by a trained peer support worker who has recovered from psychosis or
schizophrenia and remains stable. Peer support workers should receive support
from their whole team, and support and mentorship from experienced peer
workers. [2014]

[Link] Consider a manualised self-management programme delivered face-to-face with

service users, as part of the treatment and management of psychosis or
schizophrenia. [2014]

[Link] Peer support and self-management programmes should include information and
advice about:

• psychosis and schizophrenia

• effective use of medication

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Psychosis and schizophrenia in adults: prevention and management (CG178)

• identifying and managing symptoms

• accessing mental health and other support services

• coping with stress and other problems

• what to do in a crisis

• building a social support network

• preventing relapse and setting personal recovery goals. [2014]

1.2 Preventing psychosis

1.2.1 Referral from primary care

[Link] If a person is distressed, has a decline in social functioning and has:

• transient or attenuated psychotic symptoms or

• other experiences or behaviour suggestive of possible psychosis or

• a first-degree relative with psychosis or schizophrenia

refer them for assessment without delay to a specialist mental health service
or an early intervention in psychosis service because they may be at
increased risk of developing psychosis. [2014]

1.2.2 Specialist assessment

[Link] A consultant psychiatrist or a trained specialist with experience in at-risk mental
states should carry out the assessment. [2014]

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Psychosis and schizophrenia in adults: prevention and management (CG178)

1.2.3 Treatment options to prevent psychosis

[Link] If a person is considered to be at increased risk of developing psychosis (as
described in recommendation [Link]):

• offer individual cognitive behavioural therapy (CBT) with or without family

intervention (delivered as described in the section on how to deliver
psychological interventions) and

• offer interventions recommended in NICE guidance for people with any of the
anxiety disorders, depression, emerging personality disorder or substance
misuse. [2014]

[Link] Do not offer antipsychotic medication:

• to people considered to be at increased risk of developing psychosis (as

described in recommendation [Link]) or

• with the aim of decreasing the risk of or preventing psychosis. [2014]

1.2.4 Monitoring and follow-up

[Link] If, after treatment (as described in recommendation [Link]), the person continues
to have symptoms, impaired functioning or is distressed, but a clear diagnosis of
psychosis cannot be made, monitor the person regularly for changes in
symptoms and functioning for up to 3 years using a structured and validated
assessment tool. Determine the frequency and duration of monitoring by the:

• severity and frequency of symptoms

• level of impairment and/or distress and

• degree of family disruption or concern. [2014]

[Link] If a person asks to be discharged from the service, offer follow-up appointments
and the option to self-refer in the future. Ask the person's GP to continue
monitoring changes in their mental state. [2014]

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Psychosis and schizophrenia in adults: prevention and management (CG178)

1.3 First episode psychosis

1.3.1 Early intervention in psychosis services

[Link] Early intervention in psychosis services should be accessible to all people with a
first episode or first presentation of psychosis, irrespective of the person's age or
the duration of untreated psychosis. [2014]

[Link] People presenting to early intervention in psychosis services should be assessed

without delay. If the service cannot provide urgent intervention for people in a
crisis, refer the person to a crisis resolution and home treatment team (with
support from early intervention in psychosis services). Referral may be from
primary or secondary care (including other community services) or a self- or
carer-referral. [2014]

[Link] Early intervention in psychosis services should aim to provide a full range of
pharmacological, psychological, social, occupational and educational
interventions for people with psychosis, consistent with this guideline. [2014]

[Link] Consider extending the availability of early intervention in psychosis services

beyond 3 years if the person has not made a stable recovery from psychosis or
schizophrenia. [2014]

1.3.2 Primary care

[Link] Do not start antipsychotic medication for a first presentation of sustained
psychotic symptoms in primary care unless it is done in consultation with a
consultant psychiatrist. [2009, amended 2014]

1.3.3 Assessment and care planning

[Link] Carry out a comprehensive multidisciplinary assessment of people with psychotic
symptoms in secondary care. This should include assessment by a psychiatrist, a
psychologist or a professional with expertise in the psychological treatment of

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Psychosis and schizophrenia in adults: prevention and management (CG178)

people with psychosis or schizophrenia. The assessment should address the

following domains:

• psychiatric (mental health problems, risk of harm to self or others, alcohol

consumption and prescribed and non-prescribed drug history)

• medical, including medical history and full physical examination to identify

physical illness (including organic brain disorders) and prescribed drug
treatments that may result in psychosis

• physical health and wellbeing (including weight, smoking, nutrition, physical

activity and sexual health)

• psychological and psychosocial, including social networks, relationships and

history of trauma

• developmental (social, cognitive and motor development and skills, including

coexisting neurodevelopmental conditions)

• social (accommodation, culture and ethnicity, leisure activities and recreation,

and responsibilities for children or as a carer)

• occupational and educational (attendance at college, educational attainment,

employment and activities of daily living)

• quality of life

• economic status. [2009, amended 2014]

[Link] Structural neuroimaging techniques are not recommended in NICE technology

appraisal guidance as a routine part of initial investigations for managing first-
episode psychosis. For full details, see the guidance on structural neuroimaging
in first-episode psychosis (TA136, 2008).

[Link] Assess for post-traumatic stress disorder and other reactions to trauma because
people with psychosis or schizophrenia are likely to have experienced previous
adverse events or trauma associated with the development of the psychosis or
as a result of the psychosis itself. For people who show signs of post-traumatic
stress, follow the recommendations in the NICE guideline on post-traumatic
stress disorder. [2014]

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Psychosis and schizophrenia in adults: prevention and management (CG178)

[Link] Routinely monitor for other coexisting conditions, including depression, anxiety
and substance misuse particularly in the early phases of treatment. [2009,
amended 2014]

[Link] Write a care plan in collaboration with the service user as soon as possible
following assessment, based on a psychiatric and psychological formulation, and
a full assessment of their physical health. Send a copy of the care plan to the
primary healthcare professional who made the referral and the service user.
[2009, amended 2014]

[Link] For people who are unable to attend mainstream education, training or work,
facilitate alternative educational or occupational activities according to their
individual needs and capacity to engage with such activities, with an ultimate
goal of returning to mainstream education, training or employment. [2014]

1.3.4 Treatment options

[Link] For people with first episode psychosis offer:

• oral antipsychotic medication (see the section on how to use antipsychotic

medication) in conjunction with

• psychological interventions (family intervention and individual CBT, delivered

as described in the section on how to deliver psychological interventions).
[2014]

[Link] Advise people who want to try psychological interventions alone that these are
more effective when delivered in conjunction with antipsychotic medication. If the
person still wants to try psychological interventions alone:

• offer family intervention and CBT

• agree a time (1 month or less) to review treatment options, including

introducing antipsychotic medication

• continue to monitor symptoms, distress, impairment and level of functioning

(including education, training and employment) regularly. [2014]

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Psychosis and schizophrenia in adults: prevention and management (CG178)

[Link] If the person's symptoms and behaviour suggest an affective psychosis or

disorder, including bipolar disorder and unipolar psychotic depression, follow the
recommendations in the NICE guidelines on bipolar disorder or depression.
[2014]

1.3.5 Choice of antipsychotic medication

[Link] The choice of antipsychotic medication should be made by the service user and
healthcare professional together, taking into account the views of the carer if the
service user agrees. Provide information and discuss the likely benefits and
possible side effects of each drug, including:

• metabolic (including weight gain and diabetes)

• extrapyramidal (including akathisia, dyskinesia and dystonia)

• cardiovascular (including prolonging the QT interval)

• hormonal (including increasing plasma prolactin)

• other (including unpleasant subjective experiences). [2009, amended 2014]

1.3.6 How to use antipsychotic medication

[Link] Before starting antipsychotic medication, undertake and record the following
baseline investigations:

• weight (plotted on a chart)

• waist circumference

• pulse and blood pressure

• fasting blood glucose or glycosylated haemoglobin (HbA1c)

• blood lipid profile and prolactin levels

• assessment of any movement disorders

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Psychosis and schizophrenia in adults: prevention and management (CG178)

• assessment of nutritional status, diet and level of physical activity. [2014,

amended 2021]

[Link] Before starting antipsychotic medication, offer the person with psychosis or
schizophrenia an electrocardiogram (ECG) if:

• specified in the summary of product characteristics (SPC)

• a physical examination has identified specific cardiovascular risk (such as

diagnosis of high blood pressure)

• there is a personal history of cardiovascular disease or

• the service user is being admitted as an inpatient. [2009]

[Link] Treatment with antipsychotic medication should be considered an explicit

individual therapeutic trial. Include the following:

• Discuss and record the side effects that the person is most willing to tolerate.

• Record the indications and expected benefits and risks of oral antipsychotic
medication, and the expected time for a change in symptoms and
appearance of side effects.

• At the start of treatment give a dose at the lower end of the licensed range
and slowly titrate upwards within the dose range given in the British national
formulary (BNF) or SPC.

• Justify and record reasons for dosages outside the range given in the BNF or
SPC.

• Record the rationale for continuing, changing or stopping medication, and the
effects of such changes.

• Carry out a trial of the medication at optimum dosage for 4 to 6 weeks.

[2009, amended 2014]

[Link] Monitor and record the following regularly and systematically throughout
treatment, but especially during titration:

• response to treatment, including changes in symptoms and behaviour

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Psychosis and schizophrenia in adults: prevention and management (CG178)

• side effects of treatment, taking into account overlap between certain side
effects and clinical features of schizophrenia (for example, the overlap
between akathisia and agitation or anxiety) and impact on functioning

• the emergence of movement disorders

• weight, weekly for the first 6 weeks, then at 12 weeks, at 1 year and then
annually (plotted on a chart)

• waist circumference annually (plotted on a chart)

• pulse and blood pressure at 12 weeks, at 1 year and then annually

• fasting blood glucose or HbA1c, and blood lipid levels at 12 weeks, at 1 year
and then annually

• adherence

• overall physical health. [2014, amended 2021]

[Link] The secondary care team should maintain responsibility for monitoring service
users' physical health and the effects of antipsychotic medication for at least the
first 12 months or until the person's condition has stabilised, whichever is longer.
Thereafter, the responsibility for this monitoring may be transferred to primary
care under shared care arrangements. [2014]

[Link] Discuss any non-prescribed therapies the service user wishes to use (including
complementary therapies) with the service user, and carer if appropriate. Discuss
the safety and efficacy of the therapies, and possible interference with the
therapeutic effects of prescribed medication and psychological treatments.
[2009]

[Link] Discuss the use of alcohol, tobacco, prescription and non-prescription

medication and illicit drugs with the service user, and carer if appropriate. Discuss
their possible interference with the therapeutic effects of prescribed medication
and psychological treatments. [2009]

[Link] 'As required' (p.r.n.) prescriptions of antipsychotic medication should be made as

described in recommendation [Link]. Review clinical indications, frequency of

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Psychosis and schizophrenia in adults: prevention and management (CG178)

administration, therapeutic benefits and side effects each week or as

appropriate. Check whether 'p.r.n.' prescriptions have led to a dosage above the
maximum specified in the BNF or SPC. [2009]

[Link] Do not use a loading dose of antipsychotic medication (often referred to as 'rapid
neuroleptisation'). [2009]

[Link] Do not initiate regular combined antipsychotic medication, except for short
periods (for example, when changing medication). [2009]

[Link] If prescribing chlorpromazine, warn of its potential to cause skin photosensitivity.

Advise using sunscreen if necessary. [2009]

1.3.7 How to deliver psychological interventions

[Link] CBT should be delivered on a one-to-one basis over at least 16 planned sessions
and:

• follow a treatment manual (with evidence of efficacy from a clinical trial, if

possible) so that:

－ people can establish links between their thoughts, feelings or actions and
their current or past symptoms, and/or functioning

－ the re-evaluation of people's perceptions, beliefs or reasoning relates to

the target symptoms

• also include at least one of the following components:

－ people monitoring their own thoughts, feelings or behaviours with

respect to their symptoms or recurrence of symptoms

－ promoting alternative ways of coping with the target symptom

－ reducing distress

－ improving functioning. [2009]

[Link] Family intervention should:

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Psychosis and schizophrenia in adults: prevention and management (CG178)

• include the person with psychosis or schizophrenia if practical

• be carried out for between 3 months and 1 year

• include at least 10 planned sessions

• take account of the whole family's preference for either single-family

intervention or multi-family group intervention

• take account of the relationship between the main carer and the person with
psychosis or schizophrenia

• have a specific supportive, educational or treatment function and include

negotiated problem solving or crisis management work. [2009]

1.3.8 Monitoring and reviewing psychological interventions

[Link] When providing psychological interventions, routinely and systematically monitor
a range of outcomes across relevant areas, including service user satisfaction
and, if appropriate, carer satisfaction. [2009]

[Link] Healthcare teams working with people with psychosis or schizophrenia should
identify a lead healthcare professional within the team whose responsibility is to
monitor and review:

• access to and engagement with psychological interventions

• decisions to offer psychological interventions and equality of access across

different ethnic groups. [2009]

1.3.9 Competencies for delivering psychological interventions

[Link] Healthcare professionals providing psychological interventions should:

• have an appropriate level of competence in delivering the intervention to

people with psychosis or schizophrenia

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• be regularly supervised during psychological therapy by a competent

therapist and supervisor. [2009]

[Link] Trusts should provide access to training that equips healthcare professionals with
the competencies required to deliver the psychological therapy interventions
recommended in this guideline. [2009]

1.4 Subsequent acute episodes of psychosis or

schizophrenia and referral in crisis

1.4.1 Service-level interventions

[Link] Offer crisis resolution and home treatment teams as a first-line service to support
people with psychosis or schizophrenia during an acute episode in the
community if the severity of the episode, or the level of risk to self or others,
exceeds the capacity of the early intervention in psychosis services or other
community teams to effectively manage it. [2014]

[Link] Crisis resolution and home treatment teams should be the single point of entry to
all other acute services in the community and in hospitals. [2014]

[Link] Consider acute community treatment within crisis resolution and home treatment
teams before admission to an inpatient unit and as a means to enable timely
discharge from inpatient units. Crisis houses or acute day facilities may be
considered in addition to crisis resolution and home treatment teams depending
on the person's preference and need. [2014]

[Link] If a person with psychosis or schizophrenia needs hospital care, think about the
impact on the person, their carers and other family members, especially if the
inpatient unit is a long way from where they live. If hospital admission is
unavoidable, ensure that the setting is suitable for the person's age, gender and
level of vulnerability, support their carers and follow the recommendations in the
NICE guideline on service user experience in adult mental health. [2014]

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1.4.2 Treatment options

[Link] For people with an acute exacerbation or recurrence of psychosis or
schizophrenia, offer:

• oral antipsychotic medication (see the section on how to use antipsychotic

medication) in conjunction with

• psychological interventions (family intervention and individual CBT, delivered

as described in the section on how to deliver psychological interventions).
[2014]

1.4.3 Pharmacological interventions

[Link] For people with an acute exacerbation or recurrence of psychosis or
schizophrenia, offer oral antipsychotic medication or review existing medication.
The choice of drug should be influenced by the same criteria recommended for
starting treatment (see the section on how to use antipsychotic medication). Take
into account the clinical response and side effects of the service user's current
and previous medication. [2009, amended 2014]

1.4.4 Psychological and psychosocial interventions

[Link] Offer CBT to all people with psychosis or schizophrenia (delivered as described in
recommendation [Link]). This can be started either during the acute phase or
later, including in inpatient settings. [2009]

[Link] Offer family intervention to all families of people with psychosis or schizophrenia
who live with or are in close contact with the service user (delivered as described
in recommendation [Link]). This can be started either during the acute phase or
later, including in inpatient settings. [2009]

[Link] Consider offering arts therapies to all people with psychosis or schizophrenia,
particularly for the alleviation of negative symptoms. This can be started either
during the acute phase or later, including in inpatient settings. [2009]

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[Link] Arts therapies should be provided by a Health and Care Professions Council
registered arts therapist with previous experience of working with people with
psychosis or schizophrenia. The intervention should be provided in groups unless
difficulties with acceptability and access and engagement indicate otherwise.
Arts therapies should combine psychotherapeutic techniques with activity aimed
at promoting creative expression, which is often unstructured and led by the
service user. Aims of arts therapies should include:

• enabling people with psychosis or schizophrenia to experience themselves

differently and to develop new ways of relating to others

• helping people to express themselves and to organise their experience into a

satisfying aesthetic form

• helping people to accept and understand feelings that may have emerged
during the creative process (including, in some cases, how they came to have
these feelings) at a pace suited to the person. [2009]

[Link] When psychological treatments, including arts therapies, are started in the acute
phase (including in inpatient settings), the full course should be continued after
discharge without unnecessary interruption. [2009]

[Link] Do not routinely offer counselling and supportive psychotherapy (as specific
interventions) to people with psychosis or schizophrenia. However, take service
user preferences into account, especially if other more efficacious psychological
treatments, such as CBT, family intervention and arts therapies, are not available
locally. [2009]

[Link] Do not offer adherence therapy (as a specific intervention) to people with
psychosis or schizophrenia. [2009]

[Link] Do not routinely offer social skills training (as a specific intervention) to people
with psychosis or schizophrenia. [2009]

1.4.5 Violence, aggression and self-harm

[Link] Occasionally people with psychosis or schizophrenia pose an immediate risk to

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themselves or others during an acute episode and may need rapid

tranquillisation. The management of immediate risk should follow the NICE
guideline on violence and aggression, and the NICE guideline on self-harm.
[2009]

[Link] After rapid tranquillisation, offer the person with psychosis or schizophrenia the
opportunity to discuss their experiences. Provide them with a clear explanation of
the decision to use urgent sedation. Record this in their notes. [2009]

1.4.6 Early post-acute period

[Link] After each acute episode, encourage people with psychosis or schizophrenia to
write an account of their illness in their notes. [2009]

[Link] Healthcare professionals may consider using psychoanalytic and psychodynamic

principles to help them understand the experiences of people with psychosis or
schizophrenia and their interpersonal relationships. [2009]

[Link] Inform the service user that there is a high risk of relapse if they stop medication
in the next 1 to 2 years. [2009]

[Link] If withdrawing antipsychotic medication, undertake gradually and monitor

regularly for signs and symptoms of relapse. [2009]

[Link] After withdrawal from antipsychotic medication, continue monitoring for signs
and symptoms of relapse for at least 2 years. [2009]

1.5 Promoting recovery and possible future care

1.5.1 General principles

[Link] Continue treatment and care in early intervention in psychosis services or refer
the person to a specialist integrated community-based team. This team should:

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Psychosis and schizophrenia in adults: prevention and management (CG178)

• offer the full range of psychological, pharmacological, social and

occupational interventions recommended in this guideline

• be competent to provide all interventions offered

• place emphasis on engagement rather than risk management. [2014]

[Link] Consider intensive case management for people with psychosis or schizophrenia
who are likely to disengage from treatment or services. [2014]

[Link] Review antipsychotic medication annually, including observed benefits and any
side effects. [2014]

1.5.2 Return to primary care

[Link] Offer people with psychosis or schizophrenia whose symptoms have responded
effectively to treatment and remain stable the option to return to primary care for
further management. If a service user wishes to do this, record this in their notes
and coordinate transfer of responsibilities through the care programme approach.
[2009]

1.5.3 Primary care

Monitoring physical health in primary care

[Link] Develop and use practice case registers to monitor the physical and mental
health of people with psychosis or schizophrenia in primary care. [2009]

[Link] GPs and other primary healthcare professionals should monitor the physical
health of people with psychosis or schizophrenia when responsibility for
monitoring is transferred from secondary care, and then at least annually. The
health check should be comprehensive, focusing on physical health problems
that are common in people with psychosis and schizophrenia. Include all the
checks in recommendation [Link] and refer to relevant NICE guidance on
monitoring for cardiovascular disease, diabetes, obesity and respiratory disease.

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A copy of the results should be sent to the care coordinator and psychiatrist, and
put in the secondary care notes. [2014]

[Link] Identify people with psychosis or schizophrenia who have high blood pressure,
have abnormal lipid levels, are obese or at risk of obesity, have diabetes or are at
risk of diabetes (as indicated by abnormal blood glucose levels), or are physically
inactive, at the earliest opportunity following relevant NICE guidelines on
cardiovascular disease: risk assessment and reduction, including lipid
modification, preventing type 2 diabetes, obesity, hypertension, prevention of
cardiovascular disease and physical activity. [2014]

[Link] Treat people with psychosis or schizophrenia who have diabetes and/or
cardiovascular disease in primary care according to the appropriate NICE
guidance (for example, see the NICE guidelines on lipid modification, type 1
diabetes and type 2 diabetes). [2009]

[Link] Healthcare professionals in secondary care should ensure, as part of the care
programme approach, that people with psychosis or schizophrenia receive
physical healthcare from primary care as described in recommendations [Link] to
[Link]. [2009]

Relapse and re-referral to secondary care

[Link] When a person with an established 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),
primary healthcare professionals should refer to the crisis section of the care
plan. Consider referral to the key clinician or care coordinator identified in the
crisis plan. [2009]

[Link] For a person with psychosis or schizophrenia being cared for in primary care,
consider referral to secondary care again if there is:

• poor response to treatment

• non-adherence to medication

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• intolerable side effects from medication

• comorbid substance misuse

• risk to self or others. [2009]

[Link] When re-referring people with psychosis or schizophrenia to mental health

services, take account of service user and carer requests, especially for:

• review of the side effects of existing treatments

• psychological treatments or other interventions. [2009]

Transfer

[Link] When a person with psychosis or schizophrenia is planning to move to the

catchment area of a different NHS trust, a meeting should be arranged between
the services involved and the service user to agree a transition plan before
transfer. The person's current care plan should be sent to the new secondary
care and primary care providers. [2009]

1.5.4 Psychological interventions

[Link] Offer CBT to assist in promoting recovery in people with persisting positive and
negative symptoms and for people in remission. Deliver CBT as described in
recommendation [Link]. [2009]

[Link] Offer family intervention to families of people with psychosis or schizophrenia

who live with or are in close contact with the service user. Deliver family
intervention as described in recommendation [Link]. [2009]

[Link] Family intervention may be particularly useful for families of people with
psychosis or schizophrenia who have:

• recently relapsed or are at risk of relapse

• persisting symptoms. [2009]

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[Link] Consider offering arts therapies to assist in promoting recovery, particularly in

people with negative symptoms. [2009]

1.5.5 Pharmacological interventions

[Link] The choice of drug should be influenced by the same criteria recommended for
starting treatment (see the section on how to use antipsychotic medication).
[2009]

[Link] Do not use targeted, intermittent dosage maintenance strategies (use of

antipsychotic medication only during periods of incipient relapse or symptom
exacerbation) routinely. However, consider them for people with psychosis or
schizophrenia who are unwilling to accept a continuous maintenance regimen or
if there is another contraindication to maintenance therapy, such as side-effect
sensitivity. [2009]

[Link] Consider offering depot/long-acting injectable antipsychotic medication to

people with psychosis or schizophrenia:

• who would prefer such treatment after an acute episode

• where avoiding covert non-adherence (either intentional or unintentional) to

antipsychotic medication is a clinical priority within the treatment plan.
[2009]

1.5.6 Using depot/long-acting injectable antipsychotic medication

[Link] When initiating depot/long-acting injectable antipsychotic medication:

• take into account the service user's preferences and attitudes towards the
mode of administration (regular intramuscular injections) and organisational
procedures (for example, home visits and location of clinics)

• take into account the same criteria recommended for the use of oral
antipsychotic medication (see the section on how to use antipsychotic
medication), particularly in relation to the risks and benefits of the drug

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regimen

• prescribe according to the procedures set out in the BNF or SPC. [2009,
amended 2022]

1.5.7 Interventions for people whose illness has not responded

adequately to treatment
[Link] For people with schizophrenia whose illness has not responded adequately to
pharmacological or psychological treatment:

• Review the diagnosis.

• Establish that there has been adherence to antipsychotic medication,

prescribed at an adequate dose and for the correct duration.

• Review engagement with and use of psychological treatments and ensure

that these have been offered according to this guideline. If family intervention
has been undertaken suggest CBT; if CBT has been undertaken suggest
family intervention for people in close contact with their families.

• Consider other causes of non-response, such as comorbid substance misuse

(including alcohol), the concurrent use of other prescribed medication or
physical illness. [2009]

[Link] Offer clozapine to people with schizophrenia whose illness has not responded
adequately to treatment despite the sequential use of adequate doses of at least
2 different antipsychotic drugs. At least 1 of the drugs should be a non-clozapine
second-generation antipsychotic. [2009]

[Link] For people with schizophrenia whose illness has not responded adequately to
clozapine at an optimised dose, healthcare professionals should consider
recommendation [Link] (including measuring therapeutic drug levels) before
adding a second antipsychotic to augment treatment with clozapine. An
adequate trial of such an augmentation may need to be up to 8 to 10 weeks.
Choose a drug that does not compound the common side effects of clozapine.
[2009]

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Psychosis and schizophrenia in adults: prevention and management (CG178)

[Link] Electroconvulsive therapy (ECT) is recommended in NICE technology appraisal

guidance as an option for rapid short-term treatment of severe symptoms of
catatonia when other treatments have not worked or the condition is life-
threatening. It is not recommended for general use in managing schizophrenia.
For full details, see the guidance on the use of electroconvulsive therapy (TA59,
2009).

1.5.8 Employment, education and occupational activities

For guidance on providing support with employment to people with psychosis or
schizophrenia, see the NICE guideline on workplace health: long-term sickness absence
and capability to work.

[Link] Offer supported employment programmes to people with psychosis or

schizophrenia who wish to find or return to work. Consider other occupational or
educational activities, including pre-vocational training, for people who are
unable to work or unsuccessful in finding employment. [2014]

[Link] Routinely record the daytime activities of people with psychosis or schizophrenia
in their care plans, including occupational outcomes. [2009]

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Recommendations for research

The Guideline Development Group has made the following recommendations for research,
based on its review of evidence, to improve NICE guidance and patient care in the future.
The Guideline Development Group's full set of recommendations for research are detailed
in the full guideline.

1 Peer support interventions

What is the clinical and cost effectiveness of peer support interventions in people with
psychosis and schizophrenia?

Why this is important

Service users have supported the development of peer support interventions, which have
recently proliferated in the UK, but current evidence for these interventions in people with
psychotic disorders is not strong and the studies are mainly of very low quality. Moreover
the content of the programmes has varied considerably, some using structured
interventions, others providing more informal support. There is therefore an urgent need
for high-quality evidence in this area.

The programme of research would be in several stages. First, there should be

development work to establish what specifically service users want from peer support
workers, as opposed to what they want from professionals, and what the conditions are
for optimal delivery of the intervention. This development work should be co-produced by
exploring the views of service users, experienced peer support workers and developers of
peer support interventions, and suitable outcome measures should be identified reflecting
the aims of peer support. Second, the intervention, delivered as far as possible under the
optimal conditions, should be tested in a high-quality trial. Further research should test
structured and manualised formats versus unstructured formats (in which service user and
peer decide together what to cover in the session). Benefits and adverse effects
experienced by peer support workers should also be measured.

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2 People who choose not to take antipsychotic

medication
What is the clinical and cost effectiveness of psychological intervention alone, compared
with treatment as usual, in people with psychosis or schizophrenia who choose not to take
antipsychotic medication?

Why this is important

The development of alternative treatment strategies is important for the high proportion of
people with psychosis and schizophrenia who choose not to take antipsychotic
medication, or discontinue it because of adverse effects or lack of efficacy. There is
evidence that psychological interventions (CBT and family intervention) as an adjunct to
antipsychotic medication are effective in the treatment of psychosis and schizophrenia
and are cost saving. However, there is little evidence for family intervention or CBT alone,
without antipsychotic medication.

The programme of research should compare the clinical and cost effectiveness of
psychological intervention alone (CBT and/or family intervention) with treatment as usual
for people with psychosis or schizophrenia who choose not to take antipsychotic
medication, using an adequately powered study with a randomised controlled design. Key
outcomes should include symptoms, relapse rates, quality of life, treatment acceptability,
social functioning and the cost effectiveness of the interventions.

3 The physical health benefits of discontinuing

antipsychotic medication
What are the short- and long-term benefits to physical health of guided medication
discontinuation and/or reduction in first episode psychosis and can this be achieved
without major risks?

Why this is important

There is growing concern about the long-term health risks, increased mortality and
cortical grey matter loss linked to cumulative neuroleptic exposure in people with
psychosis. The majority of young adults discontinue their medication in an unplanned way

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Psychosis and schizophrenia in adults: prevention and management (CG178)

because of these risks. A Dutch moderately-sized open trial has reported successful
discontinuation of medication in 20% of people without serious relapse; at 7-year follow-
up there was continuous benefit for guided reduction in terms of side effects, functioning
and employment, with no long-term risks. If replicated, this would mark a significant
breakthrough in reducing the long-term physical health risks associated with antipsychotic
treatment and improving outcomes.

The programme of research should use an adequately powered, multicentre, double-blind,

randomised controlled design to test the physical health benefits, risks and costs of
discontinuing or reducing antipsychotic medication among young adults with first episode
psychosis who have achieved remission. The primary outcomes should be quality of life
and metabolic disorder, including weight gain; secondary outcomes should include side
effects, serious relapse, acceptability and user preference.

4 Maintaining the benefits of early intervention in

psychosis services after discharge
How can the benefits of early intervention in psychosis services be maintained once
service users are discharged after 3 years?

Why this is important

Early intervention in psychosis services deliver evidence-based interventions in a positive,
youth-friendly setting, improve outcomes, are cost effective and have high service user
acceptability and engagement. Once people are transferred to primary care or community
mental health services these gains are diminished. The guideline recommends that trusts
consider extending these services. However, the extent to which gains would be
maintained and who would benefit most is not known. The successful element of early
intervention in psychosis services might be incorporated into mainstream services for
psychosis, but how this would function, and its cost effectiveness, needs to be
determined.

The suggested programme of research should use an adequately powered, multi-centre

randomised trial comparing extending early intervention in psychosis services (for
example, for 2 years) versus providing augmented (step-down) care in community mental
health services versus treatment as usual to determine whether the gains of early
intervention can be maintained and which service users would benefit most under each

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Psychosis and schizophrenia in adults: prevention and management (CG178)

condition. The primary outcome should be treatment or service engagement and

secondary outcomes should include relapse, readmission, functioning and user
preference.

5 Interventions for PTSD symptoms in people with

psychosis and schizophrenia
What is the benefit of a CBT-based trauma reprocessing intervention on PTSD symptoms
in people with psychosis and schizophrenia?

Why this is important

PTSD symptoms have been documented in approximately one-third of people with
psychosis and schizophrenia. The absence of PTSD symptoms in this context predicts
better mental health outcomes, lower service use and improved life satisfaction. Two-
thirds of the traumatic intrusions, observed in first episode and established psychosis,
relate to symptoms of psychosis and its treatment (including detention). One study has
demonstrated proof-of-principle in first episode psychosis for trauma reprocessing,
focusing on psychosis-related intrusions. Replication of the study will fill a major gap in
treatment for this population and may have other benefits on psychotic symptoms and
service use.

The suggested programme of research would use an adequately powered, multi-centre

randomised trial to test whether a CBT-based trauma reprocessing intervention can
reduce PTSD symptoms and related distress in people with psychosis and schizophrenia.
The trial should be targeted at those with high levels of PTSD symptoms, particularly
traumatic intrusions, following first episode psychosis. The follow-up should be up to
2 years and the intervention should include 'booster' elements, extra sessions of CBT-
based trauma reprocessing interventions, and a health economic evaluation.

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Context
This guideline covers the treatment and management of psychosis and schizophrenia and
related disorders in adults (18 years and older) with onset before 60 years. The term
'psychosis' is used in this guideline to refer to the group of psychotic disorders that
includes schizophrenia, schizoaffective disorder, schizophreniform disorder and delusional
disorder. The recognition, treatment and management of affective psychoses (such as
bipolar disorder or unipolar psychotic depression) are covered by other NICE guidelines.
The guideline does not address the specific treatment of young people under the age of
18 years, except those who are receiving treatment and support from early intervention in
psychosis services; there is a separate NICE guideline on psychosis and schizophrenia in
children and young people.

Psychosis and the specific diagnosis of schizophrenia represent a major psychiatric

disorder (or cluster of disorders) in which a person's perception, thoughts, mood and
behaviour are significantly altered. The symptoms of psychosis and schizophrenia are
usually divided into 'positive symptoms', including hallucinations (perception in the
absence of any stimulus) and delusions (fixed or falsely held beliefs), and 'negative
symptoms' (such as emotional apathy, lack of drive, poverty of speech, social withdrawal
and self-neglect). Each person will have a unique combination of symptoms and
experiences.

Typically there is a prodromal period, which precedes a first episode of psychosis and can
last from a few days to around 18 months. The prodromal period is often characterised by
some deterioration in personal functioning. Changes include the emergence of transient
(of short duration) and/or attenuated (of lower intensity) psychotic symptoms, memory
and concentration problems, unusual behaviour and ideas, disturbed communication and
affect, and social withdrawal, apathy and reduced interest in daily activities. The
prodromal period is usually followed by an acute episode marked by hallucinations,
delusions and behavioural disturbances, usually accompanied by agitation and distress.
Following resolution of the acute episode, usually after pharmacological, psychological and
other interventions, symptoms diminish and often disappear for many people, although
sometimes a number of negative symptoms remain. This phase, which can last for many
years, may be interrupted by recurrent acute episodes that may need additional
pharmacological, psychological and other interventions, as in previous episodes.

Although this is a common pattern, the course of schizophrenia varies considerably. Some

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people may have positive symptoms very briefly; others may experience them for many
years. Others have no prodromal period, the disorder beginning suddenly with an acute
episode.

Over a lifetime, about 1% of the population will develop psychosis and schizophrenia. The
first symptoms tend to start in young adulthood, at a time when a person would usually
make the transition to independent living, but can occur at any age. The symptoms and
behaviour associated with psychosis and schizophrenia can have a distressing impact on
the individual, family and friends.

Psychosis and schizophrenia are associated with considerable stigma, fear and limited
public understanding. The first few years after onset can be particularly upsetting and
chaotic, and there is a higher risk of suicide. Once an acute episode is over, there are often
other problems such as social exclusion, with reduced opportunities to get back to work or
study, and problems forming new relationships.

In the last decade, there has been a new emphasis on services for early detection and
intervention, and a focus on long-term recovery and promoting people's choices about the
management of their condition. There is evidence that most people will recover, although
some will have persisting difficulties or remain vulnerable to future episodes. Not everyone
will accept help from statutory services. In the longer term, most people will find ways to
manage acute problems, and compensate for any remaining difficulties.

Carers, relatives and friends of people with psychosis and schizophrenia are important
both in the process of assessment and engagement, and in the long-term successful
delivery of effective treatments. This guideline uses the term 'carer' to apply to everyone
who has regular close contact with people with psychosis and schizophrenia, including
advocates, friends or family members, although some family members may choose not to
be carers.

Psychosis and schizophrenia are commonly associated with a number of other conditions,
such as depression, anxiety, post-traumatic stress disorder, personality disorder and
substance misuse. This guideline does not cover these conditions. NICE has produced
separate guidance on the management of these conditions (see the NICE topic page on
mental health, behavioural and neurodevelopmental conditions).

The guideline will assume that prescribers will use a drug's summary of product
characteristics to inform decisions made with individual patients.

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Finding more information and committee

details
To find NICE guidance on related topics, including guidance in development, see the NICE
topic page on mental health, behavioural and neurodevelopmental conditions.

For full details of the evidence and the guideline committee's discussions, see the full
guideline and appendices. You can also find information about how the guideline was
developed, including details of the committee.

NICE has produced tools and resources to help you put this guideline into practice. For
general help and advice on putting NICE guidelines into practice see resources to help you
put guidance into practice.

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Update information
March 2014: A correction was made to the wording of recommendation [Link] to clarify
that it is the hydrocarbons in cigarette smoke that cause interactions with other drugs,
rather than nicotine.

February 2014: We reviewed the evidence and made new recommendations on

maintaining and improving physical health, peer support and self-management, preventing
psychosis, service-level interventions, employment, education and occupational activities,
and supporting carers. These recommendations are marked [2014].

We have also made some changes without an evidence review:

• Some recommendations have been aligned with the NICE guideline on psychosis and
schizophrenia in children and young people. This promotes early intervention in
psychosis services for young people aged 15 years and over.

• Substance misuse has been included as a coexisting condition that should be looked
for.

• A recommendation has been amended to indicate that antipsychotics should not be

started in primary care unless under the supervision of a consultant psychiatrist.

• A recommendation has been amended to reflect recent terminology relating to ethnic

groups and to remove reference to specific agencies.

These recommendations are marked as [2009, amended 2014].

Recommendations marked [2009] last had an evidence review in 2009. In some cases,
minor changes have been made to the wording to bring the language and style up to date,
without changing the meaning.

Minor updates since publication

September 2024: We added links to relevant technology appraisal guidance in the

sections on assessment and care planning and interventions for people whose illness has
not responded adequately to treatment.

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July 2024: We have simplified the guideline by removing recommendations that are
covered in other sources (such as other NICE guidelines or the BNF), and
recommendations that are general good practice advice with no supporting evidence.

This is a presentational change only, and no changes to practice are intended.

November 2022: In recommendation [Link] we removed the wording about initially using a
small test dose when initiating depot/long-acting injectable antipsychotic medication, as
this is no longer always appropriate. See the surveillance report for more information.

December 2021: Following a surveillance review we have updated recommendations

[Link] and [Link] to say that either glycosylated haemoglobin (HbA1c) or fasting blood
glucose may be used to test for diabetes in people taking antipsychotic medication.

August 2019: Text has been added to recommendation [Link] to indicate that the advice
has not changed after our review of the 2019 STEPWISE trial. The recommendation label
has been changed to [2019] to indicate that the evidence was last reviewed in 2019. Links
have been updated.

ISBN: 978-1-4731-0428-0

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