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SchizophreniaTHE NICE GUIDELINE ON CORE INTERVENTIONS IN THE TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA IN ADULTS IN PRIMARY AND SECONDARY CARE UPDATED EDITION)

Praise for Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (Updated edition)There are still many inequalities that exist in mental health, some of which are particularly pertinent for people with schizophrenia, such as not getting access to effective and evidence based psychological and pharmacological treatments. These inequalities are even more difficult to overcome for people from ethnic minorities, who often gain access to help at a very late stage. This guideline is the first to tackle these problematic issues by undertaking a full evidence review of the problems faced by people from African Caribbean groups in accessing UK services. The guideline provides all the evidence underpinning which services and treatments work for people with schizophrenia, including people from black and minority ethnic groups, such as family interventions, cognitive behavioural therapy, arts therapies and careful use of antipsychotics. I can thoroughly recommend this world class guideline to anyone with an interest in the evidence about what works for people with schizophrenia. Professor DINESH BHUGRA, MA, MSc, MBBS, FRCPsych, MPhil, PhD, President, Royal College of Psychiatrists

SCHIZOPHRENIACORE INTERVENTIONS IN THE TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA IN ADULTS IN PRIMARY AND SECONDARY CARE (UPDATED EDITION)National Clinical Guideline Number 82 National Collaborating Centre for Mental Health commissioned by the National Institute for Health & Clinical Excellence

published by The British Psychological Society and The Royal College of Psychiatrists

The British Psychological Society & The Royal College of Psychiatrists, 2010The views presented in this book do not necessarily reflect those of the British Psychological Society, and the publishers are not responsible for any error of omission or fact. The British Psychological Society is a registered charity (no. 229642). All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN-: 978-1-85433-479-4 Printed in Great Britain by Stanley Hunt. Additional material: data CD-Rom created by Pix18 (www.pix18.co.uk)developed by National Collaborating Centre for Mental Health Royal College of Psychiatrists Research Unit 4th Floor, Standon House 21 Mansell Street London E1 8AA www.nccmh.org.uk National Institute for Health and Clinical Excellence MidCity Place, 71 High Holborn London WCIV 6NA www.nice.org.uk The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR www.bps.org.uk and The Royal College of Psychiatrists 17 Belgrave Square London SW1X 8PG www.rcpsych.ac.uk

commissioned by

published by

Contents

CONTENTSGUIDELINE DEVELOPMENT GROUP MEMBERS ACKNOWLEDGEMENTS 1 PREFACE 1.1 National guideline 1.2 The national schizophrenia guideline 2 SCHIZOPHRENIA 2.1 The disorder 2.2 Incidence and prevalence 2.3 Possible causes of schizophrenia 2.4 Assessment 2.5 Engagement, consent and therapeutic alliance 2.6 Language and stigma 2.7 Issues for families and carers 2.8 Treatment and management of schizophrenia in the NHS 2.9 The economic cost of schizophrenia 3 METHODS USED TO UPDATE THIS GUIDELINE 3.1 Overview 3.2 The scope 3.3 The guideline development group 3.4 Clinical questions 3.5 Systematic clinical literature review 3.6 Health economics methods 3.7 Stakeholder contributions 3.8 Validation of the guideline 4 EXPERIENCE OF CARE 4.1 Introduction 4.2 Methodology 4.3 Personal accounts from people with schizophrenia 4.4 Personal accounts from carers 4.5 Summary of themes from service users and carers experiences 4.6 Recommendations 5 ACCESS AND ENGAGEMENT 5.1 Introduction 5.2 Early intervention 5.3 Access and engagement to service-level interventions 6 9 10 10 13 16 16 22 22 23 23 25 26 27 30 33 33 33 34 35 37 44 47 48 49 49 49 50 57 65 70 74 74 74 80 3

Contents 6 PHARMACOLOGICAL INTERVENTIONS IN THE TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA 6.1 Introduction 6.2 Initial treatment with antipsychotic medication 6.3 Oral antipsychotics in the treatment of the acute episode 6.4 Promoting recovery in people with schizophrenia that is in remission pharmacological relapse prevention 6.5 Promoting recovery in people with schizophrenia whose illness has not responded adequately to treatment 6.6 Treatment with depot/long-acting injectable antipsychotic medication 6.7 Side effects of antipsychotic medication 6.8 Effectiveness of antipsychotic medication 6.9 Health economics 6.10 From evidence to recommendations 6.11 Recommendations 7 ECONOMIC MODEL COST EFFECTIVENESS OF PHARMACOLOGICAL INTERVENTIONS FOR PEOPLE WITH SCHIZOPHRENIA 7.1 Introduction 7.2 Economic modelling methods 7.3 Results 7.4 Discussion of findings limitations of the analysis 7.5 Conclusions 8 PSYCHOLOGICAL THERAPY AND PSYCHOSOCIAL INTERVENTIONS IN THE TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA 8.1 Introduction 8.2 Adherence therapy 8.3 Arts therapies 8.4 Cognitive behavioural therapy 8.5 Cognitive remediation 8.6 Counselling and supportive therapy 8.7 Family intervention 8.8 Psychodynamic and psychoanalytic therapies 8.9 Psychoeducation 8.10 Social skills training 8.11 Recommendations (Across all treatments) 9 SERVICE-LEVEL INTERVENTIONS IN THE TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA 9.1 Introduction 9.2 Interface between primary and secondary care 9.3 Community mental health teams 4

96 97 100 105 114 120 140 145 154 156 170 174

179 179 180 227 234 241

243 243 247 251 257 275 283 290 310 314 320 327 328 328 329 334

Contents 9.4 9.5 9.6 9.7 9.8 9.9 Assertive outreach (Assertive community treatment) Acute day hospital care Vocational rehabilitation Non-acute day hospital care Crisis resolution and home treatment teams Intensive case management 337 342 345 351 353 357 362 362 365 367 370 374 376 449 485

10 SUMMARY OF RECOMMENDATIONS 10.1 Care across all phases 10.2 Initiation of treatment (First episode) 10.3 Treatment of the acute episode 10.4 Promoting recovery 10.5 Research recommendations 11 APPENDICES 12 REFERENCES 13 ABBREVIATIONS

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Guideline development group members

GUIDELINE DEVELOPMENT GROUP MEMBERSProfessor Elizabeth Kuipers (Chair, Guideline Development Group) Professor of Clinical Psychology, Head of Department, Institute of Psychiatry, Kings College London Honorary Consultant Clinical Psychologist, Maudsley Hospital, South London and Maudsley NHS Foundation Trust Dr Tim Kendall (Facilitator, Guideline Development Group) Joint Director, The National Collaborating Centre for Mental Health Deputy Director, Royal College of Psychiatrists Research and Training Unit Consultant Psychiatrist and Medical Director, Sheffield Health and Social Care NHS Foundation Trust Ms Janey Antoniou Service user representative and freelance writer, trainer and researcher on mental health issues Professor Thomas Barnes Professor of Clinical Psychiatry, Imperial College London Professor Kamaldeep Bhui Professor of Cultural Psychiatry and Epidemiology, Wolfson Institute of Preventative Medicine, Barts and The London, Queen Mary University of London Ms Victoria Bird Research Assistant, The National Collaborating Centre for Mental Health Dr Alison Brabban Consultant Clinical Psychologist, Tees, Esk and Wear Valley NHS Trust Ms Esther Flanagan Guideline Development Manager, The National Collaborating Centre for Mental Health (2008 to 2009) Professor Philippa Garety Professor of Clinical Psychology, Institute of Psychiatry, Kings College London Trust Head of Psychology, South London and Maudsley NHS Foundation Trust

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Guideline development group members Ms Sarah Hopkins Project Manager, The National Collaborating Centre for Mental Health (2006 to 2008) Mr Ryan Li Research Assistant, The National Collaborating Centre for Mental Health (2007) Ms Anna Maratos Head of Profession, Arts Therapies, Central and North West London NHS Foundation Trust Dr Ifigeneia Mavranezouli Senior Health Economist, The National Collaborating Centre for Mental Health Dr Jonathan Mitchell Consultant Psychiatrist, Sheffield Health and Social Care NHS Foundation Trust Honorary Systematic Reviewer, The National Collaborating Centre for Mental Health Professor Irwin Nazareth Professor of Primary Care and Population Sciences Director, Medical Research Council General Practice Research Framework Mr J Peter Pratt Chief Pharmacist, Sheffield Health and Social Care NHS Foundation Trust and Doncaster and South Humber NHS Trust Dr Robert Paul Rowlands Consultant Psychiatrist, Derbyshire Mental Health Services NHS Trust Ms Christine Sealey Centre Manager, The National Collaborating Centre for Mental Health (2008 to 2009) Ms Jacqueline Sin Education and Practice Lead in Psychosocial Interventions, Berkshire Healthcare NHS Foundation Trust and Thames Valley University Ms Sarah Stockton Senior Information Scientist, The National Collaborating Centre for Mental Health Dr Geraldine Strathdee Trust Director of Clinical Services, Oxleas NHS Foundation Trust

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Guideline development group members Dr Clare Taylor Editor, The National Collaborating Centre for Mental Health Dr Clive Travis Service user representative Professor Douglas Turkington Professor of Psychosocial Psychiatry, Newcastle