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Psychosis and schizophrenia overview

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Psychosis and schizophrenia

About

What is covered

This pathway covers the recognition and management of psychosis and schizophrenia in children and young people under 18 years, and the care and management of adults with psychosis and schizophrenia (with onset before the age of 60 years). It includes care provided by primary, community, secondary, tertiary and other health and social care professionals, including professionals in CAMHS and early intervention in psychosis services. The term 'psychosis' refers to the group of psychotic disorders that includes schizophrenia, schizoaffective disorder, schizophreniform disorder and delusional disorder.

Updates

Updates to this pathway

24 May 2016 Recommendations in choosing antipsychotic medication amended in line with the update of NICE guideline CG155 on psychosis and schizophrenia in children and young people: recognition and management.
14 October 2015 Bipolar disorder, psychosis and schizophrenia in children and young people (NICE quality standard 102) added to this pathway.
29 May 2015 Link to NICE pathway on challenging behaviour and learning disabilities added.
11 February 2015 Psychosis and schizophrenia in adults (NICE quality standard 80) added to this pathway.
23 September 2014 Link added to bipolar disorder pathway.
17 July 2014 Link added to cardiovascular disease prevention pathway.
18 March 2014:
The recommendation on help to stop smoking in care across all phases in this pathway has been corrected. This is to make it clear that it is the hydrocarbons in cigarette smoke that cause interactions with other drugs, rather than nicotine. The corrected recommendation reads:
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.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

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

Short Text

Everything NICE has said on psychosis and schizophrenia recognition and manin children and young people and management adults in an interactive flowchart.

What is covered

This pathway covers the recognition and management of psychosis and schizophrenia in children and young people under 18 years, and the care and management of adults with psychosis and schizophrenia (with onset before the age of 60 years). It includes care provided by primary, community, secondary, tertiary and other health and social care professionals, including professionals in CAMHS and early intervention in psychosis services. The term 'psychosis' refers to the group of psychotic disorders that includes schizophrenia, schizoaffective disorder, schizophreniform disorder and delusional disorder.

Updates

Updates to this pathway

24 May 2016 Recommendations in choosing antipsychotic medication amended in line with the update of NICE guideline CG155 on psychosis and schizophrenia in children and young people: recognition and management.
14 October 2015 Bipolar disorder, psychosis and schizophrenia in children and young people (NICE quality standard 102) added to this pathway.
29 May 2015 Link to NICE pathway on challenging behaviour and learning disabilities added.
11 February 2015 Psychosis and schizophrenia in adults (NICE quality standard 80) added to this pathway.
23 September 2014 Link added to bipolar disorder pathway.
17 July 2014 Link added to cardiovascular disease prevention pathway.
18 March 2014:
The recommendation on help to stop smoking in care across all phases in this pathway has been corrected. This is to make it clear that it is the hydrocarbons in cigarette smoke that cause interactions with other drugs, rather than nicotine. The corrected recommendation reads:
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.

Quality standards

Bipolar disorder, psychosis and schizophrenia in children and young people

These quality statements are taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice for bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statements

Assessment for a first episode of psychosis

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people who are referred to a specialist mental health service with a first episode of psychosis start assessment within 2 weeks.

Rationale

Starting assessment for a first episode of psychosis within 2 weeks can improve outcomes by reducing the duration of untreated psychosis, as longer periods of untreated psychosis are linked to worse outcomes. Specialist mental health services can improve symptoms and clinical outcomes such as admission and relapse rates.

Quality measures

Structure
Evidence of local arrangements to ensure that systems are in place for children and young people who are referred to a specialist mental health service with a first episode of psychosis to start assessment within 2 weeks.
Data source: Local data collection.
Process
Proportion of children and young people who are referred to a specialist mental health service with a first episode of psychosis who start assessment within 2 weeks.
Numerator – the number in the denominator who start assessment within 2 weeks of referral.
Denominator – the number of children and young people who are referred to a specialist mental health service with a first episode of psychosis.
Data source: Local data collection. National data are collected in the Health and Social Care Information Centre Child and Adolescent Mental Health Services Data Set.
Outcome
a) Mental health admission rates for children and young people.
Data source: Local data collection. National data are collected in the Health and Social Care Information Centre Child and Adolescent Mental Health Services Data Set.
b) Duration of untreated psychosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (such as child and adolescent mental health services and early intervention in psychosis services) ensure that systems and protocols are in place for children and young people who are referred to a specialist mental health service with a first episode of psychosis to start assessment within 2 weeks.
Healthcare professionals (such as psychologists and psychiatrists) start assessment of children and young people who are referred with a first episode of psychosis within 2 weeks of referral.
Commissioners (such as clinical commissioning groups and NHS England) commission specialist mental health services that start assessment within 2 weeks for children and young people who are referred with a first episode of psychosis.

What the quality statement means for children, young people, parents and carers

Children and young people who have been having hallucinations or delusions (believing things that aren’t true) for 4 weeks or more for the first time start an assessment within 2 weeks of being referred to a specialist mental health service (such as a child and adolescent mental health service or an early intervention in psychosis service). These services find out why the child or young person is having hallucinations or delusions, and will provide support and treatment to prevent them from coming back. This will reduce the chance that the child or young person needs to be admitted to hospital.

Source guidance

Definitions of terms used in this quality statement

A first episode of psychosis
A first presentation of sustained psychotic symptoms (lasting 4 weeks or more). Symptoms may include ‘positive symptoms’ such as hallucinations (perception in the absence of any stimulus) and ‘negative symptoms’ such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self-neglect.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.1 (key priority for implementation) and Introduction]
Specialist mental health service
An age-appropriate multidisciplinary service such as a child and adolescent mental health service or an early intervention in psychosis service.

Equality and diversity considerations

Assessments should be adjusted if necessary to take account of any learning disabilities, autism or cognitive impairment, and healthcare professionals should consider consulting a relevant specialist.

Family intervention

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people with a first episode of psychosis and their family members are offered family intervention.

Rationale

Families play an important part in providing care and support to children and young people with a first episode of psychosis. When family intervention forms part of a broad-based approach that combines different treatment options tailored to the needs of the individual and their family, it can improve coping skills and relapse rates for children and young people with a first episode of psychosis.

Quality measures

Structure
Evidence of local arrangements to ensure that family intervention is an available treatment option for children and young people with a first episode of psychosis and their family members.
Data source: Local data collection.
Process
a) Proportion of children and young people with a first episode of psychosis whose family members receive family intervention.
Numerator – the number in the denominator whose family members receive family intervention.
Denominator – the number of children and young people with a first episode of psychosis.
Data source: Local data collection.
b) Proportion of children and young people with a first episode of psychosis who receive family intervention.
Numerator – the number in the denominator who receive family intervention.
Denominator – the number of children and young people with a first episode of psychosis.
Data source: Local data collection.
Outcome
Relapse rates for children and young people with psychosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as child and adolescent mental health services and early intervention in psychosis services) ensure that family intervention is an available treatment option for children and young people with a first episode of psychosis and their family members. They should ensure that practitioners are trained and have the appropriate competencies to deliver it.
Healthcare professionals (such as psychologists and psychiatrists) offer family intervention to children and young people with a first episode of psychosis and their family members.
Commissioners (such as clinical commissioning groups and NHS England) commission family intervention services and ensure that referral pathways are in place for children and young people with a first episode of psychosis and their family members to be referred for family intervention.

What the quality statement means for children, young people, parents and carers

Children and young people with a first episode of psychosis and their family members are offered a psychological therapy called family intervention. This helps support families or carers to work together to help children and young people with psychosis cope and to reduce stress.

Source guidance

Definitions of terms used in this quality statement

Family members
Family members include parents and carers, siblings and other family members who the child or young person with a first episode of psychosis lives with or is in close contact with.
A first episode of psychosis
A first presentation of sustained psychotic symptoms (lasting 4 weeks or more). Symptoms may include ‘positive symptoms’ such as hallucinations (perception in the absence of any stimulus) and ‘negative symptoms’ such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self-neglect.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.1 (key priority for implementation) and Introduction]
Family intervention
Family intervention is a psychological therapy that should:
  • include the child or young person with psychosis, 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 parents or carers and the child or young person with psychosis
  • have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.27]

Equality and diversity considerations

The delivery and duration of family intervention should be adjusted if necessary to take account of any learning disabilities, autism or cognitive impairment in the child or young person with psychosis or their family members, and healthcare professionals should consider consulting a relevant specialist.
The workforce across agencies should, as far as possible, reflect the local community. Practitioners should have training to ensure that they have a good understanding of the culture of families they are working with. Interpreters should be provided if no practitioner is available who speaks a language in which the family members can communicate easily.

Psychological intervention

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people newly diagnosed with bipolar depression or a first episode of psychosis are offered a psychological intervention.

Rationale

Psychological interventions (in conjunction with antipsychotic medication, or on their own if medication is declined or not needed) can improve outcomes for bipolar depression and psychosis. The psychological intervention will be based on a psychological assessment and formulation, and will aim to reduce distress, promote social and educational recovery, reduce social anxiety and depression, and prevent relapse in children and young people.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people newly diagnosed with bipolar depression or a first episode of psychosis are offered a psychological intervention.
Data source: Local data collection.
Process
a) Proportion of children and young people newly diagnosed with bipolar depression who receive cognitive behavioural therapy or interpersonal therapy.
Numerator – the number in the denominator who receive cognitive behavioural therapy or interpersonal therapy.
Denominator – the number of children and young people newly diagnosed with bipolar depression.
Data source: Local data collection.
b) Proportion of children and young people newly diagnosed with a first episode of psychosis who receive cognitive behavioural therapy.
Numerator – the number in the denominator who receive cognitive behavioural therapy.
Denominator – the number of children and young people newly diagnosed with a first episode of psychosis.
Data source: Local data collection.
Outcomes
a) Relapse rates for children and young people with bipolar depression.
Data source: Local data collection.
b) Relapse rates for children and young people with psychosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as child and adolescent mental health services and early intervention in psychosis services) ensure that a psychological intervention is available as a treatment option for children and young people newly diagnosed with bipolar depression or a first episode of psychosis. They should ensure that practitioners are trained and have the appropriate competencies to deliver psychological interventions.
Healthcare professionals (such as psychologists, psychiatrists and psychotherapists) offer a psychological intervention to children and young people newly diagnosed with bipolar depression or a first episode of psychosis.
Commissioners (such as clinical commissioning groups and NHS England) commission services that offer a psychological intervention to children and young people newly diagnosed with bipolar depression or a first episode of psychosis.

What the quality statement means for children, young people, parents and carers

Children and young people who are diagnosed with bipolar depression or a first episode of psychosis are offered a psychological therapy. This involves meeting a healthcare professional on their own or with a parent or carer to talk about their feelings and thoughts, which can help them to find ways to cope with their symptoms. For children and young people with psychosis, psychological therapy works better when they also take antipsychotic medication (medicine to help with psychosis).

Source guidance

Definitions of terms used in this quality statement

Psychological intervention
Children and young people with a first episode of psychosis should be offered cognitive behavioural therapy. It should be delivered in at least 16 planned sessions, follow a treatment manual and include at least 1 of the following:
  • normalising
  • personal monitoring
  • promoting alternative ways of coping
  • reducing distress
  • improving functioning.
Children and young people newly diagnosed with bipolar depression should be offered cognitive behavioural therapy or interpersonal therapy. The intervention should be delivered over at least 3 months and have a published evidence-based manual describing how it should be delivered.
[Adapted from Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.28 and Bipolar disorder (NICE guideline CG185) recommendation 1.11.11 (key priority for implementation)]

Equality and diversity considerations

The delivery and duration of a psychological intervention should be adjusted if necessary to take account of any learning disabilities, autism or cognitive impairment a child or young person with bipolar depression or psychosis has, and healthcare professionals should consider consulting a relevant specialist.
Specialist mental health services should provide children and young people from diverse ethnic and cultural backgrounds with culturally appropriate psychological and psychosocial treatment, and address cultural and ethnic differences in beliefs about biological, social and family influences on mental states.

Support for carers

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Parents and carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia are given information about carer-focused education and support.

Rationale

Carer-focused education and support enhances engagement and reduces carer burden and psychological distress, and may improve the carer’s quality of life. As part of the initial process of assessment and engagement, carer-focused education and support can also help carers of children and young people with bipolar disorder, psychosis or schizophrenia to be able to identify and monitor symptoms of concern.

Quality measures

Structure
Evidence of local arrangements to ensure that parents and carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia are given information about carer-focused education and support.
Data source: Local data collection.
Process
Proportion of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia whose parents or carers receive information about carer-focused education and support.
Numerator – the number in the denominator whose parents or carers receive information about carer-focused education and support.
Denominator – the number of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
Outcome
a) Satisfaction of parents and carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia with the information and support provided to meet their own needs.
Data source: Local data collection.
b) Quality of life for parents and carers of children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as GP surgeries, community health services, child and adolescent mental health services and early intervention in psychosis services) ensure that processes are in place for parents or carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia to be given information and encouragement to participate in carer-focused education and support.
Health and social care practitioners (such as psychologists, social workers and GPs) give parents or carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia information about carer-focused education and support, and encourage them to participate.
Commissioners (clinical commissioning groups and NHS England) ensure that carer-focused education and support is available, and that appropriate referral pathways are in place for parents or carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia.

What the quality statement means for children, young people, parents and carers

Parents or carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia are given information about education and support. This can help carers to cope by improving their understanding of the condition and treatments for it, and giving them the opportunity to discuss their experiences with others.

Source guidance

Definitions of terms used in this quality statement

Carer-focused education and support
This will include information about support groups and education programmes available locally, including those provided by the third sector. Support groups and education programmes will provide information, mutual support and open discussion to carers through voluntary participation. Support groups and education programmes should be available as needed and offer a positive message about recovery.
[Adapted from Bipolar disorder (NICE guideline CG185) recommendation 1.1.18 and Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.1.14]

Equality and diversity considerations

If a person does not have access to specialist training or support near their home, and has difficulty travelling long distances (because of the financial cost or other reasons), they may need additional support.
Equality of language and capability in training carers needs to be considered.

Healthy lifestyle advice

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people with bipolar disorder, psychosis or schizophrenia are given healthy lifestyle advice at diagnosis and at annual review.

Rationale

As they get older, children and young people with bipolar disorder, psychosis or schizophrenia have poorer physical health than the general population and a reduced life expectancy. Health problems may sometimes be linked to lifestyle factors and risky behaviours, and are exacerbated by the use of antipsychotic drugs. It is important that primary care and specialist mental health services take a proactive approach to promoting positive health behaviours from a young age by giving age-appropriate healthy lifestyle advice at diagnosis and at annual review.

Quality measures

Structure
a) Evidence of local arrangements to ensure that children and young people with bipolar disorder, psychosis or schizophrenia are given healthy lifestyle advice at diagnosis.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that children and young people with bipolar disorder, psychosis or schizophrenia being supported in primary care or specialist mental health services are given healthy lifestyle advice at their annual review.
Data source: Local data collection.
Process
a) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia who receive healthy lifestyle advice at diagnosis.
Numerator – the number in the denominator who receive healthy lifestyle advice at diagnosis.
Denominator – the number of children and young people with a new diagnosis of bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
b) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia who receive healthy lifestyle advice at their annual review.
Numerator – the number in the denominator who receive healthy lifestyle advice at their annual review.
Denominator – the number of children and young people with bipolar disorder, psychosis or schizophrenia who are supported in primary care or specialist mental health services.
Data source: Local data collection.
Outcomes
a) Obesity rates in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data on BMI values are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to children and young people with bipolar disorder, psychosis or schizophrenia).
b) Physical activity in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
c) Drug use in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
d) Alcohol consumption in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data on alcohol consumption are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to children and young people with bipolar disorder, psychosis or schizophrenia).
e) Smoking rates in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data on smoking status are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to children and young people with bipolar disorder, psychosis or schizophrenia).
f) Infection rates for sexually transmitted diseases in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
g) Premature mortality of people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP surgeries, community health services, child and adolescent mental health services and early intervention in psychosis services) ensure that processes are place for children and young people with bipolar disorder, psychosis or schizophrenia to receive age-appropriate healthy lifestyle advice at diagnosis and at annual review.
Healthcare professionals (such as GPs, psychologists and mental health nurses) offer age-appropriate healthy lifestyle advice to children and young people with bipolar disorder, psychosis or schizophrenia at diagnosis and at annual review.
Commissioners (such as clinical commissioning groups and NHS England) commission services that offer age-appropriate healthy lifestyle advice to children and young people with bipolar disorder, psychosis or schizophrenia at diagnosis and at annual review.

What the quality statement means for children, young people, parents and carers

Children and young people with bipolar disorder, psychosis or schizophrenia should be offered advice that is suitable for their age at diagnosis and at annual review on healthy eating, how to make sure they get enough exercise, practising safe sex and the importance of avoiding drug and alcohol misuse and smoking. If they smoke, they should be given advice on how to stop.

Source guidance

Definitions of terms used in this quality statement

Healthy lifestyle advice
Age-appropriate advice on healthy eating, physical activity, drug and alcohol use, smoking and sexual health.
[Adapted from Bipolar disorder (NICE guideline CG185), recommendation 1.8.2 and Psychosis and schizophrenia in children and young people (NICE guideline CG155), recommendations 1.3.4 and 1.5.13.]

Equality and diversity considerations

Healthcare professionals should be aware of the impact of social factors (such as inadequate housing, lack of access to affordable physical activity, poor cooking skills and limited budgets for food) on continued healthy eating and physical activity.
Healthcare professionals should take into account cultural and communication needs when giving healthy lifestyle advice to a child or young person.

Monitoring for side effects of antipsychotic medication

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication have their treatment monitored for side effects.

Rationale

Children and young people with bipolar disorder, psychosis or schizophrenia are particularly vulnerable to the adverse side effects of antipsychotic medication, including rapid weight gain and metabolic disturbances. This, combined with higher rates of smoking, leads to a higher risk of cardiovascular disease and metabolic disorders than the general population. Regular monitoring will allow antipsychotic medication to be adjusted so that side effects are minimised, and so that physical health interventions can be offered if needed.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication have their treatment monitored for side effects.
Data source: Local data collection.
Process
a) Proportion of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication who have a record of baseline physical health investigations.
Numerator – the number in the denominator who have a record of baseline physical health investigations.
Denominator – the number of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication.
Data source: Local data collection. The Prescribing Observatory for Mental Health (POMH-UK) audit-based quality improvement programme on prescribing antipsychotics for children and adolescents includes data (for participating trusts) on documented tests and measures taken before starting antipsychotic treatment.
b) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia newly prescribed antipsychotic medication who have a record of side-effect monitoring 12 weeks after starting treatment.
Numerator – the number in the denominator who have a record of side-effect monitoring 12 weeks after starting treatment.
Denominator – the number of children and young people with bipolar disorder, psychosis or schizophrenia newly prescribed antipsychotic medication.
Data source: Local data collection.
c) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication for more than a year with a record of side-effect monitoring within the last 6 months.
Numerator – the number in the denominator with a record of side-effect monitoring within the last 6 months.
Denominator – the number of children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication for more than a year.
Data source: Local data collection. The (POMH-UK) audit-based quality improvement programme on prescribing antipsychotics for children and adolescents includes data (for participating trusts) on a documented review of therapeutic response and side effects of antipsychotic medication at least once every 6 months.
Outcome
a) Obesity rates in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data on BMI values are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to children and young people with bipolar disorder, psychosis or schizophrenia).
b) Incidence of cardiovascular disease in people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data can be collected for adults with schizophrenia using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, question 30.
c) Incidence of type 2 diabetes in people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data can be collected for adults with schizophrenia using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, question 30.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP surgeries, community health services, child and adolescent mental health services and early intervention in psychosis services) ensure that systems and protocols are in place to monitor the side effects of antipsychotic medication for children and young people with bipolar disorder, psychosis or schizophrenia, and to share the results when the child or young person is in the care of primary and secondary care services.
Healthcare professionals (such as GPs, mental health nurses, and psychiatrists) monitor the side effects of antipsychotic medication for children and young people with bipolar disorder, psychosis or schizophrenia, and share the results when the child or young person is in the care of primary and secondary care services.
Commissioners (such as clinical commissioning groups and NHS England) commission services that monitor the side effects of antipsychotic medication for children and young people with bipolar disorder, psychosis or schizophrenia. They should also ensure that arrangements are in place to share the results of monitoring when the child or young person is in the care of primary and secondary services.

What the quality statement means for children, young people, parents and carers

Children and young people with bipolar disorder, psychosis or schizophrenia who are taking antipsychotic medication (medicine to help with psychosis) should see their healthcare professional regularly to check for side effects. This will include regular checks such as blood tests and measurements of their weight, height, waist, hip, pulse and blood pressure, to check for problems that may be caused by their medication (such as weight gain, diabetes, and heart, lung and breathing problems). The results of all health checks should be discussed with the child or young person and their parents or carers and shared between their GP surgery and mental health team.

Source guidance

Definitions of terms used in this quality statement

Baseline physical health investigations
Before starting antipsychotic medication, the following baseline investigations should be undertaken and recorded:
  • weight and height (both plotted on a growth chart)
  • waist and hip circumference
  • pulse and blood pressure
  • fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile and prolactin levels
  • assessment of any movement disorders
  • assessment of nutritional status, diet and level of physical activity.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.16 and Bipolar disorder (NICE guideline CG185) recommendation 1.10.5]
Monitoring for side effects of antipsychotic medication
Side effects of antipsychotic medication can be:
  • 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).
The following should be monitored and recorded regularly and systematically throughout treatment with antipsychotic medication, but especially during titration:
  • efficacy, including changes in symptoms and behaviour
  • 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)
  • the emergence of movement disorders
  • weight, weekly for the first 6 weeks, then at 12 weeks and then every 6 months (plotted on a growth chart)
  • height every 6 months (plotted on a growth chart)
  • waist and hip circumference every 6 months (plotted on a percentile chart)
  • pulse and blood pressure (plotted on a percentile chart) at 12 weeks and then every 6 months
  • fasting blood glucose, HbA1c, blood lipid and prolactin levels at 12 weeks and then every 6 months
  • adherence
  • physical health.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.19 (key priority for implementation) and Bipolar disorder (NICE guideline CG185) recommendation 1.10.8]

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs when explaining how the side effects of antipsychotic medication will be monitored.

Home treatment in crisis (developmental)

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

Children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis are offered home treatment if it is suitable.

Rationale

Hospital admissions can be disruptive for a child or young person and their family or carers. It may be possible to avoid hospital admission if treatment and support can be provided at home. A crisis assessment will determine whether home treatment is a suitable option, based on the child or young person’s needs, risks and circumstances.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis are offered home treatment if it is suitable.
Data source: Local data collection.
Process
a) Proportion of crisis episodes in children and young people with bipolar disorder, psychosis or schizophrenia that are assessed for the suitability of home treatment.
Numerator – the number in the denominator that are assessed for the suitability of home treatment.
Denominator – the number of crisis episodes in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
b) Proportion of crisis episodes in children and young people with bipolar disorder, psychosis or schizophrenia that are assessed as suitable for home treatment and result in home treatment.
Numerator – the number in the denominator that result in home treatment.
Denominator – the number of crisis episodes in children and young people with bipolar disorder, psychosis or schizophrenia that are assessed as suitable for home treatment.
Data source: Local data collection.
Outcome
Mental health admission rates for children and young people.
Data source: Local data collection. National data are collected in the Health and Social Care Information Centre Child and Adolescent Mental Health Services Data Set.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as child and adolescent mental health services and early intervention in psychosis services) ensure that home treatment is available for children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis.
Health and social care practitioners (such as psychologists and social workers) assess the suitability of home treatment for children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis.
Commissioners (clinical commissioning groups and NHS England) commission home treatment services for children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis.

What the quality statement means for children, young people, parents and carers

Children and young people with bipolar disorder, psychosis or schizophrenia who have a crisis should have a discussion with their mental health professional to agree if treatment at home would be better for them than treatment in hospital. Treatment in hospital can be very disruptive (for example, they may miss time in school).

Source guidance

Definitions of terms used in this quality statement

Crisis
A crisis may be suicidal behaviour or intention, panic attacks or extreme anxiety, psychotic episodes, or behaviour that seems out of control or irrational and likely to endanger the person or others.
[Mental health crisis care concordat, Department of Health (2014) and expert opinion]
Assessment for suitability for home treatment
A crisis assessment should be carried out by health and social care professionals who are experienced and competent in crisis working. The decision to start home treatment should depend not on the diagnosis, but on:
  • the level of distress
  • the severity of the problems
  • the vulnerability of the child or young person and issues of safety and support at home
  • the child or young person’s ability to adhere to treatment.
[Service user experience in adult mental health (NICE guideline CG136) recommendation 1.5.3 and Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.5.3]
Home treatment
A service that assesses, supports and provides treatment at home to promote engagement and avoid admission to hospital. The service should be available 24 hours a day, 7 days a week.
[Service user experience in adult mental health (NICE guideline CG136) full guideline and recommendation 1.5.7]

Equality and diversity considerations

Home treatment should be available to all children and young people with bipolar disorder, psychosis or schizophrenia in crisis, regardless of their age, if it is assessed as suitable.
Children and young people with psychosis from black and minority ethnic backgrounds are more frequently subject to compulsory admissions. It is therefore important that health and social care practitioners take into consideration ethnic and cultural backgrounds when making assessments for suitability for home treatment, so that compulsory admission is avoided whenever possible.

Referral to early intervention in psychosis services

This quality statement is taken from the psychosis and schizophrenia in adults quality standard. The quality standard defines clinical best practice in psychosis and schizophrenia in adults care and should be read in full.

Quality statement

Adults with a first episode of psychosis start treatment in early intervention in psychosis services within 2 weeks of referral.

Rationale

Early intervention in psychosis services can improve clinical outcomes, such as admission rates, symptoms and relapse, for people with a first episode of psychosis. They do this by providing a full range of evidence based treatment including pharmacological, psychological, social, occupation and educational interventions. Treatment from these services should be accessed as soon as possible to reduce the duration of untreated psychosis.

Quality measures

Structure
a) Evidence of local arrangements to ensure that early intervention in psychosis services are in place.
Data source: Local data collection
b) Evidence of local arrangements to ensure that local referral pathways are available for adults with a first episode of psychosis to start treatment in early intervention in psychosis services within 2 weeks of referral.
Data source: Local data collection
Process
Proportion of adults referred with a first episode of psychosis who receive treatment from early intervention in psychosis services within 2 weeks of referral.
Numerator – the number in the denominator who receive treatment from early intervention in psychosis services within 2 weeks.
Denominator – the number of adults referred with a first episode of psychosis.
Data source: Local data collection.
Outcome
a) Acute hospital admission rates.
Data source: Local data collection. National data are collected in the Health and Social Care Information Centre Mental health and learning disabilities data set.
b) Duration of untreated psychosis.
Data source: Local data collection. National data are collected in Health and Social Care Information Centre Mental health and learning disabilities data set.

What the quality statement means for service providers, health and social care practitioners, and commissioners.

Service providers (such as GPs, community health services, mental health services and drug and alcohol misuse services) ensure that systems and protocols are in place for people with a first episode of psychosis to be referred to mental health services and start treatment in an early intervention in psychosis services within 2 weeks of referral.
Health and social care practitioners are aware of local referral pathways for adults with a first episode of psychosis and ensure that they start treatment in an early intervention in psychosis services within 2 weeks of referral.
Commissioners (such as clinical commissioning groups, NHS England local area teams and local authorities) ensure that they commission early intervention in psychosis services and ensure that local referral pathways are in place for adults with a first episode of psychosis to start treatment in early intervention in psychosis services within 2 weeks of referral. This needs integrated commissioning.

What the quality statement means for patients, service users and carers

Adults with a first episode of psychosis start treatment within 2 weeks of being referred to an early intervention service. This service provides support and treatment to help people with symptoms of psychosis. Early treatment (within 2 weeks) in these services is often successful at treating symptoms and preventing symptoms from coming back, and helps to reduce the number of people who need to be admitted to hospital.

Source guidance

Definitions of terms used in this quality statement

Early intervention in psychosis services
Early intervention in psychosis services are multidisciplinary community mental health teams that assess and treat people with a first episode of psychosis without delay (within 2 weeks). They aim to provide a full range of pharmacological, psychological, social, occupation and educational interventions for people with psychosis.
Early intervention in psychosis services provide care for adults with a first episode of psychosis during the first 3 years of psychotic illness. However, this may be extended if the person has not made a stable recovery from psychosis or schizophrenia.
Services should also take into account the ‘negative’ symptoms of psychosis and schizophrenia (such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self neglect), and ensure services are accessible for people with these symptoms. [Achieving better access to mental health service by 2020 (Department of Health), Psychosis and schizophrenia in adults (NICE guideline CG178) recommendations 1.3.1.2 and 1.3.1.3 and expert consensus]

Equality and diversity considerations

Early intervention in psychosis services should ensure that culturally appropriate psychological and psychosocial treatment is provided to people from diverse ethnic and cultural backgrounds ensuring they address cultural and ethnic differences in beliefs regarding biological, social and family influences on mental states.

Cognitive behavioural therapy

This quality statement is taken from the psychosis and schizophrenia in adults quality standard. The quality standard defines clinical best practice in psychosis and schizophrenia in adults care and should be read in full.

Quality statement

Adults with psychosis or schizophrenia are offered cognitive behavioural therapy for psychosis (CBTp).

Rationale

CBTp in conjunction with antipsychotic medication, or on its own if medication is declined, can improve outcomes such as psychotic symptoms. It should form part of a broad based approach that combines different treatment options tailored to the needs of individual service users.

Quality measures

Structure
Evidence of local arrangements to ensure that CBTp is available to adults with psychosis or schizophrenia.
Data source: Local data collection.
Process
a) Proportion of adults with psychosis who receive CBTp.
Numerator – the number in the denominator who receive CBTp.
Denominator – the number of adults with psychosis.
Data source: Local data collection. Data can be collected using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, questions 42 and 44.
b) Proportion of adults with schizophrenia who receive CBTp.
Numerator – the number in the denominator who receive CBTp.
Denominator – the number of adults with schizophrenia.
Data source: Local data collection. Data can be collected using the Royal College of Psychiatrists’ NAS audit of practice tool National audit of schizophrenia Audit of practice tool, questions 42 and 44.
Outcome
Relapse rates of psychosis and schizophrenia in adults.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as GPs, community health services and mental health services) ensure that systems are in place for adults with psychosis or schizophrenia to be offered CBTp. They should ensure that practitioners have appropriate competencies to deliver CBTp and have access to training.
Healthcare professionals ensure that they offer CBTp to adults with psychosis or schizophrenia.
Commissioners (such as clinical commissioning groups, NHS England local area teams and local authorities) commission CBTp services and ensure that referral pathways are in place for adults with psychosis or schizophrenia to be referred to these services.

What the quality statement means for patients, service users and carers

Adults with psychosis or schizophrenia are offered a psychological therapy called ‘cognitive behavioural therapy for psychosis’ (sometimes shortened to CBTp). This involves meeting a healthcare professional on their own to talk about their feelings and thoughts, which can help them to find ways to cope with their symptoms.

Source guidance

Definitions of terms used in this quality statement

Cognitive behavioural therapy for psychosis (CBTp)
CBTp should be delivered over at least 16 planned sessions and:
  • follow a treatment manual so that:
    • people can establish links between their thoughts, feelings or actions and their current or past symptoms and functioning
    • the re evaluation of people's perceptions, beliefs or reasoning relates to the target symptoms
  • also include at least 1 of the following components:
    • people monitoring their own thoughts, feelings or behaviours about their symptoms or recurrence of symptoms
    • promoting alternative ways of coping with the target symptom
    • reducing distress
    • improving functioning. [Adapted from Psychosis and schizophrenia in adults (NICE guideline CG178) recommendation 1.3.7.1]

Equality and diversity considerations

For adults with psychosis or schizophrenia who have a learning disability or cognitive impairment, methods of delivering treatment and treatment duration should be adjusted if necessary to take account of the disability or impairment, with consideration given to consulting a relevant specialist.

Family intervention

This quality statement is taken from the psychosis and schizophrenia in adults quality standard. The quality standard defines clinical best practice in psychosis and schizophrenia in adults care and should be read in full.

Quality statement

Family members of adults with psychosis or schizophrenia are offered family intervention.

Rationale

Family intervention can improve coping skills and relapse rates of adults with psychosis and schizophrenia. Family intervention should involve the person with psychosis or schizophrenia if practical, and form part of a broad based approach that combines different treatment options tailored to the needs of individual service users.

Quality measures

Structure
Evidence of local arrangements to ensure that family intervention is available to family members of adults with psychosis or schizophrenia.
Data source: Local data collection.
Process
a) Proportion of adults with psychosis whose family members receive family intervention.
Numerator – the number in the denominator whose family members receive family intervention.
Denominator – the number of adults with psychosis who live with or are in close contact with family members.
Data source: Local data collection. Data can be collected using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, questions 43 and 44.
b) Proportion of adults with schizophrenia whose family members receive family intervention.
Numerator – the number in the denominator whose family members receive family intervention.
Denominator – the number of adults with schizophrenia who live with or are in close contact with family members.
Data source: Local data collection. Data can be collected using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, questions 43 and 44.
Outcome
Relapse rates of psychosis and schizophrenia in adults.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as GPs, community health services and mental health services) ensure that systems are in place for family members of adults with psychosis or schizophrenia to be offered family intervention. They should receive this intervention from practitioners with appropriate competencies to deliver it and who have access to training.
Healthcare professionals ensure that they offer family intervention to family members of adults with psychosis or schizophrenia.
Commissioners (such as clinical commissioning groups, NHS England local area teams and local authorities) commission family intervention services and ensure that referral pathways are in place for family members of adults with psychosis or schizophrenia to be referred to this service.

What the quality statement means for patients, service users and carers

Family members of adults with psychosis or schizophrenia are offered psychological therapies called family intervention. These help support families to work together to help adults with psychosis and schizophrenia cope and to reduce stress.

Source guidance

Definitions of terms used in this quality statement

Family members
Family members include carers and family members who the person with psychosis or schizophrenia lives with or is in close contact with. [Psychosis and schizophrenia in adults (NICE guideline CG178)]
Family intervention
Family intervention is a psychological therapy that should:
  • 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. [Psychosis and schizophrenia in adults (NICE guideline CG178) recommendation 1.3.7.2]

Equality and diversity considerations

For adults with psychosis or schizophrenia or members of their family who have a learning disability or cognitive impairment, methods of delivering treatment and treatment duration should be adjusted if necessary to take account of the disability or impairment, with consideration given to consulting a relevant specialist.
The workforce across agencies should, as far as possible, reflect the local community. Practitioners should have training to ensure that they have a good understanding of the culture of families they are working with. Interpreters should be provided if no practitioner is available who speaks a language in which the family members can communicate easily.

Treatment with clozapine

This quality statement is taken from the psychosis and schizophrenia in adults quality standard. The quality standard defines clinical best practice in psychosis and schizophrenia in adults care and should be read in full.

Quality statement

Adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs are offered clozapine.

Rationale

Clozapine is the only drug with established efficacy in reducing symptoms and the risk of relapse for adults with treatment resistant schizophrenia. It is licensed only for use in service users whose schizophrenia has not responded to, or who are intolerant of, conventional antipsychotic drugs.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotics drugs (at least 1 of which should be a non clozapine second generation antipsychotic) are offered clozapine.
Data source: Local data collection.
Process
Proportion of adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs (at least 1 of which should be a non clozapine second generation antipsychotic) who receive clozapine.
Numerator – the number in the denominator who receive clozapine.
Denominator – the number of adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs (at least 1 of which should be a non clozapine second generation antipsychotic).
Data source: Local data collection.
Outcome
Relapse rates of schizophrenia in adults.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community health services, mental health services and hospitals) ensure that there are procedures and protocols in place to monitor the prescribing of clozapine for adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs (at least 1 of which should be a non clozapine second generation antipsychotic).
Healthcare professionals ensure that adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs (at least 1 of which should be a non clozapine second generation antipsychotic) are offered clozapine.
Commissioners (such as NHS England area teams and clinical commissioning groups) monitor rates of prescribing of clozapine and commission services only from providers who can demonstrate that they have procedures and protocols in place to monitor this prescribing.

What the quality statement means for patients, service users and carers

Adults with schizophrenia that has not improved after treatment with at least 2 different antipsychotic drugs are offered an antipsychotic drug called clozapine to try and improve their symptoms.

Source guidance

Definitions of terms used in this quality statement

Schizophrenia that has not responded adequately to treatment
Schizophrenia that has not improved 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. [Psychosis and schizophrenia in adults (NICE guideline CG178) recommendation 1.5.7.2]

Supported employment programmes

This quality statement is taken from the psychosis and schizophrenia in adults quality standard. The quality standard defines clinical best practice in psychosis and schizophrenia in adults care and should be read in full.

Quality statement

Adults with psychosis or schizophrenia who wish to find or return to work are offered supported employment programmes.

Rationale

Supported employment programmes can increase employment rates in adults with psychosis or schizophrenia. It is estimated that just 5–15% of people with schizophrenia are in employment, and people with severe mental illness (including psychosis and schizophrenia) are 6 to 7 times more likely to be unemployed than the general population. Unemployment can have a negative effect on the mental and physical health of adults with psychosis or schizophrenia.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with psychosis or schizophrenia who wish to find or return to work are offered supported employment programmes.
Data source: Local data collection.
Process
Proportion of adults with psychosis or schizophrenia who wish to find or return to work who receive supported employment programmes.
Numerator – the number in the denominator who receive supported employment programmes.
Denominator – the number of adults with psychosis or schizophrenia who wish to find or return to work.
Data source: Local data collection.
Outcome
Employment rates for adults with psychosis or schizophrenia.
Data source: Local data collection. National data are collected in the Health and Social Care Information Centre Mental health and learning disabilities data set.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as GP practices, community health services and mental health services) ensure that systems are in place for adults with psychosis or schizophrenia who wish to find or return to work to be offered supported employment programmes.
Health and social care practitioners ensure that they are aware of local referral pathways to supported employment programmes, and offer these to adults with psychosis or schizophrenia who wish to find or return to work.
Commissioners (such as NHS England area teams and clinical commissioning groups) ensure that they commission services that offer supported employment programmes and ensure that referral pathways are in place for adults with psychosis or schizophrenia who wish to find or return to work.

What the quality statement means for patients, service users and carers

Adults with psychosis or schizophrenia who wish to find or return to work are offered a place on an employment scheme that supports them to find or return to work quickly.

Source guidance

Definitions of terms used in this quality statement

Supported employment programmes
Supported employment programmes, sometimes referred to as individual placement and support, are any approach to vocational rehabilitation that attempts to place service users in competitive employment immediately. Supported employment can begin with a short period of preparation, but this has to last less than 1 month and not involve work placement in a sheltered setting, training or transitional employment. [Psychosis and schizophrenia in adults (NICE guideline CG178) full guideline]

Equality and diversity considerations

Services should work in partnership with local stakeholders, including those representing black, Asian and minority ethnic groups, to enable adults with psychosis or schizophrenia to stay in work or education or access new employment, volunteering and educational opportunities.
Services should make reasonable adjustments to help adults with learning disabilities and psychosis or schizophrenia stay in work or education or find new employment, volunteering and educational opportunities.
Some adults may be unable to work or unsuccessful in finding employment. In these cases, other occupational or education activities should be considered, including pre vocational training.

Assessing physical health

This quality statement is taken from the psychosis and schizophrenia in adults quality standard. The quality standard defines clinical best practice in psychosis and schizophrenia in adults care and should be read in full.

Quality statement

Adults with psychosis or schizophrenia have specific comprehensive physical health assessments.

Rationale

Life expectancy for adults with psychosis or schizophrenia is between 15 and 20 years less than for people in the general population. This may be because people with psychosis or schizophrenia often have physical health problems, including cardiovascular and metabolic disorders, such as type 2 diabetes, that can be exacerbated by the use of antipsychotics. Comprehensively assessing physical health will enable health and social care practitioners to offer physical health interventions if necessary.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with psychosis or schizophrenia receive comprehensive physical health assessments.
Data source: Local data collection.
Process
a) Proportion of adults having treatment for first episode of psychosis who receive a comprehensive physical health assessment within 12 weeks.
Numerator – the number in the denominator who receive a comprehensive physical health assessment within 12 weeks.
Denominator – the number of adults having treatment for a first episode of psychosis.
Data source: Local data collection. Data can be collected using NHS England’s Commissioning for Quality Innovation (CQUIN) indicator Improving physical healthcare to reduce premature mortality in people with severe mental illness, indicator 1 and the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, questions 30 to 39.
b) Proportion of adults having treatment for first episode of psychosis who have a comprehensive physical health assessment 1 year after starting treatment.
Numerator – the number in the denominator who have a comprehensive physical health assessment 1 year after starting treatment.
Denominator – the number of adults having treatment for a first episode of psychosis.
Data source: Local data collection. Data can be collected using NHS England’s Commissioning for Quality Innovation (CQUIN) indicator Improving physical healthcare to reduce premature mortality in people with severe mental illness, indicator 1 and the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, questions 30 to 39.
c) Proportion of adults with psychosis and schizophrenia who have an annual comprehensive physical health assessment.
Numerator – the number in the denominator who have an annual comprehensive physical health assessment.
Denominator – the number of adults with psychosis or schizophrenia.
Data source: Local data collection. Data can be collected using NICE Quality and Outcomes Framework menu indicators NM15, NM16, NM17, NM18 and NM42.
Outcome
Premature mortality of adults with psychosis or schizophrenia.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as GPs, community health services and mental health services) ensure that protocols are in place to carry out comprehensive physical health assessments in adults with psychosis or schizophrenia, and share the results (under shared care arrangements) when the service user is in the care of primary and secondary services.
Health and social care practitioners ensure that they carry out comprehensive physical health assessments in adults with psychosis or schizophrenia, and share the results (under shared care arrangements) when the service user is in the care of primary and secondary services.
Commissioners (such as NHS England local area teams and local authorities) ensure that they commission services that can demonstrate they are carrying out comprehensive physical health assessments in adults with psychosis or schizophrenia, and include this requirement in continuous training programmes. They should also ensure that shared care arrangements are in place when the service user is in the care of primary and secondary services, to ensure that the results of assessments are shared.

What the quality statement means for patients, service users and carers

Adults with psychosis or schizophrenia should have a regular health check (at least once a year) that includes taking weight, waist, pulse and blood pressure measurements and blood tests. This checks for problems such as weight gain, diabetes, and heart, lung and breathing problems that are common in adults with psychosis or schizophrenia and often related to treatment. The results should be shared between their GP surgery and mental health team.

Source guidance

Definitions of terms used in this quality statement

Comprehensive physical health assessments
Comprehensive physical health assessments for adults with psychosis or schizophrenia should focus on physical health problems common in people with psychosis and schizophrenia by monitoring the following:
  • weight (plotted on a chart) – weekly for the first 6 weeks, then at 12 weeks, at 1 year and then annually
  • waist circumference annually (plotted on a chart)
  • pulse and blood pressure at 12 weeks, at 1 year and then annually
  • fasting blood glucose, HbA1c and blood lipid levels at 12 weeks, at 1 year and then annually
  • overall physical health.
Interventions should be offered in line with NICE guidelines on lipid modification, preventing type 2 diabetes, obesity, hypertension, prevention of cardiovascular disease and physical activity. [Adapted from Psychosis and schizophrenia in adults (NICE guideline CG178) recommendations 1.1.3.2, 1.5.3.2 and 1.5.3.3]
Shared care arrangements
Secondary care teams should assess the service user’s 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, assessments may be transferred to primary care under shared care arrangements and should take place at least annually. Service users may no longer be under the care of shared care arrangements if they are discharged from secondary care services [Adapted from Psychosis and schizophrenia in adults (NICE guideline CG178) recommendation 1.3.6.5]

Promoting healthy eating, physical activity and smoking cessation

This quality statement is taken from the psychosis and schizophrenia in adults quality standard. The quality standard defines clinical best practice in psychosis and schizophrenia in adults care and should be read in full.

Quality statement

Adults with psychosis or schizophrenia are offered combined healthy eating and physical activity programmes, and help to stop smoking.

Rationale

Rates of obesity and type 2 diabetes in adults with psychosis or schizophrenia are higher than those for the general population. Rates of tobacco smoking are also high in people with psychosis or schizophrenia. These factors contribute to premature mortality. Offering combined healthy eating and physical activity programmes and help to stop smoking can reduce these rates and improve physical and mental health.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults with psychosis or schizophrenia are offered combined healthy eating and physical activity programmes.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that adults with psychosis or schizophrenia who smoke are offered help to stop smoking.
Data source: Local data collection.
Process
a) Proportion of adults with psychosis or schizophrenia who received combined healthy eating and physical activity programmes within the past 12 months.
Numerator – the number in the denominator who received combined healthy eating and physical activity programmes within the past 12 months.
Denominator – the number of adults with psychosis or schizophrenia.
Data source: Local data collection. Data can be collected using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, question 40.
b) Proportion of adults with psychosis or schizophrenia who smoke who received help to stop smoking within the past 12 months.
Numerator – the number in the denominator who received help to stop smoking within the past 12 months.
Denominator – the number of adults with psychosis or schizophrenia who smoke.
Data source: Local data collection. Data can be collected using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, question 40.
Outcome
a) Type 2 diabetes rates in adults with psychosis or schizophrenia.
Data source: Local data collection.
b) Obesity rates in adults with psychosis or schizophrenia.
Data source: Local data collection.
c) Smoking rates in adults with psychosis or schizophrenia.
Data source: Local data collection. Data can be collected using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, question 31.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (mental health services) ensure that systems are in place for adults with psychosis or schizophrenia to be offered combined healthy eating and physical activity programmes, and help to stop smoking.
Health and social care practitioners ensure that they are aware of local healthy eating and physical activity programmes and offer these to adults with psychosis or schizophrenia. They should also offer them help to stop smoking if they smoke.
Commissioners (such as NHS England local area team and local authorities) ensure that they commission services that make sure adults with psychosis or schizophrenia are offered combined healthy eating and physical activity programmes, and help to stop smoking.

What the quality statement means for patients, service users and carers

Adults with psychosis or schizophrenia are offered help with healthy eating and physical activity to help prevent weight gain, diabetes and other health problems that are common in adults with psychosis or schizophrenia and often related to treatment. Smoking is also common in adults with psychosis or schizophrenia and those who smoke should be offered help to stop smoking.

Source guidance

Definitions of terms used in this quality statement

Help to stop smoking
Health and social care practitioners should consider one of the following to help people with psychosis or schizophrenia stop smoking, even if previous attempts have been unsuccessful:
  • nicotine replacement therapy (usually a combination of transdermal patches with a short acting product such as an inhalator, gum, lozenges or spray) for people with psychosis or schizophrenia or
  • bupropionAt the time of publication of Psychosis and schizophrenia in adults NICE guideline CG178 (2014), bupropion was contraindicated in people with bipolar disorder. Therefore, it is not recommended for people with psychosis unless they have a diagnosis of schizophrenia. for people with a diagnosis of schizophrenia or
  • varenicline for people with psychosis or schizophrenia.
They should warn people taking bupropion or varenicline that there is an increased risk of adverse neuropsychiatric symptoms and monitor them regularly, particularly in the first 2–3 weeks.
Health and social care practitioners should be aware of the potential significant impact of reducing cigarette smoking on the metabolism of other drugs, particularly clozapine and olanzapine. [Psychosis and schizophrenia in adults (NICE guideline CG178)]

Equality and diversity considerations

When referring people to services, health and social care practitioners should take into account the ‘negative’ symptoms of psychosis and schizophrenia (such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self neglect), and ensure services are accessible for people with these symptoms.
Health and social care practitioners should be aware of the impact of social factors, such as inadequate housing, lack of access to affordable physical activity, poor cooking skills and limited budget for food, on continued healthy eating and physical activity.

Carer-focused education and support

This quality statement is taken from the psychosis and schizophrenia in adults quality standard. The quality standard defines clinical best practice in psychosis and schizophrenia in adults care and should be read in full.

Quality statement

Carers of adults with psychosis or schizophrenia are offered carer focused education and support programmes.

Rationale

Providing carer focused education and support reduces carer burden and psychological distress, and may improve the carer’s quality of life. As part of the initial process of assessment and engagement, carer focused education and support programmes can also help carers of adults with psychosis or schizophrenia to be able to identify symptoms of concern.

Quality measures

Structure
Evidence of local arrangements to ensure that carers of adults with psychosis or schizophrenia are offered a carer focused education and support programme.
Data source: Local data collection.
Process
Proportion of adults with psychosis or schizophrenia whose carers receive a carer focused education and support programme.
Numerator – the number in the denominator whose carers receive a carer focused education and support programme.
Denominator – the number of adults with psychosis or schizophrenia with an identified carer.
Data source: Local data collection.
Outcome
Quality of life for carers of adults with psychosis or schizophrenia.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as community health services and mental health services) ensure that systems are in place for carers of adults with psychosis or schizophrenia to be offered a carer focused education and support programme.
Health and social care practitioners ensure that they are aware of the role of carers and offer a carer focused education and support programme to carers of adults with psychosis or schizophrenia.
Commissioners (such as clinical commissioning groups and NHS England local area teams) ensure that carer focused education and support programmes are available and that the appropriate referral pathways are in place for carers of adults with psychosis or schizophrenia. They should also ensure that community and mental health teams are able to work collaboratively with education and support programmes.

What the quality statement means for patients, service users and carers

Carers of adults with psychosis or schizophrenia are offered an education and support programme, which provides information, mutual support and discussion. This can help carers to cope and give them information, such as which symptoms of concern they should look out for.

Source guidance

Definitions of terms used in this quality statement

Carers
Carers can be anyone who has regular close contact with adults with psychosis and schizophrenia, including advocates, friends or family members, although some family members may choose not to be carers [Psychosis and schizophrenia in adults (NICE guideline CG178)]
Carer-focused education and support programme
A carer focused education and support programme should be offered as soon as possible. Such groups provide information, mutual support and open discussion to carers through voluntary participation. The programme should be available as needed and offer a positive message about recovery. [Adapted from Psychosis and schizophrenia in adults (NICE guideline CG178) recommendation 1.1.5.7]

Equality and diversity considerations

If a person does not have access to specialist training or support near their homes, and has difficulty travelling long distances (because of the financial cost or other reasons), they may need additional support.
Equality of language and capability in training carers need to be considered.

Effective interventions library

Effective interventions library

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Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

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

Supporting information

Glossary

Cognitive behavioural therapy.
Electrocardiogram.
Child and adolescent mental health services.
Glycosylated haemoglobin.
British national formulary.
British national formulary for children.
Summary of product characteristics.

Paths in this pathway

Pathway created: February 2014 Last updated: May 2016

© NICE 2016

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