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Rehabilitation for adults with complex psychosis

About

What is covered

This NICE Pathway covers mental health rehabilitation for adults with complex psychosis. It aims to ensure people can have rehabilitation when they need it and promotes a positive approach to long-term recovery. It includes recommendations on organising rehabilitation services, assessment and care planning, delivering programmes and interventions, and meeting people's physical healthcare needs.
The NICE Pathway does not cover people who have a primary diagnosis of a non-psychotic illness. However, rehabilitation practitioners can also provide advice to services outside the rehabilitation pathway on appropriate treatment and support, including specialist placements and tailored support packages, for people with other primary mental health diagnoses or neurodevelopmental conditions, such as personality disorders or autism spectrum disorder.
NICE has also produced NICE Pathways on psychosis and schizophrenia and bipolar disorder.
The recommendations in this NICE Pathway were developed before the coronavirus pandemic.
MHRA advice on valproate: Valproate must not be used in women of childbearing potential, unless other options are unsuitable and the pregnancy prevention programme is in place. Follow the MHRA safety advice on valproate use by women and girls. The MHRA has also published temporary advice on the valproate pregnancy prevention programme during the COVID-19 pandemic.

Updates

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on rehabilitation for adults with complex psychosis in an interactive flowchart.

What is covered

This NICE Pathway covers mental health rehabilitation for adults with complex psychosis. It aims to ensure people can have rehabilitation when they need it and promotes a positive approach to long-term recovery. It includes recommendations on organising rehabilitation services, assessment and care planning, delivering programmes and interventions, and meeting people's physical healthcare needs.
The NICE Pathway does not cover people who have a primary diagnosis of a non-psychotic illness. However, rehabilitation practitioners can also provide advice to services outside the rehabilitation pathway on appropriate treatment and support, including specialist placements and tailored support packages, for people with other primary mental health diagnoses or neurodevelopmental conditions, such as personality disorders or autism spectrum disorder.
NICE has also produced NICE Pathways on psychosis and schizophrenia and bipolar disorder.
The recommendations in this NICE Pathway were developed before the coronavirus pandemic.
MHRA advice on valproate: Valproate must not be used in women of childbearing potential, unless other options are unsuitable and the pregnancy prevention programme is in place. Follow the MHRA safety advice on valproate use by women and girls. The MHRA has also published temporary advice on the valproate pregnancy prevention programme during the COVID-19 pandemic.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Guidance on the use of electroconvulsive therapy (2003 updated 2009) NICE technology appraisal guidance 59

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Rehabilitation services for people with complex psychosis should:
  • be embedded in a local comprehensive mental healthcare service
  • provide a recovery-orientated approach that has a shared ethos and agreed goals, a sense of hope and optimism, and aims to reduce stigma
  • deliver individualised, person-centred care through collaboration and shared decision making with service users and their carers involved
  • be offered in the least restrictive environment and aim to help people progress from more intensive support to greater independence through the rehabilitation pathway
  • recognise that not everyone returns to the same level of independence they had before their illness and may require supported accommodation(such as residential care, supported housing or floating outreach) in the long term.
Consider training all rehabilitation staff in psychologically informed approaches such as motivational interviewing, positive behaviour support, behavioural activation, trauma-informed care, and simple techniques for supporting people who are having troubling thoughts and feelings.
Commissioners and providers of inpatient rehabilitation services and supported accommodation should be aware of the benefits to people of providing rehabilitation in smaller facilities, for example for promoting self-management, autonomy and social integration.
At the time of publication, the development of integrated care systems, integrated care providers and NHS provider collaboratives is changing the commissioning landscape in the English health and care system. This may be formalised within new legislation. All references to 'commissioners' and 'commissioning' in this NICE Pathway should therefore be read in that context, wherever the commissioning function may sit and however it may operate in the future NHS in England.
Teams providing specialist skills and care coordination to identify and address people's rehabilitation needs in the community. These teams can work in all community settings, but commonly work with people living in supported accommodation, often over many years, to enable their optimum level of functioning and independence.
Teams providing specialist skills and care coordination to identify and address people's rehabilitation needs in the community. These teams can work in all community settings, but commonly work with people living in supported accommodation, often over many years, to enable their optimum level of functioning and independence.
Inpatient rehabilitation units that are set outside hospital grounds. These units provide the full complement of multidisciplinary treatment and support for people with ongoing complex needs that prevent them from being discharged from a high-dependency rehabilitation unit directly to supported accommodation. They build on the progress made in the high-dependency inpatient rehabilitation unit and have a strong focus on promoting independent living skills and community participation. Most referrals come from high-dependency rehabilitation units or acute inpatient units. Community rehabilitation units can only care for detained people under the Mental Health Act 1983 if the unit is registered as a ward. If they are not registered as a ward, they can care for people who are voluntary or those subject to a community order (for example, a community treatment order, guardianship, or conditionally discharged Section 37/41). The expected length of stay in a community rehabilitation unit is 1 to 2 years.
In this NICE Pathway 'complex psychosis' refers to a primary diagnosis of a psychotic illness (this includes schizophrenia, bipolar affective disorder, psychotic depression, delusional disorders and schizoaffective disorder) with severe and treatment-resistant symptoms of psychosis and functional impairment.
People with complex psychosis usually also have 1 or more of the following:
  • cognitive impairments associated with their psychosis
  • co-existing mental health conditions (including substance misuse)
  • pre-existing neurodevelopmental disorders, such as autism spectrum disorder or attention deficit hyperactivity disorder
  • physical health problems, such as diabetes, cardiovascular disease or pulmonary conditions.
Together, these complex problems severely affect the person's social and everyday functioning, and mean they need a period of rehabilitation to enable their recovery and ensure they achieve their optimum level of independence.
Services providing support to people living in time-unlimited, usually self-contained, individual tenancies. Staff are based off-site and visit for a few hours per week, providing practical and emotional support, with the aim of reducing support over time to zero.
Supporting a person to learn how to take and manage their own medicines. This usually involves them managing 1 day of medicines to begin with, with staff undertaking spot checks before progressing to managing 2 days, then 3 days and so on.
Inpatient rehabilitation units for people with complex psychosis whose symptoms have not yet been stabilised and whose associated risks and challenging behaviours remain problematic. Units aim to maximise benefits of medication, address physical health comorbidities, reduce challenging behaviours, re-engage families and facilitate access to the community. Most people in high-dependency units are detained under the Mental Health Act. Most (80%) referrals to high-dependency units are from acute inpatient units and 20% from forensic units, with only occasional referrals of people living in the community. The expected length of stay is around 1 year.
Inpatient rehabilitation units for people with complex psychosis whose symptoms have not yet been stabilised and whose associated risks and challenging behaviours remain problematic. Units aim to maximise benefits of medication, address physical health comorbidities, reduce challenging behaviours, re-engage families and facilitate access to the community. Most people in high-dependency units are detained under the Mental Health Act. Most (80%) referrals to high-dependency units are from acute inpatient units and 20% from forensic units, with only occasional referrals of people living in the community. The expected length of stay is around 1 year.
Inpatient rehabilitation units for people with psychosis and comorbid conditions who need a specialist programme tailored to their specific comorbidity (such as acquired brain injury, severe personality disorder, autism spectrum disorder or Huntingdon's disease). Often, the complexity of the person's coexisting conditions is associated with greater support needs (more challenging behaviours and/or a greater risk to themselves and others) than people having treatment in a high-dependency rehabilitation unit. Referrals come from acute inpatient units or high-dependency rehabilitation units, and the expected length of stay is over 3 years.
Inpatient rehabilitation units for people with psychosis and comorbid conditions who need a specialist programme tailored to their specific comorbidity (such as acquired brain injury, severe personality disorder, autism spectrum disorder or Huntingdon's disease). Often, the complexity of the person's coexisting conditions is associated with greater support needs (more challenging behaviours and/or a greater risk to themselves and others) than people having treatment in a high-dependency rehabilitation unit. Referrals come from acute inpatient units or high-dependency rehabilitation units, and the expected length of stay is over 3 years.
A method of supporting people with severe mental health problems into work. IPS finds people a job quickly and then provides time-unlimited individualised support to keep the job and manage their mental health.
A panel not specific to rehabilitation, who agree funding (health, social care or both) for people to receive treatment within area or out of area, for example in a nursing or residential care home, or in an inpatient rehabilitation unit. The panel has a commissioner and senior managers, as well as clinicians (a senior rehabilitation practitioner plus possibly a senior clinician who works in general adult care, not specifically rehabilitation).
These units provide longer-term inpatient rehabilitation for people with high levels of disability due to treatment-resistant symptoms and comorbid conditions that take more than 1 year to stabilise, and who have ongoing risks to others and/or challenging behaviours. The aims of longer-term high-dependency rehabilitation units are the same as for high-dependency rehabilitation units, and most referrals come from high-dependency rehabilitation units.
A placement that provides treatment and support in an inpatient rehabilitation unit or supported accommodation outside the local area where a person usually lives and/or outside the catchment area for the local authority that has responsibility for their housing. The placement may be away from the person's local area because there is no local service available, or because there are clinical or legal reasons that make local rehabilitation inappropriate for their needs, or because they prefer to have treatment outside their local area.
A placement that provides treatment and support in an inpatient rehabilitation unit or supported accommodation outside the local area where a person usually lives and/or outside the catchment area for the local authority that has responsibility for their housing. The placement may be away from the person's local area because there is no local service available, or because there are clinical or legal reasons that make local rehabilitation inappropriate for their needs, or because they prefer to have treatment outside their local area.
There is no single definition of recovery for people with mental health problems, but the guiding principle is the belief that it is possible for someone to regain a meaningful life, despite serious mental illness. In this NICE Pathway, it refers to someone achieving the best quality of life they can, while living and coping with their symptoms. It is an ongoing process whereby the person is supported to build up their confidence and skills and resilience, through setting and achieving goals to minimise the impact of mental health problems on their everyday life.
Peer-led education and training programmes for mental health service users. They provide education as a route to recovery, not as a form of therapy. The courses are co-devised and co-delivered by people with lived experience of mental illness and by mental health professionals.
Communal facilities, staffed 24 hours, where day-to-day needs are provided (including meals, supervision of medicines and cleaning), and placements are not time limited. People do not hold a tenancy in a residential care home.
Shared or individual self-contained, time-limited tenancies with staff based on site up to 24 hours a day who help the person to gain skills to move on to less supported accommodation. The intended length of stay is usually about 2 years but in practice, only around one-third of people move on in that time.
A shared understanding of the issues that brought the person into rehabilitation services. It is their story, but draws on information from theory and research, as well as the experiences of the person, professionals and, where possible, others such as carers. It includes factors that made the person vulnerable to developing problems, factors that triggered the problems and factors that keep the problems going. A team formulation includes strengths and resources and points to ways that problems can be addressed.
These schemes give people a supported occupation in which to gain pre-vocational work experiences and potentially prepare for mainstream employment. One of the original examples was the 'clubhouse' model of psychosocial rehabilitation developed at Fountain House in New York.
Care that is built on an understanding that anyone using services could have experienced psychosocial trauma and that this is likely to influence how they engage with care. Key principles include safety and avoiding re-traumatisation; relationship building; peer support; collaboration and mutuality; empowerment and choice; and an awareness of cultural, historical and gender issues.

Glossary

(a low-intensity intervention using goal setting and activity schedules to encourage people to engage in activities they have previously avoided due to factors such as low mood or motivation)
cognitive behavioural therapy
(a manualised intervention to improve people's cognitive function)
chronic obstructive pulmonary disease
electrocardiogram
electroconvulsive therapy
(units providing specialist inpatient care to people with complex psychosis; they can be based within a hospital or in the community)
Individual Placement and Support
(a person-centred psychologically informed approach that supports behavioural change by helping people explore and resolve ambivalence towards change)
(a behaviour management system that seeks to understand the reasons behind problematic behaviours and to find alternative ways to meet goals and needs)
(brief skills-based interventions that can be delivered by any staff member or service user who has had suitable training in the intervention; they include guided self-help using online resources or workbooks, relaxation or mindfulness, stress workshops and behavioural activation groups)
Quality Indicator for Rehabilitative Care
QuIRC-Supported Accommodation
(an umbrella term covering residential care, supported housing, and floating outreach)
(persistent symptoms that have not responded to the range of treatments [including pharmacological treatments] recommended in the NICE guidance for the person's condition)

Paths in this pathway

Pathway created: August 2020 Last updated: August 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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