1.3 Treatment of the acute episode [61]

1.3.1 Service-level interventions

The services most likely to help people who are acutely ill include crisis resolution and home treatment teams, early intervention teams, community mental health teams and acute day hospitals. If these services are unable to meet the needs of a service user, or if the Mental Health Act is used, inpatient treatment may prove necessary for a period of time. Whatever services are available, a broad range of social, group and physical activities are essential elements of the services provided.

1.3.1.1 Community mental health teams are an acceptable way of organising community care and may have the potential for effectively co-ordinating and integrating other communitybased teams providing services for people with schizophrenia. However, there is insufficient evidence of their advantages to support a recommendation which precludes or inhibits the development of alternative service configurations.

1.3.1.2 Crisis resolution and home treatment teams should be used as a means to manage crises for service users, and as a means of delivering high-quality acute care. In this context, teams should pay particular attention to risk monitoring as a high-priority routine activity.

1.3.1.3 Crisis resolution and home treatment teams should be considered for people with schizophrenia who are in crisis to augment the services provided by early intervention services and assertive outreach teams.

1.3.1.4 Crisis resolution and home treatment teams should be considered for people with schizophrenia who may benefit from early discharge from hospital following a period of inpatient care.

1.3.1.5 Acute day hospitals should be considered as a clinical and cost-effective option for the provision of acute care, both as an alternative to acute admission to inpatient care and to facilitate early discharge from inpatient care.

1.3.1.6 Social, group and physical activities are an important aspect of comprehensive service provision for people with schizophrenia as the acute phase recedes, and afterwards. All care plans should record the arrangements for social, group and physical activities.

1.3.2 Pharmacological interventions

During an acute episode, antipsychotic drugs are necessary. Wherever possible, service users should make an informed choice as to the antipsychotic they prefer. If a service user is unable to make his or her preference known, an atypical should be prescribed. It is best to use a single drug, using doses within the British National Formulary (BNF) dose range and not to use high or loading doses. Clinical response and side effects should be monitored routinely and regularly. If, with conventional antipsychotics, side effects are troublesome or symptom control is inadequate, an atypical should be offered. During an acute episode, some service users become behaviourally disturbed and may need rapid tranquillisation. The recommendations for this can be found in subsection 1.5.

1.3.2.1 The choice of antipsychotic drug should be made jointly by the individual and the clinician responsible for treatment based on an informed discussion of the relative benefits of the drugs and their side-effect profiles. The individual’s advocate or carer should be consulted where appropriate.

1.3.2.2 Antipsychotic therapy should be initiated as part of a comprehensive package of care that addresses the individual's clinical, emotional and social needs. The clinician responsible for treatment and key worker should monitor both therapeutic progress and tolerability of the drug on an ongoing basis. Monitoring is particularly important when individuals have just changed from one antipsychotic to another.

1.3.2.3 The dosage of conventional antipsychotic medication for an acute episode should be in the range of 300–1000 mg chlorpromazine equivalents per day for a minimum of 6 weeks. Reasons for dosage outside this range should be justified and documented. The minimum effective dose should be used.

1.3.2.4 In the treatment of the acute episode for people with schizophrenia, massive loading doses of antipsychotic medication, referred to as ‘rapid neuroleptization’, should not be used.

1.3.2.5 The oral atypical antipsychotic drugs (amisulpride, olanzapine, quetiapine, risperidone, zotepine) should be considered as treatment options for individuals currently receiving conventional antipsychotic drugs who, despite adequate symptom control, are experiencing unacceptable side effects, and for those in relapse who have previously experienced unsatisfactory management or unacceptable side effects with conventional antipsychotic drugs. The decision as to what are unacceptable side effects should be taken following discussion between the patient and the clinician responsible for treatment.

1.3.2.6 When full discussion between the clinician responsible for treatment and the individual concerned is not possible, in particular in the management of an acute schizophrenic episode, the oral atypical drugs should be considered as the treatment options of choice because of the lower potential risk of extrapyramidal symptoms (EPS). In these circumstances, the individual’s carer or advocate should be consulted where possible and appropriate. Although there are limitations with advance directives regarding the choice of treatment for individuals with schizophrenia, it is recommended that they are developed and documented in individuals’ care programmes whenever possible.

1.3.2.7 It is not recommended that, in routine clinical practice, individuals change to one of the oral atypical antipsychotic drugs if they are currently achieving good control of their condition without unacceptable side effects with conventional antipsychotic drugs.

1.3.2.8 Antipsychotic drugs, atypical or conventional, should not be prescribed concurrently, except for short periods to cover changeover.

1.3.2.9 When prescribed chlorpromazine, individuals should be warned of a potential photosensitive skin response as this is an easily preventable side effect.

1.3.2.10 Where a potential to cause weight gain or diabetes has been identified (and/or included in the Summary of Product Characteristics) for the atypical antipsychotic being prescribed, there should be routine monitoring in respect of these potential risks.

1.3.3 Early post-acute period

Towards the end of an acute episode of schizophrenia, service users should be offered help to better understand the period of illness, and given the opportunity to write their account in their notes. Carers may also need help in understanding the experience. Assessment for further help to minimise disability, reduce risk and improve quality of life should be routinely undertaken during recovery from the acute phase. In particular, psychological and family help, contingency planning and identifying local resources/services are important. Advice about drug treatments to maintain recovery is also important.

Service user focus

1.3.3.1 Consideration should be given, where practicable, to encouraging service users to write their account of their illness in their notes.

1.3.3.2 Psychoanalytic and psychodynamic principles may be considered to help health professionals to understand the experience of individual service users and their interpersonal relationships.

Assessment

The purpose of this guideline is to help improve the experience and outcomes of care for people with schizophrenia. These outcomes include the degree of symptomatic recovery, quality of life, degree of personal autonomy, ability and access to work, stability and quality of living accommodation, degree and quality of social integration, degree of financial independence and the experience and impact of side effects.

1.3.3.3 The assessment of needs for health and social care for people with schizophrenia should, therefore, be comprehensive and address medical, social, psychological, occupational, economic, physical and cultural issues.

Psychological treatments

1.3.3.4 Cognitive behavioural therapy (CBT) should be available as a treatment option for people with schizophrenia.

1.3.3.5 Family interventions should be available to the families of people with schizophrenia who are living with or who are in close contact with the service user.

1.3.3.6 Counselling and supportive psychotherapy are not recommended as discrete interventions in the routine care of people with schizophrenia where other psychological interventions of proven efficacy are indicated and available. However, service user preferences should be taken into account, especially if other more efficacious psychological treatments are not locally available.

Medication advice

1.3.3.7 Given the high risk of relapse following an acute episode, the continuation of antipsychotic drugs for up to 1 to 2 years after a relapse should be discussed with service users, and carers where appropriate.

1.3.3.8 Withdrawal from antipsychotic medication should be undertaken gradually whilst regularly monitoring signs and symptoms for evidence of potential relapse.

1.3.3.9 Following withdrawal from antipsychotic medication, monitoring for signs and symptoms of potential relapse should continue for at least 2 years after the last acute episode.