NICE Guidance– Schizophrenia [61]

Family interventions are offered to any family who lives with or is in close contact with a family member with schizophrenia, and especially where any of the following circumstances apply.

The individual:

• has experienced a recent relapse
• is considered at risk of relapse
• has persisting symptoms. The course of family intervention should be for longer than 6 months with more than 10 planned sessions.

Family interventions to be offered to 100% of families of individuals with schizophrenia who have experienced a recent relapse, are considered to be ‘at risk’ of relapsing, or who have persisting symptoms, and are living with or in close contact with their family.

All individuals who receive family interventions should be offered more than 10 sessions, the course of treatment lasting for more than 6 months.

The individual with schizophrenia who is not able to participate in an informed discussion with the clinician responsible for treatment at the time and an advocate or carer is not available. The individual with schizophrenia who refuses to allow discussion of family interventions with his or her family. The family who refuses to participatein family interventions.

The notes should indicate that the clinician responsible for treatment has discussed the process and benefits of family interventions with the individual and, subject to the individual’s agreement, with his or her family, or that the individual was not capable of making a choice at the time. The notes should refer to the involvement of the individual’s advocate or carer, where applicable. The term ‘at risk’ refers to following an acute episode, or if a person has had 2 or more episodes in the last year. The term ‘persisting symptoms’ refers to positive or negative symptoms, which persist, with limited or no response to anti-psychotic medication.

CBT is offered to any individual with schizophrenia, and especially to the individual who is experiencing persistent psychotic symptoms. The course of CBT offered should normally be of more than 6 months’ duration and include more than 10 planned sessions.

100% of individuals with schizophrenia who are experiencing persisting psychotic symptoms should be offered CBT. All individuals who receive CBT should be offered treatment lasting for over 6 months and including more than 10 planned sessions.

The individual with schizophrenia who is not able to participate in an informed discussion with the clinician responsible for treatment the time and an advocate or carer is not available.

The notes should indicate that the clinician responsible for treatment has discussed the process and benefits of CBT, or that the individual was not capable of making a choice at the time. The term ‘persisting symptoms’ refers to positive or negative symptoms, which persist, with limited or no response to antipsychotic medication.

(AOT)/assertive community treatment (ACT)

AOT/ACT services are provided for the individual with schizophrenia where any of the following circumstances apply:

• risk of repeated relapse
• high use of inpatient services
• poor history of engagement with services
• homelessness.

100% of individuals with schizophrenia who are at risk of repeated relapse, have made high use of inpatient services, or have a poor history of engagement with services, or are homeless are offered treatment via an AOT/ACT.

The individual with schizophrenia has been accepted for treatment with an AOT but the individual refuses all attempts to engage with the team.

The notes should indicate that the clinician responsible for treatment has discussed the process and benefits of AOT, or that the individual was not capable of making a choice at the time. The notes should refer to the involvement of the individual’s advocate or carer, where applicable.

Service users should report that this choice was offered. The term ‘risk of repeated relapse’ Refers to following an acute Episode or if a person has relapsed 2 or more times in the last year.

The term ‘high use’ refers to the top 100 people in terms of frequency of inpatient dmission and/or length of stay.

‘Homeless’ refers to no fixed abode, not in owner- or renter- occupied accommodation.

A patient who has received parenteral medication during rapid tranquillisation has baseline recordings, repeated at regular intervals, for blood pressure, pulse, temperature, and respiratory rate.

100% of patients receiving parenteral medication during rapid tranquillisation have baseline and follow-up recordings of blood pressure, pulse, temperature and respiratory rate.

Where to carry out such procedures would cause further agitation and increase the possible risk to either the individual with schizophrenia or to others.

The notes contain a record of the individual’s blood pressure, pulse, temperature and respiratory rate, monitored at the specified time intervals, which depends upon a full clinical assessment, which is recorded in the notes. Where baseline observations are not carried out, the reasons for this are recorded in the clinical notes.

Patients who are subject to rapid tranquillisation are debriefed and offered the opportunity to write their account in the notes.

100% of patients who are subject to rapid tranquillisation have recorded in their notes that they have been debriefed with record of patient's entry in the notes.

Those patients who refuse to be debriefed and/or to write in their own notes. This must be recorded in the notes.

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Individuals receive only one antipsychotic at a time.

100% of individuals with schizophrenia.

Individuals with schizophrenia who are receiving clozapine but who have not responded sufficiently; and individuals who are changing from one antipsychotic to another.

The audit should include a discussion of the treatment choice with the individual with schizophrenia, relevant outcomes including the incidence of side effects, and the reasons for prescribing antipsychotics, the reasons for prescribing additional antipsychotics, dose/dose range and total dose equivalents, and the prescribing of other drugs in combination with antipsychotics (such as anticholinergics, antidepressants and laxatives).

Care plans contain advance directives detailing the individual's treatment choices in the event of an acute episode of illness which may require rapid tranquillisation.

100% of individuals with schizophrenia.

The individual with schizophrenia who is not able to participate in an informed discussion with the clinician responsible for treatment at the time and an advocate or carer is not available.

The care programme approach (CPA) documentation contains an advance directive that describes preferred treatment choices in the event of the individual experiencing an acute episode of illness. The term ‘treatment choices’ refers to the choice of oral antipsychotic, lorazepam or other treatments that may be used without the service users consent.

In the event of an acute episode of illness, the CPA co-ordinator ensures that the individual’s advance directive is notified to the clinicians responsible for their care during the acute phase. The receipt of the advance directive is recorded in the individual’s notes.

100% of individuals with schizophrenia experiencing an acute episode of illness have advance directives in their notes where appropriate.

No advance directive has been made.

The notes indicate that the advance directive was received by the clinician responsible for the care of the individual during the acute episode of illness.

Individuals and their families receive written material about their illness and treatment from the health care professionals who care for them, including a copy of the NICE schizophrenia guideline produced for people with schizophrenia, their advocates and carers, and the public.

100% of individuals with schizophrenia and their families.

None

Local services should agree what information is to be made available, by whom, and when. Service users and their carers should report satisfaction with the accessibility and quality of information.

Individuals have a comprehensive assessment of occupational status and potential, and vocational aspirations.

100% of individuals with schizophrenia. 100% of individuals on enhanced CPA to receive an assessment not less than once a year.

Individuals who are employed, or who do not want an occupational assessment.

Local CPA documentation should include review of occupational status and potential, and vocational aspirations. The CPA documentation should indicate that this is reviewed, or if a person is employed, or if a person does not want to be assessed.

Individuals are identified and recorded on a case register in primary care.

100% of individuals with schizophrenia within primary care are recorded on a case register.

Individuals who refuse to be included in a case register.

The case register is used as the basis of monitoring the physical health needs and routine screening for people with schizophrenia, and for auditing the implementation of this guideline in primary care.

Individuals have a physical health check at regular intervals. The frequency of health checks will be agreed between the GP and the service user and documented in the notes.

100% of individuals with schizophrenia who are registered with a GP are offered physical health screens within primary care.

Those individuals who refuse physical health care in primary care or those who wish to receive it from secondary services.

The notes document the agreed frequency of health checks, and the frequency is matched by the checks being carried out.

1) Health checks should include blood pressure monitoring, screening for diabetes, blood lipids testing in people with raised blood pressure, screening for smoking, alcohol and drug use.

2) Health promotion advice is offered, for example advice on smoking, alcohol and drug use, and exercise.

3) Screening for side effects of drug treatments, including sexual dysfunction, lethargy, weight gain, extrapyramidal side effects (including tardive dyskinesia).

The individual with an initial diagnosis of schizophrenia who requests a second opinion should be supported in doing so.

100% of individuals with an initial diagnosis of schizophrenia.

None

The notes document that following a first episode where a diagnosis has been given the GP or psychiatrist has offered a referral for a second opinion if requested by the service user. Service users should report satisfaction with the support that they received when asking for a second opinion.