1.4 Promoting recovery [61]

There are a number of options for promoting and maintaining recovery. The general principles for all phases apply equally in this situation. Early intervention to provide early additional treatment and care should the need arise remains important.

1.4.1 Primary care

Primary care professionals have an important part to play in the physical and mental health care of people with schizophrenia. They are best placed to monitor the physical health of people with schizophrenia and should do so regularly. Case registers will be an important means of doing so. In addition, primary care workers should monitor the mental health and treatment of their service users, work closely with secondary services and refer before crises arise wherever possible.

1.4.1.1 The organisation and development of practice case registers for people with schizophrenia is recommended as an essential step in monitoring the physical and mental health of people with schizophrenia in primary care.

1.4.1.2 GPs and other primary health workers should regularly monitor the physical health of people with schizophrenia registered with their practice. The frequency of checks will be a clinical decision made jointly between the service user and clinician. The agreed frequency should be recorded in the patient’s notes.

1.4.1.3 Physical health checks should pay particular attention to endocrine disorders, such as diabetes and hyperprolactinaemia, cardiovascular risk factors, such as blood pressure and lipids, side effects of medication, and lifestyle factors such as smoking. These must be recorded in the notes.

1.4.1.4 The decision to re-refer a service user from primary care to mental health services is a complex clinical judgment that should take account of the views of the service user and, where appropriate, carers. Issues of confidentiality should be respected when involving carers. Referral may be considered in a number of circumstances, but particular factors indicating referral include the following:

• where treatment adherence is a problem, referral is usually indicated
• a poor response to treatment would make referral a higher priority
• if co-morbid substance misuse is suspected, referral is indicated
• if the level of risk to self or others is increased, referral to secondary services is indicated
• when a person with schizophrenia first joins a GP practice list, referral to secondary services for assessment and care programming is indicated, subject to the full agreement of the service user.

1.4.2 Secondary services

Secondary services should undertake regular and full assessment of the mental and physical health of their service users, addressing all the issues relevant to a person’s quality of life and well-being. When a service user chooses not to receive physical care from his or her GP, this should be monitored by doctors in secondary care. Carers should be contacted routinely, subject to the agreement of the service user, and should be provided with a care plan.

The possible presence of co-morbid conditions, including substance and alcohol misuse or physical illness, or the existence of a forensic history, will necessitate the development of treatment and care plans outside the scope of this guideline. Nevertheless, full assessment of these issues should be included.

1.4.2.1 A full assessment of health and social care needs should be undertaken regularly, including assessment of accommodation and quality of life, the frequency of which should be based upon clinical need, and following discussion with the service user. The agreed frequency of assessment should be documented in the care plan.

The higher physical morbidity and mortality of service users with schizophrenia should be considered in all assessments. Whilst this would normally be expected to be the role of primary care services, secondary care services should nevertheless monitor these matters where they believe a service user may have little regular contact with primary care.

1.4.2.2 Primary and secondary care services, in conjunction with the service user, should jointly identify which service will take responsibility for assessing and monitoring the physical health care needs of service users. This should be documented in both primary and secondary care notes/care plans and clearly recorded by care co-ordinators for those on the enhanced care programme approach (CPA).

1.4.2.3 Moreover, all non-professional carers who provide regular care for a person on CPA should have an assessment of their caring, physical and mental health needs, at a frequency agreed in conjunction with the carer and recorded in their own (carer) care plan.

1.4.3 Service interventions

The range of services needed for people with schizophrenia are diverse and need to be tailored to individual circumstances and current local resources. However, some people with schizophrenia have high needs for care and tend to be lost from ordinary services. Assertive outreach teams (or assertive community treatment – ACT) are an effective way of helping to meet those needs and are better at staying in touch than ordinary services. Also, most people with schizophrenia will need rapid access to help in crises. Services need to plan how to best deliver help and treatment ensuring that teams are functionally integrated.

1.4.3.1 Assertive outreach teams should be provided for people with serious mental disorders including people with schizophrenia.

1.4.3.2 Assertive outreach teams should be provided for people with serious mental disorders, including for people with schizophrenia, who make high use of inpatient services and who have a history of poor engagement with services leading to frequent relapse and/or social breakdown (as manifest by homelessness or seriously inadequate accommodation).

1.4.3.3 Assertive outreach teams should be provided for people with schizophrenia who are homeless.

1.4.3.4 Where the needs of the service user and/or carer exceed the capacity of assertive outreach teams, referral to crisis resolution and home treatment teams, acute day hospitals or inpatient services should be considered.

1.4.3.5 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.

1.4.3.6 Integrating the care of people with schizophrenia who receive services from community mental health teams, assertive outreach teams, early intervention services and crisis resolution and home treatment teams should be carefully considered. The CPA should be the main mechanism by which the care of individuals across services is properly managed and integrated.

1.4.4 Psychological interventions

Psychological treatments should be an indispensable part of the treatment options available for service users and their families in the effort to promote recovery. Those with the best evidence of effectiveness are cognitive behavioural therapy and family interventions. These should be used to prevent relapse, to reduce symptoms, increase insight and promote adherence to medication. Relapse prevention and symptom reduction: cognitive behavioural therapy and family interventions

1.4.4.1 Cognitive behavioural therapy should be available as a treatment option for people with schizophrenia.

1.4.4.2 In particular, cognitive behavioural therapy should be offered to people with schizophrenia who are experiencing persisting psychotic symptoms.

1.4.4.3 Cognitive behavioural therapy should be considered as a treatment option to assist in the development of insight.

1.4.4.4 Cognitive behavioural therapy may be considered as a treatment option in the management of poor treatment adherence.

1.4.4.5 Longer treatments with cognitive behavioural therapy are significantly more effective than shorter ones, which may improve depressive symptoms but are unlikely to improve psychotic symptoms. An adequate course of cognitive behavioural therapy to generate improvements in psychotic symptoms in these circumstances should be of more than 6 months' duration and include more than ten planned sessions.

1.4.4.6 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.

1.4.4.7 In particular, family interventions should be offered to the families of people with schizophrenia who have recently relapsed or who are considered at risk of relapse.

1.4.4.8 Also in particular, family interventions should be offered to the families of people with schizophrenia who have persisting symptoms.

1.4.4.9 When providing family interventions, the length of the family intervention programme should normally be longer than 6 months’ duration and include more than ten sessions of treatment.

1.4.4.10 When providing family interventions, the service user should normally be included in the sessions, as doing so significantly improves the outcome. Sometimes, however, this is not practicable.

1.4.4.11 When providing family interventions, service users and their carers may prefer single-family interventions rather than multi-family group interventions.

1.4.5 Pharmacological interventions

Antipsychotic drugs are an indispensable treatment option for most people in the recovery phase of schizophrenia. The main aim here is to prevent relapse and help keep a person stable enough to live as normal a life as possible. Drugs are also necessary for psychological treatments to be effective.

The service user and clinician should jointly decide the choice of drug, but service user preferences are central. Oral and depot preparations can be used. Follow BNF guidance on dosing and test dosing. If conventional antipsychotics have been used and are not effective or are causing unacceptable side effects, change to an atypical. If an atypical is causing diabetes or excessive weight gain, this must be monitored or consider changing to a different atypical or a conventional antipsychotic. Always monitor and record clinical response, side effects and service user satisfaction. If a person is satisfied with the drug he or she is taking, make no changes. Do consider the use of psychological interventions if a person has persisting symptoms or frequent relapses.

If a service user has had two antipsychotics (including one atypical) each for 6–8 weeks without significant improvement, check out possible causes for a lack of response and consider clozapine. In some circumstances it may be supportable to add a second antipsychotic drug to clozapine if there has been a suboptimal response at standard doses. Do not use more than one antipsychotic drug in other situations, except when changing from one drug to another. Other adjunctive treatments are outside the scope of this guideline. Relapse prevention: oral antipsychotics

1.4.5.1 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.

1.4.5.2 The oral atypical antipsychotic drugs (amisulpride, olanzapine, quetiapine, risperidone and zotepine) should be considered as treatment options for individuals currently receiving typical 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 typical 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.

1.4.5.3 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 typical antipsychotic drugs.

1.4.5.4 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.

1.4.5.5 Targeted, intermittent dosage maintenance strategies should not be used routinely in lieu of continuous dosage regimens because of the increased risk of symptom worsening or relapse. However, these strategies may be considered for service users who refuse maintenance or for whom some other contraindication to maintenance therapy exists, such as side-effect sensitivity.

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

Relapse prevention: depot antipsychotics

1.4.5.7 A risk assessment should be performed by the clinician responsible for treatment and the multidisciplinary team regarding concordance with medication, and depot preparations should be prescribed when appropriate.

1.4.5.8 Depot preparations should be a treatment option where a service user expresses a preference for such treatment because of its convenience, or as part of a treatment plan in which the avoidance of covert non-adherence with antipsychotic drugs is a clinical priority.

1.4.5.9 For optimum effectiveness in preventing relapse, depot preparations should be prescribed within the standard recommended dosage and interval range.

1.4.5.10 Following full discussion between the responsible clinician and the service user, the decision to initiate depot antipsychotic injections should take into account the preferences and attitudes of the service user towards the mode of administration and organisational procedures (for example, home visits and location of clinics) related to the delivery of regular intramuscular injections.

1.4.5.11 Test doses should normally be used as set out in the BNF and full licensed prescribing information on depot antipsychotics is available from the Summary of Product Characteristics, which can be found in the electronic medicines compendium (www.emc.vhn.net).

1.4.5.12 As with oral antipsychotics, people receiving depots should be maintained under regular clinical review, particularly in relation to the risks and benefits of the drug regimen. Treatment-resistant schizophrenia

1.4.5.13 The first step in the clinical management of treatmentresistant schizophrenia (TRS) is to establish that antipsychotic drugs have been adequately tried in terms of dosage, duration and adherence. Other causes of non-response should be considered in the clinical assessment, such as co-morbid substance misuse, poor treatment adherence, the concurrent use of other prescribed medicines and physical illness.

1.4.5.14 If the symptoms of schizophrenia are unresponsive to conventional antipsychotics, the prescribing clinician and service user may wish to consider an atypical antipsychotic in advance of a diagnosis of treatment-resistant schizophrenia and a trial of clozapine. In such cases, olanzapine or risperidone may be worth considering. Service users should be informed that while these drugs may possibly be beneficial, the evidence for improvement in this situation is more limited than for clozapine.

1.4.5.15 In individuals with evidence of TRS, clozapine should be introduced at the earliest opportunity. TRS is suggested by a lack of satisfactory clinical improvement despite the sequential use of the recommended doses for 6 to 8 weeks of at least two antipsychotics, at least one of which should be an atypical.

Combining antipsychotics

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

1.4.5.17 However, the addition of a second antipsychotic to clozapine may be considered for people with TRS for whom clozapine alone has proved insufficiently effective.

1.4.6 Employment

The overall aim of mental health services is to help service users get back to living an ordinary life as far as possible. Assessment should be comprehensive and this includes assessing a person’s work potential. Mental health and social care services also need to help support the development of employment opportunities for people with schizophrenia.

1.4.6.1 People with schizophrenia experience considerable difficulty in obtaining employment and many remain unemployed for long periods of time. The assessment of people with schizophrenia should include assessment of their occupational status and potential. This should be recorded in their notes/care plans.

1.4.6.2 Supported employment programmes should be provided for those people with schizophrenia who wish to return to work or gain employment. However, it should not be the only work-related activity offered when individuals are unable to work or are unsuccessful in their attempts to find employment.

1.4.6.3 Mental health services, in partnership with social care providers and other local stakeholders, should enable people to use local employment opportunities, including a range of employment schemes to suit the different needs and level of skill, for people with severe mental health problems, including people with schizophrenia.