NICE Guidance - Acute Episode [63]

If you have a breakdown (an acute episode of schizophrenia)

The teams who provide treatment

After your GP has seen you, you may be visited at home by a psychiatric nurse, a psychiatrist or other mental health worker, or you may be invited to come to a clinic. At this stage, your GP or other health professional may tell you that you are ill and will need further help and treatment. The teams who might see you include community mental health teams, early intervention teams, crisis resolution and home treatment teams or an acute day hospital. If you have been ill before, you may already be getting help from an assertive outreach team, who will also try to help you during a crisis.

It is very important that you meet with them quickly as this may help more in the long run. When you meet the mental health team they will undertake a detailed assessment of your health, life situation and need for help. The different teams available to help people with schizophrenia are described in the glossary.

Where you’ll be treated

If all goes well, you may be treated at home. If a crisis resolution and home treatment team treats you at home, they will be careful to check regularly on you to make sure that you are safely treated at home (this is called a ‘risk assessment’). If the team that is treating you at home can’t provide all the treatment and care you need, you may be asked to come to an acute day hospital where you will receive treatment and help during the day and go home at night.

Alternatively, if you are very ill, or you have been ‘sectioned’ under the Mental Health Act, you may be asked to come to an inpatient unit – a hospital that you stay at during the day and night. If you are in an inpatient hospital, you should be offered a transfer to an acute day hospital or to treatment at home as soon as the hospital team treating you thinks you are well enough. This should keep the time you are in hospital to a minimum.

Wherever you receive treatment, part of your treatment programme should, if you want it to, include social, group and physical activities; this is especially the case as you begin to recover. The activities will be recorded in your care plans (the treatment and health record your team keeps about you). You may want to see these.

Medicines during a breakdown

After your team have discussed all the treatment options with you, and your advocate or carer if you so wish, and have discussed the effects and side effects of treatments, you will be offered antipsychotic medicines, either ‘conventional’ or ‘atypical’ (only atypicals if this is your first breakdown). Different antipsychotics have different side effects. You’ll be given enough information about the different medicines for you to be able to make an informed choice as to which one you would most prefer. Whichever medicine you choose, you should only take one antipsychotic medicine at a time, unless for a short while when changing from one to another (you may then take two while one is being reduced and the other is being started).

All medicines can have side effects, but if the medicine suits you, you may not experience any. If you do get side effects, they tend to be worse on higher doses, and using a lower dose may take them away. If the side effects don’t go away it is usually best to try a different medicine. You should not be offered very high doses of these medicines. Usually your doctor will start you on a low dose and gradually increase the dose to a standard dose. If you are taking a conventional antipsychotic (such as haloperidol, chlorpromazine or trifluoperazine) that either gives troubling side effects or simply doesn’t work very well, your doctors will suggest stopping the medicine and should offer you an atypical antipsychotic.

If you are unable to make a choice because you are very ill, the doctors should offer you an atypical antipsychotic because they tend to have different, and sometimes fewer, side effects. Whether you can choose or not, the team caring for you should regularly keep a check on side effects, and may use a questionnaire to help them do this. It usually takes about 3 to 6 weeks for antipsychotics (conventional or atypical) to work properly, although you may feel better sooner than this. The team looking after you will keep an eye on whether the treatments are working or not. If the medicine you are given doesn’t work by 6 to 8 weeks, you should then be offered a different antipsychotic medicine.

If the medicine does work, your doctors will suggest that you take it for about 1 to 2 years after getting better so that you don’t get ill again. If you are stable on an antipsychotic, with few or no side effects, it is best to stay on that medicine and not to change to another one.

Treatment for people whose behaviour is very disturbed

If you are ill enough to be admitted to hospital as an inpatient, especially if you have been admitted against your will under the Mental Health Act (‘sectioned’), you may settle very quickly and feel better. However, sometimes the illness can make some people more likely to become very angry or upset, causing them to become threatening or even to hit others.

Preventing harm to you and others

The staff on the ward should make an effort to keep things as calm and as safe as possible around you. They will also try to talk to you and take time to explain all about what is happening on the ward and about your treatments. They will make every effort to clear up misunderstandings and to treat you respectfully and with dignity and kindness. If you do become very angry in these circumstances, the staff have been trained to help you calm down by talking and listening to you. If you lash out at anyone, they will stop you. Staff are also trained in physical methods of restraining someone who is very ill and threatening. If things get very ‘out of hand’, they may put you in a room away from others to prevent you hurting anyone or yourself. This is called seclusion.

Medicines to help calm you down

Before seclusion is used, you’ll be offered some additional medication.

If extra medicines are needed, your doctors should offer you a medicine that you can take by mouth (an ‘oral preparation’). This may be a sedative called lorazepam, or an antipsychotic, either

olanzapine or haloperidol. They will not use high doses, just enough to calm you without ‘knocking you out’. If you refuse to take the extra medicines by mouth, the staff may give you these medicines by injection into your thigh or buttocks (‘intramuscular injection’). They may force you to have this if your illness has made you feel violent and act in a violent way.

Injections that might be used

If intramuscular injection proves necessary, lorazepam, haloperidol or olanzapine are the preferred medicines. If haloperidol is used, the doctors should give you a second medicine to stop you going stiff or having a bad reaction to the haloperidol. These second medicines are called anticholinergic medicines (such as procyclidine or benzatropine).

Sometimes the doctors may feel that two ‘calming drugs’ are needed, in which case they will give you lorazepam and haloperidol together. Again, if haloperidol is used, they will also give you an anticholinergic medicine. In very rare circumstances, when the doctors need to calm you very quickly, they may wish to give you these medicines into a blood vessel, usually in your arm (‘intravenous injection’).

Making sure you are OK

If you are given urgent sedation (sometimes called rapid tranquillisation), the staff should regularly check your pulse and other signs that you are OK, such as blood pressure. You should also be regularly checked for side effects. As soon as possible, staff will ask to examine you, both physically and mentally. This is important so that the staff can be sure that they are giving the right medicine for your illness, and to be sure that you are not ill in some other way.

Helping you afterwards

Rapid tranquillisation can be very upsetting. The staff knows this. As soon as possible after you have calmed down, the staff should spend time talking to you about what has happened and give you an explanation about why you have been urgently sedated. You can expect staff to be very caring and supportive at this time, so as to help you stay calm and understand what is going on. They will make detailed notes about what has happened, which you may wish to read. You may also want to write your own account in your notes. The staff should help you do this when you are calm enough to do so.

As you get better (towards the end of an acute episode)

As you begin to get better from your breakdown, your team will begin to plan what help you will need to help you recover.

Understanding your breakdown

Towards the end of an acute episode of schizophrenia, you should be offered help to understand the period of illness and given the chance to write your account in your notes, just as the doctors and nurses have done. You may well disagree with the staff working with you – they should discuss your disagreement and fully explain their position. Carers may also need help to understand the breakdown and your experience. Staff should be able to help your carers do so.

Assessing your needs for more help

After you have made a recovery, you will be assessed for what further help you might need, for example with difficult thoughts that trouble you, voices or other symptoms, which may not have completely gone away, or with help to reduce the chance that you might get ill again. You may be offered psychological help fairly quickly, or perhaps a member of your team will spend a fair bit of time talking over what has happened and help you understand things better.

The staff should also talk to you about what help you might need to get back to work or to go into education. They should also help you plan how to get back on your feet socially, and to sort out any physical health problems you have.

Planning treatments for the future

The treatments you receive after your breakdown can make further breakdowns less likely. Although you will probably need to take your antipsychotic medication for 1 or 2 years after your last breakdown, you can also be helped even more by psychological treatments: the best ones to help you are family work (sometimes called ‘family interventions’) and cognitive behavioural therapy (or CBT for short).

These psychological treatments can help you recover better and make it less likely that you will have another breakdown.

You should also be given help to plan for any crises, both in terms of how to get help quickly, and to plan your treatments should you become ill again (making advance directives). Your doctors will also discuss medication with you. Generally, it's better to keep taking antipsychotics for 1 or 2 years after your last breakdown. When you decide to stop taking medication it's best to do this slowly and for one of the mental health team to see you to check if you start feeling worse. They will see you for about 2 years after your last breakdown.