Last month, NICE published a new quality standard on psychosis and schizophrenia in adults.

The NICE website describes quality standards as a “set of specific, concise and measurable statements”, which “draw on existing guidance” to provide “an underpinning, comprehensive set of recommendations…designed to support the measurement of improvement”.

This new quality standard “covers the treatment and management of psychosis and schizophrenia (including related psychotic disorders such as schizoaffective disorder, schizophreniform disorder and delusional disorder) in adults (18 years and older) with onset before the age of 60 years in primary, secondary and community care. It will not cover adults with transient psychotic symptoms”.

The quality standard is made up of 8 quality statements. We have asked Consultant Psychiatrist Samei Huda to provide a personal critique of the new standard and give us his thoughts on how the quality statements apply to his practice. After reading Samei’s blog why not join in the discussion on this blog or on Twitter? @SameiHuda @Mental_Elf.

Psychosis and schizophrenia in adults

I will discuss each statement and how it could be improved (if at all). Then I will briefly discuss what standards could have been included, with a final section on how NICE came up with these standards and the guidance on which they are based.

1. Adults with a first episode of psychosis start treatment in early intervention in psychosis services within 2 weeks of referral

This is simultaneously laudable, vague, likely to be vulnerable to manipulation of data by providers and may potentially harm the care experience.

The positive aspects are that it’s aimed at reducing Duration of Untreated Psychosis (DUP) as longer DUP is associated with worse outcomes for people with psychosis/schizophrenia (1). It’s been shown that a significant cause of DUP is delay within services from responding to the referral (2). So hopefully it will “giddy up” services to act fast and begin treatment early.

Cue vagueness. What exactly is the treatment? Starting antipsychotics which reduce symptoms, relapse, mortality and aggression (3-6)? Being offered antipsychotics? Being seen and accepted by the Early Intervention Team with a basic care package in place?

All time standards like this are vulnerable to being “gamed” or misunderstood by service providers. Two weeks is quite a tough timetable, often referral is made first to “Single Point of Entry”, a delay up to a week before they process it and pass the referral on to the Early Intervention Team or Community Mental Health Team. There may then be delays in this team in processing the referral (even up to a week) so 2 weeks is a tight deadline to begin treatment. The temptation for “fudging figures” is there.

This rushing to meet the deadline may lead to undue haste in offering or beginning treatment the very first time the patient is seen, usually by a non-prescriber. This is unavoidable sometimes if the patient is very ill and/or risky, but in less pressing circumstances it’s preferable to have a proper assessment and discussion with a prescriber (usually a psychiatrist) who can go through the pros and cons.

So I would prefer a statement of being seen (or attempt at seeing) and accepted by the relevant mental health team and being offered information about medication and psychotherapy within 2 weeks.

2. Adults with psychosis or schizophrenia are offered cognitive behavioural therapy for psychosis (CBTp)

Since the previous NICE guideline, increasing evidence has emerged that the effect of CBTp on reducing psychotic symptoms was less than previously thought. (7,8)

My personal position is that patients should be offered psychotherapy as part of a balanced package of care. However, given the very small effects CBTp has on the researchers’ primary outcome measures of psychotic symptoms in well-conducted  studies, it doesn’t necessarily have to be CBTp.

From an NHS point of view standardising on a single type of therapy has advantages of simplifying training, arranging supervision and standardising quality. However from an individual patient point of view, I think you need a plurality of options as not everyone finds the CBTp model helpful and may respond to other psychotherapeutic approaches (9). This standardisation also limits the development (and research of) other types of psychotherapy that may prove equivalent or superior to CBTp.

So I would add the following at the end of this statement “… with availability of different psychotherapy types for patients who do not want CBTp or do not find the model helpful”.

3. Family members of adults with psychosis or schizophrenia are offered family intervention

It’s clearly important that all family members including partners need to be offered information and support. However, my interpretation of the evidence base is that the type of intervention recommended here is intended for families where the patient experiences hostile or critical comments from the family who they spend a great deal of time with (10,11).

Therefore this statement should say “…offered family intervention where the adult lives with his family and there is evidence of unhelpful, even if understandable, interpersonal factors affecting the adult’s mental health”.

Other types of family support/ psychoeducation and interventions could be offered in the other situations (see statement 7).

4. Adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs are offered clozapine

I would have preferred a statement that explicitly stated “not responded adequately to treatment with at least 2 antipsychotics taken for at least 6 weeks at maximum BNF doses (or lower doses considered therapeutic if unable to tolerate a higher dose)”. This is a reasonable statement given the good evidence for clozapine in people not responding sufficiently to other antipsychotics (12).

However, it is important not to use the “2 drug rule” rigidly (like the National Audit of Schizophrenia does). For example, somebody might have had to stop a drug at below therapeutic doses because the side effects were too much. In this case I would try an additional drug before jumping to using clozapine.

5. Adults with psychosis or schizophrenia who wish to find or return to work are offered supported employment programmes

They should have used the term “individual placement and support” and a clear description of this type of service which is the best-evidenced intervention to help gain employment in severe mental illness (13). It’s briefly mentioned in the further details but I have a concern that the “fudging tendency” may lead a non-evidence based scanty service to be offered as proof of meeting this standard. Hopefully this statement will lead to improved help for patients in gaining employment if that is important to them.

6. Adults with psychosis or schizophrenia have specific comprehensive physical health assessments

There is plenty of evidence for poor health, for example (14), but little good quality evidence that screening actually improves things for this patient group (15). However it would be hard to sit on our hands and do nothing.

Health screening should be done by primary care (they have the infrastructure and knowledge about what to do with abnormal results) with guidance provided by secondary care as to what tests to do. The only thing primary care would feel less comfortable in doing is e.g. changing antipsychotics on basis of abnormal results such as raised cholesterol. Good communication of results from primary care to secondary care would mitigate this concern.

Of course, in their main guidance NICE seems to recommend secondary care doing the screening for the first year (go figure).

7. Adults with psychosis or schizophrenia are offered combined healthy eating and physical activity programmes, and help to stop smoking

This is something we should be aiming to do as part of good holistic care but see (15) for caveats in physical healthcare interventions. As for smoking, bupropion and varenicline are recommended, which fits with the Cochrane review (16) but so is nicotine replacement therapy despite Cochrane saying that there is no evidence for this in people with schizophrenia, or indeed for any other intervention except contingency reinforcement with money.

8. Carers of adults with psychosis or schizophrenia are offered carer-focused education and support programmes

See my comments on Statement 3. We should be aiming to provide this as part of a holistic balanced programme of care. Carers deserve and require support.

What’s missing?

A quick wish list:

• Cognitive remediation combined with appropriate skills training for patients where cognitive impairments are contributing to impaired social functioning (17)
• First episode patients after 6-12 months of being symptom-free, and where there no major risks during the episode, are offered the chance to discontinue antipsychotic medication with follow-up of at least a year after stopping the medication (18)
• Psychiatric wards to no longer be mixed gender (not specifically schizophrenia/psychosis-related I know, but female patients can be victims of sexual assault and even homicide on mixed gender wards)
• If the decision is taken to admit someone with psychosis/schizophrenia, then 100% must have a bed available within 24 hours and 95%  admitted within own Trust unless patient requests another hospital (this is based not so much on hard evidence but good standards of care)
•  Offer residential crisis care as an alternative to admission where the risks are acceptable (19)

Final word

It struck me on reading the NICE outputs on schizophrenia that it’s crucially important for a type of treatment to have an advocate inside the “magic circle”. Hence we have cognitive remediation’s omission despite being one of the few treatments for cognitive impairments in psychosis/ schizophrenia due to the absence of a “cheerleader”. It’s all very well having people of unimpeachable reputations who act in good faith, but they must be able to overcome their cognitive biases to look beyond their field of interest and take a broader view.

More input from patients and carers as part of the committee should improve focus and the quality of recommendations in the future.

Links

Primary evidence

NICE (2015). Psychosis and schizophrenia in adults: NICE quality standard [QS80], Feb 2015.

Other references

1. Penttilä, Jääskeläinen, Hirvonen, Isohanni and Miettunen. Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. British Journal of Psychiatry (2014), 205:88-94. [PubMed abstract]
2. Brunet, Birchwood, Lester and Thornhill (2007). Delays in mental health services and duration of untreated psychosis. Psychiatric Bulletin (2007), 31: 408-410.
3. Fazel, Zetterqvist, Larsson H, et al (2014). Antipsychotics, mood stabilisers, and risk of violent crime. Lancet (2014); 384: 1206–14.
4. Leucht, Tardy, Komossa, Heres, Kissling, Salanti, Davis (2012). Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet 2012; 379: 2063–71. [PubMed abstract]
5. Leucht, Cipriani, Spineli, Mavridis, Örey, Richter, Samara, Barbui, Engel, Geddes, Kissling Stapf, Lässig, Salanti, Davis (2013). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis (PDF). Lancet 2013; Volume 382: 951-962. [PubMed abstract]
6. Tiihonen, Lönnqvist, Wahlbeck , et al (2009). 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet.(2009); 374: 620–7. [PubMed abstract]
7. Jauhar, McKenna, Radua, EFung, Salvador and Laws. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. British Journal of Psychiatry (2014); 204: 20-29.
8. Laws, Langford and Huda. Understanding psychosis and schizophrenia: a critique by Laws, Langford and Huda. The Mental Elf, 27 Nov 2014.
9. Rosenbaum, Martindale, Summers (2013). Supportive psychodynamic psychotherapy for psychosis. Advances in psychiatric treatment (2013); 19: 310–318.
10. Pharoah F, Mari JJ, Rathbone J, Wong W. Family intervention for schizophrenia. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD000088. DOI: 10.1002/14651858.CD000088.pub3
11. Kuipers, Birchwood & McGreadie (1992). Psychosocial Family Intervention in Schizophrenia: A Review of Empirical Studies. British Journal of Psychiatry (1992), 160: 272-275. [PubMed abstract]
12. Dold and  Leucht (2014). Pharmacotherapy of treatment-resistant schizophrenia: a clinical perspective. Evidence Based Mental Health (2014); 17: 33-37. [PubMed abstract]
13. Boardman and Rinaldi (2013). Difficulties in implementing supported employment for people with severe mental health problems. The British Journal of Psychiatry (2013); 203: 247–249.
14. Brown (1997). Excess mortality of schizophrenia: A meta-analysis. British Journal of Psychiatry (1997); 171: 502-508. [PubMed abstract]
15. Tosh G, Clifton AV, Xia J, White MM. Physical health care monitoring for people with serious mental illness. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD008298. DOI: 10.1002/14651858.CD008298.pub3.
16. Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation and reduction in individuals with schizophrenia. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD007253. DOI: 10.1002/14651858.CD007253.pub3.
17. Bowie, McGurk, Mausbach, Patterson & Harvey (2012). Combined Cognitive Remediation and Functional Skills Training for Schizophrenia: Effects on Cognition, Functional Competence, and Real-World Behavior. American Journal of Psychiatry (2012); 169: 710-718. [PubMed abstract]
18. Wunderink L, Nieboer RM, Wiersma D, et al (2013) Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry 2013; 70: 913–20. [PubMed abstract]
19. See British Journal of Psychiatry 2010 August; Issue Supplement 53.