While the organisation’s name may change frequently, currently National Institute for Health and Care Excellence (NICE), its role remains constant – to provide clear published guidance on the role of treatment options within the NHS. The publication of new NICE guidance represents a significant event as clinical recommendations shape the nature of provided care nationally while research recommendations can inform funding applications and decisions.

Published guidance represents a synthesis of available research evidence combined with an economic review of intervention costs. The process is spearheaded by the guideline development group consisting of academic and clinical leaders, allied professionals, health economists, service user and carer representatives. Other individuals and groups may register as stakeholders; allowing them to raise questions for the development group. The process has recently been reviewed and critiqued, particularly in relation to the manner in which dissent is handled at development group meetings (Moncrieff and Timimi, 2013). In this paper the authors argue that through the process of guideline development, using the examples of depression and ADHD, the authority of medical models of care are emphasised – echoing the observations of Foucault in which medicine provides a technological lens for the assessment of human difficulties.

On this background the update to the 2009 Schizophrenia clinical guidelines have been published with a new title, new chapters, new guidance and new research recommendations. The new additions to the 2014 guidance are described below, followed by a summary of the research recommendations. Comments on the new evidence base for changes are presented throughout. Many of the revisions to guidance are to update the 2009 guidance and bring it into line with the recently published guidance Psychosis and Schizophrenia in children and young people.

Care across all phases

Physical health

1. Offer health eating and physical activity programmes within mental healthcare services
2. Offer treatment consistent with appropriate NICE guidance for those experiencing weight gain, showing abnormal lipid profiles or blood sugar readings during physical assessment
3. Offer smoking cessation programmes
4. Offer nicotine replacement therapy
5. Consider Bupropion (care in those showing mood symptoms) or Varenicline
6. Offer nicotine replacement during inpatient stays for those not wishing to quit smoking in order to reduce consumption
7. Routinely monitor weight as well as cardiovascular and metabolic risk indicators

Comprehensive service provision 

 Support for carers

1. Mental health services should offer carers of people with psychosis and schizophrenia an assessment of their own needs and strengths, preparing a care plan in conjunction with the carer. A copy of the care plan to be shared with the GP
2. Support carers in obtaining an assessment from social care services
3. Provide carers with information relating to schizophrenia, clinical care, service provision and crisis support
4. Negotiate sharing of care information between service user and carers if the service user consents
5. Involve carers in decision making process with service users’ consent
6. Offer carer-focused information, possibly as part of a family intervention

 Peer support and self management

1. Consider offering peer support programmes aiming to improve quality of life and service experience
2. Consider a manualised self-management programme
3. Peer support and self-management programmes to provide information on psychosis, medication, symptom management, access to care, coping with stress, crisis support, building social networks, preventing relapse and setting personal recovery goals

Preventing psychosis

An entirely new chapter has been added on preventing psychosis and this is likely to be among the most widely discussed. The guideline development group conducted a review of the available literature and combined this with their own clinical experience to reach the recommendations. The major literature findings were contained within a previously published meta-analysis (Stafford et al 2013) that has been reviewed here in the Woodlands. An accompanying BMJ editorial (van Os and Murray) raised some of the key issues that trouble this area of research:

1. The point of transition from ‘at risk’ state to psychosis is often poorly, or arbitrarily defined, representing a shift from ‘mild – moderate’ psychotic phenomena to more ‘severe’
2. Those identified as at risk often have previous experience of other forms of mental disorder – transition is therefore not from ‘Health to Disorder’ but a more uncertain categorical diagnostic shift that is difficult to conceptualise
3. In longitudinal studies not all those with poor functional outcome came from ‘at risk’ populations, suggesting transition is not necessarily predictive of poorer outcome.

Primary care referral

Referral to be made into specialist mental health services for those with evidence of distress and social functioning decline in combination with:

1. Transient or attenuated psychotic symptoms
2. Other experience suggestive of psychosis
3. First-degree relative with a history of Schizophrenia

Specialist assessment

1. To be made by a consultant psychiatrist, or trained specialist.

Treatment to prevent psychosis

1. Offer individual CBT and possible family based intervention
2. Offer interventions for anxiety, depressive, substance use or personality disorder
3. Do not offer antipsychotic medication with the aim of reducing risk / preventing psychosis

The recommendations in the above section (Treatment to prevent psychosis) represent the findings from the Stafford et al meta-analysis.

Monitoring and follow up

1. Offer follow up and monitoring for worsening of symptoms for period of up to 3 years.

First episode psychosis

Early intervention in psychosis services

1. Early intervention services (EIS) to be offered to all regardless of age or duration of untreated psychosis
2. Referral to be made from any source (including self and carer referral) with no delay in assessment. Crisis resolution and home treatment service support to be provided if no facility for urgent provision within the EIS.
3. EIS to offer full range of psychological, pharmacological, social, occupational and educational interventions described within guidance
4. Consider extension of EIS contact beyond 3 years if limited evidence of recovery

Assessment and care planning

1. Given the risk of traumatic experience either antecedent or during experience of psychosis assessment for post-traumatic symptoms with provision of treatment for PTSD.
   • This recommendation followed a review of the available literature with identification of one appropriate study (Jackson et al 2009). The guideline group felt this study provided insufficient evidence to recommend intervention, or demonstrate absence of harm, but decided, on balance, that identifying and attempting to treat symptoms should be a priority.
2. For those unable to attend mainstream education, training or work provide alternatives appropriate to their previous level and facilitate return to mainstream employment.

Treatment options

Interestingly the development group opted not to substantially update their review of the clinical evidence from the 2009 guidance and could be criticised for this give recent publications that have raised concerns regarding the perceived dominance of CBT as preferred psychological treatment option (Jones et al 2012 and Jauhar et al 2014). Jones and colleagues in their Cochrane review raised concerns regarding lack of superiority of CBT over less cost intensive options. Not all findings have been critical however and a recently published meta-analysis in the American Journal of Psychiatry found evidence for the superiority of CBT, compared with other therapies, in the relief of psychotic symptoms.

Overall recommendations from 2009 haven’t changed significantly, however the presentation has changed with psychological interventions and antipsychotic medication now being presented in parallel. CBT or family intervention are also proposed  as first line treatment to be offered to those refusing antipsychotic medication (a lot of recent Woodland chatter on this topic).

Recommendations:

1. For people with first-episode psychosis offer oral antipsychotic medication in conjunction with CBT and family intervention
2. Advise people wanting to try psychological intervention alone that they are more effective in combination with antipsychotic medication. If they continue to wish to try psychological therapy alone offer family intervention or CBT. Review treatment options within one month. Continue to monitor presentation
3. If the person’s presentation is suggestive of affective psychosis follow NICE guidance for bipolar disorder.

Subsequent acute episodes of psychosis or schizophrenia and referral in crisis

 Service-level interventions

1. Offer crisis-resolution home treatment service support when the level of crisis can not be sufficiently contained within EIS or current community services
2. Crisis-resolution teams to provide single point of access to all acute community and hospital care
3. Use support from crisis resolution services, crisis houses or acute day facilities to support hospital discharge
4. Provide appropriate hospital care when necessary

Treatment options

1. Offer oral antipsychotic in conjunction with CBT and family intervention.

Promoting recovery and possible future care

1. Continue EIS support or refer to other community services
2. Consider intensive case management for those likely to disengage from treatment or services
3. Review antipsychotic medication annually – including benefits and side-effects

Research recommendations

The guideline development group highlight the following areas for research efforts:

1. Clinical and cost effectiveness of peer support?
2. What is the clinical and cost effectiveness of psychological therapy alone in people who refuse to take antipsychotic medication?
3. What are the short and long term benefits of guided medication discontinuation?
4. How can the benefits of early intervention services be maintained beyond discharge after 3 years?
5. What are the benefits of a CBT focused reprocessing intervention on PTSD symptoms in people with experiences of psychosis?

Conclusions

NICE clinical guideline development groups occupy an important position – in a sense they have the power to create measures of current and future knowledge through their definition of ‘gold-standard’ treatment paradigms and setting of the research agenda. Acceptance of an intervention’s efficacy through NICE guidance recommendation shapes emphasis of service provision and underlines the validity of a treatment. Language use and phrasing within guidelines is therefore important, conveying not only the degree of confidence in the recommendations made, but also creating objects of knowledge and technological interventions.

The development of concepts such as ‘at risk states’ for psychosis are lent credence by their inclusion in guidelines that widen their audience beyond the scope of academic publications, even the BMJ. Unfortunately the space constraints and monological nature of guidelines can not always adequately capture the nature of on-going controversial academic debate.

Finally NICE guidelines represent summaries of available research evidence, it is perhaps unfortunate in this sense, given the number of new studies published since 2009, that the decision was taken by the group not to update their review of evidence since the previous publication.

Links

Psychosis and schizophrenia in adults: treatment and management (full guideline PDF). NICE CG178, Feb 2014.

Psychosis and schizophrenia in children and young people: recognition and management (full guideline PDF). NICE CG155, Jan 2013.

Moncrieff, J and Timimi, S. (2013) The social and cultural construction of psychiatric knowledge: an analysis of NICE guidelines on depression and ADHD (PDF). Anthropology & Medicine, 2013 20:1, 59-71.

Stafford, Jackson, Mayo-Wilson, Morrison, Kendall (2013) – Early interventions to prevent psychosis: systematic review and meta-analysis BMJ 2013;346:f185

Tomlin, A. (2103) – Individual CBT, with or without family CBT, could be the first line treatment for people at high risk of schizophrenia. The Mental Elf, 30 Jan 2013.

van Os, J and Murray, RM. (2013) – Can we identify and treat “schizophrenia light” to prevent true psychotic illness? – BMJ 2013;346:f304

Jackson et al (2009) – Improving psychological adjustment following a first episode of psychosis: a randomised controlled trial of cognitive therapy to reduce post psychotic trauma symptoms. Behav Res Ther 47(6) 454-62

Jones C, Hacker D, Cormac I, Meaden A, Irving CB. Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD008712. DOI: 10.1002/14651858.CD008712.pub2.

Jauhar, McKenna, Radua, Fung, Salvador, Laws (2014) – Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. British Journal of Psychiatry 204(1) 20-9

Turner, van der Gaag, Karyotaki and Cuijpers – Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies AJP doi: 10.1176/appi.ajp.2013.13081159

Tomlin, A and Badenoch, D. (2014) – Pilot study suggests that CBT may be a viable alternative to antipsychotics for people with schizophrenia, or does it? The Mental Elf, 6 Feb 2014.

Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care (full guideline PDF). NICE CG38, Nov 2006.