Schizophrenia
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
acute psychosis
ensure safety of patient and yourself
Risk assess the situation to ensure the safety of the patient and yourself.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
If there are concerns about the patient’s risk of self-harm or harm to others:
Ensure the patient is easily observable and checked regularly[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 [107]Royal College of Emergency Medicine. The patient who absconds. June 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_Absconding_Guidance_V2.pdf
Search and remove access to potentially dangerous objects. Ensure the patient’s dignity and privacy are respected.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 [108]Betz ME, Boudreaux ED. Managing suicidal patients in the emergency department. Ann Emerg Med. 2016 Feb;67(2):276-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4724471 http://www.ncbi.nlm.nih.gov/pubmed/26443554?tool=bestpractice.com
If you are concerned that the patient is at risk and may leave without further assessment or treatment, carefully document a physical description that can be used to find the patient if they do so.[107]Royal College of Emergency Medicine. The patient who absconds. June 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_Absconding_Guidance_V2.pdf
If the patient wants to leave before further assessment and treatment, consider assessing their mental capacity to make this decision. Always assume the patient has capacity, unless there is evidence to suggest an assessment is required.[63]National Institute for Health and Care Excellence. Decision-making and mental capacity. October 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 [64]Department for Constitutional Affairs. Mental Capacity Act 2005: Code of Practice. 2007 [internet publication]. https://www.cqc.org.uk/sites/default/files/Mental%20Capacity%20Act%20Code%20of%20Practice.pdf Seek help from a senior colleague if needed.
Apply the principles of the Mental Capacity Act 2005 and its Code of Practice.[63]National Institute for Health and Care Excellence. Decision-making and mental capacity. October 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 Mental Capacity Act 2005: Code of Practice Opens in new window
In Scotland, the Adults with Incapacity Act 2000 is used. Adults with Incapacity Act Opens in new window In Northern Ireland, the Mental Capacity Act (Northern Ireland) 2016 is used. Mental Capacity Act (Northern Ireland) 2016 Opens in new window
Give the patient the opportunity to make informed decisions about their care and treatment and take into account their needs and preferences.[65]National Institute for Health and Care Excellence. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. June 2021 [internet publication]. https://www.nice.org.uk/guidance/cg138
Always ensure there is appropriate follow-up in place if the patient leaves.
Consider whether your patient may need help from the mental health team; contact the team urgently if you suspect an acute mental illness and think that the patient may require urgent treatment.[66]Soltan M, Girguis J. How to approach the mental state examination. BMJ. 2017 May 8;357:j1821. http://www.ncbi.nlm.nih.gov/pubmed/31055448?tool=bestpractice.com
In practice, many patients may have acute treatment in the community. This should be considered, with support from crisis resolution and home treatment teams if necessary, before admission to an inpatient unit.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
Practical tip
If the patient needs to be admitted, they may agree to this voluntarily or it may be necessary to use legal procedures to admit the patient involuntarily. The Mental Health Act 1983 is used in England and Wales.[69]The National Archives. Mental Health Act 2007 [internet publication]. https://www.legislation.gov.uk/ukpga/2007/12/contents Mental Health Act 1983: Code of Practice Opens in new window In Scotland, the Mental Health (Scotland) Act 2015 is used.[70]The National Archives. Mental Health (Scotland) Act 2015 [internet publication]. https://www.legislation.gov.uk/asp/2015/9/contents Mental Health (Scotland) Act 2015 Opens in new window In Northern Ireland, the Mental Capacity Act (Northern Ireland) 2016 is used. Mental Capacity Act Code of Practice (Northern Ireland) Opens in new window
oral benzodiazepine
Additional treatment recommended for SOME patients in selected patient group
If the patient is severely agitated or distressed use appropriate psychological and behavioural de-escalation techniques as first-line.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 [108]Betz ME, Boudreaux ED. Managing suicidal patients in the emergency department. Ann Emerg Med. 2016 Feb;67(2):276-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4724471 http://www.ncbi.nlm.nih.gov/pubmed/26443554?tool=bestpractice.com
Consider an oral benzodiazepine if tolerated.[109]Baldwin DS, Aitchison K, Bateson A, et al. Benzodiazepines: risks and benefits - a reconsideration. J Psychopharmacol. 2013 Nov;27(11):967-71. http://www.ncbi.nlm.nih.gov/pubmed/24067791?tool=bestpractice.com [110]Cookson J. Rapid tranquillisation: the science and advice. BJPsych Advances. 2018 Sep;24(5):346-58. https://www.cambridge.org/core/journals/bjpsych-advances/article/rapid-tranquillisation-the-science-and-advice/EE970FE23792875F2F3A7F71ACE17705
Practical tip
Use caution when giving benzodiazepines to the very young or older people and those with pre-existing brain damage or impulse control problems as disinhibition reactions are more likely.[119]Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002 Dec;26(12):460-2. https://www.cambridge.org/core/journals/psychiatric-bulletin/article/benzodiazepines-and-disinhibition-a-review/421AF197362B55EDF004700452BF3BC6
Primary options
lorazepam: 1-2 mg orally as a single dose, may repeat dose after 45-60 minutes if required
OR
midazolam: 10 mg buccally as a single dose, may repeat dose after 45-60 minutes if required
These drug options and doses relate to a patient with no comorbidities.
Primary options
lorazepam: 1-2 mg orally as a single dose, may repeat dose after 45-60 minutes if required
OR
midazolam: 10 mg buccally as a single dose, may repeat dose after 45-60 minutes if required
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
lorazepam
OR
midazolam
rapid tranquillisation
Additional treatment recommended for SOME patients in selected patient group
If the patient becomes aggressive or violent, involve a senior colleague and seek advice from the mental health team. The patient may use aggression as a defence against perceived persecutors, which can increase the risk of harm to themselves and others.
Use appropriate psychological and behavioural de-escalation techniques first-line.
Parenteral medication (rapid tranquillisation) may be used if de-escalation techniques and oral benzodiazepines have failed, and only if absolutely necessary after weighing up the risks and benefits.[111]Royal College of Psychiatrists. The risks and benefits of high-dose antipsychotic medication. November 2014 (revised January 2023) [internet publication]. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr190.pdf Physical restraint may be used if there is potential for harm to the patient or other people.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 The decision to use rapid tranquilisation and/or physical restraint should be made by a senior clinician with mental health team input. Patients at high risk of sedation may be transferred to a setting where ventilatory support is available.
Consider intramuscular treatment if oral medication is not possible or appropriate and urgent sedation with medication is needed.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 The UK National Institute for Health and Care Excellence (NICE) recommends either intramuscular lorazepam alone, or intramuscular haloperidol combined with intramuscular promethazine, for rapid tranquillisation in adults.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
Always inform the patient that medication is going to be administered and give them the opportunity to accept oral medication voluntarily.
NICE recommends against the use of intramuscular haloperidol combined with intramuscular promethazine if the patient has any evidence of cardiovascular disease (including a prolonged QT interval) or if no ECG has been carried out. Intramuscular lorazepam can be used in this patient group instead.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
NICE recommends monitoring side effects, pulse, blood pressure, respiratory rate, temperature, level of hydration, and level of consciousness at least every hour until there are no further concerns. Consider monitoring oxygen saturation using pulse oximetry; check your local protocol. Monitor the patient every 15 minutes if the maximum dose has been exceeded or they:[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
Appear to be asleep or sedated
Have taken illicit drugs or alcohol
Have a pre-existing medical condition
Have experienced harm as a result of a restrictive intervention.
Practical tip
Use caution when giving benzodiazepines to the very young or older people and those with pre-existing brain damage or impulse control problems as disinhibition reactions are more likely.[119]Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002 Dec;26(12):460-2. https://www.cambridge.org/core/journals/psychiatric-bulletin/article/benzodiazepines-and-disinhibition-a-review/421AF197362B55EDF004700452BF3BC6
Primary options
lorazepam: 2 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
Secondary options
promethazine: 50 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
and
haloperidol: 5 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
These drug options and doses relate to a patient with no comorbidities.
Primary options
lorazepam: 2 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
Secondary options
promethazine: 50 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
and
haloperidol: 5 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
lorazepam
Secondary options
promethazine
and
haloperidol
referral to specialist to start antipsychotic
Treatment recommended for ALL patients in selected patient group
Always check whether the patient could be pregnant. Pregnancy is not covered in this topic; discuss pregnant patients with a senior colleague.
An antipsychotic should be started by a specialist.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication].
https://www.sign.ac.uk/assets/sign131.pdf
[5]National Collaborating Centre for Mental Health. Psychosis and schizophrenia in adults: the NICE guideline on treatment and management. 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178/evidence/full-guideline-490503565
[68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78.
https://journals.sagepub.com/doi/10.1177/0269881119889296
http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
[111]Royal College of Psychiatrists. The risks and benefits of high-dose antipsychotic medication. November 2014 (revised January 2023) [internet publication].
https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr190.pdf
[ 
]
How does haloperidol compare with first‐generation antipsychotics for improving outcomes in adults with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.737/fullShow me the answer
[ ]
What are the benefits and harms of aripiprazole compared with other atypical antipsychotics in people with schizophrenia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.496/fullShow me the answer
The patient and/or carer should be involved as much as possible when choosing an antipsychotic. The benefits and possible side effects of each drug should be discussed with them, including:[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 [2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication]. https://www.sign.ac.uk/assets/sign131.pdf [68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
Metabolic (including weight gain and diabetes)
Extrapyramidal (including akathisia, dystonia and dyskinesia)
Cardiovascular (including prolonging the QT interval)
Hormonal (including increasing plasma prolactin)
Other (including unpleasant subjective experiences).
Aim to check the following before starting an antipsychotic:
ECG if indicated; check your local protocol because guidance varies.
The National Institute for Health and Care Excellence recommends an ECG before starting an antipsychotic if any of the following are present:[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
It is specified in the summary of product characteristics/prescribing information
A physical examination has identified specific cardiovascular risk (such as a diagnosis of high blood pressure)
There is a personal history of cardiovascular disease
The patient is being admitted as an inpatient.
If the ECG is abnormal, repeat it. If in doubt or the ECG remains abnormal, discuss this with a cardiologist.
Baseline bloods including fasting blood glucose, HbA1c, cholesterol, triglycerides, and prolactin.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
Body mass index, pulse, and blood pressure.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 [2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication]. https://www.sign.ac.uk/assets/sign131.pdf [112]Cooper SJ, Reynolds GP, Barnes T, et al. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol. 2016 Aug;30(8):717-48. https://journals.sagepub.com/doi/10.1177/0269881116645254 http://www.ncbi.nlm.nih.gov/pubmed/27147592?tool=bestpractice.com
Assessment of any movement disorders.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
Practical tip
There is little difference between the efficacy of non-clozapine antipsychotics. Choice of antipsychotic should be determined by patient preference wherever possible as well as taking into account the patient’s medication history and individual patient factors such as risk of extrapyramidal side effects, weight gain, impaired glucose tolerance, or QT-interval prolongation, or the presence of negative symptoms.[68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com [120]British National Formulary 77. Clozapine. London: BMJ Group, RCPCH Publications Ltd and the Royal Pharmaceutical Society of Great Britain. 2020. https://bnf.nice.org.uk/drug/clozapine.html
In the acute setting, consider giving a sedative antipsychotic, or a sedative in addition to an antipsychotic, to help with sleep disturbance.[121]Pollak TA, Lennox BR, Müller S, et al. Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin. Lancet Psychiatry. 2020 Jan;7(1):93-108. http://www.ncbi.nlm.nih.gov/pubmed/31669058?tool=bestpractice.com See Insomnia.
These regimens are examples only; consult local drug formulary for more options. A dose reduction may be required in patients on concomitant medications due to possible drug-drug interactions. A dose reduction may also be required in older patients. Monitoring blood concentrations of antipsychotics may be helpful in certain circumstances to prevent toxicity (e.g., drug-drug interactions, patient presents with signs of toxicity).
Primary options
aripiprazole: 10-15 mg orally once daily initially, adjust dose according to response, usual dose 15 mg/day, maximum 30 mg/day
OR
amisulpride: 400-800 mg/day orally in 2 divided doses initially, adjust dose according to response, maximum 1200 mg/day
OR
haloperidol: 2-10 mg/day orally in 1-2 divided doses initially, adjust dose according to response, usual dose 2-4 mg/day, maximum 20 mg/day
OR
lurasidone: 37 mg orally once daily initially, adjust dose according to response, maximum 148 mg/day
OR
olanzapine: 10 mg orally once daily initially, adjust dose according to response, usual dose 5-20 mg/day, maximum 20 mg/day
OR
risperidone: 2 mg/day orally in 1-2 divided doses on day 1, followed by 4 mg/day in 1-2 divided doses on day 2, then adjust dose according to response, usual dose 4-6 mg/day, maximum 16 mg/day
OR
chlorpromazine: 25 mg orally three times daily or 75 mg once daily initially, adjust dose according to response, usual dose 75-300 mg/day, maximum 1000 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
aripiprazole: 10-15 mg orally once daily initially, adjust dose according to response, usual dose 15 mg/day, maximum 30 mg/day
OR
amisulpride: 400-800 mg/day orally in 2 divided doses initially, adjust dose according to response, maximum 1200 mg/day
OR
haloperidol: 2-10 mg/day orally in 1-2 divided doses initially, adjust dose according to response, usual dose 2-4 mg/day, maximum 20 mg/day
OR
lurasidone: 37 mg orally once daily initially, adjust dose according to response, maximum 148 mg/day
OR
olanzapine: 10 mg orally once daily initially, adjust dose according to response, usual dose 5-20 mg/day, maximum 20 mg/day
OR
risperidone: 2 mg/day orally in 1-2 divided doses on day 1, followed by 4 mg/day in 1-2 divided doses on day 2, then adjust dose according to response, usual dose 4-6 mg/day, maximum 16 mg/day
OR
chlorpromazine: 25 mg orally three times daily or 75 mg once daily initially, adjust dose according to response, usual dose 75-300 mg/day, maximum 1000 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
aripiprazole
OR
amisulpride
OR
haloperidol
OR
lurasidone
OR
olanzapine
OR
risperidone
OR
chlorpromazine
ensure safety of patient and yourself
Risk assess the situation to ensure the safety of the patient and yourself.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
If there are concerns about the patient’s risk of self-harm or harm to others:
Ensure the patient is easily observable and checked regularly[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 [107]Royal College of Emergency Medicine. The patient who absconds. June 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_Absconding_Guidance_V2.pdf
Search and remove access to potentially dangerous objects. Ensure the patient’s dignity and privacy are respected.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 [108]Betz ME, Boudreaux ED. Managing suicidal patients in the emergency department. Ann Emerg Med. 2016 Feb;67(2):276-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4724471 http://www.ncbi.nlm.nih.gov/pubmed/26443554?tool=bestpractice.com
If you are concerned that the patient is at risk and may leave without further assessment or treatment, carefully document a physical description that can be used to find the patient if they do so.[107]Royal College of Emergency Medicine. The patient who absconds. June 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_Absconding_Guidance_V2.pdf
If the patient wants to leave before further assessment and treatment, consider assessing their mental capacity to make this decision. Always assume the patient has capacity, unless there is evidence to suggest an assessment is required.[63]National Institute for Health and Care Excellence. Decision-making and mental capacity. October 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 [64]Department for Constitutional Affairs. Mental Capacity Act 2005: Code of Practice. 2007 [internet publication]. https://www.cqc.org.uk/sites/default/files/Mental%20Capacity%20Act%20Code%20of%20Practice.pdf Seek help from a senior colleague if needed.
Apply the principles of the Mental Capacity Act 2005 and its Code of Practice.[63]National Institute for Health and Care Excellence. Decision-making and mental capacity. October 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 Mental Capacity Act 2005: Code of Practice Opens in new window
In Scotland, the Adults with Incapacity Act 2000 is used. Adults with Incapacity Act Opens in new window In Northern Ireland, the Mental Capacity Act (Northern Ireland) 2016 is used. Mental Capacity Act (Northern Ireland) 2016 Opens in new window
Give the patient the opportunity to make informed decisions about their care and treatment and take into account their needs and preferences.[65]National Institute for Health and Care Excellence. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. June 2021 [internet publication]. https://www.nice.org.uk/guidance/cg138
Give the patient the opportunity to make informed decisions about their care and treatment and take into account their needs and preferences.[65]National Institute for Health and Care Excellence. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. June 2021 [internet publication]. https://www.nice.org.uk/guidance/cg138
Always ensure there is appropriate follow-up in place if the patient leaves.
Consider whether your patient may need help from the mental health team; contact the team urgently if you suspect an acute mental illness and think that the patient may require urgent treatment.[66]Soltan M, Girguis J. How to approach the mental state examination. BMJ. 2017 May 8;357:j1821. http://www.ncbi.nlm.nih.gov/pubmed/31055448?tool=bestpractice.com
In practice, many patients may have acute treatment in the community. This should be considered, with support from crisis resolution and home treatment teams if necessary, before admission to an inpatient unit.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
Practical tip
If the patient needs to be admitted, they may agree to this voluntarily or it may be necessary to use legal procedures to admit the patient involuntarily. The Mental Health Act 1983 is used in England and Wales.[69]The National Archives. Mental Health Act 2007 [internet publication]. https://www.legislation.gov.uk/ukpga/2007/12/contents Mental Health Act 1983: Code of Practice Opens in new window In Scotland, the Mental Health (Scotland) Act 2015 is used.[70]The National Archives. Mental Health (Scotland) Act 2015 [internet publication]. https://www.legislation.gov.uk/asp/2015/9/contents Mental Health (Scotland) Act 2015 Opens in new window In Northern Ireland, the Mental Capacity Act (Northern Ireland) 2016 is used. Mental Capacity Act Code of Practice (Northern Ireland) Opens in new window
oral benzodiazepine
Additional treatment recommended for SOME patients in selected patient group
If the patient is severely agitated or distressed use appropriate psychological and behavioural de-escalation techniques as first-line.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 [108]Betz ME, Boudreaux ED. Managing suicidal patients in the emergency department. Ann Emerg Med. 2016 Feb;67(2):276-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4724471 http://www.ncbi.nlm.nih.gov/pubmed/26443554?tool=bestpractice.com
Consider an oral benzodiazepine if tolerated.[109]Baldwin DS, Aitchison K, Bateson A, et al. Benzodiazepines: risks and benefits - a reconsideration. J Psychopharmacol. 2013 Nov;27(11):967-71. http://www.ncbi.nlm.nih.gov/pubmed/24067791?tool=bestpractice.com [110]Cookson J. Rapid tranquillisation: the science and advice. BJPsych Advances. 2018 Sep;24(5):346-58. https://www.cambridge.org/core/journals/bjpsych-advances/article/rapid-tranquillisation-the-science-and-advice/EE970FE23792875F2F3A7F71ACE17705
Practical tip
Use caution when giving benzodiazepines to the very young or older people and those with pre-existing brain damage or impulse control problems as disinhibition reactions are more likely.[119]Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002 Dec;26(12):460-2. https://www.cambridge.org/core/journals/psychiatric-bulletin/article/benzodiazepines-and-disinhibition-a-review/421AF197362B55EDF004700452BF3BC6
Primary options
lorazepam: 1-2 mg orally as a single dose, may repeat dose after 45-60 minutes if required
OR
midazolam: 10 mg buccally as a single dose, may repeat dose after 45-60 minutes if required
These drug options and doses relate to a patient with no comorbidities.
Primary options
lorazepam: 1-2 mg orally as a single dose, may repeat dose after 45-60 minutes if required
OR
midazolam: 10 mg buccally as a single dose, may repeat dose after 45-60 minutes if required
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
lorazepam
OR
midazolam
rapid tranquillisation
Additional treatment recommended for SOME patients in selected patient group
If the patient becomes aggressive or violent, involve a senior colleague and seek advice from the mental health team. The patient may use aggression as a defence against perceived persecutors, which can increase the risk of harm to themselves and others.
Use appropriate psychological and behavioural de-escalation techniques first-line.
Parenteral medication (rapid tranquillisation) may be used if de-escalation techniques and oral benzodiazepines have failed, and only if absolutely necessary after weighing up the risks and benefits.[111]Royal College of Psychiatrists. The risks and benefits of high-dose antipsychotic medication. November 2014 (revised January 2023) [internet publication]. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr190.pdf Physical restraint may be used if there is potential for harm to the patient or other people.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 The decision to use rapid tranquillisation and/or physical restraint should be made by a senior clinician with mental health team input. Patients at high risk of sedation may be transferred to a setting where ventilatory support is available.
Consider intramuscular treatment if oral medication is not possible or appropriate and urgent sedation with medication is needed.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10 The UK National Institute for Health and Care Excellence (NICE) recommends either intramuscular lorazepam alone, or intramuscular haloperidol combined with intramuscular promethazine, for rapid tranquillisation in adults.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
Always inform the patient that medication is going to be administered and give them the opportunity to accept oral medication voluntarily.
NICE recommends against the use of intramuscular haloperidol combined with intramuscular promethazine if the patient has any evidence of cardiovascular disease (including a prolonged QT interval) or if no ECG has been carried out. Intramuscular lorazepam can be used in this patient group instead.[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
NICE recommends monitoring side effects, pulse, blood pressure, respiratory rate, temperature, level of hydration, and level of consciousness at least every hour until there are no further concerns. Consider monitoring oxygen saturation using pulse oximetry; check your local protocol. Monitor the patient every 15 minutes if the maximum dose has been exceeded or they:[60]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
Appear to be asleep or sedated
Have taken illicit drugs or alcohol
Have a pre-existing medical condition
Have experienced harm as a result of a restrictive intervention.
Practical tip
Use caution when giving benzodiazepines to the very young or older people and those with pre-existing brain damage or impulse control problems as disinhibition reactions are more likely.[119]Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002 Dec;26(12):460-2. https://www.cambridge.org/core/journals/psychiatric-bulletin/article/benzodiazepines-and-disinhibition-a-review/421AF197362B55EDF004700452BF3BC6
Primary options
lorazepam: 2 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
Secondary options
promethazine: 50 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
and
haloperidol: 5 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
These drug options and doses relate to a patient with no comorbidities.
Primary options
lorazepam: 2 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
Secondary options
promethazine: 50 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
and
haloperidol: 5 mg intramuscularly as a single dose, may repeat dose after 30-60 minutes if required
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
lorazepam
Secondary options
promethazine
and
haloperidol
Plus – referral to specialist for review of antipsychotic treatment
referral to specialist for review of antipsychotic treatment
Treatment recommended for ALL patients in selected patient group
Always check whether the patient could be pregnant. Pregnancy is not covered in this topic; discuss pregnant patients with a senior colleague.
Review the patient’s current antipsychotic; a switch to an alternative antipsychotic may be considered but this should only be done by a specialist.
[ ]
How does haloperidol compare with first‐generation antipsychotics for improving outcomes in adults with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.737/fullShow me the answer
[ ]
What are the benefits and harms of aripiprazole compared with other atypical antipsychotics in people with schizophrenia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.496/fullShow me the answer
Consider the possibility of non-adherence with prescribed medication.[90]Morrison P, Taylor DM, McGuire P. The Maudsley guidelines on advanced prescribing in psychosis. Chichester: Wiley-Blackwell; 2019.
A long-acting injectable antipsychotic should be considered if the patient is concerned about taking medication reliably.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 However, in practice, a long-acting injectable formulation should only be started after a trial of the same oral medication to make sure the patient tolerates the medication. The starting dose of the long-acting injectable formulation depends on the patient’s previous oral dose, and the oral formulation may need to be continued for a short time after the first dose of the long-acting injectable formulation. Consult a drug formulary or pharmacist for further information on starting these formulations.
Practical tip
Check adherence with antipsychotic treatment through pharmacy records because non-adherence with antipsychotics is common. This is frequently due to adverse effects of an antipsychotic; consider assessing adverse effects using a validated tool (e.g., the Glasgow Antipsychotic Side-effect Scale).[68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com [122]Hynes C, Keating D, McWilliams S, et al. Glasgow antipsychotic side-effects scale for clozapine: development and validation of a clozapine-specific side-effects scale. Schizophr Res. 2015 Oct;168(1-2):505-13. http://www.ncbi.nlm.nih.gov/pubmed/26276305?tool=bestpractice.com [123]Velligan DI, Sajatovic M, Hatch A, et al. Why do psychiatric patients stop antipsychotic medication? A systematic review of reasons for nonadherence to medication in patients with serious mental illness. Patient Prefer Adherence. 2017;11:449-68. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5344423 http://www.ncbi.nlm.nih.gov/pubmed/28424542?tool=bestpractice.com Glasgow Antipsychotic Side-effect Scale Opens in new window
These regimens are examples only; consult local drug formulary for more options. A dose reduction may be required in patients on concomitant medications due to possible drug-drug interactions. A dose reduction may also be required in older patients. Monitoring blood concentrations of antipsychotics may be helpful in certain circumstances to prevent toxicity (e.g., drug-drug interactions, patient presents with signs of toxicity).
Primary options
aripiprazole: 10-15 mg orally once daily initially, adjust dose according to response, usual dose 15 mg/day, maximum 30 mg/day
OR
amisulpride: 400-800 mg/day orally in 2 divided doses initially, adjust dose according to response, maximum 1200 mg/day
OR
haloperidol: 2-10 mg/day orally in 1-2 divided doses initially, adjust dose according to response, usual dose 2-4 mg/day, maximum 20 mg/day
OR
lurasidone: 37 mg orally once daily initially, adjust dose according to response, maximum 148 mg/day
OR
olanzapine: 10 mg orally once daily initially, adjust dose according to response, usual dose 5-20 mg/day, maximum 20 mg/day
OR
risperidone: 2 mg/day orally in 1-2 divided doses on day 1, followed by 4 mg/day in 1-2 divided doses on day 2, then adjust dose according to response, usual dose 4-6 mg/day, maximum 16 mg/day
OR
chlorpromazine: 25 mg orally three times daily or 75 mg once daily initially, adjust dose according to response, usual dose 75-300 mg/day, maximum 1000 mg/day
Secondary options
aripiprazole: 300-400 mg intramuscularly once monthly
More aripiprazoleThe 300 mg dose is recommended for CYP2D6 poor metabolisers. Continue oral aripiprazole for 14 consecutive days after the first injection. Minimum of 26 days required between injections. Alternative initiation dosing is available; consult product literature.
OR
haloperidol decanoate: long-acting injectable dose depends on previous dose of oral haloperidol; consult specialist for guidance on dose
OR
paliperidone: long-acting injectable dose depends on previous dose of oral paliperidone or risperidone; consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
aripiprazole: 10-15 mg orally once daily initially, adjust dose according to response, usual dose 15 mg/day, maximum 30 mg/day
OR
amisulpride: 400-800 mg/day orally in 2 divided doses initially, adjust dose according to response, maximum 1200 mg/day
OR
haloperidol: 2-10 mg/day orally in 1-2 divided doses initially, adjust dose according to response, usual dose 2-4 mg/day, maximum 20 mg/day
OR
lurasidone: 37 mg orally once daily initially, adjust dose according to response, maximum 148 mg/day
OR
olanzapine: 10 mg orally once daily initially, adjust dose according to response, usual dose 5-20 mg/day, maximum 20 mg/day
OR
risperidone: 2 mg/day orally in 1-2 divided doses on day 1, followed by 4 mg/day in 1-2 divided doses on day 2, then adjust dose according to response, usual dose 4-6 mg/day, maximum 16 mg/day
OR
chlorpromazine: 25 mg orally three times daily or 75 mg once daily initially, adjust dose according to response, usual dose 75-300 mg/day, maximum 1000 mg/day
Secondary options
aripiprazole: 300-400 mg intramuscularly once monthly
More aripiprazoleThe 300 mg dose is recommended for CYP2D6 poor metabolisers. Continue oral aripiprazole for 14 consecutive days after the first injection. Minimum of 26 days required between injections. Alternative initiation dosing is available; consult product literature.
OR
haloperidol decanoate: long-acting injectable dose depends on previous dose of oral haloperidol; consult specialist for guidance on dose
OR
paliperidone: long-acting injectable dose depends on previous dose of oral paliperidone or risperidone; consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
aripiprazole
OR
amisulpride
OR
haloperidol
OR
lurasidone
OR
olanzapine
OR
risperidone
OR
chlorpromazine
Secondary options
aripiprazole
OR
haloperidol decanoate
OR
paliperidone
known schizophrenia: long-term management
continue oral non-clozapine antipsychotic
Always check whether the patient could be pregnant. Pregnancy is not covered in this topic; discuss pregnant patients with a senior colleague.
The antipsychotic should be trialled for 4-6 weeks at optimum dosage.[113]Howes OD, McCutcheon R, Agid O, et al. Treatment-resistant schizophrenia: treatment response and resistance in psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. Am J Psychiatry. 2017 Mar 1;174(3):216-29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231547 http://www.ncbi.nlm.nih.gov/pubmed/27919182?tool=bestpractice.com Consider using a formal assessment tool such as the Clinical Global Impression (CGI) Scale to monitor response to treatment.[124]Busner J, Targum SD. The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont). 2007 Jul;4(7):28-37. http://www.ncbi.nlm.nih.gov/pubmed/20526405?tool=bestpractice.com Clinical Global Impression Scale Opens in new window
A reduction of 1 point on the CGI scale indicates a significant response to an antipsychotic.[68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
The patient should be reassessed following this trial.[113]Howes OD, McCutcheon R, Agid O, et al. Treatment-resistant schizophrenia: treatment response and resistance in psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. Am J Psychiatry. 2017 Mar 1;174(3):216-29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231547 http://www.ncbi.nlm.nih.gov/pubmed/27919182?tool=bestpractice.com
The antipsychotic should be continued at the current dose established if effective.
If the antipsychotic is not effective, identify any underlying reasons for this (e.g., poor adherence).
A long-acting injectable antipsychotic should be considered if the patient is concerned about taking medication reliably.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 However, in practice, a long-acting injectable formulation should only be started after a trial of the same oral medication to make sure the patient tolerates the medication. The starting dose of the long-acting injectable formulation depends on the patient’s previous oral dose, and the oral formulation may need to be continued for a short time after the first dose of the long-acting injectable formulation. Consult a drug formulary or pharmacist for further information on starting these formulations.
Practical tip
Check adherence with antipsychotic treatment through pharmacy records because non-adherence with antipsychotics is common. This is frequently due to adverse effects of an antipsychotic; consider assessing adverse effects using a validated tool (e.g., the Glasgow Antipsychotic Side-effect Scale).[68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com [122]Hynes C, Keating D, McWilliams S, et al. Glasgow antipsychotic side-effects scale for clozapine: development and validation of a clozapine-specific side-effects scale. Schizophr Res. 2015 Oct;168(1-2):505-13. http://www.ncbi.nlm.nih.gov/pubmed/26276305?tool=bestpractice.com [123]Velligan DI, Sajatovic M, Hatch A, et al. Why do psychiatric patients stop antipsychotic medication? A systematic review of reasons for nonadherence to medication in patients with serious mental illness. Patient Prefer Adherence. 2017;11:449-68. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5344423 http://www.ncbi.nlm.nih.gov/pubmed/28424542?tool=bestpractice.com Glasgow Antipsychotic Side-effect Scale Opens in new window
Continue antipsychotic treatment for 1-2 years if this is effective.[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication].
https://www.sign.ac.uk/assets/sign131.pdf
[ ]
What are the effects of maintenance treatment with antipsychotic drugs in people with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.3284/fullShow me the answer
Longer-term maintenance treatment may be considered for patients who have ongoing symptoms, or frequent relapses that are associated with high risk to themselves or others.[125]Ceraso A, Lin JJ, Schneider-Thoma J, et al. Maintenance treatment with antipsychotic drugs for schizophrenia. Cochrane Database Syst Rev. 2020 Aug 11;8(8):CD008016. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008016.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/32840872?tool=bestpractice.com
Continue to monitor the patient’s adherence to the antipsychotic and for adverse effects.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
Explore and address reasons for non-adherence (e.g., adverse effects of the antipsychotic, practical problems with access to prescriptions).
Address adverse affects where possible.
These regimens are examples only; consult local drug formulary for more options. A dose reduction may be required in patients on concomitant medications due to drug-drug interactions. A dose reduction may also be required in older patients. Monitoring blood concentrations of antipsychotics may be helpful in certain circumstances to prevent toxicity (e.g., drug-drug interactions, patient presents with signs of toxicity). The maintenance dose should be the lowest effective dose possible.
Primary options
aripiprazole: 10-15 mg orally once daily initially, adjust dose according to response, usual dose 15 mg/day, maximum 30 mg/day
OR
amisulpride: 400-800 mg/day orally in 2 divided doses initially, adjust dose according to response, maximum 1200 mg/day
OR
haloperidol: 2-10 mg/day orally in 1-2 divided doses initially, adjust dose according to response, usual dose 2-4 mg/day, maximum 20 mg/day
OR
lurasidone: 37 mg orally once daily initially, adjust dose according to response, maximum 148 mg/day
OR
olanzapine: 10 mg orally once daily initially, adjust dose according to response, usual dose 5-20 mg/day, maximum 20 mg/day
OR
risperidone: 2 mg/day orally in 1-2 divided doses on day 1, followed by 4 mg/day in 1-2 divided doses on day 2, then adjust dose according to response, usual dose 4-6 mg/day, maximum 16 mg/day
OR
chlorpromazine: 25 mg orally three times daily or 75 mg once daily initially, adjust dose according to response, usual dose 75-300 mg/day, maximum 1000 mg/day
Secondary options
aripiprazole: 300-400 mg intramuscularly once monthly
More aripiprazoleThe 300 mg dose is recommended for CYP2D6 poor metabolisers. Continue oral aripiprazole for 14 consecutive days after the first injection. Minimum of 26 days required between injections. Alternative initiation dosing is available; consult product literature.
OR
haloperidol decanoate: long-acting injectable dose depends on previous dose of oral haloperidol; consult specialist for guidance on dose
OR
paliperidone: long-acting injectable dose depends on previous dose of oral paliperidone or risperidone; consult specialist for guidance on dose
psychosocial interventions
Treatment recommended for ALL patients in selected patient group
The National Institute for Health and Care Excellence (NICE) recommends to offer all patients cognitive behavioural therapy for psychosis (CBTp).[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[ ]
How does cognitive‐behavioral therapy compare with other psychosocial treatments for individuals with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2382/fullShow me the answer
[ ]
Can adding cognitive‐behavioral therapy (CBT) to standard care improve longer‐term outcomes for people with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2618/fullShow me the answer However, a Cochrane review notes there is no clear and convincing advantage for CBT over other psychosocial therapies.[117]Jones C, Hacker D, Meaden A, et al. Cognitive behavioural therapy plus standard care versus standard care plus other psychosocial treatments for people with schizophrenia. Cochrane Database Syst Rev. 2018 Nov 15;11(11):CD008712.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008712.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/30480760?tool=bestpractice.com
Family interventions may also be used if the patient lives with or is in close contact with family.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[118]Jones C, Hacker D, Xia J, et al. Cognitive behavioural therapy plus standard care versus standard care for people with schizophrenia. Cochrane Database Syst Rev. 2018 Dec 20;(12):CD007964.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007964.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/30572373?tool=bestpractice.com
Ensure patients have follow-up depending on their needs and that long-term social support is in place. Offer support with finances, accommodation, and access to supported employment programmes if the patient is out of work and wanting to find work.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[126]Walter F, Carr MJ, Mok PLH, et al. Multiple adverse outcomes following first discharge from inpatient psychiatric care: a national cohort study. Lancet Psychiatry. 2019 Jul;6(7):582-9.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586943
http://www.ncbi.nlm.nih.gov/pubmed/31171451?tool=bestpractice.com
[ ]
In people with chronic mental illnesses, how do life skills programs affect outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.564/fullShow me the answer
Offer support for any carers involved with the patient, including an assessment of their own needs.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
monitor physical health
Treatment recommended for ALL patients in selected patient group
Monitor patients taking an antipsychotic for:[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
Side effects of treatment and impact on functioning. Use a formal rating scale such as the Glasgow Antipsychotic Side-effect Scale.[122]Hynes C, Keating D, McWilliams S, et al. Glasgow antipsychotic side-effects scale for clozapine: development and validation of a clozapine-specific side-effects scale. Schizophr Res. 2015 Oct;168(1-2):505-13. http://www.ncbi.nlm.nih.gov/pubmed/26276305?tool=bestpractice.com Glasgow Antipsychotic Side-effect Scale Opens in new window
Signs of extrapyramidal movement disorders with antipsychotic medications (EPSE).
Use a formal rating scale such as the Abnormal Involuntary Movement Scale. Abnormal Involuntary Movement Scale Opens in new window For information on managing EPSE, see Complications.
Weight; weekly for the first 6 weeks, then at 12 weeks, at 1 year, and then annually (plotted on a chart).
Waist circumference, annually.
Pulse and blood pressure at 12 weeks, at 1 year, and then annually.
Fasting blood glucose, HbA1c, and blood lipid levels at 12 weeks, at 1 year, and then annually.
Prolactin, as clinically indicated.[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication]. https://www.sign.ac.uk/assets/sign131.pdf
ECG, as clinically indicated.[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication]. https://www.sign.ac.uk/assets/sign131.pdf
Overall physical health, including smoking, exercise, and diet.
A rare but serious side effect of antipsychotics is neuroleptic malignant syndrome. Assess the patient urgently if this is suspected; consider urgent transfer to hospital.[111]Royal College of Psychiatrists. The risks and benefits of high-dose antipsychotic medication. November 2014 (revised January 2023) [internet publication]. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr190.pdf
Practical tip
Recognise and manage risk factors for cardiovascular disease and diabetes early as they can cause significant morbidity and mortality if left untreated.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 [87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf [112]Cooper SJ, Reynolds GP, Barnes T, et al. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol. 2016 Aug;30(8):717-48. https://journals.sagepub.com/doi/10.1177/0269881116645254 http://www.ncbi.nlm.nih.gov/pubmed/27147592?tool=bestpractice.com [115]Chan JKN, Wong CSM, Or PCF, et al. Risk of mortality and complications in patients with schizophrenia and diabetes mellitus: population-based cohort study. Br J Psychiatry. 2021 Jul;219(1):375-82. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/risk-of-mortality-and-complications-in-patients-with-schizophrenia-and-diabetes-mellitus-populationbased-cohort-study/BBDA7881F6EDB487FBA40712DCBBF1F2 http://www.ncbi.nlm.nih.gov/pubmed/33407970?tool=bestpractice.com
In general, this is performed poorly in patients with schizophrenia; the mean life expectancy of a patient with schizophrenia is 14.5 years shorter compared with the general population.[116]Hjorthøj C, Stürup AE, McGrath JJ, et al. Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. Lancet Psychiatry. 2017 Apr;4(4):295-301. http://www.ncbi.nlm.nih.gov/pubmed/28237639?tool=bestpractice.com This is mostly due to physical health causes; treatment with antipsychotics can cause significant and rapid weight gain. However, schizophrenia itself increases mortality, especially if untreated, and can interfere with the patient’s ability to communicate their needs and access care.[14]Firth J, Siddiqi N, Koyanagi A, et al. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry. 2019 Aug;6(8):675-712. http://www.ncbi.nlm.nih.gov/pubmed/31324560?tool=bestpractice.com [87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf [112]Cooper SJ, Reynolds GP, Barnes T, et al. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol. 2016 Aug;30(8):717-48. https://journals.sagepub.com/doi/10.1177/0269881116645254 http://www.ncbi.nlm.nih.gov/pubmed/27147592?tool=bestpractice.com
Address alcohol and substance misuse and encourage smoking cessation.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 [87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf
Smoking is a major contributor to increased mortality in individuals with serious mental illness.[9]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. 2021 [internet publication]. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [127]Reynolds RJ, Day SM, Shafer A, et al. Mortality rates and excess death rates for the seriously mentally ill. J Insur Med. 2018;47(4):212-9. https://meridian.allenpress.com/jim/article/47/4/212/73465/Mortality-Rates-and-Excess-Death-Rates-for-the http://www.ncbi.nlm.nih.gov/pubmed/30653378?tool=bestpractice.com [128]Tam J, Warner KE, Meza R. Smoking and the reduced life expectancy of individuals with serious mental illness. Am J Prev Med. 2016 Dec;51(6):958-66. http://www.ncbi.nlm.nih.gov/pubmed/27522471?tool=bestpractice.com People with schizophrenia are more likely to smoke than the general population but are less likely to be offered support to quit.[87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf [129]Gilbody S, Peckham E, Bailey D, et al. Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial. Lancet Psychiatry. 2019 May;6(5):379-90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546931 http://www.ncbi.nlm.nih.gov/pubmed/30975539?tool=bestpractice.com
2nd line – switch to alternative non-clozapine antipsychotic
switch to alternative non-clozapine antipsychotic
Always check whether the patient could be pregnant. Pregnancy is not covered in this topic; discuss pregnant patients with a senior colleague.
If the first antipsychotic is not effective, identify any underlying reasons for this (e.g., poor adherence) and consider switching to a different antipsychotic after discussion with the patient.
The patient and/or carer should be involved as much as possible when choosing an antipsychotic. The benefits and possible side effects of each drug should be discussed with them, including:[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 [2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication]. https://www.sign.ac.uk/assets/sign131.pdf [68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
Metabolic (including weight gain and diabetes)
Extrapyramidal (including akathisia, dystonia, and dyskinesia)
Cardiovascular (including prolonging the QT interval)
Hormonal (including increasing plasma prolactin)
Other (including unpleasant subjective experiences).
Practical tip
Check adherence with antipsychotic treatment through pharmacy records because non-adherence with antipsychotics is common. This is frequently due to adverse effects of an antipsychotic; consider assessing adverse effects using a validated tool (e.g., the Glasgow Antipsychotic Side-effect Scale).[68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com [122]Hynes C, Keating D, McWilliams S, et al. Glasgow antipsychotic side-effects scale for clozapine: development and validation of a clozapine-specific side-effects scale. Schizophr Res. 2015 Oct;168(1-2):505-13. http://www.ncbi.nlm.nih.gov/pubmed/26276305?tool=bestpractice.com [123]Velligan DI, Sajatovic M, Hatch A, et al. Why do psychiatric patients stop antipsychotic medication? A systematic review of reasons for nonadherence to medication in patients with serious mental illness. Patient Prefer Adherence. 2017;11:449-68. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5344423 http://www.ncbi.nlm.nih.gov/pubmed/28424542?tool=bestpractice.com Glasgow Antipsychotic Side-effect Scale Opens in new window
The antipsychotic should be trialled for 4-6 weeks at optimum dosage.[113]Howes OD, McCutcheon R, Agid O, et al. Treatment-resistant schizophrenia: treatment response and resistance in psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. Am J Psychiatry. 2017 Mar 1;174(3):216-29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231547 http://www.ncbi.nlm.nih.gov/pubmed/27919182?tool=bestpractice.com Consider using a formal assessment tool such as the Clinical Global Impression Scale (CGI) to monitor response to treatment.[124]Busner J, Targum SD. The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont). 2007 Jul;4(7):28-37. http://www.ncbi.nlm.nih.gov/pubmed/20526405?tool=bestpractice.com Clinical Global Impression Scale Opens in new window
A reduction of 1 point on the CGI scale indicates a significant response to an antipsychotic.[68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
The patient should be reassessed following this trial.[113]Howes OD, McCutcheon R, Agid O, et al. Treatment-resistant schizophrenia: treatment response and resistance in psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. Am J Psychiatry. 2017 Mar 1;174(3):216-29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231547 http://www.ncbi.nlm.nih.gov/pubmed/27919182?tool=bestpractice.com
The antipsychotic should be continued at the current dose established if effective.
A long-acting injectable antipsychotic should be considered if the patient is concerned about taking medication reliably.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 However, in practice, a long-acting injectable formulation should only be started after a trial of the same oral medication to make sure the patient tolerates the medication. The starting dose of the long-acting injectable formulation depends on the patient’s previous oral dose, and the oral formulation may need to be continued for a short time after the first dose of the long-acting injectable formulation. Consult a drug formulary or pharmacist for further information on starting these formulations.
Continue antipsychotic treatment for 1-2 years if this is effective.[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication].
https://www.sign.ac.uk/assets/sign131.pdf
[ ]
What are the effects of maintenance treatment with antipsychotic drugs in people with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.3284/fullShow me the answer
Longer-term maintenance treatment may be considered for patients who have ongoing symptoms, or frequent relapses that are associated with high risk to themselves or others.
Continue to monitor the patient’s adherence to the antipsychotic and for adverse effects.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
Explore and address reasons for non-adherence (e.g., adverse effects of the antipsychotic, practical problems with access to prescriptions).
Address adverse affects where possible.
See table above for examples of antipsychotic options.
psychosocial interventions
Treatment recommended for ALL patients in selected patient group
The National Institute for Health and Care Excellence (NICE) recommends to offer all patients cognitive behavioural therapy for psychosis (CBTp).[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[ ]
How does cognitive‐behavioral therapy compare with other psychosocial treatments for individuals with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2382/fullShow me the answer
[ ]
Can adding cognitive‐behavioral therapy (CBT) to standard care improve longer‐term outcomes for people with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2618/fullShow me the answer However, a Cochrane review notes there is no clear and convincing advantage for CBT over other psychosocial therapies.[117]Jones C, Hacker D, Meaden A, et al. Cognitive behavioural therapy plus standard care versus standard care plus other psychosocial treatments for people with schizophrenia. Cochrane Database Syst Rev. 2018 Nov 15;11(11):CD008712.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008712.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/30480760?tool=bestpractice.com
Family interventions may also be used if the patient lives with or is in close contact with family.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[118]Jones C, Hacker D, Xia J, et al. Cognitive behavioural therapy plus standard care versus standard care for people with schizophrenia. Cochrane Database Syst Rev. 2018 Dec 20;(12):CD007964.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007964.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/30572373?tool=bestpractice.com
Ensure patients have follow-up depending on their needs and that long-term social support is in place. Offer support with finances, accommodation, and access to supported employment programmes if the patient is out of work and wanting to find work.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[126]Walter F, Carr MJ, Mok PLH, et al. Multiple adverse outcomes following first discharge from inpatient psychiatric care: a national cohort study. Lancet Psychiatry. 2019 Jul;6(7):582-9.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586943
http://www.ncbi.nlm.nih.gov/pubmed/31171451?tool=bestpractice.com
[ ]
In people with chronic mental illnesses, how do life skills programs affect outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.564/fullShow me the answer
Offer support for any carers involved with the patient, including an assessment of their own needs.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
monitor physical health
Treatment recommended for ALL patients in selected patient group
Monitor patients taking an antipsychotic for:[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
Side effects of treatment and impact on functioning. Use a formal rating scale such as the Glasgow Antipsychotic Side-effect Scale.[122]Hynes C, Keating D, McWilliams S, et al. Glasgow antipsychotic side-effects scale for clozapine: development and validation of a clozapine-specific side-effects scale. Schizophr Res. 2015 Oct;168(1-2):505-13. http://www.ncbi.nlm.nih.gov/pubmed/26276305?tool=bestpractice.com Glasgow Antipsychotic Side-effect Scale Opens in new window
Signs of extrapyramidal movement disorders with antipsychotic medications (EPSE).
Use a formal rating scale such as the Abnormal Involuntary Movement Scale. Abnormal Involuntary Movement Scale Opens in new window For information on managing EPSE, see Complications.
Weight; weekly for the first 6 weeks, then at 12 weeks, at 1 year, and then annually (plotted on a chart).
Waist circumference, annually.
Pulse and blood pressure at 12 weeks, at 1 year, and then annually.
Fasting blood glucose, HbA1c, and blood lipid levels at 12 weeks, at 1 year, and then annually.
Prolactin, as clinically indicated.[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication]. https://www.sign.ac.uk/assets/sign131.pdf
ECG, as clinically indicated.[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication]. https://www.sign.ac.uk/assets/sign131.pdf
Overall physical health, including smoking, exercise, and diet.
A rare but serious side effect of antipsychotics is neuroleptic malignant syndrome. Assess the patient urgently if this is suspected; consider urgent transfer to hospital.[111]Royal College of Psychiatrists. The risks and benefits of high-dose antipsychotic medication. November 2014 (revised January 2023) [internet publication]. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr190.pdf
Practical tip
Recognise and manage risk factors for cardiovascular disease and diabetes early as they can cause significant morbidity and mortality if left untreated.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 [87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf [112]Cooper SJ, Reynolds GP, Barnes T, et al. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol. 2016 Aug;30(8):717-48. https://journals.sagepub.com/doi/10.1177/0269881116645254 http://www.ncbi.nlm.nih.gov/pubmed/27147592?tool=bestpractice.com [115]Chan JKN, Wong CSM, Or PCF, et al. Risk of mortality and complications in patients with schizophrenia and diabetes mellitus: population-based cohort study. Br J Psychiatry. 2021 Jul;219(1):375-82. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/risk-of-mortality-and-complications-in-patients-with-schizophrenia-and-diabetes-mellitus-populationbased-cohort-study/BBDA7881F6EDB487FBA40712DCBBF1F2 http://www.ncbi.nlm.nih.gov/pubmed/33407970?tool=bestpractice.com
In general, this is performed poorly in patients with schizophrenia; the mean life expectancy of a patient with schizophrenia is 14.5 years shorter compared with the general population.[116]Hjorthøj C, Stürup AE, McGrath JJ, et al. Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. Lancet Psychiatry. 2017 Apr;4(4):295-301. http://www.ncbi.nlm.nih.gov/pubmed/28237639?tool=bestpractice.com This is mostly due to physical health causes; treatment with antipsychotics can cause significant and rapid weight gain. However, schizophrenia itself increases mortality, especially if untreated, and can interfere with the patient’s ability to communicate their needs and access care.[14]Firth J, Siddiqi N, Koyanagi A, et al. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry. 2019 Aug;6(8):675-712. http://www.ncbi.nlm.nih.gov/pubmed/31324560?tool=bestpractice.com [87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf [112]Cooper SJ, Reynolds GP, Barnes T, et al. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol. 2016 Aug;30(8):717-48. https://journals.sagepub.com/doi/10.1177/0269881116645254 http://www.ncbi.nlm.nih.gov/pubmed/27147592?tool=bestpractice.com
Address alcohol and substance misuse and encourage smoking cessation.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 [87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf
Smoking is a major contributor to increased mortality in individuals with serious mental illness.[9]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. 2021 [internet publication]. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [127]Reynolds RJ, Day SM, Shafer A, et al. Mortality rates and excess death rates for the seriously mentally ill. J Insur Med. 2018;47(4):212-9. https://meridian.allenpress.com/jim/article/47/4/212/73465/Mortality-Rates-and-Excess-Death-Rates-for-the http://www.ncbi.nlm.nih.gov/pubmed/30653378?tool=bestpractice.com [128]Tam J, Warner KE, Meza R. Smoking and the reduced life expectancy of individuals with serious mental illness. Am J Prev Med. 2016 Dec;51(6):958-66. http://www.ncbi.nlm.nih.gov/pubmed/27522471?tool=bestpractice.com People with schizophrenia are more likely to smoke than the general population but are less likely to be offered support to quit.[87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf [129]Gilbody S, Peckham E, Bailey D, et al. Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial. Lancet Psychiatry. 2019 May;6(5):379-90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546931 http://www.ncbi.nlm.nih.gov/pubmed/30975539?tool=bestpractice.com
clozapine
Clozapine should be considered for patients who have not had an adequate response to a trial of two different antipsychotics; this should only be started by a specialist.[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication].
https://www.sign.ac.uk/assets/sign131.pdf
[68]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78.
https://journals.sagepub.com/doi/10.1177/0269881119889296
http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
[114]Masuda T, Misawa F, Takase M, et al. Association with hospitalization and all-cause discontinuation among patients with schizophrenia on clozapine vs other oral second-generation antipsychotics: a systematic review and meta-analysis of cohort studies. JAMA Psychiatry. 2019 Oct 1;76(10):1052-62.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669790
http://www.ncbi.nlm.nih.gov/pubmed/31365048?tool=bestpractice.com
[ ]
How does haloperidol compare with first‐generation antipsychotics for improving outcomes in adults with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.737/fullShow me the answer
[ ]
What are the benefits and harms of aripiprazole compared with other atypical antipsychotics in people with schizophrenia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.496/fullShow me the answer
Review existing medication, blood tests, general health, and smoking status before clozapine is started, particularly for drug interactions and concurrent side effects.[120]British National Formulary 77. Clozapine. London: BMJ Group, RCPCH Publications Ltd and the Royal Pharmaceutical Society of Great Britain. 2020. https://bnf.nice.org.uk/drug/clozapine.html
Check full blood count prior to starting clozapine and at set intervals thereafter.[120]British National Formulary 77. Clozapine. London: BMJ Group, RCPCH Publications Ltd and the Royal Pharmaceutical Society of Great Britain. 2020. https://bnf.nice.org.uk/drug/clozapine.html
Consider seeking specialist advice if the patient has a history of heart disease or cardiac abnormalities are found.
Monitor for adverse effects of clozapine including constipation, weight gain (and associated metabolic syndrome), postural hypotension, dry mouth/hypersalivation, neutropenia, agranulocytosis, myocarditis, and cardiomyopathy.[120]British National Formulary 77. Clozapine. London: BMJ Group, RCPCH Publications Ltd and the Royal Pharmaceutical Society of Great Britain. 2020. https://bnf.nice.org.uk/drug/clozapine.html
Advise the patient to immediately report symptoms of infection.[120]British National Formulary 77. Clozapine. London: BMJ Group, RCPCH Publications Ltd and the Royal Pharmaceutical Society of Great Britain. 2020. https://bnf.nice.org.uk/drug/clozapine.html
Monitor clozapine levels according to local protocols; there is no consensus on a defined monitoring schedule.
Practical tip
Adverse effects of clozapine tend to be more common and severe at the start of treatment. Monitor for these closely; the clozapine dose should be titrated accordingly.[9]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. 2021 [internet publication]. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
If treatment with clozapine has been omitted for more than 48 hours it must be stopped and retitrated from the starting dose. Seek advice from a senior colleague or pharmacist.
Practical tip
Be aware that patients who stop smoking while they are taking clozapine can have a doubling of their blood clozapine levels. This can lead to serious adverse effects including seizures.[137]Tsuda Y, Saruwatari J, Yasui-Furukori N. Meta-analysis: the effects of smoking on the disposition of two commonly used antipsychotic agents, olanzapine and clozapine. BMJ Open. 2014 Mar 4;4(3):e004216. https://bmjopen.bmj.com/content/4/3/e004216.long http://www.ncbi.nlm.nih.gov/pubmed/24595134?tool=bestpractice.com
Drug safety alert: MHRA/CHM advice on the potentially fatal risk of intestinal peristalsis in patients taking clozapine
In October 2017, the Medicines and Healthcare products Regulatory Agency (MHRA)/Commision on Human Medicines (CHM) issued a reminder that clozapine has been associated with varying degrees of impairment of intestinal peristalsis, including intestinal obstruction, faecal impaction, and paralytic ileus. Patients and their carers should be advised to seek immediate medical advice before taking the next dose of clozapine if constipation develops.[138]Medicines and Healthcare products Regulatory Agency. Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus. October 2017 [internet publication]. https://www.gov.uk/drug-safety-update/clozapine-reminder-of-potentially-fatal-risk-of-intestinal-obstruction-faecal-impaction-and-paralytic-ileus
If clozapine is ineffective or partially effective, augmentation strategies should be considered.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication].
https://www.sign.ac.uk/assets/sign131.pdf
However, these are highly specialist and should be used with caution.
[ ]
How do antipsychotic combinations compare with antipsychotic monotherapy for people with schizophrenia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1857/fullShow me the answer
Primary options
clozapine: consult specialist for guidance on dose
More clozapineMonitor clozapine blood concentration in addition to blood tests required to manage the risk of agranulocytosis.
psychosocial interventions
Treatment recommended for ALL patients in selected patient group
The National Institute for Health and Care Excellence (NICE) recommends to offer all patients cognitive behavioural therapy for psychosis (CBTp).[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[ ]
How does cognitive‐behavioral therapy compare with other psychosocial treatments for individuals with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2382/fullShow me the answer
[ ]
Can adding cognitive‐behavioral therapy (CBT) to standard care improve longer‐term outcomes for people with schizophrenia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2618/fullShow me the answer However, a Cochrane review notes there is no clear and convincing advantage for CBT over other psychosocial therapies.[117]Jones C, Hacker D, Meaden A, et al. Cognitive behavioural therapy plus standard care versus standard care plus other psychosocial treatments for people with schizophrenia. Cochrane Database Syst Rev. 2018 Nov 15;11(11):CD008712.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008712.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/30480760?tool=bestpractice.com
Family interventions may also be used if the patient lives with or is in close contact with family.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[118]Jones C, Hacker D, Xia J, et al. Cognitive behavioural therapy plus standard care versus standard care for people with schizophrenia. Cochrane Database Syst Rev. 2018 Dec 20;(12):CD007964.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007964.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/30572373?tool=bestpractice.com
Ensure patients have follow-up depending on their needs and that long-term social support is in place. Offer support with finances, accommodation, and access to supported employment programmes if the patient is out of work and wanting to find work.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication].
https://www.nice.org.uk/guidance/cg178
[126]Walter F, Carr MJ, Mok PLH, et al. Multiple adverse outcomes following first discharge from inpatient psychiatric care: a national cohort study. Lancet Psychiatry. 2019 Jul;6(7):582-9.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586943
http://www.ncbi.nlm.nih.gov/pubmed/31171451?tool=bestpractice.com
[ ]
In people with chronic mental illnesses, how do life skills programs affect outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.564/fullShow me the answer
Offer support for any carers involved with the patient, including an assessment of their own needs.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
monitor physical health
Treatment recommended for ALL patients in selected patient group
Monitor patients taking an antipsychotic for:[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178
Side effects of treatment and impact on functioning. Use a formal rating scale such as the Glasgow Antipsychotic Side-effect Scale.[122]Hynes C, Keating D, McWilliams S, et al. Glasgow antipsychotic side-effects scale for clozapine: development and validation of a clozapine-specific side-effects scale. Schizophr Res. 2015 Oct;168(1-2):505-13. http://www.ncbi.nlm.nih.gov/pubmed/26276305?tool=bestpractice.com Glasgow Antipsychotic Side-effect Scale Opens in new window
Signs of extrapyramidal movement disorders with antipsychotic medications (EPSE).
Use a formal rating scale such as the Abnormal Involuntary Movement Scale. Abnormal Involuntary Movement Scale Opens in new window For information on managing EPSE, see Complications.
Weight; weekly for the first 6 weeks, then at 12 weeks, at 1 year, and then annually (plotted on a chart).
Waist circumference, annually.
Pulse and blood pressure at 12 weeks, at 1 year, and then annually.
Fasting blood glucose, HbA1c, and blood lipid levels at 12 weeks, at 1 year, and then annually.
Prolactin, as clinically indicated.[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication]. https://www.sign.ac.uk/assets/sign131.pdf
ECG, as clinically indicated.[2]Scottish Intercollegiate Guidelines Network. Management of schizophrenia: a national clinical guideline. March 2013 [internet publication]. https://www.sign.ac.uk/assets/sign131.pdf
Overall physical health, including smoking, exercise, and diet.
A rare but serious side effect of antipsychotics is neuroleptic malignant syndrome. Assess the patient urgently if this is suspected; consider urgent transfer to hospital.[111]Royal College of Psychiatrists. The risks and benefits of high-dose antipsychotic medication. November 2014 (revised January 2023) [internet publication]. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr190.pdf
Practical tip
Recognise and manage risk factors for cardiovascular disease and diabetes early as they can cause significant morbidity and mortality if left untreated.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 [87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf [112]Cooper SJ, Reynolds GP, Barnes T, et al. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol. 2016 Aug;30(8):717-48. https://journals.sagepub.com/doi/10.1177/0269881116645254 http://www.ncbi.nlm.nih.gov/pubmed/27147592?tool=bestpractice.com [115]Chan JKN, Wong CSM, Or PCF, et al. Risk of mortality and complications in patients with schizophrenia and diabetes mellitus: population-based cohort study. Br J Psychiatry. 2021 Jul;219(1):375-82. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/risk-of-mortality-and-complications-in-patients-with-schizophrenia-and-diabetes-mellitus-populationbased-cohort-study/BBDA7881F6EDB487FBA40712DCBBF1F2 http://www.ncbi.nlm.nih.gov/pubmed/33407970?tool=bestpractice.com
In general, this is performed poorly in patients with schizophrenia; the mean life expectancy of a patient with schizophrenia is 14.5 years shorter compared with the general population.[116]Hjorthøj C, Stürup AE, McGrath JJ, et al. Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. Lancet Psychiatry. 2017 Apr;4(4):295-301. http://www.ncbi.nlm.nih.gov/pubmed/28237639?tool=bestpractice.com This is mostly due to physical health causes; treatment with antipsychotics can cause significant and rapid weight gain. However, schizophrenia itself increases mortality, especially if untreated, and can interfere with the patient’s ability to communicate their needs and access care.[14]Firth J, Siddiqi N, Koyanagi A, et al. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry. 2019 Aug;6(8):675-712. http://www.ncbi.nlm.nih.gov/pubmed/31324560?tool=bestpractice.com [87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf [112]Cooper SJ, Reynolds GP, Barnes T, et al. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol. 2016 Aug;30(8):717-48. https://journals.sagepub.com/doi/10.1177/0269881116645254 http://www.ncbi.nlm.nih.gov/pubmed/27147592?tool=bestpractice.com
Address alcohol and substance misuse and encourage smoking cessation.[1]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 [87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf
Smoking is a major contributor to increased mortality in individuals with serious mental illness.[9]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. 2021 [internet publication]. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [127]Reynolds RJ, Day SM, Shafer A, et al. Mortality rates and excess death rates for the seriously mentally ill. J Insur Med. 2018;47(4):212-9. https://meridian.allenpress.com/jim/article/47/4/212/73465/Mortality-Rates-and-Excess-Death-Rates-for-the http://www.ncbi.nlm.nih.gov/pubmed/30653378?tool=bestpractice.com [128]Tam J, Warner KE, Meza R. Smoking and the reduced life expectancy of individuals with serious mental illness. Am J Prev Med. 2016 Dec;51(6):958-66. http://www.ncbi.nlm.nih.gov/pubmed/27522471?tool=bestpractice.com People with schizophrenia are more likely to smoke than the general population but are less likely to be offered support to quit.[87]Public Health England. NHS RightCare toolkit: physical ill-health and CVD prevention in people with severe mental Illness. March 2019 [internet publication]. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/03/nhs-rightcare-toolkit-cvd-prevention.pdf [129]Gilbody S, Peckham E, Bailey D, et al. Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial. Lancet Psychiatry. 2019 May;6(5):379-90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546931 http://www.ncbi.nlm.nih.gov/pubmed/30975539?tool=bestpractice.com
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