Treatment

Summarised as:

• aimed at strengthening the patients ties with reality and rehabilitating him
• the patient's mood may need to be calmed by sedatives and tranquilisers
• antipsychotic drugs
• psychological treatments
• occupational therapy

With respect to primary care (1):

• initiation of treatment (first episode)
  • early referral
    • refer urgently all people first presenting with psychotic symptoms in primary care to a local community-based secondary mental health service (early intervention services, crisis resolution and home treatment team, or community mental health team). the appropriate team should be chosen based on the stage and severity of illness and the local context
      • a full assessment in secondary care should be carried out, including assessment by a psychiatrist
        • a care plan should be written the service user as soon as possible. Send a copy to the referring primary healthcare professional and the service user
        • a crisis plan should be included in the care plan, based on a full risk assessment
          • the roles of primary and secondary care should be defined in the crisis plan and include the key clinical contacts in case of emergency or impending crisis
          • if it is necessary for a GP to start antipsychotic medication they should have experience in treating and managing schizophrenia
• care after initiation of treatment
  • primary care
    • develop and use practice case registers to monitor the physical and mental health of service users
    • monitoring physical health
      • monitor the physical health of people with schizophrenia at least once a year. Focus on cardiovascular disease risk assessment because people with schizophrenia are at higher risk of cardiovascular disease than the general population
      • send a copy of the results to the care coordinator and/or psychiatrist, to include in the secondary care notes
• re-referral to secondary care
  • consider re-referral to secondary care if there is:
    • poor treatment response
    • non-adherence to medication
    • intolerable side effects from medication
    • comorbid substance misuse
    • risk to the person or others
  • if a person with established schizophrenia has a suspected relapse (for example, increased psychotic symptoms or increased use of alcohol or other substances) then consult the care plan and consider referral to the key clinician or care coordinator stated in the crisis plan

Notes:

• there is evidence that suggests that electroconvulsive therapy (ECT), combined with treatment with antipsychotic drugs, may be considered an option for people with schizophrenia, particularly when rapid global improvement and reduction of symptoms is desired (2)
• NICE suggest also that various psychological interventions are indicated (1)
  • cognitive behavioural therapy (CBT) should be offered to all people with schizophrenia
    • can be started either during the acute phase or later, including in inpatient settings
  • family intervention should be offered to all families of people with schizophrenia who live with or are in close contact with the service user
    • can be started either during the acute phase or later, including in inpatient settings
  • arts therapies should be considered as a treatment option, particularly to help negative symptoms of schizophrenia
  • counselling, supportive psychotherapy, or social skills training should not be routinely offered as specific interventions. However, the service user preferences for counselling and supportive psychotherapy should be taken into account, especially if CBT, family intervention and arts therapies are not available locally
  • adherence therapy should not be offered as a specific intervention
• depot/long-acting injectable antipsychotic medication
  • depot/long-acting injectable antipsychotics should be considered when:
    • service users would prefer this after an acute episode
    • avoiding covert non-adherence to medication is a clinical priority

Reference:

• 1. NICE (March 2009). Schizophrenia Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care
• 2. Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenai. Cochrane Database Syst Rev 2005; (2):CD00224