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New NICE guidance being published on 25 March will outline the best way to treat and manage adults with schizophrenia in primary and secondary care. This is an update of NICE’s first ever clinical guideline. New recommendations include treatment with arts therapy and tailoring treatment for disadvantaged groups. The guideline also updates NICE guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia. NICE technology appraisal guidance 43 (2002).

Schizophrenia is a condition that affects a person’s mental state, including their thoughts, mood and behaviour. The nature of the condition varies from person to person but the main symptoms are ‘psychotic’ experiences, for example hearing voices and other hallucinations or having fixed beliefs that are false but which the person believes in completely (delusions). The symptoms can be distressing for the person and upsetting for families and friends. The diagnosis of schizophrenia is still associated with considerable stigma, fear and limited public understanding. This can lead to social exclusion, reduced opportunities to get back to work or study, and problems making new relationships. People from black and minority ethnic (BME) groups with schizophrenia are more likely than people from other groups to have problems accessing mental health services, often finding difficulty engaging in services and are more likely to be subject to the Mental Health Act.

About 1% of people have schizophrenia at some point in their lives. For most people their symptoms start when they are young adults, but they can occur at any age. Some people may only have symptoms for a short time, but others may have them for months or years. Some people will recover completely from their symptoms; others will improve but may become ill again. This guideline sets out how best to treat and manage people with schizophrenia, from the first episode through to management of further acute episodes and longer term care. It emphasises a collaborative approach to treatment and the need to tailor treatment for BME groups in particular.

Key recommendations include:
• Healthcare professionals should ensure they are competent in working with people with schizophrenia from diverse ethnic and cultural backgrounds.
• Mental health services should work in partnership with local organisations, including those representing BME groups, to enable people with schizophrenia to access local employment and educational opportunities.
• Offer cognitive behavioural therapy (CBT) to all people with schizophrenia.
• Offer family intervention to all families of people with schizophrenia who live with or are in close contact with the service user.
• For people with newly diagnosed schizophrenia, offer oral antipsychotic medication. Provide information and discuss the benefits and side-effect profile of each drug with the service user. The choice of drug should be made by the service user and healthcare professional together.
• People with schizophrenia are at higher risk of cardiovascular disease than the general population. GPs and other primary healthcare professionals should monitor the physical health of people with schizophrenia at least once a year with a focus on cardiovascular disease risk assessment.
• Consider offering arts therapies to all people with schizophrenia, particularly for the alleviation of negative symptoms.

Professor Elizabeth Kuipers, Guideline Development Group Chair and Professor of Clinical Psychology, Head of Department, Institute of Psychiatry, Kings College London, said: “Schizophrenia is still associated with considerable stigma, fear and limited public understanding. People with schizophrenia and their carers need to be involved in decisions with professionals about their care. Firstly, to be able to choose together about medication, bearing in mind side effects. Secondly, to be offered psychological therapies, cognitive behaviour therapy for distressing symptoms and family intervention when there are carers, and offered arts therapies for negative symptoms. We have also emphasised the importance of regular health checks from GPs, because of evidence of impaired physical health for this group. There is good evidence that people with schizophrenia will recover. To
ensure this, we need to find ways to help manage continuing problems and overcome remaining difficulties.”

Dr Tim Kendall, Joint Director, National Collaborating Centre for Mental Health, Consultant Psychiatrist Sheffield Health and Social Care NHS Foundation Trust, said: “People from ethnic minorities with schizophrenia are six times more likely to be sectioned under the Mental Health Act than people from other backgrounds. They often present too late and end up getting a raw deal from the service. With this guideline we are looking for significant changes to be made in the way that people with schizophrenia are treated and managed and have tacked this issue head on with specific recommendations on how care should be tailored for people in this disadvantaged group.”

Ms Anna Maratos, Head of Profession, Arts Therapies, Central and North West London NHS Foundation Trust, said: "There is good evidence to show that arts therapies are particular effective on the ‘negative symptoms’ of schizophrenia such as withdrawal and poor motivation. While anecdotally we have known for a long time that people with schizophrenia from a wide range of backgrounds find the arts therapies accessible and helpful across all phases of the illness, high-quality services run by trained therapists are patchy across the UK. This guideline will hopefully result in improved access to these therapies for all."

Professor Irwin Nazareth, GP representative, Professor of Primary Care and Population Sciences; Director, MRC General Practice Research Framework, said: "People with schizophrenia have poorer physical health. General practitioners play a key role in managing people with schizophrenia. This guideline emphasises the importance of cardiovascular and diabetes risk monitoring by general practitioners and the need for secondary health care professionals to ensure that this occurs as a part of the care programme of people with schizophrenia."

Ms Janey Antoniou, Service User Representative on the GDG, said: “It has been an interesting and informative process being one of the two mental health service users on the NICE schizophrenia guideline development group. The guideline recommends that cognitive behavioural therapy and arts-based therapies should be offered to people with schizophrenia and that a choice about medication is made in collaboration with the person who is going to take them. As someone who has tried over twelve different antipsychotics before finding one I could live with, it would have been helpful to be told about the side effects ahead of having to take them and being asked about my lifestyle and what side effects I would definitely like to avoid.”

For more information call the NICE press office on 0845 003 7782 or 07775 583 813.

Notes to Editors

About the guideline

1. The schizophrenia guideline is available at: www.nice.org.uk/CG082

About NICE

2. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

3. NICE produces guidance in three areas of health:

• public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS
• clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS