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Psychosis and schizophrenia in adults: prevention and management

This Guidelines for Nurses summary includes recommendations onPreventing psychosis,First episode psychosis, andPromoting recovery and possible future care that are relevant to the primary care setting. Please refer to the full guideline for the complete set of recommendations

  • Healthcare professionals inexperienced in working with people with psychosis or schizophrenia from diverse ethnic and cultural backgrounds should seek advice and supervision from healthcare professionals who are experienced in working transculturally
  • Offer people with psychosis or schizophrenia who smoke help to stop smoking, even if previous attempts have been unsuccessful. Be aware of the potential significant impact of reducing cigarette smoking on the metabolism of other drugs, particularly clozapine and olanzapine

Preventing psychosis

Referral from primary care

  • If a person is distressed, has a decline in social functioning and has:
    • transient or attenuated psychotic symptomsor
    • other experiences or behaviour suggestive of possible psychosisor
    • a first-degree relative with psychosis or schizophrenia
  • Refer them for assessment without delay to a specialist mental health service or an early intervention in psychosis service because they may be at increased risk of developing psychosis

Specialist assessment

  • A consultant psychiatrist or a trained specialist with experience in at-risk mental states should carry out the assessment

Monitoring and follow-up

  • If, after treatment, the person continues to have symptoms, impaired functioning or is distressed, but a clear diagnosis of psychosis cannot be made, monitor the person regularly for changes in symptoms and functioning for up to 3 years using a structured and validated assessment tool. Determine the frequency and duration of monitoring by the:
    • severity and frequency of symptoms
    • level of impairment and/or distressand
    • degree of family disruption or concern
  • If a person asks to be discharged from the service, offer follow-up appointments and the option to self-refer in the future. Ask the person’s GP to continue monitoring changes in their mental state

First episode psychosis

Primary care

  • Do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist

How to use antipsychotic medication

  • Before starting antipsychotic medication, undertake and record the following baseline investigations:
    • weight (plotted on a chart)
    • waist circumference
    • pulse and blood pressure
    • fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile, and prolactin levels
    • assessment of any movement disorders
    • assessment of nutritional status, diet and level of physical activity

Return to primary care

  • Offer people with psychosis or schizophrenia whose symptoms have responded effectively to treatment and remain stable the option to return to primary care for further management. If a service user wishes to do this, record this in their notes and coordinate transfer of responsibilities through the care programme approach

Primary care

Monitoring physical health in primary care

  • Develop and use practice case registers to monitor the physical and mental health of people with psychosis or schizophrenia in primary care
  • GPs and other primary healthcare professionals should monitor the physical health of people with psychosis or schizophrenia when responsibility for monitoring is transferred from secondary care, and then at least annually. The health check should be comprehensive, focusing on physical health problems that are common in people with psychosis and schizophrenia. Include all the checks recommended inHow to use antipsychotic medication and refer to relevant NICE guidance on monitoring for cardiovascular disease, diabetes, obesity and respiratory disease. A copy of the results should be sent to the care coordinator and psychiatrist, and put in the secondary care notes
  • Identify people with psychosis or schizophrenia who have high blood pressure, have abnormal lipid levels, are obese or at risk of obesity, have diabetes or are at risk of diabetes (as indicated by abnormal blood glucose levels), or are physically inactive, at the earliest opportunity following relevant NICE guidance inMonitoring physical health in primary care
  • Treat people with psychosis or schizophrenia who have diabetes and/or cardiovascular disease in primary care according to the appropriate NICE guidance
  • Healthcare professionals in secondary care should ensure, as part of the care programme approach, that people with psychosis or schizophrenia receive physical healthcare from primary care as described in recommendations

Relapse and re-referral to secondary care

  • When a person with an established diagnosis of psychosis or schizophrenia presents with a suspected relapse (for example, with increased psychotic symptoms or a significant increase in the use of alcohol or other substances), primary healthcare professionals should refer to the crisis section of the care plan. Consider referral to the key clinician or care coordinator identified in the crisis plan
  • For a person with psychosis or schizophrenia being cared for in primary care, consider referral to secondary care again if there is:
    • poor response to treatment
    • non-adherence to medication
    • intolerable side-effects from medication
    • comorbid substance misuse
    • risk to self or others
  • When re-referring people with psychosis or schizophrenia to mental health services, take account of service user and carer requests, especially for:
    • review of the side-effects of existing treatments
    • psychological treatments or other interventions


  • When a person with psychosis or schizophrenia is planning to move to the catchment area of a different NHS trust, a meeting should be arranged between the services involved and the service user to agree a transition plan before transfer. The person’s current care plan should be sent to the new secondary care and primary care providers

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT

National Institute for Health and Care Excellence.Psychosis and schizophrenia in adults: prevention and management
First included: May 2016.