initiation of treatment (of first episode)

Last reviewed 01/2018

Initiating treatment (first episode)

• early referral
  • urgently refer 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). Choose the appropriate team 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
• early intervention services
  • early treatment
    • if it is necessary for a GP to start antipsychotic medication they should have experience in treating and managing schizophrenia

Previously the drug treatment was based on typical antipsychotics::

• the drug treatment of choice was from the phenothiazine group, for example chlorpromazine given in doses from 25 mg t.d.s.; adjusted depending on severity and response, to a usual maintenance dose of 75mg to 300mg daily (but up to 1g daily may be required in psychoses). If extra-pyramidal effects developed an anti-parkinsonian drug may be given eg procyclidine

  Once the mental state was more settled (or from the outset in the less disturbed patients) smaller doses of oral neuroleptics were appropriate. Alternative phenothiazines may have been used, for example:

  • trifluoperazine - e.g. 5 mg b.d. is also less sedative than chlorpromazine and is generally used for florid hallucinations and delusions not associated with psychomotor disturbance
  • thioridazine - this should now be restricted to the second line treatment of schizophrenia in adults (1) - this reflects the rare but serious cardiotoxicity (prolonged QT interval, ventricular arrhythmias)

NICE in 2002 (2) stated that atypical antipsychotic medication should be used in preference over typical antipsychotics but no longer make that assertion (3)

• using oral antipsychotic medication (3)
  • oral antipsychotic medication should be offered to people with newly diagnosed schizophrenia
  • information should be provided on the benefits and side effects of each antipsychotic and discuss these with the service use
  • the decision on which antipsychotic to use should be done in partnership with the service user, and carer if appropriate.
    • when deciding on the most suitable medication, consider the relative potential of individual antipsychotics to cause extrapyramidal side effects (such as akathisia), metabolic side effects (such as weight gain), and other side effects (including unpleasant subjective experiences)
    • regular combined antipsychotic medication should not be started, except for short periods (for example, when changing medication)
  • before starting antipsychotics an electrocardiogram (ECG) should be offered if:
    • specified in the summary of product characteristics (SPC)
    • physical examination shows specific cardiovascular risk (such as diagnosis of high blood pressure)
    • there is personal history of cardiovascular disease, or
    • the service user is being admitted as an inpatient
  • when using antipsychotic medication then consider treatment with antipsychotic medication as an individual therapeutic trial:
    • record the indications, expected benefits and risks, and expected time for a change in symptoms and for side effects to occur
    • start with a dose at the lower end of the licensed range and titrate upwards slowly within the dose range in the British National Formulary (BNF) or SPC
    • justify and record reasons for dosages outside the range specified in the BNF or SPC
    • monitor and record the following regularly and systematically throughout treatment, but especially during titration:
      • efficacy, including changes in symptoms and behaviour
      • side effects of treatment, taking into account overlap with some of the clinical features of schizophrenia
      • adherence
      • physical health
    • the rationale for continuing, changing or stopping medication and the effects of such changes should be recorded
    • carry out a trial of the medication at optimum dosage for 4-6 weeks
  • also the clinician should discuss with the service user, and carer if appropriate:
    • any non-prescribed therapies (including complementary therapies) the service user wishes to use
    • alcohol, tobacco, prescription and non-prescription medication and illicit drugs. Discuss their possible interference with the effects of prescribed medication and psychological treatments. Discuss the safety and efficacy of non-prescribed therapies
  • NICE recommend that a clinician should not use a loading dose of antipsychotic medication ('rapid neuroleptisation')
  • the service user should be warned of a potential photosensitive skin response with chlorpromazine and advise using sunscreen if necessary
• psychological interventions
  • 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

Reference:

• 1. Message from Professor Alasdair Breckenridge, Chairman, Committee on Safety of Medicines, Thioridazine: restricted indications and new warnings on cardiotoxicity, 11/12/00.
• 2. NICE (May 2002). Guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia
• 3. NICE (March 2009). Schizophrenia Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care