Chapter 15
Management of Schizophrenia
93
, Chapter 15: Management of Schizophrenia
1. Biological management.
2. Psychological management.
3. Social management.
1. Biological management of schizophrenia
Reference: NICE Guideline (CG178). Psychosis and schizophrenia in adults: prevention and management. Published
February 2014 (last updated March 2014).
Introduction
• Choice of antipsychotic medication
o The choice of antipsychotic medication should be made by the service user and healthcare professional
together, taking into account the views of the carer if the service user agrees.
o Provide information and discuss the likely benefits and possible side effects of each drug, including:
✓ Metabolic (including weight gain and diabetes).
✓ Extrapyramidal (including akathisia, dyskinesia and dystonia).
✓ Cardiovascular (including prolonging the QT interval).
✓ Hormonal (including increasing plasma prolactin).
✓ Other (including unpleasant subjective experiences).
• How to use antipsychotic medication
o 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.
• Before starting antipsychotic medication, offer the person with psychosis or schizophrenia an ECG if:
o Specified in the summary of product characteristics (SPC).
o A physical examination has identified specific cardiovascular risk (such as diagnosis of high blood
pressure).
o There is a personal history of cardiovascular disease or
o The service user is being admitted as an inpatient.
• Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial.
Include the following:
o Discuss and record the side effects that the person is most willing to tolerate.
o Record the indications and expected benefits and risks of oral antipsychotic medication, and the expected
time for a change in symptoms and appearance of side effects.
o At the start of treatment give a dose at the lower end of the licensed range and slowly titrate upwards
within the dose range given in the British national formulary (BNF) or SPC.
o Justify and record reasons for dosages outside the range given in the BNF or SPC.
o Record the rationale for continuing, changing or stopping medication, and the effects of such changes.
o Carry out a trial of the medication at optimum dosage for 4–6 weeks.
• Monitor and record the following regularly and systematically throughout treatment, but especially
during titration:
o Response to treatment, including changes in symptoms and behaviour.
o Side effects of treatment, taking into account overlap between certain side effects and clinical features of
schizophrenia (e.g. the overlap between akathisia and agitation or anxiety) and impact on functioning.
o The emergence of movement disorders.
o Weight, weekly for the first six weeks, then at 12 weeks, at one year and then annually (plotted on a chart).
o Waist circumference annually (plotted on a chart).
o Pulse and blood pressure at 12 weeks, at one year and then annually.
o Fasting blood glucose, HbA1c and blood lipid levels at 12 weeks, at one year and then annually.
o Adherence.
o Overall physical health.
94
Management of Schizophrenia
93
, Chapter 15: Management of Schizophrenia
1. Biological management.
2. Psychological management.
3. Social management.
1. Biological management of schizophrenia
Reference: NICE Guideline (CG178). Psychosis and schizophrenia in adults: prevention and management. Published
February 2014 (last updated March 2014).
Introduction
• Choice of antipsychotic medication
o The choice of antipsychotic medication should be made by the service user and healthcare professional
together, taking into account the views of the carer if the service user agrees.
o Provide information and discuss the likely benefits and possible side effects of each drug, including:
✓ Metabolic (including weight gain and diabetes).
✓ Extrapyramidal (including akathisia, dyskinesia and dystonia).
✓ Cardiovascular (including prolonging the QT interval).
✓ Hormonal (including increasing plasma prolactin).
✓ Other (including unpleasant subjective experiences).
• How to use antipsychotic medication
o 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.
• Before starting antipsychotic medication, offer the person with psychosis or schizophrenia an ECG if:
o Specified in the summary of product characteristics (SPC).
o A physical examination has identified specific cardiovascular risk (such as diagnosis of high blood
pressure).
o There is a personal history of cardiovascular disease or
o The service user is being admitted as an inpatient.
• Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial.
Include the following:
o Discuss and record the side effects that the person is most willing to tolerate.
o Record the indications and expected benefits and risks of oral antipsychotic medication, and the expected
time for a change in symptoms and appearance of side effects.
o At the start of treatment give a dose at the lower end of the licensed range and slowly titrate upwards
within the dose range given in the British national formulary (BNF) or SPC.
o Justify and record reasons for dosages outside the range given in the BNF or SPC.
o Record the rationale for continuing, changing or stopping medication, and the effects of such changes.
o Carry out a trial of the medication at optimum dosage for 4–6 weeks.
• Monitor and record the following regularly and systematically throughout treatment, but especially
during titration:
o Response to treatment, including changes in symptoms and behaviour.
o Side effects of treatment, taking into account overlap between certain side effects and clinical features of
schizophrenia (e.g. the overlap between akathisia and agitation or anxiety) and impact on functioning.
o The emergence of movement disorders.
o Weight, weekly for the first six weeks, then at 12 weeks, at one year and then annually (plotted on a chart).
o Waist circumference annually (plotted on a chart).
o Pulse and blood pressure at 12 weeks, at one year and then annually.
o Fasting blood glucose, HbA1c and blood lipid levels at 12 weeks, at one year and then annually.
o Adherence.
o Overall physical health.
94
