NICE Guideline CG82: Schizophrenia in adults

This is an extract from the NICE Guideline ‘Schizophrenia: Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care’ which covers the treatment and management of schizophrenia and related disorders in adults (18 years and older) with an established diagnosis of schizophrenia with onset before age 60.

The complete guidance is available at: https://publications.nice.org.uk/schizophrenia-cg82

This clinical guideline updates and replaces:

  • ‘Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care’ (NICE clinical guideline 1)
  • ‘Guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia’ (NICE technology appraisal guidance 43)

This guideline covers the treatment and management of schizophrenia and related disorders[1] in adults (18 years and older) with an established diagnosis of schizophrenia with onset before age 60. The guideline does not address the specific treatment of young people under the age of 18, except those who are receiving treatment and support from early intervention services.

Schizophrenia is a major psychiatric disorder, or cluster of disorders, characterised by psychotic symptoms that alter a person’s perception, thoughts, affect, and behaviour. Each person with the disorder will have a unique combination of symptoms and experiences. Typically there is a prodromal period often characterised by some deterioration in personal functioning. This includes memory and concentration problems, unusual behaviour and ideas, disturbed communication and affect, and social withdrawal, apathy and reduced interest in daily activities. These are sometimes called ‘negative symptoms’. The prodromal period is usually followed by an acute episode marked by hallucinations, delusions, and behavioural disturbances. These are sometimes called ‘positive symptoms’, and are usually accompanied by agitation and distress. Following resolution of the acute episode, usually after pharmacological, psychological and other interventions, symptoms diminish and often disappear for many people, although sometimes a number of negative symptoms may remain. This phase, which can last for many years, may be interrupted by recurrent acute episodes, which may need additional intervention.

Although this is a common pattern, the course of schizophrenia varies considerably. Some people may have positive symptoms very briefly while others may experience them for many years. Others have no prodromal period, the disorder beginning suddenly with an acute episode.

Over a lifetime, about 1% of the population will develop schizophrenia. The first symptoms tend to start in young adulthood, but can occur at any age, usually at a time when people are trying to make the transition to independent living. The symptoms and behaviour associated with schizophrenia can have a distressing impact on family and friends.

The diagnosis of schizophrenia is still associated with considerable stigma, fear and limited public understanding. The first few years after onset can be particularly upsetting and chaotic, and there is a higher risk of suicide. Once an acute episode is over, there are often other problems such as social exclusion, with reduced opportunities to get back to work or study, and problems making new relationships.

Recently, there has been a new emphasis in services on early detection and intervention, a focus on long-term recovery and promoting people’s choices about the management of their condition. There is evidence that most people will recover, although some will have persisting difficulties or remain vulnerable to future episodes. Not everyone will accept help from statutory services. In the longer term, most people will find ways to manage acute problems, and compensate for any remaining difficulties.

Carers, relatives and friends of people with schizophrenia are important both in the process of assessment and engagement, and in the long-term successful delivery of effective treatments. This guideline uses the term ‘carer’ to apply to everyone who has regular close contact with the person with schizophrenia, including advocates, friends or family members, although some family members may choose not to be carers.

Schizophrenia is commonly associated with a number of other conditions, such as depression, anxiety, post-traumatic stress disorder, personality disorder and substance misuse. This guideline does not cover these conditions. NICE has produced separate guidance on the management of these conditions (see section 6).

The guideline will assume that prescribers will use a drug’s summary of product characteristics (SPC) to inform their decisions for individual patients.

[1] This includes schizoaffective disorder, schizophreniform disorder and delusional disorder.