Offer talking therapies to people at risk of psychosis and schizophrenia

People considered to be at increased risk of developing psychosis should be offered cognitive behavioural therapy (CBT) as opposed to antipsychotic medication, according to updated guidelines from the UK National Healthcare System group NICE.

Around 1 in 100 people will develop psychosis and schizophrenia over the course of a lifetime. In most cases a first episode of psychosis is preceded by a ‘prodromal period’, where a person may exhibit a range of behavioural and psychological symptom. These include shortened attention spans, short periods of low intensity psychotic symptoms, withdrawal, and displays unusual behaviour and ideas.

Antipsychotic drugs are often used to prevent the development of psychosis and to treat the disorder, though these can have certain side effects. Cognitive behavioural therapy is another measure often used, where therapists work collaboratively with a patient to talk through psychotic experiences and modify unhelpful thought patterns and behaviours.

In its updated guidance on psychosis and schizophrenia, NICE recommends that CBT should be offered to a person considered to be at increased risk of developing psychosis. Furthermore, antipsychotic medication should not be offered to anyone at increased risk of developing psychosis, or with the aim of decreasing the risk of psychosis.

NICE says that individual CBT should be offered for prevention with or without family intervention, and that interventions should be offered as recommended in NICE’s guidance for people with any of the anxiety disorders, depression, emerging personality disorder or substance misuse.

For people with a first episode of psychosis, NICE recommends offering an oral antipsychotic medication in conjunction with a psychological intervention.

In addition, people who want to try psychological interventions alone should be advised that these are more effective when delivered in conjunction with antipsychotic medication.

The choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the care if the service user agrees. Doctors should provide information and discuss each drug’s likely benefits and possible side effects.

Further updated recommendations cover recovery and possible future care. NICE recommends that GPs and other primary healthcare professionals should monitor the physical health of people with psychosis and schizophrenia when responsibility for monitoring is transferred from secondary care.
The health check should be comprehensive, focusing on physical health problems that are common in people with psychosis and schizophrenia. They should include the investigations offered before starting antipsychotic medication.

Many people who have a psychotic episode often experience social exclusion, or reduced opportunities to return to work or study afterwards.

As a result, NICE also calls for supported employment programmes to be offered to people with psychosis or schizophrenia who wish to find or return to work. Occupational or educational activities, including pre-vocational training should be considered for those who are unable to work or unsuccessful in finding employment.

Elsewhere, the updated guideline calls for more support for carers, and recommends that those caring for people with psychosis or schizophrenia should be offered an assessment provided by mental health services of their own needs, which should be discussed with them.

A care plan should be developed to address any identified needs which should be reviewed annually, and a copy should be given to the carer and their GP.

Elizabeth Kuipers, Professor of Clinical Psychology at the Institute of Psychiatry, King’s College London and chair of the guideline development group, said: "There have been many developments since the original recommendations were published - we now know a lot more about successfully reducing the risk or preventing the development of psychosis.

“The newly updated guideline recommends the use of CBT, rather than antipsychotics, for people at risk of developing psychosis, along with interventions in line with NICE guidance on anxiety disorders, depression, and emerging personality disorder or substance misuse if they have coexisting problems.”

Professor Mark Baker, Director of the Centre for Clinical Practice, NICE, said: "This is the second update of NICE’s very first clinical guideline. Since the original was published in 2002 there has been a new emphasis on how to detect and treat this condition earlier and also an increased focus on long-term recovery.

“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.”

12 February 2014


It sure seems like there is a real push in mental health circles for CBT these days. I like it, it’s useful for dealing with day to day issues. Not so sure about its effects on psychosis.

But there is also this article a little further down about how CBT is NOT a good treatment.

CBT worked well for me as a way to over come some of my panic and paranoia, and start to rebuild some of my day to day functioning skills.

I do believe that in conjunction with meds it’s a good balance. Some times the science community makes me a little sad with it’s Meds only… This only, That only, attitude. There are so many pieces of the puzzle… I wish the community would work together a little more.

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I think that its probably ideal for people who get some relief from medications but not their full functioning back - CBT can help them get that much further in terms of their recovery, and may help prevent full blown psychosis if done early one because it reduces people’s stress.

@SzAdmin Have you read Keith R Laws tweets on CBT/Psychosis/ and NICE?

I’ve read some of them. Keith Laws is just one person (who seems to spend an amazing amount of time on twitter). I generally go with the current scientific consensus on treatment issues - and NICE represents that, in my opinion.

The UK is far ahead of the US in terms of treatment options. I believe that good therapy would be very beneficial to me. Unfortunately, I haven’t been able to find a good therapist. I have little money (on SSI), so I can’t afford one of those expensive good therapists. The clinic where I go to see a psychiatrist requires that you see a therapist as well, but my therapist is very ineffective. Whenever I want to talk to him about something deep or troubling, he just dismisses me and changes the subject.

Ask for a new therapist. Remember, they work for you at that clinic.

I’ve had some very poor therapists before. I wish I had spoken up and gotten a new one at the time.

A good therapist is invaluable, a poor therapist is a painful waste of time.

I already switched from a really bad therapist to this one. This clinic is subsidized by Medicaid clients, so I don’t think I can do any better than the one I have now.

That sucks. I’m on SSI as well and have limited options. Luckily I have a fantastic therapist right now but boy have I had some stinkers in the past.