Psychosis and Schizophrenia Care Pathway Overview

Based on BMJ2014;348:g1173 and ,BMJ2013;346:f185

  • Psychosis is common and schizophrenia is the most common form of psychotic disorder
  • Schizophrenia affects 7 in 100 adults, onset typically between the age of 15 and 35
  • Schizophrenia remains the most common cause of major psychosis and of course can have devastating consequences.
  • It is usually associated with a prodromal period of 1-3 years, and in very high risk patients 20-40% ‘transition’ to schizophrenia within a year
  • During the pro-dromal period brief intermittent psychotic symptoms may appear
  • Poor physical health is strongly associated with schizophrenia, with men dying 20 years and women 15 years earlier than the general population
  • Approx. 50% of people have a moderately good long term outcome

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Red Flags
Referrer Information for Mental Health Services - Gloucestershire including the Contact Centre, Mental Health Acute Response Service (MHARS) (formerly Crisis Resolution and Home Treatment Teams) can be found here. 
2gether- A Guide to Suicide Risk Assessment and Management in Primary Care can be found here
Presentation

  • unusual beliefs or delusions
  • muddled thinking or thought disorder
  • hallucinations
  • disorganised speech
  • negative symptoms such as apathy and flattened affect
  • self-neglect

  • patients with short-lived milder symptoms of psychosis within the last 3 months
  • patients who have been functioning less well over the last 12 months e.g. withdrawing from school, college or work or not being able to spend time with family or friends. Plus a family history of psychosis
  • patients who experience brief limited intermittent psychotic symptoms (BLIPs). These are psychotic level symptoms that have naturally stopped within 7 days.

  • higher levels of stress
  • social influences (relationships, family)
  • psychological factors (beliefs about self and others)
  • feeling increasingly worried or anxious
  • major life events e.g. changing school, starting college, break up of a relationship, family problems bereavement etc.
  • using substances e.g. cannabis, ecstasy, LSD, MCAT, amphetamine, cocaine
  • childhood abuse or neglect
Differential Diagnosis
Initial Primary Care Assessment

Immediate steps in primary care:

  • respectful probing and reflective listening:
    • help the patient feel understood and valued
    • promote optimism and motivation while assessment, diagnosis, and strategies are negotiated and actioned
    • this in itself is therapeutic

Perform a mental health assessment, as shown below, to review the person's mental state and associated functional, interpersonal, and social difficulties.

  • nature, frequency, and intensity of symptoms
  • rate of onset – gradual or rapid
  • recent stressful life events and lack of social support
  • significant previous trauma
  • situations that trigger or exacerbate symptoms, including first occurrence
  • personal and family history of psychosis and schizophrenia
  • concurrent substance abuse or withdrawal
  • any self-medication
  • cultural or other individual characteristics that may be important in subsequent care

  • assess whether the person has adequate social support and is aware of sources of help
  • arrange help appropriate to level of risk
  • advise the person to seek further help if the situation deteriorates

Consider physical health screen (incl. blood tests) to rule out other causes e.g. hypothyroidism 

If a person is distressed, has a decline in social functioning and has:

  • transient or attenuated psychotic symptoms or
  • other experiences of behaviour suggestive of possible psychosis or
  • a first- degree relative with psychosis or schizophrenia

Refer them for assessment without delay to the 2gether Specialist Care Contact Centre or Gloucestershire Recovery in Psychosis (GRiP) Early Intervention Service (for ages 14-35 years old).

Primary Care Referral / Prescribing Guidance / Management

  • shared decision making should take place throughout diagnosis and treatment
  • information on the disorder, its treatment, and self-help options should be provided to patients and their families and carers
  • if appropriate, the impact of the presenting problem on the care of children and young people should also be assessed and if necessary, local safeguarding procedures followed 

1st Episode

Initial presentation to Primary Care

Consider referral to:

Re-presentation

Patient with established diagnosis of Chronic Stable Psychosis presents with symptoms of other mental disorder:

Consider referral to:

Suspected relapse

Patient with an established diagnosis of psychosis or schizophrenia presents with a suspected relapse:

Please see the Prescribing Guidance section for full information.

Provide advice/refer/signpost patients to any of the following self-management services;

Consider referral or signpost patient to Gloucestershire’s Community Drug & Alcohol Recovery Service

Practice Point

The Contact Centre may be contacted for advice at any stage:
Tel: 08000 151 499
Email: 2gnft.FPCC-Admin@nhs.net
Fax: 01452 894418
Address: Tri Service Centre, Waterwells Police HQ, Waterwells Drive, Gloucester, GL2 2BP.

Practice Liaison Nurse

Available to:

  • assess psychotic mental illness’ presented by patients where there is a suspected relapse of a previously stable psychosis and facilitate rapid access to Specialist Care services where the risk/severity/complexity warrants a Specialist Care assessment.
  • treat patients short-term where there is a suspected relapse of a previously stable psychosis and facilitate maintenance of Primary Care management where the risk/severity/complexity warrants Primary Care interventions.
Ongoing Primary Care

Monitoring physical health

Complete a comprehensive annual health check, focusing on physical health problems that are common in people with psychosis and schizophrenia when responsibility is transferred from secondary care.

Consider using the RCGP guideline: Lester Cardiometabolic Intervention Framework

A copy of the results should be sent to the care coordinator and psychiatrist, and put in the secondary care notes.

Notification of Serious Untoward Incidents (SUIs)

Recent reviews of serious incidents have identified potential system and process changes which could improve the quality and responsiveness of care for people who require secondary care mental health services.

It would be helpful if GPs could please share any information in relation to substance misuse with GHC, particularly when a patient is injecting, as this aids clinical risk assessment and management. It is also really helpful if referrals into mental health services contain an appropriate risk assessment.

In all instances when a patient dies unexpectedly, especially if the cause of death is suspected suicide, GPs should inform GHC as soon as possible. This will allow GHC to quickly put in place support for those bereaved and minimise the risk of appointment letters etc. being sent to the deceased.

Contact: gordonbenson@nhs.net (Assistant Director of Governance & Compliance, GHC)

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