NICE guidelines on the treatment of schizophrenia:
Primary care and physical health1
GPs and other primary healthcare professionals should monitor the physical health of people with schizophrenia at least once a year.
Offer cognitive behavioural therapy (CBT) to all people with schizophrenia.
Offer family intervention to all families of people with schizophrenia who live with or are in close contact with the service user.
Both these can be started either during the acute phase or later, including in inpatient settings.
For people with newly diagnosed schizophrenia, offer oral antipsychotic medication.
Provide information and discuss the benefits and side-effect profile of each drug with the service user. The choice of drug should be made by the service user and healthcare professional together, considering:
The relative potential of individual antipsychotic drugs to cause extrapyramidal side effects (including akathisia), metabolic side effects (including weight gain) and other side effects (including unpleasant subjective experiences)
The views of the carer where the service user agrees.
Do not initiate regular combined antipsychotic medication, except for short periods (for example, when changing medication).
Inform the service user that there is a high risk of relapse if they stop medication in the next 1–2 years.
After withdrawal from antipsychotic medication, continue monitoring for signs and symptoms of relapse for at least 2 years.
Interventions for people with schizophrenia whose illness has not responded adequately to treatment
For people with schizophrenia whose illness has not responded adequately to pharmacological or psychological treatment:
Review the diagnosis
Establish that there has been adherence to antipsychotic medication, prescribed at an adequate dose and for the correct duration
Review engagement with and use of psychological treatments and ensure that these have been offered according to this guideline
Consider other causes of non-response, such as comorbid substance misuse (including alcohol), the concurrent use of other prescribed medication or physical illness.
Offer clozapine to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs. At least one of the drugs should be a non-clozapine second-generation antipsychotic.
II. Mood disorders: Depression.
NICE guidance on the treatment of depression2:
Antidepressants are not recommended in mild depression – watchful waiting, problem solving or exercise is more effective.
In both mild and moderate depression, psychological treatment specifically focused on depression (such as problem-solving therapy, brief CBT and counselling) of 6 to 8 sessions over 10 to 12 weeks should be considered.
When antidepressant is to be prescribed, a generic SSRI is recommended.
Prescribers should consider switching to another antidepressant if there has been no response at all after 1 month, but if there has been a partial response, a decision to switch can be postponed until 6 weeks.
Reasonable choices for a second antidepressant include a different SSRI or mirtazapine, but consideration may also be given to other alternatives, including moclobemide, reboxetine and lofepramine. Other tricyclic antidepressants (except dosulepin) and venlafaxine may be considered, especially for more severe depression
Antidepressants should be continued for at least 6 months after remission of an episode of depression, because this greatly reduces the risk of relapse.
All patients should be informed about the withdrawal effects of depression
For severe or resistant depression, combination of CBT and medication should be prescribed.
For people who have had more than 2 episodes of depression, antidepressants should be continued for at least 2 years
For patients whose depression is treatment resistant, the combination of antidepressant medication with CBT should be considered.
A trial of lithium augmentation, Venlafaxine alone, Augmenting an antidepressant with another antidepressant (mianserin or mirtazapine to SSRIs) and Phenelzine are advocated by NICE.
Augmentation of an antidepressant with carbamazepine, lamotrigrine, buspirone, pindolol, valproate or thyroid supplementation is not recommended in the routine management of treatment-resistant depression.
The antidepressant dose used for the prevention of recurrence should be maintained at the level at which acute treatment was effective.
Patients who have had multiple episodes of depression, and who have had a good response to treatment with an antidepressant and lithium augmentation, should remain on this combination for at least 6 months
It is recommended that electroconvulsive therapy (ECT) is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective, and/or when the condition is considered to be potentially life-threatening, in individuals with a severe depressive illness
II.b. Mood disorders: Bipolar disorders.
NICE guidance on treatment of Bipolar disorder (Summary)
If a patient is taking an antidepressant at the onset of an acute manic episode, the antidepressant should be stopped. This may be done abruptly or gradually, depending on the patient’s current clinical need and previous experience of discontinuation/withdrawal symptoms, and the risk of discontinuation/withdrawal
symptoms of the antidepressant in question.
Only lithium, olanzapine, quetiapine, risperidone and valproate semisodium are licensed for the treatment of acute mania in the UK.
In the initial management of acute behavioural disturbance or agitation, the shortterm use of a benzodiazepine (such as lorazepam*) should be considered in addition to the antimanic agent.
If a patient already taking an antipsychotic experiences a manic episode, the dose should be checked and increased if necessary. If there are no signs of improvement, the addition of lithium or valproate should be considered.
For patients who present with severe mania when already taking lithium or valproate*, adding an antipsychotic should be considered at the same time as gradually increasing the dose of lithium or valproate.
A patient who is prescribed antidepressant medication should also be prescribed an antimanic drug.
For patients with acute mild depressive symptoms, a further assessment should be arranged, normally within 2 weeks
For patients with moderate or severe depressive symptoms, prescribers should
prescribing an SSRI antidepressant (but not paroxetine in pregnant women), because these are less likely than tricyclic antidepressants to be associated with switching, or
Adding quetiapine, if the patient is already taking antimanic medication that is not an antipsychotic.
When a patient is in remission from depressive symptoms (or symptoms have been significantly less severe for 8 weeks), stopping the antidepressant medication should be considered, to minimise the risks of switching to mania and increased rapid cycling.
For patients with a diagnosis of bipolar disorder experiencing concurrent depressive and psychotic symptoms, prescribers should consider augmenting the current treatment plan with antipsychotic medication, such as olanzapine, quetiapine, or risperidone, or the use of electroconvulsive therapy
Lithium, olanzapine or valproate* should be considered for long-term treatment of bipolar disorder.
Valproate should not be prescribed routinely for women of child-bearing potential. If no effective alternative to valproate can be identified, adequate contraception should be used, and the risks of taking valproate during pregnancy should be explained.
If the patient has frequent relapses, or symptoms continue to cause functional impairment, switching to an alternative monotherapy or adding a second prophylactic agent (lithium, olanzapine, valproate*) should be considered. Possible combinations are lithium with valproate*, lithium with olanzapine, and valproate* with olanzapine
If a trial of a combination of prophylactic agents proves ineffective, the following should be considered:
- consulting with, or referring the patient to, a clinician with expertise in the drug treatment of bipolar disorder
- prescribing lamotrigine* (especially if the patient has bipolar II disorder) or carbamazepine.
Lamotrigine* as a single, first-line agent in bipolar I disorder is not recommended.
If a severely disturbed patient with bipolar disorder cannot be effectively managed with oral medication and rapid tranquilisation is needed, intramuscular olanzapine (10 mg), lorazepam* (2 mg) or haloperidol (2–10 mg) should be considered, wherever possible as a single agent. When making the choice of drug, prescribers should take into account:
that olanzapine and lorazepam* are preferable to haloperidol because of the risk of movement disorders (particularly dystonia and akathisia) with haloperidol
that olanzapine and benzodiazepines should not be given intramuscularly within 1 hour of each other
that repeat intramuscular doses can be given up to 20 mg per day (olanzapine), 4 mg per day (lorazepam*) or 18 mg per day (haloperidol) – the total daily dose including concurrent oral medication should not normally exceed ‘BNF’ limits
the patient’s previous response and tolerability, their current regular medication, and the availability of flumazenil.
Long-term drug treatment should normally continue for at least 2 years after an episode of bipolar disorder, and up to 5 years if the person has risk factors for relapse, such as a history of frequent relapses or severe psychotic episodes, comorbid substance misuse, ongoing stressful life events, or poor social support.
The following drugs should not be routinely prescribed for pregnant women with bipolar disorder:
- Valproate – because of risk to the fetus and subsequent child development
- Carbamazepine – because of its limited efficacy and risk of harm to the fetus
- Lithium – because of risk of harm to the fetus, such as cardiac problems
- Lamotrigine* – because of the risk of harm to the fetus
- Paroxetine – because of the risk of cardiovascular malformations in the fetus
- Long-term treatment with benzodiazepines – because of risks during pregnancy and the immediate postnatal period, such as cleft palate and floppy baby syndrome.
Women planning a pregnancy:
Women with bipolar disorder who are considering pregnancy should normally be advised to stop taking valproate, carbamazepine, lithium and lamotrigine*, and alternative prophylactic drugs (such as an antipsychotic) should be considered.
Women taking antipsychotics who are planning a pregnancy should be advised that the raised prolactin levels associated with some antipsychotics reduce the chances of conception. If prolactin levels are raised, an alternative drug should be considered.
If a woman who needs antimanic medication plans to become pregnant, a low-dose typical or atypical antipsychotic should be considered, because they are of least known risk.
III. Anxiety disorders:
1. Panic disorder4
Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder.
Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder
Any of the following types of intervention should be offered and the preference of the person should be taken into account. The interventions that have evidence for the longest duration of effect, in descending order, are:
psychological therapy (cognitive behavioural therapy [CBT])
pharmacological therapy (a selective serotonin reuptake inhibitor [SSRI] licensed for panic disorder; or if an SSRI is unsuitable or there is no improvement, imipraminea or clomipramine5 may be considered)
self-help (bibliotherapy – the use of written material to help people understand their psychological problems and learn ways to overcome them by changing their behaviour – based on CBT principles).
2. Generalised anxiety disorder6
If immediate management of generalised anxiety disorder is necessary, any or all of the following should be considered:
support and information
Benzodiazepines should not usually be used beyond 2–4 weeks.
In the longer-term care of individuals with generalised anxiety disorder, any of the following types of intervention should be offered and the preference of the person with generalised anxiety disorder should be taken into account. The interventions that have evidence for the longest duration of effect, in descending order, are
psychological therapy (CBT)
pharmacological therapy (an SSRI). There is an evidence base for the effectiveness of the SSRIs. Paroxetine, and venlafaxine in extended release formulation have license
self-help (bibliotherapy based on CBT principles).
3. Obsessive Compulsive disorder7:
In the initial treatment of adults with OCD, low intensity psychological treatments (including exposure and response prevention [ERP]) (up to 10 therapist hours per patient) should be offered if the patient’s degree of functional impairment is mild and/or the patient expresses a preference for a low intensity approach. Low intensity treatments include:
o brief individual cognitive behavioural therapy (CBT) (including ERP) using structured self-help materials
o brief individual CBT (including ERP) by telephone
o group CBT (including ERP) (note, the patient may be receiving more than 10 hours of therapy in this format).
Adults with OCD with mild functional impairment who are unable to engage in low intensity CBT (including ERP), or for whom low intensity treatment has proved to be inadequate, should be offered the choice of either a course of a selective serotonin reuptake inhibitor (SSRI) or more intensive CBT (including ERP) (more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious.
Adults with OCD with moderate functional impairment should be offered the choice of either a course of an SSRI or more intensive CBT (including ERP) (more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious.
Adults with BDD with moderate functional impairment should be offered the choice of either a course of an SSRI or more intensive individual CBT (including ERP) that addresses key features of BDD.
If treatment for OCD or BDD with an SSRI is effective, it should be continued for at least 12 months to prevent relapse and allow for further improvements
The following drugs should not normally be used to treat OCD or BDD without comorbidity:
1. tricyclic antidepressants other than clomipramine
2. tricyclic-related antidepressants
3. serotonin and noradrenaline re-uptake inhibitors (SNRIs), including
4. monoamine oxidase inhibitors (MAOIs)
5. Anxiolytics (except cautiously for short periods to counter the early activation of SSRIs).
6. Antipsychotics as monotherapy
Clomipramine should be considered in the treatment of adults with OCD or BDD after an adequate trial of at least one SSRI has been ineffective or poorly tolerated, if the patient prefers clomipramine or has had a previous good response to it.
For adults with OCD if there has been no response to a full trial of at least one SSRI alone, a full trial of combined treatment with CBT (including ERP) and an SSRI, and a full trial of clomipramine alone, the following treatment options should also be considered (note, there is no evidence of the optimal sequence of the options listed below):
1. additional CBT (including ERP) or cognitive therapy
2. adding an antipsychotic to an SSRI or clomipramine
3. Combining clomipramine and citalopram.
Initial response to trauma
For individuals who have experienced a traumatic event, the systematic provision to that individual alone of brief, single-session interventions (often referred to as debriefing) that focus on the traumatic incident, should not be routine practice when delivering services.
Where symptoms are mild and have been present for less than 4 weeks after the trauma, watchful waiting, as a way of managing the difficulties presented by people with post-traumatic stress disorder (PTSD), should be considered. A follow-up contact should be arranged within 1 month.
Trauma-focused psychological treatment
Trauma-focused cognitive behavioural therapy (8-12 sessions) should be offered to people who present with PTSD within 3 months of a traumatic event
Trauma-focused cognitive behavioural therapy should be offered to those with severe post-traumatic symptoms or with severe PTSD in the first month after the traumatic event.
All people with PTSD should be offered a course of trauma-focused psychological treatment (trauma-focused cognitive behavioural therapy [CBT] or eye movement desensitisation and reprocessing [EMDR]) 8-12 sessions.
Drug treatments for PTSD should not be used as a routine first-line treatment for adults (in general use or by specialist mental health professionals) in preference to a trauma-focused psychological therapy.
Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or phenelzine for initiation only by mental health specialists) should be considered for the treatment of PTSD in adults who express a preference not to engage in trauma focused psychological treatment9.
When an adult sufferer with PTSD has responded to drug treatment, it should be continued for at least 12 months before gradual withdrawal
Drug treatments should not be routinely prescribed for children and young people with PTSD.
IV. Eating disorders10:
Most people with anorexia nervosa should be managed on an outpatient basis with psychological treatment provided by a service that is competent in giving that treatment and assessing the physical risk of people with eating disorders.
People with anorexia nervosa requiring inpatient treatment should be admitted to a setting that can provide the skilled implementation of refeeding with careful physical monitoring (particularly in the first few days of refeeding) in combination with psychosocial interventions.
Family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa.
Medication should not be used as the sole or primary treatment for anorexia nervosa.
Caution should be exercised in the use of medication for comorbid conditions such as depressive or obsessive–compulsive features as they may resolve with weight gain alone.
As a possible first step, patients with bulimia nervosa should be encouraged to follow an evidence-based self-help programme.
As an alternative or additional first step to using an evidence-based self-help programme, adults with bulimia nervosa may be offered a trial of an antidepressant drug. SSRIs are the drug of choice, with the dose of fluoxetine up to 60mg may be required.
Cognitive behaviour therapy for bulimia nervosa (CBT-BN), a specifically adapted form of CBT, should be offered to adults with bulimia nervosa. The course of treatment should be for 16 to 20 sessions over 4 to 5 months.
Adolescents with bulimia nervosa may be treated with CBT-BN, adapted as needed to suit their age, circumstances and level of development, and including the family as appropriate.
V. Childhood conditions:
If the child or young person with ADHD has moderate levels of impairment, the parents or carers should be offered referral to a group parent-training/education programme, either on its own or together with a group treatment programme (cognitive behavioural therapy [CBT] and/or social skills training) for the child or young person.
In school-age children and young people with severe ADHD, drug treatment should be offered as the first-line treatment. Parents should also be offered a group-based parent training/education programme.
Drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.
When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider:
Methylphenidate for ADHD without significant comorbidity
Methylphenidate for ADHD with comorbid conduct disorder
Methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
Atomoxetine if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person is intolerant to low or moderate doses of methylphenidate.
Drug treatment for adults with ADHD should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs.
Following a decision to start drug treatment in adults with ADHD, methylphenidate should normally be tried first.
The three acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine are recommended as options in the management of people with Alzheimer’s disease of moderate severity only (that is, those with a Mini Mental State Examination [MMSE] score of between 10 and 20 points).
Only specialists in the care of people with dementia should initiate treatment
Patients who continue on the drug should be reviewed every 6 months by MMSE
score and global, functional and behavioural assessment.
Carers’ views on the patient’s condition at follow-up should be sought.
Memantine is not recommended as a treatment option for people with moderately severe to severe Alzheimer’s disease except as part of well-designed clinical studies. People with mild Alzheimer’s disease who are currently receiving donepezil, galantamine or rivastigmine, and people with moderately severe to severe Alzheimer’s disease currently receiving memantine, whether as routine therapy or as part of a clinical trial, may be continued on therapy (including after the conclusion of a clinical trial) until they, their carers and/or specialist consider it appropriate to stop.