David Shiers

Antipsychotics: is it time to introduce patient choice?

Evidence regarding overestimation of the efficacy of antipsychotics and underestimation of their toxicity, as well as emerging data regarding alternative treatment options, suggests it may be time to introduce patient choice and reconsider whether everyone who meets the criteria for a schizophrenia spectrum diagnosis requires antipsychotics in order to recover.

Assessment and treatment of physical health problems among people with schizophrenia: national cross-sectional study

BACKGROUND In the UK and other high-income countries, life expectancy in people with schizophrenia is 20% lower than in the general population. AIMS To examine the quality of assessment and treatment of physical health problems in people with schizophrenia. Method Retrospective audit of records of people with schizophrenia or schizoaffective disorder aged ⩾18. We collected data on nine key aspects of physical health for 5091 patients and combined these with a cross-sectional patient survey. RESULTS Body mass index was recorded in 2599 (51.1%) patients during the previous 12 months and 1102 (21.6%) had evidence of assessment of all nine key measures. Among those with high blood sugar, there was recorded evidence of 53.5% receiving an appropriate intervention. Among those with dyslipidaemia, this was 19.9%. Despite this, most patients reported that they were satisfied with the physical healthcare they received. CONCLUSIONS Assessment and treatment of common physical health problems in people with schizophrenia falls well below acceptable standards. Cooperation and communication between primary and secondary care services needs to improve if premature mortality in this group is to be reduced.

Promoting physical health for people with schizophrenia by reducing disparities in medical and dental care

Acquiring a diagnosis of schizophrenia reduces life expectancy for many reasons including poverty, difficulties in communication, side‐effects of medication and access to care. This mortality gap is driven by natural deaths; cardiovascular disease is a major cause, but outcomes for people with severe mental illness are worse for many physical health conditions, including cancer, fractures and complications of surgery. We set out to examine the literature on disparities in medical and dental care experienced by people with schizophrenia and suggest possible approaches to improving health.

Early intervention for first episode psychosis

Needs greater involvement of primary care professionals for its success Early intervention in psychosis is a relatively new concept in mental health. It describes the policy of the health service and its response to increasing evidence of unacceptably long delays in accessing specialist services and the benefits of earlier detection and treatment for young people who experience their first episode of psychosis (when someone displays typical symptoms, such as distorted contacts with reality, delusions, hallucinations, and thought disorder, and no organic disorder can be found to explain those symptoms). It is also a concept that requires primary and secondary care and wider involvement of the community to make a difference to the outcome. Like most mental disorders, functional psychoses such as schizophrenia and bipolar affective disorder usually appear when people are young (80% of first episodes of psychoses occur between 16 and 30 years of age), at a critical time in their intellectual and social development and emerging personal autonomy. Worldwide, the burden of psychosis is exceeded only by quadriplegia and dementia.1 The all cause standardised mortality ratio for schizophrenia is 298, with an unnatural cause standardised mortality ratio (that includes suicide) …

BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment

Excess deaths from cardiovascular disease are a major contributor to the significant reduction in life expectancy experienced by people with schizophrenia. Important risk factors in this are smoking, alcohol misuse, excessive weight gain and diabetes. Weight gain also reinforces service users’ negative views of themselves and is a factor in poor adherence with treatment. Monitoring of relevant physical health risk factors is frequently inadequate, as is provision of interventions to modify these. These guidelines review issues surrounding monitoring of physical health risk factors and make recommendations about an appropriate approach. Overweight and obesity, partly driven by antipsychotic drug treatment, are important factors contributing to the development of diabetes and cardiovascular disease in people with schizophrenia. There have been clinical trials of many interventions for people experiencing weight gain when taking antipsychotic medications but there is a lack of clear consensus regarding which may be appropriate in usual clinical practice. These guidelines review these trials and make recommendations regarding appropriate interventions. Interventions for smoking and alcohol misuse are reviewed, but more briefly as these are similar to those recommended for the general population. The management of impaired fasting glycaemia and impaired glucose tolerance (‘pre-diabetes’), diabetes and other cardiovascular risks, such as dyslipidaemia, are also reviewed with respect to other currently available guidelines. These guidelines were compiled following a consensus meeting of experts involved in various aspects of these problems. They reviewed key areas of evidence and their clinical implications. Wider issues relating to primary care/secondary care interfaces are discussed but cannot be resolved within guidelines such as these.

Quality of prescribing for schizophrenia: Evidence from a national audit in England and Wales

The National Audit of Schizophrenia (NAS) examined the quality of care received in England and Wales. Part of the audit set out to determine whether six prescribing standards, set by the national clinical guidelines for schizophrenia, were being implemented and to prompt improvements in care. Mental Health Trusts and Health Boards provided data obtained from case-notes for adult patients living in the community with schizophrenia or schizoaffective disorder. An audit of practice tool was developed for data collection. Most of the 5055 patients reviewed were receiving pharmacological treatment according to national guidelines. However, 15.9% of the total sample (95%CI: 14.9-16.9) were prescribed two or more antipsychotics concurrently and 10.1% of patients (95%CI: 9.3-10.9) were prescribed medication in excess of recommended limits. Overall 23.7% (95%CI: 22.5-24.8) of patients were receiving clozapine. However, there were many with treatment resistance who had no clear reason documented as to why they had not had a trial of clozapine (430/1073, 40.1%). In conclusion, whilst most people were prescribed medication in accordance with nationally agreed standards, there was considerable variation between service providers. Antipsychotic polypharmacy, high dose prescribing and clozapine underutilisation in treatment resistance were all key concerns which need to be further addressed.

Towards a new paradigm of care: the International Declaration on Youth Mental Health

A recent and growing body of evidence on youngpeople’s mental health has pointed to the need foran international response to the increasing and con-cerning rates of mental ill-health among youngpeople.1,2The periods of adolescence and emergingadulthood3are considered the peak periods for theonset of mental ill-health4with 75% of all adult diag-noses of mental ill-health having had an onsetbefore the age of 25 years.5In an era when the physi-cal health of young people has never been better,6their psychological and mental health has neverbeen worse.7This leaves young people vulnerable todeveloping potentially intractable and enduringmental health difficulties with the inevitable per-sonal, familial, social and vocational consequencesthat accompany the experience of mentalill-health

Promoting Recovery in Early Psychosis: A Practice Manual

Centred around the Early Psychosis Declaration (EPD), this book explores the declarations five themes through contributions from a sizeable number of mental health practitioners, service-users and carers. It is designed to help those working with people experiencing psychosis at an early stage of illness to develop and implement effective early intervention skills, enabling them to examine and refine their practice. Most importantly, the book is a practical guide to delivering early intervention strategies with a unique focus on recovery. Includes an abundance of case studies to link theory to practice. Evidence-based. Edited by an team with a wealth of clinical and research experience. Suitable for qualified practitioners from all disciplines working in the Early Intervention field, including mental health nurses, psychiatrists, social workers, occupational therapists, clinical psychologists and lecturer/practitioners.

The economic impact of early intervention in psychosis services for children and adolescents

To develop and populate a plausible model of the impact of early intervention (EI) for children and adolescents with psychosis to estimate potential short‐term health‐related cost savings compared to generic Child and Adolescent Mental Health Services (CAMHS).

Beyond early intervention: can we adopt alternative narratives like ‘Woodshedding’ as pathways to recovery in schizophrenia?

Aim: To consider how early intervention in psychosis can support a recovery paradigm.