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Guideline Summary
Guideline Title
Psychosis with coexisting substance misuse. Assessment and management in adults and young people.
Bibliographic Source(s)
National Institute for Health and Clinical Excellence (NICE). Psychosis with coexisting substance misuse. Assessment and management in adults and young people. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Mar. 39 p. (Clinical guideline; no. 120). 
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Psychosis with substance misuse disorders

Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Treatment
Clinical Specialty
Emergency Medicine
Family Practice
Internal Medicine
Psychiatry
Psychology
Intended Users
Allied Health Personnel
Health Care Providers
Health Plans
Hospitals
Patients
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Substance Use Disorders Treatment Providers
Guideline Objective(s)
  • To make recommendations for the assessment and management of adults and young people (aged 14 years and older) with psychosis and coexisting substance misuse
  • To review the experience of care from the servicer user and their families'/carers' perspective
  • To evaluate service delivery models
  • To evaluate the role of psychological/psychosocial interventions
  • To evaluate the role of pharmacological interventions
  • To integrate the above to provide best practice advice on the assessment and care of people with psychosis and coexisting substance misuse throughout the care pathway
  • To promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the National Health Service in England and Wales
Target Population

Adults and young people (aged 14 years and older) who have a clinical diagnosis of psychosis with coexisting substance misuse

Interventions and Practices Considered
  1. Principles of care
    • Development of a respectful trusting non-judgemental relationship
    • Competency and skills training of healthcare professionals to engage with diverse ethnic and cultural backgrounds
  2. Provision of verbal and written information
  3. Involvement of families, carers or significant others in treatment
  4. Supportive care for healthcare professionals
  5. Safeguarding procedures
  6. Provision of information to ensure informed consent about treatment decisions
  7. Assessment of mental capacity regarding treatment decisions
  8. Development of advanced decisions and advanced statements
  9. Collaboration with voluntary sector organisations
  10. Recognition and routine assessment of psychosis and coexisting substance misuse
  11. Primary care
    • Referral to secondary care mental health services or child and adolescent mental health services (CAMHS)
    • Physical health monitoring
  12. Secondary care mental health services
    • Ensure competency in recognition, treatment and care of young people with psychosis and coexisting substance misuse
    • Inclusion of patients in appropriate care pathways
    • Community based mental health teams
    • Coordination of care (seek specialist advice, joint working arrangements)
    • Care Programme Approach and care coordinator for delivery and transfer of services
    • Comprehensive multidisciplinary assessment
    • Biological and physical testing as indicated
    • Treatment plan, including the use of antipsychotics
  13. Substance misuse services
    • Ensure competency in recognition, treatment and care of young people with psychosis and coexisting substance misuse
    • Assessment (substance misuse, comprehensive multidisciplinary mental health assessment)
    • Joint working with secondary mental health services
  14. Inpatient mental health services
    • Policies and procedures for promoting a therapeutic environment
    • Comprehensive assessment
    • Biological and physical testing as indicated
    • Planned detoxification
    • Discharge procedures
  15. Staffed accommodation
  16. Management of specific issues common to psychosis and substance misuse
Major Outcomes Considered
  • Reduced mortality (all causes)
  • Reduced relapse rates (measured by exacerbation of symptoms requiring change in healthcare management)
  • Reduced substance misuse (however measured)
  • Improved global and social functioning (for example, employment, accommodation)
  • Improved subjective quality of life
  • Improved satisfaction with care
  • Reduced physical morbidity

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Systematic Clinical Literature Review

The aim of the clinical literature review was to systematically identify and synthesise relevant evidence from the literature in order to answer the specific review questions developed by the Guideline Development Group (GDG).

Methodology

A stepwise, hierarchical approach was taken to locating and presenting evidence to the GDG. The NCCMH developed this process based on methods set out by NICE (2009; see the "Availability of Companion Documents" field), and after considering recommendations from a range of other sources. These included:

  • Clinical Policy and Practice Program of the New South Wales Department of Health (Australia)
  • British Medical Journal (BMJ) Clinical Evidence
  • GRADE Working Group
  • New Zealand Guidelines Group
  • National Health Service (NHS) Centre for Reviews and Dissemination
  • Oxford Centre for Evidence-Based Medicine
  • Oxford Systematic Review Development Programme
  • Scottish Intercollegiate Guidelines Network (SIGN)
  • The Cochrane Collaboration
  • United States Agency for Healthcare Research and Quality (AHRQ)

Scoping Searches

A broad preliminary search of the literature was undertaken in January 2009 to obtain an overview of the issues likely to be covered by the scope, and to help define key areas. Searches were restricted to clinical guidelines, health technology assessment reports, key systematic reviews and randomised controlled trials (RCTs), and conducted in the following databases and websites:

  • BMJ Clinical Evidence
  • Canadian Medical Association (CMA) Infobase [Canadian guidelines]
  • Clinical Policy and Practice Program of the New South Wales Department of Health (Australia)
  • Clinical Practice Guidelines [Australian Guidelines]
  • Cochrane Central Register of Controlled Trials (CENTRAL)
  • Cochrane Database of Abstracts of Reviews of Effects (DARE)
  • Cochrane Database of Systematic Reviews (CDSR)
  • EMBASE
  • Guidelines International Network (G-I-N)
  • Health Evidence Bulletin Wales
  • Health Management Information Consortium [HMIC]
  • Health Technology Assessment (HTA) database (technology assessments)
  • MEDLINE / MEDLINE in Process
  • National Health and Medical Research Council (NHMRC)
  • National Library for Health (NLH) Guidelines Finder
  • New Zealand Guidelines Group
  • NHS Centre for Reviews and Dissemination (CRD)
  • OMNI Medical Search
  • Scottish Intercollegiate Guidelines Network (SIGN)
  • Turning Research Into Practice (TRIP)
  • United States Agency for Healthcare Research and Quality (AHRQ)
  • Websites of NICE and the National Institute for Health Research (NIHR) HTA Programme for guidelines and HTAs in development

Existing NICE guidelines were updated where necessary. Other relevant guidelines were assessed for quality using the AGREE instrument (AGREE Collaboration, 2003). The evidence base underlying high-quality existing guidelines was utilised and updated as appropriate. Further information about this process can be found in The Guidelines Manual (2009).

Systematic Literature Searches

A systematic search strategy was developed to locate all the relevant evidence. The balance between sensitivity (the power to identify all studies on a particular topic) and specificity (the ability to exclude irrelevant studies from the results) was carefully considered, and a decision made to develop highly sensitive strategies to identify as complete a set as possible of clinically relevant studies. Searches were conducted in the following databases:

  • CENTRAL
  • EMBASE
  • MEDLINE/MEDLINE In-Process
  • Psychological Information Database (PsycINFO)
  • Cumulative Index to Nursing and Allied Health Literature (CINAHL)

The search strategies were initially developed for MEDLINE before being translated for use in other databases/interfaces. Strategies were built up through a number of trial searches and discussions of the results of the searches with the review team and GDG to ensure that all possible relevant search terms were covered. In order to assure comprehensive coverage, search terms for psychosis were kept purposely broad to help counter dissimilarities in database indexing practices and thesaurus terms, and imprecise reporting of study populations by authors in the titles and abstracts of records. Search terms for substance misuse were limited to the main drugs associated with the term at the advice of the GEG. The search terms for each MEDLINE search are set out in full in Appendix 7 in the full version of the original guideline document.

See Section 3.5.2 in the full version of the original guideline document for information on use of Reference Manager, search filters, and date and language restrictions.

Full details of the MEDLINE search strategies and filters used for the systematic review of clinical evidence are provided (see Appendix 7 in the full version of the original guideline document).

Other Search Methods

Other search methods involved: (a) scanning the reference lists of all eligible publications (systematic reviews, stakeholder evidence and included studies) for more published reports and citations of unpublished research; (b) sending lists of studies meeting the inclusion criteria to subject experts (identified through searches and the GDG) and asking them to check the lists for completeness, and to provide information of any published or unpublished research for consideration (see Appendix 5 in the full version of the original guideline document); (c) checking the tables of contents of key journals for studies that might have been missed by the database and reference list searches; (d) tracking key papers in the Science Citation Index (prospectively) over time for further useful references.

Study Selection and Quality Assessment

All primary-level studies included after the first scan of citations were acquired in full and re-evaluated for eligibility at the time they were being entered into the study information database. More specific eligibility criteria were developed for each review question and are described in the relevant clinical evidence chapters. Eligible systematic reviews and primary-level studies were critically appraised for methodological quality (refer to Appendix 10 in the full version of the original guideline document for methodology checklists). The eligibility of each study was confirmed by at least one member of the GDG.

Unpublished Evidence

The GDG used a number of criteria when deciding whether or not to accept unpublished data. First, the evidence must have been accompanied by a trial report containing sufficient detail to properly assess the quality of the data. Second, the evidence must have been submitted with the understanding that data from the study and a summary of the study's characteristics would be published in the full guideline. Therefore, the GDG did not accept evidence submitted as commercial in confidence. However, the GDG recognised that unpublished evidence submitted by investigators might later be retracted by those investigators if the inclusion of such data would jeopardise publication of their research.

Health Economics Methods

Search Strategy for Economic Evidence

Scoping Searches

A broad preliminary search of the literature was undertaken in January 2009 to obtain an overview of the issues likely to be covered by the scope, and help define key areas. Searches were restricted to economic studies and health technology assessment reports, and conducted in the following databases:

  • EMBASE
  • MEDLINE/MEDLINE In-Process
  • Health Technology Assessment (HTA) database (technology assessments)
  • NHS Economic Evaluation Database (NHS EED)

Any relevant economic evidence arising from the clinical scoping searches was also made available to the health economist during the same period.

Systematic Literature Searches

After the scope was finalised, a systematic search strategy was developed to locate all the relevant evidence. The balance between sensitivity (the power to identify all studies on a particular topic) and specificity (the ability to exclude irrelevant studies from the results) was carefully considered, and a decision made to utilise a broad approach to searching to maximise retrieval of evidence to all parts of the guideline. Searches were restricted to economic studies and health technology assessment reports, and conducted in the following databases:

  • CINAHL
  • EconLit (the American Economic Association's electronic bibliography)
  • EMBASE
  • HTA database (technology assessments)
  • MEDLINE/MEDLINE In-Process
  • NHS EED
  • PsycINFO

Any relevant economic evidence arising from the clinical searches was also made available to the health economist during the same period.

The search strategies were initially developed for MEDLINE before being translated for use in other databases/interfaces. Strategies were built up through a number of trial searches, and discussions of the results of the searches with the review team and GDG to ensure that all possible relevant search terms were covered. In order to assure comprehensive coverage, search terms for psychosis were kept purposely broad to help counter dissimilarities in database indexing practices and thesaurus terms, and imprecise reporting of study populations by authors in the titles and abstracts of records. Search terms for substance misuse were limited to the main drugs associated with the term at the advice of the GDG.

For standard mainstream bibliographic databases (CINAHL, EMBASE, MEDLINE and PsycINFO) search terms for psychosis and substance misuse were combined with a search filter for health economic studies. For searches generated in topic-specific databases (EconLit, HTA, NHS EED) search terms for psychosis and substance misuse were used without a filter. The sensitivity of this approach was aimed at minimising the risk of overlooking relevant publications, due to potential weaknesses resulting from more focused search strategies. The MEDLINE search terms are set out in full in Appendix 9 in the full version of the original guideline document.

See Section 3.6.1 in the full version of the original guideline document for more information on use of Reference Manager, search filters, and date and language restrictions.

Full details of the MEDLINE search strategies and filter used for the systematic review of health economic evidence are provided in Appendix 9 in the full version of the original guideline document (see the "Availability of Companion Documents" field).

Other Search Methods

Other search methods involved scanning the reference lists of all eligible publications (systematic reviews, stakeholder evidence and included studies from the economic and clinical reviews) to identify further studies for consideration.

Inclusion Criteria for Economic Studies

The following inclusion criteria were applied to select studies identified by the economic searches for further consideration:

  • No restriction was placed on language or publication status of the papers.
  • Only studies from Organisation for Economic Co-operation and Development countries were included, as the aim of the review was to identify economic information transferable to the UK context.
  • Selection criteria based on types of clinical conditions and service users as well as interventions assessed were identical to the clinical literature review.
  • Studies were included provided that sufficient details regarding methods and results were available to enable the methodological quality of the study to be assessed, and provided that the study's data and results were extractable.
  • Full economic evaluations that compared two or more relevant options and considered both costs and consequences (that is, cost–consequence analysis, cost effectiveness analysis, cost–utility analysis or cost–benefit analysis), as well as costing analyses that compared only costs between two or more interventions, were included in the review.
  • Economic studies were included if they used clinical effectiveness data from an RCT, a cohort study, or a systematic review and meta-analysis of clinical studies. Studies that had a mirror-image design were excluded from the review.
  • Studies were included only if the examined interventions were clearly described. This involved the dosage and route of administration and the duration of treatment in the case of pharmacological interventions; and the types of healthcare professionals involved as well as the frequency and duration of treatment in the case of psychological therapies. Evaluations in which drugs were treated as a class were excluded from further consideration.

Applicability and Quality Criteria for Economic Studies

All economic papers eligible for inclusion were appraised for their applicability and quality using the methodology checklist for economic evaluations recommended by NICE (NICE, 2009), which is shown in Appendix 18 of the full version of the guideline. The methodology checklist for economic evaluations was also applied to the economic models developed specifically for this guideline. All studies that fully or partially met the applicability and quality criteria described in the methodology checklist were considered during the guideline development process, along with the results of the economic modelling conducted specifically for this guideline. The completed methodology checklists for all economic evaluations considered in the guideline are provided in Appendix 18 of the full version of the guideline.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Grading of Recommendations Assessment, Development and Evaluation (GRADE) Scheme

High: Further research is very unlikely to change the confidence in the estimate of effect.

Moderate: Further research is likely to have an important impact on the confidence in the estimate of effect and may change the estimate.

Low: Further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimate.

Very low: Any estimate of effect is very uncertain.

Methods Used to Analyze the Evidence
Meta-Analysis
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Data Extraction

Study characteristics and outcome data were extracted from all eligible studies, which met the minimum quality criteria, using Review Manager 5 (Cochrane Collaboration, 2008).

In most circumstances, for a given outcome (continuous and dichotomous), where more than 50% of the number randomised to any group were lost to follow-up, the data were excluded from the analysis (except for the outcome 'leaving the study early', in which case, the denominator was the number randomised). Where possible, dichotomous efficacy outcomes were calculated on an intention-to-treat (ITT) basis (that is, a 'once-randomised-always-analyse' basis). Where the Guideline Development Group (GDG) advised that those participants who ceased to engage in the study were likely to have an unfavourable outcome, early withdrawals were included in both the numerator and denominator. For example, for the outcome of relapse of psychotic symptoms, in studies that did not use an ITT analysis, participants who left the study early were counted as relapsing. Adverse effects were entered into Review Manager as reported by the study authors because it is usually not possible to determine whether early withdrawals had an unfavourable outcome. Where there was limited data for a particular review, the 50% rule was not applied. In these circumstances the evidence was downgraded due to the risk of bias.

Consultation with another reviewer or members of the GDG was used to overcome difficulties with coding. Data from studies included in existing systematic reviews were extracted independently by one reviewer and cross-checked with the existing dataset. Where possible, two independent reviewers extracted data from new studies. Where double data extraction was not possible, data extracted by one reviewer were checked by the second reviewer. Disagreements were resolved through discussion. Where consensus could not be reached, a third reviewer or GDG members resolved the disagreement. Masked assessment (that is, blind to the journal from which the article comes, the authors, the institution and the magnitude of the effect) was not used since it is unclear that doing so reduces bias.

Synthesising the Evidence

Meta-analysis

Where possible, meta-analysis based on a random-effects model was used to synthesise the evidence using Review Manager. If necessary, reanalyses of the data or sub-analyses were used to answer review questions not addressed in the original studies or reviews.

Dichotomous outcomes were analysed as relative risks (RR) with the associated 95% confidence interval [CI]. A relative risk (also called a risk ratio) is the ratio of the treatment event rate to the control event rate. An RR of 1 indicates no difference between treatment and control.

The CI shows a range of values within which we are 95% confident that the true effect will lie. If the effect size has a CI that does not cross the 'line of no effect', then the effect is commonly interpreted as being statistically significant.

Continuous outcomes were analysed using the mean difference (MD), or standardised mean difference (SMD) when different measures were used in different studies to estimate the same underlying effect. If reported by study authors, ITT data, using a valid method for imputation of missing data, were preferred over data only from people who completed the study.

Heterogeneity

To check for consistency of effects among studies, both the I2 statistic and the chi-squared test of heterogeneity, as well as a visual inspection of the forest plots were used. The I2 statistic describes the proportion of total variation in study estimates that is due to heterogeneity. The I2 statistic was interpreted in the following way:

  • >50%: notable heterogeneity
  • ≥30 to ≤50%: moderate heterogeneity
  • <30%: mild heterogeneity

Two factors were used to make a judgement about importance of the observed value of I2: a) the magnitude and direction of effects, and b) the strength of evidence for heterogeneity (for example, P value from the chi-squared test, or a confidence interval for I2). Where heterogeneity was judged to be important, an attempt was made to explain the variation by conducting sub-analyses to examine potential moderators.

Publication Bias

Where there was sufficient data, we intended to use funnel plots to explore the possibility of publication bias. Asymmetry of the plot would be taken to indicate possible publication bias and investigated further. However, due to a paucity of data, funnel plots could not be used.

Presenting the Data to the GDG

Where meta-analysis was not appropriate and/or possible, the reported results from each primary-level study were included in the study characteristics table (and where appropriate, in a narrative review).

Evidence Profile Tables

A Grading of Research Assessment, Development and Evaluation (GRADE) evidence profile was used to summarise both the quality of the evidence and the results of the evidence synthesis. The GRADE approach is based on a sequential assessment of the quality of evidence, followed by judgment about the balance between desirable and undesirable effects, and subsequent decision about the strength of a recommendation. For each outcome, quality may be reduced depending on the following factors:

  • Study design (randomised trial, observational study, or any other evidence)
  • Limitations (based on the quality of individual studies)
  • Inconsistency (see Section 3.5.4 in the full version of the guideline for how consistency was assessed)
  • Indirectness (that is, how closely the outcome measures, interventions and participants match those of interest)
  • Imprecision (based on the confidence interval around the effect size)

For observational studies, the quality may be increased if there is a large effect, plausible confounding would have changed the effect, or there is evidence of a dose-response gradient (details would be provided under the other considerations column). Each evidence profile also included a summary of the findings: number of service users included in each group, an estimate of the magnitude of the effect, and the overall quality of the evidence for each outcome.

Health Economics Methods

Data Extraction

Data were extracted by the health economist using a standard economic data extraction form (see Appendix 18 in the full version of the original guideline document).

Presentation of Economic Evidence

The economic evidence considered in the guideline is provided in the respective evidence chapters of the full version of the guideline, following presentation of the relevant clinical evidence. The references to included studies as well as the evidence tables with the characteristics and results of economic studies included in the review, are provided in Appendix 17 of the full version of the original guideline document. Methods and results of any economic modelling undertaken alongside the guideline development process are presented in the relevant evidence chapters. Characteristics and results of all economic studies considered during the guideline development process are summarised in economic evidence profiles accompanying respective GRADE clinical evidence profiles in Appendix 17 in the full version of the original guideline.

Methods Used to Formulate the Recommendations
Expert Consensus
Informal Consensus
Description of Methods Used to Formulate the Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

The Guideline Development Group (GDG)

The GDG consisted of: a service user, a representative from a service user organisation and a carer; professionals in psychiatry, clinical psychology, nursing, social work, and general practice; academic experts in psychiatry and psychology; and experts in guideline development. The guideline development process was supported by staff from the NCCMH, who acted as full members of the GDG and undertook the clinical and health economic literature searches, reviewed and presented the evidence to the other members of the GDG, managed the process, and contributed to drafting the guideline.

Guideline Development Group Meetings

Ten GDG meetings were held between May 2009 and October 2010. During each day-long GDG meeting, in a plenary session, review questions and clinical and economic evidence were reviewed and assessed, and recommendations formulated. At each meeting, all GDG members declared any potential conflicts of interest, and service user and carer concerns were routinely discussed as part of a standing agenda.

Service Users and Carers

Individuals with direct experience of services gave an integral service-user focus to the GDG and the guideline. The GDG included a service user and a representative of a service user organisation and a carer. They contributed as full GDG members to writing the review questions, helping to ensure that the evidence addressed their views and preferences, highlighting sensitive issues and terminology relevant to the guideline, and bringing service-user research to the attention of the GDG. In drafting the guideline, the service user and carer representatives met with the NCCMH team on several occasions to develop the chapter on experience of care. In drafting the guideline, they also contributed to writing the guideline's introduction and identified recommendations from the service user and carer perspective.

National and International Experts

National and international experts in the area under review were identified through the literature search and through the experience of the GDG members. These experts were contacted to recommend unpublished or soon-to-be published studies to ensure up-to-date evidence was included in the development of the guideline. They informed the group about completed trials at the pre-publication stage, systematic reviews in the process of being published, studies relating to the cost effectiveness of treatment and trial data if the GDG could be provided with full access to the complete trial report.

Review Questions

Review (clinical) questions were used to guide the identification and interrogation of the evidence base relevant to the topic of the guideline. Before the first GDG meeting, an analytic framework (see Appendix 6 in the full version of the original guideline) was prepared by NCCMH staff based on the scope and an overview of existing guidelines, and discussed with the guideline Chair. The framework was used to provide a structure from which the review questions were drafted. Both the analytic framework and the draft review questions were then discussed by the GDG at the first few meetings and amended as necessary. Where appropriate, the framework and questions were refined once the evidence had been searched and, where necessary, sub-questions were generated. Questions submitted by stakeholders were also discussed by the GDG and the rationale for not including any questions was recorded in the minutes. The final list of review questions can be found in Appendix 6 of the full version of the original guideline.

For questions about interventions, the PICO (Patient, Intervention, Comparison and Outcome) framework was used (see Table 4 in the full version of the original guideline).

In some situations, the prognosis of a particular condition is of fundamental importance, over and above its general significance in relation to specific interventions. Areas where this is particularly likely to occur relate to assessment of risk, for example in terms of behaviour modification or screening and early intervention. In addition, review questions related to issues of service delivery are occasionally specified in the remit from the Department of Health/Welsh Assembly Government. In these cases, appropriate review questions were developed to be clear and concise.

To help facilitate the literature review, a note was made of the best study design type to answer each question. There are four main types of review question of relevance to NICE guidelines. These are listed in Table 5 in the original guideline. For each type of question, the best primary study design varies, where 'best' is interpreted as 'least likely to give misleading answers to the question'. However, in all cases, a well-conducted systematic review (of the appropriate type of study) is likely to always yield a better answer than a single study.

Deciding on the best design type to answer a specific review question does not mean that studies of different design types addressing the same question were discarded.

Forming the Clinical Summaries and Recommendations

Once the GRADE evidence profiles relating to a particular review question were completed, summary evidence tables were developed (these tables are presented in the evidence chapters). Finally, the systematic reviewer in conjunction with the members of the GDG produced a clinical evidence summary.

After the GRADE profiles and clinical summaries were presented to the GDG, the associated recommendations were drafted. In making recommendations, the GDG took into account the trade-off between the benefits and downsides of treatment as well as other important factors, such as economic considerations, social value judgements, the requirements to prevent discrimination and to promote equality, and the GDG's awareness of practical issues.

Finally, to show clearly how the GDG moved from the evidence to the recommendations, each chapter has a section called 'from evidence to recommendations'.

The strength of each recommendation is reflected in the wording of the recommendation, rather than by using labels or symbols. Where the GDG identified areas in which there are uncertainties or where robust evidence was lacking, they developed research recommendations.

Method Used to Answer a Review Question in the Absence of Appropriately Designed, High-Quality Research

In the absence of appropriately designed, high-quality research, or where the GDG were of the opinion (on the basis of previous searches or their knowledge of the literature) that there were unlikely to be such evidence, an informal consensus process was adopted. This process focused on those questions that the GDG considered a priority. The starting point for the process of informal consensus was that a member of the GDG used expert opinion about good practice and any relevant papers identified by GDG members to draft a narrative review. The draft was revised in light of comments from the GDG and used as the basis of a discussion at one or more meetings.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

Prioritisation of areas for economic modelling was a joint decision between the health economist and the Guideline Development Group (GDG). The rationale for prioritising review questions for economic modelling was set out in an economic plan agreed between National Institute for Health and Clinical Excellence (NICE), the GDG, the health economist and other members of the technical team. The economic plan is presented in Appendix 19 of the full version of the original guideline document (see the "Availability of Companion Documents" field).

Presentation of Economic Evidence

The economic evidence considered in the guideline is provided in the respective evidence chapters, following presentation of the relevant clinical evidence. The references to included studies as well as the evidence tables with the characteristics and results of economic studies included in the review, are provided in Appendix 11 of the full version of the original guideline document (see the "Availability of Companion Documents" field).

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Registered stakeholders had an opportunity to comment on the draft guideline, which was posted on the National Institute for Health and Clinical Excellence (NICE) website during the consultation period. Following the consultation, all comments from stakeholders (see Appendix 3 in the full version of the original guideline) and experts (see Appendix 4 in the full version of the original guideline) were responded to, and the guideline updated as appropriate. The Guideline Review Panel (GRP) also reviewed the guideline and checked that stakeholders' comments had been addressed.

Following the consultation period, the Guideline Development Group (GDG) finalised the recommendations and the National Collaborating Centre for Mental Health (NCCMH) produced the final documents. These were then submitted to NICE for the pre-publication check where stakeholders are given the opportunity to highlight factual errors. Any errors were corrected by the NCCMH, then the guideline was formally approved by NICE and issued as guidance to the National Health Service in England and Wales.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Principles of Care

Working with Adults and Young People with Psychosis and Coexisting Substance Misuse

When working with adults and young people with known or suspected psychosis and coexisting substance misuse, take time to engage the person from the start, and build a respectful, trusting, non-judgemental relationship in an atmosphere of hope and optimism. Be direct in your communications, use a flexible and motivational approach, and take into account that:

  • Stigma and discrimination are associated with both psychosis and substance misuse.
  • Some people will try to conceal either one or both of their conditions.
  • Many people with psychosis and coexisting substance misuse fear being detained or imprisoned, being given psychiatric medication forcibly or having their children taken into care, and some fear that they may be 'mad'.

When working with adults and young people with known or suspected psychosis and coexisting substance misuse:

  • Ensure that discussions take place in settings in which confidentiality, privacy and dignity can be maintained.
  • Avoid clinical language without adequate explanation.
  • Provide independent interpreters (who are not related to the person) if needed.
  • Aim to preserve continuity of care and minimise changes of key workers in order to foster a therapeutic relationship.

Race and Culture

Healthcare professionals working with adults and young people with psychosis and coexisting substance misuse should ensure that they are competent to engage, assess, and negotiate with service users from diverse cultural and ethnic backgrounds and their families, carers or significant others. ('Significant others' refers not just to a partner but also to friends and any person the service user considers to be important to them.)

Work with local black and minority ethnic organisations and groups to help support and engage adults and young people with psychosis and coexisting substance misuse. Offer organisations and groups information and training about how to recognise psychosis with coexisting substance misuse and access treatment and care locally.

Providing Information

Offer written and verbal information to adults and young people appropriate to their level of understanding about the nature and treatment of both their psychosis and substance misuse. Written information should:

  • Include the 'Understanding NICE guidance' booklet (available in English and Welsh from www.nice.org.uk/guidance/CG120 External Web Site Policy), which contains a list of organisations that can provide more information
  • Be available in the appropriate language or, for those who cannot use written text, in an alternative format (audio or video)

All healthcare professionals in primary, secondary or specialist substance misuse services working with adults and young people with psychosis should offer information and advice about the risks associated with substance misuse and the negative impact that it can have on the experience and management of psychosis.

Working with and Supporting Families, Carers and Significant Others

Encourage families, carers or significant others to be involved in the treatment of adults and young people with psychosis and coexisting substance misuse to help support treatment and care and promote recovery.

When families, carers or significant others live or are in close contact with the person with psychosis and coexisting substance misuse, offer family intervention as recommended in the NGC summary of the NICE guideline Psychosis and schizophrenia in adults: treatment and management.

When families, carers or significant others are involved in supporting the person with psychosis and coexisting substance misuse, discuss with them any concerns about the impact of these conditions on them and on other family members.

Offer families, carers or significant others a carer's assessment of their caring, physical, social, and mental health needs. Where needs are identified, develop a care plan for the family member or carer.

Offer written and verbal information to families, carers or significant others appropriate to their level of understanding about the nature and treatment of psychosis and substance misuse, including how they can help to support the person. Written information should be available in the appropriate language or, for those who cannot use written text, in an accessible format (audio or video).

Offer information to families, carers or significant others about local family or carer support groups and voluntary organisations, including those for psychosis and for substance misuse, and help families, carers or significant others to access these.

Negotiate confidentiality and sharing of information between the person with psychosis and coexisting substance misuse and their family, carer or a significant other.

Ensure the needs of young carers or dependent adults of the person with psychosis and coexisting substance misuse are assessed. Initiate safeguarding procedures where appropriate.

Support for Healthcare Professionals

Working with people with psychosis and coexisting substance misuse can be challenging and healthcare professionals should seek effective support – for example, through professional supervision or staff support groups.

Safeguarding Issues

If people with psychosis and coexisting substance misuse are parents or carers of children or young people, ensure that the child's or young person's needs are assessed according to local safeguarding procedures.

If children or young people being cared for by people with psychosis and coexisting substance misuse are referred to child and adolescent mental health services (CAMHS) under local safeguarding procedures:

  • Use a multi-agency approach, including social care and education, to ensure that various perspectives on the child's life are considered.
  • Consider using the Common Assessment Framework; advice on this can be sought from the local named lead for safeguarding.

If serious concerns are identified, health or social care professionals working with the child or young person should develop a child protection plan.

When working with people with psychosis and coexisting substance misuse who are responsible for vulnerable adults, ensure that the home situation is risk assessed and that safeguarding procedures are in place for the vulnerable adult. Advice on safeguarding vulnerable adults can be sought from the local named lead for safeguarding.

Consider adults with psychosis and coexisting substance misuse for assessment according to local safeguarding procedures for vulnerable adults if there are concerns regarding exploitation or self-care, or if they have been in contact with the criminal justice system.

Consent, Capacity and Treatment Decisions

Before undertaking any investigations for substance misuse, and before each treatment decision is taken:

  • Provide service users with full information appropriate to their needs about psychosis and substance misuse and the management of both conditions, to ensure informed consent.
  • Understand and apply the principles underpinning the Mental Capacity Act (2005), and be aware that mental capacity is decision-specific (that is, if there is doubt about mental capacity, assessment of mental capacity should be made in relation to each decision).
  • Be able to assess mental capacity using the test set out in the Mental Capacity Act (2005).

These principles should apply whether or not people are being detained or treated under the Mental Health Act (1983; amended 1995 and 2007).

Advance Decisions and Statements

Develop advance decisions and advance statements in collaboration with adults with psychosis and coexisting substance misuse, especially if their condition is severe and they have been treated under the Mental Health Act (1983; amended 1995 and 2007). Record the decisions and statements and include copies in the care plan in primary and secondary care. Give copies to the person, their care coordinator, and their family, carer or a significant other if the person agrees.

Take advance decisions and advance statements into account in accordance with the Mental Capacity Act (2005). Although advance decisions and advance statements can be overridden using the Mental Health Act (1983; amended 1995 and 2007), try to honour them wherever possible.

Working with the Voluntary Sector

Healthcare professionals in primary care and secondary care mental health services, and in specialist substance misuse services, should work collaboratively with voluntary sector organisations that provide help and support for adults and young people with psychosis and coexisting substance misuse. Ensure that advocates from such organisations are included in the care planning and care programming process wherever this is possible and agreed by the person with psychosis and coexisting substance misuse.

Healthcare professionals in primary care and secondary care mental health services, and in specialist substance misuse services, should work collaboratively with voluntary sector organisations providing services for adults and young people with psychosis and coexisting substance misuse to develop agreed protocols for routine and crisis care.

Recognition of Psychosis with Coexisting Substance Misuse

Healthcare professionals in all settings, including primary care, secondary care mental health services, CAMHS and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely ask adults and young people with known or suspected psychosis about their use of alcohol and/or prescribed and non-prescribed (including illicit) drugs. If the person has used substances ask them about all of the following:

  • Particular substance(s) used
  • Quantity, frequency and pattern of use
  • Route of administration
  • Duration of current level of use

In addition, conduct an assessment of dependency (see the NICE guideline Drug misuse: opioid detoxification External Web Site Policy and the NGC summary of the NICE guideline Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence) and also seek corroborative evidence from families, carers or significant others, where this is possible and permission is given.

Healthcare professionals in all settings, including primary care, secondary care mental health services, CAMHS and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely assess adults and young people with known or suspected substance misuse for possible psychosis. Seek corroborative evidence from families, carers or significant others, where this is possible and permission is given.

Primary Care

Referral from Primary Care

Refer all adults and young people with psychosis or suspected psychosis, including those who are suspected of coexisting substance misuse, to either secondary care mental health services or CAMHS for assessment and further management.

Refer all adults and young people with substance misuse or suspected substance misuse who are suspected of having coexisting psychosis to secondary care mental health services or CAMHS for assessment and further management.

Physical Healthcare

Monitor the physical health of adults and young people with psychosis and coexisting substance misuse, as described in the guideline on schizophrenia. Pay particular attention to the impact of alcohol and drugs (prescribed and non-prescribed) on physical health. Monitoring should be conducted at least once a year or more frequently if the person has a significant physical illness or there is a risk of physical illness because of substance misuse.

Secondary Care Mental Health Services

Competence

Healthcare professionals working within secondary care mental health services should ensure they are competent in the recognition, treatment and care of adults and young people with psychosis and coexisting substance misuse.

Healthcare professionals working within secondary care mental health services with adults and young people with psychosis and coexisting substance misuse should consider having supervision, advice, consultation and/or training from specialists in substance misuse services. This is to aid in the development and implementation of treatment plans for substance misuse within CAMHS or adult community mental health services.

Pathways into Care

Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate mental healthcare because of their substance misuse.

Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate substance misuse services because of a diagnosis of psychosis.

For most adults with psychosis and coexisting substance misuse, treatment for both conditions should be provided by healthcare professionals in secondary care mental health services such as community-based mental health teams.

Coordinating Care

Consider seeking specialist advice and initiating joint working arrangements with specialist substance misuse services for adults and young people with psychosis being treated by community mental health teams, and known to be:

  • Severely dependent on alcohol or
  • Dependent on both alcohol and benzodiazepines or
  • Dependent on opioids and/or cocaine or crack cocaine

Adult community mental health services or CAMHS should continue to provide care coordination and treatment for the psychosis within joint working arrangements.

Consider seeking specialist advice and initiate joint working arrangements with specialist substance misuse services if the person's substance misuse:

  • Is difficult to control and/or
  • Leads to significant impairment of functioning, family breakdown or significant social disruption such as homelessness

If a person with psychosis and coexisting substance misuse requires planned detoxification from either drugs or alcohol, this should take place in an inpatient setting.

Delivery of care and transfer between services for adults and young people with psychosis and coexisting substance misuse should include a care coordinator and use the Care Programme Approach.

Assessment

Adults and young people with psychosis and coexisting substance misuse attending secondary care mental health services should be offered a comprehensive, multidisciplinary assessment, including assessment of all of the following:

  • Personal history
  • Mental, physical and sexual health
  • Social, family and economic situation
  • Accommodation, including history of homelessness and stability of current living arrangements
  • Current and past substance misuse and its impact upon their life, health and response to treatment
  • Criminal justice history and current status
  • Personal strengths and weaknesses and readiness to change their substance use and other aspects of their lives

The assessment may need to take place over several meetings to gain a full understanding of the person and the range of problems they experience, and to promote engagement.

When assessing adults and young people with psychosis and coexisting substance misuse, seek corroborative evidence from families, carers or significant others where this is possible and permission is given. Summarise the findings, share this with the person and record it in their care plan.

Review any changes in the person's use of substances. This should include changes in:

  • The way the use of substances affects the person over time
  • Patterns of use
  • Mental and physical state
  • Circumstances and treatment

Share the summary with the person and record it in their care plan.

When assessing adults and young people with psychosis and coexisting substance misuse, be aware that low levels of substance use that would not usually be considered harmful or problematic in people without psychosis, can have a significant impact on the mental health of people with psychosis.

Regularly assess and monitor risk of harm to self and/or others and develop and implement a risk management plan to be reviewed when the service users' circumstances or levels of risk change. Specifically consider additional risks associated with substance misuse, including:

  • Physical health risks (for example, withdrawal seizures, delirium tremens, blood-borne viruses, accidental overdose, and interactions with prescribed medication) and
  • The impact that substance use may have on other risks such as self-harm, suicide, self-neglect, violence, abuse of or by others, exploitation, accidental injury and offending behaviour

Biological/Physical Testing

Biological or physical tests for substance use (such as blood and urine tests or hair analysis) may be useful in the assessment, treatment and management of substance misuse for adults and young people with psychosis. However, this should be agreed with the person first as part of their care plan. Do not use biological or physical tests in routine screening for substance misuse in adults and young people with psychosis.

Treatment

Before starting treatment for adults and young people with psychosis and coexisting substance misuse, review:

  • The diagnosis of psychosis and of the coexisting substance misuse, especially if either diagnosis has been made during a crisis or emergency presentation and
  • The effectiveness of previous and current treatments and their acceptability to the person; discontinue ineffective treatments

When developing a care plan for an adult or young person with psychosis and coexisting substance misuse, take account of the complex and individual relationships between substance misuse, psychotic symptoms, emotional state, behaviour and the person's social context.

Ensure that adults and young people with psychosis and coexisting substance misuse are offered evidence-based treatments for both conditions (see recommendations below).

For the treatment of psychosis, see Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care External Web Site Policy or the guideline on schizophrenia (see the NGC summary of the NICE guideline Psychosis and schizophrenia in adults: treatment and management).

For the treatment of substance misuse, (see the following NICE guidelines):

When developing a treatment plan for a person with psychosis and coexisting substance misuse, tailor the plan and the sequencing of treatments to the person and take account of:

  • The relative severity of both the psychosis and the substance misuse at different times and
  • The person's social and treatment context and
  • The person's readiness for change

Do not exclude adults and young people with psychosis and coexisting substance misuse from contingency management programmes because of their psychosis.

Use antipsychotics according to the guideline on schizophrenia or bipolar disorder because there is no evidence for any differential benefit for one antipsychotic over another for people with psychosis and coexisting substance misuse.

Use depot/long-acting injectable antipsychotics according to the guideline on schizophrenia (Psychosis and schizophrenia in adults: treatment and management) in managing covert non-adherence with treatment for psychosis and not as a specific treatment for psychosis and coexisting substance misuse.

When prescribing medication for adults and young people with psychosis and coexisting substance misuse:

  • Take into account the level and type of substance misuse, especially of alcohol, as this may alter the metabolism of prescribed medication, decrease its effectiveness and/or increase the risk of side effects.
  • Warn the person about potential interactions between substances of misuse and prescribed medication.
  • Discuss the problems and potential dangers of using non-prescribed substances and alcohol to counteract the effects or side effects of prescribed medication.

Substance Misuse Services

Competence

Healthcare professionals in substance misuse services should be competent to:

  • Recognise the signs and symptoms of psychosis
  • Undertake a mental health needs and risk assessment sufficient to know how and when to refer to secondary care mental health services.

Assessment

Adults and young people with psychosis and coexisting substance misuse attending substance misuse services should be offered a comprehensive, multidisciplinary mental health assessment in addition to an assessment of their substance misuse.

Joint Working

Healthcare professionals in substance misuse services should be present at Care Programme Approach meetings for adults and young people with psychosis and coexisting substance misuse within their service who are also receiving treatment and support in other health services.

Specialist substance misuse services should provide advice, consultation, and training for healthcare professionals in adult mental health services and CAMHS regarding the assessment and treatment of substance misuse, and of substance misuse with coexisting psychosis.

Specialist substance misuse services should work closely with secondary care mental health services to develop local protocols derived from this guideline for adults and young people with psychosis and coexisting substance misuse. The agreed local protocols should set out responsibilities and processes for assessment, referral, treatment and shared care across the whole care pathway.

Inpatient Mental Health Services

Substance Misuse

All inpatient mental health services should ensure that they have policies and procedures for promoting a therapeutic environment free from drugs and alcohol that have been developed together with service users and their families, carers or significant others. These should include: search procedures, visiting arrangements, planning and reviewing leave, drug and alcohol testing, disposal of legal and illicit substances, and other security measures. Soon after admission, provide all service users, and their families, carers or significant others, with information about the policies and procedures.

When carrying out a comprehensive assessment for all adults and young people admitted to inpatient mental health services, ensure that they are assessed for current substance misuse and evidence of withdrawal symptoms at the point of admission.

Biological or physical tests for substance use should only be considered in inpatient services as part of the assessment and treatment planning for adults and young people with psychosis and coexisting substance misuse. Obtain consent for these tests and inform the person of the results as part of an agreed treatment plan. Where mental capacity is lacking, refer to the Mental Capacity Act (2005).

Ensure that planned detoxification from either drugs or alcohol is undertaken only:

  • With the involvement and advice of substance misuse services
  • In an inpatient setting, preferably in specialist detoxification units, or designated detoxification beds within inpatient mental health services and
  • As part of an overall treatment plan

For the further management of opioid detoxification see the NGC summary of the NICE guideline Drug misuse: opioid detoxification External Web Site Policy. For the further management of assisted alcohol withdrawal see the NGC summary of the NICE guideline Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.

Discharge

Do not discharge adults and young people with psychosis and coexisting substance misuse from an inpatient mental health service solely because of their substance misuse.

When adults and young people with psychosis and coexisting substance misuse are discharged from an inpatient mental health service, ensure that they have:

  • An identified care coordinator and
  • A care plan that includes a consideration of needs associated with both their psychosis and their substance misuse and
  • Been informed of the risks of overdose if they start reusing substances, especially opioids that have been reduced or discontinued during the inpatient stay

Staffed Accommodation

Exclusion from Services

Do not exclude people with psychosis and coexisting substance misuse from staffed accommodation (such as supported or residential care) solely because of their substance misuse.

Do not exclude people with psychosis and coexisting substance misuse from staffed accommodation aimed at addressing substance misuse solely because of their diagnosis of psychosis.

Aims of Treatment

Ensure that people with psychosis and coexisting substance misuse who live in staffed accommodation receive treatment for both their psychosis and their substance misuse with the explicit aim of helping the person remain in stable accommodation.

Specific Issues for Young People with Psychosis and Coexisting Substance Misuse

Competence

Professionals in Tier 1 (primary care and educational settings) should be competent to recognise early signs of psychosis and substance misuse in young people.

Healthcare professionals in Tier 3 (community mental health teams) and Tier 4 (specialist inpatient and regional services) CAMHS, and in early intervention in psychosis services, should be competent in the management of psychosis and substance misuse in young people.

Identification and Referral

Professionals in Tier 1 (primary care and educational settings) should seek advice or consultation from Tier 2 CAMHS (primary care) when signs of psychosis are detected in young people. If healthcare professionals in Tier 2 CAMHS detect signs of psychosis in young people, a referral to Tier 3 CAMHS or early intervention in psychosis services for young people should be made according to local protocols.

Ask all young people seen in Tier 3 and Tier 4 CAMHS and in early intervention in psychosis services who have psychosis or suspected psychosis about substance misuse (see "Recognition of Psychosis with Coexisting Substance Misuse" recommendations above).

Children and young people who, after comprehensive assessment, are considered to be at high risk of harm to themselves or others, should be referred directly to Tier 4 CAMHS including inpatient services where necessary.

Assessment and Treatment

Healthcare professionals working with young people with psychosis and coexisting substance misuse should ensure they are familiar with the legal framework that applies to young people including the Mental Health Act (1983; amended 1995 and 2007), the Mental Capacity Act (2005), and the Children Act (2004).

For psychological, psychosocial, family and medical interventions for young people, follow the recommendations for adults in this guideline; they may need to be adapted according to the young person's circumstances and age. In addition, other agencies, including children's services, should be involved to ensure that the young person's educational, employment, family and housing needs are met.

When prescribing medication, take into account the young person's age and weight when determining the dose. If it is appropriate to prescribe unlicensed medication, explain to the young person and/or their parents or carers the reasons for doing this.

Those providing and commissioning services should ensure that:

  • Age-appropriate mental health services are available for young people with psychosis and coexisting substance misuse and
  • Transition arrangements to adult mental health services are in place where appropriate
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

Clinical practice recommendations are evidence-based, where possible, and, if evidence is not available, informal consensus methods are used and the need for future research is specified.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate management and treatment of patients with psychosis and coexisting substance misuse to improve outcomes and prevent relapse

Potential Harms
  • Adverse effects of medications, including interactions with other medications
  • Caution should be taken with possible drug interactions with substances of misuse. Dosage should be adjusted according to age and weight/body mass index.

See Table 33 in the full version of the original guideline document for full descriptions of recommended medications.

Contraindications

Contraindications

Clozapine is contraindicated in alcoholic and other toxic psychoses, drug intoxication and comatose conditions.

See Table 33 in the full version of the original guideline document for full descriptions of recommended medications, including side effects and potentially harmful interactions.

Qualifying Statements

Qualifying Statements
  • This guidance represents the view of the National Institute for Health and Clinical Excellence (NICE), which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.
  • Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
  • In using guidelines, it is important to remember that the absence of empirical evidence for the effectiveness of a particular intervention is not the same as evidence for ineffectiveness. In addition, and of particular relevance in mental health, evidence based treatments are often delivered within the context of an overall treatment programme including a range of activities, the purpose of which may be to help engage the person and provide an appropriate context for the delivery of specific interventions. It is important to maintain and enhance the service context in which these interventions are delivered; otherwise the specific benefits of effective interventions will be lost. Indeed, the importance of organising care in order to support and encourage a good therapeutic relationship is at times as important as the specific treatments offered.

Implementation of the Guideline

Description of Implementation Strategy

The National Institute for Health and Clinical Excellence (NICE) has developed tools to help organisations implement this guidance (see www.nice.org.uk/guidance/CG120 External Web Site Policy).

Key Priorities for Implementation

Working with Adults and Young People with Psychosis and Coexisting Substance Misuse

When working with adults and young people with known or suspected psychosis and coexisting substance misuse, take time to engage the person from the start, and build a respectful, trusting, non-judgemental relationship in an atmosphere of hope and optimism. Be direct in your communications, use a flexible and motivational approach, and take into account that:

  • Stigma and discrimination are associated with both psychosis and substance misuse.
  • Some people will try to conceal either one or both of their conditions.
  • Many people with psychosis and coexisting substance misuse fear being detained or imprisoned, being given psychiatric medication forcibly or having their children taken into care, and some fear that they may be 'mad'.

Recognition of Psychosis with Coexisting Substance Misuse in Adults and Young People

Healthcare professionals in all settings, including primary care, secondary care mental health services, child and adolescent mental health services (CAMHS) and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely ask adults and young people with known or suspected psychosis about their use of alcohol and/or prescribed and non- prescribed (including illicit) drugs. If the person has used substances ask them about all of the following:

  • Particular substance(s) used
  • Quantity, frequency and pattern of use
  • Route of administration
  • Duration of current level of use

In addition, conduct an assessment of dependency (see the National Guideline Clearinghouse [NGC] summaries for the NICE guidelines Drug misuse: opioid detoxification External Web Site Policy and Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence and also seek corroborative evidence from families, carers or significant others, where this is possible and permission is given. ('Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.)

Secondary Care Mental Health Services

Competence

Healthcare professionals working within secondary care mental health services should ensure they are competent in the recognition, treatment and care of adults and young people with psychosis and coexisting substance misuse.

Pathways into Care

Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate mental healthcare because of their substance misuse.

Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate substance misuse services because of a diagnosis of psychosis.

Coordinating Care

Consider seeking specialist advice and initiating joint working arrangements with specialist substance misuse services for adults and young people with psychosis being treated by community mental health teams, and known to be:

  • Severely dependent on alcohol or
  • Dependent on both alcohol and benzodiazepines or
  • Dependent on opioids and/or cocaine or crack cocaine

Adult community mental health services or CAMHS should continue to provide care coordination and treatment for the psychosis within joint working arrangements.

Substance Misuse Services

Competence

Healthcare professionals in substance misuse services should be competent to:

  • Recognise the signs and symptoms of psychosis
  • Undertake a mental health needs and risk assessment sufficient to know how and when to refer to secondary care mental health services

Inpatient Mental Health Services

Substance Misuse

All inpatient mental health services should ensure that they have policies and procedures for promoting a therapeutic environment free from drugs and alcohol that have been developed together with service users and their families, carers or significant others. These should include: search procedures, visiting arrangements, planning and reviewing leave, drug and alcohol testing, disposal of legal and illicit substances, and other security measures. Soon after admission, provide all service users, and their families, carers or significant others, with information about the policies and procedures.

Specific Issues for Young People with Psychosis and Coexisting Substance Misuse

Assessment and Treatment

Those providing and commissioning services should ensure that:

  • Age-appropriate mental health services are available for young people with psychosis and coexisting substance misuse and
  • Transition arrangements to adult mental health services are in place where appropriate
Implementation Tools
Audit Criteria/Indicators
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
National Institute for Health and Clinical Excellence (NICE). Psychosis with coexisting substance misuse. Assessment and management in adults and young people. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Mar. 39 p. (Clinical guideline; no. 120). 
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2011 Mar
Guideline Developer(s)
National Collaborating Centre for Mental Health - National Government Agency [Non-U.S.]
Source(s) of Funding

National Institute for Health and Clinical Excellence (NICE)

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Guideline Development Group: Professor Peter Tyrer (Chair), Professor of Community Psychiatry, Imperial College, London; Professor Tim Kendall (Facilitator), Director, National Collaborating Centre for Mental Health (NCCMH), Medical Director, Sheffield Health and Social Care Trust, Consultant Adult Psychiatrist; Professor Mohammed T Abou-Saleh, Professor of Psychiatry, St George's, University of London and Honorary Consultant in Addiction Psychiatry, South West London and St George's Mental Health NHS Trust, London; Professor Christine Barrowclough, Professor of Clinical Psychology, University of Manchester; Ms Tina Braithwaite, Representing service user/carer interests, Director of Service User Involvement, Revolving Doors Agency; Dr Andy Cotgrove, Medical Director and Consultant in Adolescent Psychiatry, Cheshire and Wirral Partnership NHS Foundation Trust; Dr Mike Crawford, Reader in Mental Health Services Research, Imperial College London/Central and North West London Mental Health NHS Trust; Professor Ilana Crome, Professor of Addiction Psychiatry, Keele University Medical School, Honorary Consultant Addiction Psychiatrist, South Staffordshire and Shropshire NHS Foundation Trust; Mr Matthew Dyer, Health Economist, NCCMH; Mr Mike Firn, Clinical Service Development Lead, South West London and St George's Mental Health NHS Trust; Dr Frank Holloway, Consultant Psychiatrist and Clinical Director, Bethlem Royal Hospital; Dr Cheryl Kipping, Nurse Consultant, South London and Maudsley NHS Foundation Trust; Ms Katherine Leggett, Guideline Development Manager, NCCMH; Dr Kate McKinnell, Senior Medical Officer (Addictions), Sefton Integrated Recovery Team (Crime Reduction Initiatives); Dr Jonathan Mitchell, Consultant Psychiatrist, Early Intervention and Continuing Needs Services, Sheffield Health and Social Care Trust; Dr David Ndegwa, Consultant Forensic Psychiatrist/Strategy Director, South London and Maudsley NHS Foundation Trust; Mr Peter Pratt, Chief Pharmacist, Sheffield Health and Social Care Trust/Rotherham Doncaster and South Humber NHS Trust; Ms Theresa Renwick, Social Care Lead for Mental Health, Royal Borough of Kensington and Chelsea; Ms Laura Shields, Research Assistant, NCCMH; Mr Leroy Simpson, Representing service user/carer interests, Board Member, Salvation Army Housing Association; Ms Sarah Stockton, Senior Information Scientist, NCCMH; Dr Clare Taylor, Editor, NCCMH; Dr Craig Whittington, Senior Systematic Reviewer, NCCMH; Mrs Penelope Wigram, Representing service user/carer interests, Psychoanalytic Psychotherapist, British Psychoanalytic Council

Financial Disclosures/Conflicts of Interest

To minimise and manage any potential conflicts of interest, and to avoid any public concern that commercial or other financial interests have affected the work of the Guideline Development Group (GDG) and influenced the guideline, members of the GDG must declare as a matter of public record any interests held by themselves or their families which fall under specified categories. These categories include any relationships they have with the healthcare industries, professional organisations and organisations for people with psychosis and coexisting substance misuse and their families, carers or significant others.

Individuals invited to join the GDG were asked to declare their interests before being appointed. To allow the management of any potential conflicts of interest that might arise during the development of the guideline, GDG members were also asked to declare their interests at each GDG meeting throughout the guideline development process. The interests of all the members of the GDG are listed in Appendix 2 of the full version of the original guideline document (see the "Availability of Companion Documents" field), including interests declared prior to appointment and during the guideline development process.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Psychosis with coexisting substance misuse. Assessment and management in adults and young people. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Mar. 16 p. (Clinical guideline; no. 120). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.
  • Psychosis with coexisting substance misuse. Assessment and management in adults and young people. Full guideline. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011. 326 p. (Clinical guideline; no. 120). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Psychosis with coexisting substance misuse. Assessment and management in adults and young people. Appendices. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Mar. Various p. (Clinical guideline; no. 120). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Psychosis with coexisting substance misuse. Costing statement. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011. 10 p. (Clinical guideline; no. 120). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Psychosis with coexisting substance misuse. Clinical audit tool. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Mar. 14 p. (Clinical guideline; no. 120). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Psychosis with coexisting substance misuse. Assessment and management in adults and young people. Baseline assessment tool. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Mar. 14 p. (Clinical guideline; no. 120). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Psychosis with coexisting substance misuse. Slide set. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Mar. 19 p. (Clinical guideline; no. 120). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Psychosis with coexisting substance misuse. Clinical case scenarios for primary, secondary and third sector services. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Mar. 36 p. (Clinical guideline; no. 120). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Psychosis with coexisting substance misuse. Clinical case scenarios for primary, secondary and third sector services. Slide set. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Mar. 38 p. (Clinical guideline; no. 120). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Psychosis with coexisting substance misuse. Podcast. Available from the NICE Web site External Web Site Policy.
  • The guidelines manual 2009. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Jan. Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on April 3, 2012.

The National Institute for Health and Clinical Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. NICE has not been involved in the development or adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at www.nice.org.uk External Web Site Policy.

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This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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