Box 4 lists the most common positive symptoms of schizophrenia, and box 5 shows the ICD-10 (international classification of diseases, 10th revision) diagnostic criteria. However, few patients initially present with such florid symptoms. Patients are more likely to have more nebulous symptoms such as anxiety and depression, social problems, or changes in behaviour, particularly difficulties in concentrating or becoming withdrawn from their normal social life. Box 6 outlines useful screening questions for patients presenting in this manner.
Box 4 Most common positive symptoms of schizophreniaw17
- Lack of insight (97%)
- Auditory hallucinations (74%)
- Ideas of reference (70%)
- Delusions of reference (67%)
- Suspiciousness (66%)
- Flatness of affect (66%)
- Delusional mood (64%)
- Delusions of persecution (64%)
- Thought alienation (52%)
- Thoughts spoken aloud (50%)
Box 5 ICD-10 diagnostic criteria for schizophrenia
At least one present most of the time for a month
- Thought echo, insertion or withdrawal, or thought broadcast
- Delusions of control referred to body parts, actions, or sensations
- Delusional perception
- Hallucinatory voices giving a running commentary, discussing the patient, or coming from some part of the patient's body
- Persistent bizarre or culturally inappropriate delusions
Or at least two present most of the time for a month
- Persistent daily hallucinations accompanied by delusions
- Incoherent or irrelevant speech
- Catatonic behaviour such as stupor or posturing
- Negative symptoms such as marked apathy, blunted or incongruous mood
Box 6 Suggested screening questions for patient presenting with possible psychosis
- Do you hear voices when no one is around? What do they say?
- Do you ever think that people are talking or gossiping about you, maybe even thinking about trying to get you?
- Do you ever think that somehow people can pick up on what you are thinking or can manipulate what you are thinking?
If the onset of psychosis is suspected, the patient should be rapidly referred to secondary care (box 7). This will be the local early intervention or home treatment team in many parts of the UK, or the generic catchment area community mental health team. The risk that patients pose to themselves and others must be assessed (table) at this first assessment and this information included in the referral. If the presence of psychotic symptoms is confirmed by a psychiatrist, then after discussion it may be appropriate for the general practitioner to prescribe an antipsychotic. Current NICE guidelines16
recommend considering and offering an oral atypical antipsychotic such as amisulpiride, risperidone, quetiapine, or olanzapine in low doses. The need for hospital admission and even the use of the Mental Health Act will depend mainly on the patient's presentation, the risk assessment, and the availability of good community support. General practitioners can contribute greatly to this decision because of their long term relationship with the patient and family.
Brief risk assessment screen
Box 7 Early presentation of psychosis
John was in his mid-twenties when he was referred to the local early intervention in psychosis service on the advice of his counsellor. He lived with his partner and worked in a local shop at the time. For many years he had misused various illegal drugs including cannabis, amphetamine, LSD, and cocaine.
John's problems began a year or two earlier when he had a panic attack climbing a flight of stairs. He was treated with a β blocker and when this was unsuccessful he was given counselling. In the course of John's counselling sessions he revealed that he had experienced other unusual phenomena, particularly vivid dreams. He felt that he had some degree of control over these dreams though they were accompanied by a sense of not knowing whether he was really asleep.
When John was assessed by the early intervention service he reported that he sometimes thought that he could smell petrol and butane when others could not and that he could hear his phone ring when no one had called. He said he felt that people were murmuring about him, though he could not be sure, and if he checked he found nothing. He was also very worried about his physical health. Finally, he admitted that he had begun to notice unusual coincidences and links between events and people.
Paul met criteria for an “at risk mental state” for psychosis and was offered cognitive behaviour therapy with a clinical psychologist to deal with these symptoms. He declined treatment with an antipsychotic drug.
Nine months later John had made an excellent recovery—most of his symptoms had improved, he was not taking any illicit drugs, and he was still at work and with his girlfriend.
Is early recognition important?
Most general practitioners with a couple of thousand patients on their list will see one or two new cases of psychosis each year. The mean duration of untreated psychosis—the time between full symptoms emerging and starting continuous antipsychotic treatment—is currently around one to two years in the UK.w10
A systematic review and meta-analysis have shown that the longer this period, the worse the outcome.17w11
The idea that reducing the duration of untreated psychosis will be reflected in improved outcome has led to a recent expansion in first episode services in the UK and other countries. Whether or not this proves to be the case,18
patients with psychotic symptoms should be identified and treated as quickly as possible.
- Schizophrenia usually starts in late adolescence or early adulthood
- Genetic risk and environmental factors interact to cause the disorder
- The most common symptoms are lack of insight, auditory hallucinations, and delusions
- Clinicians should suspect the disorder in a young adult presenting with unusual symptoms and altered behaviour
- Treatments can alleviate symptoms, reduce distress, and improve functioning
- Delayed treatment worsens the prognosis
Long term management in primary care
An average general practitioner in the UK will look after about 12 patients with schizophreniaw12 and exclusively manage the care of about six. Once a patient has recovered from an acute episode of schizophrenia, current NICE guidelines recommend that they remain on prophylactic doses of antipsychotic for one to two years and continue to be supervised by specialist services. After that time, if they are well and symptom free, the drug dose can gradually be reduced and the patient carefully monitored to detect any signs of relapse; if such signs occur, then the dose must be increased until they disappear. Such a programme of careful monitoring may best be achieved by collaboration between primary and secondary care.
General practitioners are central to ensuring that patients with schizophrenia receive good quality physical health care (fig 2).19
Current NICE guidelines encourage all practices to establish a mental health register and offer regular physical health checks tailored to the needs of the patient. Special attention should be paid to screening for endocrine disorders; hyperglycaemia and hyperprolactinaemia; cardiovascular risk factors such as smoking, hypertension, and hyperlipidaemia; and side effects of medication, particularly neurological, cardiovascular, and sexual ones (box 8).
Fig 2 Physical care algorithm: adapted from NICE guidelines19
Box 8 Common side effects of antipsychotic drugs20
First generation antipsychotics
- Extrapyramidal effects:
- Tardive dyskinesia
- Reduced seizure threshold
- Postural hypotension
- Anticholinergic effects:
- Blurred vision
- Dry mouth
- Urinary retention
- Neuroleptic malignant syndrome
- Weight gain
- Sexual dysfunction
- Cardiotoxicity (including prolonged QTc)
Second generation antipsychotics
- Weight gain
- Glucose intolerance and frank diabetes mellitus
- Extrapyramidal side effects at higher doses
- Sexual dysfunction
- Extrapyramidal effects
- Reduced seizure threshold
- Hypotension and hypertension
- Weight gain
- Glucose intolerance and diabetes mellitus
- Nocturnal enuresis
- Rare serious side effects:
- Neutropenia (93%)
- Agranulocytosis (0.8%)
- Aspiration pneumonia
Some patients will inevitably need to be referred back to secondary care. Guideline criteria for this decision include:
- Poor treatment compliance
- Poor treatment response
- Ongoing substance misuse
- Increase in risk profile.
How do primary and secondary care interface?
Specialist mental health services in the UK are obliged to structure patient care using the care programme approach.w13 w14 This approach provides a statutory framework that aims to ensure that clinicians comprehensively consider the patient's main areas of need. It demands regular assessment of various aspects of the patient's life including mental and physical health, relationships, accommodation, occupation, finances, etc. Although the framework is cumbersome and proscriptive, its strength lies in this rigid approach to structuring care and reviewing risk. Whether such a framework can be successful given the current attempts of government and primary care trusts to reduce the costs of mental health care remains to be seen.