A lecture by Dr Imran Waheed, Consultant Psychiatrist, outlining the approach towards the diagnosis and management of schizophrenia, with particular reference to primary care. Delivered in March 2013 in Birmingham, UK.

1. Schizophrenia & Primary Care
D R I M R A N WA H E E D
C O N S U LTA N T P S Y C H I AT R I S T
W W W. I M R A N WA H E E D . C O M

2. Overview
 The Context
 Diagnosing schizophrenia
 Initial management
 Who is at risk?
 Drug induced psychosis vs. schizophrenia
 Management

3. The overall context
 1 in 4 GP consultations; 23% of the UK burden of
illness
 NICE estimates that 9.8% of adults are suffering from
mixed anxiety and depression
 UK: £105 billion cost of mental illness per year
 Three quarters of people with mental health problems
receive no treatment
 More than 80 per cent of depression is treated in
primary care

4. Cost of Mental Health
Reference: The economic and social costs of mental health problems 2009-2010, Centre for Mental Health, October 2010

5. GPs see a FEP at an age when other
serious mental disorders tend to develop
Victoria (Aus) Burden of Disease Study: Incident Years Lived with
Disability rates per 1000 population by mental disorder

6. Background (i)
 1961: 100 schizophrenics in South London followed
up for 1 year after discharge from hospital – GP found
to have most frequent contact with them. (Parkes)
 1991: Little change found despite the development of
CMHTs; in first 12 months 52% attended psych clinic
while 57% saw their GP. (Melzer et al.)
 Significant numbers lose contact with psychiatric
services and are looked after entirely in general
practice (King 1992)

7. Background (taken from NICE)
• Schizophrenia is a major psychiatric disorder or
cluster of disorders, characterised by psychotic
symptoms.
• About 1% of the population will develop
schizophrenia.
• The first symptoms tend to start in young
adulthood.
• A diagnosis of schizophrenia is associated with
stigma, fear and limited public understanding.
• There is a higher risk of suicide.

8. Characteristic Symptoms in Schizophrenia
 Audible thoughts
 Voices arguing or commenting
 Thought withdrawal or insertions by outside forces
 Thought broadcasting
 Impulses, volitional acts, or feelings imposed by
outside forces
 Delusional perceptions

9. Symptom dimensions in schizophrenia
 Psychotic  Neurocognitive –
 Hallucinations Impairments
 Suspiciousness  Memory
 Delusions  Attention
 Negative  Motor skills
 Impoverished speech  Social cognition
 Lack of motivation  Executive skills
 Asociality  Disorganised speech
 Decreased Affect

10. ICD 10 criteria for schizophrenia
 Characteristic symptoms for one month
 If mood disorder is present, one month of
characteristic symptoms must antedate it
 Not attributable to organic brain disease or
substance abuse

11. ICD 10: Characteristic Symptoms (i)
At least one of the following:
Thought echo, insertion, withdrawal, or broadcasting
Delusions of control, influence, or passivity; delusional percept
Voices commenting or discussing; voices coming from some
part of the body
Persistent delusions that are culturally inappropriate and
completely impossible, such as religious or political identity,
superhuman powers

12. ICD 10: Characteristic Symptoms (ii)
Or at least two of the following:
Persistent hallucinations in any modality when
accompanied by delusions
Neologisms, breaks or interpolations in the train of thought,
resulting in incoherence or irrelevant speech
Catatonic behavior
“Negative” symptoms such as marked apathy, paucity of
speech, and blunting or incongruity of emotional responses

13. ICD-10 Diagnostic criteria
 Minimum of one very clear symptom belonging to group (i) or two
symptoms from group (ii) should have been clearly present for most
of the time during a period of 1 month or more.
 Viewed retrospectively, it may be clear that a prodromal phase in
which symptoms and behaviour, such as loss of interest in work, social
activities, and personal appearance and hygiene, together with
generalized anxiety and mild degrees of depression and
preoccupation, preceded the onset of psychotic symptoms by weeks
or even months.
 Diagnosis should not be made in the presence of extensive depressive
or manic symptoms unless it is clear that schizophrenic symptoms
antedated the affective disturbance.
 Schizophrenia should not be diagnosed in the presence of overt brain
disease or during states of drug intoxication or withdrawal.

14. Early Intervention
 In 1938, Cameron observed that ‘the therapeutic results to be
obtained [in schizophrenia] are considerably better in patients in
whom there is little progression towards chronicity’
 Window of opportunity - ‘the critical period’ - early trajectory and
disability are strongly predictive of long-term course and outcome
 Association between longer periods of untreated psychosis and
poorer outcomes has become firmly established.
 Early intervention does seem to make a difference in psychosis,
influencing the early course when the disorder is at its most
aggressive. Transitioning them back to generic teams appears to
undo the gains.
 There is still some controversy/debate about the effectiveness of EI
services

15. Initial Management – from CKS NHS
 For all people with psychotic symptoms or attenuated psychotic symptoms,
undertake a risk assessment.
 For people judged to be at high risk of harm to themselves or others, arrange
same-day specialist assessment.
 If the person needs to be admitted to hospital, every attempt should be made to
persuade them to go voluntarily. If admission is necessary but the person
declines, compulsory admission may be arranged under the Mental Health Act.
 For those not at immediate risk of harm to themselves or others, urgently refer for
a specialist assessment to:
 The early intervention service if available, or
 The community mental health service
 Do not start antipsychotic treatment while awaiting referral unless you have
experience in treating and managing schizophrenia (for example GPs with a
special interest).
 For people with anxiety problems or insomnia who are awaiting referral, consider
short-term treatment with an anxiolytic or hypnotic.

16. Diagnostic Process for schizophrenia
 Physical examination/Ix to rule out psychotic disorder
due to a medical condition and substance-induced
psychosis
 Imaging (CT, MRI, PET) frequently done but seldom
helpful in diagnosis
 The diagnosis is commonly made from history and the
MSE
 There are currently no reliable biomarkers for
diagnosis or severity

17. Psychological interventions (NICE guidance)
• Offer cognitive behavioural therapy (CBT) to all people with
schizophrenia.
• Offer family intervention to all families who live with or are
in close contact with the service user.
• Both can be started either during the acute phase or later,
including in inpatient settings.

18. Pharmacological interventions (NICE guidance)
• For people with newly diagnosed schizophrenia offer oral antipsychotic
medication
• Provide information and discuss the benefits and side-effect profile of
each drug offered with the service user
• The choice of particular antipsychotic drug should be made by the
service user and healthcare professional together, considering:
 – the relative potential to cause extrapyramidal, metabolic and other
side effects
 – the views of the carer (if the service user agrees).

19. Drugs and Psychosis
 Studies have demonstrated that up to 50% of treatment-seeking
schizophrenic patients are alcohol or illicit drug dependent and
more than 70% are nicotine dependent.
 Schizophrenics, when compared with the general population, have
substantial risk (odds ratio, 4.6) for having a comorbid substance
use disorder
 Most helpful factors in making the differential diagnosis are careful
history concerning symptoms during abstinent periods and
observation of symptoms during monitored abstinence.
 Embracing of diagnostic uncertainty is crucial – particularly when
dealing with first episode psychosis

20. What are the obstacles?
 Lack of training amongst GPs and practice nurses
 Not frequently seen – average GP may have no more
than 10-15 patients with schizophrenia
 ‘Reactive’ nature of primary care – no time to go
‘looking’ for patients
 Limited time for assessments

21. Primary Care advantages
 Knowing the patient before they were ill, often from
childhood
 More easily accessible – so often the first port of call
 Ability to deal with the increased need for physical and
preventive health care

22. Primary care and physical health (NICE)
 GPs and other primary healthcare professionals should:
1. Monitor physical health at least once a year
2. Focus on cardiovascular disease risk monitoring
 People with schizophrenia are at higher risk of cardiovascular
disease than the general population
 A copy of the results should be sent to the care coordinator
and/or psychiatrist and put in the secondary care notes

23. Inequality and outcomes
 Excluded
 12% with a job
 In previous 2 weeks (Nithsdale survey)
o 39 % either had no friends or had met none
o 34 % had not gone out socially
o 50 % no interest or hobby other than TV
 one in four have serious rent arrears
 3x divorce rate
 Disease  up to 25 years less life
 33% suicide and injury
o Lifetime suicide risk 10%;
2/ within first 5yrs, especially around the FEP
3
 66% are premature deaths from physical causes
o 2-3x rate of CVS, Respiratory or infective disorders
o Lifestyle adverse factors: smoking; diet; activity
o Up to 5x rate of diabetes
o Poorer health care

24. NICE recommendations (i)
 Develop and use practice case registers to monitor the physical and mental
health of people with schizophrenia in primary care.
 People with schizophrenia at increased risk of developing cardiovascular
disease and/or diabetes should be identified at the earliest opportunity. Their
care should be managed using the appropriate NICE guidance.
 Treat people with schizophrenia who have diabetes and/or cardiovascular
disease in primary care according to the appropriate NICE guidance.
 Healthcare professionals in secondary care should ensure that people with
schizophrenia receive physical healthcare from primary care as described in
NICE recommendations
 When a person with an established diagnosis of schizophrenia presents with a
suspected relapse (for example, with increased psychotic symptoms or a
significant increase in the use of alcohol or other substances), primary
healthcare professionals should refer to the crisis section of the care plan.
Consider referral to the key clinician or care coordinator identified in the
crisis plan.

25. NICE recommendations (ii)
 Consider referral to secondary care again if there is: poor
response to treatment, non-adherence to medication, intolerable
side effects from medication, comorbid substance misuse, risk to
self or others.
 When re-referring people with schizophrenia to mental health
services, take account of service user and carer requests,
especially for: review of the side effects of existing treatments &
psychological treatments or other interventions.
 When a person with schizophrenia is planning to move to the
catchment area of a different NHS trust, a meeting should be
arranged between the services involved and the service user to
agree a transition plan before transfer.

26. Conclusion
 Huge human and financial cost of mental ill health
 Early detection, referral and treatment are vital
 “no health without mental health”
 Main role of primary care is in early detection and
referral, long term management, physical health
monitoring, joint working with secondary care

27. Schizophrenia & Primary Care
D R I M R A N WA H E E D
C O N S U LTA N T P S Y C H I AT R I S T
W W W. I M R A N WA H E E D . C O M