Psychiatric Bulletin (2004) 28: 351. doi: 10.1192/pb.28.9.351
© 2004 The Royal College of Psychiatrists
Psychiatric Bulletin (2004) 28: 351
© 2004 The Royal College of Psychiatrists
Schizophrenia. Full National Clinical Guideline on Core Interventions in Primary and Secondary Care National Collaborating Centre for Mental Health
Clive E. Adams, Chair of Adult Psychiatry
University of Leeds, Co-ordinating Editor, Cochrane Schizophrenia
Group
London: Gaskell, 2003, £50 pb, including 2 CD-ROMs, 264 pp., ISBN:
1-901242-97-8, Book ID: 1747
National schizophrenia guidelines with some relationship to evidence are
overdue. These guidelines are underpinned by substantial critical appraisal of
the literature, which is then embedded in thoughtful, concise synopses. The
presentation is clear, well-structured (if not indexed) and attractive, and
enhanced by one training CD and another containing relevant data. The document
is easy to read, represents important progress and should be used, at the very
least, by everyone interested in the care of people with schizophrenia in
England and Wales. But there are caveats. Several. Bits are missing, open to
misinterpretation, biased, and verging on the ridiculous.
Intentionally, the guide does not cover care of the elderly or very young.
It does not contain information on the management of common adverse effects,
surprisingly little on early intervention services and treatment issues of
people with concurrent depression, learning disability, personality disorder,
physical ill health or/and substance misuse. Management problems relating to
legal or forensic issues are not tackled. But then you cannot do everything in
one document. Perhaps the ambiguous ‘full’ of the title refers to
the nations and not the scope of care. It is therefore redundant; one would
hardly expect Yorkshire or Yeovil, for example, to be exempt. Perhaps the
title’s ‘core’ is also debatable.
The guidance about the use of oral atypicals has already been
misinterpreted. It recommended that expensive new drugs are considered in the
choice of first-line treatments for people with newly-diagnosed schizophrenia
(5.2.7.7). It did not recommend that they are the first-line choice as is
implied by some rosettebedraggled advertising. Older inexpensive atypicals are
not precluded, and neither are first generation drugs given in adequate but
not excessive doses (5.2.7.3).
The guidance on rapid tranquillisation may betray biases. The reporting of
one olanzapine study seemed excessive, covering half a page with
uninterpretable figures (5.5.4). This prompted me to use the accompanying CD
to seek the source study. I do not have space here to fully appraise this
shameless industry vehicle, but why it is given such exposure, considering
there are so many other shameless industry vehicles in competition, smacks of
successful ‘interested’ lobbying.
Reading the guideline, I did not expect to laugh, but did. They say audit
could take place to monitor compliance with recommendations for, among many
other things, family interventions and cognitive-behavioural therapy (CBT,
Table 8.1). Family interventions (>10 sessions, >6 months) are to be
offered to everyone with schizophrenia – and everyone with persisting
psychotic symptoms should have CBT (>10 sessions, >6 months). These
recommendations stem from trial data showing modest declining effects that
fail to report adverse effects and interventions given mostly by
highly-skilled motivated teams. These silly unrealistic recommendations
devalue both the therapies and guidelines.
These guidelines should be successful in assisting clinicians and patients
make decisions about appropriate treatment (1.1.1). I am not at all convinced,
however, that they will be the same decisions as those suggested in these
guidelines. Nevertheless this important work encourages decisions to be made
carefully and rationally. That seems like progress.
