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National Collaborating Centre for Mental Health (UK). Psychosis with Coexisting Substance Misuse: Assessment and Management in Adults and Young People. Leicester (UK): British Psychological Society; 2011. (NICE Clinical Guidelines, No. 120.)


This guideline has been developed to advise on the assessment and management of adults and young people (aged 14 years and older) with psychosis and coexisting substance misuse. The guideline recommendations have been developed by a multidisciplinary team of healthcare professionals, a service user, a representative from a service user organisation, a carer and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for people with psychosis and coexisting substance misuse while also emphasising the importance of the experience of care for people with psychosis and coexisting substance misuse and their families, carers or significant others (see Appendix 1 for more details on the scope of the guideline).

Although the evidence base is rapidly expanding, there are a number of major gaps, and future revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address gaps in the evidence base (see Appendix 12 for the recommendations that the Guideline Development Group [GDG] considered to be of high priority). In the meantime, it is hoped that the guideline will assist clinicians, people with psychosis and coexisting substance misuse and their families, carers or significant others by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists.


1.1.1. What are clinical practice guidelines?

Clinical practice guidelines are ‘systematically developed statements that assist clinicians and service users in making decisions about appropriate treatment for specific conditions’ (Mann, 1996). They are derived from the best available research evidence, using predetermined and systematic methods to identify and evaluate the evidence relating to the specific condition in question. Where evidence is lacking, the guidelines incorporate statements and recommendations based upon the consensus statements developed by the GDG.

Clinical guidelines are intended to improve the process and outcomes of healthcare in a number of different ways. They can:

  • provide up-to-date evidence-based recommendations for the management of conditions and disorders by healthcare professionals
  • be used as the basis to set standards to assess the practice of healthcare professionals
  • form the basis for education and training of healthcare professionals
  • assist service users and their families, carers or significant others in making informed decisions about their treatment and care
  • improve communication between healthcare professionals, service users and their families, carers or significant others
  • help identify priority areas for further research.

1.1.2. Uses and limitations of clinical guidelines

Guidelines are not a substitute for professional knowledge and clinical judgement. They can be limited in their usefulness and applicability by a number of different factors: the availability of high-quality research evidence, the quality of the methodology used in the development of the guideline, the generalisability of research findings and the uniqueness of individuals.

Although the quality of research in this field is variable, the methodology used here reflects current international understanding on the appropriate practice for guideline development (Appraisal of Guidelines for Research and Evaluation Instrument [AGREE];; AGREE Collaboration, 2003), ensuring the collection and selection of the best research evidence available and the systematic generation of treatment recommendations applicable to the majority of people with psychosis and coexisting substance misuse. However, there will always be some people and situations where clinical guideline recommendations are not readily applicable. This guideline does not, therefore, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual, in consultation with the person with psychosis and coexisting substance misuse or their family, carer or significant other.

In addition to the clinical evidence, cost-effectiveness information, where available, is taken into account in the generation of statements and recommendations in clinical guidelines. While national guidelines are concerned with clinical and cost effectiveness, issues of affordability and implementation costs are to be determined by the National Health Service (NHS).

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.

1.1.3. Why develop national guidelines?

The National Institute for Health and Clinical Excellence (NICE) was established as a Special Health Authority for England and Wales in 1999, with a remit to provide a single source of authoritative and reliable guidance for service users, professionals and the public. NICE guidance aims to improve standards of care, to diminish unacceptable variations in the provision and quality of care across the NHS and to ensure that the health service is person centred. All guidance is developed in a transparent and collaborative manner using the best available evidence and involving all relevant stakeholders.

NICE generates guidance in a number of different ways, three of which are relevant here. First, national guidance is produced by the Technology Appraisal Committee to give robust advice about a particular treatment, intervention, procedure or other health technology. Second, NICE commissions public health intervention guidance focused on types of activity (interventions) that help to reduce people's risk of developing a disease or condition or help to promote or maintain a healthy lifestyle. Third, NICE commissions the production of national clinical practice guidelines focused upon the overall treatment and management of a specific condition. To enable this latter development, NICE has established four National Collaborating Centres in conjunction with a range of professional organisations involved in healthcare.

1.1.4. The National Collaborating Centre for Mental Health

This guideline has been commissioned by NICE and developed within the National Collaborating Centre for Mental Health (NCCMH). The NCCMH is a collaboration of the professional organisations involved in the field of mental health, national service user and carer organisations, a number of academic institutions and NICE. The NCCMH is funded by NICE and is led by a partnership between the Royal College of Psychiatrists and the British Psychological Society's Centre for Outcomes Research and Effectiveness, based at University College London.

1.1.5. From national guidelines to local protocols

Once a national guideline has been published and disseminated, local healthcare groups will be expected to produce a plan and identify resources for implementation, along with appropriate timetables. Subsequently, a multidisciplinary group involving commissioners of healthcare, primary care professionals, specialist mental health and other relevant healthcare professionals, service users and families, carers or significant others should undertake the translation of the implementation plan into local protocols taking into account both the recommendations set out in this guideline and the priorities in the National Service Framework for Mental Health (Department of Health, 1999) and related documentation. The nature and pace of the local plan will reflect local healthcare needs and the nature of existing services; full implementation may take a considerable time, especially where substantial training needs are identified.

1.1.6. Auditing the implementation of guidelines

This guideline identifies key areas of clinical practice and service delivery for local and national audit. Although the generation of audit standards is an important and necessary step in the implementation of this guidance, a more broadly based implementation strategy will be developed. Nevertheless, it should be noted that the Care Quality Commission will monitor the extent to which Primary Care Trusts, trusts responsible for mental health and social care, and Health Authorities have implemented these guidelines.


1.2.1. Who has developed this guideline?

The GDG was convened by the NCCMH and supported by funding from NICE. The GDG included a service user, a representative from a service user organisation and a carer, and professionals from psychiatry, clinical psychology, general practice, nursing, pharmacy, social care, and guideline development.

Staff from the NCCMH provided leadership and support throughout the process of guideline development, undertaking systematic searches, information retrieval, appraisal and systematic review of the evidence. Members of the GDG received training in the process of guideline development from NCCMH staff, and the service user representatives and carer received training and support from the NICE Patient and Public Involvement Programme. The NICE Guidelines Technical Adviser provided advice and assistance regarding aspects of the guideline development process.

All GDG members made formal declarations of interest at the outset, which were updated at every GDG meeting. The GDG met a total of ten times throughout the process of guideline development. It met as a whole, but key topics were led by a national expert in the relevant topic. The GDG oversaw the production and synthesis of research evidence before presentation. All statements and recommendations in this guideline have been generated and agreed by the whole GDG.

1.2.2. For whom is this guideline intended?

This guideline will be relevant for adults and young people (aged 14 years and older) with psychosis and coexisting substance misuse and covers the care provided by primary, community, secondary, tertiary and other healthcare professionals who have direct contact with, and make decisions concerning the care of, adults and young people with psychosis and coexisting substance misuse.

The guideline will also be relevant to the work, but will not cover the practice, of those in:

  • occupational health services
  • social services
  • the independent sector.

1.2.3. Specific aims of this guideline

The guideline makes recommendations for the assessment and management of adults and young people (aged 14 years and older) with psychosis and coexisting substance misuse. It aims to:

  • review the experience of care from the servicer user's perspective, and the perspective of their families, carers or significant others
  • evaluate service delivery models
  • evaluate the role of psychological/ psychosocial interventions
  • evaluate the role of pharmacological interventions
  • 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
  • promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the NHS in England and Wales.

1.2.4. The structure of this guideline

The guideline is divided into chapters, each covering a set of related topics. The first three chapters provide a general introduction to guidelines and the topic of psychosis with coexisting substance misuse, and to the methods used to develop this guideline. Chapters 4 to 9 provide the evidence that underpins the recommendations.

Each evidence chapter begins with a general introduction to the topic that sets the recommendations in context. Depending on the nature of the evidence, narrative reviews or meta-analyses were conducted, and the structure of the chapters varies accordingly. Where appropriate, details about current practice are provided. Where meta-analyses were conducted, information is given about both the interventions included and the studies considered for review. Further sub-sections are used to present GRADE (Grading of Recommendations: Assessment, Development and Evaluation) summary tables, clinical summaries, and health economic evidence. A sub-section called ‘from evidence to recommendations’ is used to explain how the GDG developed the recommendations from the evidence. Finally, recommendations (clinical and research) related to each topic are presented at the end of each chapter or sub-section. A list of research recommendations that the GDG thought were of high priority, with the rationale for this decision, can be found in Appendix 12. Further information about the evidence and the economic plan are provided in ten separate appendices on the CD-ROM (see Table 1 for details).

Table 1. Appendices on CD-ROM.

Table 1

Appendices on CD-ROM.

Copyright © 2011, The British Psychological Society & The Royal College of Psychiatrists.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

Cover of Psychosis with Coexisting Substance Misuse
Psychosis with Coexisting Substance Misuse: Assessment and Management in Adults and Young People.
NICE Clinical Guidelines, No. 120.
National Collaborating Centre for Mental Health (UK).
Leicester (UK): British Psychological Society; 2011.


NICE (National Institute for Health and Care Excellence)

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