National guidance overview
Schizophrenia care in the UK follows NICE: early intervention, shared antipsychotic choice, psychological therapy, and defined referral points (EIP, CMHT).
Applies to adults in UK mental health services.
The management of schizophrenia in the UK is guided by a comprehensive, evidence-based framework that emphasises a holistic, person-centred approach delivered within a multidisciplinary team (MDT) context, typically coordinated by community mental health teams (CMHTs). The initial assessment should be thorough, establishing a diagnosis based on ICD-10 or ICD-11 criteria while excluding organic causes and assessing for comorbid physical and mental health conditions, substance use, and risk to self and others. For individuals experiencing a first episode of psychosis (FEP), referral to an Early Intervention in Psychosis (EIP) service is a key priority, as these services offer intensive, specialised support for a defined period, which is associated with improved long-term outcomes. Following diagnosis, the cornerstone of treatment is antipsychotic medication, with the choice of drug being a collaborative decision between the clinician and the patient, considering the side-effect profile, the patient's preferences, and previous response; oral medication is usually initiated, and if a depot/long-acting injectable antipsychotic is preferred, it should be offered alongside oral therapy. The principle of \"start low, go slow\" is advised, particularly in antipsychotic-naïve individuals, with regular monitoring of efficacy and tolerability, including for metabolic side effects (weight, blood glucose, lipids) and movement disorders. If there is an inadequate response to an adequate dose and duration of the first antipsychotic, switching to an alternative antipsychotic from a different class is recommended before considering clozapine, which is indicated for treatment-resistant schizophrenia (failure to respond to at least two different antipsychotics, each used for an adequate period). Pharmacological treatment should always be integrated with psychological interventions; cognitive behavioural therapy for psychosis (CBTp) and family interventions are recommended for all patients, with arts therapies considered for those with negative symptoms. Addressing physical health is a critical responsibility, as individuals with schizophrenia have a significantly reduced life expectancy, largely due to preventable physical illnesses; therefore, annual physical health checks are mandatory, focusing on cardiovascular and metabolic health, and support for smoking cessation and healthy lifestyles should be proactively offered. For those in an acute phase, crisis plans and access to crisis resolution and home treatment (CRHT) teams should be in place to avoid hospital admission where possible, though admission is necessary if there is significant risk. Throughout the care pathway, promoting recovery, supporting social inclusion, and facilitating access to employment, education, and housing support are essential components, with advance statements and decisions encouraged to guide future care during periods of diminished capacity. Regular review of the care plan is essential, and for patients stable on medication for over a year, a gradual reduction of dose should be considered in consultation with the patient, with close monitoring for signs of relapse.
Assessment and diagnosis
Assessment and diagnosis of schizophrenia in the UK requires a comprehensive, multi-faceted approach, typically initiated in primary care where GPs play a crucial role in recognising potential symptoms and making an urgent referral to secondary care mental health services for specialist assessment, as per the NHS pathway; the diagnosis is primarily clinical, based on a detailed psychiatric history and mental state examination conducted by a psychiatrist or other suitably qualified mental health professional within a community mental health team (CMHT) or early intervention service (EIS), focusing on the presence of characteristic positive symptoms (such as delusions, hallucinations, and disorganised thinking) and/or negative symptoms (including avolition, blunted affect, and alogia) that have persisted for a significant portion of time during a one-month period (with some signs of the disturbance persisting for at least six months) and which are not better explained by another condition, such as schizoaffective disorder, bipolar disorder, severe depression with psychotic features, or a substance-induced psychosis.
A thorough assessment must include a full medical history, physical examination, and appropriate investigations—including routine blood tests (FBC, U&E, LFTs, glucose, lipid profile, thyroid function) and potentially neuroimaging or an EEG if indicated—to rule out organic causes, alongside a detailed substance use history, given the high prevalence of comorbid drug and alcohol use which can mimic or exacerbate psychotic symptoms. It is essential to conduct a risk assessment covering risks to self and others, as well as vulnerability, which should be documented and form part of the ongoing care plan, and to engage with family members or carers (with the patient’s consent) to gather a collateral history, which can provide invaluable information about the onset and course of the illness, premorbid functioning, and potential stressors.
Pharmacological management
Pharmacological management of schizophrenia in the UK is guided by the principle of optimising symptom control while minimising the risk of adverse effects, with antipsychotic medication forming the cornerstone of treatment; the choice of antipsychotic should be made collaboratively with the individual, following a comprehensive assessment and discussion of the potential benefits and risks of different options, including the side-effect profiles which can significantly impact adherence and quality of life. For individuals experiencing a first episode of psychosis, a second-generation antipsychotic (SGA) is typically recommended as the first-line treatment due to a generally lower propensity for extrapyramidal side effects compared to first-generation antipsychotics (FGAs), although the selection must be individualised, considering factors such as the predominant symptom profile (e.g., positive vs. negative symptoms), the person's physical health status (particularly metabolic parameters), and their personal preferences after a balanced discussion of the evidence for different medications.
If the chosen antipsychotic is ineffective or poorly tolerated after an adequate trial (typically 4-6 weeks at a therapeutic dose), switching to an alternative antipsychotic from a different class or with a different side-effect profile is recommended, and clozapine is indicated for treatment-resistant schizophrenia, defined as an inadequate response to at least two different antipsychotic drugs, including at least one SGA, each used for a sufficient duration and at an adequate dose.
Long-term care and monitoring
Long-term care and monitoring for individuals with schizophrenia in the UK is a continuous, collaborative process focused on promoting recovery, maintaining stability, and improving quality of life, requiring a coordinated approach primarily through Community Mental Health Teams (CMHTs) which provide the core structure for delivering the Care Programme Approach (CPA); the cornerstone of management involves ensuring adherence to an effective antipsychotic medication regimen, with regular review of its efficacy and side-effects, and consideration of depot/long-acting injectable antipsychotics for those where adherence is a concern, alongside the provision of psychological interventions such as Cognitive Behavioural Therapy for psychosis (CBTp) and family interventions, which are recommended to be available to all patients and their families. Physical health monitoring is a critical and often neglected aspect, necessitating annual physical health checks that include monitoring of weight, waist circumference, blood pressure, blood glucose, and lipid profile to mitigate the significantly increased risk of metabolic syndrome, cardiovascular disease, and premature mortality, with clear pathways for intervention and referral to primary care or specialist services as needed.