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NICE CG178 Psychosis and Schizophrenia in Adults: Treatment and Management – an evidence-based guideline?

  • Mark Taylor (a1) and Udayanga Perera (a2)

National Institute for Health and Care Excellence (NICE) clinical guideline (CG)178 was published in 2014. NICE guidelines occupy an important international position. We argue that CG178 overemphasises the use of cognitive–behavioural therapy for schizophrenia and those ‘at risk’ of psychosis, with recommendations that do not always reflect the evidence base. The CG178 recommendations on medications are limited.

Corresponding author
Mark Taylor, NHS Lothian, Royal Edinburgh Hospital, Edinburgh EH10 5HF, UK. Email:
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Declaration of interest

M.T. chaired the SIGN 131 guideline, and has accepted fees and/or hospitality from Endo, Janssen, Lundbeck and Roche in the past 3 years.

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2 National Collaborating Centre for Mental Health. Psychosis and Schizophrenia in Adults: Treatment and Management. NICE Clinical Guideline 178. NICE, 2014 (
3 National Collaborating Centre for Mental Health. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care. NICE Clinical Guideline 82. NICE, 2009.
4 Scottish Intercollegiate Guidelines Network. Management of Schizophrenia: A National Clinical Guideline. SIGN 131. SIGN, 2013 (
5 Tiihonen, J, Lönnqvist, J, Wahlbeck, K, Klaukka, T, Niskanen, L, Tanskanen, A, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009; 374: 620–7.
6 Stafford, MR, Jackson, H, Mayo-Wilson, E, Morrison, AP, Kendall, T. Early intervention to prevent psychosis: systematic review and meta-analysis. BMJ 2013; 346: f185.
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NICE CG178 Psychosis and Schizophrenia in Adults: Treatment and Management – an evidence-based guideline?

  • Mark Taylor (a1) and Udayanga Perera (a2)
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Taylor, M. and Perera, U. (2015) NICECG178 Psychosis and Schizophrenia in Adults: Treatment and Management-an evidence-based guideline?

Fiona M. Martin, Lecturer (Nursing), THORN Steering Group
29 July 2015

Dear Sir,

Taylor and Perera (2015) pose some challenging questions regarding the National Institute for Health and Care Excellence (NICE) clinical guideline (CG178): Psychosis and schizophrenia in adults. I would particularly like to draw attention to their discussion surrounding Cognitive Behaviour Therapy (CBT). In the first instance CBT is recommended by NICE (2015) as a treatment of choice very early in the patient’s journey. In addition the clinical guideline (CG178) focuses exclusively on CBT in the traditional sense but does not discuss/include/make reference to CBTp (CBT for psychosis) CBa (Cognitive Behavioural Approaches) and CBi (Cognitive Behavioural Interventions), all of which are psychological approaches that are currently employed in practice.

Traditional CBT, as recommended in the NICE guideline (2015), is a therapy that focuses on symptoms and behaviour interaction. It is typically time limited and the patient needs to be quite well and have the motivation to engage with the therapy. CBTp/CBa/CBi on the other hand, use the principles of CBT; but are not as intensive therapeutically. They involve working with patients who may be still quite ill and at a pace that reflects their stage of recovery. CBTp/CBi/CBa aim to engage the patient in a broader psychosocial/normalising approach, by developing an undertstandability of their psychotic experience. The aim is not to change/modify behaviours or thoughts but to reduce distress and develop resilience (Zubin and Spring, 1977; Morrison and Barrett, 2010; Kumari et al, 2011; Southwick et al, 2011). CBTp/CBi, CBa also recognises the importance of the family’s expertise and knowledge of the person experiencing psychosis, as well as the impact of psychosis on the family.

Where does this leave the current state of CBT for psychosis and schizophrenia? The first step required is clarification of these terms: CBT/ CBTp/CBa/CBi; if terms are not defined it is more difficult to measure impact and outcome. There is also a need for precision of language and definitions of interventions. Over the past 20 years we have seen health care transformed from being based on the opinions of experts, to being based on the systematic collection of evidence from clinical studies. It would seem there needs to be an improvement in how evidence is being used and the type of studies being done to assess the utility and effectiveness of psychological therapies for psychosis and schizophrenia. There is room for all effective therapies.


Kumari, V., Fannon, D., Peters, E., Ffytche, D., Sumich, A., Premukumar, A., Andrew, C., Phillips, M., Williams, S and Kuipers, E. (2011) Neural changes following cognitive behaviour therapy for psychosis: a longitudinal study. Brain. 134, 8, 2396-2407

Morrison, A.P. and Barratt, S. (2010) What are the components of CBT for psychosis? A Delphi study. Schizophrenia Bulletin. 36, 1, 136-142

Southwick, S., Litz, B., Charney, D. and Friedman, M. (2011) Resilience and Mental Health: Challenges across the lifespan. Cambridge University Press: Cambridge

Zubin, J. and Spring, B. (1977) Vulnerability-a new view of schizophrenia. Journal of Abnormal Psychology. 86, 2, 103-126

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Conflict of interest: None Declared

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RE: NICE CG178 Psychosis and Schizophrenia in Adults: Treatment and Management – an evidence-based guideline?

Dave Coghill, Professor of Child and Adolescent Psychiatry, University of Dundee
05 May 2015

I applaud Taylor and Perera for their clear discussion of these very important issues. For me the most important sentance in their piece is the last one that "CG178 appears to be open to a critique of bias". This is not the first occasion that such issues have arisen and I think that it is time for the National Institute for Health and Clinical Excellence (NICE) to take a long hard look at the relative standards that are set for making recomendations about the use of non-pharmacological and pharmacological treatments. A previous example is seen in CG 72 Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults where it would appear that lower quality of trials were allowed and lower standards of evidence were required to support behavioural approaches than for pharmacological treatments. A similar critisism can be made about CG 28 Depression in children and young people and there are no doubt others. Whilst the ultimate recomendations made in these guidelines may, on one level at least, be sensible, I believe that the evaluation and interpretation of the evidence includimng the selection of trials and assessment of their quality as well as their outcomes should be the same regardless of the mode of treatment. If NICE, who as Taylor and Perera point out occupy an extremely important position in our lives, then decide to interpret or weight evidence differently this should be clear and transparant. NICE must be above all claims of bias and need to work hard to ensure that they regain this position. ... More

Conflict of interest: Has accepted fees and/or research funding from Janssen Cilag, Shire, Lilly, Lundbeck, Novartis, Vifor in the past 3 years. Receives royalties from Oxford University press.

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