Care Cluster10: First Episode Psychosis

Description: This group of patients will be presenting to the service for the first time with mild to severe psychotic phenomena.

Cluster Duration: 3 years (6 monthly review interval).

Aim of Intervention: Early engagementto provide a package of assessment and care for patients with a first episode of psychosis and prevent relapse

Assessment:Ensureclear referral routes e.g. from primary care and other secondary care mental health services and prompt access to assessment for suspected first episode psychosis to reduce the Duration of Untreated Psychosis. Person- centred holistic multi -disciplinary assessment taking into account the individual, his/her environment, social circumstances, and physical and mental well- being. Additional Assessments to be considered where there are co-existing conditions.

Assessment process may last for up to 6 weeks

Note: The resource allocation and frequency of contact will be based on the individual service user/career needs and on the course of the illness. This will be mutually agreed by the clinician and service user/carer where appropriate.

No / Item Description / Rating
0 / 1 / 2 / 3 / 4
1 / Overactive, aggressive, disruptive or agitated behaviour
2 / Non-accidental self-injury
3 / Problem drinking or drug taking
4 / Cognitive Problems
5 / Physical Illness or disability problems
6 / Hallucinations and Delusions
7 / Depressed mood *
8 / Other mental and behavioural problems *
9 / Relationships
10 / Activities of daily living
11 / Living conditions
12 / Occupation & Activities
13 / Strong Unreasonable Beliefs
A / Agitated behaviour/expansive mood
B / Repeat Self-Harm
C / Safeguarding other children & vulnerable dependant adults
D / Engagement
E / Vulnerability
Must Score
Expected to Score
May Score
Unlikely to Score
Function / Resource / Time / Frequency / Outcome
1: Treatment Planning / Core Interventions
  • Ensure assessment complete
  • Assess level of engagement
  • Allocate care co-ordinator/lead professional
  • Review risk- identify coping strategies and strengths for managing distress and dealing with difficulties
  • Personal goal setting linked to assessment of emotional impact of symptoms and individual experiences
  • Comprehensive clinical assessment including consideration of physical health needs
  • Diagnosis/problem Summary
  • Bio-Psycho-social formulation
  • Physical assessment
  • Assessing for co-morbidity relating to substance misuse
  • Check co-morbidity relating to personality disorder
  • Medication review/ metabolic monitoring
  • Choice of treatment, plan, review predict and evaluate
  • Consideration of any safeguarding issues
  • Assessment of carer / family (including dependents) needs and signpost where appropriate
  • Social/housing/benefits support
  • Legal support if under MHA
  • Clarify goals for patient
  • Assess need for acute inpatient care pathway
/ Care Coordinator/Lead Professional
Psychiatrist
Other disciplines may be involved according to clinical presentation
Other professional or agency e.g.
•MIND
•Probation
•Social services / 1 – 2 hours / 1-2 sessions
(recorded via MDT meetings and face to face meetings) / All patients will be screened for CPA
Provided patient information leaflet about diagnosis
Provided with care plan
Morgan Risk Assessment completed
Patients offered choice of:-
  • Medication (different types)
  • Psychological interventions (where appropriate) and provided with relevant information about medication
Carers assessment where appropriate
Offered copying correspondence where appropriate
Compliance with NICE
2: Delivery
(up to week 36) / Core Interventions
  • Care plan in line with CPA.
  • On-going evaluation of treatment plan
  • Identify goals
  • Psychological and social interventions as identified by assessment, including psycho-education
  • Consideration of physical health checks
  • Pathway co-ordination, on- going evaluation and review, review of risk
  • Development crisis and contingency plans
  • Relapse prevention
  • On-going assessments/review
  • Pharmacological / Medical intervention
/ Care Coordinator/ lead Professional/
Psychiatrist/support staff/psychology / 1 hour / Month 1-6
Offered once every 1-2 weeks
Month 7-36
Between two weekly and four weekly according to need and negotiation with service user:
Frequency may vary according to clinical presentation
and negotiation with service user / If patient on CPA, review
Provide updated care plan
Compliance with NICE guidance
6 Monthly:-
  • HoNOS and cluster review
  • Service user experience questionnaire
  • Carer experience Questionnaire (if appropriate)

Supplementary Interventions
  • Group or individual evidence based psychological intervention for patient and or family (CBT). Initially provided by Care Coordinator/ Lead Professional within 8 weeks of being offered intervention.
  • ADL/OT assessment and/or assistance with maintaining or developing social/educational/ vocational occupation (individual or group)
  • Assist/signpost where there are needs in relation to accommodation/benefits
  • Metabolic and physical monitoring depending on medication
  • In- patient treatment where appropriate
  • Crisis resolution and home treatment where appropriate
  • Liaison with any other involved agencies
/ Care co-ordinator/Lead Professional/
Psychologist/ Therapist (refer to relevant care pathway for psychological therapies) / 1 hour / Up to 16 sessions with review
As required
As required
As required
As required / Psychological Therapy
(If appropriate)offered
Metabolic Monitoring
Admission to hospital
3: Review (in line with CPA Policy) / Core Interventions
  • Review patients’ strengths, achievements and goals in line with recovery model
  • Bio-psycho-social review
  • HoNOS/Cluster review. Re- cluster if required / continue pathway/discharge
  • CPA review/ contingency planning/ risk assessment in line with CPA Policy
  • Carer review
/ Care Coordinator/Lead professional
Include Service user and all involved in their care / 1-2 hours / 6 monthly / HoNOS and cluster review completed 6 monthly
Updated care plan/risk assessment/
crisis and contingency plan
CPA Review once every 6 months (if on CPA)
Service user/carer experience Questionnaire
4: Next steps /
  • Referral for on-going supportwhere significant needs remain e.g.
  • Social Services
  • GP (on going metabolic monitoring 12 – 36 months where appropriate)/physical health needs
  • Secondary Physical Health Care Services
  • In-patient treatment if necessary
  • Crisis Resolution Team if necessary
  • Forensic Services
  • Personality Disorder Services
  • Drug and alcohol services
  • IAPT
  • Assertive Outreach
  • Manage ending and transition
  • Sign posting for on-going carer support
  • Sustained improvement- discharge back to GP with full summary and advice for future management and possible 3rd sector involvement. To include suggestions regarding length of on-going treatment/prescribing, any risk factors, and consideration of referral to IAPT Mental Health Facilitator and how to refer to LPT should there be a relapse.
  • Re- engagement and contingency planning discussed
/ Care Coordinator/Lead Professional/
Psychiatrist / As per clinical need / As per clinical need / Service user/ Carer Experience questionnaire (when discharged from service)
Handover CPA
Most Likely Transition: / 10
Possible Transition: / Discharge, 8, 11. 12, 13, 14, 15, 16, 17 & 18
Rare transitions: / 1, 2, 3, 4, 5, 6, 7, 19, 20, 21
National Guidance and Guidelines
Core Guidance
Schizophrenia
Bi polar
Psychosis and Younger People
Dual Diagnosis
Supplementary Guidance

FINAL VERSION 24.04.13 - 1