Assessment

For all people who misuse alcohol, carry out a motivational intervention as part of the initial assessment. The intervention should contain the key elements of motivational interviewing including:

• helping people to recognise problems or potential problems related to their drinking
• helping to resolve ambivalence and encourage positive change and belief in the ability to change
• adopting a persuasive and supportive rather than an argumentative and confrontational position."

Pharmacological interventions

The choice of medication and doses depend on the current situation, for example assisted withdrawal, relapse prevention or maintenance of abstinence.

• The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam) on a fixed-dose regimen starting at a standard dose and reducing the dose to zero over 7 to 10 days.
• After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate or oral naltrexone in combination with an individual psychological intervention

Psychological and psychosocial interventions

Offer a psychological intervention (such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol-related cognitions, behaviour, problems and social networks.

NICE-guideline

Assessment

When assessing suspected bipolar disorder:

• undertake a full psychiatric assessment, documenting a detailed history of mood, episodes of overactivity and disinhibition or other episodic and sustained changes in behaviour, symptoms between episodes, triggers to previous episodes and patterns of relapse, and family history
• assess the development and changing nature of the mood disorder and associated clinical problems throughout the person’s life (for example, early childhood trauma, developmental disorder or cognitive dysfunction in later life)
• assess social and personal functioning and current psychosocial stressors
• assess for potential mental and physical comorbidities
• assess the person’s physical health and review medication and side effects, including weight gain
• discuss treatment history and identify interventions that have been effective or ineffective in the past
• encourage people to invite a family member or carer to give a corroborative history
• discuss possible factors associated with changes in mood, including relationships, psychosocial factors and lifestyle changes
• identify personal recovery goals.

Pharmacological interventions

If a person develops moderate or severe bipolar depression and is not taking a drug to treat their bipolar disorder, offer fluoxetine combined with olanzapine, or quetiapine on its own, depending on the person’s preference and previous response to treatment.

• If the person prefers, consider either olanzapine (without fluoxetine) or lamotrigine on its own.
• If there is no response to fluoxetine combined with olanzapine, or quetiapine, consider lamotrigine on its own.

Psychological and psychosocial interventions

Offer adults with bipolar depression:

• a psychological intervention that has been developed specifically for bipolar disorder and has a published evidence-based manual describing how it should be delivered or
• a choice of psychological intervention (cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy) in line with the advice on treatment options for more severe depression.

Discuss with the person the possible benefits and risks of psychological interventions and their preference. Monitor mood for signs of mania or hypomania or deterioration of the depressive symptoms.

NICE-guideline

Assessment

When assessing a person with possible borderline personality disorder in community mental health services, fully assess:

• psychosocial and occupational functioning, coping strategies, strengths and vulnerabilities
• comorbid mental disorders and social problems
• the need for psychological treatment, social care and support, and occupational rehabilitation or development
• the needs of any dependent children

Pharmacological interventions

Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk-taking behaviour and transient psychotic symptoms).

Drug treatment may be considered in the overall treatment of comorbid conditions.

Psychological and psychosocial interventions

When considering a psychological treatment for a person with borderline personality disorder, take into account:

• the choice and preference of the service user
• the degree of impairment and severity of the disorder
• the person’s willingness to engage with therapy and their motivation to change
• the person’s ability to remain within the boundaries of a therapeutic relationship
• the availability of personal and professional support.

For women with borderline personality disorder for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy programme.

NICE-guideline

Assessment

Conduct a comprehensive assessment that does not rely simply on a symptom count when assessing a person who may have depression, but also takes into account severity of symptoms, previous history, duration and course of illness. Also, take into account both the degree of functional impairment and/or disability associated with the possible depression and the length of the episode.

Discuss with the person how the factors below may have affected the development, course and severity of their depression in addition to assessing symptoms and associated functional impairment:

• any history of depression and coexisting mental health or physical disorders
• any history of mood elevation (to determine if the depression may be part of bipolar disorder)
• any past experience of, and response to, previous treatments
• personal strengths and resources, including supportive relationships
• difficulties with previous and current interpersonal relationships
• current lifestyle (for example, diet, physical activity, sleep)
• any recent or past experience of stressful or traumatic life events, such as redundancy, divorce, bereavement, trauma (also see the NICE guideline on post-traumatic stress disorder)
• living conditions, drug (prescribed or illicit) and alcohol use, debt, employment situation, loneliness and social isolation. "

Pharmacological interventions

When offering a person medication for the treatment of depression, discuss and agree a management plan with the person. Include:

• the reasons for offering medication
• the choices of medication (if a number of different antidepressants are suitable)
• the dose, and how the dose may need to be adjusted
• the benefits, covering what improvements the person would like to see in their life and how the medication may help
• the harms, covering both the possible side effects and withdrawal effects, including any side effects they would particularly like to avoid (for example, weight gain, sedation, effects on sexual function)
• any concerns they have about taking or stopping the medication (also see the recommendations on stopping medication).

Make sure they have written information to take away and to review that is appropriate for their needs.

Psychological and psychosocial interventions

Consider one of the following psychological treatment options if the patient experiences an episode of moderate or severe depression:

• Combination of individual CBT and an antidepressant
• Individual CBT
• Individual behavioural activation

NICE-guideline

Assessment

Carry out a comprehensive multidisciplinary assessment of people with psychotic symptoms in secondary care. This should include assessment by a psychiatrist, a psychologist or a professional with expertise in the psychological treatment of people with psychosis or schizophrenia. Address the following domains:

• psychiatric (mental health problems, risk of harm to self or others, alcohol consumption and prescribed and non-prescribed drug history)
• medical, including medical history and full physical examination to identify physical illness (including organic brain disorders) and prescribed drug treatments that may result in psychosis
• physical health and wellbeing (including weight, smoking, nutrition, physical activity and sexual health)
• psychological and psychosocial, including social networks, relationships and history of trauma
• developmental (social, cognitive and motor development and skills, including coexisting neurodevelopmental conditions)
• social (accommodation, culture and ethnicity, leisure activities and recreation, and responsibilities for children or as a carer)
• occupational and educational (attendance at college, educational attainment, employment and activities of daily living)
• quality of life
• economic status.

Pharmacological interventions

For people with an acute exacerbation or recurrence of psychosis or schizophrenia, offer oral antipsychotic medication or review existing medication. The choice of drug should be influenced by the same criteria recommended for starting treatment. Take into account the clinical response and side effects of the service user’s current and previous medication.

Psychological and psychosocial interventions

• Offer CBT to all people with psychosis or schizophrenia
• Offer family intervention to all families of people with psychosis or schizophrenia who live with or are in close contact with the service user. This can be started either during the acute phase or later, including in inpatient settings.

NICE-guideline

Consider a brief course of CBT involving 12 weekly or biweekly sessions of 60-90 minutes with the following key elements:

• Safety plan (see separate module)
• Basic emotion regulation skills (relaxation, mindfulness, other skills identified by patient)
• Cognitive strategies to reduce beliefs and assumptions that serve as vulnerabilities to suicidal behavior (hopelessness, perceived burdensomeness, guilt and shame)
• Relapse prevention (i.e., identifying precipitating factors and practicing coping skills)

Additional reading

Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., Williams, S. R., Arne, K. A., Breitbach, J., Delano, K., Wilkinson, E., & Bruce, T. O. (2015). Brief Cognitive-Behavioral Therapy Effects on Post-Treatment Suicide Attempts in a Military Sample: Results of a Randomized Clinical Trial With 2-Year Follow-Up. American Journal of Psychiatry, 172(5), 441–449. https://doi.org/10.1176/appi.ajp.2014.14070843

Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive-behavioral therapy for suicide prevention. The Guilford Press.

DBT is a comprehensive psychological treatment program that should be delivered by therapists with adequate training.

DBT directly targets (1) suicidal behavior, (2) behaviors that interfere with treatment delivery, and (3) other dangerous, severe, or destabilizing behaviors. The treatment addresses the following five functions: (1) increasing behavioral capabilities, (2) improving motivation for skillful behavior, (3) assuring generalization of gains to the natural environment, (4) structuring the treatment environment so that it reinforces functional rather than dysfunctional behaviors, and (5) enhancing therapist capabilities and motivation to treat patients effectively.

There are four modes of service delivery: (1) individual psychotherapy once per week, (2) group skills training once per week, (3) telephone consultation as needed, and (4) weekly therapist consultation team meetings.

Additional reading

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., Korslund, K. E., Tutek, D. A., Reynolds, S. K., & Lindenboim, N. (2006). Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder. Archives of General Psychiatry, 63(7), 757–766. https://doi.org/10.1001/archpsyc.63.7.757

Linehan, M. (2015). DBT skills training manual (Second edition). The Guilford Press.