People with an established diagnosis of schizophrenia commonly have care shared between a specialist mental health team and primary care. However, GP’s and primary health care professionals should monitor the physical and mental health and the social needs of the patient annually.

Physical Health Review
It is vital that patients with schizophrenia that are taking long-term antipsychotics undergo routine physical health monitoring. This is because:

 

• People with schizophrenia typically have an increased risk for the development of cardiovascular disease, diabetes and dyslipidaemia. This could be a result of poor lifestyle choices such as a high fat diet, smoking and a lack of exercise.
• There is an increased risk of metabolic syndrome which is associated with atypical antipsychotic drugs. The metabolic syndrome is described as a cluster of abnormalities including obesity, hyperlipidaemia, hypertension and hyperglycaemia which can increase the risk of cardiovascular disease. 

A physical health review should take into account: 
• Side effects of the medication
• Blood tests
• Assessing cardiovascular risk (people with schizophrenia are at higher risk of      cardiovascular disease than the general population).
• Weight and body mass index.
• Blood pressure.
• Smoking status.
• Alcohol intake.
• Substance misuse.

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​Mental Health Review
A mental health review should include:
• Assessment of symptom control by:
 -Screening for psychotic symptoms.
 -Assessing for any decline in personal functioning. This can be achieved by asking about any changes in work, academic achievement, social interaction, or personal care.
 -Assessing for depression and anxiety.
• Review adherence to medication and any adverse effects experienced. 
• Arranging annual antipsychotic drug monitoring if not undertaken in secondary care.
• Asking about illicit drug use.
• Arranging a specialist review if medication compliance is poor, symptoms are poorly controlled, or adverse effects are poorly tolerated.



Social Needs Review

The social needs review should consider:
• Whether the individual is receiving support from family and carers. Referral to a Community Mental Health Team (CMHT) can be considered to manage any problems or conflicts that can result in a relapse.
• Those individuals with schizophrenia and their carer’s are made aware of the support available with regards to employment, education, housing options, and entitlements to benefits and driving.