Schizophrenia affects millions of people worldwide, according to WHO, and is associated with significantly reduced life expectancy, largely due to preventable physical illnesses. Psychosis, a loss of contact with reality, can also occur in bipolar disorder, severe depression, with drug use, and with medical conditions. In many countries, people with psychosis face severe stigma and even human rights abuses such as chaining. Nurses in every setting can help by offering respectful, informed care.
Recognising psychosis
- Hallucinations: hearing, seeing or feeling things others don’t. Hearing voices is most common.
- Delusions: fixed false beliefs, such as being persecuted, controlled, or having special powers.
- Disorganised thinking and speech.
- Negative symptoms (especially in schizophrenia): withdrawal, reduced motivation, flat emotions, poor self-care.
- Cognitive difficulties: attention and memory.
Rule out medical causes
New psychotic symptoms, especially in older adults or with confusion, may be due to delirium, infection (including cerebral malaria, HIV, syphilis), head injury, epilepsy, thyroid disease, drug intoxication or withdrawal, or medicines (steroids). Assess physical health thoroughly.
Communicating with someone experiencing psychosis
- Stay calm and speak clearly and simply.
- Introduce yourself and explain what you’re doing.
- Don’t argue about delusions or hallucinations, but don’t pretend to agree either: “I don’t hear the voices, but I can see they’re frightening you.”
- Focus on feelings and practical needs.
- Give space; avoid crowding.
- Ask about command hallucinations (voices telling them to harm themselves or others) and about suicidal thoughts. People with psychosis have a raised suicide risk. See our suicide risk guide.
- Use de-escalation skills if the person becomes distressed.
Treatment
- Antipsychotic medicines (e.g. risperidone, olanzapine, haloperidol, aripiprazole; clozapine for treatment-resistant schizophrenia). Some are given as long-acting injections.
- Psychological interventions: CBT for psychosis, family interventions.
- Psychosocial rehabilitation: supported employment, housing, social skills.
- Early intervention in psychosis services improve outcomes.
- WHO’s mhGAP guide supports care in primary health settings.
Antipsychotic side effects to monitor
- Movement effects: acute dystonia (muscle spasms, eyes rolling up), parkinsonism, akathisia (restlessness), tardive dyskinesia.
- Metabolic effects: weight gain, diabetes, high cholesterol, especially with olanzapine and clozapine.
- Sedation, constipation, raised prolactin (sexual dysfunction, breast changes, missed periods), QT prolongation.
- Neuroleptic malignant syndrome: rare emergency with fever, rigidity, confusion, unstable vital signs.
- Clozapine: requires regular blood monitoring for neutropenia; constipation can be life-threatening; watch for myocarditis early in treatment.
Physical health matters
People with severe mental illness die on average many years earlier than the general population, mostly from cardiovascular disease, diabetes, respiratory disease and infections. Nurses should check weight, blood pressure, glucose, lipids and smoking, and support healthy lifestyles.
Rights and dignity
- Use person-first, respectful language: “a person with schizophrenia”, not “a schizophrenic”.
- Involve the person in decisions as much as possible.
- Any compulsory treatment must follow mental health law.
- Speak out against chaining, beating and other abuses, which still occur in some prayer camps and facilities. WHO’s QualityRights initiative promotes rights-based care.
Supporting families
Families are often the main carers and may be exhausted, frightened or blamed by their community. Provide information, include them in care planning (with consent), and connect them to support groups.
Based on WHO schizophrenia fact sheet, WHO mhGAP Intervention Guide, WHO QualityRights and NICE CG178 (Psychosis and schizophrenia in adults). Educational content.