You are a psychiatrist working in a college student healthcare center when Anna, a junior, comes to your office escorted by her resident advisor. Anna describes feeling severely depressed. Sleeping excessively, she has missed most of her classes over the last two weeks. For the past week, she has heard voices telling her she is worthless and will never amount to anything. When she walks on campus, she thinks she sees former middle school classmates who used to bully her and wonders if they are going to harm her. She has started to think she would be better off dead, but denies any current plans to harm herself.
Evaluating a first episode of psychosis in college students is challenging—it’s not clear from the outset if the episode will represent a one-time occurrence or the start of a lifelong illness. The differential diagnosis is large and includes depression with psychotic features, bipolar disorder, a primary psychotic disorder like schizophrenia or schizoaffective disorder, drug-induced psychosis, and transient psychotic episodes. Here are the five ways I try to narrow down the possibilities during an initial evaluation.
1. Develop an alliance
College students with psychosis who come into my office, whether on their own or encouraged by university personnel, are usually in a great deal of distress. The sources of distress are generally twofold: the experience of psychosis itself and the accompanying academic difficulties. You can best develop an alliance with college students by rapidly acknowledging their distress and informing them you will work together to decrease that distress and improve academic functioning. When I first met with Anna, she spoke minimally while fearfully staring out the window. I gently asked her if she was concerned about anything outside. She said she had the feeling that classmates from middle school were hiding in the bushes outside and were following her. Afraid to go to class, she had fallen significantly behind in her work. I told Anna I understood how distressed she must be feeling, and that I would work with her to help her feel safe so she could get to class and achieve her academic goals. Anna sighed, looked at me tearfully, and said, “I’ll be really glad if you can help me.”
2. Ask targeted questions to narrow down the diagnosis
To distinguish between a primary psychotic disorder and mood disorder with psychotic features, ask about the patient’s current and past history of depressive, manic or hypomanic, and psychotic symptoms. I asked Anna if her feelings of being followed were new or if she’d had them for a long time. She revealed that she had been cyberstalked and sometimes physically harassed in middle school, but said these events had stopped when she moved to another school; the feelings of being followed had only resurfaced recently. I asked Anna if she had felt either revved up or sad before the voices started. She told me she had been feeling depressed the whole semester, but started feeling worse a few weeks ago and began sleeping all the time. When asked if she had ever been treated for depression before this episode, Anna said she had taken Lexapro during high school for about 6 months. I made a diagnosis of depression with psychotic features based on the recurrence of depression and the new onset of psychotic symptoms during an episode of depression.
3. Consider the developmental and family history
While we often consider psychosis to be mainly a biologically based disorder, it’s important to probe for potential developmental aspects. I find it helpful to bring parents into this discussion if possible. Anna’s mother confirmed that Anna was severely bullied in middle school. Research has shown that being bullied increases the risk of depression and psychotic symptoms (Wolke D et al, Psychological Medicine 2014;44:9(10):2199–2211), and indeed some of Anna’s psychotic symptoms centered on bullying. In addition, Anna’s uncle had a diagnosis of schizophrenia; having a second-degree relative with schizophrenia increases the lifetime risk of having this disorder to 4%, versus 1% for others (Gejman P et al, Psychiatr Clini North Am 2010;33(1):35–66). While Anna’s diagnosis was consistent with depression with psychotic features, schizophrenia should be considered in a patient’s differential diagnosis.
4. Probe to see if drugs could have played a role in the psychosis
In my experience, psychosis in college students is frequently associated with drug use. Common culprits include overuse of recreational psychostimulants, chronic use of cannabis with high THC content, and regular use of hallucinogens like LSD. In fact, the most complicated episodes of psychosis I have treated are recurrent episodes in students who use one or several drugs. When I inquired about any substance use, Anna denied drinking or using drugs.
5. Rule out medical causes of psychosis
While medical causes of psychosis are rare in the college-aged population, I recommend ordering a standard battery of tests in any case of first episode psychosis. This includes a comprehensive metabolic panel (electrolytes, renal function tests, liver function tests), glycosylated hemoglobin, thyroid function tests, lipid panel, B12, folate, and urine drug screen. Consider testing for syphilis, HIV, hepatitis B, and hepatitis C if the patient is sexually active and ordering a CT scan or an MRI, as well as a neurology referral, if a student has an unusual clinical picture or describes neurological symptoms like worsening headaches or seizure-like movements.
Comprehensive treatment approach
My approach to treating psychosis in college students is aligned with a comprehensive treatment system demonstrated by the RAISE study to improve functional outcomes in adults (mean age of 23) with first episode psychosis (Kane JM et al, Am J Psychiatry 2016;173:(4):362– 372). Conducted at community mental health centers over a two-year period, the RAISE study enrolled 223 participants in the NAVIGATE system of manual-based care, and 181 in usual care. NAVIGATE consisted of personalized medication management, family psychoeducation, resilience-focused individual therapy, and supported employment and education. (See TCPR, November/December 2015 for a Research Update on NAVIGATE for psychosis.) The NAVIGATE recipients had significantly better outcomes: They were more likely to stay in treatment, had fewer symptoms, and were more likely to participate in work and school.