The NAVIGATE family education and therapy model is particularly relevant to working with college students. After a few introductory sessions, patients and their families meet with a counselor for 10–12 weekly sessions to focus on improved communication among family members, relapse prevention, and suicide prevention. Family members are encouraged to reinforce progress by observing and praising what the patient is doing well in life, which could be volunteering while taking a semester off or registering for a few classes. These weekly sessions are followed by monthly check-ins, either in person or by phone.
The NAVIGATE approach also has a supported education and employment (SEE) specialist working closely with the patient to encourage engagement in work or education. The SEE specialist will regularly meet with the patient to set a goal of finding employment or education within the next three months. The specialist may go with the patient to the job interview or to visit the campus if the patient needs additional support and will continue to provide support even after school or a job begins.
It’s important to note that while the RAISE study constitutes an ideal kind of treatment, you might not be able to offer all aspects of it when resources are limited, either in the college setting or after a student takes time off from college. But as orchestra leader, you do what you can to put into place as comprehensive a plan as possible, so you can at least use the RAISE points as guideposts. You can view the manuals for the NAVIGATE system online at http://www.raiseetp.org/studymanuals/index.cfm.
Evaluate safety/level of treatment needed
The first stage of treatment is to decide what sort of treatment environment your patient needs—outpatient, inpatient, or something in between? Concerned about Anna’s auditory hallucinations and passive suicidal thoughts, I asked her to describe the voices in more detail. Anna said unknown men’s voices told her that she was worthless and her life did not matter. I asked if they ever ordered her to harm herself, and she said no, but she admitted thinking it might be easier if she were dead. She would not harm herself now, she said, but if she continued to experience her current level of depression, she might consider suicide in the future. Although Anna described a potential future risk of suicide, I concluded that she was not in imminent danger of harming herself, and because her mother was able to stay with her, I felt comfortable seeing her as an outpatient. Had there not been a parent nearby, I might have recommended that she stay in a peer respite unit, a supportive inpatient environment that is not as restrictive as a locked psychiatric unit.
Start appropriate medication
To treat psychotic depression, I often prescribe an antidepressant and a low dose of an antipsychotic that is not overly sedating. Good non-sedating options include risperidone, aripiprazole, and lurasidone. I have found lurasidone quite effective for bipolar depression in students, although this medication is costly and insurance companies will not always cover it. For students with psychosis and prominent insomnia, I will often use quetiapine. I prescribed Anna escitalopram as well as a low dose of risperidone.
Get the family involved
Parent support through phone calls or visits can be critical when students are feeling overwhelmed or struggling with suicidal thoughts. Parents can also act as consultants, helping students decide whether to stay in school or facilitating the process of taking a medical leave. I recommended that Anna’s mother stay in town for a few days until Anna felt safe and showed some response to her medications. I find this to be a reasonable alternative to hospitalization, which poses its own challenges. Anna confirmed that if her voices escalated to the point that she felt she would hurt herself, she would tell her mother and would agree to hospitalization.
Ensure the patient receives psychotherapy
Encourage your patient to undergo individual and/or group therapy with a therapist who has experience working with people with psychosis. Anna participated in an educational group called the Wellness Recovery Action Plan® (WRAP®) (http://mentalhealthrecovery.com/wrap-is/). Each group session focused on specific aspects of wellness and recovery: identifying wellness tools that could keep her feeling good most days, understanding the triggers that bring on symptoms, and creating action plans for when symptoms return or escalate. Anna developed a plan—if the voices became more threatening, she would at first try to distract herself by spending time with her roommate. Next, she would call her mother or a friend. She would also contact our counseling center on-call system or see me the next day about a medication adjustment. Knowing she had a plan made her feel more empowered to cope with the voices.
Ensure peer support
Peer support that focuses on wellness and recovery is helpful for young adults with chronic psychotic symptoms. Encourage your patient to join Active Minds (http://www.activeminds.org) or any other peer support group on campus. You can link your patient to community peer support groups offered by organizations like the National Alliance on Mental Illness (http://nami.org) and the Depression and Bipolar Support Alliance (http://dbsalliance.org). Anna obtained peer support in her WRAP group and continued to connect with members even after the group sessions had ended.
Consider vocational rehab
Vocational rehab programs also exist in many communities to link patients who experience chronic mental health issues to meaningful work. Campus case managers can recommend programs if your patient needs to take time off from school.
Work closely with the college
Some students may be unable to remain in college due to psychotic symptoms. They may not be adherent to medication and therapy, they may continue to use drugs that exacerbate their symptoms, or they may have a more severe form of psychosis that is not responsive to treatment. Contacting the dean of students’ office or a case manager in the counseling center directly can help with coordinating a reduced course load or other accommodations, or facilitating the patient’s transition to more intensive treatment, such as a partial hospitalization or intensive outpatient program.
In Anna’s case, I called the dean of students’ office and helped Anna and her mother make an appointment with a case manager to decide if she should reduce her course load or medically withdraw from the semester. I told Anna that I could write a letter to support whatever decision she made. Anna thought she would be okay if she dropped two of her classes; she had kept up with work in the other two. I also recommended Anna register with the campus disability resource center so she could get extra support and coaching regarding her school work.
It is critical to offer patients hope. The suicide rate for people with psychotic disorders is highest in the first year after diagnosis (Ventriglio A et al, Front Psychiatry 2016;7:116), so you want to throw out the lifeline of hope to attenuate suicidal urges. College students may feel hopeless if they are not able to keep up with academic work due to cognitive difficulties stemming from psychosis or medication. Fortunately, the comprehensive treatment outlined above does improve outcomes. I let Anna and her mother know that I have successfully worked with other students with similar symptoms. Some have had to reduce their course load or take a semester off from school, while others have not had to take any time off at all.
CCPR VERDICT: There is something of a wild card aspect to cases involving psychosis, because you don’t know up front if the patient is experiencing a onetime episode or the first sign of a chronic, ongoing condition. Still, regardless of the particular path needed, providing a comprehensive and collaborative approach offers our patients the best chance of a mindset of recovery and purpose.