Psychiatry Research 284 (2020) 112699

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Letter to the Editor

Treatment and services for psychosis: Are college campuses a novel frontier for early detection and T
intervention?

Psychosis and the diagnostic context of schizophrenia spectrum over 36,000 students. Counselors at these colleges are connected and
disorders describe clinically significant positive symptoms (delusions, have received accredited specialty workshops in early psychosis edu-
hallucinations), negative symptoms (social withdrawal, flat affect) and cation from our team of psychiatrists at the UMass Medical School.
neurocognitive impairment that often present during adolescence and Counselors can refer students with symptoms of serious mental illness
early adulthood. Early identification of the prodrome, the time when to our UMass College Consultation Service that then guides individuals
attenuated psychotic symptoms emerge, predicts a high-risk phase for at risk of FEP to our Screening and Treatment of Early Psychosis (STEP)
psychotic disorder development and is critical for long-term recovery outpatient clinic that provides comprehensive evaluation, medication
and maintaining a high quality of life. The peak incidence of the pro- treatment, psychotherapy, substance use treatment, family education
dromal period leading up to first-episode psychosis (FEP) occurs in the and therapy and integrated primary care. STEP serves as a gatekeeper
late teens and early 20s, coinciding with the typical age of college en- to the mental health system for these students, helping to connect them
rollment. Delayed recognition of FEP due to the insidious pattern of to community programs and CSC while they attend or return to college .
behavioral and perceptual disturbances impacts academic performance, Such emphasis on intensive individualized care for young patients aims
work activities and interpersonal relations (Kane et al., 2016). Given to empower them to act as primary and active participants in their own
the chronic and costly state of psychotic illness, early detection and education and recovery.
intervention to treat or prevent the onset of psychosis in the college Moreover, existing models for mental health education and aware-
setting offers significant potential for improved outcomes. ness on college campuses should be adapted for early psychosis re-
More than 20 million students are enrolled in colleges and uni- cognition. With over a decade of effort, campus and community re-
versities across the United States and have access to mental health sources have integrated education and advocacy for the QPR (Question,
services mainly focused on depression, anxiety and eating disorders. Persuade, and Refer) Gatekeeper Training for Suicide Prevention. This
Still, college campuses stand unequipped to detect and deal with early short educational program has trained thousands of students, faculty
psychosis among students. Individuals experiencing FEP with a longer and staff to recognize and help students in distress (Hangartner et al.,
duration of untreated psychosis (DUP) (e.g. >1-1.5 years without 2019). Uniting the college community to support distressed students
treatment) experience smaller improvements in clinical and functional and connect them to the appropriate resources serves to promote
outcomes compared to those receiving earlier intervention (Kane et al., community wellness and decrease social isolation. Education on the
2016). Implementation of on-campus psychosis programs can reduce warning signs and importance of help-seeking behaviors for early psy-
perceived stigma of psychotic symptoms and decrease the dropout rate chosis could occur in parallel with already established mental health
among students with FEP, thus raising retention and graduation rates. programs on college campuses. Importantly, accredited training in early
Coordinated specialty care (CSC) uses a comprehensive treatment psychosis intervention from experts in psychosis care should be pro-
approach involving a multidisciplinary team and family members to vided to on-campus health professionals as misdiagnosis or unconscious
provide person-centered interventions for FEP. The National Institute of stigmas often prevent or delay student treatment or referral to off-
Mental Health-supported NAVIGATE program includes four core ser- campus specialty programs.
vices following the CSC model: family psychoeducation, individual re- Primary care structured screening conducted at student health
silience training, supported employment and education and medication centers appears a helpful starting point in bringing psychosis-specific
management. A two-year study comparing the effectiveness of the screening interventions onto the college campus. At the eight uni-
NAVIGATE program to that of community care in patients with FEP versities participating in the College Breakthrough Series-Depression
found that NAVIGATE recipients underwent a longer duration of Project study, over 71,000 students (69%) screened positive for de-
treatment and demonstrated improved psychopathology, quality of life pression in their primary care visit at their respective student health
and participation in school and work compared to participants in usual centers. Approximately 800 students with depressive symptoms re-
community care (Kane et al., 2016). Following NAVIGATE's success, ceived treatment through an experimental chronic care model which
Congress has allotted a significant and increasing amount of block grant achieved most of its predetermined treatment goals and outcomes
funds for CSC programs. There now exists over 270 CSC-FEP treatment (Chung et al., 2011). Including voluntary psychosis screening during
programs, with at least one in every state (Lutterman, 2018). routine student visits at college health centers may serve as a practical
College campuses could implement one or more elements of the CSC approach for early psychosis detection and intervention. Existing
model depending on student health center resources and staff training. screening tools such as the Prodromal Questionnaire-Brief (PQ-B),
However, a more effective early psychosis intervention initiative will Youth Psychosis At-Risk Questionnaire-Brief (YPARQ-B) or Prime
undoubtedly rely on partnerships formed between college student Screen-Revised (PS-R) could be utilized (Kline and Schiffman, 2014).
health centers and professional mental health providers. For example, Early psychosis services and resources that adopt the principles of
Worcester, Massachusetts is home to nine colleges and universities with the CSC model are lacking on college campuses. A combination of a top-

https://doi.org/10.1016/j.psychres.2019.112699
Received 24 August 2019; Received in revised form 17 November 2019; Accepted 22 November 2019
Available online 22 November 2019
0165-1781/ © 2019 Elsevier B.V. All rights reserved.
Letter to the Editor Psychiatry Research 284 (2020) 112699

down and bottom-up approach appears needed: collaboration between C., 2011. A pilot for improving depression care on college campuses: results of the
professional mental health providers that provide high-quality early College Breakthrough Series-Depression (CBS-D) project. J. Am. Coll. Health 59 (7),
628–639.
psychosis intervention and college student health centers to develop Hangartner, R.B., Totura, C.M.W., Labouliere, C.D., Gryglewicz, K., Karver, M.S., 2019.
CSC networks can lead to the establishment of pipelines for at-risk Benchmarking the "question, persuade, refer" program against evaluations of estab-
students to be referred to treatment programs; meanwhile, educating lished suicide prevention gatekeeper trainings. Suicide Life Threat Behav. 49 (2),
353–370.
the campus community helps break stigma surrounding psychosis while Kane, J.M., Robinson, D.G., Schooler, N.R., Mueser, K.T., Penn, D.L., Rosenheck, R.A.,
training and screening can link students to on-campus resources or off- Addington, J., Brunette, M.F., Correll, C.U., Estroff, S.E., Marcy, P., Robinson, J.,
campus health providers. For high-risk college-aged students, raising Meyer-Kalos, P.S., Gottlieb, J.D., Glynn, S.M., Lynde, D.W., Pipes, R., Kurian, B.T.,
Miller, A.L., Azrin, S.T., Goldstein, A.B., Severe, J.B., Lin, H., Sint, K.J., John, M.,
awareness of early psychosis detection and implementing treatment Heinssen, R.K., 2016. Comprehensive versus usual community care for first-episode
without delay has the potential to maximize syndromal and functional psychosis: 2-year outcomes from the NIMH RAISE early treatment program. Am. J.
recovery during this critical time period for their personal and career Psychiatry 173 (4), 362–372.
Kline, E., Schiffman, J., 2014. Psychosis risk screening: a systematic review. Schizophr.
development.
Res. 158 (1-3), 11–18.
Lutterman, T.K., Mihran, 2018. Snapshot of state plans for using the community mental
Declaration of Competing Interest health block grant 10 percent set-aside to address first episode psychosis, in: NRI/
NASMHPD (Ed.). SAMHSA/CMHS.

XF has received research support or honoraria from Alkermes,

Neurocrine, Avanir, Allergen, Otsuka, Lundbeck, Boehringer Ingelheim Amy Cheung, Mona Polavarapu, Sindhu Kosuru, Mathew Chiang,
and Janssen. Other authors report no competing interests. Domenico Lombardi, Mark Liu, Delia Bakeman, Abita Raj,
Brian Skehan, Xiaoduo Fan
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References UMass Memorial Health Care/University of Massachusetts Medical School,

Worcester, MA, 01655, USA
Chung, H., Klein, M.C., Silverman, D., Corson-Rikert, J., Davidson, E., Ellis, P., Kasnakian, E-mail address: xiaoduo.fan@umassmed.edu (X. Fan).

⁎
Corresponding author: Biotech One, Suite 100, 365 Plantation Street, Worcester, MA 01605, USA.