Feasibility of an Early Detection Program for Early Psychosis on a College Campus

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Specific Aims: Feasibility of an Early Detection Program for Early Psychosis on a College Campus Long duration of untreated psychosis (DUP) is associated with poor outcomes, including higher rates of suicide, hospitalization, and overall low functioning.1,2 More widespread use of effective strategie...

Specific Aims: Feasibility of an Early Detection Program for Early Psychosis on a College Campus Long duration of untreated psychosis (DUP) is associated with poor outcomes, including higher rates of suicide, hospitalization, and overall low functioning.1,2 More widespread use of effective strategies to decrease DUP are needed to address the substantial discrepancy between the actual (i.e., on average 2 years) and recommended time (i.e., 3 months) between the appearance of psychotic symptoms and the initiation of treatment.3 Early detection (ED) programs aim to decrease DUP by increasing case identification and removal of barriers to coordinated specialty care (CSC).4 The most studied components of ED programs include: (i) educational campaigns;5 ED response teams designed to optimize the referral processes to CSC;6 and to a lesser extent, screening among high-risk groups.7 While results of studies on individual ED components have been inconsistent, combinations of ED components have had more success in reducing DUP.8 For example, the Treatment and Intervention in Psychosis ED program, which included educational campaigns and ED teams, reported an average decrease in DUP from 1.5 years to 0.5 years pre-post implementation.9,10 The evidence on community-based ED programs is large and growing but very little is known about the effectiveness of ED services on college campuses in the United States. This gap in the literature is problematic because, with the first symptoms of psychosis being most likely to surface among college age young adults, college campuses are critical locations to identify and refer individuals to CSC who are at increased risk of first episode psychosis (FEP).11 We aim to address this gap in the literature. The long-term goal of our program of research is to improve clinical and functional outcomes among college students with early stages of psychosis by reducing DUP. The objective of our proposed study is to determine the feasibility of an ED program that aims to: (i) identify college students at CHR of psychosis or with FEP, and (ii) efficiently link them to CSC services for a 2nd stage screen and a clinical assessment among those determined eligible. Students will be referred to treatment based on the results of the assessment (the University of New Mexico Department of Psychiatry CSC program includes clinical services for both FEP and CHR). We will also provide preliminary estimates of effectiveness with respect to the intervention. Our ED program will include two organizational level changes. First, we will implement universal screening (i.e., the Prodromal Questionnaire Brief12) for psychosis among college students who are seeking help at a college counseling center. Second, we will implement a collaborative, person-centered, and rapid referral process (<2 weeks) to CSC. Person-centered elements of the referral process include shared-decision making and a warm handoff (i.e., transfer of care between the college counseling center and CSC with the student present). The organizational-level changes will be facilitated by training, monthly meetings, and a decision support tool. Our focus on these two components was informed by: (i) input collected from the existing CSC clinical team, college counseling center staff, and students through campus-based meetings; (ii) evidence for universal screening7 and processes that facilitate rapid access to CSC9,10; and (iii) the pathways to care literature showing a strong link between health system factors and extended DUP.13 We planned our intervention and will evaluate it based on a combination of two theoretical frameworks: (i) Precede-Proceed Public Health Model14, and the (ii) RE-AIM15. Mixed methods will be used to attain our objective and achieve the following two specific aims: Identify whether (i) case identification, and (ii) referral-related barriers to CSC are important targets for ED programs on college campuses. We will compare number of referrals from the college counseling center to our CSC program in the preceding three years to the number received during the 2.5 years of implementation. Also, during the same time-period we will compare DUP, and pathways and perceived barriers to care between college students referred from the college counseling center and students presenting to CSC from other referral sources. We hypothesize that through our two mechanisms of change the number of college students referred to CSC will increase. We also hypothesize that, among college students referred to CSC from the college counseling center compared to those presenting from other referral sources, DUP will be shorter among those with FEP, and there will be fewer steps and perceived barriers for students with FEP or at CHR. We will also examine psychosis literacy among referrers from the counseling center. We hypothesize that psychosis literacy will increase pre-post implementation. Evaluate the feasibility of our ED program from the perspectives of various stakeholders. The proposed study is innovative because we will be pilot testing an ED program on a college campus. At the completion of the proposed research, our expected outcomes are preliminary data and knowledge on the feasibility of and effective targets for an ED program on a college campus. If determined feasible and effective, our proposed ED program has a high potential for widespread uptake and scale-up given the nominal costs and ease of replication of its components. The brief screener will be part of the routine intake and the warm handoff/rapid CSC access will be facilitated by CSC staff posing minimal burden on college counseling centers. With a diverse target population in terms of ethnicity and race, our findings will be generalizable to college campuses nationwide and may therefore ultimately impact DUP - a major public health problem.

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