A First-Episode Psychosis Treatment Program: “The Disease Doesn’t Define Me”

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Figure 1. Coordinated specialty care for psychosis in the military. The Psychiatric Transition Program (PTP) clinical team consists of a psychiatrist (including third- and fourth-year psychiatry residents), behavioral health technicians, nurse case managers, and a social worker. Referrals come principally from inpatient psychiatrists throughout the US and Western Pacific (Japan, Guam, etc), and the PTP team works closely with inpatient psychiatry at the Naval Medical Center San Diego. Specialized military commands, co-located on the hospital grounds, work alongside the clinical team to support the Marines and Sailors. The therapeutic community of PTP patients is an important support for the service members as they navigate their psychiatric illness and make the transition to civilian life. Patients’ families provide a stable foundation throughout the program.

KEY POINTS ABOUT THE PSYCHIATRIC TRANSITION PROGRAM

Figure 2. Progression of Psychiatric Transition Program (PTP) treatment. Patients usually come to the PTP following inpatient admission for a first psychotic episode. The initial goal is stabilization. Patients are introduced to a community of other patients, supported by the behavioral health technicians. The family is often engaged as early as the initial appointment. With clinical improvement comes re-expansion of the patient’s social sphere. Patients participate in daily community and psychoeducation groups and in scheduled outings. In time, patients find their niche in regular structured recreational activities, job placements at the hospital or in local internships, or college classes. At the same time, the patient develops an individualized plan for successfully transitioning from Sailor/Marine to civilian. The family is fully engaged as patients prepare to leave the military, and medical care is transferred to the Department of Veterans Affairs.

“US Marine Corps -requesting medevac for psychiatric injury. Non-surgical urgent; ambulatory. How copy over?”

“Good copy.”

Deep in the arid California desert, the Twentynine Palms Marine Corps Air Ground Combat Center requests medical evacuation of a young Marine. Let’s call him Richard. To those in his unit, initially he had seemed uncharacteristically distracted. As his behavior became increasingly odd, their concern grew. He stopped bathing and eating. When Richard started to imitate his Sergeant’s movement and speech, it was time to act.

Every year, among active duty service members in the US military, there are 350 to 650 incident cases of schizophrenia, and 1000 to nearly 1700 incident cases of other psychotic disorders.^1,2 There are also 2200 to 2500 incident cases of bipolar disorder.³

On the flight deck of an aircraft carrier, those who experience psychotic symptoms present enormous risks to themselves, their fellow Sailors and Marines, and the mission. As a consequence, they are quickly moved to robust military medical facilities, such as the Naval Medical Center San Diego, commonly called Balboa Hospital.

Psychiatric Transition Program

Set amidst the rolling hills of historic Balboa Park, Balboa Hospital is the largest naval hospital west of the Mississippi. One small piece is the Psychiatric Transition Program (PTP), which is dedicated to caring for service members with newly diagnosed psychotic illnesses and to easing the transition to civilian life. Based on the Coordinated Specialty Care/NAVIGATE model of the Recovery After an Initial Schizophrenia Episode (RAISE) study, PTP is a multi-modal team of psychiatrists, social workers, nurse case managers, and behavioral health technicians.⁴

PTP adopted the Coordinated Specialty Care model for several reasons. The notion of shared decision making and treatment planning between a patient and the clinical team resonated philosophically. The dual psychosocial goals of family engagement and education, and vocational and educational rehabilitation were particularly relevant in light of patients’ transition to veteran status. Finally, the pharmacotherapeutic and psychotherapeutic interventions specifically designed for a unique population with first-episode psychosis were a natural fit.

PTP receives referrals from all over the world, usually from inpatient psychiatric wards. The program cares for up to 30 patients at a time and treats 60 to 70 each year. Treatment lasts anywhere from 6 to 12 months. Two-thirds of the patients have primary psychotic disorders, and most of the remainder have relatively unstable bipolar I disorder.

The team consists of a staff psychiatrist, 4 psychiatry residents, 2 nurse case managers, a social worker, and 4 behavioral health technicians (Figure 1). The inpatient unit is only steps away from the psychiatry providers, and informal case discussions occur almost daily. Strong clinical ties exist with the primary care team, recreational therapists, and the Veterans Administration liaisons.

Progression of treatment

For Richard, 3 weeks, at most, elapsed between the time he first experienced hallucinations and delusions and the start of antipsychotic medication. Evidence suggests that the briefer this interval -the duration of untreated psychosis (DUP) -the better the outcome. For example, in the RAISE study, subjects with a DUP of less than 74 weeks showed greater improvement in quality of life and psychopathology.⁴ Our clinical experience suggests that the DUP in active-duty patients tends to be much briefer than that in civilian samples, in which average durations of 61 to 166 weeks have been described.⁵

While this observation warrants rigorous empirical validation, intuitively it makes sense. The military culture, with its tight-knit and engaged community and stressful operational demands, is very sensitive to behavioral changes. This translates to a patient population uniquely positioned to benefit from care focused on early rehabilitation.

Richard struggled during his first few months in PTP. He wrestled with persistent positive, negative, and cognitive symptoms. Richard turned to over-the-counter medications for relief -and was readmitted. But he didn’t suffer alone.

In many ways, behavioral health technicians, who are active-duty Hospital Corpsmen, are the heart of PTP. Working from the barracks where Richard and the other patients live, the Corpsmen keep a watchful eye. They run daily groups, community outings, and team sports, such as soccer and volleyball. For patients who are new or more impaired, Corpsmen escort them to their appointments and the pharmacy. Corpsmen support medication adherence with a supervised monitoring program and take turns carrying a 24/7 emergency phone. They curate the therapeutic community.

The family is engaged early. To use a military phrase, they are considered “force multipliers.” From the initial intake, loved ones are invited to be active collaborators. Whether it is by providing vital history, encouraging medication adherence, or alerting the team to acute issues in the middle of the night, open communication with the family is a cornerstone of recovery.

Richard made the transition to long-acting injectable antipsychotic therapy, and his condition steadily became more stable (Figure 2). His cognition improved and affective range widened as his positive symptoms subsided. Richard became a regular on the community outings. His illness sparked his curiosity, and he became an avid participant in our weekly psychoeducation group, affectionately called “Doc Talk.”

Transition to civilian life

Richard identified his post-military goal: to become a sports journalist. With clinical improvement we see a re-expansion of the social world. Some patients assume jobs around the hospital; others start internships or vocational training; and others find their place with wellness-based activities, such as the surfing clinic. In a very real sense, we see identities re-emerge and grow.

For Marines, our clinical team works closely with our para-clinical partners, Wounded Warrior Battalion. A unique and specialized military command, Wounded Warrior Battalion leads and supports their Marines every step of the way. Richard’s Marine leaders sat beside him during those long nights in the emergency department. They visited him during his admissions and checked on him over the weekends. Wounded Warrior Battalion set Richard up with an internship with a sports journalist at a local newspaper. As transition neared, they guided him through college enrollment.

From start to finish, medical separation from the military usually takes about 8 months. As the separation date looms, Sailors and Marines recognize that the net of relationships they have built is coming to an end. Our patients enter another period of vulnerability. Many return to faraway homes. Some have no families to return to.

The nurse case managers take the lead in coordinating not only medical and mental health care, but also living arrangements and finances. On their final day, patients surrender their military ID, take off their uniform for the last time, and depart as civilians.

Conclusion

On reflection, the development of hundreds of new cases of psychosis and mania in the military each year makes sense. With more than 1.3 million active-duty personnel, almost half aged 25 years or younger, a baseline incidence of psychotic illness should be expected.⁶ The ability to detect and treat illness earlier, the ability to transfer care to centralized expertise, the robustness of the military medical system, and the engaged support inherent in traditional command leadership such as the Wounded Warrior Battalion offer distinct advantages. PTP capitalizes on these with evidence-based multi-modal care.

Richard is in college now, far from the sand and rock of Twentynine Palms. “I think the best therapy was to get my civilian life going,” he said. “My team emphasized that the disease doesn’t define me.”

Disclosures:

Dr. Hurdiss is a Third-Year Psychiatry Resident at Naval Medical Center San Diego; Dr. Voss is a Third-Year Psychiatry Resident at Naval Medical Center San Diego; Dr. Hann is a Fourth-Year Psychiatry Resident, and the Chief Resident for the Psychiatric Transition Program (PTP), at Naval Medical Center San Diego; Dr. Loeffler is a Staff Psychiatrist, and PTP Division Officer, at Naval Medical Center San Diego; Dr. Marrone is a Staff Psychiatrist at Naval Medical Center San Diego, in San Diego, CA.

The authors report no conflicts of interest concerning the subject matter of this article.

References:

1. Armed Forces Health Surveillance Center (AFHSC). Mental disorders and mental health problems, active component, US Armed Forces, 2000-2011. Medical Surveillance Monthly Report (MSMR). 2012;19:11-17.

2. Armed Forces Health Surveillance Center (AFHSC). Mental disorders and mental health problems, active component, US Armed Forces, January 2000–December 2009. Medical Surveillance Monthly Report (MSMR). 2010;17:6-13.

3. Otto JL, O’Donnell FL, Ford SA, Ritschard HV. Selected mental health disorders among active component members, US Armed Forces, 2007-2010. Medical Surveillance Monthly Report (MSMR). 2010;17:2-5.

4. Kane JM, Robinson DG, Schooler NR, et al. Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE Early Treatment Program. Am J Psychiatry. 2016;173:362-372.

5. Addington J, Heinssen RK, Robinson DG, et al. Duration of untreated psychosis in community treatment settings in the United States. Psychiatr Serv. 2015;66:753-756.

6. Military OneSource. 2014 Demographics: Profile of the Military Community. http://download.militaryonesource.mil/12038/MOS/Reports/2014-Demographics-Report.pdf. Accessed September 8, 2016.