Understanding the different types of Psychosis and its Treatment

The image header for this article was drawn by a former client who suffered from schizophrenia, this was how he represented his experience. I think of him every time I start working with a new family. Families at the beginning of this journey with a loved one suddenly faced with an initial psychiatric hospitalization after having a psychotic break or delusional thought episode feel lost about what to do, where to go, and what to expect.

Education and self-advocacy are key.

Psychosis can manifest in various ways, and it’s essential to recognize the different facets to understand its origins and treatment options. There are three essential categories of psychosis:

1. Substance-Induced Psychosis: This type arises as a direct result of substance use with THC being at the top of the culprit list. To mitigate symptoms and reduce the risk of future episodes, individuals need to abstain from all substance use and closely monitor their mental health with guidance from a team of mental health professionals; a psychiatrist, therapist, and recovery coach are a good start.
2. Psychosis from Mood Disorders: This includes conditions where mood regulation is affected, such as bipolar disorder or major depression. In mood disorders, individuals may experience severe highs (mania) and lows (depression) that go beyond typical emotional fluctuations. When mood episodes escalate beyond a certain threshold, psychosis can occur, leading to a diagnosis noted as a mood disorder with psychotic features. If the individual did not suffer from an anxiety disorder prior to the episode, it is highly likely that they will after.
3. Psychosis from a Psychotic Disorder: This occurs when a person has a psychotic disorder, such as schizophrenia or schizoaffective disorder but can also include mood or thought disorders with severe psychotic symptoms. Individuals in this category typically require ongoing treatment with antipsychotic medications as well as mood regulators and sleep aids to manage their symptoms.

It's important to remember this is a layman's breakdown for understanding what's going on and you should seek the help of a psychiatrist and clinical psychologist for an in-depth evaluation of the condition. These types and/or categories can overlay with one another and co-occurring conditions can play a major factor.

For individuals with mood disorders, various medications can help stabilize their mood and prevent episodes of psychosis. Common treatments include lithium, Abilify, and Latuda, among others. Some suffering from mood disorders with psychotic features may find they can manage their symptoms with mood stabilizers alone, without needing an antipsychotic.

In contrast, those diagnosed with a psychotic disorder generally require antipsychotic medication as part of their treatment regimen. A concept called medication optimization is one to consider for the long term. This is finding the minimum effective dose for the individual suffering from these symptoms. There are standard "therapeutic doses" for medications, and you'll want to start there but as time goes on and ongoing stability is established, you can work with a psychiatrist on finding the minimum effective dose.

Someone struggling with substance-induced psychosis will do best to avoid substances, this includes any amphetamine-based focus medications such as Adderall, and maintain a proactive approach to their mental health, similar to managing remission from a serious illness like cancer. This involves establishing a strong relationship with your psychiatrist and therapist to navigate any ongoing challenges. You may, however, be among those who do not need mood regulating or anti-psychotic medications to manage this condition.

Some who are using or experimenting with substances already predisposed towards either bipolar or thought disorder or psychotic spectrum disorders end up triggering their first psychotic episode through substance use. Once triggered, psychosis becomes a chronic symptom of their condition no longer simply drug induced.

Regardless of what you glean from this information it is important to get a comprehensive neuropsychological assessment from a clinical psychologist whose practice is dedicated to performing assessments. Genomic testing can provide valuable insights for medication evaluation and treatment planning as well, but you want an established psychiatrist who specializes in psychotic spectrum and/or thought disorders. Understanding the specifics of your psychotic or delusional thought symptoms is crucial for effective management and recovery. A good psychiatrist even over and above specialty will take time, like an hour not 15min, with their patients to understand them as a person and work on medication management as the cornerstone of the relationship. Avoid medication changes with outpatient providers as much as possible, they can be complicated and result in hospitalization if not supported by comprehensive care as with residential treatment. Take anything you get from a hospital psychiatrist with a large grain of salt, the very rarely have enough time to truly assess and properly medicate someone in their care. You'll know good help when you get it, and it makes all the difference.

That leads us to the topic of protocol for treatment. I've written about levels of care, but I will lay them out here for simplicity.

Hospitalization: (2 to 5 days sometimes more depending on acuity and have to meet criterion for admission; in danger of or imminently in danger of harm to self or others this includes property damage. Hospitals will often refer you to an IOP immediately after discharge. This level of care is inappropriate post psychiatric hospitalization but it's all they know and all that many of their patients can access. It is still a wildly inappropriate discharge plan.)

Stabilization: (2 to 5 days is not enough for true stabilization. Some RTCs can manage this step but some cases require a specialty assessment and stabilization center)

Residential Treatment Center (RTC): (30 to 90 days or more. Insurance coverage maximums often stop at anywhere from 7 to 28 days, but 30 days is not enough time for residential care. You want 45 days minimum post hospitalization.)

Partial Hospitalization (PHP) (6 to 8 weeks, 5 days a week, 3 to 6 hours a day of clinical programming. Often but not always accompanied by supportive housing.)

Intensive Outpatient (IOP): (4 to 6 weeks, 3 days a week, 3+ hours a day of clinical programming. Often but not always accompanied by supportive housing.)

Transitional or Supported Living: (6 months minimum for anyone who needs this level of care)

Supported Outpatient Care: Wherever they land after completing these levels of care to the satisfaction of their care teams and begin to re-start their interrupted life families will do well to create a Wellness Recovery Action Plan (WRAP). You may want to consider establishing a Health Care Power of Attorney or Psychiatric Advance Directive. In extreme cases, temporary and/or full guardianship may be appropriate. It is also important to look at long term considerations such as establishing a special needs trust and/or involving someone to be representative payee for managing finances and income especially when disability benefits are involved. Some families will find it necessary to file for disability for their loved one to receive both income and insurance benefits. There are individuals and organizations that can help families with this process, but I advise always retaining private pay health insurance, a PPO plan with out of network and residential mental health care coverage. Medicare and Medicaid do not pay for residential mental health care other than hospitalization; it's absurd but also true. Another resource I share with families regularly is getting a TrueLink card for their loved one for at least one year post completion of treatment. There are all kinds of professional resources for navigating these care supports such as Special Needs & Trust attorneys, Guardianship attorneys, Professional Guardians, Care Management organizations, and Long-Term Care providers specializing in mental health care.

Finances are often a concern for families, but I advise to the extent a family is able to afford to pay for appropriate treatment even if not covered. Observe a budget but evaluate resources and providers and get the best you can manage. Fight with your insurance company without hesitation... Don’t Deny Me (parityregistry.org). Find the right care and do it for long enough to get sustainable long-term recovery results. These are serious and often severe conditions, do not make the mistake of dismissing the symptoms and signs when they arise.

Also, don't give up hope.

Recovery from even severe mental illness and substance use disorder is possible, even likely with the right care, don't let anyone tell you different.

#MentalHealthMatters