Outcomes involving real-world functioning, such as engagement in work and school, may provide more meaningful indices of recovery than metrics focused solely on symptom severity. In this study, we conducted a longitudinal medical record review of all patients in a transdiagnostic outpatient FEP program. We found that the majority (81.5%) of individuals experienced disruptions to their college education due to FEP, but that return to college after a leave also occurred in substantial numbers. Within the subset of individuals whose college experience was disrupted, the median time to return to college was 18 months. Comparing individuals by baseline diagnostic category, we found that though a significant proportion of both FEPP (51%) and FEAP (60%) patients returned to college, there was a significant difference between the 2 groups’ survival curves, with time to college return being shorter in FEAP than in FEPP. Lastly, we found that in addition to having a FEAP diagnosis, having no cannabis use in the 6 months prior to intake and no more than 1 psychiatric hospitalization prior to intake increased the likelihood of returning to college after a FEP.

Research suggests that a college education can be more difficult for individuals with psychiatric disord-ers,^{11,33,38,41–43,51,53} and especially those with psychotic dis-rders,^{12,34,37,71,72} to attain. Young people with psychotic disorders participate in postsecondary education at much lower rates than their healthy peers,^12,34,37 and those who do matriculate perform more poorly.^37,39,49 For example, one study found that students with psychosis took more time-outs from school and longer to graduate compared to students with other psychiatric disorders, students with learning disorders, and students without disability.³⁹ Reports of educational underachievement in students with psychotic disorders are unsurprising, as schizophrenia and related psychotic disorders are considered among the severest of mental illneses,⁷³ and they are often preceded by a prodrome in which cognitive deficits are already present.^74–76

On the other hand, it is now more possible for individuals with psychotic disorders to participate in higher education. US federal laws (ie, Section 504 of the Rehabilitation Act and the Americans with Disabilities Act, Amended Act [ADA-AA]) require colleges to ensure that students with psychiatric or other disabilities have equal access to academic programs.^44,77 Treatments for mental illnesses have also resulted in individuals with psychotic disorders being less severely disabled by their illness.^44,78–81 Importantly, while the expanded arsenal of antipsychotic and other psychotropic agents has given patients a way to alleviate symptoms, there is growing recognition that symptomatic recovery is distinct from functional recovery,^82–84 and FEP programs have enhanced efforts to promote recovery of functioning as well as purpose and meaning in individuals with psychotic disorders.^9,85 In this conceptualization of recovery,^9,86–88 recovery is a journey toward attainment of meaningful goals and full human potential,⁸⁹ not merely absence of symptoms. The role that education can play in developing human capital and in improving health is highly relevant within this framework, and consensus has been established that young people with psychosis should have the same educational opportunities as their nonpsychotic peers.⁹⁰ Indeed, not only do many patients identify going back to school or getting more education as an important part of their recovery,^50,91 education outranks symptomatic recovery among patient priorities.⁹¹

In our sample, 56% of FEP patients whose college education was interrupted returned to college while in OnTrack. That a considerable proportion of FEP individuals successfully return to college is consistent with literature pointing to the potential of some FEP patients to achieve successful educational outcomes.^35,37,48,55 A study looking at the educational attainment of patients with psychotic disorders in relation to expected educational level as predicted by parental education found that, contrary to what the authors had hypothesized, patients with psychotic disorders had a higher level of education than their parents, even if the intergenerational increase was smaller than that made by healthy individuals.³⁵ Successful return to college is also consistent with the small but positive genetic correlation that has been reported between schizophrenia risk and educational attainment⁵⁵ (though also see ref.⁹²) as well as with the finding that polygenic risk scores for schizophrenia and BP predict creativity.⁹³

Research has shown that to successfully participate in higher education, students with FEP might rely on different motivational factors, supports, and strategies for managing their time and effort relative to students without FEP.^37,50 Indeed, though our ability to interpret the findings from our exploratory analysis of cognitive functioning is severely limited by the small number of patients for whom cognitive measures were available, the lack of detectable differences in cognition (among the limited subset who did have cognitive data) by diagnostic group as well as by whether patients did or did not return to college suggests that successful return to college is unlikely to be determined by cognitive functioning alone. Rather, as proposed by the bioecological framework for understanding college mental health, a host of both immediate and broader contextual factors across the college mental health ecosystem influence educational outcomes.⁵⁴ Relevant to factors at the level of the individual student, a meta-synthesis of qualitative research exploring the experiences of students with mental illness has shown that beyond the capacity to do the academic work, factors such as knowing oneself, managing one’s mental illness, and the ability to negotiate the social space are key to postsecondary educational success.⁴⁸ The importance of engaging factors beyond cognitive capacity is further underscored by the finding that genetic factors associated with traits such as openness to experience⁵⁵ and self-efficacy⁵⁶ also influence educational attainment. It is also worth pointing out that the time it took for patients in our sample to return to college extends the expected time for college completion beyond the traditional college trajectory. Adjusting expectations amongst individuals with FEP, their family, and colleges—ie, that undergraduate trajectories after a FEP may be longer but that students with FEP can be successful—is pertinent. We would particularly recommend to families to adjust expectations around the timing for school return, and to schools that flexible policies during this process is essential to foster success.

Diagnosis was the strongest factor in our model for predicting a successful return to college. That the FEAP group showed faster time to college return than FEPP patients (median 12 vs 24 mo) is consistent with a recent study that showed that individuals with BP are more likely to complete university than individuals with schizophrenia (and even healthy controls).³⁶ At the same time, it is important to recognize that the path back to college for those with FEAP is also frequently challenging and nonlinear.^33,38 Though cognitive deficits in BP are less severe than in schizophrenia and there is no strong evidence for premorbid cognitive and academic difficulties in BP (in contrast to schizophrenia), it is increasingly recognized that cognitive impairment is present in the FEP of both FEAP and FEPP.^61–63 There is a clear need for both groups to receive specialized accommodations as they transition back to school.

Having no more than 1 psychiatric hospitalization was also significantly associated with successful college return. Repeated hospitalizations may be a marker for more severe illness, unremitted symptoms, poor illness insight, and/or treatment nonadherence, all of which predict poorer functional outcome.^94–96 Patients with multiple hospitalizations may need extra support and guidance around optimal timing and resources when attempting to return to campus. Our findings also highlight the need for better relapse prevention, with patients, schools, treaters, and families ideally working collaboratively to prevent relapse before a situation escalates into a crisis. It is worth noting that hospitalizations can themselves disrupt educational timelines, especially as many colleges mandate that students take a leave of absence following psychiatric hospitalization.⁹⁷ While a leave from school may be appropriate in some cases, blanket policies that force all students to take a leave of absence after hospitalization or a psychotic episode may not be universally helpful.

Finally, return to college was also predicted by the absence of cannabis use in the 6 months prior to intake. The transition to college is a peak risk period for cannabis use, with peer influence being a potent predictor.⁹⁸ Cannabis use among college students, even in nonpsychotic samples, is associated with a lower grade point average and higher risks of discontinuous enrollment and delayed graduation.^99–102 Abundant evidence also points to the detrimental effects of cannabis on psychosis and psychosis risk, particularly during the critical period of adolescence, and especially among those with increased susceptibility to psychosis.¹⁰³ These psychosis-related risks may be exacerbated with increasingly wider exposure (through the legalization of recreational cannabis in many states) and the increased availability of higher potency marijuana.¹⁰⁴ Abstinence from cannabis is a potentially modifiable variable, and our findings suggest that FEP individuals who avoid cannabis are more likely to return to college.

Though OnTrack provides specialized treatment for FEP and general support toward the attainment of educational and vocational goals, the achievement of college return in our sample occurred in the absence of formal supported education services in OnTrack. Supported education is based on the principles of psychiatric rehabilitation and provides assistance, preparation, and supports to people with psychiatric disabilities who wish to pursue postsecondary education or training.^105–107 Supported education and employment services are increasingly seen as critical components of coordinated specialty care programs for early psychosis, with evidence suggesting benefits for both educational and vocational outcomes when compared with standard care^108–110 (though also see a systematic review¹¹¹ which found benefits for employment but not education). Thus, we predict that college return rates in our sample might be even higher with supported education services. Unfortunately, despite the personal, public health, and socioeconomic importance of education and employment, neither supported education nor vocational counseling is currently reimbursed through third-party payers. Federal legislation enacted in 2014 provided funds to the Substance Abuse and Mental Health Services Administration (SAMHSA) to support the development of early psychosis treatment programs, including supported education and employment services, through mental health block grants.¹¹² These grants have provided important stimulus and support for early psychosis programs across the United States. However, OnTrack has not been a recipient of this type of funding and thus has had to creatively utilize the resources already available, including asking clinicians to address the educational and vocational needs of patients while also providing psychotherapy, family support, and/or psychopharmacologic management. More recently, in 2018, OnTrack was fortunate to receive philanthropic funding to hire a certified peer specialist trained in the Individual Placement and Support (IPS) vocational model. OnTrack has also benefited from a weekly “jobs club” group run by a vocational specialist who works at an affiliated clubhouse program at McLean. In spite of these developments since the study period, there still remains a gap with respect to supported education in OnTrack. We believe that the experience of OnTrack highlights some of the practical and financial challenges faced by many early psychosis programs, even those like OnTrack that are embedded within academically affiliated private psychiatric hospitals.

Our findings should be considered in the context of several limitations. First, the sample of 88 patients included in our survival analysis is modest. Second, our study included limited data on cognitive impairments and no data on premorbid functioning. We were able to access systematic data about cognitive functioning through data sharing with another FEP research study. However, as only a third of the sample in the survival analysis underwent cognitive testing through voluntary research participation, we were constrained to only group-wise comparisons, rather than including cognitive measures as covariates in our Cox model. Given that cognitive data were available for a limited subset of patients, the findings from our exploratory analysis of cognitive functioning should be interpreted with caution.

Third, with the exception of the cognitive measures which were collected through data sharing with another study, all data were extracted from chart reviews, and such data are restricted to what clinicians document in their notes. However, the clinicians in the specialized FEP care environment of OnTrack are highly attuned to the importance of functional recovery in preventing negative outcomes and more often provided ample documentation of events such as return to college in their notes. Fourth, data are limited to events that took place while patients were treated in OnTrack. If a disproportionate number of patients dropped out of care because they were doing well and returning to college, our findings could underestimate college return rates. Conversely, if patients tended to drop out because of more severe illness, we would risk overestimation. However, our supplementary analysis shows that FEP patients who terminated early were comparable to those who stayed ≥2 years on most baseline characteristics, suggesting non-informative censoring. More importantly, our data, derived from chart review, includes clinically rich longitudinal data from patients who have ever been seen in the clinic, and are thus free from bias related to including only individuals who are willing and able to sign informed consent.^113,114 That cognitive measures, collected through voluntary participation in a FEP research study, were available for only a third of the patients in the analysis underscores the advantages of medical record review in capturing a more representative sample.

Finally, it could be argued that graduation from college might be a more valid measure of educational success than college return, as return to college does not guarantee a satisfactory grade point average or graduation. However, only 9 of the 49 patients who returned to college graduated during the study period. The median time to college return was 18 months, and the median duration in college among those who returned but had not yet graduated was 12 months. As a college education in the United States typically takes at least 4 years, the mean follow-up period of 22 months for patients in OnTrack is likely insufficient to capture graduation events. Though the number of graduation events in our sample was too small to meaningfully analyze time to graduation, to address the issue of persistence in college, we ran additional survival analyses using return to college with no subsequent failures or dropouts as the endpoint and found that the results did not substantially change from the original analyses which examined college return with no failure or dropout within the same 6-month period. Importantly, our study outcome of return to college is compatible with US federal laws pertaining to postsecondary educational settings (ie, ADA-AA), the goal of which is to provide students with equal access to academic programs.⁷⁷ Not all the benefits of a college experience—eg, acquiring knowledge, practicing critical thinking and problem-solving skills, becoming acculturated to the values and behaviors necessary for achievement, and developing independence, among others—are contingent upon graduating, and returning to college represents more than just a step toward earning a degree. Participating in higher education facilitates the pursuit of personal development, career goals, and social inclusion.^48,115 Moreover, returning to college has value in itself if it is a goal with personal meaning and purpose for a young person after a FEP.¹¹⁶

To conclude, the pursuit of higher education is well-aligned with the conceptualization of recovery as the attainment of meaningful goals and full human potential. Our findings indicate that interruption of college is very common after a FEP, but also provide evidence of the potential of both FEAP and FEPP patients for successful college return, albeit with longer trajectories than the conventional 4-year college timeline.