By Julie Wernau

Noah Hudnut’s family had already spent $150,000 on his psychiatric care when he was hauled in handcuffs by police to the emergency room of UCLA medical center.

On top of the family’s past expenses, Hudnut’s insurance company was billed at least $1,000 a day for his hospitalizations. Yet, his psychosis persisted. He believed he grew to gigantic proportions and knocked down the Twin Towers on 9/11, even though he had been 6 years old. He also was certain he caused the Covid-19 pandemic.

After Hudnut started driving erratically and throwing away valuables in a delusional state, his family called the police in November 2022, and he was taken to UCLA. While in the hospital, Hudnut said, “I came to the conclusion that either I was insane or everyone around me was.”

Following Hudnut’s release from the hospital, his family enrolled him at California OnTrack, a treatment program offered by Pand Health. His 14 months of treatment cost a fraction of what the family and health insurers had paid for his care over the previous six years. So far, it has worked.

Hudnut, 28 years old, has a job with a company that helps people negotiate with the Internal Revenue Service to pay overdue taxes. His own condition, schizoaffective disorder with bipolar condition, feels like a cancer in remission, he said.

“I don’t feel like I’m out of the woods,” Hudnut said. “But I feel like if I do everything in my power to prevent it from happening again, I have a good chance.”

California OnTrack uses a skills-based therapy program called coordinated specialty care, which is offered through at least 381 programs in all 50 states. The program substantially reduces symptoms of psychosis, as well as hospitalizations and homelessness compared with traditional treatment, according to published studies.

The premise of the treatment is simple: Teach people with psychosis to live with their imagined voices, hallucinations and false memories. With practice, such symptoms can be managed or ignored. The techniques taught in the program, in conjunction with medication, diminish symptoms over time and keep new ones at bay.

People who enroll in the treatment within two years of their first psychotic episode fare the best, studies found. People with longer-term psychosis also improved but to a lesser degree.

“It’s not like a switch where all the symptoms subside. It’s like a dimmer switch,” said Carlos Larrauri, who completed a similar treatment in Florida after being diagnosed with schizophrenia in 2011 at age 24. He has since finished law school, trained as a nurse practitioner, married and now works as a lawyer.

For more than a decade, the federal government and psychiatric associations have identified coordinated specialty care as the gold standard to treat early psychosis. Yet few people know about it, and fewer still have a chance to benefit from it. Three of the largest private insurers only recently began covering the treatment, which has largely been limited to Medicaid patients. California OnTrack is one of the few providers in the U.S. that has secured coverage from private insurance.

Researchers can’t fully explain the growing epidemic of people suffering from psychosis, particularly younger men. The rate of schizophrenia-related emergency-room visits for men ages 18 to 44 years old is 16% higher so far in 2024 compared with 2018, according to health-analytics company Truveta; men ages 30 to 44 showed a 24% increase.

Americans experiencing first-time psychosis typically have symptoms for more than a year before receiving treatment, studies found. What follows for many with schizophrenia and bipolar disorder is a revolving door of hospitals, jails, psychiatric facilities or homelessness. Treatment options in the U.S., public or private, are relatively scarce for all but the most costly programs.

Research shows that young adults whose lives are unraveled by psychosis have the best chance to recover. The longer mental illnesses go untreated, the more deeply rooted they become. While work is advancing on new drugs, the clock is ticking for the more than an estimated 100,000 Americans who develop psychosis each year.

“If we can intervene at the first episode of psychosis, think of all the tragedy and pain we could eliminate,” said Heather O’Donnell, senior vice president of public policy for Thresholds, which runs a coordinated-specialty-care program in Illinois.

Illinois was the first state in the U.S. to require private insurers to cover the treatment, which costs as little as $1,000 a month. The California OnTrack program, which provides three full days of care a week, charges people without insurance about $17,000 a month for adults and $15,000 a month for teenagers. That compares with $15,000 to $60,000 a month for inpatient psychiatric programs.

California OnTrack said that of the 29 patients who have completed at least one month of treatment and participated in six months of follow-up, 19 returned to work or school, two had to be hospitalized and the rest have continued to recover.

“We don’t want to feed this endless cycle that creates a small life,” said Dr. Eric Wexler, medical director and co-owner of California OnTrack, which opened in August 2022. “You can get better, and you have a role in getting better.”

Shadows and demons

Jaime Meza was hospitalized eight times when he was 16. He heard voices that told him he was going to hurt people and ordered him to take his own life first. “I was afraid to step outside,” he said, because of the anxiety and delusions of schizophrenia.

A social worker at UCLA arranged with Meza’s mother to try a new treatment with a radical premise—learning to live with the voices. His mother agreed.

Coordinated specialty care relies on training. Patients learn how to question thoughts and assumptions distorted by psychosis, as well as rebuild memory. They practice speaking in social situations and get support as they look for jobs, organize résumés and make appointments.

When Meza started California OnTrack in February, he couldn’t sit through an hourlong group session. He saw shadows and thought they were demons.

After months of three-day-a-week treatment, Meza said he was learning to carry on with his life despite the voices. During a workout class in July at the clinic, the voices grew louder, and the 18-year-old walked out.

The clinic’s co-founder Adrian Marroquin intercepted him in the hallway.

“We don’t let the voices make decisions for us,” Marroquin said. “What skills can we use to get you back in there?”

Meza considered the question and then repeated to himself, “When the voices get louder, I work harder.”

He returned to class and got into a plank position alongside his peers, holding his torso inches above the ground.

One by one, his classmates dropped in exhaustion.

They cheered Meza after he outlasted them all.

False beliefs

Noah Hudnut’s delusional thoughts began when he was in college, and during his first weeks at California OnTrack, he struggled to sort fact from fiction. “Client expressed a need to move to Jerusalem and herd sheep and suggested he may be in recovery and ready to move on with his life,” Hudnut’s counselor Kyle Menschel wrote in his notes early in 2023.

“If you’re interested in Jerusalem, I’m down with that, but we need a few additional pieces of information,” Menschel recalled telling Hudnut.

Rather than arguing or dismissing Hudnut’s idea as delusional, Menschel asked questions. People suffering psychosis have difficulty working through the steps required to make plans and decisions, Menschel said, often relying instead on snap judgments clouded by illness.

“A delusion is a fixed false belief. If it wasn’t fixed, it wouldn’t be a delusion,” said Menschel, a trained clinical therapist and social worker. “If you try to argue against it, you will create a mechanism to strengthen it.”

The program teaches a fact-checking process to help patients kick the tires on unrealistic thoughts. Menschel asked Hudnut about the logistics of sheepherding in Jerusalem: Have you done something like this before? Do you speak Hebrew? Do you speak Arabic?”

After thinking through the many steps required for a sheepherding job in Jerusalem, Hudnut decided he didn’t want to go.

Other delusions took longer to dispel, including Hudnut’s imagined roles in the Sept. 11, 2001, attacks. “It’s like this big ball of yarn that needs to be unraveled,” Menschel said of his work. “When you unravel enough, the center falls out.”

On a typical Monday, patients arrive at 10:30 a.m. and engage in brain-training exercises, followed by a life-skills class. After lunch, there is music therapy, mind-body training, socializing and a class to help people manage stress and setbacks.

“The more stressed you are, the more psychotic you’ll be—and the more psychotic you are, the more stressed you’ll be,” Menschel said. “It loops and loops and loops.”

Hudnut said he was helped by both the guidance of his counselors and the delusions of his peers. “You can’t really just jump on board with someone who thinks you’re an alien,” he said. “You’re like, ‘If that’s not true, maybe what I’m thinking is also not true.’”

In one group activity, patients looked at a photo of a man wearing a red baseball cap. A counselor asked what conclusions they could draw about him and how confident they were in their assessment. Noah said he was 80% sure wearing the cap meant the man was in a gang. One person was 95% sure the man was dead. By the end of their discussion, they all agreed it was difficult to draw a conclusion with any certainty from the photo.

“It was almost like I was able to study what it means to be delusional by being with other people who are delusional,” Hudnut said.

Among Hudnut’s false memories was the belief he had fathered a child in Guatemala, and he couldn’t shake the urgency to send text messages to the mother. “People often hallucinate in the present tense, but I was having hallucinations about the past,” he said. “I thought I had done a lot of horrible things.”

As the months passed, Hudnut told Menschel he was learning to recognize when he was having impulsive ideas and to question false memories and beliefs. “He would occasionally have pangs of memories,” Menschel said, “but identified them as delusions.”

Regarding the child in Guatemala, Hudnut later told Menschel, Remember when I believed that?

“You don’t have to grab on to every thought that comes your way,” Hudnut said. “You can let them pass like the clouds.”

He took classes remotely and graduated from Colorado College in Colorado Springs in May. He lives at home, takes medication and is saving up money for his own place.

While at California OnTrack, Hudnut drafted a plan in case he relapsed and gave copies to his family. It spells out conditions for another hospitalization if he starts to isolate, becomes extremely irritable or engages into verbal or physical altercations.

“I’ve had a great recovery, and you just never know when it will come back,” he said. “That’s a very real possibility that I live with.”

Curable

In the 1980s, Dr. Patrick McGorry, a psychiatrist in Australia, began developing the program that evolved into coordinated specialty care. At the time, people who experienced delusions weren’t expected to fully recover. “There was no real treatment,” he said.

McGorry and his team started from the premise that psychosis could be cured. Their idea was to use medications in conjunction with therapies found to have helped people with delusions.

The program was designed for people who show first signs of psychosis. “Diagnose it early and treat it comprehensively,” he said. “These are principles from the rest of healthcare.”

The method he pioneered in Melbourne was tested, implemented and standardized in Denmark and the U.K. Studies of the treatment found the countries had fewer hospitalizations for psychosis. They also reported improvement in work and school participation among people who enrolled in the care.

In 2008, the National Institute of Mental Health began looking into McGorry’s method. A federal study of 34 community mental-health treatment centers in 21 states found that patients who completed coordinated specialty care had symptoms 40% lower than those in traditional treatment, according to a 2015 report, and a substantially higher quality of life.

Congress in 2014 committed $25 million to fund coordinated specialty care. The Centers for Medicare and Medicaid Services, Substance Abuse and Mental Health Services Administration, Department of Veterans Affairs and Labor Department have said it was the best treatment for people with early psychosis.

For most people with psychosis, “the only hospitalization that’s provided is the emergency room and a brief inpatient stay, if that,” said McGorry, who isn’t affiliated with California OnTrack. “That’s just like patching up someone who’s been hit by a car, stopping the bleeding and kicking them out. It’s a global disgrace.”

Lived on Mars

On a recent day at California OnTrack, a group of men arrived at midmorning and began what looked like videogaming but was an exercise to strengthen memory. Cognition generally declines in people experiencing psychotic episodes from schizophrenia, schizoaffective disorders, bipolar and other conditions that trigger psychosis.

The program’s daily routine typically includes group sessions, individual therapy, a lunch break and exercise classes. The program’s physical activities improve learning and help prevent weight gain, a common side effect of medications.