Symbolic illustration of the crossroads in psychosis prevention, highlighting the choice between clinical and public health strategies.

Rethinking Psychosis: Are 'At-Risk' Mental State Clinics Missing the Mark?

Kai Mendoza in Health & Wellness August 2025 • 4 min read.

"A critical look at ARMS clinics and the potential of public health approaches in preventing psychosis."

For years, early intervention (EI) services have been vital in aiding people through their first episode of psychosis (FEP). These services, like the Lambeth Early Onset and OPUS, strive to improve long-term outcomes, and specific clinical criteria were developed to pinpoint individuals at high risk of developing psychosis, creating the At Risk Mental State (ARMS) classification.

This approach led to claims that identifying individuals at ultra-high risk (UHR) could prevent many from transitioning to clinical psychosis, leading to the rise of ARMS clinics. These specialized mental health services aim to support young, help-seeking people, typically aged 14-35, considered at high risk of developing psychosis by reducing transitions to clinical psychotic disorder.

However, a recent study casts doubt on the widespread effectiveness of ARMS clinics. The article delves into the core issue: Are ARMS clinics truly equipped to prevent psychosis on a large scale, or should we shift our focus to broader public health strategies that address underlying risk factors?

The Challenge of Defining and Identifying 'At Risk' Individuals

Symbolic illustration of the crossroads in psychosis prevention, highlighting the choice between clinical and public health strategies.

The ARMS phase is characterized by either attenuated psychotic symptoms or brief, self-limiting psychotic episodes. It may also manifest as a significant decline in functioning alongside a familial risk for schizophrenia or subtle cognitive and behavioral disturbances. To standardize assessment, tools like the Comprehensive Assessment of At-Risk Mental States (CAARMS) and the Structured Interview for Prodromal Syndromes/Scale of Prodromal Symptoms (SIPS/SOPS) have been developed.

Despite these efforts, accurately identifying individuals truly at risk remains challenging. Reports indicate that a significant percentage of those identified as being at risk do not develop a psychotic disorder within 2-3 years, leading to a high rate of 'false positives'. Even experienced clinicians face challenges in accurately diagnosing ARMS, highlighting the difficulty in defining the construct itself.

Variability in Criteria: The proportion of adolescents meeting ARMS criteria varies widely based on slight variations in the criteria.
Lack of Biological Markers: Attempts to find specific biological markers or reliable predictors of transition from ARMS to clinical psychosis have been unsuccessful.
Feasibility Concerns: Some argue that early intervention based solely on screening criteria for subclinical psychosis may not be feasible in the general population.

The core issue lies in whether the individuals who seek help from ARMS services are truly representative of all pre-psychotic individuals. Research indicates that those attending ARMS clinics are more likely to be UK-born, have strong family support, and possess higher educational achievements. Migrants and ethnic minorities, often less trusting of mental health services, are less likely to access these clinics.

A Call for a Broader Public Health Strategy

While ARMS clinics have contributed valuable research and increased awareness, their limited reach calls for a shift toward a public health approach. By targeting known risk factors, such as cannabis use, urban upbringing, and childhood adversity, we can potentially reduce the overall incidence of psychosis. This approach mirrors successful strategies in preventing other medical conditions like heart disease and lung cancer.

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Everything You Need To Know

What does 'At Risk Mental State' (ARMS) mean, and why is identifying it important?

At Risk Mental State, or ARMS, refers to a set of conditions and symptoms that suggest an individual may be at increased risk of developing psychosis. This state is characterized by attenuated (milder) psychotic symptoms, brief and self-limiting psychotic episodes, a decline in functioning combined with a family history of schizophrenia, or subtle cognitive and behavioral disturbances. The significance of identifying ARMS lies in the potential for early intervention to prevent the onset of full-blown psychotic disorders. However, the challenge is in accurately identifying those truly at risk, as many individuals identified as ARMS do not transition to psychosis, leading to 'false positives'.

What role do early intervention (EI) services play in psychosis, and why are they important?

Early intervention (EI) services, like the Lambeth Early Onset and OPUS, play a crucial role in supporting individuals experiencing their first episode of psychosis (FEP). These services aim to improve long-term outcomes by providing timely and appropriate treatment and support. They are significant because they can potentially alter the course of the illness, reducing the severity and duration of psychotic episodes, and improving the individual's overall quality of life. These services rely on early detection and intervention strategies to mitigate the impact of psychosis. EI uses specific clinical criteria to help identify and aid people through FEP.

What are CAARMS and SIPS/SOPS, and how are they used?

The Comprehensive Assessment of At-Risk Mental States (CAARMS) and the Structured Interview for Prodromal Syndromes/Scale of Prodromal Symptoms (SIPS/SOPS) are standardized assessment tools used to identify individuals in the ARMS phase. They involve structured interviews and scales designed to evaluate the presence and severity of attenuated psychotic symptoms, functional decline, and other risk factors associated with psychosis. These tools are significant because they aim to provide a more objective and reliable way of identifying individuals at risk of developing psychosis. However, they are not perfect, and challenges remain in accurately predicting who will transition to psychosis.

What is meant by a 'public health approach' to psychosis prevention, and why is it needed?

A public health approach to psychosis prevention involves targeting known risk factors at a population level, rather than focusing solely on individuals identified as being at ultra-high risk (UHR). This may include addressing factors such as cannabis use, urban upbringing, and childhood adversity through broad-based interventions and prevention programs. This approach is important because it has the potential to reach a larger number of people and address the underlying causes of psychosis, rather than just treating the symptoms after they emerge. By focusing on prevention, a public health approach aims to reduce the overall incidence of psychosis in the population. ARMS clinics have a limited reach, especially in migrant and ethnic minority communities.

What makes it so difficult to accurately identify people who are truly at risk of developing psychosis?

Several factors contribute to the difficulty in accurately identifying individuals at risk of developing psychosis. These include variability in the criteria used to define ARMS, the lack of reliable biological markers or predictors of transition to psychosis, and the challenges in distinguishing between transient symptoms and true prodromal signs. Additionally, individuals who seek help from ARMS services may not be representative of all pre-psychotic individuals, leading to biased samples and inaccurate predictions. The implication is that many individuals may be incorrectly identified as being at risk, while others who are truly at risk may be missed.