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?

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Kai Mendoza in Health & Wellness November 2026 • 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?

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Monitoring and the available statistics

NICE recommends regularly monitoring people who continue to have symptoms, impaired functioning, or distress when a clear psychosis diagnosis cannot be made, for up to three years using a structured, validated assessment tool. The supplied CDC and NIMH material describes sources of mental-health statistics, including U.S. prevalence, treatment, and cost data, but gives no psychosis-specific figures. These sources therefore support a description of follow-up and available data resources, not an estimate of psychosis prevalence or impact.

Clinical-high-risk approaches and their limits

A 2025 review describes the clinical high risk for psychosis (CHR-P) paradigm, based on subclinical psychosis symptoms, as one of psychiatry’s most established preventive approaches. A 2020 review synthesized findings from 42 meta-analyses on detection, prognosis, and prevention interventions, and offered updated practice recommendations. Early-intervention services were founded on the principles that intervening early may alter illness trajectory and prognosis, and that multicomponent care may promote psychosocial recovery and reduce iatrogenic damage. However, the supplied review also notes a shift from psychosis-focused prevention toward accessible youth mental-health centers serving transdiagnostic conditions, with their efficacy for preventing psychosis still a subject for future study.

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.
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Outcomes without transition

A meta-analysis examines clinical outcomes among people at clinical high risk of psychosis who do not transition to psychosis. Its source material says it remains unclear how many of these individuals improve, whether improvement is permanent or temporary, and whether poor mental-health outcomes are largely driven by people who do transition. The supplied excerpt therefore highlights uncertainty about outcomes in the non-transitioning group rather than resolving it.

Limits in prediction and treatment evidence

An updated meta-analysis of transition probability reports substantial sampling biases in the CHR-P paradigm, including risk enrichment among young people recruited for assessment, and notes that reported transition risks span adult and child or adolescent populations. The Cochrane review finds some low-quality evidence that omega-3 fatty acids may be effective, but no high-quality evidence that any type of treatment is effective. It concludes that firm conclusions cannot be made. Together, these findings caution against treating risk estimates or preventive treatment effects as settled.

From targeted assessment to primary prevention

A proposal to move beyond the at-risk mental state approach points to cannabis use as a psychosis risk factor that is readily open to a universal primary-prevention strategy. The authors advocate public-health campaigns educating young people about the harms of regular use of high-potency cannabis. This offers a population-level prevention direction, in contrast to focusing only on identifying people already considered at risk.

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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Evidence appraisal and recommendations

A review titled “Prevention of Psychosis: Advances in Detection, Prognosis, and Intervention” identifies detection, prognosis, and indicated interventions for people at clinical high risk for psychosis (CHR-P) as key components of preventive psychiatry. It set out to provide a comprehensive, evidence-based appraisal of advances and limitations in those areas. Its stated objective also included formulating updated recommendations. The supplied abstract excerpt does not specify what those recommendations were.

Broadening prevention priorities

A 2025 commentary, “Ten priorities that are shaping the future of mental health prevention,” describes prevention strategies as underdeveloped and underutilized despite mental health being an escalating global health priority. It advocates expanding the At-Risk Mental State (ARMS) framework beyond psychosis to include other common mental disorders. It also calls for routine, dynamic risk assessment, particularly targeting early-life adversities. These are proposals outlined by the commentary, not established outcomes reported in the supplied material.

Prevention in public health and pathways to care

A 2023 systematic literature review set out to quantify how much public-health research focuses on preventing mental illness versus intervening after illness onset, and how much published work in maternal and child health (MCH) focuses on mental health. A 2024 systematic review examined public-health initiatives and interventions intended to affect duration of untreated psychosis (DUP) and pathways to care. Its target groups included potential patients, families, friends, carers, communities, the general public, and non-healthcare professionals. The supplied excerpts describe the reviews’ aims and scope, but do not provide their results.

What clinic reach and prediction evidence show

Only a small share of people presenting to psychiatric care with first-episode psychosis had come through ARMS services; a separate account from an area with a well-developed clinic reports a similarly small share. These figures describe clinic reach among people with first-episode psychosis, not the causes of limited reach.[1] [2]

Specialist clinics use psychometric interviews that have good prognostic accuracy for group-level predictions. However, an umbrella review found that few predictors had enough evidence to guide clinical practice, citing generalizability concerns in small, varied samples with relatively few transitions.[3] [4]

Early identification is complicated by overlapping symptoms between people considered at risk and people experiencing other mental-health problems, as well as a lack of clinical consensus. This helps explain why assessment can be difficult without establishing how accurately any one person can be classified.[5]

The prevention discussion also includes social determinants: selective or universal approaches could act by addressing social factors that predispose people to psychosis. ARMS services have also been described as aiming to manage current symptoms and psychological and functional difficulties, alongside seeking to ameliorate, delay, or prevent onset.[1] [6]

Questions about reach, prediction, and improvement

  • What factors explain why so few people presenting with first-episode psychosis had previously accessed ARMS services? The reported proportions establish limited prior clinic contact, but do not identify its causes.[1] [2]
  • How well do group-level prognostic results translate to decisions about individuals, given the overlap in symptoms and the limited evidence for predictors that generalize across samples?[3] [4] [5]
  • Among people who do not transition, how durable is the improvement seen at follow-up, and how does symptom management relate to the broader aim of preventing or delaying onset?[6] [7]

Sources

  1. Reimagining psychosis prevention: responding to the accessibility issues of At-Risk Mental State (ARMS) services through a selective public health approach | BJPsych Bulletin | Cambridge Core Logo for (www.cambridge.org)
  2. 'At risk mental state' clinics for psychosis - an idea whose time has come - and gone! (pubmed.ncbi.nlm.nih.gov)
  3. Preventing psychosis in people at clinical high risk: an updated meta-analysis by the World Psychiatric Association Preventive Psychiatry section (pmc.ncbi.nlm.nih.gov)
  4. Predictors of transition in patients with clinical high risk for psychosis: an umbrella review (pmc.ncbi.nlm.nih.gov)
  5. Identifying individuals at risk of developing psychosis: A systematic review of the literature in primary care services (pmc.ncbi.nlm.nih.gov)
  6. The reality of at risk mental state services: a response to recent criticisms (pmc.ncbi.nlm.nih.gov)
  7. Clinical outcomes in individuals at clinical high risk of psychosis who do not transition to psychosis: a meta-analysis (pmc.ncbi.nlm.nih.gov)

About this Article -

Written with AI assistance from published research, and reviewed by the Mystum team. See our About page for more information.

Everything You Need To Know

1

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'.

2

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.

3

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.

4

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.

5

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.

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