Urban cityscape transforming into a forest, symbolizing the shift from risk factors to protective environments.

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

Nico Varela in Health & Wellness June 2025 • 5 min read.

"Experts are questioning whether specialized ARMS clinics are the most effective way to prevent psychosis, advocating for broader public health strategies focused on known risk factors."

For decades, mental health professionals have pursued the goal of preventing psychosis, a condition that can significantly impact a person's life. Early intervention (EI) services emerged as a promising strategy, aiming to improve long-term outcomes for individuals experiencing their first episode of psychosis (FEP). These services, like the Lambeth Early Onset (LEO) team and OPUS, have shown encouraging results, leading to their widespread adoption.

Building on this momentum, researchers developed specific clinical criteria to identify individuals at high clinical risk of developing psychosis, known as the At-Risk Mental State (ARMS). The idea was that by identifying and supporting these individuals, a substantial proportion could be prevented from transitioning to clinical psychosis. This led to the creation of specialized ARMS clinics in many countries, offering targeted interventions to young people deemed at ultra-high risk (UHR).

But are ARMS clinics the most effective way to tackle psychosis prevention? Some experts are beginning to question their impact, suggesting that a broader public health approach might be more beneficial. This involves focusing on known environmental risk factors rather than solely targeting individuals already exhibiting ARMS symptoms.

The Promise and Limitations of ARMS Clinics

Urban cityscape transforming into a forest, symbolizing the shift from risk factors to protective environments.

ARMS clinics are specialized mental health services designed for young people, typically aged 14-35, who are considered at ultra-high risk of developing psychosis. These clinics aim to reduce the transition from the ARMS to a full-blown psychotic disorder, providing 'evidence-based recommendations' and 'guidance' for treatment. Many studies have reported the benefits of ARMS clinics, claiming they can prevent the development of psychosis.

However, the effectiveness of ARMS clinics in preventing psychosis on a large scale is now being debated. A study conducted in South London, an area with a well-established ARMS clinic, revealed that only a small fraction (4%) of patients with first-episode psychosis had previously been seen at the clinic with ARMS symptoms. This raises concerns about the reach and impact of these specialized services.

High False Positive Rates: Studies show that a significant percentage of individuals identified as being at risk for psychosis using scales like the CAARMS (Comprehensive Assessment of At-Risk Mental States) do not develop a psychotic disorder within 2-3 years. This leads to a high number of 'false positives,' questioning the accuracy of the screening methods.
Defining the Construct: There is significant variability in the proportion of adolescents meeting ARMS criteria, ranging from 0.9% to 22.6%, depending on slight variations in the diagnostic criteria. This inconsistency highlights the difficulty in defining the ARMS construct itself.
Lack of Specific Biomarkers: Attempts to identify specific biological markers for the ARMS phase and predictors of transition to clinical psychosis have so far been unsuccessful, making it difficult to objectively determine who will develop the condition.

The central issue is that ARMS clinics may only be reaching a specific subgroup of pre-psychotic individuals, rather than a representative sample of the entire population at risk. Individuals who attend these clinics tend to be help-seeking, have strong family support, and possess a good understanding of mental health issues. Migrants, ethnic minorities, and those with less social support may be less likely to access these services, creating a skewed representation.

A Public Health Approach to Prevention

Drawing parallels with preventive approaches for conditions like lung cancer and heart disease, experts suggest that a public health strategy targeting known risk factors for psychosis may be more effective. Instead of focusing solely on individuals in the ARMS phase, this approach would aim to reduce exposure to environmental factors that increase the risk of developing the disorder.

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Everything You Need To Know

What is the At-Risk Mental State (ARMS) and why were ARMS clinics established?

The At-Risk Mental State (ARMS) refers to a clinical condition where individuals, typically young people aged 14-35, exhibit early signs or symptoms that suggest a high likelihood of developing psychosis. ARMS clinics were specifically created to identify and support these individuals with the goal of preventing or delaying their transition into a full-blown psychotic disorder. These clinics provide targeted interventions based on 'evidence-based recommendations' and guidance for treatment.

What are the primary criticisms or limitations of ARMS clinics in preventing psychosis?

The main criticisms of ARMS clinics revolve around their effectiveness and reach. Studies indicate that ARMS clinics might only be reaching a small percentage of individuals who eventually experience psychosis. Additionally, ARMS clinics have shown high false positive rates, meaning that a significant number of individuals identified as being at risk for psychosis using tools like the CAARMS (Comprehensive Assessment of At-Risk Mental States) do not develop the condition. Further, the diagnostic criteria for ARMS vary widely, leading to inconsistencies in identifying who qualifies for ARMS status. Finally, the absence of specific biomarkers makes it difficult to objectively predict who will transition to psychosis.

How do ARMS clinics differ from Early Intervention (EI) services like the Lambeth Early Onset (LEO) team and OPUS?

Early Intervention (EI) services, such as the Lambeth Early Onset (LEO) team and OPUS, are designed to support individuals after they have experienced their first episode of psychosis (FEP). These services focus on improving long-term outcomes for those already experiencing the condition. In contrast, ARMS clinics aim to intervene *before* the onset of psychosis, targeting individuals identified as being at risk based on specific criteria. While both are crucial, they address different stages of the illness, with EI serving those who have already developed psychosis and ARMS aiming to prevent its onset.

What alternative approaches are being proposed to ARMS clinics for psychosis prevention and what are their advantages?

Experts suggest a shift towards a public health approach, which focuses on broader strategies to reduce the incidence of psychosis by targeting known risk factors. Instead of solely targeting individuals in the ARMS phase, this approach would involve reducing exposure to environmental risk factors, mirroring preventive strategies for conditions like lung cancer and heart disease. The advantages of this approach include potentially reaching a larger and more diverse population, including those less likely to seek help from specialized services. It can also address underlying causes and promote overall mental well-being, ultimately aiming for a more comprehensive prevention strategy.

Why is there a concern that ARMS clinics might not be reaching a representative sample of those at risk for psychosis?

The concern stems from the fact that ARMS clinics may primarily attract a specific demographic: help-seeking individuals with strong family support and a good understanding of mental health issues. Those with less social support, migrants, and ethnic minorities might be less likely to access these services, creating a skewed representation of the population at risk. This raises questions about the inclusivity and the potential for these clinics to widen existing health disparities, leading to less effective prevention on a broader scale.