‘At risk mental state’ clinics for psychosis – an idea whose time has come – and gone!
Open accessAbstract
At Risk Mental State (ARMS) clinics are specialised mental health services for young, help-seeking people, thought to be at ultra-high risk of developing psychosis. Their stated purpose is to reduce transitions from the ARMS state to clinical psychotic disorder. Reports of ARMS clinics provide ‘evidence-based recommendations’ or ‘guidance’ for the treatment of such individuals, and claim that such clinics prevent the development of psychosis. However, we note that in an area with a very well-developed ARMS clinic (South London), only a very small proportion (4%) of patients with first episode psychosis had previously been seen at this clinic with symptoms of the ARMS. We conclude that the task of reaching sufficient people to make a major contribution to the prevention of psychosis is beyond the power of ARMS clinics. Following the preventative approaches used for many medical disorders (e.g. lung cancer, coronary artery disease), we consider that a more effective way of preventing psychosis will be to adopt a public health approach; this should attempt to decrease exposure to environmental factors such as cannabis use which are known to increase risk of the disorder.
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- Findingcitation
In South London, only 4.1% of patients with first-episode psychosis had previously contacted ARMS services and met ARMS criteria.
“only a very small proportion (4%) of patients with first episode psychosis had previously been seen at this clinic with symptoms of the ARMS.”
- Also stated in: § A public health approach · plain
“They found that only 4.1% of FEP patients had previously made contact with ARMS services and met the ARMS criteria”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Ajnakina et al. (2017)
Not checked in the free run.
- Also stated in: § A public health approach · plain
- Interpretationcitation
It is difficult to determine with certainty when an individual moves from pre-psychotic symptoms to ARMS, and from ARMS to clinical psychosis.
“Thus, it is difficult to define with certainty when an individual transits from pre-psychotic symptoms to the ARMS, and at the other end from the ARMS to clinical psychosis (David and Ajnakina, 2016).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites David and Ajnakina, 2016
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- Interpretationcitation
The reduced estimated transition rates from ARMS to clinical psychosis are likely at least partly due to factors other than successful interventions, such as changes in sample characteristics, pathways to care, and different definitions of transition.
“However, it is likely that the reduced estimated transition rates are, at least in part, a consequence of other factors such as changes in characteristics of the sample or their pathways to care (Wiltink et al., 2015) as well as different definitions of what constitutes transition to psychosis employed across studies (van Os and Guloksuz, 2017).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Wiltink et al., 2015
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- cites van Os and Guloksuz, 2017
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- Interpretationcitation
The presence of psychotic symptoms by itself should not be taken as indicating risk of transition to psychosis.
“Therefore, the presence of psychotic symptoms in themselves should not be seen as an indication of the risk to making the transition to psychosis (Murray and Jones, 2012).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Murray and Jones, 2012
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- Premisecitation
The risk of psychosis increases linearly with greater frequency, longer duration, and stronger potency of cannabis used.
“This risk has been shown to increase linearly with a greater frequency, longer length of use and the stronger potency of the cannabis used (Di Forti et al., 2014;Marconi et al., 2016).”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Di Forti et al., 2014
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- cites Marconi et al., 2016
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- Interpretationreasoning
Under current pathway configurations, ARMS services attract a subgroup of pre-psychotic individuals who are atypical of all people who will develop first-episode psychosis.
“Therefore, the evidence suggests that under current pathway configurations, services for those who meet the criteria for the ARMS appear to attract a subgroup of prepsychotic individuals who are atypical of all those people who will develop FEP.”
Quote in the paperSubstantial claim - Premisecitation
Cannabis use is an important risk factor for later developing psychotic symptoms and/or psychotic disorder.
“The evidence that cannabis use is an important risk factor for later developing psychotic symptoms and/or psychotic disorder is especially strong (Murray et al., 2016).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Murray et al., 2016
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- Premisecitation
The evidence for the effectiveness of interventions offered by prodromal clinics is weak.
“Even for those individuals who were identified at UHR by the ARMS services, the evidence for effectiveness of the interventions that these prodromal clinics offer is weak (Castle, 2012).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Castle, 2012
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- Premisecitation
Even when the diagnosis of ARMS was made by experienced clinicians, the false-positive rate remained substantially high at 47%.
“Even when the diagnosis of the ARMS was made by experienced clinicians, the false-positive rate remained substantially high (47%) (Yung et al., 2008).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Yung et al., 2008
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- Premisecitation
The proportion of adolescents who meet criteria for ARMS varies from 0.9 to 22.6% depending on slight variations in the ARMS criteria.
“Indeed, it has been shown that the proportion of adolescents who meet criteria for the ARMS varies from 0.9 to 22.6% depending on slight variations in the ARMS criteria (Kelleher et al., 2012).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Kelleher et al., 2012
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- Interpretationown data
The task of reaching enough people to make a major contribution to preventing psychosis is beyond the capacity of ARMS clinics.
“We conclude that the task of reaching sufficient people to make a major contribution to the prevention of psychosis is beyond the power of ARMS clinics.”
- Also stated in: § Conclusion · boosted
“However, it is clear that the task of making a major contribution to the prevention of psychosis is beyond the power of the ARMS clinics.”
Quote in the paperSubstantial claim- Rests on an assumption: The 4.1% figure from South London is representative of other areas with well-developed ARMS clinics.
- Also stated in: § Conclusion · boosted
- Premisecitation
A substantial proportion of first-episode psychosis cases (24% in London) would have been prevented if no one had consumed high-potency cannabis.
“Importantly, it has been demonstrated that a substantial proportion of first episode psychosis cases (24% in London) would have been prevented if no one consumed cannabis of high potency (Di Forti et al., 2015).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Di Forti et al., 2015
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- Interpretationreasoning
A public health approach to preventing psychosis has the potential to be more effective than ARMS clinics.
“we consider that a more effective way of preventing psychosis will be to adopt a public health approach”
- Also stated in: § Conclusion · hedged
“A public health approach to prevention of psychosis has the potential to be more effective.”
Quote in the paperSubstantial claim- Rests on an assumption: Public education can effectively reduce society's consumption of high-potency cannabis.
- Rests on an assumption: Reducing exposure to risk factors such as cannabis will substantially reduce the incidence of psychosis.
- Also stated in: § Conclusion · hedged
- Premisecitation
Over 80% of individuals referred to as 'at risk for psychosis' will never develop clinical psychosis.
“A recent review suggested that over 80% of individuals referred to as 'at risk for psychosis' will never develop clinical psychosis (van Os and Reininghaus, 2016).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites van Os and Reininghaus, 2016
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- Premisecitation
As many as 84% of individuals identified as at risk using ARMS scales did not develop a psychotic disorder within 2-3 years.
“However, it has been reported that as many as 84% of those individuals who were identified as being at risk for the illness using these scales did not develop a psychotic disorder within 2-3 years (i.e.these individuals are normally referred to as 'false positives') (Corcoran et al., 2010).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Corcoran et al., 2010
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- Premisecitation
The most common diagnoses reported in young people attending ARMS clinics are anxiety, depression, and personality disorders.
“The realisation that the most common diagnoses reported in young people attending the ARMS clinics are anxiety, depression and personality disorders (Kelleher et al., 2012) prompted McGorry”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Kelleher et al., 2012
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- Interpretationnone given
ARMS clinics have provided a valuable source of pre-psychotic patients for research.
“We recognise, of course, that ARMS clinics have provided a valuable source of pre-psychotic patients for research.”
Quote in the paperNot a substantial claim - Premisecitation
When the transition rate was estimated based on the actual prevalence of ARMS in the general population, it was shown to be around 1%.
“In fact, when the transition rate was estimated based on the actual prevalence of the ARMS in the general population it was shown to be around 1% (van Os, 2005).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites van Os, 2005 source
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- Interpretationreasoning
The benefits claimed for ARMS clinics may reflect the population attracted to the clinics rather than the care offered.
“This in turn should raise some doubts as to whether some of the benefits claimed for ARMS clinics (Valmaggia et al., 2015) are actually a reflection of the population attracted to the ARMS clinics, rather than the care offered by the clinics.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Valmaggia et al., 2015
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- Premisecitation
An early evaluation of youth mental health services in Australia found that evidence of benefit was inconclusive.
“This approach has much to commend it but an early evaluation of such services in Australia found that evidence of benefit was inconclusive (Hilferty et al., 2015).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Hilferty et al., 2015
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- Interpretationcitation
The high positive predictive values reported by some studies for transition from ARMS to clinical psychosis are a result of sample enrichment from mainstream sample selection procedures, leading to spuriously increased incidence and predictive values.
“Further, van Os (2005) highlighted that the high positive predictive values presented by some studies when predicting the transition from the ARMS phase to clinical psychosis (Miller et al., 2002;Yung et al., 2003) are actually an outcome of the sample enrichment that results from the mainstream sample selection procedures.This in turn leads to spuriously increased incidence and predictive values”
Quote in the paperSubstantial claim0 of 1 sources checked- cites van Os, 2005 source
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- Premisecitation
The strength of claims that ARMS clinics can prevent transition to psychosis has not been established.
“However, the strength of such claims has not been established (Morrison et al., 2012).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Morrison et al., 2012
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- Interpretationreasoning
Temporary amelioration of psychosis at baseline may cause people to be wrongly assigned to the UHR group rather than the psychotic group.
“As the expression of psychosis naturally fluctuates in intensity and severity within individuals over time, temporary amelioration of psychosis at the time of the baseline assessment may cause these people to be wrongly assigned to the UHR group rather than the psychotic group.”
Quote in the paperSubstantial claim
- May combine two claims. 3
- Classified as probably not a substantial claim. 2
May combine two claims.
PremisecitationAttempts to identify specific biological markers of the ARMS phase and predictors of transition from ARMS to clinical psychosis have been unsuccessful.
“Furthermore, attempts to identify specific biological markers of the ARMS phase and predictors of a transition from the ARMS to clinical psychosis have been unsuccessful (Castle, 2012;Wood et al., 2013).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Castle, 2012
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- cites Wood et al., 2013
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May combine two claims.
InterpretationreasoningThe process of developing psychosis has already begun in people with ARMS, so intervening at this stage may already be too late.
“Nonetheless, this does imply that the process of developing psychosis has already begun in people with the ARMS.Therefore, it reinforces the point that intervening at this stage may already be too late.”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationcitationThe scope for ARMS services to reduce or postpone the onset of psychosis is limited, as is their public health or economic impact.
“This very low proportion suggests that the scope for ARMS services reducing or postponing the onset of psychosis is limited as is their public health or economic impact (van Os and Guloksuz, 2017).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites van Os and Guloksuz, 2017
Not checked in the free run.
- Rests on an assumption: The 4.1% figure from South London is representative of other areas with well-developed ARMS clinics.
Classified as probably not a substantial claim.
InterpretationreasoningThe identified pre-psychotic patients are diluted in more recent studies by large numbers of patients with other psychiatric problems.
“Another important reason why transition rates are lower than previously reported may be that the identified pre-psychotic patients are diluted in more recent studies by large numbers of patients with other psychiatric problems.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Interpretationnone givenThe development of ARMS clinics has increased awareness of a greater opportunity for prevention and early intervention.
“The development of ARMS clinics has also increased awareness of a greater opportunity for prevention and EI.”
Quote in the paperNot a substantial claim
The paper relies on this without support.
The 4.1% figure from South London is representative of other areas with well-developed ARMS clinics.
“in an area with a very well-developed ARMS clinic (South London), only a very small proportion (4%) of patients with first episode psychosis had previously been seen at this clinic with symptoms of the ARMS.”
“Ajnakina et al. (2017) carried out a comprehensive evaluation of FEP patients in an area of South-London which has had a welldeveloped ARMS service for more than 10 years serving the same catchment area.”
The paper relies on this without support.
Public education can effectively reduce society's consumption of high-potency cannabis.
“However, an obvious place to start is by attempting to reduce society's consumption of high-potency cannabis through public education (Di Forti et al., 2015;Gage Psychological Medicine et al., 2016).”
The paper relies on this without support.
Reducing exposure to risk factors such as cannabis will substantially reduce the incidence of psychosis.
“In the long-term, attempts to reduce exposure to these risk factors for psychosis should be made.”
“A similar approach should be adopted for psychosis.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Conventional mental health services are not generally engineered to detect and prevent psychosis onset from anxiety or depressive disorders, as claimed by some authors.
“Conventional mental health services are not generally engineered to detect and prevent psychosis onset from anxiety or depressive disorders, as claimed by some authors 195,231”
From Preventive psychiatry: a blueprint for improving the mental health of young people (2021) · cites this paper as [195]
Resources invested in prevention services may not reach population segments with a high prevalence of risk factors but low access to mental health care services.
“Help-seeking behavior is associated with beneficial social determinants, and resources invested in prevention services -especially the few providing specialized early intervention -may not reach population segments with a high prevalence of risk factors but low access to mental health care services 135,196 .”
From Ethical challenges in contemporary psychiatry: an overview and an appraisal of possible strategies and research needs (2024) · cites this paper as [135]
Help-seeking behavior is associated with beneficial social determinants.
“Help-seeking behavior is associated with beneficial social determinants, and resources invested in prevention services -especially the few providing specialized early intervention -may not reach population segments with a high prevalence of risk factors but low access to mental health care services 135,196 .”
From Ethical challenges in contemporary psychiatry: an overview and an appraisal of possible strategies and research needs (2024) · cites this paper as [135]
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Bentall, R. P., & Morrison, A. P. (2002) · Journal of Mental Health · doi:10.1080/09638230020023723 · Cited by 97 · see citing works
Ajnakina, O., Morgan, C., Gayer-Anderson, C. E., Oduola, S., Bourque, F., Bramley, S., Williamson, J., MacCabe, J. H., Dazzan, P., Murray, R. M., et al. (2017) · BMC Psychiatry · doi:10.1186/s12888-017-1468-y · Cited by 85 · see citing works
Self-citationValmaggia, L., Byrne, M., Day, F., Broome, M. R., Johns, L., Howes, O. D., Power, P., Badger, S., Fusar‐Poli, P., & McGuire, P. K. (2015) · The British Journal of Psychiatry · doi:10.1192/bjp.bp.114.150623 · Cited by 82 · see citing works
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Cannabis use and symptom severity in individuals at ultra high risk for psychosis: a meta‐analysis
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Insight in individuals with an At Risk Mental State☆
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Flagged first, then by citations
Research works printed but not linked: 4
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Cited by
Sorted by citations
Preventive psychiatry: a blueprint for improving the mental health of young people
Fusar‐Poli, P., Correll, C. U., Arango, C., Berk, M., Patel, V., & Ioannidis, J. P. A. (2021) · World Psychiatry · doi:10.1002/wps.20869 · Cited by 497 · see citing works
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Galderisi, S., Appelbaum, P. S., Gill, N., Gooding, P., Herrman, H., Melillo, A., Myrick, K., Pathare, S., Savage, M., Szmukler, G., et al. (2024) · World Psychiatry · doi:10.1002/wps.21230 · Cited by 76 · see citing works
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“Therefore, a prevention approach targeted to those individuals in the general population, who experience subclinical symptoms but who are not necessarily help-seeking yet, seems promising [22, 43–45].”
Background
- Authors
- Ajnakina, O., David, A. S., & Murray, R. M.
- Affiliations
- King's College London (GB)
- University College London (GB)
- Corresponding author
- Ajnakina, Olesya
- Venue
- Psychological Medicine
- Publisher
- Cambridge University Press (CUP)
- Published
- 2018-12-26
- Volume
- 49
- Issue
- 4
- Pages
- 529-534
- ISSN
- 0033-2917 (ISSN-L)
- 1469-8978
- OpenAlex
- W2905843893
- Semantic Scholar
- c0ed96d4bbc63d0c0b612e57c66c3fb527e01808
- Cited by
- 82
- References
- 65
- Citations by year
- 2026: 6 · 2025: 5 · 2024: 11 · 2023: 5 · 2022: 15 · 2021: 15 · 2020: 14 · 2019: 11
- FWCI
- 7.87
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Psychological Medicine (publishedVersion)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- Funders
- National Institute for Health and Care Research
- Department of Health and Social Care
- King's College London
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- psychosis prevention, first-episode psychosis, public health approach, cannabis use, environmental risk factors, service utilization
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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