At-risk mental state for psychosis: identification and current treatment approaches

Abstract

SummaryThe concept of an ‘at-risk mental state’ for psychosis arose from previous work attempting to identify a putative psychosis prodrome. In this article we summarise the current criteria used to identify ‘at-risk’ individuals, such as the ultra-high-risk (UHR) criteria, and the further identification of important clinical risk factors or biomarkers to improve prediction of who might develop a psychotic disorder. We also discuss important ethical issues in classifying and treating at-risk individuals, current treatment trials in this area and what treatment current services can offer.

The access and waiting-time standard for first-episode psychosis: an opportunity for identification and treatment of psychosis risk states?

“…Third, we may be able to use, at an earlier stage of illness, more benign treatments that are potentially less costly, less stigmatising and better tolerated. 2 This preventive model also represents an opportunity to broaden treatment paradigms within mental health, not just for psychosis but for other disorders, fitting perfectly with another current health development strategy – low-stigma, accessible and responsive youth mental health services. Debate continues as to whether such services are appropriately placed within established early intervention for psychosis or whether new, dedicated teams with a more public health emphasis should be created.…”

“…With the advent of the new access and waiting-time standard for first-episode psychosis published by NHS England in February 2015, 1 there is now a definite move to adopt service models aimed at preventing transition to psychosis in vulnerable individuals, as originally developed in 1994 by the Personal Assistance and Crisis Evaluation clinic in Melbourne. 2 There is an expectation that early intervention in psychosis services will now also offer interventions for at-risk mental state for psychosis (ARMS), based on our evolving understanding of best practice in this area.…”

“…The criteria commonly used in the UK for ARMS depend on the presenting clinical features, relative functional impairment and help-seeking. 2 Consistent quantification of distress relating to these features is currently lacking. It also remains unclear how these clinical risk features differ from more widespread psychotic phenomena in the general population.…”

“… 8 The large majority of those identified as ARMS do not cross this severity threshold within 3 years of follow-up, although many remain functionally impaired or develop other disorders. 2 Whether other transition criteria, or modifications of existing criteria, are better able to predict longer-term outcome remains to be established. The reliability of identifying such thresholds in clinical practice is also less than in research settings, 9 despite using widely available tools.…”

“…The reliability of identifying such thresholds in clinical practice is also less than in research settings, 9 despite using widely available tools. 2 This is further complicated by concurrent substance misuse, common in such clinical populations. However, the definition and adoption of such thresholds is clearly necessary to educate clinicians, decide when to appropriately intervene and support research.…”