The reality of at risk mental state services: a response to recent criticisms

Abstract

BackgroundIn the 1990s criteria were developed to detect individuals at high and imminent risk of developing a psychotic disorder. These are known as the at risk mental state, ultra high risk or clinical high risk criteria. Individuals meeting these criteria are symptomatic and help-seeking. Services for such individuals are now found worldwide. Recently Psychological Medicine published two articles that criticise these services and suggest that they should be dismantled or restructured. One paper also provides recommendations on how ARMS services should be operate.MethodsIn this paper we draw on the existing literature in the field and present the perspective of some ARMS clinicians and researchers.ResultsMany of the critics' arguments are refuted. Most of the recommendations included in the Moritz et al. paper are already occurring.ConclusionsARMS services provide management of current problems, treatment to reduce risk of onset of psychotic disorder and monitoring of mental state, including attenuated psychotic symptoms. These symptoms are associated with a range of poor outcomes. It is important to assess them and track their trajectory over time. A new approach to detection of ARMS individuals can be considered that harnesses broad youth mental health services, such as headspace in Australia, Jigsaw in Ireland and ACCESS Open Minds in Canada. Attention should also be paid to the physical health of ARMS individuals. Far from needing to be dismantled we feel that the ARMS approach has much to offer to improve the health of young people.

Progression from being at-risk to psychosis: next steps

“…As outlined in this review, future CHR research must be collaborative, accessible and harmonized with respect to criteria and outcomes. Unfortunately, there have been critics of the field raising issues that are often unfounded [105][106][107] and which have had to be addressed in thorough counter arguments by experts in the field 108 . Thankfully, there are already initiatives underway that have adopted these steps.…”

Association of preceding psychosis risk states and non‐psychotic mental disorders with incidence of clinical psychosis in the general population: a prospective study in the NEMESIS‐2 cohort

“…Following our critical perspective papers on the CHR concept 3,5 , an intense debate has started, splitting the field into proponents 6‐8 , opponents 9‐12 , and those with ambivalent attitudes toward that concept 13‐16 .…”

Evidence for preventive treatments in young patients at clinical high risk of psychosis: the need for context

“…Although we agree that further high quality research (trials) is needed to enhance outcomes and determine the most effective type and sequence of interventions, the evidence base shows that help-seeking individuals at high risk for psychosis benefit from the available treatments, including 'standard treatment', without iatrogenic harm associated with antipsychotic medications. 10 This potential for improvement is a key message that patients, families and practitioners should be made aware of rather than negatively frame the evidence base and fail to convey any treatment benefits, which we are concerned is the inaccurate message of this recent Cochrane review. If heeded, the review's message would result in many help-seeking young people being denied much needed psychosocial care and exposed to risks of worsening symptoms and functioning.…”