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+abstract: |
+  Expansion of early intervention services to identify and clinically
+  manage at-risk mental state for psychosis has been recently
+  commissioned by NHS England. Although this is a welcome development
+  for preventive psychiatry, further clarity is required on thresholds
+  for definition of such risk states and their ability to predict
+  subsequent outcomes. Intervention studies for these risk states have
+  demonstrated that a variety of interventions, including those with
+  fewer adverse effects than antipsychotic medication, may potentially
+  be effective but they should be interpreted with caution.
+author:
+- Richard Whale
+- Andrew Thompson
+- Rick FraserCorrespondence to Richard Whale
+  (<richard.whale@brighton.ac.uk>) [^1]
+date: 2017-2
+institute:
+- 1Early Intervention Service, Sussex Partnership NHS Foundation Trust,
+  UK
+- 2Brighton and Sussex Medical School, UK
+- 3Division of Mental Health and Wellbeing, Warwick Medical School,
+  University of Warwick, Coventry, UK
+- 4North Warwickshire Early Intervention in Psychosis Service, Coventry
+  and Warwickshire Partnership NHS Trust, UK
+references:
+- id: R1
+- id: R2
+- id: R3
+- id: R4
+- id: R5
+- id: R6
+- id: R7
+- id: R8
+- id: R9
+- id: R10
+- id: R11
+- id: R12
+title: "The access and waiting-time standard for first-episode
+  psychosis: an opportunity for identification and treatment of
+  psychosis risk states?"
+---
+
+With the advent of the new access and waiting-time standard for
+first-episode psychosis published by NHS England in February 2015,
+^[@R1]^ 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. ^[@R2]^ 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.
+
+This move is exciting for a number of reasons. It represents a
+commitment from the Government to support mental health service
+development and reform, especially preventive approaches, at a time when
+many services are experiencing cuts. Cost-effectiveness of ARMS services
+has been demonstrated. ^[@R3]^ Second, as a treatment paradigm the
+preventive strategy represents a possibility that we can alter the
+trajectory of a potentially serious condition and improve outcomes in
+all domains, including symptoms and functioning. 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. ^[@R2]^
+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. However, existing services have expertise in both
+defining first-episode psychosis thresholds and offering relevant
+clinical support packages for both ARMS and first-episode psychosis.
+^[@R4]^
+
+The criteria commonly used in the UK for ARMS depend on the presenting
+clinical features, relative functional impairment and help-seeking.
+^[@R2]^ 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. Psychotic experiences in non-help-seeking populations appear
+relatively common, affecting about 5%, ^[@R5]^ and higher in child and
+adolescent samples; ^[@R6]^ there is apparent sharing of aetiological
+risk factors with schizophrenia. Clinical outcomes of this
+non-help-seeking group are unknown. Psychosis transition threshold is
+commonly defined by three Positive and Negative Syndrome Scale items
+(delusions, hallucinations or conceptual disorganisation) achieving
+adequate severity for at least 7 days, ^[@R7]^ but such psychosis
+thresholds are not without controversy. ^[@R8]^ 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. ^[@R2]^ 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, ^[@R9]^ despite using widely available tools. ^[@R2]^
+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. The complexity of the
+psychosis sub-syndrome groups (including individuals with a family
+history of psychotic illness, those with schizotypal disorder or the
+attenuated psychosis syndrome, those with brief limited intermittent
+notable severity psychotic episodes and those help-seeking or not) and
+their undetermined probable outcomes may lead to services primarily
+adopting a more discrete threshold for inception, such as the DSM-5
+research-appendix-defined attenuated psychosis syndrome, which has
+marked clinical overlap with ARMS-defined populations. ^[@R9]^
+
+Without clear diagnostic robustness of a condition, and with a wide
+variation in clinical outcome, interpretation of intervention studies is
+problematic. Initially, randomised studies of diverse interventions for
+operationally defined ARMS (termed ultra high risk for psychosis) seemed
+to show similar beneficial effects *v.* control. Reviews pooling
+outcomes of these studies clearly advocated intervention. ^[@R7],[@R10]^
+More recent randomised studies have demonstrated less clear benefits
+over control than earlier studies, as is often seen in health research
+(arguably 'active' controls were used in many of these studies). Primary
+intervention recommendations of supportive counselling/case management
+for this clinical group have emerged, as previously used as a control
+intervention. Several factors will need to be considered, with future
+investigations including previous low sample size due to recruitment
+problems, use of robust and consistent thresholds for group inclusion,
+and transition to psychosis to reduce heterogeneity of outcome,
+consistent inclusion of functional outcomes, translation of findings to
+usual clinical care (away from research clinics), ensuring timely
+publication of results and the importance of replication of existing
+findings.
+
+While considerable progress has been made in this area, we remain at the
+early stages of defining a risk syndrome for psychosis. The currently
+adopted clinical threshold for ARMS seems to be a valid construct to
+identify clinical need but the heterogeneity of subsequent clinical
+outcomes is wide. Specific interventions for ARMS are unclear, aside
+from those for commonly identified comorbidities (such as anxiety,
+depression and substance misuse). Intervention studies to date highlight
+the importance of methodological rigour and consistency of diagnostic
+thresholds used, to which end the DSM-5 attenuated psychosis syndrome
+may be a positive step. ^[@R9]^ Biological models for psychosis risk
+need replication, clinical validation and combining with clinical
+markers in larger, longitudinal studies to enhance risk determination.
+^[@R2],[@R11],[@R12]^
+
+Despite these caveats, this field of study represents an important
+advance in the development of preventive psychiatry. The current move to
+incorporate earlier psychosis states in more widespread clinical
+services, with appropriate threshold definition and outcome monitoring,
+may also have important societal impact.
+
+[^1]: **Richard Whale** is Principal Lecturer at Brighton and Sussex
+    Medical School and a Consultant Psychiatrist with the Early
+    Intervention Services at Sussex Partnership NHS Foundation Trust.
+    **Andrew Thompson** is Associate Clinical Professor in Psychiatry at
+    the University of Warwick and a Consultant Psychiatrist in the North
+    Warwickshire Early Intervention in Psychosis Service. **Rick
+    Fraser** is Honorary Senior Lecturer at Brighton and Sussex Medical
+    School and Lead Psychiatrist with the Early Intervention Services at
+    Sussex Partnership NHS Foundation Trust.