Over the last twenty-five years, psychiatry has tried to catch psychosis earlier — ideally before a person ever has a full episode. The clinical category that grew out of that effort is called Clinical High Risk (CHR) for psychosis (also known as the "ultra-high risk" or "at-risk mental state" in some research traditions). The category has changed how early intervention services are organised. It has also been widely misunderstood, both by patients and by the press. This guide is about what CHR actually is, what it predicts, and what it does not.
Clinical High Risk identifies young people with mild or brief psychotic-like symptoms who have a higher than average chance of developing a psychotic disorder — though most never will.
Where the concept came from
The CHR concept was developed in the 1990s, most prominently by Patrick McGorry's team at the PACE Clinic in Melbourne and by Tom McGlashan's group at Yale. Both groups were trying to identify the period before a first episode of psychosis — what older clinicians called the prodrome. The challenge was that the prodrome can only be confirmed retrospectively, after a full episode occurs. CHR was an attempt to define the same state prospectively, using observable criteria.
The three CHR pathways
Most research uses the Structured Interview for Psychosis-Risk Syndromes (SIPS) or the Comprehensive Assessment of At-Risk Mental States (CAARMS). A young person typically meets criteria for CHR if any of these apply over the past year:
- Attenuated Psychotic Symptoms (APS) — mild or sub-threshold versions of hallucinations, delusions, or disorganised thought. The person retains some doubt about the experience and is distressed or impaired by it.
- Brief Intermittent Psychotic Symptoms (BIPS) — full psychotic symptoms that resolve quickly (within a week) without treatment.
- Genetic Risk and Deterioration (GRD) — a first-degree relative with a psychotic disorder and a clear functional decline.
Critically, the criteria require functional impact. Brief unusual experiences without distress or decline do not qualify.
What CHR actually predicts
Early CHR research suggested that as many as 35–40% of young people meeting criteria would transition to a full psychotic disorder within 2–3 years. Newer studies, including the large North American Prodrome Longitudinal Study (NAPLS) and meta-analyses by Fusar-Poli and colleagues, have settled on a lower figure: roughly 15–20% transition within 2 years, and around 25–30% by year 3 or beyond. (See Fusar-Poli et al., JAMA Psychiatry, 2012.)
That number has dropped over time partly because clinical services are catching cases earlier (lower-risk presentations) and partly because of better treatment of related symptoms during follow-up.
What "high risk" does not mean
This is the part most easily lost. A 15–20% two-year transition rate also means that roughly four in five young people identified as CHR do not develop a psychotic disorder in that window. They may:
- Recover fully from the symptoms that led to assessment
- Develop a different mental health condition (depression, anxiety, OCD)
- Continue with mild attenuated symptoms that never cross into psychosis
This is why most early intervention clinics frame CHR as an indication for monitoring and treatment of present distress — not as a diagnosis of impending illness.
What treatment looks like in a CHR clinic
Almost no CHR clinic prescribes antipsychotics as first-line. Instead, the typical approach (recommended by NICE, the European Psychiatric Association, and most US guidelines) involves:
- Watchful clinical follow-up every few weeks
- CBT for psychosis-spectrum experiences (see our CBTp guide)
- Treatment of comorbid depression or anxiety
- Family education and support
- Help with school, work, and sleep
- Avoiding cannabis and other psychotogenic substances
The NICE psychosis and schizophrenia guideline (CG178) recommends offering CBT and family intervention to those at clinical high risk and reserving antipsychotics for clear conversion to a first episode.
Controversies around the diagnosis
The CHR category has been debated for decades. Critics (notably Allen Frances and colleagues during the DSM-5 process) have argued that:
- A category with a 15–20% positive predictive value risks heavy false-positive labelling
- Young people may internalise the label of "pre-schizophrenic" with real psychological harm
- Pharmaceutical companies have an obvious incentive to push antipsychotics earlier
Largely because of these concerns, the proposed "Attenuated Psychosis Syndrome" was placed in the DSM-5 appendix as a condition for further study rather than added as a formal diagnosis.
How CHR is used today
Major early intervention services (OASIS in London, PACE in Melbourne, the PRIME Clinic at Yale, EDAPT in California, the NAPLS network in the US) all use CHR criteria to organise their work. The framework is also central to coordinated specialty care models — see our overview of CSC and the RAISE trial.
If you or your child has been told "high risk"
Some practical points to hold onto:
- "High risk" is a statistical category, not a destiny. Most young people in this category never develop a psychotic disorder.
- What matters most in the next year is treating the symptoms causing distress now — anxiety, depression, sleep problems, school stress.
- Avoiding heavy cannabis use is one of the few clearly modifiable risk factors.
- Stay connected with the clinic. Regular contact catches changes early and dramatically improves outcomes if a transition does occur.
- The label belongs to the situation, not to the young person's identity.
Brief experiences become persistent or strongly believed, sleep collapses, the person stops eating or speaking, or there is any thought of self-harm. CHR clinics expect these calls — they are part of why they exist.
The bigger picture
CHR is one of the most ambitious ideas in modern psychiatry: that we might catch one of medicine's most disabling conditions before it fully forms. The evidence so far suggests that early support genuinely helps — perhaps not by preventing every transition, but by softening the trajectory and giving young people more of their lives back. The work continues, both in research consortia like NAPLS-3 and in everyday clinics around the world.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.