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Outreach and support in south London (OASIS):

Implementation of a clinical service for
prodromal psychosis and the at risk mental
state
ARTICLE in EUROPEAN PSYCHIATRY SEPTEMBER 2005
Impact Factor: 3.44 DOI: 10.1016/j.eurpsy.2005.03.001 Source: PubMed

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European Psychiatry 20 (2005) 372378

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Original article

Outreach and support in south London (OASIS): implementation

of a clinical service for prodromal psychosis and the at risk mental state
Matthew R. Broome a,*, James B. Woolley a, Louise C. Johns a, Lucia R. Valmaggia a,b,
Paul Tabraham a, Rafael Gafoor a, Elvira Bramon a, Philip K. McGuire a
b

a
OASIS, PO 67, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands

Received 15 June 2004; received in revised form 2 February 2005; accepted 7 March 2005
Available online 13 April 2005

Abstract
Background. While recent research points to the potential benefits of clinical intervention before the first episode of psychosis, the
logistical feasibility of this is unclear.
Aims. To assess the feasibility of providing a clinical service for people with prodromal symptoms in an inner city area where engagement with mental health services is generally poor.
Method. Following a period of liaison with local agencies to promote the service, referrals were assessed and managed in a primary care
setting. Activity of the service was audited over 30 months.
Results. People with prodromal symptoms were referred by a range of community agencies and seen at their local primary care physician
practice. Over 30 months, 180 clients were referred; 58 (32.2%) met criteria for an at risk mental state, most of whom (67.2%) had attenuated
psychotic symptoms. Almost 30% were excluded due to current or previous psychotic illness, of which two-thirds were in the first episode of
psychosis. The socio-demographic composition of the at risk group reflected that of the local population, with an over-representation of
clients from an ethnic minority. Over 90% of suitable clients remained engaged with the service after 1 year.
Conclusion. It is feasible to provide a clinical service for people with prodromal symptoms in a deprived inner city area with a large
ethnic minority population.
2005 Elsevier SAS. All rights reserved.
Keywords: Prodromal; Psychosis; Clinical; Service; Risk; OASIS

1. Introduction
Recent evidence suggests that intervention in the prodromal phase that precedes the first episode of psychosis may be
beneficial. Treatment may ameliorate prodromal symptoms
such as attenuated psychotic phenomena [20]. Secondly, if
individuals subsequently develop psychosis, the delay before
treatment (duration of untreated psychosis; DUP) can be
reduced, which may improve long-term outcome [5]. Finally,
treatment may abort or defer the onset of psychosis [12,14].
However, there are concerns about the feasibility and the

* Corresponding author. Tel.: +44 207 848 0369; fax: +44 207 848 0976.
E-mail address: m.broome@iop.kcl.ac.uk (M.R. Broome).
0924-9338/$ - see front matter 2005 Elsevier SAS. All rights reserved.
doi:10.1016/j.eurpsy.2005.03.001

ethics of intervention at this stage. The prodrome can be difficult to identify as the symptoms and signs are subtle and
relatively non-specific [12,13,21]. Moreover, potential clients may be difficult to engage if the local population has a
poor relationship with mental health services or is socioeconomically deprived [3,1]. Yet it is in these communities
that the incidence of psychosis is highest [9,2,7] and intervention may be most valuable.

2. Aims
To assess the feasibility of running a clinical service for
people with prodromal symptoms of psychosis in a deprived
inner city area with a large ethnic minority population and a
high incidence of psychosis.

M.R. Broome et al. / European Psychiatry 20 (2005) 372378

3. Methods
3.1. Catchment area
The service was designed to cater for clients in Lambeth
and most of the data reflect activity in this borough. Referrals
were also accepted from the other boroughs served by the
South London and Maudsley (SLaM) NHS Trust: Southwark, Croydon, and Lewisham. An age range of 1435 was
chosen to be consistent with that employed by the PACE clinic
[21] and recommended in the UK National Service Framework for schizophrenia [19]. Lambeth has a population of
275,800 of which 34% are from ethnic minorities [18], and
has the highest proportion of AfricanCaribbean residents in
London. The rate of unemployment is high (8.4%) [11], with
almost half being long-term unemployed (6 months or longer).
The proportions of single person households (54%), homelessness and refugees and asylum seekers (~11,000) [11] are
also high. Lambeth has three wards in the top 10% most
deprived wards in the UK and 16 (almost three quarter of all
wards) in the top 20%. The local incidence of psychosis is
approximately four times the UK average [9], with the incidence especially increased in ethnic minority groups [2,7].
The local prevalence of the at risk mental state (ARMS) or
prodromal symptomatology is unknown, but if it is correlated with the incidence of psychosis, it is likely to be comparably high.
3.2. Referrals
3.2.1. Consultation and liaison with potential sources
of referral
Many health care professionals are unfamiliar with the concept of the prodrome or ARMS [16]. Initial work involved
a programme of liaison with local health and non-health agencies who may encounter people with prodromal symptoms
suggestive of an ARMS. These included general practitioners/primary care physicians (GPs), primary care counsellors and psychiatric nurses, college and university counsellors, community mental health teams as well as child and
adolescent services. Acute and out of hours psychiatric services were also contacted. Contact involved informal meetings, presentations and the distribution of information materials. All of the 50 primary care practises in Lambeth had
both written information and telephone contact, and over twothirds of the practises took part in at least one face-to-face
teaching session. Information was also posted on a website
(www.oasislondon.com), and distributed in leaflets and newsletters. Mental health charities and voluntary organisations
were also informed about OASIS. Such work has continued
since OASIS began: there is an ongoing process of liaison
and education will local pastoral, health and educational services.
3.2.2. Referral process
Referrals were accepted by telephone, fax, letter, or e-mail
and could be made by clients friends and relatives as well as

373

health professionals. The referrer was contacted by telephone to make a preliminary assessment of the suitability of
the referral. Such screening focussed around the inclusion
criteria of the service (age, address of client) as well as discussion of any prior psychiatric contact of the client. An
assessment was then offered, either at the clients general practice or their home, usually comprising two 1-h sessions. A
psychiatrist and a clinical psychologist typically assessed clients together.
3.3. Assessment measures
The term ARMS refers to a clinical syndrome regarded
as a risk factor for subsequent psychosis [21]. An individual
can meet criteria for the ARMS in one or more of three ways.
1) A recent decline in function coupled with either schizotypal personality disorder or a first degree relative with psychosis. 2) Attenuated positive psychotic symptoms. 3) A
brief psychotic episode of less than 1 weeks duration that
resolves without antipsychotic medication (Brief Limited
Intermittent Psychosis or BLIP). The presence of the ARMS
was determined via a detailed clinical assessment using the
comprehensive assessment of the at risk mental state
(CAARMS) [17]. Family history was examined using the family interview for genetic studies (FIGS) [15]. All participants
fulfilling ARMS criteria underwent a detailed clinical assessment. The SCID-1 and SCID-2 [8] were used both to assess
the presence of a schizotypal personality disorder as well as
to confirm/exclude any co-morbid diagnoses. Quantitative
measures of psychopathology were further obtained upon
entry using the following instruments: Hamilton depression
and anxiety scale and PANSS.
4. Results
Over 30 months OASIS received 180 referrals. Of these,
157 were offered an assessment, 23 having been screened out
due to living outside of the boroughs served by SLaM NHS
Trust, being outside of the age range of the service, or after
discussion with the referrer. Of these 157 suitable referrals,
19 clients either refused an assessment or recurrently failed
to meet with the team. Of the 138 assessments carried out by
OASIS over 30 months, 58 (32.2% of all referrals, 42% of
assessments) met criteria for the ARMS.
4.1. Socio-demographic characteristics of ARMS clients
The mean age of ARMS clients was 24 years and twothird were male (Table 1). Subjects came from all social
classes and most were working, either in full-time employment or as a student. A high proportion (62.1%) were from
ethnic minorities and most were not in a long-term relationship (86.2%) (Table 1).
4.2. Referral sources and pathways to care
Most (29.3%) clients with an ARMS were referred from
primary care (GPs, counsellors or psychiatric nurses attached

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M.R. Broome et al. / European Psychiatry 20 (2005) 372378

Table 1
Demographic characteristics of OASIS referrals

N
Age in years (S.D.)

Sex (%male)
Place of birth (%) United Kingdom
Africa
Europe (outside UK)
Caribbean
Middle East
South America
Ethnicity (%)
White British
Caribbean and African
Black British
Other white
Mixed
Asian Oriental
Middle East
Asian Indian
Employment (%) Student
Unemployed
Employed
Marital status (%) Never married
Married/living with partner
Separated/divorced

All referrals ARMS

subjects
180
58
24.3 (S.D.
24.1
6.1)
(S.D.
4.165)
61.7
65.5
78.8
77.8
8.3
9.3
6.4
5.6
4.5
5.6
1.3
1.9
0.6
0
36.1
38.6
27.8
24.5
17.1
15.8
8.2
8.8
3.8
3.5
2.5
3.5
2.5
3.5
1.9
1.8
41.1
30.9
32.3
30.9
25.6
38.2
83.8
89.3
9.0
7.2
7.2
3.6

to the practice), the local first episode psychosis service (Lambeth Early Onset services) (27.6%), and from general adult
and adolescent mental health services (27.5%). Other referrers included emergency clinic (5.2%), relatives (3.4%),
school counsellors (1.7%), and self-referral (5.2%). Of the
58 ARMS clients, three referred themselves or were referred

by their relatives 13 (22.3%) had only seen one other health

service professional before being referred to OASIS (10 GP,
one student counsellor, one Maudsley emergency clinic, one
primary care counsellor). Forty-two (72.4%) had more than
one previous healthcare professional contact, the breakdown
of which is shown in Table 2.
4.3. Diagnoses and symptoms
32.2% of all referrals met criteria for the ARMS. Despite
an emphasis on the distinction between the ARMS and psychosis in the information provided to referrers, subjects in
the first episode of psychosis were common, comprising
18.3% of all referrals, and 21% of all those assessed. In most
cases these were individuals in the early stages of psychosis,
when the severity of symptoms was such that a diagnosis of
psychosis was not immediately obvious. The remaining referrals met criteria for a range of other psychiatric disorders,
including depression, and anxiety disorders (Fig. 1). Almost
all those referred met DSM-IV diagnostic criteria for some
disorder; all those who did not meet ARMS criteria had an
alternate DSM-IV diagnosis.
Attenuated psychotic symptoms were by far the commonest feature of the ARMS, being evident in 39 (67.2%) of those
meeting the PACE criteria (Fig. 2). Among those with an
ARMS, 56.8% (33 clients) had additional psychiatric morbidity in addition to their ARMS symptoms (Fig. 1).
Of all the clients with an ARMS, there was only one case
of serious self harm but there were no completed suicides or
acts of violence. Of those who remain with the ARMS (not
having made transition to psychosis), none have required
either voluntary or compulsory admission.

Table 2
Pathways to care for subjects with potential ARMS in South London
Number of services consulted by client before OASIS
Self or relative
One service
Two services
Three services
Four services
Five or more services

Of all 180 referrals received (data for 172)

13 (7.2)
50 (27.8%)
53 (29.4%)
32 (17.8%)
11 (6.1%)
13 (7.2%)

Fig. 1. Diagnosis at assessment (ARMS = at risk mental state).

Of 58 referrals with ARMS

3 (5.2%)
13 (22.3%)
20 (34.5%)
12 (34.5%)
3 (5.2%)
7 (12.1%)

M.R. Broome et al. / European Psychiatry 20 (2005) 372378

375

OASIS. Of the 53 who were followed up, six later developed

psychosis, five dropped out of follow up after 6 months
because they did not wish further contact or failed to attend
appointments, and six moved out the catchment area and were
transferred to other services. Clients and their relatives were
generally happy with the service offered by OASIS, particularly with clinical contact being outside traditional mental
health settings and that the staff were flexible about the timing of appointments. Primary care clinicians liked having clients seen in their surgery and the accessibility of the service.

5. Discussion
5.1. Recruitment of clients with an ARMS

Fig. 2. Subgroups of ARMS (total number of clients = 58).

4.4. Treatment
The present study was not designed to formally evaluate
the effectiveness of treatment. Clients were provided with an
intervention package that included social support, symptom
monitoring plus cognitive behaviour therapy, antidepressant
and antipsychotic medication, depending on the presentation
and the clients preferences. At the time of entry to the service, none of the clients had been prescribed antipsychotics
by their referrer or other health professional. Subsequent to
entry to OASIS, 23 clients (39.7%) received a combination
of medication (SSRI or low dose atypical neuroleptic) together
with psychological treatment (CBT or supportive psychotherapy), 18 (31%) received only psychological intervention
and three clients (5.2%) received only medication. All these
treatments were well tolerated and practicable. Most clients
were keen to receive treatment. Some were reluctant to take
medication, sometimes because they wanted to see if they
could manage with psychological input alone. Others specifically requested medication, often because they sought rapid
relief from distressing symptoms. The issue of stigmatisation
was not raised by any of the clients, and none felt that they
had been stigmatised through their contact with the service.
4.5. Transition to psychosis
Six clients who met ARMS criteria subsequently developed a first episode of psychosis. Five were male, and one
female with an average age of 25.4 years. In these individuals the mean delay between the onset of frank psychosis and
the initiation of treatment for psychosis was 12 days (range
721). Four of these clients (66.7%) required admission and
one case (16.7%) involved assessment for compulsory admission under the UK Mental Health Act 1983.
4.6. Engagement and user satisfaction
Five clients with the ARMS preferred to be followed-up
by their referring clinician (usually their GP) rather than

OASIS received 180 referrals over the first 30 months, of

whom 58 met criteria for the ARMS. This is broadly comparable with data from the PACE clinic in Melbourne, which
received 162 referrals in its first 20 months, of whom 49 met
criteria [16], despite OASIS operating in area which is more
socio-economically deprived, has a larger ethnic minority
population and a more difficult relationship between service
users and mental health services. The difference in the total
number of referrals may reflect multiple factors but a critical
one may have been the presence in Melbourne (but not London) of an additional Early Psychosis Assessment and Crisis
Team (EPCAT) which accounted for 45% of the PACE referrals [16]. The latter, plus better integration between adult and
adolescent services for psychosis, may also have contributed
to the younger age of PACE compared to OASIS clients
(18 years in Melbourne as opposed to 24 years of age in London). The gender distribution of clients in both services was
similar, with an excess of males.
There was an average of 2.34 prior contacts (such as GP,
private psychiatrist, counsellor) before assessment, comparable to a figure of 2.36 from PACE [16]. This suggests that
OASIS clients were actively seeking help, with most having
already consulted primary care and one other health professional before referral.
Thirty-two percent of all referrals met ARMS criteria.
Thus, approximately 2.4 assessments were required per
ARMS case identified. The proportion of referrals which met
criteria was higher than expected, but is comparable to the
33% figure from the PACE clinic. This may both reflect the
high prevalence and incidence of psychosis in South London, which if continuum models of psychosis are correct, may
impact upon the epidemiology of the ARMS.
In addition to those with an ARMS, a further 20% of referrals were experiencing a first episode of psychosis and almost
10% had a prior history of psychotic illness. Thus, in addition to detecting cases at high risk of developing psychosis,
OASIS supplemented additional mental health services in
being able to detect established psychotic illness, particularly the first episode. As OASIS had good links with the local
first episode psychosis service [4], cases with psychosis could

376

M.R. Broome et al. / European Psychiatry 20 (2005) 372378

readily access appropriate treatment with a seamless continuity of care. Almost 65% of referrals had either an ARMS
or a psychotic illness, suggesting that services like OASIS
can significantly facilitate implementation of national guidelines, such as the UK National Service Framework for schizophrenia. This suggests that although most referrers were not
mental health professionals, a high proportion of referrals
were appropriate for the service. This may reflect the impact
of the educational work carried out by OASIS but also indicates that clinicians with no specialist training in this area are
able to identify people with the ARMS.
5.2. Ethnicity
Almost two-thirds of referrals of the ARMS cohort came
from ethnic minorities and over 20% were born outside of
the UK (Table 1). Although the age and social class of those
referred was broadly comparable to that of the local population, a high proportion of our clients were from ethnic minorities: 64% as opposed to 34% of the local population. As can
be seen in Table 1, the definition of ethnic minority was broad
and included everyone who described themselves other than
white British. This over-representation of people from ethnic
minorities is also evident locally among patients with first
episode psychosis [4,7], and is consistent with evidence that
environmental factors that are associated with psychotic disorders (such as discrimination) are also associated with psychotic symptoms [10] also demonstrates that services for
people with prodromal symptoms are able to engage clients
from ethnic minority populations. This is a key objective of
mental health services in the UK, as the latter are especially
at risk of psychosis but their engagement with conventional
services is relatively poor. Initiating contact before symptoms become severe and the client is in crisis may facilitate
engagement in these groups.

The age of subjects with the ARMS was lower than that of
those with a first episode of psychosis in the same area [4],
who had a mean age of 26 years.
The concept of the ARMS remains somewhat controversial, but even if the symptoms that contribute to the presence
of the ARMS are excluded, over 55% of the ARMS group
had additional psychiatric morbidity (see Fig. 1). All of the
referrals who were not categorised as ARMS met criteria for
a psychiatric disorder as defined by DSM-IV. Thus, independent of the validity of the ARMS, most of those referred to
OASIS had unmet mental health needs which were causing
them distress and disability. Referrers of those who did not
have an ARMS were provided with a detailed assessment,
advice on management and the offer of liasing with alternate
services that could provide clinical care for the client. This
was appreciated by both clients and referrers.
5.4. Transition to psychosis
Six clients developed psychosis while being managed by
OASIS. Because they had already been engaged and were
regularly monitored for signs of frank psychosis, the delay
before they were referred for treatment of frank psychosis
was much shorter than is typical in the UK (12 days as
opposed to 10.5 months). While the present study cannot
assess the long-term outcome in these cases, there is evidence that a shorter DUP is associated with improved prognosis [6]. Of the six clients who developed psychosis, only
one required compulsory assessment, which is lower than
among patients presenting with a first episode of psychosis
locally [4], and our overall clinical impression was that their
management was generally easier and less traumatic. However, the question of whether engagement in the prodromal
phase improves long-term outcome in psychosis needs to be
examined in controlled trials with larger numbers of subjects.

5.3. Presenting symptoms and clinical characteristics

5.5. Logistical demands
Most OASIS clients experienced attenuated symptoms,
either alone or in combination with one of the other inclusion
criteria. Only 12.1% of clients met criteria purely due to a
BLIP, and 1.7% for state and trait factors (a decline in function coupled with a schizotypal personality disorder or a family history of a first degree relative with a psychotic illness).
This is consistent with the distribution of symptoms in clients of the PACE clinic, who mainly had attenuated symptoms, although they were more likely to have them in combination with other diagnostic features [21] these differences
may reflect the fact that referrers in the UK find it easier to
identify attenuated symptoms than the other criteria, and that
these symptoms are more likely to enable the client to access
health care or consider seeking help. Those who present to
health services may not be representative of the total ARMS
population and thus the distribution of symptoms in our
sample may not reflect that of the ARMS population as a
whole.

Because clinical contact was usually at each clients general practice, management involved a great deal of travel for
the clinicians, with journeys of up to 1 h each way. Moreover,
the assessments usually involved two clinicians and were
detailed, taking place over two 1-h sessions. The clinicians
involved were typically a psychiatrist and clinical psychologist and the assessment included, wherever possible, a detailed
collateral history. At the time of its inception, the service consisted of one part-time consultant psychiatrist, one part-time
psychiatrist in training, and one part-time clinical psychologist. During the period detailed, more staff joined the service
including a full-time clinical psychologist, two further parttime psychiatrists in training, a team leader, and a part-time
team administrator. After the assessment, clients were seen
weekly to fortnightly for the first 12 months, and subsequently for a period of 2 years at a frequency determined by
clinical need. The above approach thus placed considerable

M.R. Broome et al. / European Psychiatry 20 (2005) 372378

logistical demands on the service. However, it was popular

with both clients and referrers and much of the work could be
planned and organised in advance: there were relatively few
crises that required urgent clinical contact. The assessment
itself was a further opportunity to liase and train our referrers: frequently the clinicians could meet and discuss the case
with the referrer both prior to and immediately after the assessment having taken place.

low. Thanks go to all the clients in OASIS and our referrers,

especially the Lambeth Early Onset (LEO) psychosis service.

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5.6. The future of OASIS

As mentioned above, a formal trial is now underway with
the client in our service to assess the acceptability and efficacy of intervention in the at-risk group. The aims of such a
study will be to determine whether intervention not only can
improve DUP and the prognosis of psychotic illness once
established, but also whether intervention may abort or defer
the transition to frank psychosis. The clients in our service
are characterised by good engagement and an active desire to
take part in research: thus, in addition to taking part in evaluation of the service and the treatments OASIS offer, clients
also have been taking part in neuropsychology, cognitive psychology, imaging, and neurophysiology research. Further, a
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Clinical Implications:
It is possible to identify and manage people with an
ARMS for psychosis, even in a deprived inner city area
with a high proportion of people from ethnic minorities.
All referrals were help-seeking, distressed and would otherwise have had difficulty accessing mental health services.
Services for people with prodromal symptoms complement first episode psychosis services and help meet the
objectives of the United Kingdom National Service Framework for schizophrenia.
Limitations of the study:
Those referred to the service may not represent the population of people with prodromal symptoms as a whole.
Although the prodrome was defined using the most widely
employed criteria, the findings may have differed had other
diagnostic criteria been used.
The study was not designed to evaluate the effectiveness
of treatment in this group.

Acknowledgements
Dr. Mark Ashworth helped set up the service. Ms. Corinne
Prescott and Mrs. Sandra Whitehead provided administrative
support. Professor Philippa Garety and Professor Elizabeth
Kuipers supervised the clinicians providing psychological
treatment. The study was supported by the Mental Health
Foundation and Guys and St Thomas Charitable Foundation. Dr. Elvira Bramon is a Wellcome Research Training Fel-

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