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Psychosis risk screening: A systematic review

Impact Factor: 4.43 DOI: 10.1016/j.schres.2014.06.036 Source: PubMed


Emily Kline
Harvard Medical School

Available from: Emily Kline

Retrieved on: 21 August 2015

Schizophrenia Research 158 (2014) 1118

Contents lists available at ScienceDirect

Schizophrenia Research
journal homepage:

Psychosis risk screening: A systematic review

Emily Kline, Jason Schiffman
Department of Psychology, University of Maryland, Baltimore County, Baltimore, MD 21250, United States

a r t i c l e

i n f o

Article history:
Received 15 April 2014
Received in revised form 13 June 2014
Accepted 16 June 2014
Available online 14 July 2014
Attenuated symptoms
Clinical high-risk

a b s t r a c t
Despite the wealth of evidence linking duration of untreated psychosis to critical illness outcomes, most clinicians
do not utilize any formal evaluation tools to identify attenuated or emerging psychotic symptoms. Given the costs
associated with training and administration, interview-based assessments such as the Structured Interview for
Psychosis Risk Syndromes (SIPS) are not likely to be widely adopted for clinical use. The ability to identify
high-risk individuals through low-cost, brief methods is essential to the success of scalable prevention efforts.
The aim of this article is to present a comprehensive review of the use of self-report forms as psychosis risk
screeners. A literature search revealed 34 investigations in which authors used a self-report questionnaire as
a rst-step screener in a clinical high-risk assessment protocol. Information about each screener, including reported psychometric data, is presented within the review. Psychosis risk screeners have been used in diverse
samples with the goals of validating assessments, screening populations for clinical referral, recruiting samples
of interest for research participation, and estimating symptom prevalence and severity. Screeners focusing on attenuated psychotic experiences appear to measure a reliable construct with variable prevalence in help-seeking
and general population samples. Administration of screeners to help-seeking populations can identify enriched
samples with substantially elevated likelihood of meeting CHR criteria and transitioning to psychosis over
time. More research is needed, however, to establish reliable norms and screening thresholds, as score elevations
indicating a likely high-risk respondent appear to be unreliable across populations and settings.
2014 Elsevier B.V. All rights reserved.

1. Introduction
Duration of untreated psychosis has received considerable attention as a potentially modiable prognostic factor impacting a variety
of meaningful outcomes for individuals with schizophrenia and
other psychotic spectrum disorders. Identication and intervention
earlier in the course of illness appears to maximize treatment effectiveness and quality of life (Marshall et al., 2005). The imperative
to reduce duration of untreated psychosis, as well as ndings that
symptoms of a psychosis prodrome may appear months or years before onset of orid symptoms, has led to intensive research efforts
regarding the possibility of identifying and treating illness during a
pre-psychotic or clinical high-risk (CHR) phase.
Interview-based measures such as the Structured Interview for
Psychosis Risk Syndromes (SIPS; Miller et al., 2003) and Comprehensive Assessment of At-Risk Mental States (CAARMS; Yung et al.,
2005) have established a common set of risk criteria among researchers embarking on related but unique programs of research.

Corresponding author at: Department of Psychology, University of Maryland,

Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250, United States. Tel.: +1 410
455 1535; fax: +1 410 455 1055.
E-mail address: (J. Schiffman).
0920-9964/ 2014 Elsevier B.V. All rights reserved.

For several reasons, however, these measures are not well suited
for contexts beyond specialty settings. Interviews targeting CHR status are typically lengthy, and clinicians must receive training to become familiar with the constructs, rating scales, and diagnostic
criteria (McGlashan et al., 2010). The development of brief, easyto-use instruments that can be exported for clinical use is a crucial
step toward establishing and disseminating evidence-based care
for individuals most vulnerable to psychosis.
Brief self-report questionnaires have the potential to screen populations of interest and may ultimately aid in the detection of far more
CHR individuals than would be possible through clinician- or selfreferrals to specialized programs, offering a potential solution to the
challenge of sample ascertainment for CHR research programs. Although
interview-based assessments appear to reliably identify a group with
distinctive clinical impairment and at substantially increased risk for developing a psychotic illness, the majority of individuals meeting SIPS- or
CAARMS-based CHR criteria are not expected to develop a psychotic disorder (Fusar-Poli et al., 2012). Rening the CHR construct by clarifying its
characteristic symptoms and predictive relation to future psychopathology represents a broader goal that will inform and enhance treatment
options for this population. Preliminary evidence suggests that screening
provides a valid and efcient means of identifying and recruiting highrisk samples; samples recruited through screening may be even more
likely to be truly prodromal (i.e., have higher likelihood of transition)


E. Kline, J. Schiffman / Schizophrenia Research 158 (2014) 1118

relative to samples identied through more idiosyncratic referral processes (Rietdijk et al., 2012; van der Gaag et al., 2012).
Within the past decade, researchers have developed several brief
self-report instruments to assess risk for developing psychosis (Kline
et al., 2012). In several of these measures, item content focuses on
symptoms associated with the attenuated symptom construct such as
unusual perceptions and sensations, difculty concentrating, affective
changes, superstitious beliefs, or abnormally suspicious thoughts (e.g.,
Heinimaa et al., 2003; Ord et al., 2004; Loewy et al., 2005). These questionnaires differ from previous iterations of self-report forms designed
to assess psychotic-spectrum experiences (e.g., Wisconsin Schizotypy
Scales, Schizotypal Personality Questionnaire; Raine, 1991; Kwapil
et al., 2008) in that the more recent questionnaires intend to predict
CHR status rather than measuring schizotypy as a trait construct. To
this end, measures have been validated against the SIPS, CAARMS,
schizotypy-focused interviews, and modied versions of the Structured
Clinical Interview for DSM Disorder (SCID) and Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS), with an emphasis on establishing clinical utility (i.e., predicting psychosis risk states and/or
transitions to frank psychosis), rather than construct specicity per se
(Liu et al., 2013; Cicero et al., in press). The use of various gold-standard measures of the psychosis risk construct across validation studies
also reects the heterogeneous settings, cultures, target populations,
and aims of researchers employing CHR screening questionnaires.
The aim of the current investigation is to conduct a systematic review of psychosis risk screening efforts to date, with the goal of consolidating available information about screening measures and strategies
used in the eld. By consolidating this information, we hope to identify
successful approaches to psychosis risk screening as well as the limitations of current approaches and areas in need of further investigation.

2. Methods
2.1. Search method
A systematic literature search was conducted using the PubMed and
psycINFO databases to identify all articles published to date that used a
self-report symptom questionnaire to assess putative risk for psychosis.
No limitation regarding participants' age, gender, nationality, or clinical
symptom presentation was applied. The last date on which a database
search was conducted was June 8, 2014. The following search terms
were selected and subsequently combined with the Boolean term
and: (1) prodrome or prodromal or psychosis risk or clinical
high risk or ultra high risk or attenuated psychosis or early initial
prodromal state or minor psychotic symptoms; (2) screener or
screen or screening or self-report; (3) psychosis or schizophrenia.1 Reference lists of included articles were also reviewed to identify
additional relevant studies that may have been missed by the literature

2.2. Eligibility criteria and study selection

Articles were included in the systematic review if they met the following criteria: available in English; reported original research; reported the name of the screener used by investigators; and provided data on
either the proportion of the screened sample scoring above reported
measure cutoffs, or the proportion of the screened sample meeting
interview-based CHR criteria. Studies that reported only the covariance
of screener scores with other self-report measures (e.g., Mller et al.,
2009, 2010) were not included in the review.

Hyphenation of terms such as clinical high-risk (as opposed to clinical high risk)
did not impact search results.

2.3. Data extraction

For each included article, the following features of the study were
noted and compiled: screening tool selected; nation in which research
was conducted; number of participants screened; method of participant
selection; whether screen results were compared to a more in-depth
evaluation (and if so, type of evaluation used); threshold used for positive screen result; sensitivity and specicity of screener to interviewbased diagnosis; and conclusions related to screen results. Both authors
independently read and extracted information from each study. Inconsistencies were minor and resolved through consensus discussion.
3. Results
The search term yielded a total of 121 studies on PsycINFO and 131
on PubMed. Reviewing the reference lists revealed additional articles
that were scanned for potential inclusion. Thirty-ve articles met the
criteria listed in Section 2.2 for inclusion in this systematic review.
Included investigations can generally be grouped into three categories. Measure validation studies involve explicit comparison of screener
results to a gold standard assessment of psychosis risk status (e.g.,
Loewy et al., 2005). A second category involves the real world use of
screeners to detect symptomatic individuals for clinical referral or to recruit samples of interest to CHR research (e.g., Quijada et al., 2010). A
third category of research comprises studies in which questionnaires
were employed not for actual screening but rather to examine the covariance of psychosis risk symptoms with other demographic and/or
clinical covariates within a given sample. Studies in this last category
were further considered only if authors also reported the screening results (that is, how many participants were positive screens and/or
how screening results aligned with clinician diagnoses; e.g. Kobayashi
et al., 2011). The included articles describe a total of 13 different measures that had been used as psychosis risk screeners. A list of measures
and details regarding each of the 34 studies appears in Table 1. All instruments were administered as self-report (as opposed to clinicianor parent-focused checklists) measures unless otherwise specied.
4. Discussion
4.1. Review of screening research
The systematic review identied 13 self-report measures used in 14
countries with the goal of identifying individuals at clinical high risk for
psychosis. Studies comparing screening results to CHR/psychosis diagnoses based on more validated interview measures (e.g., SIPS, CAARMS) reported a wide range of psychometric data. Depending on the setting,
population, measure, score threshold, and gold standard assessment,
sensitivities ranged from 0.50 to 1.00 and specicities ranged from 0.10
to 1.00. No single measure has demonstrated both sensitivity and specicity exceeding 0.70 on more than two studies. Overall, given the imperfect ability of screening to predict clinician diagnoses, studies in which
self-report scores serve as a proxy for face-to-face psychosis risk evaluations should be interpreted bearing the limitations of this approach.
The measures themselves vary in the extent to which they focus on attenuated positive symptoms vs. assessing a range of symptoms associated
with high-risk states. Although the psychosis prodrome is characterized
by a number of cognitive, behavioral, and affective changes (Yung and
McGorry, 1996), the widely-used SIPS and CAARMS emphasize the emergence of positive symptoms in their CHR syndrome criteria. Given this
emphasis on positive symptoms for risk identication, it is not surprising
that screeners with a narrow focus on attenuated positive symptoms (e.g.,
Prodromal Questionnaire Brief [PQ-B], Prime Screen Revised [PS-R],
Youth Psychosis At-Risk Questionnaire Brief [YPARQ-B], Eppendorf
Schizophrenia Inventory [ESI]) appear to align more reliably with SIPSand CAARMS-based diagnoses. Measures such as the PROD-Screen
(PROD) and General Health Questionnaire (GHQ) that contain many

E. Kline, J. Schiffman / Schizophrenia Research 158 (2014) 1118


Table 1
Screening tools for detection of psychosis risk states.

First author, year



Prodromal Questionnaire
(PQ; 92 items)

Loewy et al., 2005

US adolescents and young adults ages 1235

referred for CHR evaluation (N = 113)

Loewy et al., 2007

US university students (N = 1020)

Lindgren, 2010

Finnish adolescents ages 1518 seeking

psychiatric treatment (N = 836)

Ising et al., 2012

Dutch young adults ages 1835 seeking mental

health services (N = 420)

Loewy et al., 2012

Finnish adolescents ages 1518 seeking

psychiatric treatment (N = 408)

Rietdijk et al., 2012

Dutch young adults ages 1835 seeking

psychiatric treatment (N = 3671)

van der Gaag et al.,


Dutch adolescents and young adults ages 1435

seeking psychiatric treatment (N = 5800)

Loewy et al., 2011

US adolescents and young adults ages 1235

referred for CHR evaluation (N = 141)

Jarrett et al., 2012

United Kingdom incarcerated men age 21 and

older (N = 750)

Kline et al., 2012

US adolescents and young adults ages 1222

receiving mental health services (N = 49)

Kline et al., 2014

US adolescents and young adults ages 1222

receiving mental health services (N = 66)

Zhang et al., 2014

Chinese outpatients ages 1545 seeking

psychiatric treatment (N = 2101)

Ising et al., 2012

Dutch young adults ages 1835 seeking mental

health services (N = 420)

Chen et al., 2014

Chinese college students ages 1622 (N = 579)

Using a cutoff of eight or more positive symptom endorsements, the PQ

achieved sensitivity of 0.90, specicity of 0.49, and PPV of 0.78 with regard to SIPS CHR or psychosis diagnoses.
43% of respondents scored above the threshold of 8 positive symptom
responses. 2% endorsed eight or more positive symptoms that they
described as distressing. No follow-up clinical interviews were conducted.
Measure used as a rst-step screener for possible inclusion in a study
investigating neurocognition in CHR youth. Of those scoring above the
cutoff of 18 positive symptom endorsement (15% of those screened),
49% (n = 62) met criteria for a SIPS CHR diagnosis. (Participants with
psychosis were not included in analysis sample.)
An optimized threshold score of 18 positive symptoms yielded
sensitivity of 0.90, specicity of 0.90, and PPV of 0.52 with regard to
CAARMS CHR or psychosis diagnoses.
Authors report that a threshold of 18 positive symptom endorsements
yielded optimal psychometrics within a pilot subsample of participants.
After screening 408 help-seeking adolescents, investigators conducted
SIPS assessment with the highest-scoring 20%, as well as 10% of the remaining sample (interviewed N = 99). A threshold of 18 positive
symptom endorsements achieved sensitivity of 0.82, specicity of 0.49,
and PPV of 0.51 with regard to SIPS CHR diagnoses (8 participants with
psychosis were excluded from analyses). 14 high PQ participants were
followed for 1 year, 3 of whom transitioned to psychotic illness.
Measure administered upon rst contact with the mental health system.
Screening identied 420 patients (11%) who endorsed 18 positive
symptoms. Of these, 199 (47%) met CAARMS criteria for ARMS (n = 147,
35%) or psychosis (n = 52, 12%). Screening yielded a greater number of
identied cases than clinician referrals, and screen-recruited cases were
more likely to progress to psychosis. At 12-month follow-up, 21 of 78
(27%) positive screens had converted to psychosis.
PQ used to screen for inclusion in a high-risk intervention trial. 5800
patients were screened with the measure. Those scoring 18 on the
positive symptom scale (864 or 15%) were assessed using the CAARMS.
Of those interviewed, 302 were determined to be high-risk and 112 had a
current or past psychotic disorder, yielding an overall PPV of 0.48.
Authors created PQ-B by reducing the total number of items to 21 and
adding a distress scale on which respondents use a 5-point Likert scale
to indicate the degree of distress associated with each endorsed symptom. An optimized cut-off score of 3 endorsements on the PQ-B yielded
sensitivity of 0.89, specicity of 0.58, and PPV of 0.93 with regard to SIPS
CHR or psychosis diagnoses. A distress score of 6 yielded sensitivity of
0.88, specicity of 0.68, and PPV of 0.95.
PQ-B used to screen 750 newly arrived inmates at a men's prison. All of
the 329 positive-screen participants (44% of the screened population)
completed CAARMS interviews; 60 negative-screen participants were
also interviewed. A screening threshold of 4 items that cause distress
yielded sensitivity of 0.90, specicity of 0.44, and PPV of 0.29 with regard
to psychosis or ARMS diagnoses.
The author-recommended screening threshold (6) yielded sensitivity
of 0.95, specicity of 0.28, and PPV of 0.48. The within-sample optimized
threshold was substantially higher (38) and yielded sensitivity of 0.70,
specicity of 0.82, and PPV of 0.74 with regard to SIPS CHR or psychosis
A distress score of 18 yielded sensitivity of 0.77, specicity of 0.68, and
PPV of 0.61 with regard to SIPS CHR or psychosis diagnosis. Counting only
items for which respondents positively endorsed distress, a threshold of
4 endorsements yielded sensitivity of 0.73, specicity of 0.83, and PPV
of 0.73.
80% of respondents scored above the author-recommended score
threshold of 6 or greater, and a subsample of 1461 (representing both
positive and negative screens) was assessed via SIPS. According to a
owchart provided by the authors, the measure yielded sensitivity of
0.97 and specicity of 0.06 with regard to SIPS CHR or psychosis diagnoses.
Researchers employed a step-wise logistic regression to select the most
predictive items from the PQ-92. Similar to the PQ-B, the PQ-16 contains
a distress scale. Using a total score cutoff of 6, PQ-16 demonstrated
sensitivity of 0.87, specicity of 0.87, and PPV of 0.44 with regard to
CAARMS CHR or psychosis diagnoses within this sample.
54 (9%) of screened participants scored over a score threshold of 6. 49
of the positive screen cases and 50 negative screen cases were further
assessed via SIPS. Within this subsample of 99, 20 were found to meet
SIPS CHR criteria, yielding sensitivity of 1.00, specicity of 0.63, and PPV
of 0.41. No participants were found to have psychosis on interview.

Prodromal Questionnaire
Brief (PQ-B; 21 items)

Prodromal Questionnaire-16
(16 items)

(continued on next page)


E. Kline, J. Schiffman / Schizophrenia Research 158 (2014) 1118

Table 1 (continued)

First author, year


Prime Screen Revised

(PS-R; 12 items)

Miller et al., 2004

Using a score threshold of 2 endorsements of somewhat or denitely

agree to indicate a possible positive case yielded sensitivity of 0.90 and
specicity of 1.00 with regard to SIPS CHR or psychosis diagnoses. (Information was gathered from a poster indicating that data collection was
Japanese outpatients ages 1630 (N = 528)
28% of respondents scored above a moderately revised screening threshold.
A randomly selected subsample (N = 115) was selected for further assessment using the SIPS. Within the interviewed subsample considering either
risk or psychosis, authors found PS-R sensitivity to be 1.00, specicity to be
0.73, and positive predictive value (PPV) to be 0.46. Using six-month followup interviews to detect transition to psychosis, authors determined the
predictive sensitivity to be 1.00, specicity to be 0.60, and PPV to be 0.11.
Japanese high school (N = 285) and university
University students' mean total (14.5) was signicantly higher than the
(N = 496) students
high school students' (12.9); however, a greater number of high school
students (13%) scored above the screening threshold of 2 or more agree
endorsements relative to university students (9%). The factor structure
was similar in the 2 groups. No clinical interviews were conducted.
Japanese outpatients ages 1630 (N = 750) and
Within the outpatient sample, 27% of respondents scored above the
high school students (N = 781)
screen threshold on the PS-R; within the high school sample, 10% scored
over threshold. No clinical interviews were conducted.
US adolescents and young adults ages 1222
The author-recommended screening threshold (2) yielded sensitivity
receiving mental health services (N = 49)
of 0.80, specicity of 0.48, and PPV of 0.52 with regard to SIPS CHR/psychosis diagnoses. The within-sample optimized threshold was three or
more endorsements and yielded sensitivity of 0.75, specicity of 0.66,
and PPV of 0.60.
US adolescents receiving mental health services
A caregiver version (CGPS-R) of the PS-R was created by changing the
(N = 52)
phrasing of PS-R items from I/me to my child. The PS-R, CGPS-R, and
SIPS were administered to 52 adolescentparent dyads referred for CHR
evaluation. The PS-R alone yielded sensitivity of 0.81, specicity of 0.60,
and PPV of 0.69 with regard to SIPS CHR/psychosis diagnoses. Combining
data from both parent and teen reports yielded sensitivity of 0.74, specicity of 0.76, and PPV of 0.77.
Kenyan youth ages 1429 recruited from a Nairobi Culturally modied version. A threshold of three 5 (somewhat agree)
neighborhood (N = 182)
or one 6 (denitely agree) responses yielded sensitivity of 0.40, specicity of 0.64, and a PPV of .12 with regard to SIPS diagnoses (authors do
not specify whether any individuals met criteria for a psychotic disorder
following SIPS assessment).
Palau high school students (N = 648)
15% of respondents scored above a threshold of 11 or more
endorsements. 74 high scoring and 56 other participants underwent
clinician interviews (the study authors used a modied version of the
Kiddie Schedule for Affective Disorder and Schizophrenia (K-SADS) to
assess psychosis risk symptoms). With regard to clinician diagnosis from
the K-SADS, the authors found the sensitivity of 0.98, specicity of 0.81,
and PPV of 0.82.
US university students (N = 998)
5% of respondents scored above the author-recommended threshold of
11 endorsements; responses used as selection criteria for (psychometrically-dened) high-risk sample recruitment.

Kobayashi et al.,

Kobayashi et al.,

Kobayashi et al.,
Kline et al., 2012

Kline et al., 2013

Owoso et al., 2014

Ord et al., 2004

Youth Psychosis At-Risk
Questionnaire Brief Version
(YPARQ-B; 28 items)

Bedwell and
Donnelly, 2005;
Bedwell and Orem,
Kline et al., 2012

PROD-screen (21 items)

Eppendorf Schizophrenia
Inventory (ESI; 40 items)


United States (US) adolescents and young adults

referred for CHR evaluation (N = 36)

US adolescents and young adults ages 1222

receiving mental health services (N = 49)

Heinimaa et al., 2003 Epidemiologically mixed (outpatient, general

population, genetic high-risk) Finnish adult sample (N = 132)
Gran et al., 2011

Finnish adolescents ages 1220 referred for CHR

evaluation (N = 87)

Niessen et al., 2010

Dutch patients ages 1635 referred to high-risk

treatment program (N = 160)

Kang et al., 2012

Korean high school students (N = 1190)

Chung et al., 2013

Korean high school students ages 1617

(N = 1002)

The author-recommended screening threshold (11) yielded sensitivity of

0.65, specicity of 0.76, and PPV of 0.65 with regard to SIPS CHR/psychosis
diagnoses. The within-sample optimized threshold was slightly higher
(13) and yielded sensitivity of 0.65, specicity of 0.90, and PPV of 0.81.
41% of respondents scored above the authors' threshold of 2 specic
symptoms. Using this threshold, the PROD achieved sensitivity of 0.80,
specicity of 0.75, and PPV of 0.57 with regard to CHR status as determined by SIPS interview.
Participants completed the PROD screen as a written self-report measure,
then answered PROD items in face-to-face interview with clinician. The
mean self-report score (3.89) was signicantly lower than the mean interview score (2.30), suggesting that participants endorsed fewer items
when assessed via clinician interview. A self-report score of 2 yielded
sensitivity of 1.00, specicity of 0.50, and PPV of 0.70 with regard to
interview-based PROD diagnoses of CHR/psychosis.
Participants were assessed using a structured clinical interview (SIPS or
BSABS). The authors report sensitivities ranging from 0.50 to 0.81 and
specicities of 0.520.94 using various score thresholds to distinguish
CHR/psychosis cases from low-risk individuals.
Translated and modied for Korean. 78 students (7%) scored above the
Korean ESI (K-ESI) threshold of 29 or higher. Of those who scored above
the threshold, 15 (19% of high scorers, or 1% of the sample) met CAARMS
high-risk criteria.
Translated and modied for Korean. Students completed a general
mental health screeners, the Korean Youth Self Report (K-YSR). 120
students who screened above K-YSR clinical thresholds completed an ESI
and CAARMS. 13 (1% of the study sample) met CAARMS UHR criteria. The
authors found that an ESI score of 29 yielded sensitivity of 0.77 and
specicity of 0.70 with regard to CAARMS high-risk diagnosis.

E. Kline, J. Schiffman / Schizophrenia Research 158 (2014) 1118


Table 1 (continued)

First author, year


Early Recognition Inventory

(ERIraos) Checklist
(17 items)

Hfner et al., 2004;

Bechdolf et al., 2005

German participants seeking mental health

services ages 1935 (N = 1212)

Quijada et al., 2010

BASC Atypicality Scale

(9 items within a 176-item

Thompson et al.,

Thompson et al.,

Composite Psychosis Risk

Questionnaire (15 items)

Liu et al., 2013

Early Detection Primary Care

Checklist (PCCL; 20 item
and 6 item versions)

French et al., 2012

General Health Questionnaire Razali et al., 2011

(GHQ-12; 12 items)
Community Assessment of
Psychic Experiences
(CAPE; 42 items)

Mossaheb et al.,


Checklist and scoring instructions appear in Hfner et al., 2004. Screener

was administered by general practitioners, counselors, psychiatrists, and
psychotherapists. 994 respondents (82%) scored over the screening
threshold of 6. Of these, 388 (39%) met high-risk criteria as dened by
the clinician-administered Early Recognition Inventory (ERIraos symptom list).
Spanish patients ages 1256 seeking mental
Any person scoring 3 on the checklist was referred for specialized
health care (screened N not reported)
assessment and completed a SIPS. Of 55 cases assessed, 29 (53%) met
criteria for high-risk state or emergent psychosis.
US adolescents and young adults ages 1222
The BASC-2 scoring system provides standardized t-scores for each
receiving mental health services (N = 70)
assessed domain, with a t-score of 60 indicating likely clinical problems. Using this threshold for the atypicality subscale of the measure
yielded sensitivity of 0.65, specicity of 0.87, and PPV of 0.80 with regard
to SIPS CHR/psychosis diagnosis.
US adolescents and young adults ages 1222
The BASC-2 self- and parent-report forms were completed by 62 carereceiving mental health services (N = 63)
giveryouth dyads. A threshold t-scores of 60 on the atypicality subscale of the self-report form yielded sensitivity of 0.68, specicity of 0.79,
and PPV of 0.79 with regard to SIPS CHR/psychosis diagnosis. When
parent reports were considered alongside self-report, a mean score of
60 yielded sensitivity of 0.82, specicity of 0.79, and PPV of 0.82.
Taiwanese participants ages 1632 designated as Items were drawn from Mandarin translations of the Schizophrenia
high-risk (N = 111), low-risk help-seeking
Proneness Scale, the Schizotypal Personality Questionnaire, as well as a
(N = 95), or controls (N = 129)
basic symptoms scale. Fifteen items with the strongest ability to
distinguish high-risk from low-risk cases within this sample were selected from a 231-item pool. A cutoff of 8 or more endorsements within
these 15 items yielded sensitivity of 0.56, specicity of 0.88, and PPV of
0.70 with regard to UHR diagnoses (participants with psychosis were
excluded from analysis sample).
The PCCL was completed by primary care practitioners who referred
UK adolescents and young adults ages 1434
positive screens for specialized psychiatric assessment. With regard to
referred for CHR assessment by a primary care
CAARMS CHR/psychosis diagnoses, the PCCL was found to have excellent
provider (N = 136)
sensitivity (0.96) but poor specicity (0.10). An optimized 6-item version
yielded a sensitivity of .88 and specicity of .47; an optimized 20-item
version sensitivity of .89 and specicity of .60.
Malaysian relatives of patients with schizophrenia Following CAARMS assessment, only 3 participants were determined to
ages 1330 (N = 111)
meet criteria for a high-risk state, thus precluding further analysis of
screener effectiveness.
Austrian adolescents and young adults ages 1324 A threshold of 3.20 on the positive symptom scale yielded sensitivity of
referred for a psychosis risk evaluation (N = 165) 0.67, specicity of 0.73, and PPV of 0.72 with regard to CAARMS CHR diagnoses (15 participants found to have psychosis were excluded from
analyses). A threshold of 2.80 yielded sensitivity of 0.83, specicity of
0.49, and PPV of 0.63.

items assessing non-positive symptoms (e.g., mood and sleep disturbances) may be too non-specic to distinguish between SIPS/CAARMS
identied CHR respondents and those with non-psychotic affective disorders, although they may effectively capture other relevant clinical
Most studies that used a screener for clinical assessment have done
so within the context of help-seeking populations and psychiatric
clinics. Individuals presenting for psychiatric care represent a selfselected enriched group in that they are, at a minimum, experiencing
some type of distress and/or disturbance in functioning. Screeners have
been used effectively within general psychiatric or counseling settings
to triage or refer likely high-risk patients for more specialized evaluations. When used as the basis for referrals to specialized clinics, positive
predictive values for screeners have ranged from 39 to 53%, indicating
that these tools are clinically useful for selecting a group with heightened psychosis risk as opposed to unrelated psychiatric or behavioral
concerns (Bechdolf et al., 2005; Lindgren et al., 2010; Niessen et al.,
2010; Quijada et al., 2010; Ising et al., 2012; Rietdijk et al., 2012; van
der Gaag et al., 2012). In particular, the Prodromal Questionnaire, PQB, and PQ-16 have collectively garnered the most real world evidence
for their screening utility use relative to less tested measures.
In contrast, studies in which investigators screened general populations such as those found in school, primary care, and community settings generally found poor specicity (French et al., 2012; Owoso
et al., 2014) and/or a very low case prevalence (Razali et al., 2011;
Kang et al., 2012). Due to such limitations, these studies were generally

less effective in leveraging screening tools for CHR identication. It is

possible that a higher threshold or more specic items would be necessary to minimize false positives in general population screening; alternatively, the incidence of psychosis within the general population may
be too low to justify the costs of screening.
The specic goals and contexts of various screening efforts will likely
dictate the justiable costs. A recruitment effort in which investigators
hope to identify every possible case would prioritize a highly sensitive instrument, even at the cost of reduced specicity or an overall low yield of
identied cases. Alternatively, a setting with high need and limited resources for conducting lengthy clinical evaluations would demand a highly specic tool that would quickly narrow the pool of likely CHR
individuals, even at the risk of missing some cases. Because ndings regarding CHR prevalence and appropriate scoring thresholds have been inconsistent across heterogeneous samples, assessors should be sensitive to
context when choosing a measure and/or threshold score for screening.
4.2. Estimating CHR prevalence
Studies that conducted a two-step screening and interview procedure using an accepted gold-standard assessment for CHR status (i.e.,
the CAARMS or SIPS) enable estimation of CHR prevalence within
these samples. Within unselected help-seeking adolescent and young
adult populations, the prevalence of identied CHR cases was estimated
to be quite consistent at 45% across several studies (Lindgren et al.,
2010; Ising et al., 2012; Jarrett et al., 2012; Rietdijk et al., 2012; van


E. Kline, J. Schiffman / Schizophrenia Research 158 (2014) 1118

der Gaag et al., 2012; Zhang et al., 2014). Researchers who conducted
screening and interviews within adolescent and young adult general
population samples estimated prevalence of 1% (Kang et al., 2012;
Chung et al., 2013), 3% (Chen et al., 2014), and 4% (Owoso et al.,
2014). Unsurprisingly, samples in which participants were referred for
specialized psychosis evaluations reported higher proportions (33
51%) of CHR cases, regardless of whether participants were formally
screened prior to SIPS/CAARMS assessment (Loewy et al., 2005;
Niessen et al., 2010; Gran et al., 2011; Kline et al., 2012; Mossaheb
et al., 2012). Although these studies were not intended to describe
CHR epidemiology and could potentially underestimate prevalence
due to the assumption that negative screens are in fact true negatives,
these gures may prove useful for planning CHR evaluation and treatment services.
4.3. Criteria for effective screening
Across instances of illness, clinicians must consider similar disease,
screening, and outcome criteria in order to determine whether a screening protocol is justied and/or likely to reduce morbidity in a given population. To this end, an article reviewing ten criteria for effective
screening (Table 2), offers a valuable review of important considerations for any screening mechanism (Obuchowski et al., 2001). Although this list of criteria is certainly not exhaustive, the criteria
provide a useful heuristic for examining the potential benets and
pitfalls of screening for psychosis risk symptoms.
Given literature to date on the costs and long-term disability associated with schizophrenia and related disorders, it is clear that psychosis
is associated with substantial morbidity and mortality (Saha et al., 2007;
criterion one from Table 2). Most individuals on a trajectory toward
psychosis experience a recognizable prodromal phase, which has been
described and codied within the current standards for high-risk identication (Fusar-Poli et al., 2013; criterion two). The body of research
reviewed highlights problems as well as potential solutions regarding existing screening tools and procedures (criteria three and four).
Intervention trials utilizing cognitive behavioral therapies (Morrison
et al., 2007; Hutton and Taylor, 2014; Okuzawa et al., in press) and pharmacologic agents (Stafford et al., 2012; van der Gaag et al., 2013) have
demonstrated some evidence that detection and treatment of clinical
high-risk states may have the potential to prevent or minimize the
impact of psychosis (criteria ve and eight); however, more research
is needed to establish the safety and efcacy of intervention in CHR
populations relative to standard treatment (criteria nine and ten). Finally, although concerns regarding stigma and clinician burden pose challenges regarding criteria six and seven, several of the studies featured in
Table 1 suggest that some screening programs have successfully managed these possible barriers (e.g., Quijada et al., 2010; Bechdolf et al.,
2012; Jarrett et al., 2012; Rietdijk et al., 2012; van der Gaag et al.,
2012). These criteria help to highlight gaps in the current knowledge
that must be addressed in order to implement effective screening.
4.4. Limitations of the current review
The current review represents a rapidly expanding eld of study,
and thus is subject to many limitations that preclude any broad conclusions about the ultimate success or failure of psychosis risk screening efforts. First, it is difcult to compare the use of a single screener across
settings and populations. Given these differences, as well as the variety
of aims of the screening studies included in this review, screener effectiveness should be considered in the context of each investigation. Second, the measures themselves including their content, number of
items, and score thresholds vary widely. Third, the gold standard
against which screener psychometrics are estimated varies across studies. Finally, few of the studies included in this review contain longitudinal data. Long-term follow-up after screening will help to determine the

extent to which screeners are able to select a group with increased likelihood of developing psychosis over time.
4.5. Future directions for research
The instability of optimal screening thresholds across populations
and settings constitutes a major barrier to successful screening efforts.
This variability may be due to local differences in culture, development,
and clinical severity across a wide range of settings. Administering
screeners to large general population samples is crucial for establishing
culturally- and developmentally-sensitive norms. Without normative
data and sensitivity to different populations, it is difcult to determine
what constitutes a clinically meaningful elevation.
Beyond the aim of initial detection and diagnosis, the expansion of
evidence-based care will require tools for ongoing symptom monitoring. Pending further controlled trials investigating potential intervention approaches for preventing psychosis among CHR patients, current
practice guidelines emphasize frequent clinical monitoring to detect
symptom exacerbation or transition to psychosis (Fusar-Poli et al.,
2013). Although the use of brief self-report assessments at regular intervals to monitor clinical status has become routine in many clinical practices (Lambert et al., 2003), no instrument assessing attenuated
psychotic symptoms has yet been validated for this purpose.
Finally, this review does not address the issue of psychosis stigma,
which may profoundly impact the risk to benet ratio of screening efforts. Whether screening creates distress for those referred for further
evaluation, or negatively impacts an individual's trust in his or her mental health care providers, is likely to vary widely across settings and cultures. Assessing attenuated psychosis symptoms within a broader
clinical evaluation may help to minimize the stigma that could accompany psychosis risk screening (Thompson et al., 2013). Patients' perceptions of psychosis risk screening have not yet been studied and should
be weighed alongside psychometric and cost considerations.
4.6. Conclusion
Effective screening would allow the low-cost identication of individuals at clinical high risk for psychosis, either in the general population
or at their rst contact with mental health services. This systematic review identied 34 studies reporting the results of psychosis risk screening investigations. Although screeners have successfully been used to
identify high-risk cases, no screener has emerged that can reliably predict the result of face-to-face evaluations such as the SIPS and CAARMS
across all contexts and populations. An improved understanding of normative and elevated scores, as well as thoughtful consideration of how to
minimize the cost and stigma incurred by screening, will help to improve
the usefulness of existing measures. Findings to date suggest that screening appears to be effective for identifying those who may benet from a
more specialized, clinician-administered evaluation within indicated
(i.e., help-seeking) populations.
Role of the funding source
The funders were not involved in study design, analyses, manuscript preparation, or
decision to submit for publication.
Table 2
Ten criteria for effective screening (from Obuchowski et al., 2001).

The disease has serious consequences

There is high prevalence of a detectable pre-clinical phase
Screening detects little pseudodisease
Screening test has high accuracy
Screening detects disease before a critical point
Screening causes little morbidity
Screening is affordable and available
Treatment exists
Treatment is more effective when applied during stage detected by screening
Treatment is not too risky

E. Kline, J. Schiffman / Schizophrenia Research 158 (2014) 1118

Emily Kline conducted the systematic review and prepared the manuscript. Jason
Schiffman served as advisor and editor for all components of the project.

Conict of interest
The authors have no actual or potential conicts of interest to disclose.

This work was supported in part by funding from the Maryland Department of Health
and Mental Hygiene, Mental Hygiene Administration through the Center for Excellence on
Early Intervention for Serious Mental Illness (OPASS# 14-13717G/M00B4400241) and the
1915(c) Home and Community-Based Waiver Program Management, Workforce Development and Evaluation (OPASS# 13-10954G/M00B3400369).

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