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Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres
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
Keywords:
Psychosis
Attenuated symptoms
Clinical high-risk
Prodrome
Schizophrenia
Screening
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.
http://dx.doi.org/10.1016/j.schres.2014.06.036
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)
12
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
search.
1
Hyphenation of terms such as clinical high-risk (as opposed to clinical high risk)
did not impact search results.
13
Table 1
Screening tools for detection of psychosis risk states.
Measure
Sample
Findings
Prodromal Questionnaire
(PQ; 92 items)
Lindgren, 2010
Prodromal Questionnaire
Brief (PQ-B; 21 items)
Prodromal Questionnaire-16
(16 items)
14
Table 1 (continued)
Measure
Sample
Kobayashi et al.,
2008
Kobayashi et al.,
2010
Kobayashi et al.,
2011
Kline et al., 2012
Bedwell and
Donnelly, 2005;
Bedwell and Orem,
2008
Kline et al., 2012
Eppendorf Schizophrenia
Inventory (ESI; 40 items)
Findings
15
Table 1 (continued)
Measure
Sample
Thompson et al.,
2013
Thompson et al.,
2014
Mossaheb et al.,
2012
Findings
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
concerns.
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
16
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).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Conict of interest
The authors have no actual or potential conicts of interest to disclose.
Acknowledgment
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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