FRENCH VALIDATION OF THE SELF-SCREENING PRODROME, AN EARLY DETECTION TOOL FOR PSYCHOSIS

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Data may be preliminary. 3 February 2026 V1 Latest version Share on FRENCH VALIDATION OF THE SELF-SCREENING PRODROME, AN EARLY DETECTION TOOL FOR PSYCHOSIS Authors : Aurore LEGOUX--PIERRE , Mélissa FENOT 0009-0005-4328-8862 , Dalfin W. , Vincent ORY , Frédéric VERHAEGEN , Anita Riecher-Rössler , Vincent Laprevote , and Florent Bernardin 0000-0002-0784-990X [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.177012731.10661915/v1 195 views 76 downloads Contents Abstract Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract INTRODUCTION. Preventive actions for individuals with Clinical High Risk for psychosis (CHR) are highly effective in reducing the risk of transition to psychosis. Improving the identification of at-risk individuals could enable earlier access to care and reduce both the personal and societal burden of psychotic disorders. In this context, screening questionnaires are essential tools for identifying early signs of psychosis in the general population and referring individuals with a CHR to specialized centers. The Self-Screen Prodrome questionnaire (S-PRO) is a screening questionnaire designed for this purpose. The first aim of this study is to validate the French version of this instrument. Secondly, we will explore the reduction of its items to improve precision and reduce administration time. METHODS. Following international guidelines, items were translated and pre-tested for clarity and relevance. Seventy-two CHR patients or patients experiencing a first psychotic episode according to the Comprehensive Assessment of At-Risk Mental States (CAARMS) criteria were included. RESULTS. Cronbach’s alpha score of the French version of the S-PRO was 0.893, and specificity/sensitivity were respectively 0.86 and 0.61 with an optimal cut-off point at 15 positive items. Using logistic regression, we reduced the S-PRO to a 12-items version. Cronbach’s alpha score of the S-PRO12 was 0.71, and specificity/sensitivity remain the same, respectively 0.86 and 0.61. DISCUSSION. These results suggest that the 12-item version of the S-PRO could be an effective screening instrument for its use by general health practitioners in primary care. Title: FRENCH VALIDATION OF THE SELF-SCREENING PRODROME , AN EARLY DETECTION TOOL FOR PSYCHOSIS Aurore LEGOUX–PIERRE 1 , Mélissa FENOT 2 , William DALFIN 1, 2, 3 , Vincent ORY 3 , Frédéric VERHAEGEN 1, 5 , Anita RIECHER-RÖSSLER 4 , Vincent LAPREVOTE 1, 2, 3 , Florent BERNARDIN 2, 3 * 1- Université de Lorraine, Vandoeuvre-Lès-Nancy, France 2- INSERM UMR-S 1329, Federation of Translational Neuroscience & Psychiatry, Regional University Hospital of Strasbourg, Strasbourg, France. 3- Pôle Transversal Universitaire, Centre psychothérapique de Nancy, Laxou, France 4- Medical Faculty, University of Basel, Basel, Switzerland 5- Laboratoire InterPsy (EA 4432), Université de Lorraine, Vandoeuvre-Lès-Nancy, France *Address for Correspondence: Florent Bernardin CLIP - Centre de Liaison et d’Intervention Précoce Centre Psychothérapique de Nancy 1, rue du Dr Archambault F-54 520 Laxou France [email protected] phone: +33 3 83 26 08 63 Journal: Early Intervention in Psychiatry Article type: Article Running title: French validation of the self-screening prodrome Number of words in the article: 2985/3000 Number of words in the abstract: 237/250 Number of figures: 2 Number of tables: 1 Number of Appendix: 1 Number of supplementary materials: 0 Acknowledgements: The authors would like to thank Professor Raymund Schwan and Dr Jean-David Sirbat, both of the University of Lorraine, for their contribution to the translation and subsequent reflections on this work. Abstract INTRODUCTION. Preventive actions for individuals with Clinical High Risk for psychosis (CHR) are highly effective in reducing the risk of transition to psychosis. Improving the identification of at-risk individuals could enable earlier access to care and reduce both the personal and societal burden of psychotic disorders. In this context, screening questionnaires are essential tools for identifying early signs of psychosis in the general population and referring individuals with a CHR to specialized centers. The Self-Screen Prodrome questionnaire (S-PRO) is a screening questionnaire designed for this purpose. The first aim of this study is to validate the French version of this instrument. Secondly, we will explore the reduction of its items to improve precision and reduce administration time. METHODS. Following international guidelines, items were translated and pre-tested for clarity and relevance. Seventy-two CHR patients or patients experiencing a first psychotic episode according to the Comprehensive Assessment of At-Risk Mental States (CAARMS) criteria were included. RESULTS. Cronbach’s alpha score of the French version of the S-PRO was 0.893, and specificity/sensitivity were respectively 0.86 and 0.61 with an optimal cut-off point at 15 positive items. Using logistic regression, we reduced the S-PRO to a 12-items version. Cronbach’s alpha score of the S-PRO12 was 0.71, and specificity/sensitivity remain the same, respectively 0.86 and 0.61. DISCUSSION. These results suggest that the 12-item version of the S-PRO could be an effective screening instrument for its use by general health practitioners in primary care. Introduction Over the past years, research in the field of psychosis has focused on identifying early signs preceding the onset of a first psychotic episode in order to reduce the duration of untreated psychosis (DUP) (Yung & McGorry, 1996). The DUP is significantly associated with a poorer remission and prognosis (Howes et al., 2021). Therefore, early identification of at-risk patients allows early interventions to prevent the onset of psychosis by reducing the DUP and improving clinical outcomes. Prodromes of psychosis have been largely investigated within two main conceptual frameworks: the Basic Symptoms (BS) approach and the Ultra High Risk (UHR) approach. The BS concept refers to the very early stage in the development of psychotic disorders. It consists in non-specific and subjective symptoms such as disturbances in language, thought, emotional, or perceptual processes (Gross & Huber, 1985; Schultze-Lutter, Ruhrmann, Berning, Maier, & Klosterkötter, 2008). The later prodromal stage corresponds to the UHR approach (Yung et al., 1998). It is characterized by attenuated psychotic symptoms in their severity and/or frequency. The Clinical High Risk for Psychosis (CHR) concept comes from these two approaches (Fusar-Poli et al., 2012) and can be assessed using two main instruments. The first is the Comprehensive Assessment of At-Risk Mental States (CAARMS) (Yung et al., 2005), grounded in the UHR framework. It is a semi-structured interview that enables the classification of individuals into three groups: (1) the attenuated psychosis group, which refers to sub-threshold psychotic symptoms in terms of intensity or frequency; (2) the brief limited intermittent psychotic symptoms group, characterized by frank psychotic symptoms that resolve spontaneously within one week; and (3) the vulnerability group, which includes individuals with a genetic risk or schizotypal traits combined with a significant decline in global functioning (Yung & Nelson, 2013). The second instrument is the Schizophrenia Proneness Instrument Adult version (SPI-A) (Schultze-Lutter, Addington, Ruhrmann, & Klosterkötter, 2007) and its children/youth form the SPI-CY (Schultze-Lutter & Koch, 2010), based on the BS approach. Two criteria are extracted from the SPI-A/SPI-CY: the Cognitive-Perceptive Basic Symptoms (COPER), and the Cognitive Disturbances (COGDIS). The UHR, COGDIS and COPER criteria show similar 2-year conversion rates (Schultze-Lutter et al., 2015). Although these tools are the gold standard for identifying CHR individuals, their administration is time-consuming and requires specialized training for professionals, this is why self-report screening questionnaires are useful tools for the initial identification of CHR. General health practitioners, generalist psychiatrists, and school nursing services are usually the first professionals CHR individuals seek help from. For these professionals who are not trained to diagnostic interviews, screening tools to identify a potential CHR are of the utmost importance. Several studies have already focused on the lack of screening tools for CHR population and the limitations of those that currently exist (Kline et al., 2012). One of the most important caveats is the heterogeneity of definitions of CHR on which these questionnaires are based, resulting in considerable variability in the symptoms assessed, even extending beyond the psychotic spectrum (Bernardin, Gauld, Martin, Laprévote, & Dondé, 2023). A recent study focusing on the limitations of CHR detection in primary care identified several major issues. The authors highlighted the limited knowledge of CHR among general practitioners, insufficient consideration of the functional impact of symptoms, the persistence of high false positive rates in existing tools, and the lack of scientifically validated screening instruments (Radez, Waite, Izon, & Johns, 2023). To meet this need, the Self-Screen Prodrome (S-PRO) was developed as a self-assessment tool based on the FePsy study (Riecher-Rössler et al., 2007), with the objective of improving early screening and facilitating timely intervention. Several studies have demonstrated its solid psychometric properties, both in distinguishing individuals with a psychological disorder from healthy controls with good sensitivity and specificity at a cut-off score of 6 (0.85 and 0.91 respectively), and in identifying CHR individuals among those with another psychiatric condition with good sensitivity and lower specificity (0.85, 0.39) (Kammermann, Stieglitz, & Riecher-Rössler, 2009). Furthermore, compared to the Eppendorf Schizophrenia Inventory (ESI) (Mass, Haasen, & Wolf, 2000), the S-PRO has demonstrated superior predictive properties for identifying cases of psychotic symptoms (Müller et al., 2010). To our knowledge, the most commonly used screening questionnaires to date, namely the Prodromal Questionnaire (PQ-16) and the Perceptual and Cognitive Aberrations questionnaire (PCA), do not demonstrate such psychometric properties. The initial validation of the PQ-16 (Ising et al., 2012) and its French adaptation (Lejuste et al., 2021) both reported lower sensitivity and specificity. The initial validation of the PCA (McDonald et al., 2019) also reported lower specificity and moderate sensitivity, depending on the cut-off used. Finally, the French validation of the PCA did not investigate its psychometric properties beyond internal item and overall consistencies (Spillebout et al., 2023). Therefore, given its strong psychometric properties, we aim to validate a French version of the S-PRO in a population of patients in early stages of psychosis (CHR and FEP - First Episode Psychosis - patients) in order to provide a more validated tool than those currently available in French. As ease of use and brevity are key factors in the successful implementation of screening tools by general health professionals (Radez et al., 2023), our second objective is to reduce the number of items of the French S-PRO, while maintaining its psychometric properties. Materials and methods Population We recruited patients referred to the Centre de Liaison et d’Intervention Précoce (CLIP), an early intervention center of the Centre Psychothérapique de Nancy (France). Participants were referred to the CLIP for a suspected CHR or untreated FEP by various means: by their general practitioner, psychiatric emergencies, community psychiatrists, school nurse, etc. After referral, a trained clinician (author FB) conducted the CAARMS interviews within 15 days. Inclusion criteria were referral to CLIP, being aged between 18 and 30 years, completion of the S-PRO questionnaire and completion of the CAARMS. Data from 72 individuals were collected and anonymized. The S-PRO questionnaire was given to each patient at the first CLIP appointment to be completed on site or at home. The authors attest that all procedures contributing to this work comply with the ethical standards of the national and institutional regulations on human experimentation and the Declaration of Helsinki, revised in 2008. This study was categorized as a non-interventional study in accordance with French bioethics laws, as it involved anonymized clinical data that are routinely collected in medical records. Compliance with French regulations concerning the collection of personal data was supervised by the personal data referent of the Centre Psychothérapique de Nancy. Instruments S-PRO: Self-screening Prodrome (Kammermann et al., 2009) The S-PRO is a self-assessment questionnaire which consists of 32 items containing psychotic symptoms as well as risk factors for the risk of developing a future psychosis. Items are written as simple statements, each of which the subject has to answer dichotomously by true or false. An item should only be scored as true if it corresponds to a durable change that has occurred in recent years. Items 1 to 24 refer to newly occurring psychopathological changes corresponding to: (1) positive and negative psychotic symptoms or (2) non-specific symptoms often present in the prodromal phase, such as mood, affect or concentration disorders. Items 24 to 29 refer to impairment in interpersonal skills and occupational or school functioning. Items 30 to 32 refer to established risk factors such as regular drug use, and personal and family history of mental disorder. In order to discriminate healthy individuals from those with a psychiatric disorder, previous studies have established an optimal positivity threshold for a number of positive S-PRO items ≥ 6 (Kammermann et al., 2009). The French version of the S-PRO was translated by a German-speaking investigator (author VL). It was then back-translated from French to German by a native speaker. The translator, the back-translator and one of the authors of the original version (author ARR) met to discuss potential disputes about the translation. The final version was approved by ARR and VL and can be found in Appendix A. CAARMS: Comprehensive Assessment of At Risk Mental States (Yung et al., 2005) The S-PRO has been compared to the French version of the CAARMS (Krebs et al., 2014). The CAARMS explores seven different dimensions: (1) Positive Symptoms, (2) Cognitive Change, (3) Emotional Disturbance, (4) Negative Symptoms, (5) Behavioral Change, (6) Motor/Physical Changes and (7) General Psychopathology. Only the severity and frequency ratings of the positive symptoms dimension is used to identify a CHR of a FEP. The functional impact is scored separately using the Occupational Functioning Assessment Scale (SOFAS) (Morosini, Magliano, Brambilla, Ugolini, & Pioli, 2000). A reduction of more than 30% is considered significant. Statistics Statistics were conducted using Statistica and R softwares. To explore the internal consistency of the French version of the S-PRO, we calculated the Cronbach alpha coefficient. Receiver Operating Characteristic (ROC) analyses with sensitivity and specificity were assessed in comparison to a positive or negative CAARMS diagnosis. We considered a diagnosis to be positive for CAARMS if the rating obtained by the patient allows them to be classified into one of the following groups: vulnerability, attenuated psychosis, BLIPS and FEP. We used a similar method to that of Ising et al. (2012) to reduce the number of items in the S-PRO. First a stepwise logistic regression analysis with forward elimination was conducted. Then, we performed a new ROC analysis on the reduced version of the S-PRO, with calculation of sensitivity, specificity, area under the curve (AUC), and the Youden index. Finally, we assessed the internal consistency of the new version of the S-PRO by Cronbach alpha coefficient. Results Population characteristics 72 patients were included. The average age of the participants was 20.3 (3.4) years. Among these patients, 41 were male, and 31 were female. Of the participants included in the study, 23 did not exhibit symptoms severe enough to correspond to one of the four groups identified by CAARMS and have been classified in the CAARMS negative group. The positive CAARMS group consists of 49 participants divided as follows: none in the vulnerability subgroup, 30 in the attenuated psychosis subgroup, 1 in the BLIPS group and 18 in the FEP group. Each item on the S-Pro was scored as either ”true” (positive) or ”false” (negative). Out of the 32 items, the responses distribution for each S-PRO item was highly variable. In the negative CAARMS group, the mean number of positive S-PRO items was 12.0 (7.2). In the positive CAARMS group, the mean number of positive S-PRO items was 19.0 (4.9). Characteristics of the population, CAARMS and S-PRO results are detailed in Table 1. [insert Table 1 here] S-Pro-CAARMS comparison The internal consistency of the French S-PRO in this population assessed by the Cronbach alpha coefficient is 0.89. We conducted a ROC curve analysis to assess the predictive value of the S-PRO in comparison to a positive (vulnerability, attenuated psychosis, BLIPS, FEP groups) or a negative CAARMS diagnosis (figure 1). The AUC was 0.76 indicating a good ability to distinguish individuals at clinical high risk for psychosis. Regarding the cut-off of 6 explored in Kammermann et al. (2009) previous study, we found a comparable 0.98 sensitivity and 0.17 specificity for a cut-off at 6 in the French version. With the Youden index at 0.46, the sensitivity was 0.86, specificity 0.61 and the optimal cut-off point at 15 positive items. [insert Figure 1 here] Item reduction for the Reduced Version of the S-PRO The forward stepwise elimination method was employed in the logistic regression of CAARMS diagnosis (dependent variable) on the S-PRO items (independent variables), resulting in the exclusion of 20 items that were not significantly associated with being in any UHR or FEP groups. Twelve items emerged as significant with the stepwise logistic regression: items 4 (“Being short-tempered”) ( p <.05), 5 (“Nervousness, feeling tense”) ( p <.05), 6 (“Disturbed sleep”) ( p <.05), 9 (“Anxiety”) ( p <.05), 11 (“Blunted emotions”) ( p <.005), 14 (“More easily distracted”) ( p <.001), 15 (“Lower level of resilience”) ( p <.01), 17 ( p <.005), 19 (“Feeling observed, harmed of threatened”) ( p <.0005), 22 (“Withdrawing from others, isolating oneself”) ( p <.01), 24 (“Other people have mentioned changes in the way I speak (e.g my speech has become difficult to understand)”) ( p <.05) and 32 (“Do you have any close family members or relatives with mental disorders”) ( p <0001). We have retained these items for the reduced 12 items version of the S-PRO (S-PRO12). Cronbach alpha score of the S-PRO12 showed an acceptable consistency of 0.71. We then conducted a ROC curve analysis to assess the predictive value of the S-PRO12 also in comparison to a positive (vulnerability, attenuated psychosis, BLIPS, FEP groups) or a negative CAARMS diagnosis. The AUC was 0.81, indicating a good ability to distinguish individuals at risk for psychosis. Utilizing a Youden index of 0.47, the sensibility and specificity were 0.73 for an optimal cut-off at 7 positive items. In order to achieve a higher level of sensitivity, as is the case in the majority of screening tools, we explored a cut-off score at 6 positive items. This exploration yielded a sensitivity of 0.86, a specificity of 0.61, and a Youden index of 0.465 (Figure 2). [insert figure 2] Discussion The aim of this study was to explore the psychometric properties of the French version of the S-PRO. In the designated population targeted by the S-PRO, sensitivity and specificity of the French version were respectively 0.98 and 0.17 at a cut-off point of 6 positive items. An optimal cut-off score of 15 positive items was identified through ROC analysis, yielding lower sensitivity (0.86) but improved specificity (0.61). Following the reduction of items, the S-PRO12 showed a comparable level of sensitivity (0.86) and specificity (0.61) to the complete S-PRO. The findings of this study enable the validation of the French version of the SPRO, as indicated by the Cronbach’s alpha, sensitivity, and specificity values, thus achieving the primary objective of this study. To our knowledge, only few screening questionnaires are currently translated in French such as the Community Assessment of Psychic Experiences (CAPE, translation in French for a validation in a French Canadian population) (Brenner et al., 2007) or the Youth Self-Report (YSR) (Petot, Petot, & Fouques, 2022), the PCA and the PQ-16 (Spillebout et al., 2023). The French validation of the PCA did not assess sensitivity and specificity. The French version of the PQ-16 found a relatively better sensitivity (0.91) than the S-PRO (0.86) but comparable specificity (0.60 and 0.61). Although both the present study and the French validation of the PQ‑16 used logistic regression for item selection, methodological differences remain. A possible explanation for the lower sensitivity observed in the S‑PRO compared to the PQ‑16 may be the nature of the retained items. When comparing the content of selected items, the PQ‑16 appears to include a higher number of UHR-specific items (e.g., perceptual disturbances, unusual thought content), whereas the S‑PRO has more items regarding general psychopathology and negative symptoms such as sleep disturbance, emotional blunting, nervousness or social isolation. However, including general items enhances the ability of the screening questionnaire to detect CHR individuals at very early stages when symptoms are still nonspecific (Cannon et al., 2008; Velthorst et al., 2009). It may still affect the balance between sensitivity and specificity: by including more general and nonspecific symptoms, the S-PRO may identify individuals at earlier stages, leading to high sensitivity but reduced specificity. As the aim of screening tools is to detect as many at-risk individuals as possible before further investigation, sensitivity is often prioritized over specificity, even at the cost of increased false positive (Kline & Schiffman, 2014). It is also imperative to consider the practicability of these tools, with the objective of maintaining a short time of completion and providing primary care professionals with a rapid and unequivocal indication as to whether a patient must be referred to a specialized center. Statistically speaking, maintaining such requirements must be done at the expense of one of the indices. Hence, we did not maintain the same level of internal consistency after item reduction. The complete French version of the S-PRO showed higher internal consistency, which decreased to an acceptable level in the reduced version which is an expected result when reducing the number of items (Tavakol & Dennick, 2011). Nevertheless, the same level of sensitivity and specificity has been maintained, which demonstrates that the reduction has retained the most salient items while maintaining the optimal properties and reducing the time required for administration. The present study has been designed to provide robust evidence to support the validation of the questionnaire within the clinical sample that is the primary focus of the instrument. This methodological approach is particularly advantageous in the context of evaluating the validity of a screening tool. Furthermore, we compared to the CAARMS which is the gold standard recommended in the international guidelines. However, the small sample size (n = 72) reduces its statistical power and may affect the robustness of the item selection process in the logistic regression analysis. The inclusion of healthy control subjects in future studies could also contribute to the validation of the tool, as our group of negative CAARMS subjects are more likely to be considered as help seekers. Finally, item reduction and validation procedures were conducted on the same dataset. Validation on an independent sample will be necessary to confirm the stability and performance of the shortened version. Future studies should include multicenter recruitment with a larger sample to improve the validity of the instrument. Conclusion The initial Self-Screen Prodrome (S-PRO) was developed as a self-assessment instrument to improve early detection of CHR individuals and facilitate timely intervention. Following the translation process, the French version demonstrated good psychometric properties. 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Australian and New Zealand Journal of Psychiatry, 39 (11-12), 964-971. doi:10.1080/j.1440-1614.2005.01714.x Supplementary Material File (figure 1 roc curve spro-caarms.docx) Download 29.28 KB File (figure 2 roc curve spro12-caarms.docx) Download 29.09 KB File (table 1 population.docx) Download 27.68 KB Information & Authors Information Version history V1 Version 1 03 February 2026 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords clinical high risk early detection prodromal questionnaire psychosis s-pro Authors Affiliations Aurore LEGOUX--PIERRE Université de Lorraine View all articles by this author Mélissa FENOT 0009-0005-4328-8862 Universite de Strasbourg Federation de Medecine Translationnelle de Strasbourg View all articles by this author Dalfin W. Université de Lorraine View all articles by this author Vincent ORY Centre Psychotherapique de Nancy View all articles by this author Frédéric VERHAEGEN Université de Lorraine View all articles by this author Anita Riecher-Rössler University of Basel View all articles by this author Vincent Laprevote Université de Lorraine View all articles by this author Florent Bernardin 0000-0002-0784-990X [email protected] Universite de Strasbourg Federation de Medecine Translationnelle de Strasbourg View all articles by this author Metrics & Citations Metrics Article Usage 195 views 76 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Aurore LEGOUX--PIERRE, Mélissa FENOT, Dalfin W., et al. FRENCH VALIDATION OF THE SELF-SCREENING PRODROME, AN EARLY DETECTION TOOL FOR PSYCHOSIS. Authorea . 03 February 2026. 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