Received: 6 September 2022 Revised: 20 December 2022 Accepted: 1 January 2023

DOI: 10.1111/eip.13401

ORIGINAL ARTICLE

Harmonizing the structured interview for psychosis-risk

syndromes (SIPS) and the comprehensive assessment of at-risk
mental states (CAARMS): An initial approach

Jean Addington 1 | Scott W. Woods 2 | Alison R. Yung 3 | Monica E. Calkins 4,5 |

Paolo Fusar-Poli 6

1
Department of Psychiatry, Hotchkiss Brain
Institute, University of Calgary, Calgary, Abstract
Alberta, Canada
The two most used semi-structured psychometric instruments that define criteria for
2
Department of Psychiatry, Yale University,
New Haven, Connecticut, USA
being at clinical high risk (CHR) for psychosis are the Comprehensive Assessment of
3
Institute for Mental and Physical Health and At-Risk Mental States (CAARMS) and the Structured Interview for Psychosis-Risk
Clinical Translation, Deakin University,
Syndromes (SIPS). Although very similar there are important differences between
Geelong, Victoria, Australia
4
Department of Psychiatry, University of
these two measures. Developing harmonized psychometric criteria for defining CHR
Pennsylvania, Philadelphia, Pennsylvania, USA and associated outcomes would be beneficial for future research. This article
5
School of Health Sciences, University of describes the first step in this process by reporting on a NIMH workshop held in
Manchester, Manchester, UK
6
Washington DC, in February 2019 that was attended by experts in the field. The aim
Institute of Psychiatry Psychology and
Neuroscience, King's College London, of this workshop was to examine the similarities and differences between the two
London, UK
measures and consider how the harmonization process could proceed.
Correspondence
Jean Addington, Mathison Centre for KEYWORDS
Research & Education. 3330 Hospital Drive assessment, CAARMS, clinical high risk, harmonization, SIPS, ultra-high risk
NW, Calgary, AB T2N 4N1, Canada.
Email: jmadding@ucalgary.ca

1 | I N T RO DU CT I O N differ greatly across studies and even countries (Fusar-Poli

Over the last 20 years one of the key areas in the field of psychosis
has been the focus on those who appear to be, at least clinically, at
risk for developing a psychotic disorder. The hope is that this could
lead to improvements in the outcome of disorders such as schizophre-
nia. There has been considerable progress made in the prediction of
developing psychosis for those considered to be at ultra-high risk
(UHR) or clinical high risk for psychosis (hereafter CHR) (Addington
et al., 2020). About 20% of individuals identified as CHR develop psy-
chosis after 2 years, and 35% in the longer term (Fusar-Poli
et al., 2012). For those who do not make the transition to psychosis
many continue to be symptomatic and have poor functioning and only
about 40% remit (Addington et al., 2019) at 1–2 years. However,
assessment instruments and other study factors including inclusion
criteria for determining a CHR syndrome or transition to psychosis
Scott W. Woods and Alison R. Yung have contributed equally.
et al., 2016; Malda et al., 2019). This makes it difficult to synthesize
existing data and advance our understanding of CHR (Fusar-Poli
et al., 2016).
Currently, the two most used semi-structured psychometric
instruments that define criteria for being at clinical high risk for psy-
chosis are the Comprehensive Assessment of At-Risk Mental States
(CAARMS) (Yung et al., 2005) and the Structured Interview for
Psychosis-Risk Syndromes (SIPS) (McGlashan et al., 2010).
Yung and McGorry in Melbourne, Australia were the first
researchers to define putative risk criteria for psychosis. These cri-
teria, which reflect an ‘ultra-high risk’ state for developing a psychotic
disorder in the near future, include attenuated positive symptoms
(APS), brief intermittent limited psychotic states (BLIPS), and genetic/
familial risk for psychotic illness coupled with recent and dramatic
decline in functioning (GRD) (Yung et al., 1996). The Comprehensive
Assessment of At-Risk Mental States (CAARMS) is the diagnostic
interview and rating system developed by these Australian

Early Intervention in Psychiatry. 2023;1–7. wileyonlinelibrary.com/journal/eip © 2023 John Wiley & Sons Australia, Ltd. 1

2 ADDINGTON ET AL.
researchers to assess psychosis risk criteria prospectively (Yung
et al., 1996). The CAARMS manual (Yung et al., 2005) provides
detailed definitions, questions, and anchor points for eliciting and rat-
ing 27 symptoms across seven dimensions of psychopathology,
including positive symptoms, negative symptoms, deterioration of role
functioning, sleep disturbance, and impaired tolerance to normal
stress. An early version of the CAARMS demonstrated good reliability
and predictive validity (Yung et al., 2003), and a revised version, the
CAARMS II, demonstrated good to excellent concurrent, discrimina-
tive, and predictive validity, as well as excellent inter-rater reliability
(Yung et al., 2005).
Building upon Yung and McGorry's conceptual framework,
McGlashan, Miller and colleagues in the United States developed the
SIPS which elicits information regarding the presence and severity of
19 symptoms across four domains of psychopathology, including posi-
tive, negative, disorganization, and general symptoms in a rating scale
known as the Scale of Psychosis-risk Symptoms (SOPS) (Miller
et al., 2002; Miller et al., 2003). Information on family history, global
functioning, and schizotypal personality disorder is also gathered.
Operational criteria are provided for three psychosis-risk syndromes
including attenuated positive symptoms (APS), genetic risk and deteri-
oration (GRD), and brief intermittent psychotic symptoms (BIPS;
(Miller et al., 2002)). Initial studies of the SIPS demonstrating excellent
inter-rater reliability (Miller et al., 2002) and acceptable predictive
validity (Woods et al., 2009) have been replicated many times (Woods
et al., 2019).
Although, the goals of both the CAARMS and the SIPS are to
identify operationally the presence of a psychosis-risk syndrome, to
measure symptom severity over time, and to prospectively detect
onset of psychotic disorder, the two instruments and their operational
criteria are not identical. Despite these differences, the two instru-
ments deliver comparable prognostic accuracy in predicting the onset
of psychosis from a CHR state (Fusar-Poli et al., 2016). The group-
level prognostic accuracy of the CAARMS and SIPS for distinguishing
individuals who are at risk of psychosis or not is excellent, with an
Area Under the Curve of 0.9 at 48 months (CAARMS to SIPS: ROC
area 0.929; SIPS to CAARMS: ROC area 0.903). However, differences
between the instruments and criterion sets lead to uncertainties
about whether findings obtained with one instrument generalize to
samples ascertained by the other. Moreover, it is not clear whether
similar prognostic accuracy is maintained when these instruments are
used outside of help-seeking samples, for example in the general
population.
Developing harmonized psychometric criteria for defining CHR
and associated outcomes would be beneficial for future research
including clinical trials targeting prevention and treatment of psycho-
sis and data sharing for secondary analyses such as individual patient
data and aggregate meta-analyses. Improved standardization of ascer-
tainment and assessment of CHR individuals can occur through ongo-
ing research in large consortiums such as North American Prodrome
Longitudinal Studies (NAPLS), PSYSCAN (https://www.psyscan.eu/),
Promoting Resilience Outcome and Novel Integrated Approaches to
psychosis and depression (PRONIA) (https://www.pronia.eu/) and
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The Philadelphia Neurodevelopmental Cohort (PNC), (Calkins
et al., 2014) and can lead to further improvement of prediction in this
field. In fact, an ongoing project, the National Institute of Mental
Health's (NIMH) Harmonization of At-Risk Multisite Observational
Networks for Youth (HARMONY), which is a consortium of the above
four consortiums, will allow cross-validation of predictive data analytic
methods. One key task of the HARMONY group is to develop specific
cross-study diagnostic criteria.
This task became even more important with the funding by NIMH
for a new prospective study involving two separate international net-
works of CHR research programs that was being guided by input from
the Accelerating Medicine Partnership for Schizophrenia® (AMP®
SCZ®) (Woods et al., 2021). These two networks are ProNET led by
Dr Scott Woods of Yale University and PRESCIENT led by Dr Barnaby
Nelson of Melbourne University. It would be through these networks
that potential changes for ascertainment of CHR individuals and
ongoing assessment of attenuated psychotic symptoms could be
tested.
The aim of this article is to report on a workshop that was set up
by NIMH to begin the work for developing harmonized methods for
defining CHR and associated outcomes. First, some emerging data will
be summarized, second, a detailed account of the differences in the
two assessment tools as presented at the workshop including key dis-
cussion points that were raised at the workshop. Finally, this article
will serve as the lead into the development of a new harmonized mea-
sure led by Drs Woods and Yung and with input from NIMH and
AMP®-SCZ® steering committee.
2 | WORKSHOP ON CLINICAL HIGH RISK
FO R P SYC H OSIS (C HR) : T OWARD
STANDARD DEFINITIONS FOR
I D EN T I F I CA T I O N A N D OU T COM E S
The first step in this process was the setting up of a 2-day workshop
by the NIMH under the leadership of Dr Andrea Wijtenburg to focus
on harmonizing methods for diagnosing the Clinical High Risk (CHR)
state and for determining whether transition to psychosis has
occurred. The goal of the workshop was to bring together clinically
focused CHR researchers to propose common definitions at both the
conceptual and operational levels. The specific aims were to focus on:
1. Defining CHR, transition to psychosis, remission, and persistence
of CHR
2. Assessment interviews used worldwide and their commonalities
and differences as well as determining validity and calibration
across diverse groups and ages
The expected outcomes were (1) to develop common, well-
operationalized definitions for use across projects and (2) gold stan-
dard tools for case ascertainment. This workshop was held on
February 13th and 14th 2020 in Bethesda Maryland and was chaired
by Dr Jean Addington from the University of Calgary, Dr Paolo Fusar-

ADDINGTON ET AL.
Poli from the Institute of Psychiatry in London, and Dr Robert Heins-
sen from NIMH.
The focus of the workshop was to review the differences
between the two key measures and to see if there could be harmoni-
zation of the different standards. We first present below the key areas
where the standards for the two measures differ. The main areas of
differences in the standards were (1) the attenuated psychotic symp-
toms, (2) the ratings of severity and frequency for the attenuated psy-
chotic symptoms, (3) the definitions of each of the three criteria for
being at CHR including level of functioning, (4) differential diagnoses,
and (5) transition to psychosis criteria.
Further discussions facilitated by Dr Andrea Wijtenburg from
NIMH were held from April 2020 until July 2021 with Dr Scott
Woods and Dr Alison Yung, the key representatives of the SIPS and
CAARMS respectively.
2.1 | Presentations of emerging data
The workshop opened with overviews of the development of the two
scales and presentations on psychometric similarities and differences.
There was however some work comparing the two measures. First a
pilot study in the UK compared the SIPS Version 5 and CAARMS in
two samples, London, and Cambridge. There was overall substantial
agreement for both the SIPS and the CAARMS in identifying CHR par-
ticipants (n = 212, percent overall agreement = 86%, kappa = 0.78,
95% CI from 0.68 to O.88) (Fusar-Poli et al., 2016). The exception was
on the BIPS/BLIPS subgroups where there was some disagreement. In
fact, 14 out of the 25 subjects who were diagnosed as BLIPS on the
CAARMS were diagnosed as already psychotic by the SIPS. More
details on the BIPS/BLIPS differences will be detailed later in this
article.
Secondly, a pilot study from PNC, one of the Harmony consor-
tium members, was presented. This data set consisted of a subsample
of community ascertained individuals (n = 66; 46% female; mean
age = 21.3, SD = 3.5) who had previously screened positive on mea-
sures of psychosis spectrum features (Calkins et al., 2014). Impor-
tantly, these participants were not ascertained based on mental health
help-seeking. The SIPS (version 4) was conducted and rated by trained
and certified assessors as part of ongoing longitudinal follow-up
(Calkins et al., 2017). Computerization of the SIPS provided live cap-
ture of verbatim responses to individual SIPS questions. CAARMS
items were rated either contemporaneously with the SIPS or post-hoc
by an experienced rater (MEC) based on a review of individual SIPS
item responses. PNC raters had excellent SOPS (ICC = 0.96) and
CAARMS (ICC = 1.0) reliability with gold standard raters from the
Harmony consortium's reliability analyses. Among participants, 59%
(n = 48) were classified as NOT at risk according to both criteria,
while only 3% (n = 2) were classified as at risk (APS) by both SIPS and
CAARMS criteria. The remaining participants were classified as at-risk
according to SIPS but not CAARMS (24%; n = 16) or CAARMS but
not SIPS (14%; n = 9).
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3
Evaluation of component criteria suggested two key sources of
disagreement contributing to classification differences. First, the
majority of individuals classified as at-risk based on APS criteria by
SIPS (but not CAARMS) had higher global functioning during the past
year than allowed by the CAARMS criteria which requires participants
to either show a significant drop in functioning for at least 1 month
over the last year (defined as a 30% reduction in Social Occupational
Functioning Assessment Scale (SOFAS) score) or chronic low function-
ing (defined as a rating of 50 or lower on the SOFAS for at least
1 year). Second, all the participants classified as at-risk by the
CAARMS but not the SIPS had either stable positive symptoms
(i.e., subthreshold symptoms rated 3 or higher had not increased or
worsened in the past year) or they experienced improved positive
symptoms over the past year. These differences in classification are
addressed below in section 3. Thus, these data suggest that the scales
are generally similar but when they yield differing results in individual
cases, the reasons are clearly related to specific scale differences.
2.2 | Workshop review of CAARMS and SIPS
differences
Presented below in Tables 1–5 are the differences between the two
measures at the time of the workshop. This is followed by the ensuing
discussion and any changes that were potentially agreed upon at the
workshop.
2.2.1 | Attenuated positive symptoms
The cluster of symptoms for each measure are presented in Table 1.
P2, the non-bizarre ideas in the CAARMS, includes both suspicious-
ness and grandiosity.
Harmonization process
There was workshop discussion as to the possibility of combining SIPS
P1-3 and CAARMS P1-P2 so that the symptoms matched. However,
as the group discussed potential changes to the different anchors to
attain similar meaning for the anchors for each symptom the complex-
ity of this task became very apparent. Thus, in later discussions due to
TABLE 1 Attenuated positive symptoms
SIPS 5.6 CAARMS 2015
P1: Unusual thought content/ P1: Unusual thought content
Delusional ideas
P2: Suspiciousness/Persecutory P2: Non-bizarre ideas, including
ideas grandiosity
P3: Grandiose ideas –
P4: Perceptual abnormalities/ P3: Perceptual abnormalities
Hallucinations
P5: Disorganized communication P4: Disorganized speech
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4 ADDINGTON ET AL.

the complexity of creating new anchors and the risk of losing some of was further agreed that there would be some edits to the anchors to
the details of the attenuated psychotic symptoms, it was agreed not sharpen distinctions between ratings of 4, 5 and 6 such that only level
to combine the symptoms. 6 would represent a psychotic level of experience.
It was also proposed that the SIPS frequency ratings could be
woven into the 7-point CAARMS scale to create one frequency scale
2.2.2 | Severity and frequency ratings for the two to be used across the two instruments, although a precise method for
scales doing so could not be articulated in the time permitted.

See Table 2. The severity ratings were similar but with two differ-
ences: that a rating of either 5 or 6 for CAARMS P3 perceptual abnor-
malities would indicate that this symptom had reached the level of
being psychotic whereas a 6 was required for SIPS P4; and that a rat-
ing of 4–5 on CAARMS P4 indicated the CHR/UHR range while that
range was 3–5 on SIPS P5. Moreover, the scales differed on the more
detailed frequency ratings presented in the CAARMS. This is impor-
tant as on both scales determination of whether a person meets CHR
criteria or not does take frequency into account. However, severity
ratings on the SIPS are made independently of frequency and those
from the CAARMS require both intensity and frequency.
Harmonization process
In the workshop, it was agreed that the CAARMS anchors for P3 per-
ceptual abnormalities would be modified so that only a 6 would indicate
that this symptom had reached psychotic intensity. It is important to
note that in this process, previous CAARMS anchors for a rating of
5 were combined with anchors for a rating of 6, thus the same individ-
uals would be rated as psychotic on old and new CAARMS scales. It
TABLE 2 Severity and frequency ratings
SIPS 5.6 CAARMS 2015
0 = Absent 0 = Absent
1 = Questionably 1 = Questionable
present
2.2.3 | Subgroup definitions
There are three subgroups that are defined by specific criteria: the
Attenuated Positive Symptoms (APS), Brief (Limited) Intermittent Psy-
chotic Symptoms (BIPS/BLIPS) and Genetic Risk and Deterioration.
There are clear differences in how each of the Scales define these cri-
teria. The only difference for GRD was that the CAARMS used the
SOFAS, and the SIPS used the GAF to determine functioning, but the
criteria are essentially the same.
Differences for APS and BIPS/BLIPS are presented in Table 3. For
APS the CAARMS subthreshold frequency is unique. This group con-
sists of individuals who experience full threshold psychotic symptoms
very infrequently. The SIPS is rating only symptoms in the last month
and these symptoms must have begun or worsened in past
12 months. In contrast, the CAARMS only requires symptoms to have
been present in the past 12 months.
For BIPS the scales differ in that the symptoms have had to have
been present in the past 3 months for the CAARMS versus the past
12 months for the SIPS. The frequency for the symptoms is assessed
significantly more often on the CAARMS than the SIPS. One key dif-
ference between the two scales is that for the CAARMS there is a
functioning level requirement for APS and BIPS such that there must
be 30% drop in SOFAS score from premorbid level, sustained for a
month, within the past 12 months OR SOFAS score ≤ 50 for the past
12 months or more.

2 = Mild 2 = Mild
Harmonization process
3 = Moderate 3 = Moderate
At the workshop there was agreement that the GRD criteria did not
4 = Moderately severe 4 = Moderately severe
need to be harmonized and that this was not a key criterion in that,
5 = Severe but not 5 = Severe
although in most studies several participants did meet this criterion
psychotic
but only in conjunction with APS. Individuals meeting only the GRD
6 = Severe and 6 = Psychotic and severe
psychotic criteria were very few. Second, it was agreed that for both the

0: Absent CAARMS and the SIPS, the SOFAS should be completed as this was
valuable information but should not be part of the APS or BIPS cri-
1: ≥Several minutes/ 1: <1/month
day, ≥1x/month teria. Third, the subthreshold frequency APS scores on the CAARMS

2: ≥1x/week in 1 month 2: 1/month to 2/week, <1 hour per would be tabled for a later BIPS/BLIPS discussion.
occasion For APS onset, at the workshop it was proposed that symptoms
3: ≥1 hour/day, 3: 1/month to 2/week, >1 hour per meeting APS severity and frequency criteria should have been present
≥4 days/week in occasion, OR 3 to 6 times/week, in the previous 6 months and no longer that 5 years prior to assess-
1 month <1 hour per occasion ment. However, unambiguous consensus could not be achieved in the
4: 3 to 6/week, >1 hour per occasion, OR meeting time allotted, and in later post workshop discussions this pro-
daily, <1 hour per occasion
posal was cancelled.
5: Daily, >1 hour per occasion, OR several The definitions of BIPS/BLIPS were more difficult. However, sev-
times/day
eral suggestions were put forward and agreed upon in the workshop.
6: Continuous
It was agreed that severity would have to be a 6 on all positive
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ADDINGTON ET AL. 5

TABLE 3 CHR Subgroup Definition

Attenuated psychotic symptoms

SIPS 5.6.1 APSS CAARMS 2015 APS
Severity/frequency Severity score of 3–5 on at least one of P1–P5 (A) Subthreshold intensity
AND frequency score of ≥2 on at least one of P1–P5 Severity score of 3–5 on P1 or P2, or 3–4 on P3,
and/or 4–5 on P4
AND frequency score of 3–6 on P1-P4
OR
B) Subthreshold frequency
Severity score of 6 on at least one of P1, P2, and P4
and/or 5–6 on P3
AND frequency score of 3 on P1-P4
Onset Symptoms should have begun within the past year OR currently Symptoms should have been present in the previous
rate ≥1 scale point higher compared to 12 months ago 12 months AND for not longer than 5 years.
Only symptoms that occurred in the last month are rated
Brief Limited Intermittent Psychotic Symptoms
SIPS 5.6.1 BIPS CAARMS 2015 BLIPS
Severity/frequency Severity score of 6 on any of P1-P5 Severity score of 6 on any of P1, P2, and P4 and/or 5–
AND frequency score of 1 on any of P1-P5 6 on P3
AND frequency score of 4–6 on any of P1-P4
Onset Symptoms should have reached a psychotic level of intensity in the Symptoms should have been present in the last year
previous 3 months
Duration Up to 3 months Symptoms present for less than 7 days and
spontaneously remit on every occasion

symptoms. However, frequency was left for later discussion. Work- TABLE 4 Differential Diagnoses
shop discussion led to an agreement that symptoms should have been
SIPS 5.6.1 CAARMS 2015
present in the previous 6 months, a compromise between 3 and
Exclusion Symptoms are related Symptoms occur only during
12 months and it should be checked whether they had been present criteria to substance use peak intoxication from a
in the previous month. However, this recommendation for a 6-month [a] episodes substance known to be
requirement was later rejected. Symptoms are better associated with psychotic
accounted for by experiences (e.g.,
another DSM hallucinogens,
diagnosis amphetamines, and
2.2.4 | Differential diagnosis (exclusion criteria) Symptoms are seriously cocaine)
disorganizing or No criterion for ‘not better
The differences here focused on how to determine exclusion criteria. dangerous accounted for’

See Table 4. Generally, the SIPS excludes those whose symptoms are
possibly accounted for by another disorder, while the CAARMS does
not have this as an exclusion.
Harmonization process
Rather than attempt to move to any resolution the discussion here
focused on raising different issues and potential solutions, and how to
understand fully the definition of ‘seriously disorganizing or dangerous’.
Harmonization
At the end of the workshop there was no agreement on this issue.
Much of the discussion again focused on the definition of seriously
disorganizing or dangerous and whether psychosis could be deter-
mined without a duration criterion.

2.2.6 | Other conceptual entry criteria differences

2.2.5 | Transition to psychosis
This was one of the more difficult areas to attempt to resolve. Here
the differences centered on the notion of seriously disorganizing and
dangerous symptoms and frequency and duration of the psychotic
symptoms. See Table 5.
Antipsychotic use
In clinical practice the CAARMS excludes those with a history of more
than minimal antipsychotic use from having a CHR diagnosis whereas the
SIPS does not. In North America, the prevalence of those meeting criteria
who are using an antipsychotic is approximately 20% (Woods et al., 2019).
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6 ADDINGTON ET AL.

TABLE 5 Transition to psychosis DATA AVAILABILITY STAT EMEN T

SIPS 5.6.1 CAARMS 2015
Any SIPS or Sufficient frequency Sufficient frequency,
CAARMS (at least 1 h per day rated at least 4 (3–6
P1-3 at an average times per week, more
symptom at frequency of 4 days than an hour per
level 6 per week over 1 occasion OR daily but
PLUS month less than an hour per
occasion)
Or And
Symptoms are Duration (symptoms
seriously present longer than 1
disorganizing or week)
dangerous
3 | DECISIONS FOR MOVING FORWARD
The aim of the workshop was to focus on harmonizing methods for
diagnosing the CHR state and for determining whether transition to
psychosis has occurred. On one hand this seemed an important step
forward in the CHR field but through the workshop and early meet-
ings with Drs Woods and Yung, it was realized that this was a huge
undertaking and at times possibly one that might not be achieved.
However, progress was made step by step. After the NIMH work-
shop in the individual meetings, it began to look as if a consensus
might be reached on some points. One of the earlier proposals was
that for determining criteria, research sites could use only one instru-
ment either the CAARMS or the SIPS to determine CHR criteria. Sites
would select the instrument based on their familiarity and experience.
Details were added to both SIPS and CAARMS that would allow, after
rating the attenuated positive symptoms from either measure, it could
be determined if the participant met SIPS criteria, CAARMS criteria or
both. This meant that CAARMS users would use CAARMS P1-P4 and
SIPS users would use SIPS P1-P5 so that a SIPS or CAARMS severity
could be determined and then using these severity ratings participants
would be enrolled if they meet either criterion.
With this relatively straightforward proposal work continued with
the two measures. However, by this time it had been agreed by NIMH
and AMP® SCZ® that the two funded new networks ProNET and
PRESCIENT would be required to harmonize completely all their
respective measures and that it would no longer work to use either
CAARMS or SIPS positive symptoms to determine criteria. Further-
more, using slightly different symptoms would not allow for longitudi-
nal ratings on attenuated psychotic symptoms to be harmonized if
different symptom clusters were used.
Hence began the almost 2-year long process of developing a new
harmonized measure of attenuated psychotic symptoms that could be
used as a single severity scale as well as to determine both SIPS and
CAARMS criteria and the original SIPS P1-P5 and CAARMS P1-P4 rat-
ings. This process could only begin following the careful and detailed
work on reviewing the different criteria and developing a clear under-
standing of the differences and issues of these two excellent mea-
sures (Appendix).
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
OR CID
Jean Addington https://orcid.org/0000-0002-8298-0756
Paolo Fusar-Poli https://orcid.org/0000-0003-3582-6788
RE FE RE NCE S
Addington, J., Farris, M., Devoe, D., & Metzak, P. (2020). Progression from
being at-risk to psychosis: Next steps. NPJ Schizophrenia, 6(1), 1–7.
Addington, J., Stowkowy, J., Liu, L., Cadenhead, K. S., Cannon, T. D.,
Cornblatt, B. A., McGlashan, T. H., Perkins, D. O., Seidman, L. J.,
Tsuang, M. T., Walker, E. F., Bearden, C. E., Mathalon, D. H.,
Santesteban-Echarri, O., & Woods, S. W. (2019). Clinical and functional
characteristics of youth at clinical high-risk for psychosis who do not
transition to psychosis. Psychological Medicine, 49(10), 1670–1677.
Calkins, M. E., Moore, T. M., Merikangas, K. R., Burstein, M.,
Satterthwaite, T. D., Bilker, W. B., Ruparel, K., Chiavacci, R.,
Wolf, D. H., Mentch, F., Qiu, H., Connolly, J. J., Sleiman, P. A.,
Hakonarson, H., Gur, R. C., & Gur, R. E. (2014). The psychosis spec-
trum in a young US community sample: Findings from the Philadelphia
neurodevelopmental cohort. World Psychiatry, 13(3), 296–305.
Calkins, M. E., Moore, T. M., Satterthwaite, T. D., Wolf, D. H.,
Turetsky, B. I., Roalf, D. R., Merikangas, K. R., Ruparel, K., Kohler, C. G.,
Gur, R. C., & Gur, R. E. (2017). Persistence of psychosis spectrum
symptoms in the Philadelphia neurodevelopmental cohort: A prospec-
tive two-year follow-up. World Psychiatry, 16(1), 62–76.
Fusar-Poli, P., Bonoldi, I., Yung, A. R., Borgwardt, S., Kempton, M. J.,
Valmaggia, L., Barale, F., Caverzasi, E., & McGuire, P. (2012). Predicting
psychosis: Meta-analysis of transition outcomes in individuals at high
clinical risk. Archives of General Psychiatry, 69(3), 220–229. https://doi.
org/10.1001/archgenpsychiatry.2011.1472
Fusar-Poli, P., Cappucciati, M., Rutigliano, G., Lee, T. Y., Beverly, Q.,
Bonoldi, I., Lelli, J., Kaar, S. J., Gago, E., Rocchetti, M., Patel, R.,
Bhavsar, V., Tognin, S., Badger, S., Calem, M., Lim, K., Kwon, J. S.,
Perez, J., & McGuire, P. (2016). Towards a standard psychometric diag-
nostic interview for subjects at ultra high risk of psychosis: CAARMS
versus SIPS. Psychiatry Journal. https://doi.org/10.1155/2016/7146341
Malda, A., Boonstra, N., Barf, H., De Jong, S., Aleman, A., Addington, J.,
Pruessner, M., Nieman, D., de Haan, L., Morrison, A., Riecher-
Rössler, A., Studerus, E., Ruhrmann, S., Schultze-Lutter, F., An, S. K.,
Koike, S., Kasai, K., Nelson, B., McGorry, P., … Pijnenborg, G. H. M.
(2019). Individualized prediction of transition to psychosis in 1,676
individuals at clinical high risk: Development and validation of a multi-
variable prediction model based on individual patient data meta-analy-
sis. Frontiers in Psychiatry, 10, 345.
McGlashan, T., Walsh, B., & Woods, S. (2010). The psychosis-risk syndrome:
Handbook for diagnosis and follow-up. Oxford University Press.
Miller, T. J., McGlashan, T. H., Rosen, J. L., Cadenhead, K., Ventura, J.,
McFarlane, W., Perkins, D. O., Pearlson, G. D., & Woods, S. W. (2003).
Prodromal assessment with the structured interview for prodromal
syndromes and the scale of prodromal symptoms: Predictive validity,
interrater reliability, and training to reliability. Schizophrenia Bulletin,
29(4), 703–715.
Miller, T. J., McGlashan, T. H., Rosen, J. L., Somjee, L., Markovich, P. J.,
Stein, K., & Woods, S. W. (2002). Prospective diagnosis of the initial
prodrome for schizophrenia based on the structured interview for pro-
dromal syndromes: Preliminary evidence of interrater reliability and
predictive validity. American Journal of Psychiatry, 159(5), 863–865.
Woods, S. W., Addington, J., Cadenhead, K. S., Cannon, T. D.,
Cornblatt, B. A., Heinssen, R., Perkins, D. O., Seidman, L. J.,
Tsuang, M. T., Walker, E. F., & McGlashan, T. H. (2009). Validity of the
prodromal risk syndrome for first psychosis: Findings from the North

ADDINGTON ET AL.
American Prodrome longitudinal study. Schizophrenia Bulletin, 35(5),
894–908.
Woods, S. W., Choi, J., & Mamah, D. (2021). Full speed ahead on indicated
prevention of psychosis. World Psychiatry, 20(2), 223–224.
Woods, S. W., Walsh, B. C., Powers, A. R., & McGlashan, T. H. (2019). Reli-
ability, validity, epidemiology, and cultural variation of the structured
interview for psychosis-risk syndromes (SIPS) and the scale of
psychosis-risk symptoms (SOPS). In Handbook of attenuated psychosis
syndrome across cultures (pp. 85–113). Springer.
Yung, A. R., McGorry, P. D., McFarlane, C. A., Jackson, H. J.,
Patton, G. C., & Rakkar, A. (1996). Monitoring and care of young people
at incipient risk of psychosis. Schizophrenia Bulletin, 22(2), 283–303.
Yung, A. R., Phillips, L. J., Yuen, H. P., Francey, S. M., McFarlane, C. A.,
Hallgren, M., & McGorry, P. D. (2003). Psychosis prediction: 12-month
follow up of a high-risk (“prodromal”) group. Schizophrenia Research,
60(1), 21–32.
Yung, A. R., Yung, A. R., Pan Yuen, H., Mcgorry, P. D., Phillips, L. J.,
Kelly, D., Dell'Olio, M., Francey, S. M., Cosgrave, E. M., Killackey, E.,
Stanford, C., Godfrey, K., & Buckby, J. (2005). Mapping the onset of
psychosis: The comprehensive assessment of at-risk mental states.
Australian & New Zealand Journal of Psychiatry, 39(11–12), 964–971.
How to cite this article: Addington, J., Woods, S. W., Yung,
A. R., Calkins, M. E., & Fusar-Poli, P. (2023). Harmonizing the
structured interview for psychosis-risk syndromes (SIPS) and
the comprehensive assessment of at-risk mental states
(CAARMS): An initial approach. Early Intervention in Psychiatry,
1–7. https://doi.org/10.1111/eip.13401
17517893, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eip.13401 by Erasmus University Rotterdam Universiteitsbibliotheek, Wiley Online Library on [11/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
7
APPENDIX A
Workshop Participants: Jean Addington, University of Calgary; Mon-
ica Calkins, University of Pennsylvania; Ty Cannon, Yale University;
Will Carpenter, University of Maryland School of Medicine; Cheryl
Corcoran, Icahn School of Medicine at Mount Sinai; Camilo de la
Fuente-Sandoval, Instituto Nacional de Neurología y Neurocirugía;
Lauren Ellman, Temple University; Paolo Fusar-Poli, King's College
London; Ragy Girgis, Columbia University; Raquel Gur, University of
Pennsylvania; Joseph Kambeitz, University Hospital Cologne; Nikolaos
Koutsouleris, Ludwig-Maximilian-University Munich; Alexandre Loch,
University of São Paulo; Rachel Loewey, University of California San
Francisco; Daniel Mamah, Washington University School of Medicine;
Patrick McGorry, University of Melbourne; Vijay Mittal, Northwestern
University; Tara Niendem, University of California Davis; Anita
Riecher-Rössler, University of Basel; Jason Schiffman, University of
Maryland Baltimore County; Scott Woods, Yale University; Alison
Yung, University of Melbourne.
NIMH representatives: Linda Brady, Monica Carter, Stacia
Friedman-Hill, Robert Heinssen, Sarah H Lisanby, Sarah Morris,
Andrea Wijtenburg, Mi Hillefors, Steven Zalcman, Laura Rowland,
Doug Meinecke, Geetha Senthil.
FNIH representatives: Kelly Umana, Eline Appelmans.
FDA participants: Naomi Knoble, Tiffany Farchione, Bernie
Fischer.
Data sharing statement: Data not applicable.