Schizophrenia Research 125 (2011) 62–68

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Schizophrenia Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / s c h r e s

Ultra high risk (UHR) for psychosis criteria: Are there different levels of risk
for transition to psychosis?
B. Nelson ⁎, K. Yuen, A.R. Yung
Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The ultra high risk (UHR) for psychosis criteria have been validated in a number
Received 7 June 2010
of studies. However, it is not known whether particular UHR criteria (Attenuated Psychotic
Received in revised form 13 October 2010
Symptoms (APS), Brief Limited Intermittent Psychotic Symptoms (BLIPS) or Trait vulnerability
Accepted 14 October 2010
Available online 12 November 2010 criteria), or combination of criteria, is associated with a higher risk of transition to psychosis.
The current study investigated this issue over a 6-month follow-up period. We hypothesised
that the risk of transition would increase in the following order: Trait alone b APS alone b APS +
Keywords:
Trait b BLIPS.
Psychosis
Prodrome Method: Data on UHR intake criteria and transition to psychosis status at 6 months were
High risk analysed for UHR patients seen at the PACE clinic, Orygen Youth Health between January 2000
and November 2008.
Results: A total of 928 new referrals were accepted into the PACE clinic over this period of
whom 817 (88%) had baseline information available for analysis. The percentage of subjects
who presented with APS, Trait and BLIPS were 83%, 27% and 4%, respectively. When the two
intermediate groups (APS alone and APS + Trait) were combined, there was evidence that the
risk of transition increased in the order of Trait alone b APS b BLIPS (p = 0.024, adjusted
analysis).
Conclusions: Our data suggest that UHR intake criteria predict transition over 6 months in the
order of Trait alone b APS b BLIPS. The fact that BLIPS patients are at the highest risk of transition
over the short term is consistent with the “early” versus “late” prodrome model. It also
indicates that particular clinical attention may need to be paid to BLIPS patients, especially early
in the course of treatment.
© 2010 Elsevier B.V. All rights reserved.

1. Introduction (BLIPS) — individuals who have experienced episodes of frank

In the mid 1990 s criteria for identifying individuals at
“ultra-high risk” (UHR) of psychotic disorder — that is, in the
putatively prodromal phase of psychosis — were introduced
(Miller et al., 2003, 2002; Yung et al., 1996, 2003, 2004b).
Individuals at UHR were identified by one or more of the
following characteristics: 1) Attenuated Psychotic Symptoms
(APS) — individuals who have experienced subthreshold,
attenuated forms of positive psychotic symptoms during the
past year, 2) Brief Limited Intermittent Psychotic Symptoms
⁎ Corresponding author. Tel.: + 61 3 9342 2800; fax: + 61 3 9387 3003.
E-mail address: nelsonb@unimelb.edu.au (B. Nelson).
psychotic symptoms that have not lasted longer than a week
and have spontaneously abated, and 3) Trait and State Risk
Factor (Trait) — individuals who have a first-degree relative
with a psychotic disorder or who have a schizotypal per-
sonality disorder in addition to a significant decrease in
functioning during the previous year. An age range of 15-
30 years was also included in the identification approach as
this age group has been found to have the highest risk for
psychosis. The UHR criteria were adopted and adapted by
various groups internationally (see Yung and McGorry, 2007
for review). Several studies have validated the UHR criteria,
finding that help-seeking young people who meet the criteria
have a high risk of developing psychosis over 1–2 years

0920-9964/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2010.10.017
 B. Nelson et al. / Schizophrenia Research 125 (2011) 62–68
(Cannon et al., 2008; Mason et al., 2004; Yung et al., 2003).
Ruhrmann et al (2003) estimated that the average 1 year rate
of transition to psychosis across centres in UHR subjects who
did not receive antipsychotic medication to be 36.7%.
However, it remains unclear whether particular UHR
criteria (i.e., APS, BLIPS or Trait), or combination of criteria,
is associated with a higher risk of transition to psychosis. It is
of value to know this because it may clarify whether par-
ticular UHR patients are at higher risk of transition than
others. In previous work, the data suggested that presence of
both APS and Trait criteria was a significant predictor of
psychosis within a 12-month follow-up period (Yung et al.,
2004b). In another study, we found that the transition rate
has been decreasing over time (from 1995 to 2000) for all
UHR subjects, and particularly among those who meet both
the APS and Trait criteria (Yung et al., 2007). Additional
significant predictors for onset of psychotic disorder in this
study were a long duration of symptoms prior to entry to the
service, high levels of depression, and reduced attention. The
recent North American Prodromal Longitudinal Study (NAPLS)
(Addington et al., 2007; Cannon et al., 2008) found that
independent predictive variables at baseline included a genetic
risk for schizophrenia (assessed through family history of
psychotic disorder) with a recent deterioration in functioning,
higher levels of unusual thought content, higher levels of
suspicion/paranoia, greater social impairment, and a history of
substance abuse.
Using a large data set of 817 subjects, the current study is
an attempt to investigate whether the risk of transition to
psychotic disorder within the first 6 months of admission
differs between UHR subjects who meet the different UHR
criteria. We examined transition rates over a 6-month period,
as this period has been found in previous studies to be the
highest risk period for transition (Cannon et al., 2008; Yung
et al., 2004b). Four subgroups were initially set up to classify
UHR subjects: presence of BLIPS (regardless of APS and Trait
status), presence of APS and Trait but no BLIPS (APS + Trait),
APS alone and Trait alone. We hypothesised that the risk of
transition across the subgroups would increase in the
following order: Trait alone b APS alone b APS + Trait b BLIPS.
The expectation that APS + Trait would have a higher
transition rate than both APS alone and Trait alone was
based on our previous finding using a sample size of 114
that APS + Trait displayed the highest transition rate over
12 months (Yung et al., 2004b). The expectation that BLIPS
would have the highest risk of transition was based on the
fact that this group have already experienced full-threshold
positive psychotic symptoms and therefore could be at
highest risk of relapse of these symptoms for a longer
duration. In addition, if the decreasing transition rate over
time for APS + Trait subjects compared to other UHR subjects
is a persistent trend coupled with the fact that only a small
percentage of subjects present with all three characteristics,
the BLIPS subgroup may display in more recent data a higher
transition rate than the APS + Trait subgroup. The large
sample size in the current study has enabled us to examine
the data with a more refined hypothesis than in previous
studies.
The hypothesis that the Trait alone subgroup has a lower
risk than both BLIPS and APS over the short term is also
consistent with the “early” versus “late” prodrome model
63
proposed by the German Research Network on Schizophrenia
(GRNS) (Bechdolf et al., 2005; Ruhrmann et al., 2007;
Ruhrmann et al). In this model, the Trait group and subjects
with “basic symptoms” are thought to be in the “early” phase
of the prodrome, while the APS and BLIPS groups are thought
to be in the “late” phase of the prodrome. Accordingly, BLIPS
and APS subjects are thought to be closer to transition to
psychosis than subjects in the “early” phase, including Trait
subjects. There is some empirical support for this model (see
Bechdolf et al., 2005; Ruhrmann et al., 2007).
2. Method
2.1. Setting and sample
Orygen Youth Health (OYH) is a public mental health
service for young people aged between 15 and 25 years living
in metropolitan Melbourne, Australia. The clinical service
consists of an inpatient facility, crisis support team and three
continuing care teams: EPPIC (the Early Psychosis Prevention
and Intervention Centre) for patients with first episode
psychosis, PACE (the Personal Assessment and Crisis Evalu-
ation) for UHR patients, and Youthscope for young people
with non-psychotic disorders. Referrals to OYH are accepted
from a range of sources, including general practitioners and
other primary care services, educational support services,
drug and alcohol services, carers, families and young people
themselves. A central Triage service takes all referrals and
refers to the appropriate clinic based on clinical judgement
and semi-structured clinical interviews. Prior to August 2006
the age range accepted to PACE was 15–30 years. This age
range was amended to 15–25 years since then to accord with
other clinics at OYH.
Young people are accepted to PACE if they meet at least
one of the three sets of UHR criteria: APS, BLIPS and Trait (see
Table 1). Exclusion criteria for PACE are presence of a current
or past psychotic disorder, known organic cause for presen-
tation, or past use of neuroleptics equivalent to a total
continuous haloperidol dose of N50 mg.
The study aimed to assess all UHR patients seen at the
PACE clinic between January 2000 and November 2008 at
baseline and 6 months. The study was approved by the local
research and ethics committee.
2.2. Instruments
Intake criteria were assessed using the Comprehensive
Assessment of At Risk Mental States (CAARMS) (Yung et al.,
2005). The CAARMS is a semi-structured interview that
assesses a range of prodromal symptomatology. The exposure
of interest was UHR intake criteria (BLIPS, APS and/or Trait).
This was assessed using the CAARMS, Global Assessment of
Functioning (GAF) (Association, 1994) and the Family
Interview for Genetic Studies (FIGS) (Maxwell, 1992).
2.3. Procedure
All assessments conducted to determine intake criteria
were carried out by a trained research assistant or clinician.
The outcome of interest was transition to psychotic disorder,
which was defined as per previous research as over 1 week of
64 B. Nelson et al. / Schizophrenia Research 125 (2011) 62–68

Table 1
Ultra high risk criteria: (1) must be aged between 15 and 25 years (15 to 30 years prior to August 2006), (2) have been referred to a specialized service for help,
and (3) meet the criteria for one or more of the following three groups.

Group 1: Attenuated positive psychotic symptoms
Group 2: Brief limited intermittent psychotic symptoms
Group 3: Trait and state risk factors
• Presence of at least one of the following symptoms: ideas of reference, odd beliefs
or magical thinking, perceptual disturbance, paranoid ideation, odd thinking and
speech, odd behavior and appearance
• Frequency of symptoms: at least several times a week
• Recency of symptoms: present within the last year
• Duration of symptoms: present for at least 1 week and no longer than 5 years
• Transient psychotic symptoms. Presence of at least one of the following: ideas of
reference, magical thinking, perceptual disturbance, paranoid ideation, odd thinking
or speech
• Duration of episode: less than 1 week
• Frequency of symptoms: at least several times per week
• Symptoms resolve spontaneously
• Recency of symptoms: must have occurred within the last year
• Schizotypal personality disorder in the identified individual, or a first-degree relative
with a psychotic disorder
• Significant decline in mental state or functioning, maintained for at least 1 month and
not longer than 5 years
• This decline in functioning must have occurred within the past year

clear threshold level psychotic symptoms (delusions, hallu-
cinations and formal thought disorder), and approximates
the level at which antipsychotic medication would be
commenced in common clinical practice (Yung et al., 2003).
This was assessed using the CAARMS. 307 subjects (38%) had
no follow-up CAARMS data available. For these cases, State
Medical records were checked to ascertain if any psychiatric
services were accessed by the individual and if so, records
were reviewed to determine psychosis status. The State
Medical records record all contact with public mental health
services in the State of Victoria.
2.4. Statistical analysis
Time to transition to psychosis was measured from first
presentation to PACE. Transition rates over time were
calculated using the Kaplan-Meier method. Transition within
6 months was considered as an event in the analysis. Log rank

Table 2
Baseline characteristics of the sample (N = 817).

Characteristic Number of subjects %

Total 817
Female 484 59%
Age at presentation (yr) median: 18
range: 14–29
Year of presentation
2000–2002 186 23%
2003–2004 243 30%
2005–2006 210 26%
2007–2008 178 22%
UHR status
Trait alone 117 14%
APS alone 572 70%
APS + Trait 92 11%
BLIPS 36 4%

Research trial subject 208 25%

Risperidone prescribed by UHR status 41 5.0%

Trait alone 2 1.7% (% of 117)
APS alone 29 5.1% (% of 572)
APS + Trait 3 3.3% (% of 92)
BLIPS 7 19.4% (% of 36)
Lithium prescribed by UHR status 21 2.6%
Trait alone 2 1.7% (% of 117)
APS alone 17 3.0% (% of 572)
APS + Trait 2 2.2% (% of 92)
BLIPS 0 –
GAF at entry Median: 51
540 cases with available data Range: 10–81
 B. Nelson et al. / Schizophrenia Research 125 (2011) 62–68 65

and Cox regression analyses were used to assess the 12

association of transition rate with various factors, either 95% confidence interval
singly (univariable) or as part of multivariable analyses; 10

Estimated % transitioned
when subgroups consisted of ordered categories, a test for
trend was used. All p-values are 2-sided. Two multivariable 8
analyses were performed. For the first analysis involving all
817 subjects, the association of transition rate with intake 6
group status was examined after adjusting for sex, age,
treatment with antipsychotic medication (risperidone), year 4
of presentation, and whether the subject was previously
involved in trials or not. An additional variable GAF was 2
added in the second analysis; as information on GAF was only
available for 540 subjects, this analysis was performed using a 0
0 1 2 3 4 5 6
reduced data set. Treatment with lithium was not included in
any of the multivariable analyses above as none of the 21 Months following first presentation to PACE
Number at risk
subjects who had been prescribed lithium had transitioned. 817 796 773 770 760 753 0
This variable, if included, would lead to spurious results in the
parameter estimates. Instead, we performed a univariable Fig. 2. Time to transition — overall.
analysis of the significance of treatment with lithium on the
rate of transition using an exact log-rank test. This test was subjects corresponding to each possible combination of the
based on the distribution of the sum of independent three UHR criteria. The percentage of subjects who presented
hypergeometric random variables and we found that the with APS, Trait and BLIPS were 83%, 27% and 4%, respectively.
result was not statistically significant (p = 0.27). Three subjects (0.4%) met all three UHR criteria. Of the 610
Hazard ratio (HR) representing the risk of transition subjects who entered the PACE clinic prior to August 2006
corresponding to a given subgroup within a factor relative to (when the age range changed), 27 (4.43%) presented with
a designated (reference) subgroup was used to summarise BLIPS. The percentage of subjects presenting with BLIPS was
the prognostic significance of a factor. A hazard ratio of similar among those subjects who entered PACE from August
greater than 1 signifies a higher risk than the reference 2006 (9/207, 4.35%, p = 1.0 [Fisher exact test]). Hence, it does
subgroup and a value of less than 1 signifies a lower risk. not appear that the change in age range from August 2006 in
the ultra high risk criteria influenced the frequency of BLIPS.
3. Results

A total of 928 new referrals were accepted into the PACE
clinic between January 2000 and November 2008 of whom
817 (88%) had baseline information available for analysis.
208 (25%) cases had participated in trials (41 of
risperidone (Yung et al., in press), 21 of lithium, and 146 of
non-pharmacological investigations).
3.1. Baseline characteristics
Baseline characteristics of the 817 cases are displayed in
Table 2. Fig. 1 is a Venn diagram showing the number of
3.2. Overall transition to psychosis
Of the 817 subjects, 72 (8.8%) transitioned to psychosis
within 6 months following first presentation to PACE. See
Fig. 2 for the estimated transition rates over the 6-month
period. 24 (33%) of these cases transitioned to a schizophre-
nia spectrum disorder, 10 (14%) to a mood disorder with
psychotic features, and 38 (53%) to Psychotic Disorder Not
Otherwise Specified.

14
APS BLIPS (36 cases)
12 APS+Trait (92 cases)
Estimated % transitioned

APS alone (572 cases)

Trait alone (117 cases)
572 (70%) 10
P = 0.10 (trend)
8

13 (1.6%) 92 (11%) 6
3 (.4%)
BLIPS 4
Trait
15 (1.8%) 117 (14%)
5 (.6%) 2

0
0 1 2 3 4 5 6
Months following first presentation to PACE
Fig. 1. Venn diagram displaying the number and percentage of subjects
corresponding to each combination of the three UHR groups. Fig. 3. Time to transition by intake group status (four levels).
66 B. Nelson et al. / Schizophrenia Research 125 (2011) 62–68

14
transition (p = 0.09, Table 4). The risk of transition decreased
BLIPS (36 cases) with increasing GAF score (p = 0.06).
12 APS (664 cases)
Estimated % transitioned

Trait alone (117 cases)

10 4. Discussion
P = 0.039 (trend)

8 This study investigated which of the UHR criteria, or

6 transition to psychosis over a 6-month period following first
4 date to analyse the relationship between UHR intake criteria
2
0
0 1 2 3 4 5
Months following first presentation to PACE
Fig. 4. Time to transition by intake group status (three levels).
3.3. Transition by intake group status
Our pre-specified hypothesis involved four distinct groups
of subjects (see Introduction for details): Trait alone, APS
alone, APS + Trait and BLIPS (from lowest to highest level
with respect to risk of transition). At 6 months following
intake, the percentage of subjects who had transitioned were
4.3%, 9.4%, 8.7% and 13.9%, respectively. The result of testing
our hypothesis was not statistically significant (p = 0.10,
Fig. 3). Contrary to our expectation, the risks of transition
associated with APS alone and APS + Trait over the 6-month
period were similar. Hazard ratios for APS alone, APS + Trait
and BLIPS relative to Trait alone were 2.3, 2.1 and 3.4,
respectively. Hence, in our next analysis, we combined APS
alone and APS + Trait to form three distinct groups of sub-
jects: Trait alone, APS (APS alone and APS + Trait combined)
and BLIPS. The result suggested that the risk of transition
increased in the following order: Trait alone b APS b BLIPS
(p = 0.039, Fig. 4). Hazard ratios for APS and BLIPS relative to
Trait alone were 2.2 and 3.4, respectively.
After adjusting for sex, age, treatment with antipsychotic
medication (risperidone), year of presentation, and whether
the subject was previously involved in trials or not, intake
group level remained a significant factor in the analysis
(p = 0.024, Table 3). Analysing the subset containing 540
subjects who had available data on GAF and after adjusting
for GAF and all baseline variables included in the above
analysis, there was still suggestion in the data that higher
intake group level was associated with a higher risk of
combination of criteria, are associated with a higher risk of
presentation to the PACE clinic. It used the largest sample to
and transition. We hypothesised that the risk of transition
would increase (from least to highest) in the following order:
Trait alone b APS alone b APS + Trait b BLIPS. Although the
6 complete order was not fully supported, we observed from
the analysis that Trait alone had the lowest risk and BLIPS the
highest risk overall, and the rates of transition of the two
intermediate groups were similar. A further analysis was
carried out after combining these two intermediate groups.
After adjusting for other potential prognostic factors, intake
group status remained a significant predictive factor of
transition.
These findings suggest that although the UHR criteria as a
whole have been found to reliably identify young people at
risk of imminent transition to psychosis, some UHR patients
may be at higher short term (6 month) risk than others.
Specifically, UHR patients who have experienced BLIPS have
the highest risk, followed by subjects with APS, followed by
those who meet the Trait criterion alone. As argued above, the
fact that BLIPS subjects are at highest risk is not surprising,
given that they have already experienced full-threshold
positive psychotic symptoms, albeit for a period of time
below threshold for frank psychosis.
These findings are consistent with the “early” versus “late”
prodrome model of the German Research Network on
Schizophrenia (GRNS), described above. According to this
model, the APS and the BLIPS groups both belong to the “late”
phase of the prodrome, therefore being closer to transition
than the Trait and the “basic symptoms” groups. It is possible,
based on the current data, that the “late” phase of the
prodrome might be further subdivided, with the BLIPS group
being further along in the “late” phase (i.e., being closer to
transition) than the APS group. This possibility will require
further examination of the current cohort beyond 6 months.
The identification of levels of risk for transition within the
UHR population and the division of the prodrome into
different “phases” is consistent with the clinical staging
model's attempt to classify patients by the degree of progress
and severity of disorder and using this to guide choice of

Table 3
Time to transition by intake group adjusting for sex, age, treatment with antipsychotic medication, year of presentation, and research status (72 transitioned cases
from 817 subjects).

Variable Level HR 95% CI p

Intake group Each level increase a 2.0 (1.1, 3.5) 0.024

Sex Female: male 0.88 (0.55, 1.4) 0.61
Age 18 and over: under 18 1.3 (0.81, 2.1) 0.29
Antipsychotic medication Prescribed: not prescribed 0.38 (0.05, 3.0) 0.36
Year of presentation 2005 and up: prior to 2005 b 1.3 (0.83, 2.2) 0.23
Trial subject indicator Trial subject: non-trial subject 0.63 (0.32, 1.2) 0.18
a
Trait alone (level 1), APS (level 2), BLIPS (level 3).
b
Year of presentation was cut at 2005 to ensure comparable numbers of subjects in each category.
 B. Nelson et al. / Schizophrenia Research 125 (2011) 62–68
Table 4
Time to transition by intake group adjusting for sex, age, treatment with antipsychotic medication, year of presentation, research status and GAF (43 transitioned
cases from 540 subjects).
Variable Level
Intake group Each level increase a
Sex Female: male
Age 18 and over: under 18
Antipsychotic medication Prescribed: not prescribed
Year of presentation 2005 and up: prior to 2005
Trial subject indicator Trial subject: non-trial subject
GAF Each unit increase in score
a
Trait alone (level 1), APS (level 2), BLIPS (level 3).
intervention strategy (McGorry et al., 2006, 2007). The
current findings are consistent with the GRNS model of the
Trait group being in the “early” phase of the prodrome.
The findings have some implications for clinical practice.
First, given the increased risk of transition of BLIPS subjects,
clinicians working with UHR patients may need to pay
particular clinical attention to BLIPS patients, especially
early in the course of treatment. Second, it is possible that
BLIPS patients require a different, or a more intensive form of,
treatment than other UHR patients. The effect of different
intervention strategies, e.g., antipsychotic medication, neu-
roprotective agents, and psychosocial interventions (see
McGorry et al., 2009 for a review), on the different UHR
groups remains to be evaluated.
The strengths of this study include its large sample size
and close monitoring of transition outcome in general. The
majority of subjects are either still being treated at PACE or
were involved in research studies in which intensive follow-
up of subjects was conducted. The study, however, has some
limitations. First, the findings may have been confounded by
the fact that subjects received treatment over the follow-up
period. This included comprehensive psychosocial interven-
tion and, for a subset of patients involved in intervention
studies, antipsychotic medication. All subjects received the
comprehensive psychosocial intervention in accordance with
the PACE treatment model (Nelson and Yung, 2008; Yung
et al., 2004a). This may have influenced the “natural course”
of UHR subjects. Thus, it is possible that BLIPS patients were
less responsive to these intervention strategies compared to
other UHR patients rather than inherently being at higher risk
of imminent transition. Second, baseline functioning data
(GAF scores) were not available on the full cohort (277 cases
had missing GAF data). Although the data also suggest that
baseline functioning was an independent predictor of
transition, one should be cautious not to generalise this
finding since the analysis was only performed on a subset of
the full cohort. Finally, the analysis was not adjusted for
duration of symptoms prior to presentation due to lack of
available data. As longer duration of symptoms has previously
been found to be related to increased risk of transition (Yung
et al., 2007), inclusion of this variable in a multivariable
analysis may diminish the effect of intake group on risk of
transition.
5. Conclusions
The stratification of risk found in this study may be a
means of further “closing in” on those at highest risk within
67
HR 95% CI p
1.9 (0.9, 4.2) 0.09
1.2 (0.63, 2.3) 0.54
0.89 (0.48, 1.6) 0.70
0.35 (0.04, 2.8) 0.31
1.2 (0.59, 2.4) 0.63
0.78 (0.36, 1.7) 0.53
0.97 (0.94, 1.0) 0.06
the UHR population. The findings particularly suggest that
close monitoring and possibly more intensive intervention for
UHR patients who meet BLIPS criteria is warranted. The
relative efficacy of different intervention strategies for UHR
subjects who meet the different intake criteria should be the
subject of future research. The longer term outcome of this
cohort will be investigated in future work with a particular
focus on ascertaining whether the above relationship be-
tween risk of transition and the three levels of intake groups
holds beyond 6 months.
Role of the funding source
This work was supported by the National Health and Medical Research
Council (NHMRC) Senior Research Fellowship to Prof Yung and by a Ronald
Griffith Fellowship and National Alliance for Research on Schizophrenia and
Depression (NARSAD) Young Investigator Award to Dr. Nelson, by a NHMRC
Program Grant (#566529) and by the Colonial Foundation Philanthropic
Trust. These funding sources had no role in study design; in the collection,
analysis and interpretation of data; in the writing of the report; and in the
decision to submit the paper for publication.
Contributors
All authors contributed to and have approved the final manuscript.
Conflict of interest
The authors declare that they have no conflicts of interest.
Acknowledgments
The authors thank Ms. Annie Bruxner for assisting with data preparation
and Ms. Jenny Beresford, Peter MacCallum Cancer Centre, for providing S-
PLUS programming codes for plotting survival graphs.
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