Beyond conversion: extending the NAPLS-2 risk calculator to predict clinical outcomes in CHR within the CAPR study

Psychosis risk calculators are widely used to estimate the likelihood of conversion among individuals at clinical high risk (CHR) for psychosis; however, conversion represents only a minority of outcomes, and the broader clinical utility of these tools remains unclear. This study validated the performance of the North American Prodrome Longitudinal Study (NAPLS-2 RC) risk calculator in a fully remote, longitudinal CHR sample ( n = 369; 23 converters) and examined whether its predictive utility extends beyond psychosis conversion to other clinically meaningful outcomes. Outcomes included conversion to psychosis, illness progression, remission, newly onset mood disorders, mood disorder relapse, and psychotropic medication initiation. The NAPLS-2 RC demonstrated fair discrimination when predicting conversion within two years (AUC = 0.66) within the fully remote study. The NAPLS-2 RC also showed fair discrimination for remission (AUC = 0.63) and antidepressant initiation (AUC = 0.63). In contrast, the calculator showed poor discrimination for illness progression (AUC = 0.51), mood disorder onset (AUC = 0.56), mood disorder relapse (AUC = 0.54), and antipsychotic initiation (AUC = 0.49). These findings suggest that the NAPLS-2 risk calculator demonstrates relative specificity for psychosis-related outcomes and may be useful as a screening tool to guide further evaluation.