Frequently Asked Questions

Yes. In this study of 14 publicly available psychosis self-report measures developed in the United States, all measures had a mean readability score above the recommended sixth-grade level, and all instruction and item sections also exceeded that threshold. The authors concluded that psychosis self-report tools are generally written above American Medical Association recommendations for patient-facing materials.

The average reading demand was about ninth grade for both parts of the questionnaires. The mean reading level was 9.08 for instructions (SD = 1.44; range, 7.13-10.70) and 9.06 for items (SD = 1.98; range, 7.08-13.79).

Eight of the 14 measures, or 62%, required a high school reading comprehension level or above. The authors highlighted this as a potential accessibility problem, especially for patients with lower literacy or cognitive and attentional impairments related to psychotic disorders.

The Prodromal Questionnaire 16 Questions (PQ-16) had the lowest readability scores in this analysis, making it the easiest to understand among the measures studied. Its instructions averaged 7.13, and its items averaged 7.77.

The Prodromal Screen (PROD) had the highest reported item readability score in this study. Its item section scored 13.79, indicating substantially greater reading complexity than the other measures analyzed.

No. The instruction and item sections had very similar average reading levels across the 14 measures: 9.08 for instructions and 9.06 for items. This suggests that comprehension burden was not limited to directions alone, because both parts were written above the recommended sixth-grade level.

The authors assessed readability with Readable software using 4 standard indices: Gunning Fog, SMOG, FORCAST, and Flesch Reading Ease. They averaged the 4 scores to estimate overall readability for each measure, and they analyzed instruction sections and item sections separately.

FORCAST produced the highest mean grade-level estimate among the 4 indices used. The mean FORCAST score was 10.50, compared with 8.50 for SMOG, 8.42 for Flesch Reading Ease, and 7.70 for Gunning Fog.

Readability matters because self-report tools are used to screen and monitor psychosis, but psychotic disorders can impair cognition and attention, which may make reading more difficult. The authors noted that early detection of psychosis is associated with better outcomes, so questionnaires that exceed recommended reading levels may reduce accessibility and raise concerns about how well these tools function in diverse patient populations.

The authors stated that readability formulas are only estimates and do not account for other factors that affect comprehension, such as font, text size, and layout. They also noted that the formulas are based on US grade levels and may not translate directly to other English-speaking countries, and that their analysis included only English-language questionnaires, so the findings cannot be applied to translated versions in other languages.

The findings suggest that clinicians should be aware that commonly used psychosis self-report measures may place a substantial literacy burden on patients. Because all 14 measures exceeded the recommended sixth-grade reading level and readability varied across tools, the authors suggest that readability should be considered as part of measure evaluation alongside other psychometric properties.