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Psychometric properties of the Chinese version of the Functioning Assessment Short Test (FAST) in bipolar disorder
Journal of Affective Disorders 238 (2018) 156–160
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Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research paper
Psychometric properties of the Chinese version of the Functioning Assessment Short Test (FAST) in bipolar disorder
T
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Yong Zhanga, , Xingning Longa, Xiaojuan Mab, Qianqian Hec, Xingguang Luod, Yanhui Biana, ⁎⁎ Yuanyuan Xia, Xia Suna, Chee H. Nge, Eduard Vietaf, Yu-Tao Xiangg, a
Department of Bipolar Disorder, Tianjin Anding Hospital, 13 Liulin Road, Hexi District, Tianjin 300222, China Tianjin Medical College, Tianjin, China c Huzhou 3rd Hospital, HuZhou, China d Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA e Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia f Psychiatry and Psychology Department of the Hospital Clínic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, 170 Villarroel St, Barcelona, Catalonia 08036, Spain g Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Avenida da Universidade 3/F, Building E12, Taipa, Macao, SAR, China b
A R T I C LE I N FO
A B S T R A C T
Keywords: Bipolar disorder Functioning Assessment Short Test Psychometric properties China
Objectives: Bipolar disorder (BD) is often associated with significant functional impairment. However, there is currently no valid and reliable instrument for this variable that is both brief and easy to administer in China. We thus aimed to evaluate the psychometric properties of the Chinese version of the Functioning Assessment Short Test (FAST) in Chinese adults with BD. Methods: In this sample of adult subjects, 176 with BD and 53 healthy controls were included. The Chinese version of the FAST, the Young Mania Rating Scale (YMRS), the 17-item Hamilton Depression Rating Scale (HDRS-17) and the Global Assessment Functioning (GAF) were administered, and the psychometric analysis of the FAST was conducted. Results: The internal consistency (Cronbach's alpha) was 0.89 and 0.88 for the FAST at the baseline and week 1, respectively. Four domains (occupational functioning, cognitive functioning, interpersonal relationship and financial issues) at baseline had high item-total correlations. The FAST assessments at baseline and week 1 were highly correlated, indicating high test-retest reliability. The FAST total score was strongly associated with GAF total scores at week 0 (r = −0.952, p < 0.001), HDRS (r = 0.575, p < 0.001) and YRMS (r = 0.394, p < 0.001) and at week 1 (r = −0.945, p < 0.001; r = 0.582, p < 0.001; r = 0.363, p < 0.001), respectively, suggesting high concurrent validity. The FAST showed four dimensional measurement properties in exploratory factor analysis at baseline. Conclusions: The Chinese version of the FAST has satisfactory psychometric properties in terms of validity and reliability in Chinese adults with BD.
1. Introduction Functional impairment is a common feature in bipolar disorder (BD) and has received increasing attention in research (Baune et al., 2013; Robinson and Ferrier, 2006; Vaskinn et al., 2017). Although several standardized instruments including the Social and Occupational Functioning Assessment Scale (SOFAS) (Goldman et al., 1992), the Global Assessment of Functioning scale (GAF) (Endicott et al., 1976) and the Social Adjustment Scale (SAS) (Weissman and Bothwell, 1976) have been used in both clinical practice and research, most either failed to
⁎
cover all aspects of functioning in BD patients (Berns et al., 2007), or are excessively long and inconvenient for clinicians (Ware et al., 1994). Therefore, an efficient and brief instrument to assess functional impairment in BD patients is much needed. The Functioning Assessment Short Test (FAST) is a validated userfriendly and rapid scale to assess key areas of functional impairment in patients with psychiatric disorders (Bonnin et al., 2016; Rosa et al., 2007; Rotger et al., 2014), including BD (Cacilhas et al., 2009; Rosa et al., 2007). In China there are approximately 1.54 million people living with BD (Zhang et al., 2017), but to date there is no appropriate
Corresponding author. Corresponding author. E-mail addresses: [email protected] (Y. Zhang), [email protected] (Y.-T. Xiang).
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https://doi.org/10.1016/j.jad.2018.05.019 Received 20 February 2018; Received in revised form 8 April 2018; Accepted 15 May 2018 0165-0327/ © 2018 Elsevier B.V. All rights reserved.
Journal of Affective Disorders 238 (2018) 156–160
Y. Zhang et al.
and valid measure of functional impairment available for this population. Thus we set out to evaluate the psychometric properties of the Chinese version of the FAST in Chinese adults with BD.
Table 1 Demographic and clinical characteristics of the bipolar and healthy control subjects.
2. Methods 2.1. Subjects This study was conducted in Tianjin Anding Hospital between February and July, 2016. Adult patients being treated in Tianjin Anding Hospital were consecutively recruited if they (1) had a diagnosis of BD including bipolar depressive episode, manic episode or euthymic phase based on a clinical interview by two consultant psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders-Fourth edition (DSM-IV) (APA, 1994); (2) were able to understand the contents of the interview; and (3) provided written informed consent. Patients who had major physical diseases or history of alcohol or substance abuse were excluded (First et al., 1995). Total 180 patients were recruited from Tianjin Anding Hospital and 60 healthy controls matched in age and gender with BD subjects and had no family history of psychiatric disorders were recruited via advertisements in the community. The study protocol was approved by the Ethics Committee of Tianjin Anding Hospital. 2.2. Assessment procedure Basic socio-demographic and clinical variables of all subjects were obtained during a clinical interview. The severity of depressive and manic/hypomanic symptoms were measured using the Young Mania Rating Scale (YMRS) (Young et al., 1978) and the 17-item Hamilton Depression Rating Scale (HDRS-17) (Xie and Shen 1984), respectively. Functional impairment was measured using the Global Assessment Functioning (GAF) (Jones et al., 1995) and the FAST, respectively at baseline and week one. To reduce clinical bias, different raters were used for the FAST and the GAF assessments. Euthymic BD patients were defined as those with YMRS total score ≤ 6, HDRS total score ≤ 8 (Samalin et al., 2016) and in clinical remission for at least one month. After obtaining appropriate permission, the original English version of the FAST was translated into Chinese and then translated back into English and re-edited by independent bilingual experts. The FAST comprises 24 items, covering 6 domains of functioning: autonomy (items 1–4), occupational functioning (items 5–9), cognitive functioning (items 10–14), financial issues (items 15–16), interpersonal relationships (items 17–22), and leisure time (items 23–24) (Rosa et al., 2007). Each item is scored from 0 (no difficulty), to 3 (severe difficulty). The total score is the sum of all items, with a higher score indicating more severe functional impairment.
Items (n %)
BD (n = 176)
HC (n = 53)
df
t/χ2
P value
Age (years) Education (years) Male Marital status Single Married Divorced Occupation Employed Unemployed Cohabitants Spouse Parents Friend Living alone Residence Urban Rural Alcohol history Never Occasionally Frequently Smoking history Never Occasionally Frequently FAST GAF YMRS HDRS
34.6 ± 8.1 13.4 ± 3.0 86 (48.9%)
34.4 ± 7.8 14.3 ± 2.6 27 (50.9%)
227 227 1 2
−0.7 −1.95 0.07 3.20
0.94 0.049 0.79 0.20
59 (33.5%) 92 (52.3%) 25 (14.2%)
17 (32.5%) 33 (62.3%) 3 (5.7%) 1
9.40
<0.01
91 (51.7%) 85 (48.3%)
40 (75.5%) 13 (24.5%) 3
4.39
0.36
90 (51.1%) 68 (38.6%) 6 (3.5%) 12 (6.8%)
33 (62.3%) 14 (26.4%) 1 (1.9%) 5 (9.4%) 1
0.85
0.36
132 (75.0%) 44 (25.0%)
43 (81.1%) 10 (18.9%) 2
1.03
0.60
110 (62.5%) 55 (31.3%) 11 (6.2%)
29 (54.7%) 20 (37.7%) 4 (7.6%) 2
0.57
0.75
104 (59.1%) 15 (8.5%) 57 (32.4%) 33.6 ± 10.4 57.1 ± 12.8 11.2 ± 10.1 10.6 ± 9.2
31 (58.5%) 3 (5.7%) 19 (35.8%) 4.5 ± 1.7 85.5 ± 9.8
227 227
20.14 −15.89
<0.001 <0.001
BD: bipolar disorder; HC: healthy control.
and sensitivity for the FAST were determined by the Receiver Operating Characteristic (ROC) curve analysis. Principal component analysis by varimax rotation was conducted to determine the optimal factor structure of the FAST. Items coefficients with loading ≥0.5 were retained (Kline, 2000). All tests are two-tailed (p < 0.05). 3. Results 3.1. Demographic characteristics One hundred and eighty patients with bipolar disorder and 60 healthy controls were screened; finally, 176 patients (57 in depressive phase, 65 in manic phase and 54 in euthymic phase) and 53 healthy controls were included for analyses. Only 11 participants (4 patients and 7 healthy controls) were excluded due to side effects (2 patients), failure to complete the assessment (2 patients and 4 healthy controls) and lack of interest (3 healthy controls). Psychotropic medications prescribed for BD patients included lithium, valproate, olanzapine, quetiapine and risperidone. Table 1 shows the comparison of demographic and clinical characteristics between BD patients and healthy controls. There were significant group differences in employment status, education level, the FAST and GAF total scores (all p values < 0.001).
2.3. Statistical analysis Data analyses were performed using SPSS Version 16.0. Independent samples t-test, Mann–Whitney U test, and chi-square test were used to compare the demographic and clinical variables between patients and healthy controls if applicable and appropriate. Internal consistency was measured using the Cronbach's alpha and the itemscale correlations using Pearson correlation coefficients at baseline. Internal reliability was acceptable in case that the Cronbach's alpha was greater than 0.6 (Lako et al., 2012). Test-retest reliability was assessed using Pearson correlation coefficients between the FAST total scores at baseline and 1-week assessments. Concurrent validity was measured by Pearson's correlation to examine the association between the FAST and GAF. The discriminant validity was measured by the analysis of covariance (ANCOVA) to compare the FAST total scores between depressive, manic and euthymic groups, as well as those between acute phase, euthymic phase and health controls after controlling for basic demographic variables that significantly differed between groups. Specificity
3.2. Reliability test The Cronbach's Alpha in the internal consistency analysis was 0.89 at baseline, and 0.88 in week 1. The Cronbach's Alpha in the six functioning domains also indicated good internal consistency, ranging from 0.84 to 0.90 at week 0, and from 0.83 to 0.88 at week 1, respectively. The item-scale correlation analyses revealed that four domains (occupational functioning, cognitive functioning, interpersonal 157
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structure was obtained when the coefficients lower than or equal to 0.50 was omitted (KMO: 0.904, p < 0.001). The four domains included autonomy (factor 1 with nine items), interpersonal relationship (factor 2 with six items), occupational functioning (factor 3 with five items), and cognitive functioning (factor 4 with four items), which accounted for 77.2% of the variance. The items in each domain are shown in Table 3.
Table 2 The FAST assessment at baseline (n = 176). Item
Mean (SD)
Item-total correlation
Alpha if item deleted
1. 2. 3. 4. 5.
3.3 9.9 5.1 3.3 9.5
(1.5) (2.8) (1.8) (1.3) (3.3)
0.66a 0.86a 0.84a 0.83a 0.88a
0.88 0.85 0.85 0.87 0.86
2.5 (1.4) 33.6 (10.4)
a
0.90
Autonomy Occupational functioning Cognitive functioning Financial issues Interpersonal relationship 6. Lesiure time Total scores
a
0.49
4. Discussion Our results found that the Chinese version of the FAST has satisfactory psychometric properties in Chinese adults with BD. Other validation studies in different socio-cultural contexts also found similar psychometric properties (Aydemir and Uykur, 2012; Barbato et al., 2013; Rosa et al., 2007). Our finding showed the FAST had a high internal consistency, with the total Cronbach's alpha ranging from 0.88 to 0.89, which is in line with earlier findings (Moro et al., 2012; Rosa et al., 2007). The long-term internal consistency was not examined in our study, but a Spanish study found that the internal consistency of the FAST was still above 0.90 after one year assessment (GonzalezOrtega et al., 2010). Similar to earlier findings (Na et al., 2010; Suominen et al., 2015), occupational functioning, cognitive functioning, interpersonal relationship and financial issues had high itemtotal correlation (>0.80), while the test-retest reliability was satisfactory. The GAF is a widely used instrument to assess functioning (Startup et al., 2002). In this study the FAST total score was significantly and negatively associated with the GAF at both week 0 and week 1, which is consistent with the fact that a high score in the GAF means good functioning whereas in the FAST high scores mean greater disability. Additionally, the FAST scores on interpersonal relationship, occupational functioning, cognitive functioning and financial issues were significantly associated with the GAF, indicating that the FAST overlap considerably with the GAF, but has more focus on the functioning domains related to BD, such as social, occupational and cognitive functioning (Comes et al., 2017; Martino et al., 2017; Reyes et al., 2017). Furthermore, the FAST showed high discriminant properties; after adjusting for the education level and occupation status, we found that patients with acute BD (including those with manic and depressive episodes) had more severe functioning impairment compared to euthymic patients and healthy controls as measured by the FAST, which is also consistent with previous findings (Bora et al., 2016; Rosa et al., 2007). Moreover, we also found that the bipolar depressed patients had more severe functional impairment compared to manic and euthymic patients as reported previously in other settings (Aparicio et al., 2017). The cut-off value of 12 in FAST showed good discriminant ability in Chinese patients, which is comparable to earlier findings (Moro et al., 2012; Rosa et al., 2007). Similarly, the cutoff value of 29 could discriminate between those with acute BD and euthymic patients. Most item loadings in principal component analysis ranged between 0.70 and 0.90 (only item 11 was 0.59), indicating good internal structure of the FAST (Kline, 2000). This study found four dimensions, including autonomy, interpersonal relationship, occupational functioning, and cognitive functioning in the FAST, which is slightly different from previous studies of the Portuguese, Spanish and Italian versions (Barbato et al., 2013; Cacilhas et al., 2009; Rosa et al., 2007), with five dimensions (the abovementioned four dimensions plus the financial issue factor). The discrepancy between Chinese and other versions could be due to different cultural contexts; i.e., in Chinese tradition, personal autonomy usually covers financial issues and leisure time in daily life, such as family financial management, personal hobbies or activities. The strengths of this study are the relatively large sample size and inclusion of BD patients at different illness phases. However, there are several methodological limitations. First, euthymia was defined in this study as at least one month of remission, rather than three months as
<0.01.
relationship and financial issues) at baseline had high item-total correlation coefficients higher than 0.80, while the domain leisure time had the lowest item-total correlation coefficient. All domains, if deleted individually, decreased the total scale alpha at baseline (Table 2). As for the test and re-test reliability, the Pearson correlation coefficient between the week 0 and week 1 assessments was 0.96, while the corresponding figure in the six domains was 0.97 in Autonomy, 0.96 in Occupational functioning, 0.94 in Interpersonal relationships, 0.91 in Cognitive functioning, 0.87 in Leisure time, and 0.82 in Financial issues. 3.3. Validity test The associations between the FAST and GAF, HDRS and YMRS were analyzed using the Pearson correlation analysis to test concurrent validity. The FAST total score was highly associated with GAF (r = −0.952, p < 0.001), HDRS (r = 0.575, p < 0.001) and YRMS total scores (r = 0.394, p < 0.001) at both week 0 and at week 1 (r = −0.945, p < 0.001; r = 0.582, p < 0.001; r = 0.363, p < 0.001), respectively. Furthermore, the GAF score was negatively associated with the six functioning domains at week 0 (autonomy: r = −0.70, occupational functioning: r = −0.87, cognitive functioning: r = −0.87, financial issues: r = −0.83, interpersonal relationship: r = −0.89, and leisure time: r = −0.55) and week 1 (autonomy: r = −0.74, occupational functioning: r = −0.86, cognitive functioning: r = −0.83, financial issues: r = −0.75, interpersonal relationship: r = −0.86, and leisure time: r = −0.60). Using the baseline data, the discriminant capacity of the FAST between depressive (n = 57), manic (n = 65) and euthymic (n = 54) groups, and also between acute (n = 122), euthymic groups (n = 54) and healthy controls (n = 53) were tested using ANCOVA. After adjusting for education level and occupation status, there were significant differences in the FAST total scores between the three mood states (F = 35.6, p < 0.001), and between BD patients and healthy controls (F = 140.3, p < 0.001) (Fig. 1). Further, we found the FAST score in manic patients was lower than in depressed patients (F = −3.05, p < 0.01). The specificity and sensitivity for the FAST at baseline was tested. Following the Younden's index for diagnostic tests (Youden, 1950) that were used in other validation studies (Bech et al., 2011; Forty et al., 2010; Kim et al., 2018), the optimal cut-offs in this study was chosen by maximizing the combination of sensitivity and specificity. Finally, the cut-off value was 29 (sensitivity of 100% and specificity of 73%) to differentiate between the acute and the euthymic phases, and 12 to differentiate between the euthymic phase and healthy controls (sensitivity of 100% and specificity of 64%). 3.4. Principal component analysis (PCA) The exploratory PCA with the varimax rotation was performed to test the internal structure of the FAST at week 0. A four domains 158
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Y. Zhang et al.
Fig. 1. Comparisons of the FAST scores between different phases in bipolar disorder and healthy controls using analysis of covariance. Note: The baseline FAST scores between different phases in bipolar patients and healthy controls were compared after adjusting for education and occupation. There were significant differences in the FAST scores between depressive (41.4 ± 5.5), manic (38.4 ± 5.0) and euthymic phases (20.3 ± 2.1) (F = 35.6, p < 0.001), and between BD patients and healthy controls (4.5 ± 1.7) (F = 140.3, p < 0.001). Further, the FAST score in manic patients was lower than in depressed patients (F = −3.05, p < 0.01).
Author disclosure
Table 3 Factor loading of the FAST in principal component analysis. FAST
1
FAST15 FAST01 FAST03 FAST16 FAST02 FAST04 FAST10 FAST23 FAST24 FAST17 FAST22 FAST18 FAST19 FAST20 FAST21 FAST07 FAST06 FAST09 FAST05 FAST08 FAST14 FAST12 FAST13 FAST11
0.889 0.851 0.804 0.791 0.781 0.779 0.745 0.713 – 0.544
0.510
2
3
Role of funding
4
NA. Contributors Study design: Yong Zhang, Xingguang Luo, Yu-Tao Xiang. Data collection, analysis and interpretation of data: Xingning Long, Xiaojuan Ma, Qianqian He, Yanhui Bian. Drafting of the manuscript: Yong Zhang, Yuanyuan Xi, Xia Sun, Yu-Tao Xiang. Critical revision of the manuscript: Chee H. Ng, Eduard Vieta. Approval of the final version for publication: all co-authors.
0.924 0.881 0.809 0.783 0.769 –
Acknowledgment 0.916 0.909 0.890 0.847 0.833
0.527
NA. Conflict of interest 0.887 0.886 0.801 0.593
The authors declare that they have no conflicts of interest concerning this paper. References
Note: coefficient lower than or equal to 0.50 was omitted.
APA, 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington: American Psychiatric Association. Aparicio, A., Santos, J.L., Jimenez-Lopez, E., Bagney, A., Rodriguez-Jimenez, R., SanchezMorla, E.M., 2017. Emotion processing and psychosocial functioning in euthymic bipolar disorder. Acta Psychiatr. Scand. 135, 339–350. Aydemir, O., Uykur, B., 2012. Reliability and validity study of the Turkish version of Functioning Assessment Short Test in bipolar disorder. Turk. Psikiyatr. Derg. 23, 193–200. Barbato, A., Bossini, L., Calugi, S., D'Avanzo, B., Fagiolini, A., Koukouna, D., Parabiaghi, A., Rapisarda, F., Rucci, P., Vallarino, M., 2013. Validation of the Italian version of the Functioning Assessment Short Test (FAST) for bipolar disorder. Epidemiol. Psychiatr. Sci. 22, 187–194. Baune, B.T., Li, X., Beblo, T., 2013. Short- and long-term relationships between neurocognitive performance and general function in bipolar disorder. J. Clin. Exp. Neuropsychol. 35, 759–774. Bech, P., Christensen, E.M., Vinberg, M., Bech-Andersen, G., Kessing, L.V., 2011. From items to syndromes in the hypomania checklist (HCL-32): psychometric validation and clinical validity analysis. J. Affect Disord. 132, 48–54. Berns, S., Uzelac, S., Gonzalez, C., Jaeger, J., 2007. Methodological considerations of measuring disability in bipolar disorder: validity of the multidimensional scale of independent functioning. Bipolar Disord. 9, 3–10. Bonnin, C.M., Torrent, C., Arango, C., Amann, B.L., Sole, B., Gonzalez-Pinto, A., Crespo, J.M., Tabares-Seisdedos, R., Reinares, M., Ayuso-Mateos, J.L., Garcia-Portilla, M.P., Ibanez, A., Salamero, M., Vieta, E., Martinez-Aran, A., 2016. Functional remediation
previously recommended (Torrent et al., 2013), which might reduce the discriminant ability of the FAST between different BD stages. Second, the use of psychotropic medications could bias the functioning assessment (Dias et al., 2012; Pompili et al., 2014) to an uncertain extent. Finally, this sample was followed up only for one week. Therefore the long-term consistency of the FAST could not be examined although previous studies suggested that the FAST had high consistency even at 6–12 months assessments in BD patients (Gonzalez-Ortega et al., 2010; Strejilevich et al., 2013). In conclusion, the Chinese version of the FAST shows satisfactory psychometric properties in Chinese adults with BD. Compared to other functioning assessment instruments, the FAST is shorter and easier to administer, and thus can be useful in BD patients for both research and clinical practice in China.
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Y. Zhang et al.
Kapczinski, F., Silva, R.A., 2017. Functional impairment and cognitive performance in mood disorders: a community sample of young adults. Psychiatry Res. 251, 85–89. Robinson, L.J., Ferrier, I.N., 2006. Evolution of cognitive impairment in bipolar disorder: a systematic review of cross-sectional evidence. Bipolar Disord. 8, 103–116. Rosa, A.R., Sanchez-Moreno, J., Martinez-Aran, A., Salamero, M., Torrent, C., Reinares, M., Comes, M., Colom, F., Van Riel, W., Ayuso-Mateos, J.L., Kapczinski, F., Vieta, E., 2007. Validity and reliability of the Functioning Assessment Short Test (FAST) in bipolar disorder. Clin. Pract. Epidemiol. Mental Health 3, 5. Rotger, S., Richarte, V., Nogueira, M., Corrales, M., Bosch, R., Vidal, R., Marfil, L., Valero, S., Vieta, E., Goikolea, J.M., Torres, I., Rosa, A., Mur, M., Casas, M., Ramos-Quiroga, J.A., 2014. Functioning Assessment Short Test (FAST): validity and reliability in adults with attention-deficit/hyperactivity disorder. Eur. Arch. Psychiatry Clin. Neurosci. 264, 719–727. Samalin, L., de Chazeron, I., Vieta, E., Bellivier, F., Llorca, P.M., 2016. Residual symptoms and specific functional impairments in euthymic patients with bipolar disorder. Bipolar Disord 18, 164–173. Startup, M., Jackson, M.C., Bendix, S., 2002. The concurrent validity of the global assessment of functioning (GAF). Br. J. Clin. Psychol. 41, 417–422. Strejilevich, S.A., Martino, D.J., Murru, A., Teitelbaum, J., Fassi, G., Marengo, E., Igoa, A., Colom, F., 2013. Mood instability and functional recovery in bipolar disorders. Acta Psychiatr. Scand. 128, 194–202. Suominen, K., Salminen, E., Lahteenmaki, S., Tupala, T., Isometsa, E., 2015. Validity and reliability of the finish version of the Functioning Assessment Short Test (FAST) in bipolar disorder. Int. J. Bipolar Disord. 3, 10. Torrent, C., Bonnin Cdel, M., Martinez-Aran, A., Valle, J., Amann, B.L., Gonzalez-Pinto, A., Crespo, J.M., Ibanez, A., Garcia-Portilla, M.P., Tabares-Seisdedos, R., Arango, C., Colom, F., Sole, B., Pacchiarotti, I., Rosa, A.R., Ayuso-Mateos, J.L., Anaya, C., Fernandez, P., Landin-Romero, R., Alonso-Lana, S., Ortiz-Gil, J., Segura, B., Barbeito, S., Vega, P., Fernandez, M., Ugarte, A., Subira, M., Cerrillo, E., Custal, N., Menchon, J.M., Saiz-Ruiz, J., Rodao, J.M., Isella, S., Alegria, A., Al-Halabi, S., Bobes, J., Galvan, G., Saiz, P.A., Balanza-Martinez, V., Selva, G., Fuentes-Dura, I., Correa, P., Mayoral, M., Chiclana, G., Merchan-Naranjo, J., Rapado-Castro, M., Salamero, M., Vieta, E., 2013. Efficacy of functional remediation in bipolar disorder: a multicenter randomized controlled study. Am. J. Psychiatry 170, 852–859. Vaskinn, A., Lagerberg, T.V., Bjella, T.D., Simonsen, C., Andreassen, O.A., Ueland, T., Sundet, K., 2017. Impairment in emotion perception from body movements in individuals with bipolar I and bipolar II disorder is associated with functional capacity. Int. J. Bipolar Disord. 5, 13. Ware, J.E., Kosisnki, M, Keller, S.D, 1994. SF-36 Physical and Mental Health Summary Scales: A User's Manual. Boston: The Health Institute. Weissman, M.M., Bothwell, S., 1976. Assessment of social adjustment by patient selfreport. Arch. Gen. Psychiatry 33, 1111–1115. Xie, G.R., Shen, Q.J, 1984. Use of the Chinese version of the Hamilton Rating Scale for depression in general population and patients with major depression. Chin. J. Nerv. Mental Dis. 10, 346. Youden, W.J., 1950. Index for rating diagnostic tests. Cancer 3, 32–35. Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A., 1978. A rating scale for mania: reliability, validity and sensitivity. Br. J. Psychiatry 133, 429–435. Zhang, L., Cao, X.L., Wang, S.B., Zheng, W., Ungvari, G.S., Ng, C.H., Zhong, B.L., Wang, G., Xiang, Y.T., 2017. The prevalence of bipolar disorder in China: a meta-analysis. J. Affect Disord. 207, 413–421.
in bipolar disorder: 1-year follow-up of neurocognitive and functional outcome. Br. J. Psychiatry 208, 87–93. Bora, E., Bartholomeusz, C., Pantelis, C., 2016. Meta-analysis of theory of mind (ToM) impairment in bipolar disorder. Psychol. Med. 46, 253–264. Cacilhas, A.A., Magalhaes, P.V., Cereser, K.M., Walz, J.C., Weyne, F., Rosa, A.R., Vieta, E., Kapczinski, F., 2009. Validity of a short functioning test (FAST) in Brazilian outpatients with bipolar disorder. Value Health 12, 624–627. Comes, M., Rosa, A., Reinares, M., Torrent, C., Vieta, E., 2017. Functional impairment in older adults with bipolar disorder. J. Nerv. Mental Dis. 205, 443–447. Dias, V.V., Balanza-Martinez, V., Soeiro-de-Souza, M.G., Moreno, R.A., Figueira, M.L., Machado-Vieira, R., Vieta, E., 2012. Pharmacological approaches in bipolar disorders and the impact on cognition: a critical overview. Acta Psychiatr. Scand. 126, 315–331. Endicott, J., Spitzer, R.L., Fleiss, J.L., et al., 1976. Global assessment scale. Arch. Gen. Psychiatr. 33, 766–771. First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B., 1995. Structured Clinical Interview for DSM-IV Axis I disorders-Patient Edition (SCID-I/P, Version 2.0). Biometrics Research Department, New York State Psychiatric Institute, New York, pp. 722. Forty, L., Kelly, M., Jones, L., Jones, I., Barnes, E., Caesar, S., Fraser, C., Gordon-Smith, K., Griffiths, E., Craddock, N., Smith, D.J., 2010. Reducing the hypomania checklist (HCL-32) to a 16-item version. J. Affect Disord. 124, 351–356. Goldman, H.H., Skodol, A.E., Lave, T.R., 1992. Revising axis V for DSM-IV: a review of measures of social functioning. Am. J. Psychiatry 149, 1148–1156. Gonzalez-Ortega, I., Rosa, A., Alberich, S., Barbeito, S., Vega, P., Echeburua, E., Vieta, E., Gonzalez-Pinto, A., 2010. Validation and use of the Functioning Assessment Short Test in first psychotic episodes. J. Nerv. Mental Dis. 198, 836–840. Jones, S.H., Thornicroft, G., Coffey, M., Dunn, G., 1995. A brief mental health outcome scale-reliability and validity of the global assessment of functioning (GAF). Br. J. Psychiatry 166, 654–659. Kim, B.N., Lee, E.H., Kim, H.J., Kim, J.H., 2018. Comparing the screening property of the shortened versions of the hypomania checklist-32 (HCL-32): cross-validation in Korean patients with bipolar disorder and major depressive disorder. J. Affect Disord. 227, 384–390. Kline, P., 2000. Handbook of Psychological Testing, 2nd ed. New York: Routledge. Lako, I.M., Bruggeman, R., Knegtering, H., Wiersma, D., Schoevers, R.A., Slooff, C.J., Taxis, K., 2012. A systematic review of instruments to measure depressive symptoms in patients with schizophrenia. J. Affect Disord. 140, 38–47. Martino, D.J., Igoa, A., Scapola, M., Marengo, E., Samame, C., Strejilevich, S.A., 2017. Functional outcome in the middle course of bipolar disorder: a longitudinal study. J. Nerv. Mental Dis. 205, 203–206. Moro, M.F., Colom, F., Floris, F., Pintus, E., Pintus, M., Contini, F., Carta, M.G., 2012. Validity and reliability of the Italian version of the Functioning Assessment Short Test (FAST) in bipolar disorder. Clin. Pract. Epidemiol. Mental Health 8, 67–73. Na, H.R., Kim, S.Y., Chang, Y.H., Park, M.H., Cho, S.T., Han, I.W., Kim, T.Y., Hwang, S.A., 2010. Functional assessment staging (FAST) in Korean patients with Alzheimer's disease. J. Alzheimers Dis. 22, 151–158. Pompili, M., Innamorati, M., Gonda, X., Serafini, G., Erbuto, D., Ricci, F., Fountoulakis, K.N., Lester, D., Vazquez, G., Rihmer, Z., Amore, M., Girardi, P., 2014. Pharmacotherapy in bipolar disorders during hospitalization and at discharge predicts clinical and psychosocial functioning at follow-up. Hum. Psychopharmacol. 29, 578–588. Reyes, A.N., Cardoso, T.A., Jansen, K., Mondin, T.C., Souza, L.D., Magalhaes, P.V.,
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Research paper
Psychometric properties of the Chinese version of the Functioning Assessment Short Test (FAST) in bipolar disorder
T
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Yong Zhanga, , Xingning Longa, Xiaojuan Mab, Qianqian Hec, Xingguang Luod, Yanhui Biana, ⁎⁎ Yuanyuan Xia, Xia Suna, Chee H. Nge, Eduard Vietaf, Yu-Tao Xiangg, a
Department of Bipolar Disorder, Tianjin Anding Hospital, 13 Liulin Road, Hexi District, Tianjin 300222, China Tianjin Medical College, Tianjin, China c Huzhou 3rd Hospital, HuZhou, China d Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA e Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia f Psychiatry and Psychology Department of the Hospital Clínic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, 170 Villarroel St, Barcelona, Catalonia 08036, Spain g Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Avenida da Universidade 3/F, Building E12, Taipa, Macao, SAR, China b
A R T I C LE I N FO
A B S T R A C T
Keywords: Bipolar disorder Functioning Assessment Short Test Psychometric properties China
Objectives: Bipolar disorder (BD) is often associated with significant functional impairment. However, there is currently no valid and reliable instrument for this variable that is both brief and easy to administer in China. We thus aimed to evaluate the psychometric properties of the Chinese version of the Functioning Assessment Short Test (FAST) in Chinese adults with BD. Methods: In this sample of adult subjects, 176 with BD and 53 healthy controls were included. The Chinese version of the FAST, the Young Mania Rating Scale (YMRS), the 17-item Hamilton Depression Rating Scale (HDRS-17) and the Global Assessment Functioning (GAF) were administered, and the psychometric analysis of the FAST was conducted. Results: The internal consistency (Cronbach's alpha) was 0.89 and 0.88 for the FAST at the baseline and week 1, respectively. Four domains (occupational functioning, cognitive functioning, interpersonal relationship and financial issues) at baseline had high item-total correlations. The FAST assessments at baseline and week 1 were highly correlated, indicating high test-retest reliability. The FAST total score was strongly associated with GAF total scores at week 0 (r = −0.952, p < 0.001), HDRS (r = 0.575, p < 0.001) and YRMS (r = 0.394, p < 0.001) and at week 1 (r = −0.945, p < 0.001; r = 0.582, p < 0.001; r = 0.363, p < 0.001), respectively, suggesting high concurrent validity. The FAST showed four dimensional measurement properties in exploratory factor analysis at baseline. Conclusions: The Chinese version of the FAST has satisfactory psychometric properties in terms of validity and reliability in Chinese adults with BD.
1. Introduction Functional impairment is a common feature in bipolar disorder (BD) and has received increasing attention in research (Baune et al., 2013; Robinson and Ferrier, 2006; Vaskinn et al., 2017). Although several standardized instruments including the Social and Occupational Functioning Assessment Scale (SOFAS) (Goldman et al., 1992), the Global Assessment of Functioning scale (GAF) (Endicott et al., 1976) and the Social Adjustment Scale (SAS) (Weissman and Bothwell, 1976) have been used in both clinical practice and research, most either failed to
⁎
cover all aspects of functioning in BD patients (Berns et al., 2007), or are excessively long and inconvenient for clinicians (Ware et al., 1994). Therefore, an efficient and brief instrument to assess functional impairment in BD patients is much needed. The Functioning Assessment Short Test (FAST) is a validated userfriendly and rapid scale to assess key areas of functional impairment in patients with psychiatric disorders (Bonnin et al., 2016; Rosa et al., 2007; Rotger et al., 2014), including BD (Cacilhas et al., 2009; Rosa et al., 2007). In China there are approximately 1.54 million people living with BD (Zhang et al., 2017), but to date there is no appropriate
Corresponding author. Corresponding author. E-mail addresses: [email protected] (Y. Zhang), [email protected] (Y.-T. Xiang).
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https://doi.org/10.1016/j.jad.2018.05.019 Received 20 February 2018; Received in revised form 8 April 2018; Accepted 15 May 2018 0165-0327/ © 2018 Elsevier B.V. All rights reserved.
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and valid measure of functional impairment available for this population. Thus we set out to evaluate the psychometric properties of the Chinese version of the FAST in Chinese adults with BD.
Table 1 Demographic and clinical characteristics of the bipolar and healthy control subjects.
2. Methods 2.1. Subjects This study was conducted in Tianjin Anding Hospital between February and July, 2016. Adult patients being treated in Tianjin Anding Hospital were consecutively recruited if they (1) had a diagnosis of BD including bipolar depressive episode, manic episode or euthymic phase based on a clinical interview by two consultant psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders-Fourth edition (DSM-IV) (APA, 1994); (2) were able to understand the contents of the interview; and (3) provided written informed consent. Patients who had major physical diseases or history of alcohol or substance abuse were excluded (First et al., 1995). Total 180 patients were recruited from Tianjin Anding Hospital and 60 healthy controls matched in age and gender with BD subjects and had no family history of psychiatric disorders were recruited via advertisements in the community. The study protocol was approved by the Ethics Committee of Tianjin Anding Hospital. 2.2. Assessment procedure Basic socio-demographic and clinical variables of all subjects were obtained during a clinical interview. The severity of depressive and manic/hypomanic symptoms were measured using the Young Mania Rating Scale (YMRS) (Young et al., 1978) and the 17-item Hamilton Depression Rating Scale (HDRS-17) (Xie and Shen 1984), respectively. Functional impairment was measured using the Global Assessment Functioning (GAF) (Jones et al., 1995) and the FAST, respectively at baseline and week one. To reduce clinical bias, different raters were used for the FAST and the GAF assessments. Euthymic BD patients were defined as those with YMRS total score ≤ 6, HDRS total score ≤ 8 (Samalin et al., 2016) and in clinical remission for at least one month. After obtaining appropriate permission, the original English version of the FAST was translated into Chinese and then translated back into English and re-edited by independent bilingual experts. The FAST comprises 24 items, covering 6 domains of functioning: autonomy (items 1–4), occupational functioning (items 5–9), cognitive functioning (items 10–14), financial issues (items 15–16), interpersonal relationships (items 17–22), and leisure time (items 23–24) (Rosa et al., 2007). Each item is scored from 0 (no difficulty), to 3 (severe difficulty). The total score is the sum of all items, with a higher score indicating more severe functional impairment.
Items (n %)
BD (n = 176)
HC (n = 53)
df
t/χ2
P value
Age (years) Education (years) Male Marital status Single Married Divorced Occupation Employed Unemployed Cohabitants Spouse Parents Friend Living alone Residence Urban Rural Alcohol history Never Occasionally Frequently Smoking history Never Occasionally Frequently FAST GAF YMRS HDRS
34.6 ± 8.1 13.4 ± 3.0 86 (48.9%)
34.4 ± 7.8 14.3 ± 2.6 27 (50.9%)
227 227 1 2
−0.7 −1.95 0.07 3.20
0.94 0.049 0.79 0.20
59 (33.5%) 92 (52.3%) 25 (14.2%)
17 (32.5%) 33 (62.3%) 3 (5.7%) 1
9.40
<0.01
91 (51.7%) 85 (48.3%)
40 (75.5%) 13 (24.5%) 3
4.39
0.36
90 (51.1%) 68 (38.6%) 6 (3.5%) 12 (6.8%)
33 (62.3%) 14 (26.4%) 1 (1.9%) 5 (9.4%) 1
0.85
0.36
132 (75.0%) 44 (25.0%)
43 (81.1%) 10 (18.9%) 2
1.03
0.60
110 (62.5%) 55 (31.3%) 11 (6.2%)
29 (54.7%) 20 (37.7%) 4 (7.6%) 2
0.57
0.75
104 (59.1%) 15 (8.5%) 57 (32.4%) 33.6 ± 10.4 57.1 ± 12.8 11.2 ± 10.1 10.6 ± 9.2
31 (58.5%) 3 (5.7%) 19 (35.8%) 4.5 ± 1.7 85.5 ± 9.8
227 227
20.14 −15.89
<0.001 <0.001
BD: bipolar disorder; HC: healthy control.
and sensitivity for the FAST were determined by the Receiver Operating Characteristic (ROC) curve analysis. Principal component analysis by varimax rotation was conducted to determine the optimal factor structure of the FAST. Items coefficients with loading ≥0.5 were retained (Kline, 2000). All tests are two-tailed (p < 0.05). 3. Results 3.1. Demographic characteristics One hundred and eighty patients with bipolar disorder and 60 healthy controls were screened; finally, 176 patients (57 in depressive phase, 65 in manic phase and 54 in euthymic phase) and 53 healthy controls were included for analyses. Only 11 participants (4 patients and 7 healthy controls) were excluded due to side effects (2 patients), failure to complete the assessment (2 patients and 4 healthy controls) and lack of interest (3 healthy controls). Psychotropic medications prescribed for BD patients included lithium, valproate, olanzapine, quetiapine and risperidone. Table 1 shows the comparison of demographic and clinical characteristics between BD patients and healthy controls. There were significant group differences in employment status, education level, the FAST and GAF total scores (all p values < 0.001).
2.3. Statistical analysis Data analyses were performed using SPSS Version 16.0. Independent samples t-test, Mann–Whitney U test, and chi-square test were used to compare the demographic and clinical variables between patients and healthy controls if applicable and appropriate. Internal consistency was measured using the Cronbach's alpha and the itemscale correlations using Pearson correlation coefficients at baseline. Internal reliability was acceptable in case that the Cronbach's alpha was greater than 0.6 (Lako et al., 2012). Test-retest reliability was assessed using Pearson correlation coefficients between the FAST total scores at baseline and 1-week assessments. Concurrent validity was measured by Pearson's correlation to examine the association between the FAST and GAF. The discriminant validity was measured by the analysis of covariance (ANCOVA) to compare the FAST total scores between depressive, manic and euthymic groups, as well as those between acute phase, euthymic phase and health controls after controlling for basic demographic variables that significantly differed between groups. Specificity
3.2. Reliability test The Cronbach's Alpha in the internal consistency analysis was 0.89 at baseline, and 0.88 in week 1. The Cronbach's Alpha in the six functioning domains also indicated good internal consistency, ranging from 0.84 to 0.90 at week 0, and from 0.83 to 0.88 at week 1, respectively. The item-scale correlation analyses revealed that four domains (occupational functioning, cognitive functioning, interpersonal 157
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structure was obtained when the coefficients lower than or equal to 0.50 was omitted (KMO: 0.904, p < 0.001). The four domains included autonomy (factor 1 with nine items), interpersonal relationship (factor 2 with six items), occupational functioning (factor 3 with five items), and cognitive functioning (factor 4 with four items), which accounted for 77.2% of the variance. The items in each domain are shown in Table 3.
Table 2 The FAST assessment at baseline (n = 176). Item
Mean (SD)
Item-total correlation
Alpha if item deleted
1. 2. 3. 4. 5.
3.3 9.9 5.1 3.3 9.5
(1.5) (2.8) (1.8) (1.3) (3.3)
0.66a 0.86a 0.84a 0.83a 0.88a
0.88 0.85 0.85 0.87 0.86
2.5 (1.4) 33.6 (10.4)
a
0.90
Autonomy Occupational functioning Cognitive functioning Financial issues Interpersonal relationship 6. Lesiure time Total scores
a
0.49
4. Discussion Our results found that the Chinese version of the FAST has satisfactory psychometric properties in Chinese adults with BD. Other validation studies in different socio-cultural contexts also found similar psychometric properties (Aydemir and Uykur, 2012; Barbato et al., 2013; Rosa et al., 2007). Our finding showed the FAST had a high internal consistency, with the total Cronbach's alpha ranging from 0.88 to 0.89, which is in line with earlier findings (Moro et al., 2012; Rosa et al., 2007). The long-term internal consistency was not examined in our study, but a Spanish study found that the internal consistency of the FAST was still above 0.90 after one year assessment (GonzalezOrtega et al., 2010). Similar to earlier findings (Na et al., 2010; Suominen et al., 2015), occupational functioning, cognitive functioning, interpersonal relationship and financial issues had high itemtotal correlation (>0.80), while the test-retest reliability was satisfactory. The GAF is a widely used instrument to assess functioning (Startup et al., 2002). In this study the FAST total score was significantly and negatively associated with the GAF at both week 0 and week 1, which is consistent with the fact that a high score in the GAF means good functioning whereas in the FAST high scores mean greater disability. Additionally, the FAST scores on interpersonal relationship, occupational functioning, cognitive functioning and financial issues were significantly associated with the GAF, indicating that the FAST overlap considerably with the GAF, but has more focus on the functioning domains related to BD, such as social, occupational and cognitive functioning (Comes et al., 2017; Martino et al., 2017; Reyes et al., 2017). Furthermore, the FAST showed high discriminant properties; after adjusting for the education level and occupation status, we found that patients with acute BD (including those with manic and depressive episodes) had more severe functioning impairment compared to euthymic patients and healthy controls as measured by the FAST, which is also consistent with previous findings (Bora et al., 2016; Rosa et al., 2007). Moreover, we also found that the bipolar depressed patients had more severe functional impairment compared to manic and euthymic patients as reported previously in other settings (Aparicio et al., 2017). The cut-off value of 12 in FAST showed good discriminant ability in Chinese patients, which is comparable to earlier findings (Moro et al., 2012; Rosa et al., 2007). Similarly, the cutoff value of 29 could discriminate between those with acute BD and euthymic patients. Most item loadings in principal component analysis ranged between 0.70 and 0.90 (only item 11 was 0.59), indicating good internal structure of the FAST (Kline, 2000). This study found four dimensions, including autonomy, interpersonal relationship, occupational functioning, and cognitive functioning in the FAST, which is slightly different from previous studies of the Portuguese, Spanish and Italian versions (Barbato et al., 2013; Cacilhas et al., 2009; Rosa et al., 2007), with five dimensions (the abovementioned four dimensions plus the financial issue factor). The discrepancy between Chinese and other versions could be due to different cultural contexts; i.e., in Chinese tradition, personal autonomy usually covers financial issues and leisure time in daily life, such as family financial management, personal hobbies or activities. The strengths of this study are the relatively large sample size and inclusion of BD patients at different illness phases. However, there are several methodological limitations. First, euthymia was defined in this study as at least one month of remission, rather than three months as
<0.01.
relationship and financial issues) at baseline had high item-total correlation coefficients higher than 0.80, while the domain leisure time had the lowest item-total correlation coefficient. All domains, if deleted individually, decreased the total scale alpha at baseline (Table 2). As for the test and re-test reliability, the Pearson correlation coefficient between the week 0 and week 1 assessments was 0.96, while the corresponding figure in the six domains was 0.97 in Autonomy, 0.96 in Occupational functioning, 0.94 in Interpersonal relationships, 0.91 in Cognitive functioning, 0.87 in Leisure time, and 0.82 in Financial issues. 3.3. Validity test The associations between the FAST and GAF, HDRS and YMRS were analyzed using the Pearson correlation analysis to test concurrent validity. The FAST total score was highly associated with GAF (r = −0.952, p < 0.001), HDRS (r = 0.575, p < 0.001) and YRMS total scores (r = 0.394, p < 0.001) at both week 0 and at week 1 (r = −0.945, p < 0.001; r = 0.582, p < 0.001; r = 0.363, p < 0.001), respectively. Furthermore, the GAF score was negatively associated with the six functioning domains at week 0 (autonomy: r = −0.70, occupational functioning: r = −0.87, cognitive functioning: r = −0.87, financial issues: r = −0.83, interpersonal relationship: r = −0.89, and leisure time: r = −0.55) and week 1 (autonomy: r = −0.74, occupational functioning: r = −0.86, cognitive functioning: r = −0.83, financial issues: r = −0.75, interpersonal relationship: r = −0.86, and leisure time: r = −0.60). Using the baseline data, the discriminant capacity of the FAST between depressive (n = 57), manic (n = 65) and euthymic (n = 54) groups, and also between acute (n = 122), euthymic groups (n = 54) and healthy controls (n = 53) were tested using ANCOVA. After adjusting for education level and occupation status, there were significant differences in the FAST total scores between the three mood states (F = 35.6, p < 0.001), and between BD patients and healthy controls (F = 140.3, p < 0.001) (Fig. 1). Further, we found the FAST score in manic patients was lower than in depressed patients (F = −3.05, p < 0.01). The specificity and sensitivity for the FAST at baseline was tested. Following the Younden's index for diagnostic tests (Youden, 1950) that were used in other validation studies (Bech et al., 2011; Forty et al., 2010; Kim et al., 2018), the optimal cut-offs in this study was chosen by maximizing the combination of sensitivity and specificity. Finally, the cut-off value was 29 (sensitivity of 100% and specificity of 73%) to differentiate between the acute and the euthymic phases, and 12 to differentiate between the euthymic phase and healthy controls (sensitivity of 100% and specificity of 64%). 3.4. Principal component analysis (PCA) The exploratory PCA with the varimax rotation was performed to test the internal structure of the FAST at week 0. A four domains 158
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Fig. 1. Comparisons of the FAST scores between different phases in bipolar disorder and healthy controls using analysis of covariance. Note: The baseline FAST scores between different phases in bipolar patients and healthy controls were compared after adjusting for education and occupation. There were significant differences in the FAST scores between depressive (41.4 ± 5.5), manic (38.4 ± 5.0) and euthymic phases (20.3 ± 2.1) (F = 35.6, p < 0.001), and between BD patients and healthy controls (4.5 ± 1.7) (F = 140.3, p < 0.001). Further, the FAST score in manic patients was lower than in depressed patients (F = −3.05, p < 0.01).
Author disclosure
Table 3 Factor loading of the FAST in principal component analysis. FAST
1
FAST15 FAST01 FAST03 FAST16 FAST02 FAST04 FAST10 FAST23 FAST24 FAST17 FAST22 FAST18 FAST19 FAST20 FAST21 FAST07 FAST06 FAST09 FAST05 FAST08 FAST14 FAST12 FAST13 FAST11
0.889 0.851 0.804 0.791 0.781 0.779 0.745 0.713 – 0.544
0.510
2
3
Role of funding
4
NA. Contributors Study design: Yong Zhang, Xingguang Luo, Yu-Tao Xiang. Data collection, analysis and interpretation of data: Xingning Long, Xiaojuan Ma, Qianqian He, Yanhui Bian. Drafting of the manuscript: Yong Zhang, Yuanyuan Xi, Xia Sun, Yu-Tao Xiang. Critical revision of the manuscript: Chee H. Ng, Eduard Vieta. Approval of the final version for publication: all co-authors.
0.924 0.881 0.809 0.783 0.769 –
Acknowledgment 0.916 0.909 0.890 0.847 0.833
0.527
NA. Conflict of interest 0.887 0.886 0.801 0.593
The authors declare that they have no conflicts of interest concerning this paper. References
Note: coefficient lower than or equal to 0.50 was omitted.
APA, 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington: American Psychiatric Association. Aparicio, A., Santos, J.L., Jimenez-Lopez, E., Bagney, A., Rodriguez-Jimenez, R., SanchezMorla, E.M., 2017. Emotion processing and psychosocial functioning in euthymic bipolar disorder. Acta Psychiatr. Scand. 135, 339–350. Aydemir, O., Uykur, B., 2012. Reliability and validity study of the Turkish version of Functioning Assessment Short Test in bipolar disorder. Turk. Psikiyatr. Derg. 23, 193–200. Barbato, A., Bossini, L., Calugi, S., D'Avanzo, B., Fagiolini, A., Koukouna, D., Parabiaghi, A., Rapisarda, F., Rucci, P., Vallarino, M., 2013. Validation of the Italian version of the Functioning Assessment Short Test (FAST) for bipolar disorder. Epidemiol. Psychiatr. Sci. 22, 187–194. Baune, B.T., Li, X., Beblo, T., 2013. Short- and long-term relationships between neurocognitive performance and general function in bipolar disorder. J. Clin. Exp. Neuropsychol. 35, 759–774. Bech, P., Christensen, E.M., Vinberg, M., Bech-Andersen, G., Kessing, L.V., 2011. From items to syndromes in the hypomania checklist (HCL-32): psychometric validation and clinical validity analysis. J. Affect Disord. 132, 48–54. Berns, S., Uzelac, S., Gonzalez, C., Jaeger, J., 2007. Methodological considerations of measuring disability in bipolar disorder: validity of the multidimensional scale of independent functioning. Bipolar Disord. 9, 3–10. Bonnin, C.M., Torrent, C., Arango, C., Amann, B.L., Sole, B., Gonzalez-Pinto, A., Crespo, J.M., Tabares-Seisdedos, R., Reinares, M., Ayuso-Mateos, J.L., Garcia-Portilla, M.P., Ibanez, A., Salamero, M., Vieta, E., Martinez-Aran, A., 2016. Functional remediation
previously recommended (Torrent et al., 2013), which might reduce the discriminant ability of the FAST between different BD stages. Second, the use of psychotropic medications could bias the functioning assessment (Dias et al., 2012; Pompili et al., 2014) to an uncertain extent. Finally, this sample was followed up only for one week. Therefore the long-term consistency of the FAST could not be examined although previous studies suggested that the FAST had high consistency even at 6–12 months assessments in BD patients (Gonzalez-Ortega et al., 2010; Strejilevich et al., 2013). In conclusion, the Chinese version of the FAST shows satisfactory psychometric properties in Chinese adults with BD. Compared to other functioning assessment instruments, the FAST is shorter and easier to administer, and thus can be useful in BD patients for both research and clinical practice in China.
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Kapczinski, F., Silva, R.A., 2017. Functional impairment and cognitive performance in mood disorders: a community sample of young adults. Psychiatry Res. 251, 85–89. Robinson, L.J., Ferrier, I.N., 2006. Evolution of cognitive impairment in bipolar disorder: a systematic review of cross-sectional evidence. Bipolar Disord. 8, 103–116. Rosa, A.R., Sanchez-Moreno, J., Martinez-Aran, A., Salamero, M., Torrent, C., Reinares, M., Comes, M., Colom, F., Van Riel, W., Ayuso-Mateos, J.L., Kapczinski, F., Vieta, E., 2007. Validity and reliability of the Functioning Assessment Short Test (FAST) in bipolar disorder. Clin. Pract. Epidemiol. Mental Health 3, 5. Rotger, S., Richarte, V., Nogueira, M., Corrales, M., Bosch, R., Vidal, R., Marfil, L., Valero, S., Vieta, E., Goikolea, J.M., Torres, I., Rosa, A., Mur, M., Casas, M., Ramos-Quiroga, J.A., 2014. Functioning Assessment Short Test (FAST): validity and reliability in adults with attention-deficit/hyperactivity disorder. Eur. Arch. Psychiatry Clin. Neurosci. 264, 719–727. Samalin, L., de Chazeron, I., Vieta, E., Bellivier, F., Llorca, P.M., 2016. Residual symptoms and specific functional impairments in euthymic patients with bipolar disorder. Bipolar Disord 18, 164–173. Startup, M., Jackson, M.C., Bendix, S., 2002. The concurrent validity of the global assessment of functioning (GAF). Br. J. Clin. Psychol. 41, 417–422. Strejilevich, S.A., Martino, D.J., Murru, A., Teitelbaum, J., Fassi, G., Marengo, E., Igoa, A., Colom, F., 2013. Mood instability and functional recovery in bipolar disorders. Acta Psychiatr. Scand. 128, 194–202. Suominen, K., Salminen, E., Lahteenmaki, S., Tupala, T., Isometsa, E., 2015. Validity and reliability of the finish version of the Functioning Assessment Short Test (FAST) in bipolar disorder. Int. J. Bipolar Disord. 3, 10. Torrent, C., Bonnin Cdel, M., Martinez-Aran, A., Valle, J., Amann, B.L., Gonzalez-Pinto, A., Crespo, J.M., Ibanez, A., Garcia-Portilla, M.P., Tabares-Seisdedos, R., Arango, C., Colom, F., Sole, B., Pacchiarotti, I., Rosa, A.R., Ayuso-Mateos, J.L., Anaya, C., Fernandez, P., Landin-Romero, R., Alonso-Lana, S., Ortiz-Gil, J., Segura, B., Barbeito, S., Vega, P., Fernandez, M., Ugarte, A., Subira, M., Cerrillo, E., Custal, N., Menchon, J.M., Saiz-Ruiz, J., Rodao, J.M., Isella, S., Alegria, A., Al-Halabi, S., Bobes, J., Galvan, G., Saiz, P.A., Balanza-Martinez, V., Selva, G., Fuentes-Dura, I., Correa, P., Mayoral, M., Chiclana, G., Merchan-Naranjo, J., Rapado-Castro, M., Salamero, M., Vieta, E., 2013. Efficacy of functional remediation in bipolar disorder: a multicenter randomized controlled study. Am. J. Psychiatry 170, 852–859. Vaskinn, A., Lagerberg, T.V., Bjella, T.D., Simonsen, C., Andreassen, O.A., Ueland, T., Sundet, K., 2017. Impairment in emotion perception from body movements in individuals with bipolar I and bipolar II disorder is associated with functional capacity. Int. J. Bipolar Disord. 5, 13. Ware, J.E., Kosisnki, M, Keller, S.D, 1994. SF-36 Physical and Mental Health Summary Scales: A User's Manual. Boston: The Health Institute. Weissman, M.M., Bothwell, S., 1976. Assessment of social adjustment by patient selfreport. Arch. Gen. Psychiatry 33, 1111–1115. Xie, G.R., Shen, Q.J, 1984. Use of the Chinese version of the Hamilton Rating Scale for depression in general population and patients with major depression. Chin. J. Nerv. Mental Dis. 10, 346. Youden, W.J., 1950. Index for rating diagnostic tests. Cancer 3, 32–35. Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A., 1978. A rating scale for mania: reliability, validity and sensitivity. Br. J. Psychiatry 133, 429–435. Zhang, L., Cao, X.L., Wang, S.B., Zheng, W., Ungvari, G.S., Ng, C.H., Zhong, B.L., Wang, G., Xiang, Y.T., 2017. The prevalence of bipolar disorder in China: a meta-analysis. J. Affect Disord. 207, 413–421.
in bipolar disorder: 1-year follow-up of neurocognitive and functional outcome. Br. J. Psychiatry 208, 87–93. Bora, E., Bartholomeusz, C., Pantelis, C., 2016. Meta-analysis of theory of mind (ToM) impairment in bipolar disorder. Psychol. Med. 46, 253–264. Cacilhas, A.A., Magalhaes, P.V., Cereser, K.M., Walz, J.C., Weyne, F., Rosa, A.R., Vieta, E., Kapczinski, F., 2009. Validity of a short functioning test (FAST) in Brazilian outpatients with bipolar disorder. Value Health 12, 624–627. Comes, M., Rosa, A., Reinares, M., Torrent, C., Vieta, E., 2017. Functional impairment in older adults with bipolar disorder. J. Nerv. Mental Dis. 205, 443–447. Dias, V.V., Balanza-Martinez, V., Soeiro-de-Souza, M.G., Moreno, R.A., Figueira, M.L., Machado-Vieira, R., Vieta, E., 2012. Pharmacological approaches in bipolar disorders and the impact on cognition: a critical overview. Acta Psychiatr. Scand. 126, 315–331. Endicott, J., Spitzer, R.L., Fleiss, J.L., et al., 1976. Global assessment scale. Arch. Gen. Psychiatr. 33, 766–771. First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B., 1995. Structured Clinical Interview for DSM-IV Axis I disorders-Patient Edition (SCID-I/P, Version 2.0). Biometrics Research Department, New York State Psychiatric Institute, New York, pp. 722. Forty, L., Kelly, M., Jones, L., Jones, I., Barnes, E., Caesar, S., Fraser, C., Gordon-Smith, K., Griffiths, E., Craddock, N., Smith, D.J., 2010. Reducing the hypomania checklist (HCL-32) to a 16-item version. J. Affect Disord. 124, 351–356. Goldman, H.H., Skodol, A.E., Lave, T.R., 1992. Revising axis V for DSM-IV: a review of measures of social functioning. Am. J. Psychiatry 149, 1148–1156. Gonzalez-Ortega, I., Rosa, A., Alberich, S., Barbeito, S., Vega, P., Echeburua, E., Vieta, E., Gonzalez-Pinto, A., 2010. Validation and use of the Functioning Assessment Short Test in first psychotic episodes. J. Nerv. Mental Dis. 198, 836–840. Jones, S.H., Thornicroft, G., Coffey, M., Dunn, G., 1995. A brief mental health outcome scale-reliability and validity of the global assessment of functioning (GAF). Br. J. Psychiatry 166, 654–659. Kim, B.N., Lee, E.H., Kim, H.J., Kim, J.H., 2018. Comparing the screening property of the shortened versions of the hypomania checklist-32 (HCL-32): cross-validation in Korean patients with bipolar disorder and major depressive disorder. J. Affect Disord. 227, 384–390. Kline, P., 2000. Handbook of Psychological Testing, 2nd ed. New York: Routledge. Lako, I.M., Bruggeman, R., Knegtering, H., Wiersma, D., Schoevers, R.A., Slooff, C.J., Taxis, K., 2012. A systematic review of instruments to measure depressive symptoms in patients with schizophrenia. J. Affect Disord. 140, 38–47. Martino, D.J., Igoa, A., Scapola, M., Marengo, E., Samame, C., Strejilevich, S.A., 2017. Functional outcome in the middle course of bipolar disorder: a longitudinal study. J. Nerv. Mental Dis. 205, 203–206. Moro, M.F., Colom, F., Floris, F., Pintus, E., Pintus, M., Contini, F., Carta, M.G., 2012. Validity and reliability of the Italian version of the Functioning Assessment Short Test (FAST) in bipolar disorder. Clin. Pract. Epidemiol. Mental Health 8, 67–73. Na, H.R., Kim, S.Y., Chang, Y.H., Park, M.H., Cho, S.T., Han, I.W., Kim, T.Y., Hwang, S.A., 2010. Functional assessment staging (FAST) in Korean patients with Alzheimer's disease. J. Alzheimers Dis. 22, 151–158. Pompili, M., Innamorati, M., Gonda, X., Serafini, G., Erbuto, D., Ricci, F., Fountoulakis, K.N., Lester, D., Vazquez, G., Rihmer, Z., Amore, M., Girardi, P., 2014. Pharmacotherapy in bipolar disorders during hospitalization and at discharge predicts clinical and psychosocial functioning at follow-up. Hum. Psychopharmacol. 29, 578–588. Reyes, A.N., Cardoso, T.A., Jansen, K., Mondin, T.C., Souza, L.D., Magalhaes, P.V.,
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