Performance-based assessment of functional skills in severe mental illness: Results of a large-scale study in China
Open accessAbstract
Performance-based assessments of everyday living skills have been shown to be highly correlated with cognitive functioning in schizophrenia and bipolar disorder, as well as being predictive of deficits in real-world outcomes such as independent living and employment. In this study, we expand our assessments of impairments in everyday living skills to China, evaluating people with schizophrenia, bipolar disorder, and major depression, and comparing their performance to that of healthy controls. Samples of people with schizophrenia (n = 272), bipolar disorder (n = 61), major depression (n = 50), and healthy controls (n = 284) were examined with the Chinese version of the UCSD performance-based assessment, brief version (UPSA-B). Performance was compared across the groups and the association between age, gender, educational attainment, marital status, and UPSA-B scores was evaluated. When the performance on the UPSA was compared across the groups, with education as a covariate, significant effects of both diagnosis (F = 86.3, p < .001) and education were found (F = 228.3, p < .001). Sex and age did not contribute significantly when age and education were considered. Post-hoc comparisons revealed that total UPSA-B scores were lowest in the schizophrenia patients, followed by the patients with major depression. Patients with bipolar disorder did not differ from the healthy comparison subjects on overall performance. Scores for all groups were lower than previously reported in western samples (e.g., HC mean = 64). While diagnostic differences in UPSA-B scores are similar to those previously seen in western samples, the education effect is considerably more substantial. These data suggest that in developing countries educational attainment may be strongly associated with levels of adaptive outcomes and the utilization and interpretation of functional capacity measures be adjusted accordingly.
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Functional skills are significantly impaired in depressed individuals compared to healthy control participants.
“a recent study examining performance-based assessment of functional skills (e.g., paying a bill or rescheduling an appointment) in Chinese participants with severe mental illness found that functional skills were significantly impaired in depressed individuals compared to healthy control participants [13].”
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“In contrast to the extensive body of literature describing performance-based functional deficits in schizophrenia, relatively few reports have assessed similar measures in BD (McIntosh et al., 2011).”
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“…these functional capacity (FC) measures are themselves potential endophenotypes, reflecting skills that are quite similar across different cultures (McIntosh et al., 2011), present in individuals with spectrum conditions (McClure et al., 2014), and not influenced by wide variations in…”
BackgroundSelf-citationValidation of the Chinese version of Brief Assessment of Cognition in Schizophrenia
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“The Chinese version of the UPSA-B was developed and has been validated in patients with mental illnesses among Chinese populations.(30) The UPSA-B served as the validity criterion for the BACS in this study.”
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“However, it should be kept in mind that there is a lack of psychometric research of the UPSA in these types of patients, although it has been employed in different studies (Henry et al., 2013; McIntosh et al., 2011; Mausbach et al., 2010).”
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“These cross-diagnostic relative levels of impairments hold across different countries and cultures (McIntosh et al., 2011), although the correlations between skills deficits and outcomes seems quite consistent on a crossnational basis.”
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“…(Jardim et al., 2015, Lima et al., 2006) UPSA brief 16 1 4 Portuguese version (Mantovani et al., 2015); Japanese (Sumiyoshi et al., 2014); Chinese ( McIntosh et al., 2011); Spanish (Garcia-Portilla et al., 2013); Swedish (Olsson et al., 2012); Mobile app version (Moore et al., some important data…”
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“To date, several studies have presented data of a normal population (Leifker et al., 2010; McIntosh et al., 2011).”
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“FC performance, like NP performance, appears to be minimally affected by psychotic symptoms (Bowie, Reichenberg, Patterson, Heaton, & Harvey, 2006), to not be fully accounted for by poor motivation or educational disadvantage (McIntosh et al., 2011), and to be similarly performed across different phases of the illness…”
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“A study using the Chinese version of the UPSA-B found an association between USPA-B scores and educational attainment (but not age or sex) in a sample of participants with severe mental illnesses and healthy comparison participants (McIntosh et al., 2011).”
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“Not surprisingly, evidence supports that Functional Capacity is strongly related to Cognitive Performance, but only moderately to real-world scores (Keefe et al., 2006; Bowie et al., 2006).”
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Self-citationNeurocognitive predictors of performance‐based functional capacity in bipolar disorder
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“…UPSA scores are more impaired in patients with BD compared with controls, these differences generalize cross-culturally, and that UPSA scores correlate with neurocognition and other measures of functional outcome (Bello et al., 2008; Depp et al., 2009; Mausbach et al., 2010; McIntosh et al., 2011).”
BackgroundResultA systematic review of a functional assessment Tool: UCSD Performance-based skill assessment (UPSA)
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“…effects of the five selected demographics (i.e. patients’ age, gender, education, duration of illness and number of mental health services used) due to their significant correlation with patients’ functioning and symptom severity found in previous studies (McIntosh et al. 2011, Chien et al. 2014).”
ResultLanguage-dependent performance on the letter fluency task in patients with schizophrenia
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“The effect of languages on evaluation for cognitive performance and functional outcome has attracted interest among researchers engaged in global clinical trials for newly developed neuroleptic agents (Harvey and Velligan, 2011; McIntosh et al., 2011; Martini et al., 2012; Velligan et al., 2012).”
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“Along these lines, additional evidence has accrued to suggest that performance on the UPSA-B is similar in other western cultures (i.e., Sweden [Harvey et al., 2009]) and that diagnostic differences in UPSA-B scores are similar between western samples and a Chinese sample, though the effect of education was much stron…”
ResultInfluentialChristensen, M. C., Sluth, L. B., & McIntyre, R. S. (2018) · Journal of Affective Disorders · doi:10.1016/j.jad.2018.11.034 · Cited by 9 · see citing works
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Self-citationFunctional Ability of Clients with Bipolar Disorders in Tertiary Hospital, Puducherry.
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“Several variables of this dataset had been reported to be associated with the disorders, such as age [35–38], gender [39, 40], PMI [41, 42] and lifetime drug usage [43, 44].”
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“A large number of studies have reported that patients with schizophrenia have cognitive impairments in many aspects, including speech learning, visual memory, attention, processing speed, working memory, and executive function (40, 41).”
BackgroundValidation of the Chinese Version of the Schizophrenia Cognition Rating Scale
Huang, K.-W., Lin, P., Lee, Y., Huang, Y., Hung, C., Lee, S.-Y., Chen, C., & Wang, L. (2022) · Psychiatry Investigation · doi:10.30773/pi.2021.0322 · Cited by 4 · see citing works
Patmisari, E., Huang, Y., McLaren, C., Bhatia, P., Orr, M., Govindasamy, S., Hielscher, E., & McLaren, H. (2025) · Scandinavian Journal of Occupational Therapy · doi:10.1080/11038128.2025.2468421 · Cited by 3 · see citing works
“Interventions that focus on skill and health improvements led to substantial lifestyle changes, reducing hospital read-missions, and improving daily functioning [77, 78].”
Chandran, M. C., Saji, F., Samuel, R., & Jacob, K. (2021) · Indian Journal of Psychiatry · doi:10.4103/psychiatry.indianjpsychiatry_872_20 · Cited by 3 · see citing works
“[7] The University of California San Diego Performance-Based Skills Assessment (UPSA) is a widely used scale, assessing performance in five domains of independent community living skills-household chores, communication, finance, transportation, and planning recreational activities.”
The clinical utility of newer antidepressant agents: Understanding the role in management of MDD
Waters, K. (2022) · Mental Health Clinician · doi:10.9740/mhc.2022.10.309 · Cited by 3 · see citing works
“An increase of 6 to 7 points after 8 weeks of antidepressant treatment is considered the threshold for clinical relevance.(60,61) This analysis identified patients who were considered dual responders, meaning that they had achieved 50% reduction in baseline MADRS score plus a change in the UPSA composite score of 7 po…”
BackgroundAssociation between the HHEX polymorphism and delayed memory in first-episode schizophrenic patients
Zhu, Z. H., Yin, X. Y., Cai, Y., Jia, N. N., Wang, P. J., Qi, Q., Hou, W. L., Man, L. J., & Hui, L. (2024) · Schizophrenia Research Cognition · doi:10.1016/j.scog.2024.100304 · Cited by 2 · see citing works
“Cognitive deficits of schizophrenia have been reported to mainly exist in the following domains, such as memory, language, attention, learning, cognitive processing speed, and executive functioning (Mclntosh et al., 2011; Han et al., 2012; Hui et al., 2013, 2016).”
BackgroundInfluentialNovotny, P. M. (2011) · UST Research Online (University of St. Thomas - Minnesota) · Cited by 2 · see citing works
Wu, S., Huang, Y., Hung, C., & Wang, L. (2022) · International Journal of Mental Health Promotion · doi:10.32604/ijmhp.2022.022784 · Cited by 2 · see citing works
Performance-based measures of functioning in schizophrenia
Depp, C. A., de Dios, L. V., Mausbach, B. T., & Patterson, T. L. (2013) · Cambridge University Press eBooks · doi:10.1017/cbo9781139003872.015
Assessment and treatment of cognitive impairment and related features
Harvey, P. D. (2013) · Cambridge University Press eBooks · doi:10.1017/cbo9781139003872.014
Self-citationRequisite Skills and the Meaningful Measurement of Cognition
Keefe, R. S. E., Green, M. F., & Harvey, P. D. (2020) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2020.1618
Self-citationAhorsu, D. K., Chung, K., Wong, H. H., Yiu, M. G. C., Mok, Y. F., Lei, K. S., & Tsang, H. W. H. (2021) · Asian Journal of Social Health and Behavior · doi:10.4103/shb.shb_66_20
PADRÕES DE ATIVIDADES INSTRUMENTAIS DA VIDA DIÁRIA ENTRE IDOSOS DA COMUNIDADE
Sigrist, A. D. A. F. (2021) · doi:10.17771/pucrio.acad.53089
Chan, C., Leung, K. P. Y., Mok, C. C. M., & Siu, A. M. H. (2026) · Acta Psychologica · doi:10.1016/j.actpsy.2026.107430
Zhu, Z. H., Wu, Y. M., Wang, J. J., Zhang, L. W., Yin, X. Y., Jia, N. N., Zhu, H. H., Cai, Y., Hou, W. L., Yu, X., et al. (2026) · BMC Psychiatry · doi:10.1186/s12888-026-07791-x
Agner, J., Seol, J. Y., Zan, H., & Pereira, H. (2026) · BMC Health Services Research · doi:10.1186/s12913-026-14112-1
“…Skills Assessment (UPSA) which requires the individual being assessed to demonstrate planning, finance, communication, mobility, and house management skills by completing relevant tasks, in addition to clinician judgment, may be useful for assessing functional needs in people with SMI [67–69].”
McKeegan, G. F. (2026) · Evidence-based practices in behavioral health · doi:10.1007/978-3-032-18372-9_14
Silverman, I. H., Kaur, D., Campbell, L. M., Mahmood, Z., Keller, A. V., & Twamley, E. W. (2026) · Psychiatry Research · doi:10.1016/j.psychres.2026.117386
- Authors
- McIntosh, B. J., Zhang, X. Y., Kosten, T., Tan, S. P., Xiu, M. H., Rakofsky, J., & Harvey, P. D.
- Affiliations
- Emory University (US)
- Baylor University (US)
- Beijing HuiLongGuan Hospital (CN)
- University of Miami (US)
- Corresponding author
- Harvey, Philip D.
- Venue
- Journal of Psychiatric Research
- Publisher
- Elsevier BV
- Published
- 2011-08
- Volume
- 45
- Issue
- 8
- Pages
- 1089-1094
- ISSN
- 0022-3956 (ISSN-L)
- PMC
- PMC3112265
- OpenAlex
- W2169576081
- Cited by
- 58
- References
- 36
- Citations by year
- 2026: 5 · 2025: 1 · 2024: 2 · 2022: 4 · 2021: 3 · 2020: 4 · 2019: 3 · 2018: 5 · 2017: 5 · 2016: 2 · 2015: 6 · 2014: 6 · 2013: 7 · 2012: 1
- FWCI
- 3.96
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Psychiatric Research (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- NIMH (K05-DA0454, P50-DA18827 and U01-MH79639, MH 78775)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Safety Research › Disability Education and Employment
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Keywords
- performance-based assessment, functional skills, severe mental illness, schizophrenia, bipolar disorder, major depressive disorder, educational attainment, adaptive behavior
- MeSH terms
- Adult, Aged, Mental Disorders, China, Cognition Disorders, Disability Evaluation, Educational Status, Female, Humans, Male, Middle Aged, Neuropsychological Tests, Psychiatric Status Rating Scales, Psychomotor Performance, Surveys and Questionnaires
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