Healthcare providers and other medical decision-makers for patients with chronic schizophrenia and other serious mental illnesses often must make decisions on whether their patients are capable of residing independently or would be better served by assisted care settings such as B&C facilities. Although many factors play a role in this decision, including neurocognitive functioning, level of positive, negative, and depressive symptoms, our study sought to establish the usefulness of the UPSA, a brief assessment of functional capacity, for prediction of residential independence. We found that the UPSA was significantly better than chance and better than classical clinical features of schizophrenia such as positive and negative symptoms and global cognitive functioning at predicting residential independence.
It has been suggested that assessments focusing on functional skills (e.g., the UPSA) do not adequately take other cognitively relevant features of everyday functioning into account. Specifically, Revheim and Medalia (2004a)
argued that tests of functional capacity (e.g., observing a patient’s ability to pay bills) do not take into account important functional features such as remembering to pay bills or otherwise initiate functionally relevant tasks. Although not discounting this observation, our data demonstrates that performance on the UPSA is highly related to global cognitive performance (see ) and serves as a significantly better predictor of residential independence than does global cognitive functioning. Thus, if this assessment could incorporate assessments of tendencies toward initiation, it might be even more sensitive.
The UPSA offers several advantages relative to other clinical measures (e.g., DRS, PANSS, HAM-D). For example, the brevity of the UPSA (i.e., 30 minutes) makes it preferable to lengthy batteries assessing multiple cognitive domains. Indeed recent research (Bowie et al., 2006
; Keefe et al., 2006
) has indicated that the prediction of real-world outcomes is not enhanced by cognitive performance when scores on the UPSA are considered. In addition, unlike assessments of global cognitive functioning (e.g., DRS) healthcare professionals do not need specialized training in order to administer the UPSA. Further, our data suggest that clinical symptoms, particularly negative symptoms, failed to provide any meaningful advantage to predicting residential independence. However, participants scoring 75 or above on the UPSA had significantly fewer positive and negative symptoms, indicating these symptoms are captured by performance on the UPSA. Therefore, we believe the UPSA serves as a brief measure of both functional capacity and as a proxy measure of global cognitive functioning and clinical symptoms that can adequately predict residential independence.
In addition to the brevity and ease with which the UPSA may be administered, there are advantages to establishing an UPSA cutoff for predicting residential independence. For example, researchers conducting clinical trials on the benefits of medications (e.g., cognitive-enhancing drugs, antipsychotic medications) or psychosocial interventions may seek to move participants above the UPSA threshold of 75 as an indication that these treatments improve the likelihood that patients may live independently. Indeed, Patterson et al (2006)
found that a behavioral intervention, known as Functional Adaptations and Skills Training (FAST), significantly improved performance on the UPSA, with average scores for patients in the FAST intervention improving from 60 to 70. These results were similar to those of a small pilot study of Hispanic patients with schizophrenia examining the effects of a behavioral intervention for improving functional capacity (Patterson et al., 2005
). Although these studies did not examine the percentage of participants moving above scores of 75, they provide evidence that the UPSA is sensitive to treatment and that patients can make substantial gains on the UPSA. We encourage future investigations to examine not only overall change on the UPSA, but the success of treatments for moving patients above a cutoff of 75.
Our study provides preliminary evidence that the UPSA is a valid instrument for predicting independent living status. However, data from this study were cross-sectional rather than prospective in nature. Therefore, one interpretation of our findings is that patients living in independent living situations have greater opportunity to practice the skills assessed on the UPSA (e.g., counting change, scheduling appointments) or that patients living in B&C settings are limited in their ability to practice these skills, thus accounting for differences in UPSA scores. If true, we believe this adds strength to our previous assertion that psychosocial skills-training interventions (rather than psychotropic medications) may be useful for improving patients’ functional abilities, given their emphasis on repeated practice of skills. While the cross-sectional nature of this study is a limitation, we believe assessment of patient ability to perform these tasks may still be useful in terms of discharge planning. Yet, future research is needed to determine if the UPSA serves as a prospective predictor of residential independence in patients with schizophrenia.
Our study did not include a clinical assessment of functioning such as the Global Assessment of Functioning (GAF) scale of the DSM-IV (American Psychiatric Association, 2000
). We believe the UPSA would perform particularly well compared to clinical assessments such as GAF scores. Previous studies have found GAF scores to be poor predictors of living status and functioning (Revheim et al., 2004a
; Roy-Byrne et al., 1996
) and suggest that relying on the GAF to assess patients’ functioning may be problematic. Nonetheless, we recommend that future studies should compare the AUC for clinical ratings of functioning such as GAF scores to that of the UPSA. Future research should also examine whether using the UPSA in conjunction with clinical assessments provides a better assessment than either of these assessments alone. Finally, future work should examine the predictive power of the UPSA prospectively across multiple placement settings to determine success in those settings and generalization to other functional outcomes.
We did not assess other indicators of functional outcome such as employment. We believe future studies should examine whether the UPSA adequately predicts employment status as a means of further validating the UPSA’s usefulness as a clinical tool. We suggest two methods of establishing the UPSA’s validity for predicting work-related outcomes. First, similar to our current study, ROC curves could be used to establish cutoffs for predicting employment status (e.g., employed vs non-employed; full-time vs part-time). Second, survival curves for maintaining employment over time could be calculated. Relevant to this point, it was recently reported (Rosenheck et al., 2006
) that work outcomes are tightly linked to disability status and less strongly related to cognitive performance. It would be of interest to determine if UPSA scores were more relevant than cognitive test scores at predicting employment when disability status is also considered.
Cutoff scores between 75 and 80 most accurately predicted residential independence, although this accuracy was 68%. It should be noted, however, that our sample did not include participants who resided in care settings where maximum supervision is necessary (e.g., inpatient settings). Instead, our sample consisted entirely of community-dwelling patients. We believe that inclusion of an inpatient sample would further increase the UPSA’s specificity and sensitivity and might further enable healthcare providers to differentiate cutoffs at which individuals may be safely moved into the community (i.e., higher levels of independence). As such, we strongly encourage this line of research.
In sum, we find that the UPSA serves as an adequate predictor of residential independence for individuals suffering from chronic schizophrenia. Furthermore, the UPSA was superior to measures of psychiatric symptom severity and global cognitive performance in predicting residential independence. Additionally, the UPSA is a brief assessment that can be easily administered to patients.