Author’s Accepted Manuscript

Self-Reported Graphic Personal and Social

Performance Scale (SRG-PSP) for Measuring
Functionality in Patients with Bipolar Disorder

Ya Mei Bai, Cheng-Ta Li, Mu-Hong Chen, Yen

Kuang Yang
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PII: S0165-0327(16)31991-7
DOI: http://dx.doi.org/10.1016/j.jad.2017.02.018
Reference: JAD8780
To appear in: Journal of Affective Disorders
Received date: 27 October 2016
Revised date: 7 January 2017
Accepted date: 13 February 2017
Cite this article as: Ya Mei Bai, Cheng-Ta Li, Mu-Hong Chen and Yen Kuang
Yang, Self-Reported Graphic Personal and Social Performance Scale (SRG-PSP)
for Measuring Functionality in Patients with Bipolar Disorder, Journal of
Affective Disorders, http://dx.doi.org/10.1016/j.jad.2017.02.018
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Self-Reported Graphic Personal and Social Performance Scale (SRG-PSP) for

Measuring Functionality in Patients with Bipolar Disorder

Ya Mei Bai1,2, Cheng-Ta Li1,2, Mu-Hong Chen1,2, Yen Kuang Yang3,4

1
Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan

2
Department of Psychiatry, College of Medicine, National Yang-Ming University, Taipei, Taiwan

3
Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National

Cheng Kung University, Tainan, Taiwan

4
Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin,

Taiwan

*
Correspondent: No. 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan. Tel.: +886 2

28712121; Fax: +886 2 28712121. ymbi@mail2000.com.net

Abstract:

Objectives:

The self-reported graphic version of the Personal and Social Performance Scale

(SRG-PSP) is the first graphic, self-reported rating scale that assesses functioning, and

its reliability and validity have been documented in patients with schizophrenia. This

study investigated the validity of SRG-PSP in patients with bipolar disorder (BD).

Methods:

Patients with BD were recruited from psychiatric outpatient clinics, and assessed with

the Young Mania Rating Scale (YMRS), the Montgomery–Åsberg Depression Rating

Scale (MADRS), the Clinical Global Impression Scale (CGI)–Bipolar and CGI–

1
Depression, the Positive and Negative Symptom Scale (PANSS), the Global

assessment of function (GAF), and the PSP. All participants completed the self-rating

questionnaires: the SRG-PSP, the 36-Item Short-Form Health Survey (SF-36), and the

Sheehan disability Scale (SDS).

Results:

In total, 114 patients with BD were enrolled. The criterion-related validities between

the SRG-PSP and the PSP were all significantly correlated with their counterparts.

The global score of the SRG-PSP was significantly correlated with the scores of the

YMRS, MADRS, PANSS, CGI-Depression, GAF, SF-36, and SDS. Three SRG-PSP

domains (socially useful activities, personal and social relationships, and self-care)

were negatively correlated with the scores of the MADRS, PANSS, CGI-depression,

and SDS; and were positively correlated with the GAF, SF-36 scores. The disturbing

and aggressive behavior domain was positively correlated with the scores of the

YMRS, MADRS, PANSS, CGI-Bipolar, CGI-Depression, and SDS; and was

negatively correlated with the GAF, SF-36 scores (all p < 0.01).

Conclusion:

The SRG-PSP is a validated self-reported scale for assessing functionality in patients

with BD.

Keywords: Bipolar disorder, functionality, SRG-PSP scale.

2
1. Introduction

Patients with bipolar disorder (BD) experience substantial life adversity and

neurocognitive deficits including the impairment of working memory (Ferrier et al.

1999), sustained attention (Clark et al. 2002, Harmer et al. 2002), abstract reasoning

(Ali et al. 2000),verbal memory (Bas et al. 2015, van Gorp et al. 1999, van Gorp et al.

1998), and verbal fluency (Lebowitz et al. 2001). Numerous studies have documented

high rates of functional impairment among patients with BD, even during phases of

remission (Baune & Malhi 2015, Rosa et al. 2007, Sole et al. 2012). BD has become a

leading cause of disability worldwide (Nitzburg et al. 2016). In addition to mood

symptoms, functionality is a crucial outcome for patients with BD (Baune & Malhi

2015, Sole et al. 2012) and is highly correlated with neurocognitive function (Anaya

et al. 2016, Baune & Malhi 2015, Miguelez-Pan et al. 2014, Van Rheenen & Rossell

2014a, b, Vierck & Joyce 2015), life quality (Gonda et al. 2016), the risk of suicide

(Esposito-Smythers et al. 2010, Nanda et al. 2016), and relapse (Jiang 1999, Lobban

et al. 2011, Solomon et al. 1996). For the assessment of functionality, the most

commonly used scale, the Global Assessment of Function (GAF), has the advantages

of being brief and simple. However, its main disadvantage is that it incorporates

psychopathological aspects without clearly differentiating them from the psychosocial

function. Upon this criticism, the Social and Occupational Functioning Assessment

3
Scale (SOFAS) was developed to rectify this shortcoming but lacks clear operational

instructions for rating the severity of disability (Juckel & Morosini 2008). Other

instruments are available for measuring psychosocial functioning, such as the

Activities of Daily Living Rating Scale (Dinnerstein et al. 1965), the Social

Adjustment Scale (Aumack 1962), and the International Classification of Functioning,

Disability and Health (ICF) (Ayuso-Mateos et al. 2013). However, these measures are

complex and require a profound knowledge of the patients and their specific

circumstances, or an extended interview administered by mental health professionals.

Thus, the instruments available for assessing functionality are not suitable for use in

clinical practice. Functioning Assessment Short Test (FAST) is another popular

measure for functionality used in many studies (Moro et al. 2012, Rosa et al. 2014,

Rosa et al. 2007) showing it is easy to apply with strong psychometric properties to

detect differences between euthymic and acute bipolar patients. However, it’s still an

interview-administered instrument. Previous studies showed that the most frequent

reasons for psychiatrists not using scales to monitor outcomes were a lack of time and

lack of training(Lee et al. 2010, Zimmerman & McGlinchey 2008). Therefore, a

self-reported scale for measuring functionality would be invaluable in clinical

practice.

4
 We have developed a self-reported graphic version of the Personal and Social

Performance scale (SRG-PSP) with a questionnaire of cartoon-like pictures, and the

internal reliability and validity have been documented in patients with schizophrenia

(Bai et al. 2014). This SRG-PSP scale is based on the Personal and Social

Performance (PSP) scale which developed by Morosini et al (Morosini et al. 2000).

Without mixing psychopathological with psychosocial aspects, PSP provides a more

specific operationalization assessment of four domains (socially useful activities,

personal and social relationships, self-care, and disturbing and aggressive behaviors),

yielding a final global score rating of 1–100; a higher score represents a higher level

of personal and social function. The PSP scale has high test–retest reliability, good

inter-rater reliability validity (Brissos et al. 2012, Morosini et al. 2000, Schaub &

Juckel 2011, Srisurapanont et al. 2008), and significant correlations with the GAF,

SOFAS, ICF, and Positive and Negative Syndrome scale (PANSS) (Apiquian et al.

2009, Garcia-Portilla et al. 2011, Nafees et al. 2012, Nasrallah et al. 2008, Patrick et

al. 2009, Wu et al. 2013). Additionally, it has been translated into German (Juckel et

al. 2008), Spanish (Apiquian et al. 2009), Portuguese (Brissos et al. 2012), Thai

(Srisurapanont et al. 2008), Chinese (Tianmei et al. 2011), and Taiwanese Mandarin

(Hsieh et al. 2011, Wu et al. 2013) versions. Nevertheless, like FAST, the PSP scale

has to administrated by mental health professionals. Therefore, we developed the

5
self-rating SRG-PSP scale according to the four domains of the PSP with Cartoon-like

pictures (Figure 1, and supplement file) that the participant could easily understand

the meaning of the questionnaire. Gender specific versions were created for male and

female patients accordingly. All the items were rated from 1 (seldom) to 3 (always),

and the domain score was summed. The global score summed up the scores of the

socially useful activities, personal and social relationships, and self-care domains and

reversed the score of the disturbing and aggressive behavior domain. A higher global

score meant a higher level of personal and social functioning. Our previous study

confirmed the internal reliability and validity of the SRG-PSP in patients with

schizophrenia (Bai et al. 2014)(supplementary file). The criterion-related validities

between the SRG-PSP and PSP were all significantly correlated with their counterpart.

The SRG-PSP global score and three domains (socially useful activities, personal and

social relationships, and self-care) were positively correlated to the Activities of Daily

Living Rating Scale II, and the World Health Organization Quality of Life–Brief, and

negatively correlated with the PANSS (Bai et al. 2014).

The functional assessment is the crucial outcome in patients with BD. Reviewing

the literature, there is no self-rating scale for assessing functionality in patients with

BD, and their verbal memory is more impaired than their visual-spatial memory, even

in the euthymic state (Scala et al. 2013, Zubieta et al. 2001). The SRG-PSP with

6
Cartoon-like pictures is the first graphic, self-reported rating scale that assesses

functioning, and may be more applicable to them than the narrative rating scales. The

study is aimed to test the validity of the SRG-PSP in patients with BD.

7
2. Methods

2.1. Participants

A total of 114 patients with BD were recruited from outpatient clinics of the

Departments of Psychiatry in a medical center in Taiwan. To be included in the study,

patients had to meet the DSM-IV criteria for bipolar disorder and be aged > 20 years.

Patients who met any of the following criteria were excluded: a) patients with a

history of major medical or neurological disease, b) patients with a history of alcohol

or substance dependence or abuse, c) patients with previous head injury, d) patients

with mental retardation, f) patients with severe vision deficiency, (e.g., color blindness

or any corrected visual acuity <0.5), and g) patients who were illiterate, disabled, or

unable to read traditional Chinese characters. The Ethics Committee of Human

Research at Taipei Veterans General Hospital approved the study protocol, and all

participants gave written informed consent.

The participants' demographic data, physical history, and psychiatric history were

collected. Subsequently, a psychiatrist assessed their clinical symptoms through the

Young Mania Rating Scale (YMRS) for manic symptoms (Young et al. 1978), the

Montgomery–Åsberg Depression Rating Scale (MADRS) for depressive symptoms

(Montgomery & Asberg 1979), the Clinical Global Impression(CGI)-Bipolar,

CGI-Depression scale (Khan et al. 2002, Spearing et al. 1997), the Positive and

8
Negative Symptom Scale (PANSS) for psychotic symptoms (Kay et al. 1987); and

assessed functionality through the GAF for global function, and the PSP. The

SRG-PSP, the 36-Item Short-Form Health Survey (SF-36), and the Sheehan disability

Scale (SDS) are three self-rating questionnaires, which all participants completed. The

SF-36 is a 36 item questionnaire that measures quality of life across 8 domains

(physical functioning, physical roles, emotional roles, bodily pain, vitality, mental

health, social functioning, and general health) and provides two measures, physical

component summary (PCS) and mental component summary (MCS) (McHorney et al.

1994, McHorney et al. 1993, Ware & Sherbourne 1992). The SDS was designed to

measure life impairment in three domains (work, family life, and social life) by using

a self- rated 10-point visual analog scale and an aggregate total score (on a 5-point

visual analog scale) of the three scores (Sheehan et al. 1996).

The data were analyzed using SPSS 17.0 software. The Cronbach's alpha

coefficient was used to test the internal consistency reliability, and Spearman's ρ was

used to examine the correlation between the SRG-PSP and other scales as

criterion-related validity. The threshold for statistical significance was 0.05.

9
3. Results

The demographics and other characteristics of the patients are presented in Table

1. The recruited patients included 34 (30%) males, had an average age of 46.1 ± 11.6

years and average illness duration of 17.9 ± 11.3 years. The patients could complete

the SRG-PSP within 5-10 minutes. The criterion-related validities between the

SRG-PSP and PSP were all significantly correlated with their counterparts (for

socially useful activities, personal and social relationships, self-care, disturbing and

aggressive behavior, and global score: ρ = -0.574, -0.556, -0.414, 0.188, and 0.639,

respectively, all p < 0.05). Within the SRG-PSP, the global score was correlated with

all individual domains significantly. The SRG-PSP global score was positively

correlated with three domains (socially useful activities, personal and social

relationships, and self-care, ρ = 0.546~0.851, all p < 0.01), and were negatively

correlated with the disturbing and aggressive behavior domain (ρ = -0.546, p < 0.01).

The socially useful activities, personal and social relationships, and self-care domains

also were positively correlated with each other significantly (ρ = 0.502~0.610, all p <

0.01) and were negatively correlated with disturbing and aggressive behavior

significantly (ρ = -0.243~-0.546, all p < 0.01).

Significant correlations were noted between the SRG-PSP and the scores of the

clinical symptoms, life quality, and disability scales. The SRG-PSP global score were

10
negatively correlated with the scores of the YMRS (ρ = -0.24, p < 0.01), MADRS (ρ =

-0.571, p < 0.01), CGI-Depression (ρ = -0.524, p < 0.01), PANSS (ρ = -0.511, p <

0.01) and SDS domains ( ρ = -0.580~-0.723, p < 0.01), but were positively with the

GAF (ρ = 0.634, p < 0.01), PCS (ρ = 0.560, p < 0.01), and MCS (ρ = 0.643, p < 0.01)

scores. Three domains of the SRG-PSP (socially useful activities, personal and social

relationships, and self-care) were negatively correlated with the scores of the MADRS,

PANSS, CGI-Depression, and SDS (ρ = -0.295~-0.635, all p < 0.01), but were

positively correlated with the scores of the GAF, PCS, and MCS (ρ = 0.367~0.643, all

p < 0.01). The disturbing and aggressive behavior domain of the SRG-PSP were

positively correlated with the scores of the YMRS, MADRS, PANSS, CGI-Bipolar,

CGI-Depression, and SDS (ρ = 0.214~0.454, all p < 0.05) and negatively with the

scores of the GAF, PCS, and MCS (ρ = -0.246~-0.511, all p < 0.01). More details of

the relationships are provided in Table 2.

We further analyzed the correlations between the severity of mood symptoms

and functionality, life quality, and disability scores. The MADRS and CGI-Depression

scores were negatively correlated with the scores of the SRG-PSP (ρ = -0.571, -0.524,

p < 0.01), PSP (ρ = -0.545, -0.515, p < 0.01), GAF (ρ = -0.674, -0.626, p < 0.01), PCS

(ρ = -0.348, -0.260, p < 0.01), and MCS (ρ = -0.669, -0.674, p < 0.01), but positively

with the score of the SDS (ρ = 0.474~0.599, all p < 0.01). The YMRS score were

11
correlated positively with the scores of the SRG-PSP (ρ = -0.240, p < 0.05), PSP (ρ =

-0.353, p < 0.01), GAF (ρ = -0.417, p < 0.01), and MCS (ρ = -0.212, p < 0.01), but

negatively with all SDS domains (ρ = 0.194~0.262, p < 0.05). The CGI-Bipolar score

were only correlated with the scores of the disturbing and aggressive behavior domain

of the SRG-PSP and PSP (ρ = 0.214, 0.266, p < 0.01), and the GAF (ρ = -0.237, 0.266,

p < 0.01). Details of the aforementioned correlations are shown in Table 3. In

summary, functionality, life quality, and disability scores were significantly more

correlated with the depressive symptoms than with the manic symptoms.

4. Discussion

The SRG-PSP is the first graphic, self-reported rating scale that assesses

functioning. The internal reliability and validity of the SRG-PSP have been

documented in patients with schizophrenia (Bai et al. 2014). This study also showed

the SRG-PSP is a validated self-reported scale for assessing functionality in patients

with BD. The results reveal that the criterion-related validities between the SRG-PSP

and the PSP all were significantly correlated with their counterparts. Within the

SRG-PSP, the global score was positively correlated with three domains (socially

useful activities, personal and social relationships, and self-care) and was negatively

12
correlated with the disturbing and aggressive behavior domain. Socially useful

activities, personal and social relationships, and self-care domains were also

significantly positively correlated, whereas they were significantly negatively

correlated with disturbing and aggressive behavior.

Furthermore, the subjective self-rating SRG-PSP scores were significantly

correlated with the scores of the objective rating of clinical symptoms by the

psychiatrists and the subjective self-rating of life quality and disability. Many studies

showed that functional deficits in patients with bipolar disorder occur across different

phases of the disorder and were impacted by symptom severity (Dickerson et al. 2010,

Henry et al. 2013, Kebede et al. 2006, Koutra et al. 2016, Strejilevich et al. 2013,

Vergunst et al. 2013, Wingo et al. 2010). The SRG-PSP global score was correlated

negatively with the scores of the MADRS, CGI-Depression, PANSS, and all SDS

domains, but positively correlated with the GAF, PCS, and MCS scores. Three

SRG-PSP domains (socially useful activities, personal and social relationships, and

self-care) were correlated negatively with the scores of the MADRS, PANSS,

CGI-Depression, and all SDS domains, but was positively correlated with the GAF,

PCS, and MCS scores. The disturbing and aggressive behavior domain of the

SRG-PSP was positively correlated with the scores of the YMRS, MADRS, PANSS,

CGI-Bipolar, CGI-Depression, and all SDS domains, but was negatively correlated

13
with the GAF, PCS, and MCS scores. These results suggest that the SRG-PSP is a

valid instrument for assessing psychosocial functioning in patients with BD. The

verbal memory of patients with BD is more impaired than their visual–spatial memory

(Scala et al. 2013, Zubieta et al. 2001), they may be more motivated to complete the

graphical scale SRG-PSP. As a brief, self-rating instrument, the SRG-PSP is a valid,

convenient and useful measure of functionality for both research and daily clinical

practice.

We further analyzed the correlation between the severity of manic/depressive

symptoms and functionality, life quality, and disability scores. An important finding is

that depressive symptoms were correlated with the functionality, life quality, and

disability scores more significantly than are the manic symptoms. The MADRS and

CGI-Depression scores were significantly correlated with all the scores of the

SRG-PSP, PSP, GAF, PCS, MCS, and SDS. Nevertheless, the YMRS and the

CGI-Bipolar scores were only correlated with the disturbing and aggressive behavior

domain of the SRG-PSP and PSP. These results are consistent with previous reports

(Altshuler et al. 2002, Altshuler et al. 2006, Amini & Sharifi 2012, Bas et al. 2015).

Altshuler et al. observed an association between subsyndromal depression and

functional impairment functioning in work and home roles, as well as in family and

friend relationships (Altshuler et al. 2002, Altshuler et al. 2006). Additionally, Bas et

14
al. observed that residual depressive symptoms had major impacts on psychosocial

functioning (Bas et al. 2015). Furthermore, Amini et al. demonstrated that depressive

symptoms may be the primary determinant of impaired quality of life in patients with

bipolar I disorder than the manic symptoms(Amini & Sharifi 2012). However, those

previous studies used objective functional assessments (Altshuler et al. 2002,

Altshuler et al. 2006, Amini & Sharifi 2012, Bas et al. 2015). Our study is the first to

use patients’ subjective ratings of psychosocial functioning to validate the association

between depressive symptoms and functional impairment. Previous studies have

demonstrated that depression is the predominant mood state in both bipolar I and

bipolar II (Kupka et al. 2007). Our results further support the observation that

treatment of residual depressive symptoms is critical for the functional outcomes of

patients with BD.

The present study has several limitations. First, the sample size was

relatively small, and thus further studies with more subjects are required to confirm

the findings. Second, the study was conducted in relatively stable patients from the

outpatient clinics. Patients in the acute manic state may be less capable of

over-estimating their functionality and we suggest that the SRG-PSP is more

applicable for patients not in the acute manic phase. In conclusion, numerous studies

have documented high rates of functional impairment among patients with BD, even

15
during phases of remission (Baune & Malhi 2015, Rosa et al. 2007, Sole et al. 2012).

The SRG-PSP is a valid, convenient and useful instrument for monitoring the

functional outcomes of patients with BD.

16
Role of Funding Source

The study was supported by grant V104C-039 from Taipei Veterans General

Hospital, and MOST 104-2314-B-075-017, MOST 105-2314-B-075 -025 -MY3 by

the Ministry of Education, Taiwan, ROC.

Conflict of interest

All authors declare that they have no competing interests. The funding

institutions of this study had no further role in the study design, the collection,

analysis, and interpretation of data, the writing of this paper, or the decision to submit

it for publication.

Contributors

Professor Ya Mei Bai designed the study, conducted the clinical ratings and

wrote the manuscript. Dr. Cheng-Ta Li and Dr. Mu-Hong Chen helped to design the

study and contributed to the statistical analyses. Professor Yen Kuang Yang helped the

design of the SRG-SPS. All authors interpreted the analysis of the results and helped

to revise the manuscript.

17
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Fig. 1. An example of the self-reported version of the graphic Personal and Social
Performance scale

Table 1. Demographics and characteristics of the participants

Mean SD Range

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Age (years) 46.1 11.6 22-71

Education (yrs) 12.9 3.7 0-18

Duration of illness (yrs) 17.9 11.3 0.-51

Gender, male (%) 34 30%

SRG-PSPa

Socially useful activities 13.1 3.4 6-18

Personal and social relationships 9.3 3.1 5-15

Self-care 16.4 2.0 9-18

Disturbing and aggressive behavior 6.3 1.9 5-14

Global score 32.5 8.1 13-46

PSPb

Socially useful activities 2.0 0.9 1-4

Personal and social relationships 1.9 0.9 1-4

Self-care 1.2 0.5 1-4

Disturbing and aggressive behavior 1.1 0.4 1-4

Global score 72.5 10.1 45-90

Young Mania Rating Scale (YMRS) 2.5 3.7 0-19

Montgomery–Åsberg Depression Rating Scale 11.3 12.4 0-18

(MADRS)

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 Clinical Global Impression-Bipolar 1.1 0.4 1-3

Clinical Global Impression-Depression 1.7 1.0 1-4

Positive and Negative Syndrome Scale (PANSS) 38.7 9.4 30-98

Global assessment of function (GAF) 71.6 11.6 45-90

The 36-Item Short-Form Health Survey(SF-36)

physical component scale (PCS) 44.6 8.6 20.2-60.2

mental component scale (MCS) 37.8 11.7 14.1-62.9

Sheehan disability Scale (SDS)

work 3.9 3.2 010

social life 4.2 3.1 0-10

family life 4.2 3.1 0-10

aggregate total score 2.9 1.4 1-5

a
: For the SRG-PSP (Self-reported version of the graphic Personal and Social Performance scale)
sub-domains, the scores ranged from 0–18 and higher scores represent higher functioning in socially
useful activities, personal and social relationships, and self-care domain, but lower functioning in
disturbing and aggressive behavior. The global score summed up the aforementioned three similar
domains and reversed the disturbing and aggressive behavior score; a higher global score indicates
higher personal and social functioning. b: For the PSP (Personal and Social Performance scale)
sub-domains, the scores ranged from 1– 7, higher scores represent more severe functional impairment.
The global score provided a single, overall rating from 1–100, where a higher score represented higher
personal and social function.

Table 2. Spearman's ρ correlation between the SRG-PSP and other outcome measures

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SRG-PSP Socially Personal Self-care Disturbing Global score

useful and social and

activities relationshi aggressive

ps behavior

SRG-PSP

Socially useful activities 1.00 .610** .560** -.243** .851**

Personal and social .610** 1.00 .502** -.294** .835**

relationships

Self-care .560** .502** 1.000 -.362** .765**

Disturbing and aggressive -.243** -.294** -.362** 1.00 -.546**

behavior

Global score .851** .835** .765** -.546** 1.00

PSP

Socially useful activities -.574** -.457* -.473** .276** -.600**

Personal and social -.509** -.556** -.523** -.335** -.638**

relationships

Self-care -.385** -.367** -.414** .140 -.439**

Disturbing and aggressive -.172* -.241** -.186* .188* -.256**

behavior

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 Global score .537** .560** .491** -.317** .639**

YMRS -.109 -.193* -.197* .292** -.240**

MADRS -.518** -.400** -.398** .422** -.571**

CGI-Bipolar .053 -.092 -.054 .214* -.078

CGI-Depression -.469** -.378** -.295** .450** -.524**

Positive and Negative Syndrome -.461** -.369** -.330** .391** -.511**

Scale

Global assessment of function .518** .538** .482** -.376** .634**

(GAF)

SF-36

physical component scale .613** .367** .409** -.246** .560**

(PCS)

mental component scale .468** .537** .470** -.511** .643**

(MCS)

Sheehan disability Scale (SDS)

work -.478** -.397** -.470** .455** -.580**

social life -.600** -.519** -.437** .377** -.650**

family life -.581** -.459** -.486** .417** -.641**

aggregate total score -.635** -.575** -.504** .459** -.723**

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 *p < .05;
**p < 0.01
SRG-PSP: Self-reported version of the graphic Personal and Social Performance scale
PSP: The Personal and Social Performance scale
MADRS: Montgomery–Åsberg Depression Rating Scale.
CGI: Clinical Global Impression
YMRS: Young Mania Rating Scale
SF-36: The 36-Item Short Form Health Survey

Table 3. Spearman's ρ correlation between manic and depressive symptoms and the SRG-PSP,
PSP, and other outcome measures

SRG-PSP MADRS CGI-depression YMRS CGI-bipolar

SRG-PSP

Socially useful activities -0.518** -0.469** -0.109 0.053

Personal and social relationships -0.400** -0.378** -0.193** -0.092

Self-care -0.398** -0.295** -0.197** -0.054

Disturbing and aggressive behavior 0.422** 0.450** 0.292** 0.214*

Global score -0.571** -0.524** -0.240* -0.078

PSP

Socially useful activities 0.493** 0.439** 0.303** 0.125

Personal and social relationships 0.548** 0.528** 0.266** 0.084

Self-care 0.460** 0.462** 0.225** 0.021

Disturbing and aggressive behavior 0.237** 0.227** 0.470** 0.266**

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 Global score -0.545** -0.515** -0.353** -0.154

Global assessment of function (GAF) -0.674** -0.626** -0.417** -0.237*

SF-36

physical component scale (PCS) -0.348** -0.260** -0.137 0.010

mental component scale (MCS) -0.669** -0.574** -0.212** -0.097

Sheehan disability Scale (SDS)

work 0.596** 0.521** 0.230* 0.103

social life 0.528** 0.516** 0.087 -0.118

family life 0.541** 0.474** 0.194* 0.024

aggregate total score 0.599** 0.553** 0.262* 0.100

*p < .05;
**p < 0.01
SRG-PSP: Self-reported graphic version of the Personal and Social Performance scale
PSP: The Personal and Social Performance scale
MADRS: Montgomery–Åsberg Depression Rating Scale.
CGI: Clinical Global Impression
YMRS: Young Mania Rating Scale
SF-36: The 36-Item Short Form Health Survey

Highlights
 Bipolar disorder has become a leading cause of disability worldwide, and
assessment of functionality is important for patients’ outcome
 The self-reported graphic version of the Personal and Social Performance
Scale (SRG-PSP) is the first graphic and self-reported rating scale that

29
 assesses functioning, and its reliability and validity have been documented in
patients with schizophrenia.
 This study shows the SRG-PSP is a validated self-reported scale for assessing
functionality in patients with bipolar disorder.

30