FAST: How to Implement Functional Assessment in Bipolar Disorder Podcast

Katherine Sullivan, MSN, APN, and Tina Matthews-Hayes, DNP, FNP-BC, PMHNP-BC, discuss the benefits of implementing functional assessments for patients with bipolar disorder in clinical practice.

Transcript: 

Kate Sullivan (KS): Hello, and welcome to this Peer Exchange Podcast on how to implement functional assessment in bipolar disorder. I’m Kate Sullivan. I’m a psychiatric-mental health nurse practitioner. I've been working in clinics throughout Knoxville, Tennessee for the last 15 years. I currently reside at a clinic called Forensic and Clinical Services and work with many populations, including first responders, neurodivergent folks, and mood disorders as well. This is my colleague, Tina. 

Tina Matthews-Hayes (TM): Hello. I am Tina Matthews-Hayes. I’m a dual-certified family and psychiatric nurse practitioner working in my own private practice between Portland, Oregon, and Virginia Beach, Virginia, pretty much working for the last 18 years in family practice, so ages 3 to 103, specializing more in the SMI population, so bipolar, schizophrenia, as well as pediatric psychiatry. So, thank you so much for joining me, Kate, as we talk about a functional assessment tool that may be worth incorporating into your clinical practice for patients with bipolar I disorder, or bipolar disorder, as a key component of measurement-based care. 

KS: Bipolar I disorder, or BP-1, is defined by at least one manic episode, which may or may not be accompanied by depressive episodes.^1,2 While both types of episodes are associated with disability and impairment, depressive episodes tend to predominate during the course of illness and have been shown to be more strongly linked to increased risk of suicide and psychiatric comorbidities. Together, these can contribute to premature mortality.^3-6  

TM: So, even if the mood symptoms resolve, subsyndromal symptoms can persist.¹ About 70% of patients with bipolar disorder can still experience cognitive dysfunction even when in a euthymic state, so when their mood is considered quote “stable.”⁷ Poorer cognitive function may also be associated with worse functional outcomes.⁸ My experience is that patients report feeling better but express that there is still something missing or they don't feel like they are quite back to their baseline. 

KS: I would tend to agree with that. Impaired daily functioning can affect almost every aspect of a patient’s life, including verbal memory, attention, executive function, and social cognition.⁷ Functional impairments may manifest in struggles with maintaining relationships, social activities, daily living activities, and remaining employed.^7,9 These impairments can be episodic or persistent, depending upon the phase of illness and presence of subsyndromal symptoms.¹⁰ 

TM: So, Kate, this means that in a large portion of patients with bipolar I disorder, functional recovery may often lag behind symptomatic recovery.⁸ I had a perfect example in my clinic yesterday. The patient had come home from the hospital after a significant manic episode, actually his first manic episode. He’s super excited that he’s no longer an inpatient, and he’s no longer manic. So, he’s feeling much, much better, but as the weeks progressed, when he’s following up, he says he just feels empty. He doesn’t feel anything. His day, to him, feels like Groundhog Day. He wakes up, he goes to work, he comes home. And he misses excitement, he misses engaging, he just doesn’t feel anything. And I encounter this a lot where they feel better, they are stable, but they don’t really feel.  

KS: I couldn’t agree more there. True recovery for a patient means more than just resolution of mood symptoms.¹¹ Functional recovery should be an essential component of managing BP-1 and can be addressed through a measurement-based care approach in clinical practice.   

TM: So, Kate, how do we, as nurse practitioners, help address this problem? A more basic question is, how can we capture that information to know even where to start? Tools such as mood charts, which are sometimes used to monitor mood symptoms, don’t necessarily capture patient information about day-to-day functioning. However, there is one option: an assessment tool that can capture psychosocial functional information even when patients are euthymic.¹² 

KS: While behavioral health has many scales for evaluating psychosocial functioning in patients, the Functioning Assessment Short Test—or FAST— is a scale that focuses on some of the principal problems observed in patients with bipolar.¹³  

TM: That’s right, Kate. The FAST is a useful assessment tool for patients with BP because it can help evaluate functioning in terms of severity. It was validated for use for BP back in 2007, but it initially didn’t include a way to grade the severity of impairment in psychosocial functioning. That came a little bit later, with a study published in 2018, which showed that the FAST scores from 0 to 11 indicated no impairment, scores from 12 to 20 represented mild impairment, scores from 21 to 40 indicated moderate impairment, and scores above 40 represented severe functional impairment. Today’s version of the FAST reflects these severity categories of functional impairments based off of the results of the study, which can help enable nurse practitioners to interpret the results in terms of clinical relevance.¹³  

KS: In addition, it’s suitable for both clinical and research settings, but particularly for clinical settings because it is a short instrument.¹³ Let’s dive a little deeper and discuss how functional assessment using tools such as the FAST can be implemented in daily practice.  

TM: Sure. First, a study published in 2023 demonstrated that the FAST is equally reliable when self-reported as it is when clinician-led, so you can administer it either way.¹² 

The assessment takes about 6 minutes to complete, and it consists of 24 items that span 6 domains of functioning that include autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time.¹⁴ Patients rate each item on a four-point scale, where zero means they have no difficulties doing that task, and one indicates mild difficulty, two moderate difficulty, and three indicates severe difficulty.  

KS: That makes sense. Some examples of items included on the FAST include holding down a paid job, concentrating on a book, remembering new names, and so on.⁹ If a clinician administers the assessment, they might elaborate and probe further on a particular item, such as, “Have you had any difficulty concentrating or remembering things, such as appointments or conversations?” Another example would be, “Have you had any challenges getting along with family members?” “Are you pursuing any hobbies?” “Have you been out with friends lately?”  

Patients rate their answers based on their experiences within the last 14 days. Then, the clinician sums the scores to get the FAST total score, which ranges from zero to 72 points. As mentioned, a higher total score may indicate greater impairment.¹⁴ For example, a score of 30 indicates moderate difficulties in most areas of functioning,¹³ which may be a cause for clinical concern.  

TM: The FAST can fit into a clinical workflow and help clinicians get a baseline assessment of functioning at a patient’s initial intake and during follow-ups, regardless of whether the patient presents with mood symptoms. This is true measurement-based care in action!  

KS: I personally already use peer-reviewed screening and rating tools to clarify diagnosis and overall functioning every single day in my practice. My EHR, electronic health record system, has many tools embedded within it for use in sessions or for patients to fill out between sessions. The FAST tool would work well in that very setting. For BP-1, I currently use the Rapid Mood Screener, or RMS, but I have also used the Bipolar Spectrum Diagnostic Scale in the past as well.^15,16  

In terms of mood charting, sometimes those tools can be helpful, but I find one of the most important things is really clearly defining mania, depression, and mixed states for BP-1 patients. With a lot of misinformation out there, I can’t tell you how many of my patients think mania is just “a few hours of agitated behavior.” They may not understand the full breadth of how manic symptoms present, and a mood chart may not be helpful because they will not likely mark it accurately.  

TM: That is also a good point! Also, the use of FAST tool is really the key in getting our patients from "stable" to "wellness." While managing the acute presentation is very important, our goal should be helping our patients achieve mental wellness rather than just helping them feel "okay" or "better than they did before." Assessing the domains teases out which areas we can help manage and identify where we need to encourage more psychological support or social support through therapy or case management.⁹  

Also, when patients see clinicians addressing them as a whole person, and not really just as a set of symptoms, I believe we can help foster a stronger therapeutic relationship between the patients and us, as healthcare providers. That’s where true shared decision-making really shines. 

KS: Very true! Additionally, from the clinician’s perspective, this is an objective way to document patient progress and use measurement-based care to inform the care the patient may need,¹³ which ultimately may help lead to better patient outcomes. 

TM: I absolutely agree, Kate. It provides validity to our decision-making in disease management. 

KS: Tina, do you have an example from your own clinical practice when you’ve implemented functional assessment into a measurement-based care approach? How did you do it, and what patient outcomes did you observe? 

TM: Kate, like you, I use measurement-based care approach everyday in practice. I feel we exist in a world in psychiatry where things can be subjective in nature and vary between provider to provider. Using tools such as the FAST with our patients truly gives me insight, especially when making changes in any medication or treatment lines on how my patient is progressing from appointment to appointment. So, while we see a snapshot in time, recording a measurement-based score to a patient’s presentation really truly gives us something to look back on how they are progressing in care. So, again, I apply this everyday based on when I assess them, and then as I advance through the treatment plan.  

KS: That sounds like a really excellent clinical plan, and it’s one that I tend to mirror as well. I agree with you on the importance of having these ongoing measurable assessments, not just at intake or acute episodes, but to capture changes over time.¹⁷ 

Sometimes I will talk to my clients about screening tools like it's a Polaroid picture of the present moment, but it helps us to see changes in those pictures over time, just like Tina mentioned.   

As we discussed today, managing a patient with a bipolar mood episode involves more than just mood symptoms; monitoring their overall function is also a crucial part of BP-1 care, as psychosocial functionality may not return to baseline after an episode, and that can have many downstream effects in a patient’s life. To help identify lingering functional deficits, clinicians can use the FAST, a simple, brief tool specifically developed to evaluate functional impairments in patients with bipolar disorder.  

TM: Kate, it’s been a pleasure discussing the importance of the topic of bipolar I management. Thank you so much to you and our listeners for joining us on NP Psych Navigator!  

KS: Thank you, too, Tina.