Development and administration of the flexible adapted cognitive test battery for schizophrenia (FACTS)

Bing Cai; William S Stone; Xinyi Ouyang; Fei Deng; Hanhui Chen; Min Qian; Margaux M Grivel; Matcheri S Keshavan; Ezra S Susser; Lawrence H Yang; Michael R Phillips

doi:10.1016/j.scog.2025.100377

Development and administration of the flexible adapted cognitive test battery for schizophrenia (FACTS)

Schizophr Res Cogn. 2025 Aug 5:42:100377. doi: 10.1016/j.scog.2025.100377. eCollection 2025 Dec.

Authors

Bing Cai^{1

2}, William S Stone³, Xinyi Ouyang¹, Fei Deng¹, Hanhui Chen^{1

4}, Min Qian⁵, Margaux M Grivel⁶, Matcheri S Keshavan³, Ezra S Susser⁷, Lawrence H Yang^{6

8}, Michael R Phillips^{1

7

9}

Affiliations

¹ Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
² Department of Psychiatry, McGill University, Montreal, QC, Canada.
³ Harvard Medical School Department of Psychiatry at Beth Israel Deaconess Medical Center, Boston, MA, USA.
⁴ Tianjin Anding Hospital, Tianjin, China.
⁵ Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA.
⁶ Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, NY, USA.
⁷ Department of Epidemiology, Columbia University Mailman School of Public Health, Columbia University, New York, NY, USA.
⁸ Duke University School of Nursing, Durham, NC, USA.
⁹ Department of Psychiatry, Columbia University, New York, NY, USA.

Abstract

Background: Age and educational eligibility criteria for administration of the most widely used cognitive battery for schizophrenia typically exclude 20 % of individuals with schizophrenia in high-income countries and 25-50 % in middle- and low-income countries.

Methods: We developed the Flexible Adapted Cognitive Test battery for Schizophrenia (FACTS) that can be administered to all individuals with schizophrenia, regardless of age or education. To evaluate the utility and validity of the nine tests in the FACTS, two process measures are assessed during the administration of each test: 'test comprehension' and 'test completion' (successful or unsuccessful). The FACTS was administered to 495 community-dwelling individuals with schizophrenia and 308 healthy controls, including 473 (58.9 %) older or undereducated individuals typically excluded from studies of cognition in schizophrenia. Inter-rater reliability of the test comprehension and completion measures was assessed.

Findings: Older, undereducated participants successfully completed 82 % (3499/4257) of the administered tests. The mean weighted Kappa value for the nine test comprehension measures was 0.90 (range: 0.82-0.96), and the mean unweighted Kappa for the 20 test and subtest completion measures was 0.94 (range: 0.85-1.00).

Interpretation: Cognitive functioning is a core symptom cluster of schizophrenia, so the comprehensive assessment of cognitive functioning must become a standard part of the assessment of all individuals with schizophrenia, regardless of age or education. The development of the FACTS, which can be successfully administered to most older, undereducated individuals with schizophrenia, provides a model for doing this.

Funding: This study was supported by National Institute of Mental Health grants MH108385-R01 and MH127631-R01.

Keywords: FACTS, cognitive assessment; Psychometric characteristics; Schizophrenia; Undereducated, older participants.