¶ … Test Development This research is a mixed methods study designed to explore the perceptions of self-identifying individuals with anxiety and depression regarding any relation between their conditions and their ability to access appropriate healthcare under the Patient Protection and Affordable Care Act. Five respondents completed the questionnaire constructed explicitly for this research study. A review of the literature serves as a canvas of instruments also developed for assessing Axis 1 disorders as defined by the Diagnostic and Statistical Manual (DSM-5). The research on instrumentation included the following: 1) The SCID, 2) the Composite International Diagnostic Interview (CIDI), 3) the Beck Depression Inventory (BDI), 4) the Center for Epidemiologic Studies of Depression Scale (CES-D), and 5) Severity Measure for Generalized Anxiety Disorder -- Adult (an emerging online measure provided in association with the DSM-5).

Their responses negate the theoretical construct, however, an insufficient number of respondents in this pilot study meant that the hypothesis could not be tested. Recommendations for future research include selecting only respondents with diagnoses obtained from certified psychotherapists or clinical psychologists, or board certified psychiatrists.

Rationale/Problem Statement:

The construct of interest is whether co-morbid anxiety and depression are exacerbated by concerns about the availability of healthcare and potential treatments for the condition. Uncertainty about life events or access to services can contribute to increased anxiety. Difficulty accomplishing daily tasks is common for people suffering from depression. Taken together, the two conditions can present barriers that make it difficult for clients or patients to stay on top of their disordered conditions. To one degree or another, changes are challenging to nearly everyone. The construct of interest is the relation between co-morbid anxiety and depression and the prospect of difficulty obtaining appropriate care. The construct assumes that the patients or clients will anticipate difficulties even when they do not have direct experience with any particular healthcare related barrier.

The instrumentation developed for this test development proposal essentially functions as a screening device which relies on self-report and, as such is used to gauge the perceptions of the patients or clients with regard to their actual difficulties or their perceptions regarding anticipated difficulties accessing and obtaining adequate healthcare for their anxiety and depression. It is important to recognize that the proposed instrument does not actually measure behaviors or actions. This factor makes it all the more important for the instrument to demonstrate solid reliability and validity, and -- optimally -- to show correlation with instrumentation that has undergone rigorous evidence-based trials or research recognized by the American Psychological Association or other certifying body.

Assumptions

Explicitly, the focus of the proposed research is to determine whether anxiety and/or depression is further exacerbated by the fact that the Patient Protection and Affordable Care Act (PPACA) has been enacted and by worries that treatment for anxiety and depression will be as readily accessible as it was before the Patient Protection and Affordable Care Act was enacted. The Patient Protection and Affordable Care Act passed in the Senate on December 24, 2009, passed in the House on March 21, 2010, and was signed into law by President Barack Obama on March 23, 2010. Moreover, the Patient Protection and Affordable Care Act was upheld in the Supreme Court on June 28, 2012. Publicity about the law has been excessive, partisan spin regarding the possible ramifications of the law have been exaggerated, and the every hiccup expected of a new federal program of such scope has been treated as an authoritative proof that the law is ill-conceived and poorly administered. However, as the Patient Protection and Affordable Care Act has been implemented over the past year, the media and a number of well-funded key political groups have been shown to have engaged in hyperbole.

Regardless of the progress made during implementation and the evidence running contrary to the proclamations of dire effects, any patient or client who pays attention to the media will have heard, read, or seen stories predicting enormous problems and difficulties for those who must rely on the new healthcare law for their care. For patients or clients suffering from conditions characterized by anxiety and depression, this evaluation of the measures ("APA," 2013). The intention is for these instruments to be administered by clinicians and researchers at initial interviews with clients, and then used to monitor client progress ("APA," 2013). It is important to recognize that the emphasis is on the initial symptomatic status -- as reported by the client -- and on the patient reported outcome (PRO) information ("APA," 2013). Moreover, the emerging measures are designed for use in conjunction with conventionally anchored severity assessment instruments ("APA," 2013). The DSM-5 includes the instructions, scoring information, and interpretation guidelines that clinicians or researchers need to access in order to use the emerging measures in their practice or research ("APA," 2013).
In future iterations of this research, it may be that the study participants will not self-identify, but will need to have received an official diagnosis of anxiety or depression. This would be consistent with earlier research in anxiety, depression, and -- for instance -- post traumatic stress disorder (PTSD). At present, the research instrument requests that respondents: 1) Self-identify as depressed and anxious patients or clients; and 2) self-assess the severity of their symptoms in relation to the perceived threats to adequate healthcare in the near and far future.

Research Question

The research question for this study is as follows: Is either anxiety or depression, (or in the case of co-morbid anxiety and depression) or anxiety and depression exacerbated in patients or clients when considering the near-term and far-term healthcare under the Patient Protection and Affordable Care Act (PPACA)?

The hypotheses derived from this research question include:

HO: Clients who self-identify as having clinically significant depression and anxiety experience exacerbated symptoms associated with their disorders when they think about the PPACA.

HA: Clients who self-identify as having clinically significant depression and anxiety experience no difference in the symptoms associated with their disorders when they think about the PPACA.

Literature Review

The purpose of the literature review is to provide a thorough explanation of the construct of co-morbid anxiety and depression and, further, to review a number of instruments used to measure the construct that have been validated by the psychometric, psychiatric, and psychotherapeutic industries. The validated instruments serve as a benchmark of sorts against which the proposed instrument can be evaluated. Specifically, the literature review enabled a review that extends to the validity, reliability, and utility of the proposed measure. To that end, the strengths and weaknesses of the proposed measure are discussed, and the difference between the proposed measure and the established instrumentation are considered, including any justification for the development of the new instrument.

The industry validated instruments for assessing general anxiety and depression are introduced in this paragraph and reviewed in detail in the sections for each instrument that follow. The SCID is a semi-structured interview for making the major Axis I DSM-5 diagnoses. It is administered by a clinician and includes an introductory overview followed by nine modules, seven of which represent the major axis I diagnostic classes. Because of its modular construction, it can by adapted for use in studies in which particular diagnoses (e.g., depression only) are of interest. The Composite International Diagnostic Interview (CIDI) is a structured diagnostic interview designed to be used by trained interviewers who are not clinicians (Kessler et al., 1994). The Beck Depression Inventory (BDI) is a list of 21 symptoms and attitudes that are each rated in intensity. This instrument has been used to measure severity of depression in depressed samples but has also been used to assess depression in general population samples. It is also associated with other self-report measures of depression. The Center for Epidemiologic Studies of Depression Scale (CES-D) was designed to measure current level of depressive symptomatology, and especially depressive affect. Any one of the above instruments could be used in conjunction with the instrument designed for the current study. Correlation between the scores on different tests would help to verify the presence and severity of depressive symptoms. The same type of instrument could be used for verifying the presence of anxiety disorder.

1. SCID has undergone a revision in order to correspond to the DSM-5. The new version, called SCID-5, is currently in review by American Psychiatric Publishing, Inc. (APPI), the sole distributor of the SCID-5. A research version is expected to be released in the spring of 2015. A substantial number of reliability studies have been conducted on the SCID-I, the earlier…