Why do the Washington Group anxiety and depression questions take a different form than questions in other domains?

The Washington Group (WG) uses a functional approach in its data collection tools as opposed to other approaches that ask directly if someone has a disability, has conditions or impairments that can lead to disability, or has participation restrictions that result from having functional difficulties in an unaccommodating environment. For example, the Washington Group Short Set on Functioning (WG-SS) includes a question on difficulties walking, but does not include questions on impairments, like missing limbs or musculoskeletal conditions, or on participation, for example problems shopping. There are both conceptual and logistical reasons for this decision.

Conceptually, it is the functional characteristics, not the impairments or conditions, that interact with environmental characteristics to reduce participation. Policies to improve participation focus on adjusting the environment to meet those functional needs. Logistically, there are many different conditions or impairments that can lead to the same functional limitation. The number of questions needed to cover all conditions or impairments would be very large, while fewer questions can capture the major functional domains.

The WG-SS was designed to be used in censuses and surveys where space is limited, so the set needed to be as short as possible to identify most people at risk of exclusion. The six questions ask directly about functioning in each of six universal activity domains (seeing, hearing, walking, communication, cognition and self-care) and do so in a structurally consistent manner. For example, the question “Do you have difficulties concentrating or remembering?” addresses cognitive functioning using a single question and the response set is the same as that used for the other five questions.

Comprehensive approaches to identifying the population with disabilities need to obtain information on psychosocial functioning. The WG-SS does not include a specific question on psychosocial functioning as developing a single question with appropriate responses structured similarly to the other six domains is not possible. For example, it is not possible to ask respondents if they have difficulty in “psychosocial functioning.” In addition, psychosocial functioning encompasses a number of concepts, including thoughts, feelings, and behaviors, thus making it difficult to craft a single question which can be universally understood.

The population with disabilities that the WG-SS identifies does, however, include some of those with psychosocial disability, as this type of disability can manifest in functional difficulties in other WG-SS domains, such as cognitive functioning, communication and self-care. However, the six questions do not capture all persons with psychosocial disability. It is also not possible to distinguish those with psychosocial difficulties among those identified by difficulties in these other related domains. For example, reported difficulties in communication may result from psychosocial difficulties, or from hearing difficulties, or from both.

To address this gap, targeted questions on psychosocial disability were included in the WG Short Set on Functioning – Enhanced (WG-SS Enhanced) and the WG Extended Set on Functioning (WG-ES). These sets were developed for data collections where more information is needed and more questions can be included. Like questions in other domains, the psychosocial disability questions do not ask about having or being diagnosed with specific psychological or mental health conditions. However, these questions take a somewhat different approach than the other questions in the sets. They ask about feelings associated with psychosocial functioning as opposed to the functional consequences of having a psychosocial condition. For example, the question about walking does not ask about the range of impairments and conditions that can affect walking, or the non-functionally based symptoms associated with those conditions, such as pain. The questions used for psychosocial functioning ask directly about anxiety and depression  feelings that reflect psychosocial functioning and not about the functioning itself. The approach used for the psychosocial domain reflects how psychological functioning is defined. Much more than physical health conditions, the diagnosis of a psychological or mental health condition depends, in part, on the nature of its impact on daily life. Diagnoses of psychological disorders result when difficulties cause distress and interfere with how people go about their everyday lives.

An alternative to designing questions on feelings associated with anxiety and depression is to develop questions that directly tap emotional and psychological difficulties. At the time the WG-ES was developed, such questions did not exist. The approach taken by the WG to meet the need for questions addressing this functional domain was to include questions on the frequency and intensity of feelings associated with two of the most common mental health problems – anxiety and depression. The rationale is that those experiencing intense and frequent feelings of depression and anxiety are at higher risk of experiencing participation restriction, so asking about feelings of anxiety and depression is a reasonable way to address psychosocial functioning. Other mental health disorders, such as schizophrenia and schizoaffective disorder, were not included in the question set given their low prevalence and the challenges of crafting one or two questions that would capture the feelings associated with these conditions. Including direct questions on having received a mental health condition diagnosis was not considered due to the stigma associated with these conditions in some countries and limited access to mental health services for many populations, both of which would bias the reporting of diagnosed conditions. 

The WG’s Mental Health and Psychosocial Disability Work Group is returning to the development of questions that will capture psychosocial functioning that are more consistent with the functional approach for identifying the population with disabilities. The work group is developing questions that address the functional consequences of mental health and emotional problems, such as forming and maintaining relationships and friendships, interacting with people, and controlling behaviors and emotions. It should be noted, however, that the difficulties identified by these questions could result from non-psychosocial factors, but their impact would be in the psychosocial domain. As in the WG-SS, where communication difficulties could be due to difficulties hearing, cognition or could have psychosocial origins, difficulty in interacting with people can also be related to vision, hearing or communication difficulties. Testing of these questions has begun, and more testing is planned.