If you have noticed a rise in the number of patients seeking mental health disability benefits, it is not your imagination. Mental health is the fastest growing sector of the federal disability recipient pool and continues to grow steadily (Social Security Advisory Board [SSAB], 2001). Mental impairment accounted for 22% of state agency disability awards in 1999, double the percentage it was in 1980 (SSAB, 2001). Unemployment, other financial stressors and the success of public outreach efforts by the Social Security Administration (SSA) are all possible reasons for this increase (Leo, 2002).
"My impression is that over the last five years, there has been a rise of about 30%" in the number of patients seeking federal and/or employer-sponsored disability, said Marc Graff, M.D., a psychiatrist with Kaiser Permanente in Reseda, Calif. He told Psychiatric Times, "A greater percentage of my time and effort has been spent on that, more than before."
Graff believes the increase may be due to several factors: the destigmatization of mental illness and a societal trend toward bureaucratization; patients are less intimidated by paperwork than in the past and are willing to aggressively advocate for themselves; and a shift among Americans toward greater emotional investment in their jobs and careers. With this investment in career as a defining emotional focus, disruptions and conflicts in the workplace are more commonly experienced as consuming and even disabling. "Work is the major issue in people's lives," said Graff. "Workplace issues and problems have increasingly become the reason people come in."
While the number of patients seeking psychiatric disability has risen, Graff said patients seeking disability present with the same disorders as always--major depression and bipolar disorder.
Despite the growing prevalence of disability petitions, many doctors are ill-equipped to properly fill out disability forms, much less to deal with the dynamic issues that can arise. The need for expertise is especially keen in university hospital clinics and community mental health centers. The low socioeconomic status of patients in these settings, coupled with the severity of their illness, substantially boosts the likelihood that they will be applying for disability benefits (Mischoulon, 1999).
"We don't like conflicts with our patients, and we want to be helpful," said Kelly Clark, M.D., a psychiatrist with the University of Massachusetts Medical School. She told PT, "If we're not clear about the difference between wants, benefits and needs, and how much power and control we do and do not have over the disability determination, we can cause harm to the patient's life, as well as irreparable harm to the therapeutic alliance."
Understanding the Process
According to Clark, one of the most common and problematic mistakes her colleagues make is failing to understand the limits of their influence. "We don't determine disability, just as we don't determine competency," said Clark, who is also a reviewer for Peer Review Analysis, an agency that conducts specialty-matched independent peer reviews. "It's a legal definition, not a clinical one."
Leo RJ (2002), Social Security disability and psychiatric illness. Psychiatric Annals 32(5):279-280.
Mischoulon D (1999), An approach to the patient seeking psychiatric disability benefits. Academic Psychiatry 23(3):128-136.
Mischoulon D (2002), Potential pitfalls to the therapeutic relationship arising from disability claims. Psychiatric Annals 32(5):299-302.
SSAB (2001), Charting the Future of Social Security's Disability Programs: The Need for Fundamental Change. Available at: <www.ssab.gov>. Accessed Oct. 21, 2002.
SSA (2002), Disability Evaluation Under Social Security. Available at: <www.ssa.gov/disability/professionals/bluebook/Contents.htm> Accessed Oct. 21.