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In the Year 2019: Psychiatry in Law and Public Policy On Skepticism and Tolerance in Psychiatry and Forensic Psychiatry Psychiatric Disability on the Rise |
The epidemiology and management of psychiatric disability have gained increased attention for a variety of reasons in the past 3 decades. There are issues of empowerment, advocacy, and reduction of stigma. There are also concerns about cost containment as well as reliability, validity, and efficacy of the determination process.
About 20% of adults who receive Social Security disability benefits have psychiatric disability. Psychiatric disability accounts for a significant proportion of private long-term disability claims and payments.1,2 Advances in technology that have had an impact on physical disabilities have not had a corresponding effect on psychiatric disability.
This article is based on the United States Social Security Administration (SSA) model of disability assessments for psychiatric impairment. Since its inception in 1935, there have been several amendments and rulings that have attempted to expand and refine the Disability Act. Despite these efforts, the reliability and validity of the disability determination process have been impaired by several factors:
• The inherent difficulty of objectifying psychiatric signs and symptoms
• The fluctuating nature of psychiatric disorders
• Problems with language and communication (central to the collection of data from patients), which may be compromised by the disease process
In addition, many individuals who apply for disability on the basis of physical illness also have comorbid mental disorders. Hence, psychiatrists may be called on as treating physicians, consultative examiners, and expert witnesses to provide disability reports.
The SSA defines disability as “the inability to engage in any substantial gainful activity by reason of medically determinable physical or mental impairments which can be expected to result in death or which has lasted, or can be expected to last, for a continuous period of not less than 12 months.”3 SSA disability is regarded as permanent, although the disability is subject to periodic review.
Keep in mind that diagnosis of a mental illness is not necessarily equivalent to disability or functional impairment. An individual who has major depressive disorder is not legally disabled if he or she can engage in “substantive gainful activity.” Substantive gainful activity refers to a level of activity that SSA uses to establish disability. As a rule of thumb, a disabled individual should not be able to participate actively in the national economy. For example, if an attorney has a mental disorder (and therefore cannot effectively practice law) but he can work as a waiter, he is then not legally disabled according to the SSA. In assessing disability, psychiatrists should be aware of opportunities for vocational rehabilitation and work incentives as well as treatment opportunities.
The application process
The application for Social Security disability benefits is initiated by a claimant who completes a form at the local SSA field office, or by mail or telephone.3 The information obtained at the field office includes background and demographics, such as age, marital status, employment, Social Security coverage, and contact information. Information on the nature of the impairment(s) and other pertinent information relative to the potential disability are obtained. If the claimant’s information passes the initial disability requirements, his file is transmitted to a Disability Determination Service (DDS) team that consists of a disability analyst and a psychiatrist or psychologist. The analyst gets as much information as possible from treating physicians, hospitals, clinics, and other relevant sources.
Once the analyst has gathered relevant information to complete the medical evidence, the file is passed on to the DDS psychiatrist or psychologist who reviews the documentation and adjudges whether the patient’s condition:
• Meets or equals the (listed) criteria of mental impairments
• Does not meet the listed criteria
• Falls between meeting and not meeting the criteria
For patients who fall within the third category, the psychiatrist or psychologist completes a Residual Functioning Capacity form. At this time, a consultation with a vocational analyst may be requested. The disability analyst then makes a determination as to the legal eligibility of the claimant and a decision is made to approve or deny the claim.
The appeal process
There are 4 steps in the appeal process. If the claim is denied, the claimant can apply for reconsideration. It is important for the claimant to ensure that all relevant information from doctors, hospitals, clinics, and other treatment sources are submitted to the DDS. For the reconsideration process, the case is assigned to a different DDS team. If this reconsideration fails, the claimant can appeal to the next level, which is a hearing before an administrative judge. At this appeal level, the claimant may be represented by an attorney; witnesses and new evidence may be presented, and the claimant may appear in person. The next level for appeal is the SSA appeals court in Baltimore; ultimately, the appeal may be made to a federal court.
The medical evidence
Generally, individual psychiatrists may contract with their local DDS to provide consultative examinations. There are some key issues in conducting a consultative examination and completing the report. The claimants can request to have the consultative examination carried out by their own treating psychiatrists.3 The psychiatrist should be familiar with the Psychiatric Review Technique form and the Residual Functioning Capacity form used by the DDS.4,5 All available records should be reviewed before the examination to ascertain the specific reasons for the consultative examination.
The psychiatrist should specify his role in conducting the examination to dispel the myth that approval for disability is given by the physician. The provision of adequate and comprehensive information that enables the DDS team to make a reasonable, prompt, and fair determination is a sine qua non and is dependent on the accuracy and completeness of patient records.
The SSA uses “listings” to approve or deny applications for disability. There are 9 categories under the mental disorder listings used in making such decisions. Each category refers to a disease process or disorder. Using the model of disease → impairment → disability, impairment refers to the signs and symptoms of the disorder that provides medical determination of the condition (criteria A). Disability refers to the severity of restrictions and limitations of functioning (criteria B) that are directly related to criteria A.
The 9 diagnostic categories for mental impairments are:
• Organic mental disorders
• Schizophrenic, paranoid, and other psychotic disorders
• Affective disorders
• Mental retardation
• Anxiety-related disorders
• Somatoform disorders
• Personality disorders
• Substance disorders
• Autistic and other pervasive developmental disorders
