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The case for training residents to conduct evaluations of impairments in patients with chronic mental health issues.
Disability awards on the basis of mental illness have shown a substantial rise in recent decades. The percentage of adults receiving Supplemental Security Income as a result of a psychiatric disorder rose from 24.1% in 1987 to 35.9% in 2005. Since the Disability Benefits Reform Act of 1984, the number of Social Security Disability Insurance awards for mental health claims rose from 2% of new awards to 30% of all beneficiaries. An additional program, Temporary Assistance for Needy Families, has grown in providing public assistance to those with mental illness.1
Long-term costs of supporting Social Security have been shown to exceed the program’s revenue, resulting in a projected “shortfall” of funds by 2037.2 Affordable Care Act reforms aim to increase the percentage of disability enrollees that return to work by increasing coverage options, thereby lowering health insurance–motivated disability enrollment.3 Along with reforms, the psychiatrist’s role of carefully evaluating the impairments that may cause a disability remains a matter of utmost importance.
Many individuals with chronic mental health issues seek treatment in community mental health centers and are evaluated and treated by psychiatric residents. When I began treating outpatients as a resident, I was uncertain about evaluating patients’ impairments-namely, providing medical evidence for the disability claim. This is not uncommon. In 2008, Christopher and colleagues4 conducted a survey of third- and fourth-year psychiatric residents in Massachusetts and Rhode Island training programs. A majority of these residents received no didactics on this topic and desired more education to address their limited understanding of what constitutes a psychiatric disability and their lack of confidence in their ability to perform assessments.
Uncertainty as to how to provide a complete and accurate assessment of these functional impairments is not a new issue. As far back as 1985, the Social Security Administration contracted the American Psychiatric Association (APA) to conduct a 2-year study of the standards and guidelines for the evaluation of mental impairments before release of these standards. After their review of claims, the APA identified problems such as lack of sufficient medical evidence for mental health disability provided by the psychiatrist or the variability in quality of the evidence when it was present.5
To best address these problems, efforts must be made to train residents to conduct evaluations of impairments. Such endeavors should focus on teaching residents how to provide a more thorough and discerning mental status exam with language that describes the patient’s hindrances or lack thereof by making more objective statements about the patient’s functioning (ability to answer questions, follow instructions, concentrate, relate to others).
Educational tools could include more objective measurements, such as the World Health Organization Disability Assessment Schedule, the International Classification of Functioning, the Mental Residual Functional Capacity Assessment Form, the Psychiatric Review Technique Form, and the Clinical Disability Severity Rating. Research evaluating the tools that are most effective for this purpose, and instruction on how to use them, must be incorporated into residency training to reach the goal of physicians’ assistance in more careful disability determinations.
Programs such as Social Security Income and Social Security Disability Insurance and their proper use by those with mental health conditions for income support is a charged debate. The survey by Christopher and colleagues4 points out that a significant minority of residents reported identifying patients as disabled when they believed otherwise. Historically, the main opposition to the creation of Social Security Disability was the AMA, because most physicians felt wary of becoming an essential partner in the patient’s relationship with the state and sought to preserve the sanctity of the doctor-patient relationship.6 Since the creation of Social Security Disability Insurance, physicians have struggled with their role as dual agents in this regard.7 The complex role of psychiatrist as dual agent, coupled with the challenges of inexperience, causes psychiatric residents to be more susceptible to writing in support of patients claiming disability, even if they think the patient may not be disabled.
Resident trainees are also particularly vulnerable to countertransference reactions because of their lack of experience in managing such reactions, and this may influence the quality and direction of the medical evidence they provide. Biases from one’s upbringing, personal experiences with mental health or drug use problems, and burnout in the context of a stressful work environment are some examples of forces for countertransference.8
In 2012, JimÃ©nez and Thorkelson9 asked psychiatric residents to assess practices and gave their opinions on countertransference management and training. Most (95%) of the participating residents believed didactics addressing countertransference would be “clinically beneficial,” and three-fifths of them reported that “very few” to none of their didactics explored this issue.
For persons with severe mental illness, government assistance is available and the goals of treatment may be smaller gains. If the psychiatrist believes the patient may improve, writing in support of a disability claim acts as a disincentive to the patient to pursue treatment in the hope of reaching the meaningful life goals of recovery. Thoughtful resident instruction on these issues would help trainees maintain the treatment frame when evaluating impairments that cause disability, ultimately serving the best interests of both the physician and his or her patients.
Dr Traxler is a Public Psychiatry Fellow at the Yale School of Medicine in New Haven, Conn. She reports no conflicts of interest concerning the subject matter of this article.
1. Danziger S, Frank RG, Meara E. Mental illness, work, and income support programs. Am J Psychiatry. 2009:166:398-404.
2. US Social Security Administration. The Future Financial Status of the Social Security Program. http://www.ssa.gov/policy/docs/ssb/v70n3/v70n3p111.html. Accessed October 9, 2014.
3. Kennedy J, Blodgett E. Health insurance-motivated disability enrollment and the ACA. N Engl J Med. 2012;367:e16.
4. Christopher PP, Boland RJ, Recupero PR, Phillips KA. Psychiatric residents’ experience conducting disability evaluations. Acad Psychiatry. 2010;34:211-215.
5. Wunderlich GS, Rice DP, Amado NL, eds. The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs. Washington, DC: National Academies Press (US); 2002.
6. Rimlinger GV. Welfare Policy and Industrialization in Europe, America, Russia. New York: John Wiley & Sons, Inc; 1971.
7. Christopher PP, Arikan R, Pinals DA, et al. Evaluating psychiatric disability: differences by forensic expertise. J Am Acad Psychiatry Law. 2011:39:183-188.
8. Ahmedani BK. Mental health stigma: society, individuals, and the profession. J Soc Work Values Ethics. 2011:8:41-416
9. JimÃ©nez X, Thorkelson G. Medical countertransference and the trainee: identifying a training gap. J Psychiatr Pract. 2012;18:109-117.