
- Vol 31 No 11
- Volume 31
- Issue 11
Mental Health Disability: A Resident’s Perspective of Problems and Solutions
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
Long-term costs of supporting Social Security have been shown to exceed the program’s revenue, resulting in a
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,
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
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,
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.
Disclosures:
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.
References:
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.
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. Jiménez X, Thorkelson G. Medical countertransference and the trainee: identifying a training gap. J Psychiatr Pract. 2012;18:109-117.
Articles in this issue
almost 11 years ago
Introduction: A Biopsychosocial Model of Carealmost 11 years ago
Ethical Issues: The Patient’s Capacity to Make Medical Decisionsalmost 11 years ago
Psychiatric Diagnosis and Treatment of Somatizing Neuropsychiatric Disordersalmost 11 years ago
Addressing Psychosomatic Illness in the Elderly: Integrated Carealmost 11 years ago
Issues in Psycho-Oncology: What Clinicians Need to Knowalmost 11 years ago
Transplant Psychiatry: Issues for Cliniciansalmost 11 years ago
Managing Late-Life Bipolar Disorder: Current Issues and Clinical Tipsalmost 11 years ago
Eating Disorders in Late Life: Implications for Cliniciansalmost 11 years ago
The Rise of Consciousness and the Development of Emotional LifeNewsletter
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