Samuel O. Okpaku MD, PhD
Dr Okpaku is clinical professor of psychiatry at the Vanderbilt University School of Medicine and executive director of the Center for Health Culture and Society in Nashville, Tenn. The author reports no conflicts on interest concerning the subject matter of this article.
Acknowledgment—The author is grateful for the helpful assistance of Tamara Smith and staff, Betty Hood, Ann Benes, Dr Tommie Slayden, Jeffrey Eddie, and the staff at the Tennessee DDS.
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 rul-ings 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 (RFC) 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
Each listing is further qualified by criteria A and B. For organic mental disorders, schizophrenic, paranoia, and affective disorders, or other psychotic and anxiety-related disorders, an additional set of criteria (criteria C) may be used to meet the diagnostic and impairment-related restriction of functioning requirements. Disability is therefore met when criteria A and B are met, or when criteria C is met.
The report should be typewritten (not handwritten). DDS jurisdictions usually provide dictations by phone. Again, the report should provide a longitudinal and current assessment of the case. The pathogenesis of the disease is helpful in establishing the nature and duration of illness. General observations of the patient, his history, and any additional information required for that listing of diagnoses are other essential elements of the report. If there is a comorbidity, this should be stated. This is especially important for the claimant who has several minor disabilities which, when taken together, may affect his ability to work.
In addition, for consultative examinations, the number of appointments the patient has canceled and difficulties in keeping appointments may point to a diagnosis of an anxiety-related condition. Prolonged treatment by a primary care physician may be a clue to chronic treatment-resistant depression. The report must record the patient’s education or employment and rehabilitation history.
In preparing the report, the psychiatrist should be aware of how, in which manner, and to what extent the mental impairment limits the patient’s functionality.6
Items from criteria A are delusions/hallucinations, catatonic behavior, and incoherence. For criteria B, items are selected from 4 domains:
• Activities of daily living (eg, grocery shopping, doing laundry)
• Social functioning (eg, ability to interact socially with other people at home or in a public setting)
• Concentration, persistence, and pace (eg, inability to complete a task in the given time)
• Deterioration or decompensation in work or worklike setting (eg, panic attacks, psychotic decompensations, and crying)
For these domains, the documentation must be sufficiently descriptive and explicit to permit an assessment of the appropriateness, independence, sustainability, quality, and effectiveness of these functions over long periods. The examples of deficits in those domains must be tied directly to the mental disorder, rather than to circumstantial factors. For example, a statement that “the patient does not do any grocery shopping, laundry, or cooking” or a statement that the patient cannot complete a task will be inadequate without specifically saying that these examples are caused by the clinical manifestations of the mental disorder and not by circumstantial factors.
Tony is 32 years old. He has been ill since age 22, when he was a second-year law student. He came home and informed his parents that poisonous gases were being pumped into his room. He dropped out of school and made attempts to return to school but failed. He has remained paranoid; he keeps to himself and has been hospitalized 5 times. He was hospitalized 6 months ago when he became belligerent at work. He believed his supervisors were out to get him. He has been on a combination of several antipsychotics to help reduce his hallucinations and delusions. His longest period of employment in 10 years was 3 months. He has never earned more than $300 per month.
By meeting 1 item from criteria A and 2 items from criteria B, Tony meets (at least superficially) the requirement for disability under the listing of schizophrenia. Alternatively, criteria C may be used. The psychiatric report to DDS should include the date, time, and place of the assessment. It should conclude with a 5-axis diagnosis as well as a statement of daily activities. The report should not make any recommendation as to whether the application should be approved or denied. This is a function for DDS. The report should be signed and dated.
DDS evaluation forms
The use of and familiarity with the Psychiatric Review Technique form and the Residual Functioning Capacity form can greatly enhance the quality of the medical evidence. The concepts and terms in these forms are those generally used by DDS and administrative judges. Attorneys who represent mentally ill claimants frequently attempt to bolster their cases by having the treating psychiatrist complete these forms. The emphasis in completing these forms is to continuously link the signs, symptoms, and diagnosis to the restrictions and limitations of functioning.
The Psychiatric Review Technique form is completed by a DDS psychologist or psychiatrist for all claims that involve mental illness. That form should include a summary of what mental impairments are present and the degree of functional loss in criteria B and C. In activities of daily living and social functioning the functional loss ratings are none, slight, moderate, marked, extreme restrictions, and insufficient evidence. In the domains of deficiencies and concentration, persistence, or pace, the ratings are never, seldom, often, frequent, and constant. For episodes of deterioration or decompensation in work or worklike settings, the ratings range from never, or once or twice, to repeated (3 or more times), and continual. The emphasis is on how specific symptoms and signs from the Psychiatric Review Technique Form impair work-related activities in the Residual Functioning Capacity assessment.
When the medical evidence shows that the level of severity of impairment falls between “meets or equals” the listed mental criteria or “does not significantly affect work-related capacities” DDS psychiatrists or psychologists usually complete the residual capacity and assessment form. This procedure attempts to gauge what the claimant may do despite his limitations. It assesses the claimant’s impairment, related functioning limitations, the degree, severity, and frequency of the limitations, as well as the claimant’s ability to sustain work-related activities in the face of restricted functioning during a normal work day or week. The form contains examples of mental activities that are grouped under 4 headings:
• Understanding, comprehension, and memory (eg, ability to remember locations and worklike procedures)
• Sustaining concentration and persistence, ability to perform activities within a schedule (eg, attendance and punctuality)
• Social interaction (eg, ability to sustain socially appropriate behavior and to maintain a reasonable standard of neatness and cleanliness)
• Adaptation (eg, ability to respond adequately and appropriately to the work environment)
The RFC items are rated as not significantly limited, moderately limited, markedly limited, no evidence of limitation, or not rateable based on available evidence.
Some patients such as infants, children, and adolescents have special needs. In this setting, only psychiatrists who have clinical experience working with children and adolescents should agree to do consultative examinations for children under the age of 18. The listings for children are similar to those for adults, but they take into consideration age-appropriate and developmental factors, the unique presentation of certain diagnostic categories in this age group, the impact of schooling, and the need for corroborative evidence.
School teachers, social workers, and foster care parents may provide information that is essential for making appropriate decisions. Appropriate psychological tests may contribute to a more informative report. In fact, for children, the use of psychological tests may be more critical than for adults.
Another class of claimants are those with multiple minor impairments. Each condition with its concomitant restrictions and functions should be well described. Also, the needs of veterans have taken center stage: practitioners should be familiar with the subtleties of posttraumatic stress disorder.
1. Leo RJ. Social Security disability and the mentally ill: changes in the adjudicatory process and treatment source information requirements. Psychiatr Ann. 2002;32:284-292.
2. MacDonald-Wilson K, Rogers ES, Anthony WA. Unique issues in assessing work function among individuals with psychiatric disabilities. J Occup Rehabil. 2001;11:217-232.
3. Social Security Administration. Disability Evaluation Under Social Security, January 2005. http://www.socialsecurity.gov. Accessed November 25, 2008.
4. Psychiatric Review Technique form. http://www.fedforms.gov/bgfPortal/docDetails.do?dId=13996. Accessed December 8, 2008.
5. The Residual Functioning Capacity form. http://ssaconnect.com/tfiles/SSA-4734-F4.sup.pdf. Accessed December 8, 2008.
6. Okpaku SO. The psychiatrist and the Social Security Disability and Supplemental Security Income programs. Hosp Community Psychiatry. 1988;39:879-881.
Disability determination for adults with mental disorders: Social Security Administration vs independent judgments. Am J Public Health. 1994;84:1791-1795.
Okpaku SO, Anderson KH, Sibulkin AE, et al. The effectiveness of a multidisciplinary case management intervention on the employment of SSDI applicants and beneficiaries. Psychiatr Rehab J. 1997;20(3).