The Increase in Psychiatric Disability in the USA

As an academic psychiatrist, I supervise residents in an outpatient psychiatric clinic whose patients are predominantly on Medicaid (called Tenncare in Tennessee).  Many of these patients were able to qualify for Tenncare because they are on Social Security disability (SSI), and the majority of these had been placed on disability for psychiatric reasons based on the recommendations of previous psychiatrists.

In this clinic we see patient after patient with obvious personality problems who seems to be able to take care of almost any task that "normal" people can all do except hold a job. They have been labeled by psychiatrists with phony or inappropriate misdiagnoses such as bipolar II, adult ADHD, and even Asperger's syndrome. They had been put on disability with their psychiatrist's blessing.

Their families gladly go along with the psychiatrist's assessment because they do not want to take responsibility for having helped to create the patient's psychological problems in the first place.

My sources tell me that the same thing is happening all over the country.

Patients who really do have bipolar disorder should almost never be on disability anyway because, in the vast majority of cases, it is a highly treatable illness, and people are completely normal if they take their medications, are not in a manic or depressive episode, and do not have any co-occuring psychological issues.

ABC News recently reported that applications for SSI have gone up considerably since the start of the recession.  The obvious implication is that people who are just plain unemployed are attempting to support themselves by claiming to be disabled.

Then there is the outright disability fraud known in some circles as crazy checks, as I described in my post of October 10, 2010, in which parents coach their kids to act out of control for a psychiatric disability evaluation.  As I have said, apparently fooling psychiatrists into making serious diagnoses on kids who are acting out – or just plain acting – is as easy as pie.

The states have gone along with this charade because it transfers a lot of their welfare costs to the Feds. What a difference this is from the 1980's, when the Reagan administration was kicking people off of the disability roles who really were disabled (e.g., patients with chronic schizophrenia). The courts finally had to step in to stop this. I used to do SSI evaluations in California back then and saw this first hand. My evaluations were often completely ignored.

We've gone from one extreme to the other.

I do not bring up this issue merely to infuriate taxpayers.  The whole disability process has another, far more destructive and insidious effect.  It can be extremely damaging to the mental health of the involved individuals.

Consider this: if your entire family, along with professionals who are supposed to be experts, believe that you are impaired, who are you to argue? People in this situation are not only being paid to think of themselves of disabled, but really do start to believe that they are damaged goods. 

Their self-esteem, already in trouble because of their having been scapegoated by their families, goes down the toilet.  They truly and deeply believe that they are both brain damaged and big losers to boot.  They are validated in this belief by the most powerful people in their environment.

Read this description of a patient from a fellow psychiatric blogger (Thought Broadcast): 

"When I first saw her, she appeared overweight but otherwise in no distress.  An interview revealed no obvious thought disorder, no evidence of hallucinations or delusions, nor did she complain of significant mood symptoms.  During the interview, she told me, 'I just got my SSDI so I’m retired now.'  I asked her to elaborate.  'I’m retired now,' she said.  'I get my check every month, I just have to keep seeing a doctor.'

When I asked why she’s on disability, she replied, 'I don’t know, whatever they wrote, bipolar, mood swings, panic attacks, stuff like that.'  She had been off medications for over two months (with no apparent symptoms); she said she really 'didn’t notice' any effect of the drugs, except the Valium 20 mg per day, which 'helped me settle down and relax.'

Keisha is a generally healthy 27 year-old.  She graduated high school (something rare in this community, actually) and took some nursing-assistant classes at a local vocational school.  She dropped out, however, because 'I got stressed out.'” 

Retired? 

Getting someone like this off of disability is nearly impossible. Even if they start to believe in themselves and begin to succeed, they would then lose their Medicaid and would not be able to pay for the treatment that might help them to maintain their employment and make further gains. They are literally trapped by the disability system into feeling themselves to be nothings and nobodies.

And a lot of psychiatrists are doing this to their patients. 

Please keep in mind, however, that there also are a plenty of psychiatrists who are as appalled by this trend as I am.  

R. Scott Benson, M.D., the speaker-elect of the General Assembly of the American Psychiatric Association (APA), confirmed in yet another way this whole picture in a personal communication with me.  He said, “The APA has a Business collaborative. There are articles by HR [Human Resources] managers lamenting the fact that psychiatrists in general do not seem to believe that people should work.

I have been doing reviews for Disability Insurance companies and people with what appear to be mild symptoms are kept off work with no change in their treatment plan. Then they are depressed that they do not have money, lose their house and car, etc. Yes the SSI disability racket is a strange beast. The money never seems to be spent on any kind of treatment."

MentalHealthWorks, an APA publication, actually had to spell out the following recommendations to psychiatrists concerning disability:

Principle #1. Inability to work is a psychiatric crisis.

Principle #2. Return to work is a fundamental goal of treatment.

Principle #3. Occupational disability is a complex biopsychosocial phenomenon. 

Principle #4. Symptoms are not impairments; impairments are not disability. A decline in function is often temporary and does not need to meet the threshold of total incapacity. Disability often includes interpersonal issues at work, physical complaints, other medical conditions, and psychological issues.

Like, Duh! You mean these things are not obvious to someone smart enough to get into and get through medical school? Really?!?

And check out this personal communication from Randy Bock, a family practitioner who specializes in addiction treatment:

“I had a woman today who wants to go on naltrexone [a treatment for opioid addiction]. She had been doing heroin and just finished a detox.

Recently she was at [a halfway house].  They 'made' her apply for Social Security/disability (‘which they do for everyone’); so as to get their own bills paid regularly … including multiple drug tests/week. Additionally once she got her 'disability check' they were taking 'half her income' - some $400…

The halfway house sent her to a psychiatrist who diagnosed her promptly with 'PTSD, bipolar, anxiety, depression,' and gave her a disability finding.

She says they wanted her to ‘leave her past’ (which in this case meant also her job) and ‘only look forward’, and that involved her not working (at all) for the subsequent 14 months in the halfway house.”

Author Robert Whitaker (Anatomy of an Epidemic) has made a lot of noise about the large increase in psychiatric disability recently, but completely misidentifies the cause.  His thesis is that the appropriate use of psychiatric medication has been making people worse, and he seems to think that if a patient gets worse, it must be due to the medications.  This is circular reasoning.

A psychiatrist who does a complete evaluation of ALL possible biological, psychological, and social factors affecting a given patient is in a much better position to make the call as to exactly which factors have led to a patient’s deterioration (and yes, Alto, not infrequently it is from debilitating side effects from medication that are ignored by the doctor).

Then again, as another fellow blogger Moviedoc cracked, that is a moot point because problem psychiatrists are not taking much of a history nowadays anyway.