SSDI for depression and anxiety?

[erg923]

---

Members do not see this ad.

A personality disorder entails impairment in work or social function, not necessarily impairment in haranguing your doctor into signing a paper, or impairment in calling a number for a lawyer on a bus ad.

While I’ve mostly seen cases of cluster B getting SSD, I’d be curious what would happen for someone requesting it for dependent PD. Dr. E?

Unless one is in an acute affective, psychotic, or suicidal crisis that may be attributable to BPD, BPD does not make you unable to work/unemployable. It makes you likely to be a poor coworker and likely to be terminated secondary to this, I would think. Again folks, this is NOT how psychiatric disability is viewed by payers. And I would dare say it not how most of society defines it either.

 

[Doctor Eliza]

Fair point, but it’s tricky to be responsible both for treatment and these semi-forensic assessments, especially when the patient ends up seeing all of your notes in detail. While a healthier adult may be able to tolerate and even benefit from a frank discussion, these are the more fragile patients by definition, and an evaluation that goes the wrong way can essentially end a treatment relationship.

Ultimately, we need to change our entitlement system so that it encourages a transition back to wellness. I’d be much more eager to send a patient for SSD if it mandated x hours of volunteer or part time work, or bookmarked a certain amount of money for rehabilitative programs. Instead, it actively disincentivizes paid work, and hands checks to people who are claiming to be at least partially cognitively disabled.

To clarify, typically we (social security) wouldn't allow the patient to see the records that you submit (although I cannot speak to what happens when a lawyer is involved). Also, although you are sent a questionnaire, records with mental status exams are much more compelling. We do not expect you to tell us if you think the person is disabled (because, as you have said, there is a conflict being a treating source and giving a semi-forensic assessment). Let your documentation speak for itself.

Regarding your question about dependent PD, it is completely dependent on how well the person functions in a work environment. It is a functionally-driven program. They wouldn't be disqualified for having the "wrong" mental illness.

 

[Salpingo]

To clarify, typically we (social security) wouldn't allow the patient to see the records that you submit (although I cannot speak to what happens when a lawyer is involved). Also, although you are sent a questionnaire, records with mental status exams are much more compelling. We do not expect you to tell us if you think the person is disabled (because, as you have said, there is a conflict being a treating source and giving a semi-forensic assessment). Let your documentation speak for itself.

Regarding your question about dependent PD, it is completely dependent on how well the person functions in a work environment. It is a functionally-driven program. They wouldn't be disqualified for having the "wrong" mental illness.

I hear what you're saying -- just be objective and honest in documentation, do my job, and leave the rest to the experts. The only problem with that is that we don't deal with objective measures. I've had cases where a patient who had been doing relatively well will suddenly have an abrupt worsening in mood and anxiety symptoms, and then it will come out how much of it is tied to work, and how much better they would be without it. They have already hired a lawyer, whose fee is contingent on whether or not they get SSD, and I'm guessing coach their patient's what to say. As you may have guessed from this thread, very few psychiatrists feel that long-term disability is beneficial for their patients, and I now have to make a choice about what I document, how I fill out questionnaires, what I release, etc. If it was clear from the outset that my opinion wouldn't be factored in, maybe the patient would be able to have a frank conversation about going on disability.

The dependent PD question was a little tongue in cheek, the idea being that if you tell someone with dependent PD they could be paid without needing to go to work, they would jump on it (and never want to get out). Same thing with avoidant PD. So its hard to imagine how you can get a truly objective assessment from them.

 

[Salpingo]

Unless one is in an acute affective, psychotic, or suicidal crisis that may be attributable to BPD, BPD does not make you unable to work/unemployable. It makes you likely to be a poor coworker and likely to be terminated secondary to this, I would think. Again folks, this is NOT how psychiatric disability is viewed by payers. And I would dare say it not how most of society defines it either.

I was trying to rebut the point (at least what I thought was the point) that being able to get through the disability hearing process demonstrated some level of functioning, and that level of functioning would disqualify them from having a PD diagnosis.

 

[PsyDr]

So I find this discussion interesting because I work part-time evaluating claims for social security disability. (Mostly psychologists evaluate mental health claims, but there are a few psychiatrists too.) The biggest take home message I have for clinicians is this: Don't want your patient to get disability? Send your notes! Want your patient to get disability? Send your notes! Your notes provide a paper trail which allows us to see what a patient typically looks like. When you don't send records, patients are often sent to a one-time interview. As you can imagine, it is much harder to know if the person is just playing it up for the interview or if they have chronically limiting conditions.

Just my 2 cents. 🙂

Dr. E

Huh, I thought the standard of care according to white papers was to use objective measures that include svts rather than using only an interview and records. I also was sure that abfp said that ssdi exams are forensic and not “semi-forensic”.

 

[Doctor Eliza]

Huh, I thought the standard of care according to white papers was to use objective measures that include svts rather than using only an interview and records. I also was sure that abfp said that ssdi exams are forensic and not “semi-forensic”.

No, no SVTs. Semi-forensic was perhaps a poor choice of words. I was quoting the other individual who was talking about treating sources and not independent examiners.

 

[PsyDr]

No, no SVTs. Semi-forensic was perhaps a poor choice of words. I was quoting the other individual who was talking about treating sources and not independent examiners.

Without svts you are practicing outside the standard of care.

 

[Doctor Eliza]

Without svts you are practicing outside the standard of care.

I’m not practicing. I’m reviewing records. I’m just telling you that the gov’t does not administer SVTs.

 

[smalltownpsych]

Without svts you are practicing outside the standard of care.

Is it really the standard of care if nobody does it? Also, if I am conducting a disability evaluation, why would I go above and beyond what social security requires when they are the client?

 

[PsyDr]

@smalltownpsych Why worry about the evidence base at all? Why worry about the truth? Why not do whatever a patient wants despite if it’s good for them or not?

Where would you draw the line?

 

[thoffen]

We can start by not facilitating patterns of avoidance. I know, I know — that would collapse the field over night.

Really I think this is what the answer is to just about all the active threads out there relating to patients. Sleep meds, BZDs, stimulants, etc. We are not really systemically equipped to guide patients toward recovery. Even if, individually, we excel at this, it's not hard for people to find someone else. So our hope of this change rests on the relationship a patient has to a provider as a person instead of the interventions that are offered.

 

[Shikima]

What do people think the best avenue for promoting this change is as psychiatrists? I have zero faith in the APA.

We all don't have any faith in the APA beyond their own self-serving needs.

 

[Attending1985]

Really I think this is what the answer is to just about all the active threads out there relating to patients. Sleep meds, BZDs, stimulants, etc. We are not really systemically equipped to guide patients toward recovery. Even if, individually, we excel at this, it's not hard for people to find someone else. So our hope of this change rests on the relationship a patient has to a provider as a person instead of the interventions that are offered.

Well said. This is where I struggle with split treatment. If you’re also providing psychotherapy it’s much easier to guide the patient towards recovery. I would honestly love practicing in the old days where everybody did both. I know I can start my own practice but it’s annoying. I like being a part of a hospital based system. We’re the only area of medicine where you have to practice independently to provide decent care.

 

[SpinDktr]

Perhaps we are not systematically geared toward guiding patients toward recovery, but it is about the effort.

I have had multiple people who have requested SSDI. Some I have guided toward it, some not. I have actually found some of my more rewarding patients to be the ones who have used the SSDI system as it was intended; a social safety net. When someone uses it to maintain a sense of stability, get out of a bad relationship and secure their own sense of well being, that is definitely rewarding. When they are then able to move on from there, even work a part time job and build a sense of accomplishment and even self respect...well that is what keeps me going, quite honestly.

All this is done in a big medical group with 15-20 minute med checks. It isn't perfect or even what I would prefer to be doing, but nothing really is. If I had my way, I would be doing hypnotherapy, but there is a good deal of "hypnotherapy techniques" I find implementing in the brief med checks I am doing.

 

[hamstergang]

We’re the only area of medicine where you have to practice independently to provide decent care.

I doubt other fields agree with this, and those of us working not independently might be a little insulted.

I am providing decent care to my patients without doing formal psychotherapy sessions. It might not be the best they could get, but it's definitely decent.

 

[smalltownpsych]

@smalltownpsych Why worry about the evidence base at all? Why worry about the truth? Why not do whatever a patient wants despite if it’s good for them or not?

Where would you draw the line?

I don't think disability evaluations without SVT/PVTs are a good thing. I was just commenting on there is a difference between what we "should" do and what we are paid to do. SSDI pays for these evals (not much mind you) and dictates what they want done. Standard of care as I understand it relates to what other clinicians do. So if they are going beyond what SSDI requires, I would like to kbnow that, but all of the folks around here just administer the and report the measures requested and call it good.

 

[thoffen]

Perhaps we are not systematically geared toward guiding patients toward recovery, but it is about the effort.

I have had multiple people who have requested SSDI. Some I have guided toward it, some not. I have actually found some of my more rewarding patients to be the ones who have used the SSDI system as it was intended; a social safety net. When someone uses it to maintain a sense of stability, get out of a bad relationship and secure their own sense of well being, that is definitely rewarding. When they are then able to move on from there, even work a part time job and build a sense of accomplishment and even self respect...well that is what keeps me going, quite honestly.

All this is done in a big medical group with 15-20 minute med checks. It isn't perfect or even what I would prefer to be doing, but nothing really is. If I had my way, I would be doing hypnotherapy, but there is a good deal of "hypnotherapy techniques" I find implementing in the brief med checks I am doing.

I agree but want to stress the importance of the treatment relationship as being essential to change actually occurring. Your example is great because it's not necessarily about type of practice or time.

And I've had a bit of your experience too with people healthily utilizing the system when they need it and bridging themselves to independence. It is the most rewarding outcome.

Personally I think anyone comes to mental health care (regardless of setting) with ambivalence. On the one hand, they want to get better and move past the patterns and relationships that are leaving something missing. On the other hand, they want you to collude with these patterns and relationships so that their burden of responsibility is lessened.

 

[Attending1985]

I doubt other fields agree with this, and those of us working not independently might be a little insulted.

I am providing decent care to my patients without doing formal psychotherapy sessions. It might not be the best they could get, but it's definitely decent.

Maybe a better word would be excellent.