Psychiatric Disability: A Step-by-Step Guide to Assessment and Determination Tips on a Complex and Challenging Role for Consulting Psychiatrists

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.

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Your mama or your MAOA? Monoamine oxidase-A, co-implicated in mood and behavior disorders.

It is generally accepted that bad parenting leads to psychopathology -- unless the child is "resilient." But which kids are resilient? Those who overcome bad environments.

Is this a circular argument or nonsense? Some remarkable findings concerning this question have risen from an emerging interdisciplinary approach known as psychiatric epidemiology. Psychiatric epidemiology combines genetics, epidemiology and neuroscience to investigate how genes and environment affect vulnerability to psychiatric and mood disorders. Last year two of this discipline's leaders, Avshalom Caspi and Terrie Moffitt, reviewed its main findings in Nature Reviews Neuroscience. Their paper, "Gene-Environment Interactions in Psychiatry: Joining Forces with Neuroscience" [see abstract or pdf download of the paper] suggests that the gene may have less of a stranglehold on one's destiny than is often assumed. The paper also raises questions about why so-called maladaptive responses to environment, such as depression or passivity, have survived millennia of selective pressure.

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