Overview | Clinical Scenarios | Additional Tips | References

By Peter Ash, MD

OVERVIEW

General Principles

• Mental disability has different meanings in different contexts: in medical contexts the issue most often pertains to employment. Since these differences in meaning can be subtle, physicians should limit themselves to discussing mental impairments, and leave it to the relevant agency, court, or employer to determine whether those impairments constitute a disability under the applicable rule. The most common contexts are shown in Table 1.

Table 1.

Disability type	Test/ Issue for clinician
Social Security Disability	Can perform any full-time work in the national economy
Workers’ compensation	Injury occurred at work and can the employee return to previous job
Private disability insurance	Disability is defined in insurance contract and by level of impairment
Service-connected disability for veterans	Specific VA test and procedures. Evaluations typically conducted by agencies that have contracted with the VA system
Fitness for duty	Ability to return to previous employment, with or without restrictions
Americans with Disabilities Act (ADA)	If claimant has a disability, identify what reasonable accommodations the employer could provide

Social Security, the ADA, and veterans’ benefits are federal, so the rules are the same throughout the U.S. Workers’ compensations laws vary from state to state, and private insurance varies according to how the particular insurance contract is written.

• Providing information to outside parties requires a release of information from the patient. Additionally, it may place the clinician in the role of a forensic evaluator rather than treating doctor, thus raising a problem of dual agency, and some clinics or practices have policies that may limit this “Wearing Two Hats”.¹
• Importantly, a patient who is functionally impaired may not be legally disabled. If the clinician does not think the patient is seriously impaired, documenting this may lead to a disruption of the therapeutic alliance. Guidelines for forensic evaluations specifically to assess mental disability are available.²

CLINICAL SCENARIOS

In the following scenarios, it will be assumed that the treating clinician has determined it is appropriate to provide the requested information.

Scenario #1: Social Security – A 19 year-old male patient who suffers from schizophrenia and is chronically psychotic applies for Supplemental Security Income (SSI) and asks his treating doctor to complete forms supporting his application.

• The Social Security Administration generally solicits information about impairments from treating doctors, and asks that the information be provided on a Mental Residual Capacity Form. This asks the doctor to rate impairments, from none to marked, in a variety of categories such as understanding and memory, social interaction, and adaptation. The Social Security disability test is fairly strict: essentially that there is no work in the national economy that the claimant would be able to do full-time.
• There are two types of Social Security Disability Benefits: Supplemental Security Income (SSI) are awarded to those who meet the disability test but have not paid sufficient Social Security tax (typically those who have worked less than several years), and Social Security Disability Income (SSDI) which has the same test for disability, but higher benefits, and is awarded to those who have paid a threshold amount in Social Security employment taxes. Under certain circumstances, there are also benefits for disabled family members (widows, widowers, and children) of a deceased worker.
• Assuming the patient signs an appropriate release, the clinician can complete the form. It is generally useful to discuss with the patient what the clinician is going to write. If the clinician does not think the patient has marked or severe impairments, the patient may not want the form completed.

Scenario #2: Workers’ compensation  – A 46 year-old woman is in treatment for PTSD she developed following a fire at work in which several of her co-workers burned to death. Her treatment is being covered by workers’ compensation, and the employer wants a letter about whether she can return to work.

• Workers’ compensation laws were developed to provide treatment and benefits for those injured on the job without having to determine who was at fault for the injury. Most non-governmental employers of more than several workers are required to pay into their state’s workers’ compensation fund. While the test varies from state to state, typically the test includes that the worker was injured while working, that as a result the worker is unable to perform his previous job, and the employer has no other job that the employee is able to do. Most states do not cover mental illness unless the worker suffered a physical injury in an event that gave rise to the mental condition. Thus, in the example of a woman who developed PTSD from seeing her coworkers burned in a fire at work, if she herself were burned, even minimally, she would be entitled to coverage (it’s not necessary that her burns caused the PTSD), but in most states if she only observed others being physically injured but she herself was not, she would not be entitled to coverage.
• The test for workers’ compensation is focused on the type of work the employee did. Since physicians are not generally experts on what psychiatric impairments preclude what type of work, the physician typically documents the resulting psychiatric impairments, and other reviewers or vocational experts determine what job a person with those impairments could perform.

Scenario #3: Private disability insurance – A 54 year-old dentist had an episode of mania, was hospitalized for bipolar disorder, and was effectively treated with lithium. He developed a tremor as a side effect which he says precludes his working as a dentist. He wants a letter written to his private insurer saying he cannot return to work so he can continue to receive disability insurance payments.

• Private disability insurance contracts specify what the test for disability is; tests vary widely from policy to policy. Some are fairly strict, like the Social Security test, while others may involve whether the insured can return to their previous occupation and whether partial disability is covered.
• Insurance disability forms are often sent to treating physicians. The physician should obtain a release from the patient before responding. Because physicians are not experts in deciphering contracts, they should generally not opine about disability, but instead address the impairments of the patient. Typically the physician will provide sufficient data about the patient’s condition, including diagnosis and effect of treatment, to demonstrate how the impairments flow from the patient’s condition.

Scenario #4: Americans With Disability Act situations – A 37 year-old patient with social anxiety disorder wants her therapist to write a letter to her employer saying she needs a more private cubicle because, she says, working out in a large room with no walls between desks causes her such anxiety she cannot work effectively.

• The Americans with Disability Act (3) is a complex statute which has numerous facets, including prohibiting discrimination on the grounds of a disability. One requirement is that an employer is required to make “reasonable accommodations” for employees who suffer from a disability. Patients, like the one in this scenario who wants a more private workspace, may request a letter supporting the need for the accommodation. There is no specific form for such reports; the clinician typically writes a letter giving the clinical justification for the accommodation. Whether the accommodation is reasonable, given the nature of the job and the work site, is a determination initially made by the employer. That decision can be appealed by the patient.

Scenario #5: COVID-19 considerations – A 42 year-old female office worker had COVID-19 6 months ago, but has “Long COVID” with residual symptoms of impaired concentration, depression, and tiredness. She would like documentation of her mental impairments to support asking for job accommodations that would reduce the time pressure for completion of certain work tasks.

• “Long COVID” and heightened susceptibility to COVID, such as with immune-compromised workers who wish to work from home, are recognized as disabilities under the ADA, and so are entitled to ask for reasonable accommodations for their conditions.

ADDITIONAL TIPS

1. Disability issues may be contested in litigation, so it is important that the clinician review carefully the wording of the communication sent to the agency.
2. The clinician should also write with the expectation that the patient will read the letter, and a copy is often given to the patient or their attorney directly.
3. In addition to placing a copy of the communication to the outside agency or employer in the chart, the clinician should document in the chart that such a letter was sent.

REFERENCES

1. Strasburger LH, Gutheil TG, Brodsky A. On wearing two hats: role conflict in serving as both psychotherapist and expert witness. Am J Psychiatry. 1997 Apr;154(4):448-56.
2. Anfang SA, Gold LH, Meyer DJ. AAPL Practice Resource for the Forensic Evaluation of Psychiatric Disability. J Am Acad Psychiatry Law. 2018 Mar;46(1):102. Available at http:// http://jaapl.org/content/46/1_Supplement/S2
3. Americans with Disabilities Act, 42 U.S.C. §12101 (1990).