Thursday, September 8, 2011

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.'” 


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.


  1. Now please write a blog post on people who REALLY are impaired with mental disorders and do need assistance. Your blog above may and will be used by some to denagrate, and sterotype the mentally ill as phonies, lazy, and say "all they need to do is "pull themeselves up by their boot staps" or "all they need is discipline"...

  2. All these suspicions of faking are why I take great efforts to pass for normal, and do not tell people that I am on disability.

    There have been a lot of blog comments about people exaggerating mental illness for benefits, lately. The verbal witchhunt that people in the general public conduct against potential fakers makes it worse for disabled people, ruining self esteem as much as losing their job did, perhaps. I slink around in secret to hide that I am mentally ill, and slink around to hide that I am on disability. For those who know that I am disabled, but don't know me WELL, my reward for always controlling my behavior as best as possible (and staying home when I can't) is that they put me in the faker group. The only safe people to talk to are immediate family and my social worker.

    Don't folks get it that it is a helluva strain to listen to the rants about all the people "faking" mental illness, and on the other hand, hear people rant about how much they hate and fear the mentally ill? It would be difficult to find a more despised group that people with serious mental illness. You can't avoid the rants - people give you their opinions at garage sales, at the grocery store, anywhere you wait in line (my social worker says that my mistake is that I give people eye contact) and in the local newspaper opinion section. I am quiet and polite and do not tell them that they are calling me a fraud to my face. How would they know?

    Folks get a lot of milage when they rant about the mentally ill, no matter what position they take. They hardly ever take a position that helps matters for the population they are discussing.

  3. ... continued

    My social worker and therapist give me useless advice that I shouldn't worry about what other people think. Ok, you "normal" people, you try that when everybody calls you a parasite on the one hand, then bash you for being scary and so mentally ill on the other hand, every time some mental patient shoots people. My workers think I am paranoid for thinking everybody hates me and other people with serious mental problems, but it's true, isn't it? People think we are parasitic cheaters that should be feared and avoided. It isn't paranoia when it is true. Mental patients just get platitudes from their providers on these kinds of issues.

    Go ahead, people who rant about fakers may say they don't mean people like me, but how would they know? if they were my neighbor or the lady who sold me some cat carriers at a garage sale, they would bash me just the same, because they wouldn't KNOW what my problems are. One psychiatrist even told me he thought I was malingering, like 12 years ago, and I am still afraid my doctors will think that and the stress is unbearable.

    And as for bipolar not being disabling, hell, I don't know what the problem is. Yes, I got sexually abused for many years when I was little, but my depression cycles with the seasons, in almost perfect sync, allowing for variations due to drought or especially rainy weather. If it is a personality disorder, how come the depression cycles in almost perfect sync with the time of day (morning), the time of the month (euphemism there) and the time of the year? I have never heard of PTSD or a personality disorder cycling so elegantly. I did used to get classic mania and depression cycles when I was younger, so it is assumed that this cycling is still bipolar disorder, even though I no longer get mania for a few years now.

    I guess I'm getting very defensive and shouldn't read blogs anymore. I am very sorry I don't have a job, it harms me mentally that I don't have a job. I made many attempts to return to work, even part time, even volunteer, and I cannot do it. I used to be a professional and now I cannot even mop my floor or cook dinner for 8 months out of the year and I am so ashamed of myself. And isn't that the point of all the rants that mentally ill people get to hear? Shame on us for our troubles and for not trying harder. That isn't YOUR point, but I hear it ALL THE TIME, from random people in random places, people who don't know I have a serious mental illness.

    well, I guess that was a rant. I said I am feeling defensive, and I really should stay away from reading anything but hobby blogs.

  4. Anonymous, there is a plethora of information already on the web and elsewhere for what you're requesting; eg, advocacy groups such as NAMI, disability attorney ads, mainstream psychiatric publications, big pharma, and the Social Security Administration itself. By contrast, Dr. Allen's essay is a relatively lone voice in the wilderness, which is ironic considering how widespread the abuses of psychiatric disability are.

  5. After all the years of advocacy it has done, NAMI is very concerned that 80% of people living with a mental illness are unemployed. Unfortunately, mental illness is big business and actually using the kind of interventions that help individuals to recover has been pushed way down anybody's priority list. Recovery takes time and people assume, erroneously, that it needs be expensive -- better medicate'em and put'em on disability. Many people are on way too many drugs in the first place, and that, too, contributes to disability. Recovery from mental illness doesn't happen overnight. I have often thought that a person with mental illness needs reflective "time out" to make sense of why he or she has reacted to life's stresses in a particular way. Unless you have access to a monastery, time out in a lot of societies is considered an unaffordable luxury. I also feel that our society prematurely pushes people to get a job and be "normal" because it really doesn't "get" what mental illness is all about. "A mind on strike" is how John Nash thought of it. Others say it is a psycho/spiritual crisis. Either of these two ways of looking at it demands a period of "time out". Looking for work and continually failing to get it or failing at it, does not help in recovery. Neither does being labeled disabled. Most people who eventually recover have wrested recovery away from those who benefit from their being considered disabled in the first place.

  6. Kudos for an extremely well-written and timely article, David.

    As a psychiatrist myself, I try to avoid disabling people and rather concentrate my efforts on enabling people.

    While certainly there are some diseases such as classic autism, moderate to severe schizophrenia, moderate mental retardation etc. which require disability, (and I am delighted to participate in securing disability services for these patients) we must remember as psychiatrists that many of our disorders are episodic; and tend to get better with treatment.

    We need love work and play.

    James Woods M.D.

  7. Sigh!

    I don't disagree that people are on disability who shouldn't be. And of course, it is better to work if at all possible vs. being on disability. But I think it is the way that the points are being made that is really striking a negative chord in me.

    First of all Dr. Allen, as one who knows many people with AS, it is very possible to be able to engage in many normal activities but to be able to not hold a job.

    I am sure you are aware of this already but for the folks who aren't familiar with AS, one of the key components is the inability to read non verbal language due to a neurological impairment in the brain. That causes great problems socially.

    As you can well imagine, if the impairment is severe, it is going to be very hard to fit in with any employer. Even jobs that didn't stress social skills 10 years ago now are placing great emphasis on them.

    Also, the other side of the coin is that many people with AS issues have desperately tried to work only to lose several jobs because they just don't have the necessary social skills. But they can't get SSI as the assumption is that due to their work history, they are capable of holding a job.

    Unfortunately, obtaining appropriate job hunting assistance for people with conditions like AS and similar conditions is a joke. So when psychiatry talks about empowering their patients work wise (which is a noble statement), in my opinion, that really isn't helpful without your patient having access to the appropriate tools to carry that out.

    To the other points you made Dr. Allen:

    "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."

    An alternative obvious implication is that unemployed people who have a disability are being screened out when applying for new jobs due to a job history that might not be as stable. As a result, even though they want to work desperately, they feel they have no choice but to apply for disability.

    That makes sense since this economy is horrible even for people who don't have disabilities.

    I am also puzzled about your point about people with bipolar disorder should never apply for disability since you later acknowledge that the medication side effects can disable people.

    As one who feels that I would have become completely unable to work if I had continued to stay on a med cocktail of antidepressants, I can only imagine what being on BP and AP meds long term does to someone.

    After writing this post, I struggled greatly to come up with words that would describe why I was so bothered by this blog entry, Dr. Allen and I think I finally know why.

    In various blog entries, you always talk about issues as having a middle ground and that it isn't an either or situation. But I saw no attempt in this blog entry to look at all sides of the issue which I found surprising because of the sensitivity of many of the issues that were raised.

    Instead, I heard the same judgmental tones that the first two anonymous' heard and that greatly saddened me.

    Anyway, sorry for the long post but obviously, I had alot to say.



  8. AA,

    This post is primarily aimed at the psychiatrists who are doing a lot of damage, not at the patients.

    Of course real Asperger's syndrome causes permanent disability. I meant to be talking about cases in which people are given that diagnosis when they do not even come close to having it. They are told that they have a version of "autism spectrum disorder." Sorry I did not make that point clear.

    Also, if a patient with real bipolar disorder is being incapacitated by medications, which could happen, that is the fault of the psychiatrist. There is no reason for that to ever continue. If a patient can't tolerate lithium, for example, there are other drugs to chose from. Drug cocktails are only rarely necessary, and their use probably reflect the fact that the patient was misdiagnosed in the first place.

    In my defense, I did talk about the opposite end of the spectrum (what was happening in the 80's) in the post.

  9. I want to know if you really read Whitaker's book cover to cover. I think you need to before you judge his reasoning to be circular.

    His book is extremely well-reasoned and researched.

    He I think would readily agree with the words you include in your blog, "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. "

    The plain fact of the matter is, for those of us for whom the medications impair our ability to function... the "decline in function" does incapacitate.

    This is iatragenic damage. I don't personally believe the medications really correct my underlying problems. They allieviate crisis symptoms, which abate within weeks. After that period of stability, it is time to wean, so as NOT to have iatragenic effects to my endocrine system, my will and my ability to NOT oversleep (ten hours a day and upwards.)

    Now, with being able to wean responsibly, I CAN put gainful work into my recovery plan. My gainful work includes my work as freelance writer and mom.

  10. May I suggest you take a look at this blog? Interesting coincidence, today's article is specifically about Whitaker's book, from a well-read journalist who also has bipolar, and now manages his vulnerability with minimal use of medications.

  11. "hey 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."

    "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"

    conjecture like this is hardly professional and does little to advance discussion of psychiatric disability

  12. Its a shame many people who have been mis-diagnosed with psychiatric disabilities continue to receive aid when those who really do need it go without. Thanks for your article and your insights. Very much appreciated.

  13. Psychiatrist should look at western and native american medicine such as shamanism to heal mental disorders.. Otherwise.. it's just another episode of Frasier, in which many of these cases, psychiatrist are nuttier than the patient.

    And lets face it, you mental health professionals have been through med school, and made it. You guys dont want any type of "sharing the wealth" or helping the helpless out, You all think everyone can be helped, and only the MOST SEVERE cases are doomed.. and even still you all think thats shaky grounds.

    Look Bi Polar disorder can only be treated one way. by shamanism, and not meds or some health professional listening to your problems.. Other than that, I believe that most Bi Polar patients SHOULD be on disability, look at the hell they go through. Most of them are not lazy or down on their luck.. Comon man, be a little sensitive, thats quite an asshole overtone you got there. Obviously you dont truly understand all walks of life.. Well can i give you a suggestion. If you truly want to care, and have a solution, figure out what patients go through with bi polar, and in most cases, SSI/Disability is a temporary help for them until it gets better.. for some it stays the same.. but comon man.. you dont truly listen or even care about your patients.. to those Bi polar patients, you look at them as loosers who want a free ride..

    this article is disgusting

  14. I don't know how I found this site but after reading the different comments see this is about mental illness. I had a friend that got tired of working & decided he no longer wanted to work & decided to do something stupid. He says he found a way to get $700 from social security just by telling the doctor exactly what he read on the internet. He was trying to get some kind of assistance to pay his bills & read something that said you can get disability assistance if you have a mental illness. He read all he could & decided he could fool any doctor by not sleeping for days, not eating for days & suddenly felt awful. That was the start of his scam. He said he was so sick he almost died. He decided he should be diagnosed with bipolar. He passed the test and the doctor gave him all the tools. He is now on social security & says if they take him off he is capable of doing something tragic so they can see he is really mentally ill. No longer his friend but seeing all that is happening in our country by people like this, trying to proof a point, had to write this. That young man that killed the 21 elementary students & those others that have done tragic things to proof a point remind me of what that x-friend told me. Scared of what he can do if they take his $700 away. He is a real fake, I know it, cause he told me I could do it too. How can doctors do this to people. Give them strong medications & get them hooked on things that will eventually get them sick. Shame on them.

  15. This article is very disappointing and frightening.

    I'm a survivor of multiple and chronic childhood sexual, physical and emotional abuse. This followed me into adulthood. I have SEVERE PTSD, depression and GAD, as well as a host of chronic physical issues, autoimmune, degenerative disk, Fibromyalgia, chronic anemia...just to name a few...

    Impairment is not incapacitating. Interesting! I can wash my dishes and vacuum on a good day, but I cannot go to the grocery store alone and am terrified of the outside world and have uncontrollable reactions to authority, anything that resembles abuse, is a living HELL to have this disorder....

    Along with a deteriorating spine, and unpredictability of my multiple autoimmune, etc, I"m very precariously balanced. I have made so many attempts to get my psychology degree and could not complete it. My history is FULL of this. Is this what you mean by 'impaired' vs. 'incapacitated'?

    I would not survive in the world of employment, Dr. Periods of decompensation with all of my limitations combined would have me FIRED from a job. Do you really think an employer would accommodate someone like me, whose 'impairments' mean I am not and cannot be, consistent?

    People who are truly disabled, who SUFFER immensely with mental health and physical problems, HATE their inability to function like everyone else in society.

    Your article only exploits anger among the masses in a world that those of us who ARE disabled live, in that the most vulnerable in society are demonized, scapegoated and otherwise HARMED by these attitudes. Who are you to say what is good for people who struggle with 'impairments'?

    In my case, the best I can do is learn to LIVE WITH my limitations and manage it the best I can. I will never be fully healed, due to the extent of my psychological and physical damage due to extensive and prolonged abuse. IT would serve you well to take this into consideration prior to labeling those with 'impairments' as being able to do something they are NOT and something that an employer would NEVER put up with in decompensation, knee jerk reactions, inability to tolerate stress or the most minor of criticisms. Inconsistency is not employable, Sir.

    1. Sorry if I came off as implying that anyone with certain psych impairments is not disabled. Some are and some aren't. Some disability is short term, and some long-term. Some issues are fixable with therapy and/or meds and have a fairly good prognosis, and some have a really poor prognosis. This post is about doctors who tell people they are permanently impaired when that is not true.