PSYCHIATRY: Psychiatric Impairment Assessment
Psychiatric impairment is a major determinant in many individuals’ ability to return to work. There exist numerous non-medical factors
Psychiatric impairment is a major determinant in many individuals’ ability to return to work. There exist numerous non-medical factors impacting return-to-work status; these include morale of the work environment, relationship with supervisor, work load and productivity quota in current position, as well as economic prognosis of employer (e.g., is downsizing probable and is employee at high risk of being laid off temporarily or terminated).
Treating clinicians, including psychiatrists, generally focus on target symptoms such as panic episodes, anxiety, depressed mood and insomnia. Therapy such as psychotropic medication, exploratory and/or supportive psychotherapy and cognitive behavioral therapy focus on symptom reduction. Often, patient self-reports of memory and concentration difficulties as well as other symptoms are not assessed for objective findings by the treating clinician. Additionally, return to work may not be a major concern of the clinician even at times when disability benefits are being denied.
In contrast, independent psychiatric reviewers and evaluators focus on a claimant’s functional ability. Often a request for independent assessment is recommended subsequent to a claimant being turned down for disability and having appealed the insurer’s decision. Assessment may be by solely a record review, but frequently the insurer will recommend contact with one or more treating clinicians. An independent psychiatric examination of a claimant would include record review and also may include contact with the treating clinician(s). Much emphasis is placed on the activities of daily living and mental status findings. The evaluator is generally requested to determine whether claimant’s subjective, psychological, and/or cognitive impairment are consistent with objective observations and evaluation findings. If evidence exists for cognitive impairment, comment is generally requested whether a condition such as substance abuse or adverse side effects of medication are contributing to impairment.
Psychiatric evaluators are generally requested to identify appropriate restrictions and/or limitations, based on documented cognitive and/or psychiatric impairment. For example, an individual with a documented bipolar illness sensitive to time changes may fare poorly with rotating work schedules and appropriate restriction may be working on a permanent day shift schedule.
The issue of permanency of disability status can become contentious between the claimant and insurer. The longer an individual has remained out of work, the poorer the prognosis for return to work. Treating physicians tend to advocate and support their patient’s claim of being too distressed to work, although objective impairment of function may not exist. Evaluating psychiatrists seek objective evidence of impaired functioning; this includes low Global Assessment of Functioning, mini mental status scoring reflective of cognitive impairment, abnormal mental status findings, aggressive psychopharmacologic management, evidence of suicidicality with the need for higher level of care including psychiatric inpatient, or partial hospitalization.
It is imperative that the evaluating psychiatrist maintain a high level of integrity, since the conclusion that the claimant lacks impairment with the need for restrictions and/or limitations can often translate into claimant having no source of payment from the insurer. When the evaluating psychiatrist has a known treatment practice, there is an increased likelihood of meaningful assessment and concluding that a number of the appealing claimants have impairment.
With the ongoing economic recession and joblessness in the country, psychiatric recovery is critical for the claimant. Individuals who work at a meaningful job with an adequate income are more likely to maintain a high level of self-esteem and emotional well-being. Some individuals at the time of psychiatric assessment have already been granted Social Security Disability benefits; the likelihood of these individuals to return to work is low once granted this entitlement regardless of the assessment outcome. Unfortunately, many individuals become caught in the battle between their attorney and the insurer’s legal department. It remains essential that the evaluating psychiatrist maintain a high ethical standard of competence and fairness in reaching decisions.