BOX 3-3: Assessing Psychiatric Disability

Models of disability and data from research show that identifying a particular diagnosis or symptom is insufficient to determine the severity of disability, required services, or work limitations. In order to qualify for the ADA's protections a person must be an individual with an impairment that "substantially limit(s) one or more of the major life activities." EEOC investigators, employers, people with mental disorders, and mental health care providers face the challenge of determining who with a mental disorder has a psychiatric disability under the law.

The Status of Functional Assessment

Questionnaires, interviewing techniques, and observational approaches have been developed to assess disability, and disability assessment has become a standard part of vocational and psychosocial rehabilitation services. The goals of assessment may be very general, aimed at measuring social skills, the ability to maneuver every-day requirements, and work performance; or very specific, aimed at specific disorders and functions. Recent analyses have documented shortcomings of these disability assessment methods. Following a comprehensive review, one researcher concluded that no one instrument was wholly adequate for assessing functional impairments. Recently this same scholar noted that:


      [B]etter methods of assessment would improve both the
      interpretation of future evaluations and current clinical
      practice. Most evaluations use relatively idiosyncratic
      methods of measuring role functioning. What is needed is an
      easily administered, low-cost assessment tool that not only
      measures individuals' impairments and role functioning, but
      provides information that is directly relevant to treatment
      decisions.

Similarly, expert reviewers of social functioning measures concluded that modest reliability and the lack of evaluation limit the usefulness of available assessment tools. Furthermore, they concluded, none is simple enough forroutine clinical use. These conclusions are in the National Institute of Mental Health's plan for services research, which states that


      [a]lthough [disability]. . . assessment seems logical and
      straightforward enough, the truth is that the mental health
      field is still without an adequate arsenal of instruments
      and techniques to fully accomplish the task. . . No aspect
      of clinical services--or of research designed to improve
      such services--can prosper without the availability of
      meaningful and valid techniques for assessing the status of
      mentally ill patients, not only in purely clinical terms but
      also in terms of their everyday functioning in the real
      world and their strength on which rehabilitation can build.
      . . Needed are. . . ays to assess general health status and
      physical functioning, the quality of the patient's life, the
      nature of the family's burden, and the patient's
      rehabilitation potential and progress.

Disability Assessment at the Social Security Administration

The experience of the Social Security Administration (SSA) illuminates the pitfalls of implementing disability assessment. SSA administers two disability income maintenance programs: the Social Security Disability Insurance (SSDI) program and Supplemental Security Income (SSI) program. Eligibility for these programs hinges on the inability to work. The methods used by SSA to assess severe psychiatric disability in the 1980s was said to be difficult to use, too subjective, out of date, and discriminatory. "The essential problem is...that it is not possible to construct a set of medical and vocational standards that will distinguish perfectly between those who are able to work and those who are not able to work." The public outcry that resulted from a disproportionate number of people with severe mental disorders being terminated from the programs led Congress to order a revision of SSA's psychiatric disability assessment methods. The new method includes the consideration of diagnosis as well as limitations in four areas of functioning: activities of daily living; social relations; cognitive functioning such as concentration, persistence, and pace; and decompensation or deterioration in work. Consideration of environmental interventions was also provided as an option in the assessment.

SSA's current disability determination is not without its critics: An American Psychiatric Association study of the new guidelines indicates that additional changes may improve the disability determination; the use of this assessmentmethod by psychiatrists and other care providers also warrants improvement; some have criticized the increasing number of people with psychiatric disabilities who now receive SSI or SSDI.

It should be noted that the SSA's disability determination procedure is not appropriate for the ADA. The elaborate hurdle that people with disabilities must vault to receive SSA program benefits would limit unduly the ADA-guaranteed protections against discrimination. In addition, the definition of disability under the ADA obviously is not limited to individuals who cannot work at all.


Functional Assessment and the ADA

The ADA defines disability in terms of impairment and functional limitations. In general, an applicant or employee discloses the presence of a disability to an employer or covered entity, often providing very limited information. The employer may require confirmation of a disability that is not readily apparent, such as a psychiatric disability. Also, the EEOC must make a determination as to whether an individual is considered disabled under the ADA in the event that a charge of discrimination is filed. To date, in its computerized charge data system, the EEOC simply lists the marginally informative term "mental illness" as the impairment relevant to psychiatric disability. The EEOC will be implementing a new coding system for disabilities in fiscal year 1994 and it will include a category for "emotional/psychiatric impairment," under which there will be separate entries for anxiety disorder, depression, manic-depressive disorder, schizophrenia, and other emotional/psychiatric condition where none of the above clearly apply. What doesn't exist are guidelines for determining who with a mental disorder has an impairment that substantially limits a major life activity--is disabled under the ADA's definition. Convening a group of experts and interested parties to help fashion guidance for EEOC investigators and others, concerning diagnoses and other assessment criteria relevant to the ADA and employment would be useful. Continued research and the development of functional assessment tools also represent critical needs.


SOURCES:

C. Koyanagi and H. Goldman, Inching Forward: A Report on Progress Made in Federal Mental Health Policy in the 1980s (National Mental Health Association, 1991); U.S. Department of Health and Human Services, Toward a National Plan for the Chronically Mentally Ill (Public Health Service, Washington, DC, 1980); H.A. Pincus, C. Kennedy, and S.J. Simmens, American Psychiatric Association, Washington, DC, "Study of SSA Methods and Standards for Evaluating Disability Based on Mental Impairment," final report to Social Security Administration (SSA-600-84-0174), November 1987; H.A. Pincus, C. Kennedy, S.J. Simmens, et al., "Determining Disability Due to Mental Impairment: APA's Evaluation of Social Security Administration Guidelines," American Journal of Psychiatry 148:1037-1043, 1991; H.H. Goldman, A.E. Skodol, and T.R. Lave, "Revising Axis V for DSM-IV: A Review of Measures of Social Functioning," American Journal of Psychiatry 149:1148-1156, 1992; C.J. Wallace, "Functional Assessment in Rehabilitation," Schizophrenia Bulletin 12:604-630, 1987.


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