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Book Forum: Chronic Illness   |    
The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs
HARVEY BLUESTONE, M.D.
Am J Psychiatry 2003;160:1022-a-1023. doi:10.1176/appi.ajp.160.5.1022-a
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Edited by Gooloo S. Wunderlich, Dorothy P. Rice, and Nicole L. Amado, National Research Council Committee to Review the Social Security Administration’s Disability Decision Process Research. Washington, D.C., National Academies Press, 2002, 372 pp., $49.95.

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The Social Security Administration operates two disability benefit programs: Social Security Disability Insurance (SSDI) for disabled workers and Supplemental Security Income (SSI) for disabled impoverished adults and children. The SSDI program was enacted in 1956, SSI in 1972. In the year 2000 $50 billion cash benefits were paid under SSDI and $19 billion under SSI. This represents a 75% increase in benefits from 1989 to 2000. Disability allowance rates, that is, awards as a percentage of applications, have varied over time from 31% in 1980 to 47% in 2000. The allowance rate is influenced by legislative changes and judicial decisions. It varies from state to state, from decision maker to decision maker, and according to the adequacy of resources to process and review claims.

Increases in claims have resulted from economic downturn, cost shifting consequent to changes in welfare programs, and the deinstitutionalization of people with mental disorders and mental retardation previously cared for by state hospital systems.

In 1981, 11% of SSDI recipients were awarded benefits for mental disorders. This rose to 24% in 2000. In 2000, 31% of SSI benefits were based on mental disorders. Since the onset of disabling mental impairment occurs at an earlier age than cardiac or skeletomuscular impairments, the other major categories of disabling conditions, mental disorders have a greater impact on overall costs.

The Social Security Administration simply does not have the research capability to analyze the many factors influencing the utilization of these programs. One of the reiterated recommendations of this report from the Institute of Medicine and the National Research Council is that such a capacity be developed.

The development of the standard for determining psychiatric disabilities is reviewed in detail by Cille Kennedy, Ph.D., policy analyst in the U.S. Department of Health and Human Services. These standards, the Listings of Mental Disorders, were developed for the Social Security Administration by APA and adapted in 1985 (http://www.ssa.gov/disability/professionals/bluebook/12.00-MentalDisorders-Adult.htm). This contractual arrangement between the Social Security Administration and APA was unique in the promulgation of the Listings of Mental Disorders and ensured that the best thinking of the profession was made available to the Social Security Administration. The Listings of Mental Disorders, which were based on the then recently published DSM-III, are essentially unchanged. They were operationally studied in a subsequent analysis undertaken by APA for the Social Security Administration.

Dr. Kennedy acknowledges that her chapter does not go into the impact of substance abuse disorders, a major concern in disability determinations. She points out that the APA study identified problems in reviewing claims based on a mental disorder when a physical condition was also present. The Listings of Mental Disorders, based on different categories of medical impairments, are not well designed to handle concurrent disorders.

Who will read this book? Given the vast sums of money involved, policy makers in the legislative and executive branches of government will no doubt read it, even though the study was undertaken by its prestigious sponsors for more scientific purposes. There are now 14 steps between the filing of a disability application and final review by the Social Security Administration appeals council, and further recourse to federal courts is available. Psychiatrists participate in several of the steps along the way and will find this book helpful in clarifying some of the issues they face. Everyone engaged in public sector psychiatry simply cannot function without some knowledge of SSDI and SSI programs, and this volume may prove helpful to them.

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