To the Editor: In their commentary published in the April 2009 issue of the Journal, Sheldon Danziger, Ph.D., et al. (1) noted that the percentage of Social Security awards to people with diagnoses of mental illness has increased substantially since 1984. The authors raised the question as to whether these increased numbers reflect good or bad policy in the approval of Social Security awards. However, I question the basic assumption that the changed numbers actually reflect Social Security policy or any change in the application of policy.

There are at least three other unexplored explanations for the increase in Social Security awards for individuals with diagnoses of mental illness during these particular years. First, the increase in awards may reflect the laudable increase in accurate psychiatric diagnoses that has made it less likely for a patient to receive a physical diagnosis, neglecting necessary psychiatric care. Second, it could reflect a greater willingness on the part of patients and physicians to face down stigma and seek psychiatric treatment. Third, it might even be a result of the fact that while early treatment allows many more people with serious psychiatric diagnoses to enter the workplace, inconsistent support of treatment and outdated workplace policies often drive these workers back to public support programs.

Therefore, rather than trying to understand how or whether to refine award policies, it might be more useful to determine which healthcare funding mechanisms support the extended treatment necessary to maintain work function in people with mental disorders and clarify which workplace and treatment supports could keep individuals with serious mental illness in the workplace. As demonstrated with welfare reform, education and employment were more effective than refining eligibility rules and procedures.

1.Danziger S, Frank RG, Meara E: Mental illness, work, and income support programs. Am J Psychiatry 2009; 166:398–404

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