Am J Psychiatry 1991; 148:1037-1043
Copyright © 1991 by American Psychiatric Association
Determining disability due to mental impairment: APA's evaluation of Social Security Administration guidelines
HA Pincus, C Kennedy, SJ Simmens, HH Goldman, P Sirovatka and SS Sharfstein
APA Office of Research, Washington, DC 20005.
OBJECTIVE: APA evaluated the Social Security Administration's (SSA's)
medical standards and guidelines for determining disability due to mental
impairment to determine how well the standards and guidelines
operationalize the statutory definition of disability in a manner
consistent with current psychiatric practice. METHOD: Seventy-two
psychiatrists were trained in one of two procedures: those in the
sequential evaluation condition were trained in the process and forms used
by the SSA's reviewing medical consultants, and those in the statutory
definition condition were trained in the statutory definition of disability
and application of clinical judgment according to this standard. Decisions
regarding claimant's ability or inability to work were recorded on an
instrument designed for the study. Each condition consisted of 12 panels of
three members. They reviewed 732 actual claims for disability benefits. The
panelists reviewed claims independently, then rendered panel judgments.
Each claim was reviewed by one panel in each condition. RESULTS: The
proportion of agreement between conditions for panel decisions (0.77) was
higher than chance agreement (kappa = 0.46). The high level of agreement on
claims judged to have good medical evidence and on which confident
decisions were made (proportion of agreement = 0.96, kappa = 0.78) suggests
that disagreements largely reflected ambiguities in application of the
standards and guidelines to more complex cases or those with inadequate
information. CONCLUSIONS: The SSA's revised medical standards and
guidelines reflect clinical decisions about ability to work based on the
statute and, with procedural modifications, should be retained. The SSA
should be involved in further systematic studies to develop a field of
scientific inquiry into disability and psychiatric disorders.
