Social Security Disability Income Claims: Treating Mental Health Clinicians and Consultative Mental Health Examiners

Abstract

When a mental health clinician’s patient applies for Social Security Disability Insurance (SSDI) benefits on the basis of psychiatric illness, the Social Security Administration (SSA) requests that the treating clinician provide specific clinical information relevant to that claim. If additional information is needed, the SSA may request a consultative examination (CE), which is similar to an independent medical examination (IME) in its structure, goals, and relationship with the evaluee. The SSA’s disability determination process, definition of disability, and criteria for determining disability are highly specific, statutorily defined, and unique to SSA. Most mental health clinicians do not receive training or instruction in SSA’s terms, definitions, qualification process, or documentation requirements. This chapter will review the definitions, process, and requirements associated with providing SSDI documentation. This chapter will also review the role of Consultative Examiners and the nature of CEs.

Appendix I: Consultative Examination Content and Narrative Report

• I. General Observations

  • a. How did the claimant come to the examination:

    • i. Was the claimant alone or accompanied

    • ii. Distance and mode of transportation

    • iii. If by automobile, who drove

  • b. General appearance:

    • i. Dress and grooming

    • ii. Attitude and degree of cooperation

    • iii. Posture and gait

    • iv. General motor behavior, including any involuntary movements

• II. Informant:

  • a. Identify the person providing the history (usually the claimant)

  • b. Provide an estimate of the reliability of the history

• III. Chief Complaint: The claimant’s allegations concerning any mental and/or physical problems

• IV. History of Present Illness

  • a. Include a detailed chronological account of the onset and progression of the claimant’s current mental/emotional condition with special reference to:

    • i. Date and circumstances of onset of the condition

    • ii. Date the claimant reported that the condition began to interfere with work, how it interfered

    • iii. Date the claimant reported inability to work because of the condition and the circumstances

  • b. Attempts to return to work and the results

  • c. Outpatient evaluations and treatment for mental/emotional problems including:

    • i. Names of treating sources

    • ii. Dates of treatment

    • iii. Types of treatment (names and dosages of medications, if prescribed), and

    • iv. Response to treatment

  • d. Hospitalizations for mental disorders including:

    • i. Names of hospitals

    • ii. Dates, and

    • iii. Treatment and response

• V. Functional information, preferably conforming with format suggested by Paragraph B criteria, includes narrative report of functioning on a typical day:

  • a. Activities of daily living:

    • i. Give complete description of ADLs

    • ii. Can the claimant take care of cooking, cleaning, grocery shopping etc.? Give examples

    • iii. Does the claimant need assistance with self-care? Give examples

    • iv. Can the claimant handle their own money?

  • b. Social functioning:

    • i. Does the claimant socialize with family or friends or is he or she socially isolated?

    • ii. Does the claimant attend church groups, clubs, or other social events regularly?

  • c. Concentration, persistence, and pace: Can the claimant

    • i. Read a book, work at hobbies, play on the computer, etc? Give examples of hobbies or interests and how long they can sustain activity

    • ii. Finish ADLs in a timely manner?

  • d. Deterioration or decompensation, especially in a work-like setting

  • e. Functioning on a typical day

• VI. Past History: should include a longitudinal account of the claimant’s personal life

  • a. Relevant educational, medical, social, legal, military, marital, and occupational data and any associated problems in adjustment

  • b. Details (dates, places, etc.) of any past history of outpatient treatment and hospitalizations for mental/emotional problems, and

  • c. History, if any, of substance abuse, and/or treatment in detoxification and rehabilitation centers

• VII. Mental Status: should include a detailed description of the claimant’s

  • a. Appearance, behavior, and speech (if not already described)

  • b. Thought process (e.g., loosening of associations)

  • c. Thought content (e.g., delusions)

  • d. Perceptual abnormalities (e.g., hallucinations)

  • e. Mood and affect (e.g., depression, mania)

  • f. Sensorium and cognition (e.g., orientation, recall, memory, concentration, fund of information, and intelligence)

  • g. Judgment and insight, and

  • h. Capability (i.e., is the individual capable of handling awarded benefits responsibly

• VIII. Psychological and/or Neuropsychological test results

• IX. Diagnosis utilizing standard nomenclature as set forth in the current “Diagnostic and Statistical Manual of Mental Disorders” (APA 2000)

• X. Prognosis:

  • a. Likely future course of illness

  • b. Recommendations for treatment, if indicated

  • c. Recommendations for any other medical evaluation (e.g., neurological, general physical), if indicated

• XI. Summary and Discussion, including responses to any specific referral questions.