Functional impairment in people with schizophrenia: Focus on employability and eligibility for disability compensation

Abstract

Background

The Social Security Administration (SSA) is considering whether schizophrenia may warrant inclusion in their new “Compassionate Allowances” process, which aims to identify diseases and other medical conditions that invariably quality for Social Security disability benefits and require no more than minimal objective medical information. This paper summarizes evidence on the empirical association between schizophrenia and vocational disability. A companion paper examines the reliability and validity of schizophrenia diagnosis which is critically relevant for granting a long-term disability on the basis of current diagnosis.

Methods

This is a selective literature review and synthesis, based on a work plan developed in a meeting of experts convened by the National Institute of Mental Health and the SSA. This review of the prevalence of disability is focused on the criteria for receipt of disability compensation for psychotic disorders currently employed by the SSA.

Results

Disability in multiple functional domains is detected in nearly every person with schizophrenia. Clinical remission is much more common than functional recovery, but most patients experience occasional relapses even with treatment adherence, and remissions do not predict functional recovery. Under SSA's current disability determination process, approximately 80% of SSDI/SSI applications in SSA's diagnostic category of “Schizophrenia/Paranoid Functional Disorders” are allowed, compared to around half of SSDI/SSI applications overall. Moreover, the allowance rate is even higher among applicants with schizophrenia. Many unsuccessful applicants are not denied, but rather simply are unable to manage the process of appeal after initial denials.

Discussion

Research evidence suggests that disability applicants with a valid diagnosis of schizophrenia have significant impairment across multiple dimensions of functioning, and will typically remain impaired for the duration of normal working ages or until new interventions are developed.

Introduction

Over the past three years, the National Institute of Mental Health (NIMH) and the Social Security Administration (SSA) have discussed how to improve SSA's disability determination process for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). SSA first approached the National Institutes of Health (NIH) in August, 2007, to invite NIH's input in identifying diagnostic science that might let SSA improve their disability determination process. In particular, SSA has a new “Compassionate Allowances” process (http://www.ssa.gov/compassionateallowances/), under which SSI/SSDI applicants whose disability can be definitely established can be awarded benefits rapidly. The current list of Compassionate Allowances Conditions is available at http://www.ssa.gov/compassionateallowances/newconditions.htm.

SSA initially indicated that it was hoping to identify valid “tests” – e.g., genetic tests or diagnostic imaging – that would allow rapid and accurate identification of disorders that plausibly confer a priori eligibility for disability. Such diagnostic technology does not currently exist for major mental disorders. However, SSA indicated an interest in reviewing other types of scientific evidence that might help improve disability determinations. For instance, many mental disorders, including schizophrenia, which represents around 8% of the adult recipients of SSI/SSDI, are associated with significant cognitive impairment, across multiple domains of functioning. Because cognitive impairment often results in functional disability, SSA expressed interest in identifying appropriately validated benchmarks of cognitive impairment, with the possibility that standardized measures of cognitive impairment could be part of a Compassionate Allowance determination for schizophrenia and other relevant mental and physical conditions.

In the particular case of schizophrenia, the disorder itself may warrant being included in SSA's “Compassionate Allowances” process, provided that strong and reliable links can be established between disease related cognitive impairment and functional disability. That is, in this case documentation of a valid diagnosis of schizophrenia may be sufficient for SSA to award disability benefits. In this context, NIMH commissioned the authors – all internationally known experts in schizophrenia and psychiatric disability – to prepare two scientific review papers: the current paper, which examines the empirical association between schizophrenia and disability; and a second, related paper that examines the nature of schizophrenia diagnosis, including the reliability and validity of current diagnostic criteria; what data/information, methods, and expertise are needed for valid diagnosis; and the stability of the diagnosis over time. These papers were intended to help SSA determine how schizophrenia might warrant being included in SSA's Compassionate Allowances program.

Schizophrenia as currently defined is an outgrowth of the original Kraepelinian concept of “Dementia Praecox” (Kraepelin, 1919). This nosological entity was defined as a condition with features of dementia (notable cognitive and functional impairments), an early age of onset compared to Alzheimer's dementia, and a variety of associated features. These features include changes in emotional functioning, reduced drive and motivation, verbal communication abnormalities, unusual behavior, delusional thinking, and perceptual abnormalities experienced as hallucinations. Thus, from the first conceptualization of schizophrenia, the illness has been seen to be persistent, heterogenous, and associated with chronicity, and disability. The current definition of schizophrenia is actually quite similar (American Psychiatric Association, 1980).

This paper supports the argument that schizophrenia is a condition in which disability is an intrinsic part of the illness. Thus, it is not surprising that the majority of people with schizophrenia are receiving some disability compensation (Rosenheck et al., 2006). Further, formal or informal disability-related financial support is often provided soon after the diagnosis of schizophrenia: in a large sample of people recently diagnosed with schizophrenia, 80% were found to be either receiving disability compensation or to be completely dependent on a relative for financial support within 18 months of their initial contact (Ho et al., 1997).

In our companion paper we demonstrate that the current diagnostic criteria for schizophrenia can be applied with adequate validity. In this paper we focus on the disability associated with validly diagnosed schizophrenia.

In the United States, the principal sources of public disability insurance are the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs. Eligibility for SSDI and SSI is governed by regulations, the most relevant of which for this paper is SSA's Listing of Impairments (shared by SSDI and SSI). For all mental disorders, disability claimants must meet specific criteria relating to the presence of specific symptoms, to support a medical cause of disability (“A” disability criteria). Claimants must also meet specific criteria relating to impairment in at least two out of four domains of functioning (“B” disability criteria). For schizophrenia, claimants may meet an additional set of criteria relating to chronic disorder-related impairment (“C” disability criteria), instead of or in addition to the “B” disability criteria.

Table 1 lists all three sets of disability criteria.

In the next sections, we summarize evidence regarding the prevalence of multiple domains of impairments in individuals diagnosed with schizophrenia. There are several elements of outcome in schizophrenia that are central to the issues of Social Security disability. They include presence and severity of disability, the prevalence of incomplete response of psychotic symptoms, the severity of cognitive impairments, the presence of persistent negative symptoms, and occurrence of symptomatic relapse in people who have been stabilized. Disability, impaired cognition, and negative symptoms are not responsive to current treatments (Harvey and Bellack, 2009) and are central features of the illness (Heinrichs and Zakzanis, 1998). There are substantial data to suggest that cognition and negative symptoms are the primary causes of disability in everyday activities (Bowie et al., 2008, Bowie et al., 2010, Leifker et al., 2009).