Is There a “Way Out” of Psychiatric Disability?

Research Updates in Psychiatry

The largest and fastest-growing subset of Social Security Disability (SSDI) beneficiaries is patients with psychiatric diagnoses, even as the federal SSDI Trust Fund diminishes. In 2005, the Social Security Administration authorized the Mental Health Treatment Study (MHTS) to test the hypothesis that a comprehensive, team-based, supported employment program would increase the likelihood that beneficiaries would find work.

More than 2,000 SSDI beneficiaries with a primary psychiatric diagnosis (N=2,238) agreed to participate. Half (N=1,121) were randomized to an experimental condition that included multiple interventions: supported employment services according to the “individual placement and support” model; guideline-based pharmacological treatment; and teams to provide other interventions such as case management and family support. Importantly, these participants had no out-of-pocket expenses (these were paid for by SSA) and annual disability reviews were suspended for three years. The control group (N=1,117) received treatment as usual.

More participants in the intervention group than in the control group were employed at any time during the 25-month follow-up period (60.3% vs. 40.2%), and more achieved “competitive employment”—ie, a mainstream job with usual wages—than in the control group (52.4% vs. 33.0%). Those in the intervention group also reported greater scores in overall mental health and life satisfaction at the end of the study.

Although the results of this 23-site study seem impressive, only a small proportion of participants (3% in the intervention group, 2% in control group) achieved “substantial gainful activity,” the income threshold (currently $1,070 per month) at which benefits start to decrease. Only four participants (0.2% of the total) consistently worked at this level for the duration of the study. Furthermore, the total number of participants represented only 14% of the nearly 16,000 SSDI beneficiaries who were eligible and invited to participate. The authors hypothesize that the majority of SSDI recipients were simply “not interested in changing their employment status,” for reasons which may include the fear of losing benefits (Drake RE et al, Am J Psychiatry 2013;170(12):1433– 1441).

TCPR’s TAKE: SSDI beneficiaries who received supported employment services were, as a whole, more likely to be employed, earned more, and reported a better quality of life than those who received treatment as usual. However, only a minority of eligible SSDI recipients agreed to participate in the trial, and those who found jobs still earned too little for their benefits to be reduced to any significant degree. These facts, combined with the increased cost of providing employment support services, mean that any attempt to reduce overall SSDI expenses by encouraging work is best directed at those who are highly motivated to find work in the first place.

Is There a “Way Out” of Psychiatric Disability?

This article originally appeared in:

The Carlat Psychiatry Report
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This article was published in print 1/2014 in Volume:Issue 12:1.