Psychiatric Annals

CME Article 

Psychiatric Disability Evaluations

Stephen G. Noffsinger, MD; Adrienne Saxton, MD; Britta Ostermeyer, MD, MBA, FAPA

Abstract

Mental illness and substance abuse disorders are among the most frequent causes of disability in the United States and the world, rendering many people unable to be gainfully employed. As a result, psychiatrists and other mental health professionals often receive requests to perform independent medical examinations (IMEs) to provide opinions pertaining to a person's disability, work accommodation requirements, or fitness for duty. This article provides psychiatrists and other mental health professionals who conduct these examinations with pertinent background information as well as information about the examination process and report writing so they can perform a psychiatric IME when requested by lawyers, employers, or insurance companies. This article also uses an Illustrative Case to facilitate a better understanding of the information provided. [Psychiatr Ann. 2018;48(2):86–94.]

Abstract

Mental illness and substance abuse disorders are among the most frequent causes of disability in the United States and the world, rendering many people unable to be gainfully employed. As a result, psychiatrists and other mental health professionals often receive requests to perform independent medical examinations (IMEs) to provide opinions pertaining to a person's disability, work accommodation requirements, or fitness for duty. This article provides psychiatrists and other mental health professionals who conduct these examinations with pertinent background information as well as information about the examination process and report writing so they can perform a psychiatric IME when requested by lawyers, employers, or insurance companies. This article also uses an Illustrative Case to facilitate a better understanding of the information provided. [Psychiatr Ann. 2018;48(2):86–94.]

Psychiatrists and other mental health professionals are often asked to perform independent medical examinations (IMEs) on people with disability claims, requests for job accommodations, or concerns about fitness for duty for their jobs. Such independent opinion requests may come from lawyers, judges, employers, and insurance companies, among others.

It is important to understand that the mental health professional performing the IME is to provide an independent medical/psychiatric opinion, independent from any interests and desires by referral sources and patients. Therefore, it is of utmost importance that mental health professionals performing an IME only provide medical/psychiatric expertise regarding the person being examined and not mental health treatment under the usual confidential clinician-patient relationship. Trying to do both, poses great ethical concerns (as discussed in the Guest Editorial in this issue by Dr. Britta Ostermeyer).

Psychiatrists and other mental health professionals often wonder how they can best perform these IMEs. When conducting IMEs, it is helpful to have some basic understanding of psychiatric disability, emotional/psychic damages, disability income benefits programs, and certain laws and regulations, such as the Americans with Disability Act (ADA)1 and the Family and Medical Leave Act (FMLA).2 In addition, independent medical examiners need to know how to conduct such examinations and how to write detailed, well-organized reports based on the information gathered. This article provides mental health professionals who conduct these examinations with basic background information about psychiatric disability as well as explain standard examination and report writing procedures. It also has an Illustrative Case with a discussion to highlight important points.

Psychiatric Disability

Mental illness affected approximately 18% of Americans in 2015, and serious mental illness occurred in 4% of the adult population.3 Mental illness can result in significant symptomatology leading to social and occupational dysfunction, potentially causing the inability to participate in sustained, gainful remunerative activity—also known as psychiatric disability.

Neuropsychiatric disorders are the leading cause of disability in the United States, followed by cardiovascular and circulatory diseases and neoplasms.4 Although many mental disorders result in chronic symptoms and resultant long-term disability, others are episodic and may result in only temporary periods of total or partial disability (or no disability at all).

The burden of disability associated with a disease or disorder can be measured in units called disability-adjusted life years (DALYs). DALYs represent the total number of years lost to illness, disability, or premature death within a given population. For a given disease or disorder, the DALY is calculated by adding the number of years of life lost plus the number of years lived with disability. Mental and behavioral disorders account for 13.6% of total DALYs in the US.4 Major depressive disorder (27%), drug use disorders (19%), anxiety disorders (17%), alcohol use disorders (10%), schizophrenia (8%), and bipolar disorder (5%) account for the majority of mental health-related-DALYs, and thus the majority of psychiatric disability as well.4

Disability Income Benefits

Government and private insurance programs provide long-term disability income benefits for the physically and/or psychiatrically disabled.

Social Security Disability Insurance and Supplemental Security Income

Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) are two federally funded programs that provide disability income benefits. The Social Security Act of 19355 defines disability as “the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” SSDI eligibility is based, in part, on the worker's previous income being taxed under the Federal Insurance Compensation Act (FICA) for a minimum period of time and is independent of assets or other sources of income. Eligibility for SSI, in contrast, is not based on a person's prior work history and FICA contributions, but instead is based on financial need assessed via a means test.6

In April 2017, approximately 14 million people ages 18 to 64 years received benefits from the Social Security Administration on the basis of disability.7 Of 14 million people, 7.94 million received benefits from the SSDI program, 4.54 million received benefits from the SSI program, and 1.52 million received benefits from both programs concurrently.7 In April 2017, the Social Security Administration paid out almost $10.3 billion dollars in benefits to disabled workers.7

Federal and State Government Pension

Federal and state government pension plans provide, in addition to retirement benefits, disability income benefits. These pension plans typically are offered to federal, state, and municipal workers such as postal workers, police officers, firemen, teachers, and school employees. Disability definitions vary according to details of the specific plans, but in general, disability is defined as the inability, due to physical or mental illness, to participate in gainful employment for a period of at least 12 months.8

Veterans' Administration

Disability compensation is paid to veterans who are at least 10% disabled because of injuries or diseases that were incurred in or aggravated during active duty, training for active duty, or during inactive duty training.9 A disability can apply to physical conditions, such as a chronic knee condition, as well as a mental health condition, such as posttraumatic stress disorder. Compensation may also be paid for disabilities that are considered related, or secondary to, disabilities occurring during service. Similarly, disability benefits may be offered for conditions presumed to be related to circumstances of military service, even though they arose after service. The benefit amount is graduated according to the degree of the veteran's disability, on a scale from 10% to 100% (in increments of 10%). The specified disability degrees are designed to compensate for considerable loss of working time from exacerbations or illnesses.10

Private Employee Pension Funds

Some workers are covered by employee-sponsored pension plans. Disability definitions, benefits, and eligibility vary according to specific plan details.

Federal and State Workers' Compensation Programs

Workers' compensation is a form of employee insurance granting medical benefits and disability wage replacement to employees who are accidentally injured on the job. Workers' compensation claims are processed through an administrative process rather than the more adversarial tort system. Workers seeking benefits under workers' compensation must prove that they experienced an occupational injury that affects their earning capacity.

In exchange for not having to prove that their employer was at fault, employees relinquish their rights to sue for compensatory and punitive damages (unless the employer was reckless or acted in bad faith). Compensation is limited to a fixed schedule. Workers may receive benefits for physical injuries, mental disorders that flow from a physical injury, and (in some jurisdictions) mental disorders not caused by a physical injury. Benefits for the exacerbation of a preexisting condition may also be available if there is objective evidence that the occupational injury substantially aggravated a preexisting condition. Employees may be covered for acute injuries or chronic illnesses (eg, carpal tunnel syndrome) that arise due overuse or misuse in the course of their required job duties. The following situations may not be covered under worker's compensation: self-inflicted injuries (including those caused by an employee who starts a physical altercation), injuries sustained while the employee was violating the employer's policy or in the commission of a crime, or injuries sustained while an employee was not on the job. Disability benefits are available for temporary total disability and permanent (partial or total) disability.

When an employee requests compensation for employment-related psychic damages or illness arising out of their employment, the employee may be required to undergo a psychiatric evaluation. An administrative hearing officer may be assigned to determine whether a job-related injury has occurred and the extent of the compensation.

Private Disability Insurance Programs

Such programs are offered by for-profit insurance companies and are among the range of insurance products that large insurers typically market to the public. The specific details of the plans vary. In some cases, disability income benefits may be payable for employees who still retain a limited ability to work (partial disability). Other plans may offer compensation only in the event of total disability. Similarly, some benefit plans provide disability benefits if the employee is disabled from his or her chosen occupation but still retains the ability to work in less-demanding jobs (“own-occupation” benefits). Other plans provide disability benefits only if the worker is disabled from working in any capacity (“all-occupation” benefits).

Psychiatrists and other mental health professionals may be requested to conduct psychiatric IMEs of people requesting disability benefits under any of the above-mentioned disability benefit plans.

Emotional/Psychic Damages

In addition to performing evaluations for the purposes of determining eligibility for disability benefits, psychiatrists may be asked to evaluate psychiatric disability when legal claims for emotional damages arise. Legal claims for the “intentional infliction of emotional damages” may arise from a number of events. Examples include the intentional torts of discrimination and/or harassment on the basis of the plaintiff's age, gender, or race, or in the event of a physical assault with resultant psychological damages. Claims for the “negligent infliction of emotional damages” may arise from accidents, such as industrial injuries, motor vehicle accidents, and/or other unintentional physical injuries potentially leading to psychological injuries. In cases of both intentional and negligent infliction of emotional damages, plaintiffs may seek compensatory damages for mental pain and suffering and compensation for partial or total psychiatric disability.

The Americans with Disability Act

The ADA prohibits employment discrimination on the basis of workers' disabilities.1,11,12 Passed by Congress to ensure all persons the right to participate in all aspects of society, the ADA was signed into law on July 26, 1990, by former president George H. W. Bush.11 It was modeled after the Civil Rights Act of 1964, which prohibits discrimination based on race, color, gender, sex, or national origin.13 The ADA is the nation's first civil rights legislation providing “equal opportunity” to persons with disabilities. It prohibits discrimination against people with disabilities in employment, housing, public accommodations, education, transportation, communication, recreation, institutionalization, health services, voting, and access to public services.11,12

Not all medical or psychiatric conditions represent “disabilities.” As per the ADA, for a condition to rise to a level of a “disability,” a person must (1) have a physical or mental impairment that “substantially limits one or more major life activities;” (2) have a record of such impairment; or (3) be regarded as having such an impairment.1 An impairment is substantially limiting if it lasts for more than several months and prevents a person from performing a major life activity or significantly restricts the condition, manner, or duration under which a person can perform a major life activity. Learning, thinking, concentrating, interacting with others, caring for oneself, speaking, performing manual tasks, working, or sleeping can count as major life activities. Traits, symptoms, and behaviors themselves do not automatically constitute an impairment; however, it may be shown that they are related to a physical or mental impairment.1

Although the ADA does not specifically name all the impairments that are covered, Congress expressly excluded from the ADA any employee acts and impairments that are based on current alcohol or illicit drug use. The ADA also excludes transvestism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorder not resulting from physical impairments, or other sexual behavior disorder; and compulsive gambling, kleptomania, or pyromania.11,14

Under the ADA, employers must provide reasonable accommodations to qualified employees to accommodate their disabilities unless such accommodations represent undue hardship to the employer.1,11,12 To show that a particular accommodation would present undue hardship (and therefore may not be required to be covered by an employer), an employer must demonstrate that the requested accommodation is either too costly, extensive, or disruptive to be adopted in the given workplace.1,11 Qualified employees must hold the necessary degrees, skills, and experience required for the job and be able to perform the essential job functions in the first place. A disability accommodation is not intended nor required to make up for missing job-related qualifications or skills.11

Reasonable accommodations are workplace modifications that allow disabled employees to apply for a job, perform the job functions, or enjoy equal access to benefits available to other people without disability. Examples of reasonable accommodations might be modification of desk or chair height, other equipment modifications, installation of telecommunications for those who are deaf, or modification of working hours or breaks. An accommodation may include transfer of an employee to a different location to remedy certain problems at the existing location that are posing difficulties for the disabled worker. Alternatively, such a transfer could be implemented due to advantages at the new location, such as easier medical care access. Reasonable psychiatric accommodation may, for example, entail moving an employee with attention-deficit/hyperactivity disorder to an office cubicle in a quieter area with fewer distractions or switching someone with bipolar disorder from nightshifts to consistent dayshifts.1

It is important to know that if an employee represents a “direct threat” to self or others, he or she may be terminated.1 Accommodations under the ADA are not required for severe conduct problems as “nothing prevents an employer from maintaining a workplace free of violence or threats of violence, or from disciplining an employee who steals or destroys property.”1 A “direct threat” must be “a significant risk of substantial harm to the health or safety of the person or others that cannot be reduced or eliminated by reasonable accommodations.”1 Of course, an employee does not pose a “direct threat” by simply having a psychiatric illness. The employer must identify the specific behavior that poses a “direct threat.”1

When employees request that their employers make accommodations based on psychiatric disabilities, employers typically require employees to undergo a psychiatric evaluation listing a proper Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),15 diagnosis and recommended reasonable accommodations.

The Family and Medical Leave Act

The Family and Medical Leave Act (FMLA) of 19932 is a federal law requiring covered employers to provide employees with job-protected unpaid leave for qualified medical and family reasons. Qualified medical and family reasons may include personal or family illnesses, including psychiatric conditions. Other reasons may be military leave, pregnancy, adoption, or foster child care. Employees may receive up to 12 weeks of leave in a 12-month period for childbirth or illness or up to 26 weeks of leave in a 12-month period to care for a covered military service member with a serious injury or illness. Employers routinely request FMLA applications to be filled out by psychiatrists for psychiatric conditions necessitating leave.

Disability and Fitness for Duty Examinations

Psychiatrists and other mental health professionals may be asked by a referral source to conduct an IME to evaluate a person's claimed psychiatric disability or to evaluate his or her fitness for duty. These are related evaluations. The former usually arises when a person is professing that a psychiatric condition is hindering his or her ability to work. The latter may arise when the employer is concerned that there may be a psychiatric condition interfering with the employee's ability to perform the duties of his or her job.

Private disability insurers, federal/state government or private employee pension funds, workers' compensation attorneys, workers' compensation third-party plan administrators, plaintiff and defense attorneys, and the Social Security Administration are all potential sources of referrals. The referral question generally involves determining whether a claimant has a mental disorder, and if so, whether the claimant's mental disorder results in partial or total inability to participate in gainful remunerative activity (in their own occupation and/or any occupation).

Attorneys, employers, and/or workers may also seek a psychiatric IME in light of the Americans with Disabilities Act,11 seeking an opinion about whether a worker has a “disability,” whether the disability may be reasonably accommodated, and a description of the appropriate accommodations.

Professional licensing boards, hospitals, and other health care organizations, as well as employers and/or employees may also seek IMEs to evaluate psychiatric disability not for the purposes of disability benefits or ADA, but to determine whether the person is fit for duty and whether treatment and/or monitoring of the person's condition and treatment compliance should be implemented.7Table 1 summarizes the common types of disability examinations the psychiatric examiner might be asked to perform.

Common Types of Psychiatric Independent Medical Examinations

Table 1:

Common Types of Psychiatric Independent Medical Examinations

Conducting the Psychiatric Disability and/or Fitness for Duty Examination

The process of conducting a psychiatric disability evaluation typically begins with contact from the referral source by way of a telephone call, email, or written correspondence. The mental health professional should clarify the exact nature and language of the referral question because many disability plan benefits are defined by specific language. For example, workers' compensation referrals typically ask whether the claimant has a mental disorder, whether the mental disorder was causally related to his or her occupational accident, and whether the mental disorder results in temporarily total disability or permanent partial or total disability.16 Workers' compensation referrals may also seek an opinion about whether the employee has achieved maximum medical improvement of his or her condition that resulted from the workplace injury. Maximum medical improvement is generally defined as the point at which the injured employee's condition has plateaued and is unlikely to benefit in a meaningful way from further medical treatment. An opinion regarding maximum medical improvement is useful for the workers' compensation plan to decide whether to continue to pay for continued treatment of a condition (eg, ongoing psychotherapy sessions for anxiety). Alternately, some referrals will be phrased in more generic language, simply asking the examiner to determine if the claimant has a mental illness that results in psychiatric disability.

Definitions of fitness for duty also vary. For example, the administrative rules of one state medical board require that the examiner determine “Whether there was evidence that [the subject] suffers from any mental disorder or other psychopathology; …whether [the subject] is presently capable of practicing medicine according to acceptable and prevailing standards of care, and what restrictions or conditions, if any, should be placed upon his/her practice.”17 Other fitness for duty referrals may be less specific, inquiring simply whether the person has a mental illness that makes them unfit for his or her job duties.

If examiners establish that the referral question is within the scope of their mental health expertise, then examiners usually discuss their fee expectations with the referral source and inquire about payment. Examiners' fee schedules can vary greatly depending on training background, expertise, and seniority. Whereas some examiners may charge an hourly fee to include time for discussions, preparations, examinations, collateral interviews, record review, report preparation, and depositions or court appearances, some have flat fees for certain routine examinations, such as SSDI/SSI disability examinations. To ensure payment, many examiners collect fees upfront and bill toward retainers for hours worked. It is important to know that physicians must not accept contingency fees, which is compensation dependent on the dispute's outcome,18 as then examiners would no longer be seen as independent but biased toward certain outcomes.

The examiner should request, read, and summarize the claimant's job description and all pertinent medical, psychiatric, personnel, military, and correctional/legal records prior to interviewing the person. The examiner should review these records for documentation relating to (1) the presence/absence of a mental disorder; (2) the nature and severity of psychiatric symptoms; (3) the frequency of symptom occurrence; (4) exacerbating or protective factors; (5) specific impact of psychiatric symptoms on specific job duties; (6) potential for secondary gain; (7) factors that indicate the presence or absence of malingering; and (8) non–illness-related barriers to gainful employment (eg, employee discipline, loss of professional licensure).

After obtaining informed consent for the IME from the person and after providing proper (forensic) disclosure about the nature of the examination (see Guest Editorial in this issue by Dr. Britta Ostermeyer), the examiner then conducts a personal interview and examination, gathering the elements of a forensic mental health examination such as background/social, relationship, educational, occupational, military, religious, legal, medical, abuse, family psychiatric and medical, psychiatric, and substance abuse history. A thorough mental status examination must be conducted as well.

Psychological testing may be of use and should be considered. Commonly administered psychological test measures include the Minnesota Multiphasic Personality Inventory-2 Restructured Form,19 Personality Assessment Inventory,20 and Brief Battery for Health Improvement-2.21 Testing should contain objective validity scales and should seek to assess for current symptoms. Purely subjective test measures (based on self-report only with no validity scales) are typically not helpful.22 Significant attention should be paid to potential malingering by people, because people undergoing disability examinations often hope to be found to be disabled.22 Testing for malingering should be considered if feigning or exaggeration is suspected. Commonly administered malingering instruments include the Miller Forensic Assessment of Symptoms Test,23 Structured Inventory of Reported Symptoms,24 Structured Inventory of Malingered Symptomatology,25 and Test of Memory Malingering.26 If cognition and memory are a concern, the examiner may perform screening using the Montreal Cognitive Assessment,27 and/or the Repeatable Battery for the Assessment of Neuropsychological Status.28 A referral for neuropsychological testing should be considered if more subtle cognitive deficits are an issue.

The independent examiner must seek information through interviews of collateral informants who may have relevant information regarding the nature, frequency, and severity of the subject's symptoms, potential for secondary gain, and other relevant data. Data from collateral informants who have a vested interest in the outcome of the evaluation typically receive less weight in the evaluation compared to data obtained from more neutral, disinterested informants.

Based upon all of the data, the examiner needs to make proper DSM-5 diagnosis(es),15 taking into account the person's self-reported symptoms, observations made during the mental status examination, information gleaned in the medical/psychiatric/personnel/military/correctional/legal records, psychological test results, and data from any disinterested collateral informants. Table 2 summarizes the individual steps of the disability/fitness for duty examination.

Steps for Conducting a Disabilty/Fitness for Duty Examination

Table 2:

Steps for Conducting a Disabilty/Fitness for Duty Examination

Disability Report and Opinion

The disability report should be addressed to the referral source. The body of the report should include a clear statement of the referral issue; a comprehensive list of the sources of information (including all interviews of the person conducted with dates and length, all records reviewed, any psychological testing performed, collateral interviews) and indicate the total number of hours spent in the evaluation and preparing the report. The body of the report should describe the pertinent details of the personal interview and examination, all records reviewed, testing results, and all collateral interviews conducted. All factual data from interviews, records, or any other sources necessary to support the diagnosis(es) and opinion(s) must be contained in the body of the report. No opinions should be expressed in the body of the report.

After completing the body of the report, the examiner should document, using DSM-5 diagnostic criteria, the person's current diagnosis(es). Each diagnosis must be substantiated using factual data contained in the body of the report. Finally, at the end of the report the examiner needs to author a clear opinion, expressing their expert opinion(s) regarding the referral issue(s) and describe in detail the rationale and factual basis supporting the opinion(s). It is helpful to state the standard used in formulating the opinion (eg, specific definition of disability level) in a section above the opinion. The examiner may use specific language from the standard in the opinion as well. For example, one disability level may require “total occupational and social impairment” whereas a lower disability level may require “reduced reliability and productivity.” The opinion should clearly explain the evidence for the level of disability according to the specific definition. Opinions need to be expressed with a reasonable degree of medical certainty.29Table 3 summarizes the different report components.

Components of a Psychiatric Examination Report

Table 3:

Components of a Psychiatric Examination Report

Illustrative Case

The evaluee is a 55-year-old man who formerly worked in a large financial institution as a foreign currency trader, in a fast-paced environment with the potential for both great financial profit and great loss. This was a high-stress occupation due to the rapid pace and intense nature of the work, long hours, and potential for losing money in a single erroneous decision. Six months earlier, the evaluee witnessed a colleague experience a myocardial infarction while at work due, in part, to the high occupational stress.

In recent years, the evaluee had been successful at earning large commissions monthly. However, stress had taken its toll and he perceived himself as emotionally and physically “burned out.” His commission-based income had decreased in recent months, and his most recent performance evaluation reflected his reduced performance.

The evaluee began treatment with a psychiatrist 8 months prior for symptoms of an intermittently depressed mood, irritability, anergia, initial and terminal insomnia, difficulty making decisions, and episodic anxiety. His anxiety centered on his job performance, the subsequent impact with his wife and children, the possibility of large financial losses, and worry that he would suffer the same fate as his colleague. Treatment was only of marginal success.

Four months ago, the evaluee left his foreign currency trader position, moved with his wife and children to another town, and began working as a general contractor. He worked more than 40 hours per week, interacting with customers and building inspectors, and supervising contractors and the construction of several homes. He earned approximately $7,000 per month (much less than the $25,000 per month he earned in his previous job).

His private psychiatric disability insurance policy specified that he could receive disability income benefits if he “experienced a mental disorder that resulted in the inability to participate in sustained gainful remunerative activity (own occupation) for more than 60 consecutive days.” If approved, the disability income benefit provided up to $10,000 per month, for as long as he remained psychiatrically disabled.

The evaluee recently filed a claim for psychiatric disability income benefits with his insurer, seeking full payment of the $10,000 monthly benefit based on the assertion that he was psychiatrically disabled from working as a foreign currency trader.

You are asked to conduct a psychiatric IME and to form an opinion as to whether the evaluee is psychiatrically disabled from working as a foreign currency trader. During your interview, the evaluee reported that although his depression and anxiety are significantly reduced since leaving the financial institution, he continues to experience ongoing irritability, anergia, and sleep disturbance. Additionally, he asserts that should he return to working as a foreign currency trader, his depression and anxiety would worsen and he may die from a myocardial infarction. Mental status examination is unremarkable. The evaluee's primary care and psychiatric records corroborate his consistent complaints of low-level depression, irritability, fatigue, and insomnia. The records indicate a diagnosis of persistent depressive disorder for which a trial of paroxetine (20 mg daily) had been partially successful. Objective psychological testing validity scales indicate he responded to test questions in a consistent fashion without evidence of exaggeration and corroborate his depressed and anxious mood.

Discussion

The evaluee's disability evaluation presents a number of interesting issues. The critical questions in evaluating his psychiatric disability claim include the following:

  • Are his subjectively reported symptoms corroborated through objective evidence (the examination, psychological testing, collateral interviews, medical records)? In this case, the answer was “yes.” His self-reported symptoms are corroborated by his consistent reporting of similar symptoms as documented in his medical and psychiatric records, presentation during the IME, findings on mental status examination, and objective psychological test results. Clearly, his persistent depressive disorder is substantiated. However, simply having a mental disorder does not equate to psychiatric disability.
  • Do the evaluee's current psychiatric symptoms impair him from carrying out the essential job functions of a foreign currency trader? What is the impact of his current low-level depression, anxiety, irritability, anergia, and sleep disturbance on his ability to function as a foreign currency trader? The examiner would need to carefully review the foreign currency trader job description and determine to what extent the evaluee's current symptoms affect (or do not impact) the essential job functions.
  • To what extent has the evaluee chosen to no longer work as a foreign currency trader (due to lifestyle choice, distaste for working long hours in a high-stress job, fear of long-term effects on his physical health, and/or “burnout”) versus whether he is currently unable to perform the duties as a foreign currency trader due to the current symptoms of his mental disorder?
  • To what extent does his current successful performance as a general contractor indicate that he possesses the necessary mental and cognitive abilities to work as a foreign currency trader?
  • To what extent is the evaluee's speculation that, if he returned to work as a foreign currency trader his depression and anxiety would worsen and that he may die from a myocardial infarction, a factor in his perception that he is psychiatrically disabled? Disability is determined by the impact of current symptoms on occupational functioning, not speculation about what may/may not happen at a later date.

The examiner should take all of these factors into account when forming an opinion regarding the patient's psychiatric disability claim.

Conclusion

Given the high prevalence of mental illness among people applying for disability and requesting income benefits, psychiatrists and other mental health professionals may be asked to perform psychiatric IMEs. Examiners should be familiar with general disability income plans and benefits. When asked to perform an IME, mental health professionals must ensure that they are only performing IMEs on people who are otherwise not in a treating clinician-patient relationship with the examiner. Next, examiners need to pay close attention to IME referral questions and ensure that such questions are in their scope of mental health expertise and request, in writing if possible, the exact legal, judicial, or insurance company bylaw standards to be used for answering referral questions. If examiners are not providing treatment to the person to be examined, if they can determine that referral questions are within their mental health expertise, and if the mutual service fee agreements have been been reached with referral sources, then examiners can arrange to perform a detailed psychiatric examination on the person. At the time of such examinations, it is imperative for examiners to obtain informed consent for the IME and to carefully disclose to the person the inherent differences between IMEs and usual treatment services. Examiners need to be cautious about potential malingering by people and obtain copies of their prior medical, psychiatric/substance abuse, school, military, correctional/legal or other records, as well as seek collateral sources of information. Finally, examiners compile reports detailing the IME framework of the examination, the full psychiatric examination, reviewed records, collateral sources of information, the Mental Status Examinations, psychological or other testing results, proper DSM-5 diagnosis(es), and expert opinions with recommendations.

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  24. Rogers R, Sewell KW, Gillard ND. SIRS-2: Structured Interview of Reported Symptoms. 2nd ed. https://www.parinc.com/Products/Pkey/414. Accessed January 11, 2018.
  25. Smith GP, Widows MR. Structured Inventory of Malingered SymptomatologyTM (SIMS). https://www.parinc.com/Products/Pkey/410. Accessed January 11, 2018.
  26. Tombaugh TN. Test of Memory Malingering (TOMM™). https://www.pearsonclinical.com/psychology/products/100000191/test-of-memory-malingering-tomm.html. Accessed January 11, 2018.
  27. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. http://www.mocatest.org/. Accessed January 11, 2018.
  28. Randolph C. Repeatable Battery for the Assessment of Neuropsychological Status (RBANS®). https://www.pearsonclinical.com/. Accessed January 11, 2018.
  29. Gold LH, Anfang SA, Drukteinis AM, et al. AAPL practice guideline for the forensic evaluation of psychiatric disability. J Am Acad Psych Law. 2008;36:S3–S50.

Common Types of Psychiatric Independent Medical Examinations

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For disability income benefit requests <list-item>

Social Security Disability Insurance

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Supplemental Security Income

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Federal and state government pension plans

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Veterans' Administration

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Private employee pension funds

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Federal and state worker's compensation programs

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Private disability insurance

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For emotional/psychic damage allegations

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For Americans with Disability Act accommodation requests

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For Family and Medical Leave Act requests

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For fitness for duty (eg, job, military, school, professional sports team)

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Steps for Conducting a Disabilty/Fitness for Duty Examination

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Contacted by referral source (eg, attorney, employer, school, insurance company)

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Clarify exact nature of referral question and exact question to be answered by psychiatric examiner/expert; ensure question is within your psychiatric expertise

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Obtain (preferred in writing) precise standard to be used (eg, for determination disability)

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Discuss examination fee payment arrangements (eg, who pays, what fee, and when)

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Explain examination scope and logistics and schedule examination

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Request records to be sent to you (often sent via email)

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Review of records

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Make list of potential collateral sources you wish to contact and prepare consent forms so you can contact collateral sources

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Perform the examination

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Schedule collateral interviews (in person or via telephone)

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Perform collateral interviews

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May need to contact the patient to clarify any questions you may have

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Prepare your examination report

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Components of a Psychiatric Examination Report

First part <list-item>

Report usually addressed to referral source

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Brief statement of examination purpose

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Consent for independent medical examination by the evaluee and disclosure statement (ie, explain purpose of independent medical examination)

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List of sources (eg, all interviews conducted and all documents reviewed)

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Second part (body of report) <list-item>

Psychiatric examination, including background/social, relationship, educational, occupational, military, religious, legal, medical, abuse, family psychiatric and medical, psychiatric, and substance abuse history

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Additional examination data (eg, review of daily activities)

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Summary/highlights of records, other reports, and communications

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Summary of job description or other pertinent information

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Collateral interviews (eg, supervisor, peers, witnesses, neighbors, family)

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Third part <list-item>

Mental Status Examination

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Psychological testing results

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Fourth part <list-item>

Diagnosis section

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Opinion section

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Brief summary of findings and recommendations

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Full name, degree(s), academic/employer affiliations of the examiner

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Authors

Stephen G. Noffsinger, MD, is an Associate Professor and the Associate Program Director, Forensic Psychiatry Fellowship Program, Department of Psychiatry, Case Western Reserve University School of Medicine. Adrienne Saxton, MD, is an Assistant Professor of Psychiatry, Department of Psychiatry, Case Western Reserve University School of Medicine. Britta Ostermeyer, MD, MBA, FAPA, is the Paul and Ruth Jonas Chair in Mental Health and a Professor and the Chairman, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center.

Address correspondence to Stephen G. Noffsinger, MD, Department of Psychiatry, Case Western Reserve University School of Medicine, 10524 Euclid Avenue, Cleveland, OH 44106; email: sgn3@case.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20180110-02

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