Comments in Response to Advance Notice of Proposed Rulemaking on Criteria for Evaluating Mental Disorders
The Depression and Bipolar Support Alliance (DBSA) submits these comments in response to the March 17, 2003, notice in the Federal Register that the Social Security Administration (SSA) intends to revise the rules used to evaluate mental disorders in adults and children who apply for, or receive, disability benefits.

DBSA believes that the current listings for mental impairments used for disability payments under title II and Supplemental Security Income (SSI) payments based on disability under title XVI of the Social Security Act generally work well. Therefore, major revisions to the listings are unnecessary. However, certain refinements to the current definitions would serve to improve the existing system. In addition to our comments on the listings, we will address SSA's broader interest in improvements to the evaluation of adults and children with mental disorders to determine eligibility for benefits.

Medical and Non-Medical Evidence
The current distinction between medical and non-medical evidence in evaluating a claim often relegates a significant source of treatment information to a secondary status. This occurs because the current regulations require an "acceptable medical source" to establish a "medically determinable mental impairment." Once this impairment is established, other sources, such as therapists, social workers, nurse practitioners and educators, may be utilized to demonstrate the severity of the impairment and its limitations. However, reports or comments from these sources do not constitute medical evidence under the existing regulations.

In a significant number of cases, individuals involved in treatment programs are far more likely to be in frequent contact with licensed health professionals who do not meet the threshold definition of a medical source. These professionals often see an individual on a daily or weekly basis. Yet their evidence often is given less weight by adjudicators in determining the severity of an impairment than a psychiatrist, consultative examiner or state agency physician who might see the individual less frequently, sometimes only once, or who only review a file.

Recommendation: SSA should provide greater guidance to adjudicators through separate regulations to treat evidence from licensed health professionals, clinics or medically supervised treatment plans as medical evidence.

Co-occurring Disorders
A high percentage of patients with mental illness also have alcohol and substance abuse problems, just as a measurable number of alcohol and substance abuse patients are also diagnosed with mental illness. Long-term follow-up studies of adults who experienced depression as children or children at high risk for depression by virtue of parental depression show that there is a sequential unfolding, with depression developing or recurring around puberty and substance abuse developing later in young adulthood, especially in males.

With two separate mental health systems - one for traditional mental illness and another for alcohol and substance abuse, patients who should be treated for both alcohol and substance abuse and mental illness most often are treated for one or the other - not both. DBSA has long advocated for integrated treatment by dually trained professionals for patients with dual diagnosis.

Recommendation: In the case of the proposed rulemaking. SSA should provide greater clarity to adjudicators that alcohol or substance abuse should not constitute single factors for rejection of a claim. SSA should further clarify that these conditions, while not in all cases, may, in fact, in some, be symptoms of a mental impairment and, thus, relative to the determination of disability.

Medication
In many cases, appropriate medication will treat overt signs and symptoms (as defined by SSA's "A" criteria) but not those related to function (as defined by the "B" criteria). The result may mean that a person receiving appropriate pharmaceutical treatment may not meet the A criteria, even though those signs and symptoms were part of the original assessment of disability.

Recommendation: SSA should provide clarity in the regulations to ensure that individuals qualify for disability if they meet the B criteria and were diagnosed under the A criteria, even though overt signs and symptoms are subsequently controlled through the use of medication. Additionally, SSA should strengthen the C criteria to ensure that the effects of medication on signs, symptoms and ability to function, as well as side effects on patients, are sufficiently reviewed by adjudicators.

General Accounting Office Recommendations
The General Accounting Office (GAO), in its August, 2002, report, SSA and VA Disability Programs: Re-Examination of Disability Criteria Needed to Help Ensure Program Integrity, recommended that SSA initiate a "comprehensive consideration of medical treatment and assistive technologies" as part of the determination of eligibility. GAO noted that mental disorders accounted for 27% of Disability Insurance (DI) payments in 2000 and that these conditions were among the fastest growing in the DI program, having increased by 7% since 1986. Under the Supplemental Security Income (SSI) program, which provides benefits to disabled, blind or aged individuals with low income and limited resources, mental disorders accounted for 35% of SSI distributions and were also the fastest growing in that program, increasing 9% since 1986.

If SSA implements this recommendation without considering the overall availability and affordability of many of the pharmaceutical treatments on which GAO bases its conclusion, the effect could be extraordinarily harmful to many claimants. For example, since Medicare does not currently include a drug benefit, many individuals could not afford the pharmaceuticals that GAO contemplates as part of the eligibility review even while they are enrolled in the DI program. Moreover, under SSI, it is often the corresponding eligibility for Medicaid that allows individuals access to needed prescriptions. Because many states are moving to a "foul first" Medicaid drug benefit, it can be years before Medicaid recipients are able to receive the pharmaceutical treatments reviewed by GAO, even in the best of circumstances. Therefore, while some individuals could return to work while receiving the appropriate pharmaceutical treatment, these same prescriptions may be unaffordable under the current system.

Recommendation: SSA should refrain from implementing GAO's recommendation until such time as individuals with mental impairments can have affordable access to the appropriate medical treatment and assistive technologies that could be a part of the determination of disability.

Chronic Mental Impairments
Section 12.00, subsection E, should incorporate the conclusions of Social Security Ruling (SSR) 85-15 on titles II and XVI: The Capability To Do Other Work. In particular, the finding that "good mental health services and care may enable chronic patients to function adequately in the community by lowering psychological pressures, by medication, and by support from services such as outpatient facilities, day care programs, social work programs and similar assistance" should be included in determining eligibility but be expanded to include peer-to-peer oriented assistance. Peer-based services are being used as a model for rehabilitation and funded through Medicaid in various states across the country.

For example, DBSA has a grassroots network of more than 1,000 patient-run support groups that hold regular meetings across the United States and Canada. More than 50,000 people attend chapter support groups annually. Support groups play an important role in recovery, with 86 percent of support group members reporting that their group helped with treatment adherence.

Recommendation: Expand Section 12.00. Subsection E, to include SSR 85-15 language with the addition of peer-to-peer oriented support groups.

Greater Ease of Application
The existing application processes for disability and supplemental security income payments can be daunting for individuals with mental disorders. Paperwork requirements, including psychiatric history documentation, medical treatment and hospitalization, crowded SSA field offices, hearing appointments and requests in the appeals process before an Administrative Law Judge often discourage claimants seeking disability for a mental impairment.

Recommendation: SSA should recognize the distinct needs of individuals filing claims for mental impairment, particularly for failure to timely file necessary documents or appeals before rejecting a claim. Further, SSA should expand presumptive eligibility for persons with mental disorders and, specifically, for individuals with a history of serious mental illness for SSI eligibility.

Summary
DBSA agrees with SSA's statement in its Advance Notice of Proposed Rulemaking that many people with mental disorders might not need benefits if they could get treatment before their disorders make them unable to work. We further agree that many people with permanent disorders can work if they have a supporting safety net and we urge SSA to encourage peer-to-peer services as part of that support network. As it concludes its rulemaking process, SSA should avoid taking any steps that serve to reduce the safety net that has been developed through title II disability benefits and SSI payments. We recognize that the current listings of mental impairments for adults have not been revised since 1985 and the childhood listings since 1990. Further, advances in medicine and mental health treatment regimens since the listings were last revised merit SSA 's current update. However, it is essential that SSA 's revisions to the existing regulations take into account the lack of affordable access to new treatments and pharmaceuticals by individuals with mental disorders as part of any change in disability evaluation. The issue of co-occurring disorders must be addressed to recognize that alcohol and substance abuse may, in many cases, be contributing factors to and symptoms of a mental disorder. In addition, evidence from licensed health professionals, clinics or medically supervised treatment plans should be treated as medical evidence. Finally, we encourage SSA to recognize and draw upon the vast resource of community-based, peer support groups that organizations like DBSA have created across the country.