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Don't argue with an insomniac.
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I. I need to write this and get it posted before the Fingermen come and black bag me.

So you want to file a psychiatric disability claim against your former employer? Too bad.

Say you're poor and have never worked. You apply for Welfare/cash payments and state Medicaid. You are obligated to try and find work or be enrolled in a jobs program in order to receive these benefits. But who needs that? Have a doctor fill out a form saying you are Temporarily Incapacitated due to Medical Illness. Yes, just like 3rd grade. The doc will note the diagnosis, however, it doesn't matter what your diagnosis is, it only matters that a doctor says you are Temporarily Incapacitated. So cancer and depression both get you the same benefits.

Nor does it matter if he medicates you, or even believes you, so long as he signs the form and writes "depression."(1) The doc can give you as much time off as he wants (6 months is typical) and you can return, repeatedly, to get another filled out. You can be on state medicaid and receive cash payments for up to 5 years. So as long as you show up to your psych appointments, you'll can receive benefits with no work obligation.



in 2006 dollars. Which way does inflation go again?



II. "That's not how it works for me!"

...you might say, which brings us to the whole point: it's not for you. It is for the entire class of people we label as poor, about whom comic Greg Geraldo joked: "it's easy to forget there's so much poverty in the United States, because the poor people look just like black people." Include inner city whites and hispanics, and this is how the government fights the War On Poverty.

In the inner cities, the system is completely automated. Poor person rolls in to the clinic, fills out the paperwork (doc signs a stack of them at the end of the day), he sees a therapist therapist, a doctor, +/- medications, and gets his benefits.

There's no accountability, at all. I have never once been asked by the government whether the person deserved the money, the basis for my diagnosis-- they don't audit the charts, all that exists is my sig on a two page form. The system just is.

see if you can find the one poor person hidden in this picture



III. But what happens when your five years on the dole are up?


Enter SSI, Supplemental Security Income. You can earn lifetime SSI benefits (about $600/mo + medical insurance) if "you" can "show" you are "Permanently Disabled" due to a "medical illness."

"You"= your doc who fills out a packet with specific questions; and maybe a lawyer who processes the massive amounts of other paperwork, and argues your case, and charges about 20% of a year's award.

"show" has a very specific legal definition: whatever the judge feels like that day. I have been involved in thousands of these SSI cases, and to describe the system as arbitrary is to describe Blake Lively as "ordinary."



this non-sequitor here entirely for my own benefit. Thank you for your patience



"Permanently disabled" means the illness prevents you from ever working. "But what happens when you get cured?" What is this, the future? You can't cure bipolar.

"Medical illness" means anything. The diagnosis doesn't matter, only that "you" show how the diagnosis makes it impossible for you to work. Some diagnoses are easier than others, but none are impossible. "Unable to work" has specific meaning, and specific questions are asked: ability to concentrate, ability to complete a workweek, work around others, take criticism from supervisors, remember and execute simple/moderately difficult/complex requests and tasks, etc.

Fortunately, your chances of being awarded SSI are 100%. ("Not for me!" Again, it's not for you.) You may be awarded it on the first try; you may be denied and then get it on appeal; you may need a SSI hearing before the judge; or you may apply five or six times and finally get it after ten years. But if you are persistent, you will get it. (2)

IV. Why Would Anyone Permit Such A Flawed System?

At this point you are probably wondering about abuse of the system, people lying, pretending they have psychiatric illnesses just to get the benefits. If you think this-- a natural thought, I'll admit-- then you need to turn off the network news and go watch Network the movie. You're being lied to, by yourself.


i have no idea what's going on in Darfur, so I called an expert



The system isn't flawed, it isn't easily gamed: it is set up this way on purpose. The government wants you to get SSI, because it wants you off the state welfare budget and onto the federal budget, which, as you know, has unlimited funds because it can run deficits, print money, and invade Poland.

Last year SSI paid 8M people about $45B. 60% of those under 65 had a "mental disorder." Did many have a legitimate disorder? Sure. Whatever. But when the system ties benefits to a mental disorder, the point is the benefits, not the mental disorder.

What you should be asking is why, if society has decided to give the poor a stipend of $600/month, does it do this through the medical establishment and not as a traditional social policy? And the answer is very simple:


  1. you, America, would go bananas if poor people got money for nothing, you can barely stand it when they get it for a disability;
  2. if you offload a social problem to medicine, if you medicalize a social problem, then you've bought yourself a generation or two to come up with a new plan or invade Russia.
Do you want riots in the streets? How much does it cost to prevent LA (your choice) from catching fire? Answer: $600/month, plus Medicaid. Medicalizing social problems has the additional benefit of rendering society not responsible for those social ills. If it's a disease, it's nobody's fault. Yay empiricism.

Those who are arguing about the cost of healthcare or think that poor people are lying to get benefits are completely and utterly missing the point of the system. It wants this in the hands of doctors, because it would be toxic to everyone else. Can you imagine your Senator deciding who gets benefits and who doesn't?

And maybe these people get some meds as well. You know what counts as an outcome in inner city psychiatry? Guy doesn't punch his kid in the face. Or girl doesn't throw a brick at her man's testes while he's asleep. One less instance of domestic violence a month. "Well, goddam, I don't see those in the DSM-V. How much is that outcome going to cost us?" $600/month + Abilify+ Xanax + Celexa. And you can pretend it doesn't exist.

IVb. Who Pays for SSI?

SSI is funded through income taxes. It does not come from Social Security taxes. Pause for effect.

In theory, SSI payments to a child (hey, ADHD counts) would be reduced by unearned income-- including child support payments. If you've ever wondered why deadbeat dads aren't more vigorously pursued by moms, that's it. (3)

The other reason is that a deadbeat dad who collects SSI isn't obligated to make child support payments. He's disabled, after all. Phew. The kid's the government's problem.

V. It's not for you.

As easy and streamlined as this process is for the inner city guy with no other resources, it is that much harder for anyone with a driveway. It isn't for you. I know this because, by the way you phrased your question, do not own a gun and are not likely to set your town on fire when your team wins/loses. I realize in your case you're filing a disability claim with an employer, but the idea is the same: you did work. How do you show you now can't work? It would have been easier to "prove" you can't work if you never worked. That's SSI.

The "key" to your disability claim-- and your chances are not great but consult with your lawyer-- is to show how the depression impairs your cognition. Lack of energy and suicidality may sound important, but the illness has to link directly to an impairment. Not being able to read a paragraph or perform a simple repetitive task are impairments. Wanting to die is not an impairment. Prove to the judge you can't pack a box or stack some cans.

Meanwhile: do you think none of those 4M psychiatric SSI beneficiaries can pack a box or stack some cans? Of course they can't. How could they? They're depressed.

"But $600/month isn't even enough to cover the rent!" Oh, I'm not saying it's a lot, I'm saying that's exactly how much it costs to keep your city from an infrastructure upgrade. All it took to get stupid France to riot was raising the retirement age by two years. "That's a really unsophisticated understanding of the issue." Shut it. I said shut it.

VI. No one cares what you think.

I'm guessing that this probably upsets people, on both sides of an imaginary political divide that only took 40 years to get perfect. Thanks TV! Certainly I have my own opinions, but it doesn't matter what I think, what matters is what is. This is the system. If you think you can effect a huge social overhaul then feel free to vote for Hope And Change and ongoing Afghanistan deployments, otherwise understand how it works before you spew nonsense to your local Fox affiliate. "Hi, this is Bill from Cleveland, and I blame liberals." Son of a *****, why didn't I think of that.

The system not only pays poor people, it employs lots and lots of almost poor people. I'm not saying this is a good thing, or a desirable thing, I am simply stating a fact. Some of these are direct government jobs (e.g. staff down at the SSI office) and some are pretend private sector jobs. If you're a psychiatrist at an inner city clinic, you may think you're an independent contractor, but you're really working for The Man (but with no pension.) That's the system. Cut SSI payments and those docs-- and nurses and etc-- don't get paid.

"Are you saying these patients are not mentally ill?" No, many of them are. Too sick to work is another story, but whatever-- sure, those people could use a psychiatrist. But there's a fine line-- by which I mean gigantic chasm-- between mental illness as a result of a 13q33 polymorphism and mental illness due to roaches crawling through your hair while you sleep. What the hell is Abilify supposed to do for that? You're going to need heroin.




for some reason my kid always wakes up inattentive


VII. This is how it works, like it or not.

An inner city psychiatrist sees 20-40 people a day. 15 minute med checks, which in a city is 5 or 10 minutes. "Any major symptoms? Suicidality? Side effects? Here's your refill." You try and pull that off in a suburban area and the Feds will be shooting your dog to access your backdoor. But in the city (and I'm guessing rural areas) that's the standard. The government allows it because someone has to deal with those "patients." The government doesn't any other options.

Same with benzos (Xanax, Klonopin, Valium, etc) and narcotics (percocet, MS Contin etc.) Once in a while some doc gets publicly arrested for handing out Vicodins in Valu-Packs, but the amount of benzos being routinely prescribed in an inner city is unbelievable. Go to your suburban doc and try and beg for a few Xanax. Come to the inner city and you can get #90 Xannies on first visit. Why? Because the government isn't going to mess with the eleven or so sandbags they have placed in each neighborhood to hold back a flood of proletariat rage. Patients want them (to use, to sell, whatever) and docs give them because if they didn't, they wouldn't come back. If they don't come back, what are they going to do instead? Go work for Walmart? No, they're going to burn it.

And there's plenty of money to be made for the entrepreneurial. If you want to be rich in inner city psychiatry (and you don't have to be a doc), you open a clinic and hire 1 psychiatrist and lots of (talk) therapists, usually social workers. Medicaid will pay for 1 therapy visit per week (around $60/hr) and a 15 minute med check with the doc ($40/visit). The doc usually gets salaried but proportionally takes 50% of that. Let him have it all. The therapist, however, gets very little-- $20/hr. The rest goes to the clinic. If the clinic serves 100 patients, the clinic can bill $24000 a month in therapy, pay $8000 to the therapists and pocket $16k a month, minus overhead and security guards. Do you know how many patients go to clinics? Thousands. Do the math.

Do all these patients need the therapy? Of course not. But they have to go to therapy because the clinic requires it (integrated care), and they need the clinic because that's how they're getting their SSI, not to mention the Klonopin. The docs need them to come because that's how they earn their living, and the government allows this because it needs someone to deal with American poverty until either we discover cold fusion or the aliens invade. The government doesn't tolerate this, it doesn't turn a blind eye towards it, it explicitly allows it. The only thing it forbids is billing for a service not performed (e.g. ghost patient.)

The new move is for inner city primary care clinics to perform a "depression screening" (questionnaire in the waiting room) and bill out a psych visit along with the normal visit.

The rise of psychiatry is parallels the rise of poverty in industrialized societies. The reason you see psychiatry in the U.S. but not in the Sudan isn't because there's no money for it in the Sudan, but because there is not enough money in the US to make some people feel like they're not in the Sudan. Hence Zoloft. It is the government's last resort to a social problem it may or may not have created, whatever, but has absolutely no other way of dealing with. Predictably, world psychiatry will also be the temporary solution to world poverty until the aliens come to see what became of their 6000 year experiment. So invest in Pfizer, it will only go up. It has to.

I have no time to edit or rewrite this, they have already kicked in the door. If I don't return, avenge my death.


I (Frankie) did not write this. I just came across it, and I know a few TSBSers might find it interesting.
 

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Interesting find. I have multiple thoughts about this whole issue, being as I work with many of the people that are described. There are people that are malingering, obviously, some for money, others for drugs. Miraculously, the vast majority of psych patients we see are not malingering. It's funny how the system works. Some people that are likely malingering, seem to get SSI in very short order. Others, that obviously have multiple disabilities, the system takes 3 years to approve their disability and they lose their house, their marriage, and their family. This whole problem is the reason why I STOPPED filling out disability forms several years ago, unless it is blatantly obvious. I tell patients that I am here to help them get better, and that is my focus. The MD's do see 20-30 patients a day for 15 minute med checks, then make rounds at the Inpatient Unit and some of them even do private practice on top of that. As far as the "psych clinic" pocketing the money, I suppose a private clinic would pocket some cash. The problem with that is the vast majority of these clinics are government run, which means accounting for cash, being non-profit, low salaries, and if you don't spend your budget, you send the money back and get less next year. There are many things wrong with the system but I am too tired from working all day with psych patients to write anymore :D
 

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I have to admit, I didn't make it past Blake Lively.
Well there were words there and then it got all blurry except for the pic and a link. I could not scroll any farther down, at least not with that hand....
 
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