Depression

The Beatles once sang "I’m down/ I’m really down/ How can you laugh when you know I’m down?" Everyone has days when they feel down. It’s normal to have mood changes. Imagine what it would be like to have days on end when you were so depressed you couldn’t leave your home, experienced repeated episodes of tearfulness, and couldn’t tolerate being around other people. Patients with clinic depression have many such days. They can become so depressed that they are unable to work on a full time basis. This column will review the standards used by the Social Security Administration (SSA) to evaluate disability claims based on depression.

To award disability benefits on the basis of mental health impairments the SSA requires "documentation of a medically determinable impairment, consideration of the degree of limitation such impairment may impose on your ability to work, and consideration of whether these limitations have lasted or are expected to last for a continuous period of at least 12 months."

The SSA rules which govern depression appear under its Listing for Affective Disorders. SSA’s describes Affective Disorders as "characterized by a disturbance of mood, accompanied by a full or partial manic or depressive syndrome. Mood refers to a prolonged emotion that colors the whole psychic life. It generally involves either depression or elation."

To meet the level of disability that will result in the payment of disability benefits, the SSA requires the patient’s condition to meet certain symptoms described in "A" and "B" criteria or to meet the symptoms described in "C" criteria. The "A" criteria "substantiate medically the presence of a particular mental disorder." This covers such things as signs, symptoms and laboratory findings. The "B" and "C" criteria "describe impairment-related functional limitations that are incompatible with the ability to do any gainful activity."

1. Depressive Syndrome: The "A" criteria are met if the patient has been diagnosed with depressive syndrome with at least 4 of the following:

a. Pervasive loss of interest in almost all activities

b. appetite disturbance with change in weight

c. sleep disturbance

d. psychomotor agitation or retardation. Psychomotor agitation is an increase in physical activities such as restlessness, pacing, wringing hands, tapping fingers, chewing fingernails or fidgeting. Psychomotor retardation is a slowing down in mental and physical functioning such as

difficulty in motivating oneself to take showers, change clothes, lack of interest in personal hygiene, getting out of bed, doing household chores, shopping, balancing check books and forgetting appointments.

e. Decreased energy

f. feeling of guilt or worthlessness

g. difficulty in concentrating or thinking

h. thoughts of suicide

i. hallucinations, delusions or paranoid thinking

2. Manic Syndrome: If the patient has been diagnosed with manic syndrome with at least 3 of the following:

a. hyperactivity

b. pressure of speech

c. flight of ideas

d. inflated self-esteem

e. decreased need for sleep

f. easy distractibility

g. involvement in activities that have a high probability of painful consequences which are not recognized.

h. hallucinations, delusions, or paranoid thinking,

3. Bipolar syndrome: if the patient has a history of episodic periods manifested by full symptoms of both manic and depressive syndromes which result in at least two of the following

"B" criteria

"B" Criteria

1. Marked restriction of activities of daily living. Activities of daily living include such things as "cleaning, shopping, cooking, paying bills, maintaining a residence, and appropriate personal grooming and hygiene." "Marked" limitation means more than a moderate limitation but less than extreme.

2. Marked difficulties in maintaining social functioning. Social functioning describes the person’s ability to "interact independently, appropriately, effectively on a sustained basis with other individuals." This includes the ability to get along with others such as family members, friends, neighbors, and store clerks. Impaired social functioning can be demonstrated by "a history of altercations, evictions, firings, fear of strangers, and social isolation."

3. Marked difficulties in maintaining concentration, persistence and pace. This refers to the ability "to sustain focused attention and concentration long enough to permit the timely and appropriate completion of tasks commonly found in work settings."

4. Repeated episodes of decompensation, each of extended duration. Episodes of decompensation are temporary increases in symptoms accompanied by a loss of adaptive functioning." Decompensation episodes are demonstrated by an increase in symptoms that would usually require increased treatment or a less stressful situation such as hospitalization, placement in a halfway house or highly structured living environment. Repeated episodes means 3 episodes within 1 year or an average of once every 4 months with each episode lasting at least 2 weeks.

"C" Criteria

A history of medically documented chronic affective disorder lasting at least 2 years that has "caused more than a minimal limitation of ability to do basic work activities, with symptoms reduced by medication or psychosocial support with one of the following:

1. Repeated episodes of decompensation each of extended duration; or

2. A residual disease process that has resulted in the patient’s inability to make even marginal adjustments that "even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate; or

3. A current history of being unable to function out of a highly supportive living arrangement (such as a group home) with an indication of a continued need for such an arrangement.