Psychiatric Issues in Behavioral Health Disability

  • Bettina B. Kilburn


This chapter explores the essential differences between two important professional roles that a psychiatrist may routinely practice. The distinction is important because of the separate professional responsibilities associated with each. A psychiatrist may engage in the psychiatric disability or workers’ compensation process in either a forensic role or as a treating provider. Thus, it is imperative for a psychiatrist to be aware of these differences in order to avoid intrinsic ethical and potential legal issues when one attempts to perform both roles simultaneously. As a treating provider, the psychiatrist is in a position to improve an individual’s overall health function by many measures, increase quality of life for mentally ill individuals and families, and impact the multidimensional costs of mental illness. There is a growing body of evidence to support that shorter recovery and better clinical outcomes result from focusing psychiatric treatment on restoration and maintaining function. This is in contrast to traditional psychiatric thinking that recovery from mental illness requires an individual to be “away from” the demands of a stressor, such as his or her work situation. There are numerous evaluations and treatment approaches available to the treating psychiatrist who wishes to shift away from the traditional paradigm in order to serve as an advocate for his or her patient, as well as in promoting the individual’s full participation in work and in other life activities.


Psychiatry Disability Behavioral health Forensic role Medicalization Psychiatric occupational function Malingering Work stress Return to work 



Each of us has the privilege of learning on the shoulders of others. In formulating this chapter, I have drawn deeply from the well of extensive research by many scholars and practitioners, to whom I am in great debt. Special thanks to Jennifer Christian, M.D., President and CMO of Webility Corporation and Founder of Work Fitness and Disability Roundtable and Jeffrey P. Kahn, M.D., CEO, WorkPsych Associates, Inc. for providing a wealth of foundational research and to Jeffrey Segal, M.D., J.D., F.A.C.S., CEO of Medical Justice, for invaluable assistance in defining and articulating the forensic psychiatric role.


  1. Allison, T. G., Williams, D. E., Miller, T. D., et al. (1995). Medical and economic costs of psychologic distress in patients with coronary artery disease. Mayo Clinic Proceedings, 70, 734–742.CrossRefGoogle Scholar
  2. American Academy of Psychiatry and the Law. (2005). Ethics guidelines for the practice of forensic psychiatry. Available at
  3. American College of Occupational and Environmental Medicine (ACOEM). (2006). Preventing needless work disability by helping people stay employed. Journal of Occupational and Environmental Medicine, 48, 972–987.CrossRefGoogle Scholar
  4. American Psychiatric Association. (2003–2016). Clinical practice guidelines., accessed January 1, 2018
  5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th edition. Washington, D.C.: American Psychiatric AssociationGoogle Scholar
  6. American Physical Therapy Association. (2009). Guidelines: occupational health physical therapy: work conditioning and work hardening programs. Available at
  7. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th edition, text revision. In Washington. D.C: American Psychiatric Association.Google Scholar
  8. American Psychiatric Association. (2006). Practice guidelines for the treatment of psychiatric disorders, compendium (p. 2006). Washington, D.C: American Psychiatric Association.Google Scholar
  9. American Psychiatric Association. (2006). Practice guidelines for the treatment of psychiatric disorders 2006. Condition specific guidelines updated through 2017. Washington, D.C: American Psychiatric Association.Google Scholar
  10. American Psychiatric Foundation, Partnership for Workplace Mental Health. (2005). Assessing and treating psychiatric occupational disability: new behavioral health functional assessment tools facilitate return to work. Available at
  11. Barofsky, I. (1978). Compliance, adherence, and the therapeutic alliance: Steps in the development of self care. Social Science and Medicine, 12, 369–376.PubMedGoogle Scholar
  12. Barsky, A. J., Delamanter, B. A., & Orav, J. E. (1999). Panic disorder patients and their medical care. Psychosomatics, 40, 50–56.CrossRefGoogle Scholar
  13. Bartley, M. (1994). Unemployment and ill health: Understanding the relationship. Journal of Epidemiology and Community Health, 48, 333–337.CrossRefGoogle Scholar
  14. Binder, L. M. (1993). Portland digit recognition test manual. Beaverton, OR: Laurence Binder.Google Scholar
  15. Blackwell, B. (1976). Treatment adherence. The American Journal of Psychiatry, 129, 513–531.CrossRefGoogle Scholar
  16. Chodoff, P. (2002). The medicalization of the human condition. Psychiatric Services, 53, 627–628.CrossRefGoogle Scholar
  17. Conrad, P. (2007). The medicalization of society: On the transformation of human conditions into treatable disorders. Baltimore: Johns Hopkins University Press.Google Scholar
  18. Druss, B. G., Rosenheck, R. A., & Sledge, W. H. (2000). Health and disability costs of depressive illness in a major US corporation. The American Journal of Psychiatry, 157, 1274–1278.CrossRefGoogle Scholar
  19. Egede, L. E. (2004). Diabetes, major depression, and functional disability among US adults. Diabetes Care, 27, 421–428.CrossRefGoogle Scholar
  20. Eisenthal, S., Emery, R., & Lazare, A. (1979). Adherence and the negotiated approach to parenthood. Archives of General Psychiatry, 36, 393–398.CrossRefGoogle Scholar
  21. Ekman, P. (1985). Telling lies: Clues to deceit in the marketplace, politics, and marriage. New York: Norton.Google Scholar
  22. Fenton, W., Blyler, C., & Heinssen, R. (1997). Determination of medication compliance in schizophrenia: Empirical and clinical findings. Schizophrenia Bulletin, 23, 637–6510.CrossRefGoogle Scholar
  23. Fishbein, M., & Ajzen, J. (1975). Belief, attitude, intention, and behavior. Reading: Massachusetts.Google Scholar
  24. Frances, A. (2009). A warning sign on the road to DSM-V: Beware of its unintended consequences. Psychiatric Times, 26(8), 1–9.Google Scholar
  25. Frederick, R., Sargaty, S., Johnston, J. D., et al. (1994). Validation of a detour response bias on a forced-choice test of nonverbal ability. Neuropsychology, 8, 118–125.CrossRefGoogle Scholar
  26. Garriga, M. (2007). Malingering in the clinical setting. Psychiatric Times, 24(3), 1–4.Google Scholar
  27. Gerdtham, U. G., & Johannesson, M. (2003). A note on the effect of unemployment on mortality. Journal of Health Economics, 22, 505–518.CrossRefGoogle Scholar
  28. Goldfinger, S. M., Hopkin, J. T., & Surber, R. W. (1984). Treatment resisters or system resisters?: Toward a better service system for acute care recidivists. New Directions for Mental Health Services, 21, 17–27.CrossRefGoogle Scholar
  29. Greenberg, P. E., Kessler, R. C., Nells, T. L., et al. (1996). Depression in the workplace: An economic perspective. In J. P. Feighner & W. F. Boyer (Eds.), Selective serotonin re-uptake inhibitors: Advances in basic research and clinical practice. New York: Wiley and Sons.Google Scholar
  30. Hales, R. E., Yudofsky, S. C., & Gabbard, G. O. (2008). The American psychiatric publishing textbook of psychiatry (5th ed.). Arlington, VA: American Psychiatric Publishing.Google Scholar
  31. Hall, J. A., & Dornan, M. C. (1988). What patients like about their medical care and how often they are asked: A meta analysis of the satisfaction literature. Social Science and Medicine, 27, 935–939.CrossRefGoogle Scholar
  32. Harris, I., Multford, J., Solomon, M., et al. (2005). Association between compensation status and outcome after surgery. Journal of the American Medical Association, 293, 1644–1652.CrossRefGoogle Scholar
  33. Haynes, R. B., Taylor, D. W., & Sackett, D. L. (1979). Compliance in health care. Baltimore: Johns Hopkins University Press.Google Scholar
  34. Horwitz, R. I., & Horwitz, S. M. (1993). Adherence to treatment and health outcomes. Archives of Internal Medicine, 153, 1863–1868.CrossRefGoogle Scholar
  35. Jin, R. L., Shah, C. P., & Svoboda, T. J. (1995). The impact of unemployment on health: A review of the evidence. Canadian Medical Association Journal, 153, 529–540.PubMedGoogle Scholar
  36. Johnson, D. A. W. (1979). Further observations on the duration of depot neuroleptic maintenance therapy in schizophrenia. The British Journal of Psychiatry, 135, 524–530.CrossRefGoogle Scholar
  37. Kahn, J. P. (2008). Diagnosis and referral of workplace depression. Journal of Occupational and Environmental Medicine, 50, 396–400.CrossRefGoogle Scholar
  38. Kahn, J. P., & Aidinoff, S. (1999). Occupational psychiatry and the employee assistance program. In J. Oher (Ed.), The employee assistance handbook. New York: Wiley and Sons.Google Scholar
  39. Katon, W., Von, K. M., Lin, E., et al. (1990). Distressed high utilizers of medical care: DSM II diagnoses and treatment needs. General Hospital Psychiatry, 12, 355–362.CrossRefGoogle Scholar
  40. Kessler, R. C., Berglund, P., Demler, O., et al. (2005). Lifetime prevalence and age-of-onset distributions of DSM IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602.CrossRefGoogle Scholar
  41. Kessler, R. C., Greenberg, P. E., Mickelson, K. D., et al. (2001). The effects of chronic medical conditions on work loss and work cutback. Journal of Occupational and Environmental Medicine, 43, 218–225.CrossRefGoogle Scholar
  42. Krause, N., Frank, J. W., Dasinger, L. K., et al. (2001). Determinants of disability and return to work after work-related injury and illness: Challenges for future research. American Journal of Industrial Medicine, 40, 464–484.CrossRefGoogle Scholar
  43. Kroenke, K., & Mangesldorff, A. D. (1989). Common symptoms in ambulatory care: Incidence, evaluation, therapy, and outcome. The American Journal of Medicine, 86, 262–266.CrossRefGoogle Scholar
  44. Langlieb, A. M., & Kahn, J. P. (2005). How much does quality mental health care profit employers? Journal of Occupational and Environmental Medicine, 47, 1099–1199.CrossRefGoogle Scholar
  45. Lecrubier, Y. (2001). The burden of depression and anxiety in general medicine. The Journal of Clinical Psychiatry, 62(Suppl 8), 4–9.PubMedGoogle Scholar
  46. Lepine, J. P. (2002). The epidemiology of anxiety disorders: Prevalence and societal costs. The Journal of Clinical Psychiatry, 63(Suppl 14), 4–8.PubMedGoogle Scholar
  47. Lerner, B. H., Gulick, R. M., & Dubler, N. N. (1998). Rethinking nonadherence: Historical perspectives on triple-drug therapy for HIV disease. Annals of Internal Medicine, 129, 573–578.CrossRefGoogle Scholar
  48. Lustman, P. J., Griffith, L. S., & Clouse, R. E. (1997). Depression in adults with diabetes. Seminars in Clinical Neuropsychiatry, 2, 15–23.PubMedGoogle Scholar
  49. Moran, A. E., Freedman, R. I., & Sharfstein, S. S. (1984). The journey of Sylvia frumpkin: A case study for policy makers. Hospital & Community Psychiatry, 35, 887–893.Google Scholar
  50. Morgan, H. (2006). A conflict of roles: Expert witness or treating physician? SpineLine July/August, 2006, 27–30.Google Scholar
  51. National Institutes of Mental Health. (2001). Depression can break your heart. In Available at. Google Scholar
  52. Norell, S. E. (1981). Accuracy of patient interviews and estimates of clinical staff in determining medication compliance. Social Science and Medicine, 15, 57.CrossRefGoogle Scholar
  53. Palardy, N., Greenberg, L., Ott, J., et al. (1998). Adolescents’ health attitudes and adherence to treatment for insulin dependent diabetes mellitus. Journal of Developmental and Behavioral Pediatrics, 19, 31–37.CrossRefGoogle Scholar
  54. Pampallona, S., Bolini, P., Tibaldi, G., et al. (2002). Patient adherence in the treatment of depression. British Journal of Psychiatry, 180, 104–109.CrossRefGoogle Scholar
  55. Parker, J. (2009). Managing complex disability cases: A conversation about finding exceptions. Back to Work: Disability Management and Return to Work Strategies in Canada, 13(3), 6–7.Google Scholar
  56. Perkins, D. O. (2002). Predictors of noncompliance in patents with schizophrenia. The Journal of Clinical Psychiatry, 63, 118–1121.CrossRefGoogle Scholar
  57. Purcell, T. B. (2002). Factitious disorders and malingering. In J. A. Marx, H. S. Robert, & R. M. Walls (Eds.), Rosen’s emergency medicine: Concepts and clinical practice (5th ed.). St. Louis: Mosby.Google Scholar
  58. Reed, P. (Ed.). (2005). The medical disability advisor (5th ed.). Westminster, CO: Reed Group, Ltd.Google Scholar
  59. Reid, W. H. (1993). Law and psychiatry: Treating clinicians and expert testimony. Journal of Practical Psychiatry and Behavioral Health, 4, 1–3.Google Scholar
  60. Rogers, R., Harrell, E. G., & Liff, C. D. (1993). Feigning neuropsychological impairment: A critical review of methodological and clinical considerations. Clinical Psychology Review, 13, 255–274.CrossRefGoogle Scholar
  61. Rosen, J., Mulsant, B. H., Bruce, M. H., et al. (2004). Actors’ portrayals of depression to test interrater reliability in clinical trials. The American Journal of Psychiatry, 161, 1909–1911.CrossRefGoogle Scholar
  62. Rossi, A. S. (2001). Caring and doing for others: Social responsibility in the domains of family, work, and community. Chicago: University of Chicago Press.Google Scholar
  63. Sajatovic, M., Davies, M., & Hrouda, D. R. (2004). Enhancement of treatment adherence among patients with bipolar disorder. Psychiatric Services, 55, 264–269.CrossRefGoogle Scholar
  64. Samuel, R. Z., & Mittenberg, W. (2005). Determination of malingering in disability determinations. Primary Psychiatry, 12(12), 60–68.Google Scholar
  65. Schatzberg, A. F., Scully, J. H., Kupfer, D. J., & Regier, D. A. (2009). Setting the record straight: A response to Dr Frances’ commentary on DSM-V. Psychiatric Times, 26(8, 1), 9–10.Google Scholar
  66. Simon, G. E. (2003). Social and economic burdens of mood disorders. Biological Psychiatry, 54, 208–215.CrossRefGoogle Scholar
  67. Simon, G. E., Revicki, D., Heiligenstein, J., et al. (2000). Recovery from depression, work productivity, and health care costs among primary care patients. General Hospital Psychiatry, 22, 153–162.CrossRefGoogle Scholar
  68. Sleeth, J. (2009). Mental health, disability, and stress: What Selye and Mate can tell the human resources professional. Back to Work: Disability Management and Return to Work Strategies in Canada, 13(3), 8–9.Google Scholar
  69. Soumerai, S., McLaughlin, T. J., Ross-Degnan, D., et al. (1994). Effects of limiting medicaid drug reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. The New England Journal of Medicine, 331, 650–655.CrossRefGoogle Scholar
  70. Starsburger, L. H., Gutheil, T. G., & Brodsky, A. (1997). On wearing two hats: Role conflict in serving as both therapist and expert witness. The American Journal of Psychiatry, 154, 448–456.CrossRefGoogle Scholar
  71. Trueblood, W., & Schmidt, M. (1993). Malingering and other validity considerations in the neuropsychological evaluation of mild head injury. Journal of Clinical and Experimental Neuropsychology, 15, 578–590.CrossRefGoogle Scholar
  72. Trzepacz, P. T., & Baker, R. W. (1993). The psychiatric mental status exam. Oxford, UK: Oxford University Press.Google Scholar
  73. Twaddle, A. C. (1979). Sickness behavior and the sick role. Cambridge, MA: Schenkman Publishing.Google Scholar
  74. Unutzer, J., Patrick, D. L., Simon, G., et al. (1997). Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: A four year prospective study. The Journal of the American Medical Association, 277, 1618–1623.CrossRefGoogle Scholar
  75. Weiden, P., & Olfson, M. (1995). Cost of relapse in schizophrenia. Schizophrenia Bulletin, 21, 419–428.CrossRefGoogle Scholar
  76. Weiden, P., & Rao, N. (2005). Teaching medication compliance to psychiatric residents: Placing an orphan topic into a training curriculum. Academic Psychiatry, 29, 203–210.CrossRefGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Bettina B. Kilburn
    • 1
  1. 1.Disability Research and Consulting, LLCAtlantaUSA

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