Policy-makers face important challenges when designing income support policies for people with mental illnesses. Many of these difficulties—such as those of proving the illness and verifying its duration—stem from the invisible and fluctuating nature of mental illnesses.
These challenges appear intractable, but the need to address them is growing as other income replacement programs such as workers’ compensation are moving toward expanding coverage for mental illnesses, according to Dr. Ashley McAllister, a post-doctoral fellow at the Karolinksa Institute in Sweden.
And if they go unaddressed, these challenges can result in further conflicts over medical evidence, added McAllister, who recently presented her research at a plenary hosted by the Institute for Work & Health (IWH), where she was a visiting researcher for three months earlier this year.
“It’s important that policy design supports benefit administrators in determining who needs these benefits and who does not,” said McAllister, noting that many mental illnesses have an early onset, first appearing in the late teens or early 20s. As a result, being approved or rejected for benefits can have lifelong ramifications.
“Income support programs for people with mental illnesses can be very expensive, costing billions of dollars a year,” she said. “But there’s also the indirect cost of denying people the benefits they need.” These include the legal costs of adjudication and appeals, as well as the broader costs to society if the illnesses worsen and lead to hospitalization and homelessness, she added.
A policy researcher, McAllister set out to examine the challenges of designing income support policy for mental illnesses in Australia and Ontario, from the perspectives of the people involved in the process.
The programs she focused on were Australia’s Disability Support Pension and the Ontario Disability Support Program (ODSP). Her research involved interviews with 45 informants, including government officials, ministers, ministers’ advisors, doctors, legal representatives, advocates and academics.
From the interviews, five main challenges emerged. These were:
Verifying the duration: As mental illness is a recurring, episodic condition, it’s difficult to evaluate how long claimants should be off work. Income support policies aren’t designed to allow for people with an illness to go on and off benefits as symptoms come and go. As one informant said:
One day there might be no chance in the world of (someone) turning up to work, yet another day they might be fine.
This is an important component of disability income support policy design, McAllister noted.
It’s what separates disability income support from a short-term sickness absence program, she said.
You want to make sure that, in six weeks’ time, this person is still going to have the same impairment. That’s difficult given the fluctuating and episodic nature of mental illness.
Proving an illness: The people interviewed spoke of the difficulty diagnosing mental illnesses—especially when symptoms are moderate. As one doctor said,
What [ODSP adjudicators] are really looking for is almost a killer blow to your ability to do anything.
In the absence of gold-standard diagnostic tests, proxy markers such as hospital stays or drugs prescribed are sometimes used, said McAllister. However, these markers may not capture cases where symptoms are not severe but can cumulatively result in work disability, she added.
Differentiating illnesses: Mental illnesses are often spoken of as an umbrella category. Just as often, they’re thought of in terms of a hierarchy, with schizophrenia and psychosis granted more legitimacy than mood disorders and addiction, the interviews suggested. Little in the impairment tables used by the two systems helps determine the level of severity within each of these types of illnesses, McAllister pointed out.
Managing illnesses: Some informants spoke of the expectation that mental illnesses, if severe enough to warrant benefits, should be treated by psychiatrists. This expectation does not take into account well-documented barriers to access to psychiatrists in both systems (i.e. cost in Australia and wait times in Ontario).
It also ignores the trend towards collaborative care in mental health, in which mental health is managed by the general practitioner or the family physician, she said.
This illustrates a friction between what happens in the health world and what happens in policy.
Separating the illness from the person: The interviews also revealed different perspectives as to whether the programs should take into account the psychosocial context surrounding the illness. For example, should the programs focus on applicants’ level of impairment, or should they also address issues such as education, job training, etc.?
Currently, in both jurisdictions, eight out of 10 disability income support applications (not just for mental illnesses) are rejected because of insufficient medical evidence. In Ontario, almost half are overturned on appeal, McAllister noted in a recent paper.
These findings point to a need for more research about the assessment process. Tools need to be developed to measure functioning among people with mental illnesses, concluded McAllister.
A slidecast is now available of McAllister’s plenary.