The epidemiology and management of psychiatric disability has gained increased attention in the past few decades for a variety of reasons.
There are issues of advocacy, empowerment, and reduction of stigma.
There are also concerns about cost containment as well as the reliability, validity, and efficacy of the determination process in disability management.
Broadly speaking, disability is the inability to engage in any substantial gainful activity by reason of medically determinable physical or mental impairments.
The diagnosis of a mental illness is not necessarily equivalent to a disability or a functional impairment, however.
An individual who has an anxiety or depressive disorder may not be disabled if he or she can engage in substantive gainful activity as defined by the system within which disability benefits are provided.
“IME” stands for Independent Medical Examination or Independent Medical Evaluation. An IME is a medical exam conducted by third-party, unbiased physicians including Psychiatrists.
Psychiatry is the medical specialty concerned with the prevention, evaluation, and treatment of mental, addictive, and emotional disorders.
Psychiatric independent medical examinations are typically requested where there is some emotional or psychological trauma.
A Psychiatric IME is very different from a clinical or consultative exam. A consult or clinical exam is performed to treat a patient and establishes doctor-patient confidentiality. An IME contributes information to be rendered in a matter where disability is in question.
Examples of When a Psychiatric IME is Useful
In a lawsuit, for example, an IME is used to evaluate an individual as to how psychological factors may or may not be impacting their functionality and work readiness.
There is no doctor-patient relationship implied in an IME. Confidentiality is also limited.
In fact, anything said in an IME examination may be relevant if the doctor is called as an expert witness in whatever matter is under review.
It is important to note that there is always the possibility that an IME assessor may be called as an expert witness in any matter under dispute.
In their practices, psychiatrists may be involved with a wide variety of problems including schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, substance-related disorders, and adjustment disorders, etc.
Most psychiatric independent medical examinations are necessitated by trauma or injury that leads to the emergence of conditions such as depression, anxiety, or PTSD (post-traumatic stress disorder).
A psychiatric IME may also assess long-standing ongoing conditions that may be resulting in an inability to work and/or function and how they may or may not be related to the subject under review.
An IME may be requested by an insurance company in order to determine eligibility for benefits or to establish a basis for the continuation of benefits.
Lawyers may request an IME where litigation involves a psychological condition in order to determine whether the condition contributes to a disputed issue and to determine damages if a mental or emotional condition is found to be caused by the issue in question.
In criminal matters, a Forensic Psychiatrist may address the question of criminal responsibility or competency to stand trial if allegations are made that a psychiatric condition is present or relevant.
Psychiatric IME’s in the Workplace
In the world of work, sometimes, an employee’s ability to perform his or her job can be hindered by a psychological condition.
For example, he or she might be experiencing post-traumatic stress disorder (PTSD) from a workplace event or from an event occurring outside of work.
An IME may be used to assess a person’s condition based on evidence-based guidelines.
The findings can confirm or deny the need for further psychiatric treatment, how long it may be necessary, and how it affects the person’s ability to safely and efficiently perform his or her job.
In assessing mental health disabilities, psychiatrists should also be aware of opportunities for vocational rehabilitation and work incentives as well as treatment opportunities to ameliorate impediments to work functions.
For employers, it is important to note that employees suffering from psychiatric issues may have just as strong an effect on the company’s productivity as physical injuries.
Just as physical injury or illness can prevent an employee from working a particular job that they previously excelled at, so too can psychiatric issues obstruct the normal process of working.
Exactly what accommodations, limitations or restrictions might be appropriate for an employee, and for how long, are difficult questions for employers to grapple with, especially as their absences and lowered capacity may be impacting their bottom line.
When an employee is suffering from a mental illness, they are often not performing optimally.
Depending on the job, there could also be safety issues as well. In other roles that require strong communication skills, they may be unable to deliver what is required of them.
Generally, these employees will be less reliable and productive than they normally are, and that can have an effect throughout the organization.
When Looking at a Return to Work
When looking at a return to work for psychiatric disabilities, the guiding principles are very similar to those utilized when planning for a return to work due to mental illness as they would be for a physical injury.
The focus of the plan should be on the functional abilities of the worker, and not merely on the symptoms of the injury or illness.
Ideally, a psychiatric IME will assist in returning individuals to work and to optimal functioning; however, as we know, return-to-work situations can also sometimes result in legal wrangling and/or litigation.
In such circumstances, having a truly independent opinion on file can assist an employer greatly in defending their return to work decisions.
Regardless of the purpose, however, elements of a psychiatric IME include diagnosis, prognosis, and treatment questions. Damages are considered where requested.
A Psychiatrist is also trained to assess malingering (i.e. lying for secondary gain).
The IME psychiatrist obtains information for the evaluation by conducting a clinical interview, during which the examiner obtains:
- the individual’s medical history
- mental health history
- substance use history
- social history
- educational history
- occupational history
- family history
More information may be discussed of course and this is not an exhaustive list.
The IME evaluator asks questions to assess general well-being, symptomatology, gross cognition, thought processes, and evaluates whether a mental illness is present as per the DSM V and, if so, its severity.
Common reasons to expand the scope of the exam are if records are inconsistent with the individual’s responses.
In addition, during the course of the IME, an evaluee may provide a history that indicates closer examination/discussion.
Before the IME, the evaluator also reviews relevant records, including prior medical or mental health records and job records.
What Else is Included in a Psychiatric IME?
Conditions such as PTSD, depression, addiction, anxiety, panic, somatic symptoms, and bipolar disorder frequently fall into the category of mental health issues included in psychiatric IMEs.
Once the examination is concluded, the IME psychiatrist compiles a report stating their opinion on the case, answers to all questions posed, as well as a prognosis and options for additional treatment where warranted.
Who May Request a Psychiatric IME?
As indicated, an IME is typically requested by:
- insurance companies
- government agencies
…who require professional independent evaluations to help in the process of making administrative decisions concerning the individual being evaluated, i.e. determining disability status, or determining if psychiatric damage can be established or refuted in personal injury cases, and/or the appropriateness and need for psychiatric treatment.
The Benefits of a Psychiatric IME Are Many
A psychiatric IME can be useful in addressing many issues including
- effects of preexisting conditions
- the necessity of treatment
- the end of healing period
- the permanence of injury
- the ability of an employee to safely and effectively perform the essential functions of their job
- job restrictions
- the delineation of accommodations that may be required
IME Psychiatrists also have overriding ethical and legal obligations including a duty to provide opinions that are truthful, fair, objective, and non-partisan regardless of who the referral source may be.
They should also only provide opinions that are within their area of training and expertise and should ensure that individuals give informed consent, which includes the evaluator’s role to provide an opinion, which may be helpful, neutral or harmful to the evaluee’s interests.
Overall, the Psychiatric IME is a highly useful tool in managing psychiatric disability as it helps clarify, verify, and confirm medical claims, and helps to resolve disputes.
John Drudge, President – Rapid Interactive Disability Management (RIDM)