Mental Health Disability

Abstract

Mental health disability imposes an enormous cost to patients, families, and society. Across free market countries, the rate of mental health disability is growing and now constitutes about one third of all disability claimants. Living on disability benefits begets demoralization and passivity. This article reviews (a) the current status of mental health disability and mental health disability systems, (b) the encouraging findings related to research on evidence-based treatments and supported employment, and (c) policy changes that might ameliorate the problem of rising rates (and costs) of mental health disability. Mental health treatments, employment services, and disability policies powerfully shape the disability experience. Evidence-based mental health and employment services can ameliorate disability and could potentially prevent disability if applied as early interventions. Yet evidence-based mental health treatments and supported employment services are rarely available. Furthermore, current disability policies tend to trap people in a “disability benefits culture.” Policy changes should recognize that people with mental health disabilities usually want to work, that they are often able to work when provided with appropriate mental health and vocational services, and that employment is highly therapeutic. Disability policies need to strengthen work incentives for beneficiaries, providers, and employers.

Keywords

mental health disability supported employment disability policy

Introduction

The personal and family impacts related to severe mental illnesses are profound. Many people become unwell early in life and experience frightening symptoms, cognitive deficits, and social impairments for years or decades (Mueser & McGurk, 2004). Their difficulties are further compounded by social stigma, exclusion from the mainstream of society, discrimination and deprivation of basic human rights, and health care and disability benefits systems that may confer, exacerbate, or sustain their disability status (Saxena, Thornicroft, Knapp, & Whiteford, 2007; Thornicroft, 2006). From a societal perspective, severe mental illnesses comprise a major proportion of the global burden of disease (Prince et al., 2007; Wang et al., 2005). Societal costs include health and social care, amplified significantly by the impact of disability on employment status, income, and need for subsidized housing (Saxena et al., 2007).

Effective treatments and rehabilitative approaches for people with severe and persistent mental illnesses do exist (Lehman et al., 2004; Lieberman et al., 2008). Many of the personal and societal burdens related to severe mental illnesses derive from failures to use existing interventions systematically for all who can benefit and from the conferred status of disability compounded by the rigidity of existing disability systems.

In this article, we review (a) the current status of mental health disability and mental health disability systems, (b) the encouraging findings related to research on evidence-based treatments and supported employment for this population, and (c) policy changes that might ameliorate the problem of rising rates (and costs) of mental health disability. In each area, we emphasize the comparability across industrialized countries and some of the differences in low and medium resource countries (Patel et al., 2007).

Definitions

A large minority of working-age adults around the world experience some form of mental disorder each year (Wang et al., 2007), although the majority of these people go untreated (Kohn, Saxena, Levav, & Saraceno, 2004). Most of these conditions do not interfere substantially with social role functioning over time and are not considered disabling. However, a small number of mental disorders, such as schizophrenia and the most severe forms of bipolar disorder and major depressive disorder, can cause prolonged impairments and thus are considered severe and persistent mental illnesses (Bhugra, 2006; U.S. Department of Health and Human Services, 1999).

Disability is a status based on personal, environmental, and social factors as well as level of impairment (Bartlett, Lewis, & Thorold, 2006). Illness or injury is only a component. For example, an individual with the impairment of paraplegia might require a wheel chair for mobility but would become disabled only if his or her work, income, health care, housing, transportation, and interpersonal environments created unnecessary barriers. The situation is more complicated for people with mental illnesses because the conditions themselves are often unobservable, are highly stigmatized, tend to fluctuate, and have only a minimal direct relationship to functional status (Institute of Medicine, 2002; World Health Organization, 2001a).

In considering the implications of mental health disability, we can differentiate between individual and societal costs. Individual costs include the pain and suffering related to secondary disablement in addition to the primary illnesses as well as the impact on the ability to work and earn an income. Societal costs encompass all of the negative effects related to having a large group of individuals become socially and economically marginalized, often with long-term dependency on services. In the era of long-term institutionalization, these effects were predominantly the costs of running the institutions, whereas today psychiatric disablement impinges on society in more complex ways.

Epidemiology

To illustrate with a specific example, one of the more severely disabling of mental disorders is schizophrenia, which is a low-prevalence condition, affecting about 0.7% of the population (Beck, Rector, Stolar, & Grant, 2009). It is a severely disabling condition that has multiple effects on affected individuals, their families, and the wider social context, for which many of the available pharmacological and psychosocial interventions are only partly effective and acceptable to patients, and which often creates a high level of public interest (Andreasen, 1999; Geddes, 2002; Murray, Jones, Susser, van Os, & Cannon, 2002). In terms of the social impact of schizophrenia, a rich research literature documents the epidemiologic and health economic costs of this disorder (Knapp, Mangalore, & Simon, 2004), showing, for example, that it is a leading contributor to the global burden of disease (accounting for 5% of all years lived with a disability in 15–44 year olds, and 2.8% for all ages worldwide; World Health Organization, 2001b).

International Trends

The Organization for Economic Co-operation and Development (OECD, 2009) recently summarized disability statistics and trends across its 30 member countries, which represent democracies committed to free market economics. Data from all countries were derived from self-report and disability-related costs and refer to all health-related disabilities. The following trends were similar across countries: (a) Despite a decade of economic growth preceding the current recession, employment among persons with disabilities has not increased and has often decreased. People with self-reported disabilities are twice as likely as those without disabilities to be unemployed and are much more likely to be living in poverty; (b) More than half of the OECD countries have experienced significant increases in rates of disability beneficiaries among working-age adults in the past decade. The costs of disability benefits alone average 1.2% of gross domestic product and are as high as 5% in some countries; (c) Across OECD countries, the annual rate of leaving disability status due to employment is below 2%. Thus, disability benefits constitute a de facto involuntary retirement plan for the great majority of beneficiaries. (d) The proportion of disability claimants with mental health problems is increasing and now constitutes about one third of claimants across OECD nations; and (e) People with mental illnesses are 30% to 50% less likely to be employed than persons with other health or disability conditions in these countries.

Health care financing systems also powerfully shape who can access treatment and care. Prepayment systems—for example, social insurance, voluntary health insurance, or tax-based arrangements—are generally seen as better than out-of-pocket payments because they pool risks, have the potential to redistribute benefits toward people with greater needs, and may be made progressive, so that poorer individuals pay less for equivalent health care than wealthier people. Out-of-pocket payment systems cannot be as effective in targeting need nor are they as equitable, but they are still widely used (Dixon, McDaid, Knapp, & Curran, 2006). Whereas at the global level, the most common method of financing mental health care as a whole is through taxation (60%), more than a third of low-income countries rely on out-of-pocket payments as a primary source of finance (Saxena, Paraje, Sharan, Karam, & Sadana, 2006).

Some countries have chosen social health insurance rather than tax-based financing systems (Carrin, Waelkens, & Criel, 2005). Given high rates of unemployment among people with severe mental illnesses and disrupted working patterns for many people with common mental disorders, social health insurance alone does not reliably provide the coverage necessary for the treatment of people with mental illnesses, and usually needs a tax-based “safety net” if universal coverage is to be achieved.

Costs of Mental Health Disability

Mental illnesses are usually defined by clinical symptoms, but have consequences across many life domains, leading to multiple needs for support. The costs of mental illness therefore range well beyond the health system, but their precise distribution between individuals, families, and society more generally varies from country to country, depending on how support is structured, coordinated, and financed. Common across all countries, however, are the substantial impacts for individuals and families (lost income because of disrupted employment, out-of-pocket payments), employers (through lost productivity because of sickness absences and underperformance), and governments (lost taxes, criminal justice system impacts, welfare payments). Indeed, health service costs are often dwarfed by these wider economic impacts (Andlin-Sobocki, Jönsson, Wittchen, & Olesen, 2005; Sainsbury Centre, 2003; U.S. Department of Health and Human Services, 1999). Moreover, because severe mental illnesses tend to be chronic, these economic burdens persist for many years (Knapp, McCrone, Fombonne, Beecham, & Wostear, 2002; Scott, Knapp, Henderson, & Maughan, 2001).

Aside from the perennial question of the affordability of good quality care and support for people with severe mental illnesses, the main challenges stem from “silo budgets” and the disincentives and dislocations they cause. Resources are locked up within tightly controlled budgets, and difficulties in achieving greater overall effectiveness or cost-effectiveness are exacerbated by professional rivalry, increasingly rigorous performance assessments, and the slow churn of many bureaucratic processes. For example, better treatment for severe mental illness could have its biggest resource impact not in the health sector but in helping patients to access employment and reduce absenteeism, but unless resources are moved from that part of government which funds welfare support to health care providers, the dominant incentives work against the overall well-being of already disadvantaged individuals (Office of the Deputy Prime Minister, 2004).

The Disability Trap and the Disability Benefits Culture

Persons with severe and persistent mental illnesses in many countries face an untenable dilemma. In the United States, for example, many desperately need mental health services and temporary income support when they leave school or work due to illness, and for many the only opportunity to attain these benefits is through one of the two federal disability programs, Social Security Disability Insurance or Supplemental Security Income. Currently, adults with mental illnesses constitute the largest and fastest growing group of participants in Social Security disability programs as of 2007 (McAlpine & Warner, 2000): 29% of Social Security Disability Insurance beneficiaries (approximately 2.0 million people; Social Security Administration [SSA], 2008) and 39% of Supplementary Security Income recipients (also approximately 2.0 million people; SSA, 2008). Applying for and being approved for these programs is an arduous process, confounded by complex rules, and often takes years of trying to prove that one is severely disabled (Bilder & Mechanic, 2003; Burkhauser, Butler, & Weathers, 2001/2002; Estroff, Patrick, Zimmer, & Lachicotte, 1997; Zola, 1992). Nearly all beneficiaries live below the poverty line (Cook, 2006; Draine, Salzer, Culhane, & Hadley, 2002; Stapleton, O’Day, Livermore, & Imparato, 2006), but they are understandably reluctant to do anything that threatens their benefits and health insurance once they have attained disability status (MacDonald-Wilson, Rogers, Ellison, & Lyass, 2003; Rosenheck et al., 2006). A substantially higher percentage of beneficiaries express a desire to return to work (~50%) than actually agree to participate in return-to-work programs (~5%; Ruiz-Quintanilla, Weathers, Melburg, Campbell, & Madi, 2006). In fact, less than 1% per year leaves disability status for any reason except death or aging (Rupp & Scott, 1996). This situation is called the “disability trap.”

Even when individuals have a very strong desire to overcome disability and achieve independence, they are highly unlikely to be able to attain the effective services that they need to do so (Drake, Essock, & Bond, 2009). Public mental health spending in the United States, for example, has not increased since 1996 (Frank, Goldman, & McGuire, 2009). Public mental health services are relatively ineffective (Drake, Essock, et al., 2009), poorly accepted (Kreyenbuhl, Nosse, & Dixon, 2009), and currently deteriorating (Bogira, 2009; Cunningham, McKenzie, & Taylor, 2006). The majority of persons with severe and persistent mental illnesses report receiving no mental health treatments at all (Mojtabai et al., 2009; Wang, Demler, & Kessler, 2002). Because public insurance payments are not aligned with evidence-based practices, few of those in treatment receive effective interventions (Drake, Essock, et al., 2009). For example, although more than 60% of individuals with severe and persistent mental illnesses in the United States desire employment (McQuilken et al., 2003), only 2% of those in treatment are receiving supported employment services (Substance Abuse and Mental Health Services Administration [SAMHSA], 2009). In essence, the system pays people to remain disabled and gives them little or no support to escape disability. Individuals therefore become accustomed to and socialized into a life of poverty and disability. This situation constitutes what is called the “disability benefits culture.” The OECD data cited earlier suggest that the situation is similar in other developed countries.

Impact of Employment on General Well-Being

The disability benefits culture leads to demoralization and passivity. Certainly, part of the reason is unemployment, which leads to negative outcomes, including depression, social isolation, reduced self-esteem, substance use, and a general decline in mental health (Warr, 1987). Conversely, numerous advantages accrue to individuals with severe mental illnesses who do gain steady employment. These advantages include increased self-esteem, decreased psychiatric symptoms, reduced social disability, and overall greater subjective quality of life (Bond et al., 2001; Burns & Catty, 2008; Mueser et al., 1997). Perhaps because of this, the willingness to work rate is higher among people with mental illnesses than among the general population (Wheat, Brohan, Henderson, & Thornicroft, 2010). For those who become steady workers, mental health treatment costs decline dramatically over the long term after adjusting for morbidity/needs (Bush, Drake, Xie, McHugo, & Haslett, 2009). In essence, employment helps people to escape from the disabled mental patient role and establish a new identity as a working, contributing citizen.

Despite this, plentiful international evidence indicates that rates of employment among people with mental illnesses are especially low. In Europe, for example, one international study of people with schizophrenia found that the rates of those in work ranged between 5% (London, United Kingdom) and 23% (Verona, Italy; Thornicroft et al., 2004). These very low work participation rates have important consequences. The loss of the opportunity to work is by far the single greatest contributor to the costs of poor mental health in Europe, for example, accounting for two thirds of the total mental health care–related costs in Sweden, and 59% of the total costs of mental disorders in Switzerland (McDaid, Knapp, Medeiros, & the MHEEN Group, 2007).

The interrelationships between mental health problems and employment are many and various. As well as the link with individual well-being, employment is a major contributor to national productivity and competitiveness, and also has implications for the sustainability of social welfare systems. Indeed, the challenge is growing: Increasing rates of absenteeism, earlier retirement, and exclusion from the labor force due to mental health problems, particularly stress and depression, now account for an ever greater share of long-term social welfare benefits (McDaid et al., 2007).

Supported Employment

Over the last two decades, supported employment has emerged as an evidence-based practice to improve competitive employment outcomes for individuals with severe mental illnesses (Lehman et al., 2004; New Freedom Commission on Mental Health, 2003; Schneider, Heyman, & Turton, 2002). The most clearly described and widely researched supported employment model, Individual Placement and Support (IPS), is based on seven principles (Bond, 2004): (a) focus on open employment (i.e., competitive employment, which is a community job paying minimum wage and not set aside for people with disabilities), (b) eligibility based on self-determination, (c) rapid job search, (d) attention to client preferences in services and job searches, (e) individualized and long-term supports, (f) employment and treatment specialists on same team, and (g) personalized counseling on disability benefits. The essence of IPS-supported employment is a direct, individualized search for competitive employment that eschews prolonged preemployment preparation, counseling, and training.

Five reviews (Bond, 2004; Bond, Drake, & Becker, 2008; Burns et al., 2007; Crowther, Marshall, Bond, & Huxley, 2001; Twamley, Jeste, & Lehman, 2003) and one multisite randomized trial (Cook, Leff, et al., 2005) have examined the effectiveness of supported employment across multiple randomized controlled trials. All concluded that supported employment was more effective in helping clients obtain competitive employment than were alternative vocational approaches. The most recent review found that 61% of IPS-supported employment participants obtained a competitive job during follow-up, compared with 23% of controls (Bond, Drake, et al., 2008). About two thirds of IPS participants who obtained competitive employment worked 20 hr or more per week. Among those who obtained a competitive job, time to first job averaged 138 days for IPS participants compared with 206 days for controls. With respect to job tenure, the best evidence comes from two long-term follow-up studies suggesting that more than half of those who enrolled in IPS-supported employment became steady workers, working competitively at least 50% of the time over a subsequent 8- to 12-year period (Becker, Whitley, Bailey, & Drake, 2007; Salyers, Becker, Drake, Torrey, & Wyzik, 2004). Because of the disincentives associated with receiving disability payments (Drake, Skinner, Bond, & Goldman, 2009), earnings from competitive employment for supported employment participants are typically quite modest; one multisite study reported that the supported employment group averaged 33% more in monthly employment earnings than controls (Cook, Leff, et al., 2005).

Supported employment appears to generalize to different subgroups within the target population, such as patients from ethno-racial minority backgrounds and those with comorbidities (Campbell, Bond, & Drake, 2011). When augmented with supported education services, supported employment appears to be especially suitable for young adults experiencing their first episode of psychosis, with four studies suggesting increased rates of competitive employment and return to formal education (Killackey, Jackson, & McGorry, 2008; Major et al., 2010; Nuechterlein et al., 2008; Rinaldi et al., 2004). With their entry into mainstream employment and education, many can avert entry into the disability system. Furthermore, individuals seeking but not yet receiving disability insurance are 4 times more likely to participate in employment services than are beneficiaries already receiving payments, suggesting that before entering the disability system, individuals are more receptive to seeking employment (Ruiz-Quintanilla et al., 2006).

Despite major variations in social and cultural norms, diverse political structures, and labor laws, supported employment appears to have been successfully implemented in those industrialized nations in which it has been attempted (Bond, Drake, et al., 2008). Yet many barriers to dissemination remain, as indicated by the low penetration of this model, even in the United States (SAMHSA, 2009), where several large demonstrations have shown success (Becker, Lynde, & Swanson, 2008; Bond, McHugo, Becker, Rapp, & Whitley, 2008; Drake, Becker, Goldman, & Martinez, 2006; Frey et al., 2008; McHugo et al., 2007; SAMHSA, 2009). These studies have identified governmental regulations, absence of strong site leadership, the challenges of integrating supported employment with mental health treatment services, and staff turnover as implementation barriers.

Supported employment is also being disseminated in Canada (Corbière & Lecomte, 2009), several European countries (Boyce, Secker, Floyd, Schneider, & Slade, 2008; Burns et al., 2007; Rinaldi & Perkins, 2007; van Erp et al., 2007), and Australia (Waghorn, Collister, Killackey, & Sherring, 2007). The Enhancing the Quality of Life and Independence of persons disabled by severe mental illness through Supported Employment (EQOLISE) study was a randomized controlled trial of supported employment in six European Union countries that largely replicated the results in the United States and showed between-country differences in relation to the disability trap effect (Burns et al., 2007). Common barriers found in these projects included funding issues, lack of cooperation among different services (e.g., vocational rehabilitation, mental health, and substance abuse treatment), staff turnover, and insufficient time allocated for program leaders. IPS supported employment has not yet been adapted, implemented, and evaluated in low and medium income countries.

Policy Recommendations

From the analysis presented above, a series of policy recommendations follow. Severe mental illnesses have long-term impacts, and therefore health and disability policies need to avoid taking only a short-term view. Policies related to disability due to mental illnesses should focus on prevention of disability as well as treatment and rehabilitation. Interventions should address the entire trajectory of impairment from its earliest stages to its potential for disabling outcomes. There is a wide array of effects of psychiatric impairment and an equally wide array of services and supports designed to intervene on this trajectory and to promote well-being. For example, families can be key contributors in the coproduction of well-being, and they also need supports themselves. Childhood behavioral problems as well as family characteristics help to explain later employment difficulties (Caspi, Wright, Moffitt, & Silva, 1998), which is why many countries are investing in parenting interventions (Dretzke et al., 2009; Engle et al., 2007). Similarly, the positive effects of health visitation (Council on Community Pediatrics, 2009) on child development and later adulthood personal and economic well-being encourage investment in preventive community support for women with postnatal depression (Chisholm et al., 2004).

Service users can be given more choice, influence, and control to select services and to control resources intended to improve their quality of life. Self-directed support arrangements—such as personal budgets or direct payments—are now available for disabled people across many countries, although people with mental health needs are often excluded (Social Care Institute for Excellence, 2009). This is only one potential solution to address the problem of coordinating the many different silos of resources available to assist service users—resources that they often cannot access because of the bureaucratic, informational, and other boundaries between the silos (New Freedom Commission on Mental Health, 2003; World Health Organization 2001b).

Disability policies must balance the need for income and supports, during a period of unemployment, with the wishes of individuals to participate in the workforce. On one hand, there is a concern about avoiding poverty and burdensome application processes, and, on the other hand, is a concern about “moral hazard” associated with too lenient criteria for eligibility for disability benefits and creating dependency and a disincentive to work (Danziger, Frank, & Meara, 2009; Mont 2004). Those who are relatively early in the course of illness and applying for disability status need to be encouraged to pursue functional recovery rather than maintaining the disabled role while they are applying for benefits (Social Security Advisory Board, 2006). For example, a diagnosis of schizophrenia may, by itself, be sufficient to qualify for benefits, without the individual having to spend months or years proving that he or she is substantially or permanently disabled (Burkhauser et al., 2001/2002). The reality is that many people with schizophrenia have a serious impairment and need help, not barriers, to preserve functional status. At the same time, as this article has demonstrated, it is important to encourage a return to school and work, as soon as possible.

The crux of needed policy change is as follows: Initiatives must recognize that people with psychiatric disabilities usually want to work, that they are often able to work when provided with appropriate services, and that work, even part-time employment, is highly therapeutic and advantageous for them. Thus, policies need to strengthen work incentives for beneficiaries, providers, and employers (Burt & Aron, 2003; Cook et al., 2006; Flynn, 1999; MacDonald-Wilson et al., 2003; Prince et al., 2007; Social Security Advisory Board, 2006; Thornicroft, 2006). Many European countries have made changes to their welfare payments systems to create the right incentives for individuals and employers, such as the Pathways to Work program in the United Kingdom, Sweden’s rehabilitation program, and Poland’s antidiscrimination legislation (McDaid et al., 2007).

For persons with mental illnesses, effective services, including supported education and employment, need to be available for individuals in all stages of disability status. One obvious policy change is that supported employment and other evidence-based practices must receive strong leadership at the national and local governmental levels with financing mechanisms that incentivize implementation (Finnerty et al., 2009). Current estimates in the United States suggest that fewer than 2% of clients in the public mental health system have access to supported employment, and the availability of other evidence-based practices is similarly inadequate (SAMHSA, 2009). In the United Kingdom the percentage lacking access to evidence-based practices is lower, but the case for investment in supported employment is no less strong (Perkins, Farmer, & Litchfield, 2009).

For individuals early in the course of illnesses, policies should emphasize preserving functional roles and community connections rather than asylum and segregation (Killackey et al., 2008; Killeen & O’Day, 2004; Nuechterlein et al., 2008). The goal should be to reconnect people to school and work as rapidly as possible by providing needed supports to prevent disability. Prevention of disability rather than illness is the underlying premise of the current National Institute of Mental Health’s Recovery After an Initial Schizophrenic Episode initiative in the United States (Hsiao, 2008).

Finally, those who have experienced mental illness and disability status for years need to be encouraged to pursue part-time employment as a form of treatment to promote their recoveries. The rules for disability payment reductions could be more gradual to allow beneficiaries to experience steady employment for years before reductions begin. For example, because Supplemental Security Income is so meager in the United States, permitting people with psychiatric disabilities to work halftime and retain benefits would enable them to escape extreme poverty and would still reduce the health care budget as they pursue functional rather than disabled roles. A further practical measure is to allow those who have already qualified for disability benefits to have much greater flexibility in having those benefits restored quickly and in full if a period of employment is not initially successful. This is because the expectation of complex reapplication procedures appears to be a substantial disincentive for many people from taking the risk of entering employment.

Mental health providers need to be reimbursed for providing appropriate amounts of evidence-based services and for outcomes, not for total amount of services. For people with psychiatric disability, appropriate evidence-based services include interdisciplinary, team-based collaboration rather than large amounts of uncoordinated services from separate providers (Cook, Lehman, et al., 2005; Drake, Becker, Bond, & Mueser, 2003; Frey et al., 2008). In particular, mental health services need to be carefully coordinated with vocational, physical health, substance abuse, supported housing, social care, and criminal justice services because many individuals have needs in all of these areas. Accountability means that reimbursements should be based on realistic benchmarks regarding functional outcomes, adjusted for needs and exogenous circumstances. Service area data can be used to generate risk-adjusted, realistic benchmarks for independent housing, formal education, and competitive employment—outcomes that users of the mental health system desire and that are worthy of prospective payments.

To modify the disability benefits culture, a variety of strategies need to be tried, coupled with systematic evaluation of their success. A few pilot studies have been launched, some successfully. In the United States, the Mental Health Treatment Study represents one such pilot endeavor, incorporating adequate financing and integrated services with high-quality supported employment (Frey et al., 2008). A United Kingdom pilot project has found that increasing the financial incentives to individuals with disabilities to seek paid employment may be a modestly effective strategy (Adam, Emmerson, Payne, & Goodman, 2007). Another promising approach is to pay supported employment providers on the basis of client outcomes (McGrew, Johannesen, Griss, Born, & Katuin, 2005). In fact, a wide range of measures have been tried across the world from which lessons can and should be drawn (Mitra, 2009).

Employers and school officials also need realistic incentives for helping people with psychiatric disabilities maintain their connections to these institutions and to return to functioning as soon as possible if they have incurred a prolonged period of separation. This will require strengthening illness management and return-to-work programs. Tax incentives and health insurance policies could be used to reward schools and employers for encouraging supported education and supported employment services and for hiring people with disabilities part-time. Calls for policies to protect the rights of individuals to employment have been made (e.g., European Union, 2000; World Health Organization, 2001b), but whether disability rights legislation, as opposed to economic incentives, can facilitate changing employer behavior is still an open question.

These changes in disability policy will require deemphasizing the biomedical model of disability and recognizing that disability status is determined largely by psychological, social, and environmental factors. Psychiatric illness outcomes are minimally correlated with functional outcomes. Furthermore, treatment is necessary but not sufficient to help people maintain or establish functional status. Disability policies must recognize these realities, emphasize psychosocial services and supports, and minimize the adverse effects of existing policies.

In sum, people with severe and persistent mental illnesses need individualized, evidence-based services as well as policy changes to reverse the trend toward increased rates of disability. These changes could benefit the affected individuals, their families, and society.

Footnotes

Authors’ Note

All five authors have contributed to discussing and writing this review extensively.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Robert Drake acknowledges funding from the National Institute of Mental Health, the National Institute of Disability and Rehabilitation Research, the National Institute of Drug Abuse, the National Institute of Alcohol Abuse and Alcoholism, the Social Security Administration, the Substance Abuse and Mental Health Services Administration, the Johnson & Johnson Office of Corporate Contributions, the West Foundation, the Segal Foundation, the Vail Foundation, Oxford Press, Guilford Press, and Hazelden Press. Gary Bond acknowledges funding from the National Institute of Disability and Rehabilitation Research, the National Institute of Mental Health, the Social Security Administration, and the Substance Abuse and Mental Health Services Administration.

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