Social Security looks at several sources of information when it is deciding applications for disability based on mental health conditions. When it sifts through your evidence of mental health impairments, it is looking to see whether you have a "medically determinable impairment" (a solid diagnosis based on objective evidence) that has lasted or is expected to last at least a year. In addition, your mental health condition has to be so severe that it impairs your functioning so much that you cannot work.
The first source of evidence in your disability case is your application. You may complete the application paperwork yourself, or a Social Security representative may complete the forms for you during a phone or in-person interview. For a description of the various application forms Social Security uses, see our article on forms for filing for Social Security.
When you fill out your application forms, make sure you list all of your conditions and all of the ways that they prevent you from working. In the end, it may be a combination of impairments that qualifies you for disability, even though you think only one impairment is keeping you from working.
One of the forms Social Security will have you complete is a questionnaire about your “activities of daily living,” or ADLs. The form, called the Function Report (SSA-3373), asks you to describe the ways that your impairment limits your daily life. The form asks about a wide range of activities, including spending time with others, doing housework, getting around outside the home, using money, and shopping.
If your mental illness causes you to have trouble following instructions, trouble getting along with coworkers or supervisors, or trouble handling stress, then you should describe those problems in your ADL questionnaire.
Social Security is required to look at all of your relevant medical records for at least twelve months before the date of your application for benefits. When you complete your application forms, you will list all of your treatment providers (like doctors, counselors, clinics, and hospitals). Social Security will ask you to sign its Authorization to Disclose Information (SSA-827) so that the agency can get your records from your treatment providers, if you have not already submitted them. While Social Security has an obligation to help you get all of your medical records, submitting them yourself will help you avoid delays in your case.
Your medical records should contain the results of any psychiatric, neurological, or psychological tests that you have had. Most mental health conditions cannot be evaluated with an objective test, but some can. Where objective testing is possible, Social Security will be looking carefully at those results. For example, if you are applying for disability for mental retardation (which Social Security will soon start calling intellectual disability), you will need to show results of IQ testing.
Treatment notes from mental health professionals are usually the most important source of evidence in mental disability claims. However, there can be lots of problems with treatment notes. Providers often do not keep thorough notes. Social Security needs to see the details of your treatment, including things like your diagnosis, your symptoms, your treatment plan, your prognosis, the history of your treatment (including every medication prescribed), and how you responded to every kind of treatment that the provider tried.
Ideally, treatment notes should also contain details about how your mental condition has impaired your functioning. For example, if you allege that your anxiety disorder makes it impossible to work because you are unable to leave your house, it will be very helpful to your claim if your psychiatrist’s notes document your fear of leaving the house and show that your anxiety persists in spite of medication and treatment.
Even when treatment notes are thorough, they usually do not have much detail about how your mental condition affects your ability to function. Consider asking your doctor to fill out a mental residual functional capacity (RFC) assessment form. Social Security will give substantial weight to your own doctor’s opinion about your condition and ability to function as long as it is supported by medical evidence and consisted with other evidence. Having your doctor complete a full mental RFC form can be one of the most important things you can do for your case.
Social Security will not use psychotherapy notes in its evaluation of your disability. Those are notes taken during counseling or therapy sessions that have to do with your personal conversations with your doctor. Your doctor can simply not send the notes, or can black them out if they are in the middle of other relevant records.
The claims examiners at your state’s disability determination agency (DDS) will look at the information you list about your impairments, plus your medical records, and decide whether more information could be useful in approving or denying your the claim. In some cases, the claims examiner will order a consultative exam (CE).
In mental disorder cases, Social Security may refer you to a psychiatrist for a thorough examination. In general, Social Security prefers to arrange a CE with your own treating doctor. However, many claimants find themselves referred to another doctor for a CE, particularly when the doctor who has been treating them is not a psychiatrist.
Social Security may contact third parties you’ve identified to ask them about your activities. People like social workers, former employers, probation officers, teachers, friends, and family can offer valuable information about you that can support your case. Think of people who have seen the effects of your mental condition on your ability to function. If you do give Social Security certain people’s names to support your application, make sure you contact those people to tell them about it and to talk with them about your impairment.