Parsing Mental Illness and Substance Abuse in Determining Social Security Disability Benefits

Facts of the Case

Ms. Kangail received a diagnosis of bipolar disorder when in her twenties. She had a comorbid history of alcohol and cocaine abuse. Her bipolar disorder was characterized by severe depression with moderate to severe manic episodes, coupled with employment instability. Despite achieving sobriety from alcohol and drugs in 2000, she was employed in 10 different jobs during the next 3 years, working as a cashier, telemarketer, and waitress. Her longest period of employment was 8 months working as a cashier, earning $9,900.

Ms. Kangail applied for social security disability benefits in 1999 on the grounds that she could not sustain employment due to her bipolar disorder. Her final hearing before a social security ALJ was in February 2003. She testified that she had left most of her jobs because of her “blowing up” and having confrontations with customers and supervisors. She testified that her ability to function at work was affected by her “racing thoughts, insomnia, inability to concentrate, feeling overwhelmed” and depressive symptoms.

The ALJ denied Ms. Kangail social security disability benefits because her mood symptoms improved and she was able to work at different jobs after she stopped her substance abuse in 2000. The ALJ reasoned that because her symptoms improved after cessation of substance abuse, the symptoms of her bipolar disorder were most likely caused by the substance abuse. The ALJ refused to give weight to the testimony of medical experts who examined her because of “contradictions” in their testimony. The specific contradiction relied on by the ALJ was that, although the various medical experts reported that she suffered from a severe mental illness, they observed that she behaved normally while in their office.

Ms. Kangail appealed the denial of social security disability benefits to the U.S. District Court for the Northern District of Illinois, Eastern Division. The U.S. District Court affirmed the finding of the ALJ, prompting her to seek a review by the U.S. Seventh Circuit Court of Appeals in 2006.

Ruling

The Seventh Circuit vacated the decision of the district court and remanded the case to the Social Security Administration for further proceedings.

Reasoning

The Seventh Circuit Court of Appeals found that the ALJ did not provide “a rational basis” for denying Ms. Kangail's application for disability benefits. Citing various appellate decisions (Brueggemann v. Barnhart, 348 F.3d 689 (8th Cir. 2003); Bustamante v. Massanari, 262 F.3d 949 (9th Cir. 2001); and Drapeau v. Massanari, 255 F.3d 1211 (10th Cir. 2001)), the court held that, in reviewing the disability application of an individual who had a potentially disabling illness and was also a substance abuser, the most important consideration is “whether, were the applicant not a substance abuser, she would still be disabled.” The court concluded that if the answer to this question is in the affirmative, then, the individual should qualify for social security disability benefits “independent of drug addiction or alcoholism.”

The court criticized the ALJ for placing too much emphasis on Ms. Kangail's history of alcohol and drug abuse while ignoring medical evidence that suggested that her bipolar disorder was disabling. The court also criticized the ALJ for playing “doctor” by concluding that her bipolar disorder was caused by substance abuse because her symptoms improved after she stopped using drugs.

Citing the DSM-IV and several reputable papers on bipolar disorder published in the American Journal of Psychiatry, the court noted that bipolar disorder is episodic and often coexists with a substance abuse disorder. Based on those reports, the court pointed out that, contrary to the ALJ's conclusions, bipolar disorder often results in substance abuse because the “sufferer” utilizes illicit substances as a means “to alleviate” the symptoms of the bipolar disorder. The court noted that medical testimony suggested Ms. Kangail had a tendency to “indiscriminately use drugs and alcohol during her manic phases.” Furthermore, the court noted that although her bipolar disorder was aggravated by her substance abuse, it could still be disabling absent the effects of substance abuse.

The court found that the ALJ placed too much emphasis on Ms. Kangail's job experience after she stopped abusing alcohol and drugs in 2000. The court reasoned that although she had held one job for more than 6 months, this job could not be considered “substantial gainful employment” for the purpose of determining disability benefits, since her total earnings during this period were nominal. Further, the court found that it was erroneous for the ALJ to conclude that her inability to hold a job was unimportant because she could hold a job when she took her medications. The court noted that one of the hallmarks of bipolar disorder is noncompliance with medication. The court found that the ALJ erred by not considering this possibility.

Discussion

Kangail v. Barnhart illustrates some important aspects of the interplay between psychiatry and the law. First is the complex interplay of comorbid psychiatric and substance use disorders, which can be especially confounding within the legal context. It is not unusual for the causation of a primary psychiatric illness to be erroneously attributed to substance abuse, as the Social Security ALJ initially found in this case. This raises the need for psychiatry to improve the criteria by which mental health disorders are classified in a way that makes it easier for others to understand.

The second important issue illustrated by Kangail v. Barnhart is the dichotomous view of psychiatry within the legal community. On the one end are some in the legal community who view psychiatry in general, and psychiatric expert witnesses in particular, with nascent suspicion and skepticism (as reflected by some landmark case decisions, e.g., Washington v. U.S, 390 F.2d 444 (D.C Cir. 1967)). This skepticism may explain the reluctance of the ALJ to consider the medical evidence, which in this case strongly suggested that Ms. Kangail was disabled as a result of her bipolar disorder. On the other hand, some legal minds recognize the irreplaceable aid that psychiatric testimony offers in the adjudication of certain legal disputes, especially those that involve questions of mental health, as evidenced in this case. The justices of the Seventh Circuit Court of Appeals clearly belong to this second group. This attitude is reflected in this case, in which they scold the ALJ for “playing doctor” and for wrongly attributing the cause of Ms. Kangail's bipolar disorder to her substance abuse. That they also relied heavily on several articles published in the American Journal of Psychiatry indicates the value the court placed on the field of psychiatry.

The overall message from this case is that there remains a wide gap between the knowledge of mental health practitioners and the understanding of lay persons. Greater efforts should be made to educate other professionals, especially those in the legal system, so as to foster a better understanding and greater appreciation of the work of psychiatric expert witnesses.