Every day for a solid year, Krystal Nice would check the Social Security Administration website at 5:15 a.m. for updates. She had applied for disability benefits in April 2024, but kept waiting for a decision. With two children and little income or savings, the monthly $1,537 disability check could help her make ends meet, including paying the rent.
Nice, now 32, of Burkburnett, Texas, has post-traumatic stress disorder, depression, agoraphobia and anxiety — all diagnosed. She has a history of family trauma and domestic violence and doesn’t remember a time when she wasn’t depressed. Still, the past few years have been especially rough. Her grandmother’s dementia worsened, her relationship with her mother deteriorated and she hasn’t been able to work full time. Her psychiatrist — Nice was on Medicaid — suggested she file for disability benefits because of her mental health condition. She decided to try, though she’d been rejected seven years ago for lack of proof.
Denials and delays in getting disability benefits — via Social Security Disability Insurance (SSDI) or the Supplemental Security Income program (SSI) — remain a source of frustration and anguish for many people. That’s especially true for people with mental illness, which can be harder to substantiate than physical disabilities and harder to prove will prevent them from working.
In fiscal year 2023, 62% of disability claims filed with the Social Security Administration were initially denied. The agency doesn’t publish data on denial rates by type of disability, but a study released in 2018 found that while the denial rate for all claims was 62%, the rate was 76% for those with a primary diagnosis of an affective or mood disorder, such as bipolar disorder and depression.
Disability lawyers and advocates say people with mental disabilities often wait longer for an SSA decision on benefits. In fiscal 2024, the average time it took to process a disability claim was 231 days, SSA data show. The most time-consuming task is a medical determination of disability, made by SSA-funded offices in each state.
In the first four months of fiscal 2025, Texas had the third longest wait time for determining disability, at 324 days. The national overall wait time has risen by more than 105% since 2018, largely because of a shortage of state-level staff, the agency said.
A delay of months or a denial can be excruciating for applicants, exacting a financial and emotional toll. Many can’t work and if they can, they are not allowed to earn more than $1,620 a month — the federal limit per individual for 2025.
Nice said she got “paranoid” at times that the state would come take her kids because she was poor.
“It’s just a waiting game,” Nice said in January. “I am in survival mode, basically wondering, ‘How am I going to get my bills paid?”
Debora Wagner, who worked 25 years as a disability legal-aid lawyer and is now a work-incentives associate at Cornell University, said the disability benefits system is not designed to be easy for applicants. Many give up.
“I have clients who are seriously depressed and a denial is a big blow to them, and they just don’t have the energy to keep fighting,” Wagner said.
Asked to comment on the process for obtaining mental disability benefits, the SSA released a statement to Public Health Watch saying it is committed to ensuring access to disability programs for all individuals.
“We understand that the application process can present challenges, and we strive to provide clear information, accessible resources and support throughout the process,” the agency said.
“We are constantly assessing the effectiveness of our processes and outreach as we work to improve service, better assist individuals and ensure that those who qualify for benefits receive the support they need.”
Paths to Benefits
The Social Security Administration’s two disability programs target different populations but have the same determination process and strict rules for defining disability. Both offer monthly cash benefits.
In December 2024, more than 11 million people received disability benefits, with some enrolled in both programs. In Texas, more than 544,000 received SSDI benefits.
SSDI arose out of a benefits program for disabled civil defense workers in the 1940s, which led to a wider disability insurance program in 1956. It’s intended for people under full retirement age who have a disability that keeps or limits them from what’s called “substantial gainful activity.” They must have enough work history and paid Social Security taxes to qualify.
SSI is a need-based program that assists people who have very limited income and assets, regardless of their work history.
To apply for benefits, a person typically must visit a Social Security field office or apply online or by phone. An agency worker checks whether the basic non-medical requirements are met, including work history (for SSDI), income limit and citizenship or legal residency. The field office verifies the data, then forwards the case to a state agency paid to make a determination. Decisions can be appealed.
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The SSA uses 14 broad categories of impairments for adults, from musculoskeletal disorders to cancer. Each has medical requirements a person must satisfy to qualify for benefits. Mental-health impairments cover a range of conditions, such as Down Syndrome and dementia. But it’s the more prevalent disorders — and their severity and duration — that can be harder to prove, including depression, anxiety, bipolar disorder, PTSD, attention-deficit hyperactivity or schizophrenia.
Patients must not only prove they have a diagnosis, but the condition prevents them from working for at least a year or is expected to result in death. The process for any claim is complex, but while many physical impairments have measurable thresholds, mental health conditions often are more subjective, disability attorneys and advocates say.
For instance, people with chronic heart failure can prove through testing that they’re unable to perform physical tasks that elevate metabolism beyond a certain level. Someone with depression is required to show they cannot “interact with others,” “adapt or manage oneself” or “concentrate,” the SSA states.
If a person is blind or in stage four renal failure, the impairment is pretty clear, said Steve Dane, director of income and skills development at Haven for Hope, a homeless shelter in San Antonio that has helped people apply for benefits. “I think it’s more subjective with someone who has a mental health diagnosis.”
When claimants don’t meet the listed requirements, Social Security evaluates if, given the diagnosis, that person can go back to his or her previous job or perform another job. The agency evaluates factors such as how much physical work the individual can still perform. But there is no equivalent for mental illness, said David Camp, the CEO of the National Organization of Social Security Claimants Representatives.
When a mental-health claim is denied and appealed, an administrative judge will often reverse the decision — but it can take years, said Camp. “The judge almost always wants to say, ‘I am so sorry it took you five years, but this is obviously a favorable decision and best of luck to you.’”
In 2023, administrative judges ruled favorably in just over half of all disability appeal cases, SSA data show. “That means they are reversing the decision of Social Security far too much,” Camp said, which indicates something is lacking in the initial decision-making process.
This happened to a client represented by Jennifer Burdick, a supervising attorney at Community Legal Services of Philadelphia. The client has explosive anger that makes her unemployable — and she keeps getting kicked out of medical clinics. Since 2015, Burdick has taken her to four hearings and four appeals. Burdick spent a week preparing for this year’s hearing, but the judge canceled it, awarding her benefits going back a decade, to her first application.
“She should never have had to wait this long,” Burdick said a courthouse staff member told her.
To secure benefits, patients must provide the SSA with “objective medical evidence,” which includes signs or laboratory findings from a medical source.
While a blood test or an electrocardiogram qualifies as objective evidence, a screening test such as the Patient Health Questionnaire-9 (PHQ-9) — which most psychologists use to assess depression — does not, since it is self-reported. Some psychological tests qualify as objective evidence, including those that evaluate memory or cognitive performance.
The SSA does consider medical opinions from mental health providers, but it differentiates among them. Physicians, including psychiatrists and psychologists, are considered the most authoritative medical sources. Therapy notes from a counselor or social worker are given less weight.
That can heighten the barrier to being awarded benefits because people may struggle to find a psychiatrist or psychologist in their area. Shortages of mental health providers is a national issue, especially in rural areas.
Federal data from early 2025 show Texas, for instance, has enough mental-health professionals to meet only 31% of the need, slightly above the national average.
A study released in 2023 found that when the number of mental health establishments in a county increases, mental-health disability applications slightly increase. But that translates to more successful applications only in poorer counties when the locations have medical doctors.
“We know that SSI and SSDI have really complicated application processes, and having an adequate diagnosis from a physician is the most important thing for actually being awarded,” said Carly Urban, the study’s lead author and an economics professor at Montana State University.
Beyond availability, there is the cost issue. The U.S. rate of people lacking health insurance has declined to under 10% since 2014, when the Affordable Care Act took effect. But it remains high in some states, such as Texas, which hasn’t expanded Medicaid and has the nation’s highest uninsured rate, at 19.2% of people aged 64 and under in 2024. Nearly 23% of Texas adults with mental illness are uninsured, compared with about 10% nationally, according to Mental Health America, a nonprofit.
In the next decade, uninsured rates in the U.S. are expected to rise due to significant Medicaid cuts resulting from the tax and spending law pushed by President Trump. The law will require that Medicaid recipients meet new work requirements and verify their eligibility more frequently. An estimated 52 million nonelderly adults in the U.S. have a mental illness; Medicaid covers nearly one in three, or 29%, of them, the Kaiser Family Foundation reports.
“If you are someone with a mental health diagnosis, but you haven’t been able to access care because you don’t have health insurance, then you are not going to have a medical record,” said Nicole Maestas, a professor of economics and health care policy at Harvard Medical School.
“It’s a long process and if you drop any part of it, you sometimes have to start over.”
steve dane, director of income and skills development, haven for hope
Richard, 64, who lives in Monterey County, California, and asked to remain anonymous, was already diagnosed with obsessive-compulsive disorder and anxiety when he applied for disability benefits after being fired from his job in October 2023. When a lawyer suggested he return to therapy to bolster his claim, he realized his old therapist was no longer in his insurance plan’s network and it would cost $175 to see her. He couldn’t find another therapist.
“I tried that for months and most of the mental health providers I contacted didn’t even call me back,” he said. He decided to go back to his old therapist and pay out of pocket so he could initiate a claim.
His dilemma points to issues beyond the shortage of mental-health professionals, advocacy groups say. A study published by RTI International in 2024 found that insured mental-health patients are many times more likely than medical and surgical patients to go out of network for care. That greatly increases their financial burden and discourages them from seeking treatment, the study found.
Two critical problems are that reimbursements for providers are lower for mental health care, and federal and state agencies aren’t fully enforcing the 2008 Mental Health and Addiction Equity Act. The law requires parity in insurers’ coverage of mental and physical health care.
The cost of care was a factor in the SSA’s rejection of Krystal Nice’s claim for benefits seven years ago, she said. She couldn’t afford a therapist, so she didn’t have enough medical history to support her case. This time, she was seeing a therapist and psychiatrist regularly because she qualified for Medicaid after having a baby in August last year.
An assist from others
Mental health conditions often strip people of their support network — family or friends who could help them apply for disability benefits.
“People with mental health conditions may have burnt some bridges with family because of challenging behaviors,” says Wagner, the legal-aid lawyer now at Cornell. “If they had cancer and they were really cranky and irritable after chemo, you wouldn’t throw your hands up, right?”
Friends or family can help gather documents, remind patients of appointments or take them to appointments. Without the support, a patient might give up.
“It’s a long process and if you drop any part of it, you sometimes have to start over,” said Dane, of the Haven for Hope homeless shelter. Ironically, applying for disability because you cannot work requires many of the skills a person would need to work, he said. “You have to correspond. You have to meet deadlines.”
The challenge is steep for mentally ill people who are homeless. “Once you get to the street, something really bad has happened in your life to where you lost all your community support,” said David Huete, vice president of programs at Haven for Hope.
Since 2006, the Substance Abuse and Mental Health Administration (SAMHSA) has offered a program to address the challenge, called SOAR, for SSI/SSDI Outreach, Access and Recovery. The online program was designed to help people with serious mental illness who are homeless or at risk of homelessness access disability benefits — by training case managers to assist them.
SOAR reported that it has helped over 100,000 apply for the benefits, and its approval rate is 65%, reaching 79% in some states.
But recently SAMHSA announced it would stop offering online training and stop fielding questions from case managers, due to federal funding cuts. The SOAR website doesn’t work anymore, which leaves mentally ill people on the streets with fewer resources.
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The last time Krystal Nice woke up early to check the Social Security website was April 25. She checked the site again later that day — and burst into tears.
Her disability benefits had been approved.
A doctor to whom she was referred by the SSA in March had offered some hope, saying, “If it were up to me, it would be a no-brainer,” Nice recalled. But she anticipated a denial and efforts to file an appeal.
The monthly cash benefit has helped her but isn’t enough to pull her and her children out of poverty. And there’s a lingering pain over her exhaustive struggle to convince federal officials that her mental illness is disabling.
“It was an extraordinarily long process that was extremely stressful, she said, affecting her physical and mental health.
Now, more challenges are complicating her life.
She recently found out her allotment of food stamps is being cut and she was kicked off Medicaid.
“We are between a rock and a hard place as disabled people,” she said. “I will have to figure something out.”
Public Health Watch is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center and newsrooms in select states across the country.