Approach to and practical challenges in certification in Psychiatry.

Psychiatrists and mental health professionals (MHPs) are often requested to provide a certificate in connection with admission, treatment, fitness, competence, administration, legal proceedings, or welfare measures and benefits for persons with mental illness. The role of Psychiatrist and MHPs in providing a certificate is an integral part of clinical practice and more so with the implementation of the Mental Healthcare Act, 2017 (MHCA 2017). While issuing a certificate, keeping patient information confidential is a challenging task for a professional as the patient care in psychiatry involves multiple stakeholders (Central and State Mental Health Authorities, Mental Health Review Board, MHPs including psychiatrist, and caregivers). There is limited training at undergraduate or postgraduate level in documentary practices and certification. This article tries to address some of the issues related to certification, professional and legal accountability, and attempts to remove some of the ambiguities associated with the certification process in psychiatry.

INTRODUCTION

As per the Collins’ online dictionary, a medical certificate is “a document stating the result of a satisfactory medical examination.”[1] The Medical Council of India (MCI) enables doctors to issue a medical certificate in connection with medical care at the request of patients or a court order. The MCI, in its (Professional Conduct, Etiquette, and Ethics) Regulations, 2002, mentions that “A registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate, he/she shall always enter the identification marks of the patient and keep a copy of the certificate. He/She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report.”[2]

In psychiatry, psychiatrist and mental health professionals (MHPs) are often requested to provide a certificate in connection with the admission, treatment, fitness, competence, administration, legal proceedings, or welfare measures and benefits.[23] The role of psychiatrist and MHPs in providing a certificate is an integral and important part of clinical practice. However, there are various scenarios where a professional is expected to issue a certificate and encounter many gray areas, such as (a) who can certify? (b) What can be certified? (c) The validity of the certificate (d) In what context can a certificate be issued? and (e) Minimum standard assessment and prerequisite before issuing a certificate. This article will address a few issues which are commonly raised in connection with certification in clinical practice.

WHO AND WHAT CAN BE CERTIFIED?

MCI has granted the medical practitioners a right to issue certificates. In mental healthcare, psychiatrists in the government and private sector or medical officers can issue certificates. The Mental Healthcare Act, 2017 (MHCA 2017), enables the clinical psychologists, psychiatric social workers, and psychiatric nurses along with medical officer/psychiatrist to issue reports and certificates in various clinical circumstances. Table 1 shows the types of certificates that can be issued by various professionals.

Table 1

Certifying authority/individual and Certificate

Certifying authority/individual	What can be certified?
Medical Board	Certificate for invalidation from service (certificate of unfitness).
	Certificate of fitness to resume duties (Advisable to be issued by a Board)
	Certification for disability
	Mental Retardation certificate
	Certification for Adoption
	Pre-employment fitness certificate
State Mental Health Authority	Approval for Drug Trial and Research study among PMI
Mental Health Review Board	Conflict related to admission, diagnosis, treatment and discharge related decision
Psychiatrist	Certificate of fitness to resume duties (Govt. Sector)
	Certification for mental illness for government benefits
	Treatment certificate
	Capacity to consent for treatment
	Capacity to consent for admission
	Capacity to make ‘Advance Directive’ or nominate a ‘Nominated Representative’
Medical Practitioner	Certificate of fitness to resume duties (Govt. Sector)
	Certification for mental illness for government benefits
	Treatment certificate
	Capacity to consent for treatment
	Capacity to consent for admission
	Capacity to make ‘Advance Directive’ or nominate a ‘Nominated Representative’
Clinical Psychologist	Assessment for supported admission under sec. 89 of MHCA 2017
Psychiatric Social Worker	Assessment for supported admission under sec. 89 of MHCA 2017
Mental Health Nurse	Assessment for supported admission under sec. 89 of MHCA 2017

PMI – Person with Mental Illness, MHCA – Mental Healthcare Act

CERTIFICATE AND MHCA 2017

MHCA 2017[4] introduced new concepts such as mental capacity, advance directive, and nominated representative. MHPs, medical officers, and psychiatrists are expected to assess and issue certificates in relation to these and also in view of the changes introduced in the procedures for admission and discharge of Person with Mental Illness (PMI).

Supported admission

As per sections 89 and 90 of MHCA 2017, a person with mental illness (PMI) can be admitted against his/her will if it is proven that the person does not have the capacity to consent, there is a risk to self, others, or personal or public property; and the person is not able to take care of self due to the mental illness. To admit under section 89, assessment of capacity to consent for admission has to be done by one psychiatrist and one MHP independently. To continue the admission further after 30 days, under section 90, two psychiatrists independently have to examine and reassess the need for admission and capacity to consent.

Capacity assessment

Capacity is a multidimensional construct, and severe mental disorders are usually associated with a fluctuation in mental capacity. MHCA 2017 presumes that every PMI has the capacity to consent for admission, treatment-related decisions, advance directive, and nominated representative unless proved otherwise by a qualified medical officer or a psychiatrist. We do not have any official guidelines yet on capacity assessment from the Ministry of Health and Family Welfare. Until then, the clinician has to rely on clinical judgment to assess the capacity. Research tools such as McArthur's Competency Assessment Tool for consent for treatment/research[5] are available, but it has its own shortcoming, that is, not validated in an Indian setting, takes 40–50 min to administer and it does not look into Indian ethical, legal, and sociocultural context.

CERTIFICATE AND CIVIL CASES

Certificate of fitness for a job

While issuing a certificate of fitness, pre-employment or rejoining the duty, a written request from the employer asking for the opinion on the fitness or otherwise, of the employee and stating the designation and the type of job is essential. It is important to take written informed consent from the employee about assessing their fitness, about discussing the case details in front of a medical board, and about issuing a report to the employer. It is not advisable to issue such certificates without any request from the employer, a valid informed consent from the employee, and nature of the job in detail.[36] As per literature on fitness to rejoin the job or continuation of job, the following six domains are considered important: (a) health and safety risk of the individual, (b) determination of the worker's capacity, physical status, and psychological capacity for the designated job, (c) ethical considerations, (d) legal requirements, (e) predicted performance and absenteeism, and (f) economical issue.[789] Hence, an assessment of the overall fitness for a job will be done during the pre-employment period and also to rejoin the job during the course of employment. Fitness for a job compositely requires an essential skill necessary to perform the job and individual capacity to perform a requirement of the job. They need to be assessed by a comprehensive team of occupational therapist, rehabilitation expert, social worker, and clinical psychologist on a case-by-case basis.[10] After the detailed assessment and investigations, the case can be presented in front of the medical board. After a comprehensive review and consensual opinion from board members, the certificate can be issued to the employee and the employer.

Matrimonial matters

Psychiatrists are often requested to issue a certificate related to mental illness by a court of law in relation to matrimonial matters. Courts ask the psychiatrist about the mental capacity to consent for marriage, the severity of mental illness, and whether the mental illness would impede the ability to fulfill the role and obligation of marriage. In India, matrimonial and marriage issues are regulated through the Hindu Marriage Act, Muslim Marriage Act, Christian Marriage Act, Parsi Marriage Act, and Special Marriage Act. In Hindu Marriage Act,[11] a marriage is considered to be invalid or null and void, if, at the time of the marriage, either party: (a) is incapable of giving a valid consent to it because of unsoundness of mind; (b) though capable of giving a valid consent, has been suffering from a chronic mental disorder which makes them unfit for marriage and the procreation of children; or (c) has recurrent attacks of insanity.[31213]

Testamentary capacity

Psychiatrists may be requested to opine on a person's fitness to make a valid will. It is very important in old age and in persons with mental illness as cognitive impairment and impaired judgment due to mental illness can influence decision-making capacity. The mere presence of a mental illness does not exclude a person from making a valid will. Even in severe mental illness, a person may have lucid intervals and a will drafted during one such lucid interval is considered valid by the law. For legal purposes, the case of Banks v Goodfellow[14] is still considered the benchmark on the criteria for establishing testamentary capacity; the law remains relevant to date. The Court held that the four criteria to be used for determining whether a person has testamentary capacity are that the testator: (a) understands that he or she is giving instructions for the disposal of his or her property after their death; (b) can recollect the extent and character of his or her property and dispose it off with understanding and reason; (c) can recall and understand the claims of potential heirs, such as his or her family; and (d) is not suffering from any disorder of mind such as delusions or hallucinations which influence his or her decisions.

Adoption – Hindu Adoptions and Maintenance Act

According to the Hindu Adoptions and Maintenance Act (1956), any adult Hindu male/female who is of sound mind can adopt a child, provided he/she fulfills other requisite criteria.[15] Similarly, the person who is giving a child for adoption should be of sound mind as well. In such situations, certification of mental fitness may be necessary if asked for by a court of law. It is advisable to examine the person, administer necessary psychological assessments, and conduct all relevant tests on individual basis, before issuing a certificate. It is preferably done by a medical board after assessing the person in detail.

Organ donation/transplantation

Under the Transplantation of Human Organ Act of 1994 and rules[16] thereof, the donor has to be competent to consent for the removal of organs. A registered medical practitioner has to do a physical and mental evaluation of the donor and certify that he or she is in proper state of health, that he or she is not mentally challenged, and that he or she is fit to donate the organ or tissue: Provided that in case of doubt regarding mentally challenged status/mental illness of the donor, the registered medical practitioner may get the donor examined by a psychiatrist. A psychiatrist, while assessing the fitness of the donor, needs to examine if he/she is not taking the decision under any mental distress, is not coerced into the decision, and has the capacity to understand the consequences of donation and that it is an irreversible procedure and determine that the person can reasonably adjust, post-removal of organs.

Surrogacy

Surrogacy is an arrangement, whereby an intending couple commissions a surrogate mother to carry their child. Both the intending couple and the surrogate mother need to obtain a certificate of eligibility from the appropriate authority. To obtain a certificate of eligibility, the surrogate mother: (i) has to be a close relative of the intending couple, (ii) has to be an ever-married woman having a child of her own, (iii) has to be 25–35 years old, (iv) should not have been a surrogate mother earlier, and (v) should have a certificate of medical and psychological fitness.[17] A psychiatrist may be requested to issue a fitness certificate. In such a scenario, it is advisable to evaluate and examine the surrogate mother in detail, with relevant investigations and psychological assessments. It is important to ensure that the consent for surrogacy is given out of free will, with no coercion of any kind. The psychiatrist should ensure that the surrogate mother understands that once the child is delivered, she will have to relinquish all parental rights to the intending couple and the surrogate child will be deemed to be the biological child of the intending couple.

Medical leave

Certificate of leave from the job is one of the most requested certificates from any doctor; it is the same with psychiatrists as well. A PMI under treatment may require a certificate recommending leave from work. In such scenarios, a leave of absence can be given in the same format as that used for physical illnesses recommended by the MCI.[2] It is important to recommend leave for a short duration, that is, weeks, and not months, and periodical extension, if necessary, can be recommended after every detailed examination and assessment. There is no upper limit on the cumulative leave recommended.

Disability certificate

The Rights of Persons with Disability Act of 2016[18] has brought in a lot of changes to the previous act of 1995. In addition to increasing the coverage to 21 categories of disabilities from the previous seven, the new act lays a lot of emphasis on one's rights – the right to equality and opportunity, right to inherit and own property, right to home and family, and reproductive rights among others. The new act also stresses on accessibility – the government has to ensure that persons with disabilities get barrier-free access to physical infrastructure and transport systems. The new act has increased reservation for persons with disabilities in government jobs from 3% to 4% and to 5% in higher education.

An expert committee constituted by the Indian Psychiatric Society has come up with the following guidelines that can be followed while issuing a certificate of disability.

Indian Disability Evaluation Assessment Scale (IDEAS)[19] should be used for the assessment of mental illness-associated disability. A disability score of 40% or more is necessary to avail the disability benefit. However, it does not mean that a score of <40% is not a disability

Documents stating the diagnosis and details of medications, from private or government psychiatrists, can be accepted as evidence for the duration of illness. If a patient has been under care from private/government psychiatrist in the past, he/she should present Under-treatment certificate

The patient should be assessed, whenever possible, in at least three visits. If logistically feasible, the visits can be planned within the same week

Treatment for at least 3 months should ideally be given wherever possible, before considering for certification

In case of permanent certification, it was the consensus that at first, a temporary disability certificate be issued and then a permanent certificate. The duration between the assessments and the decision to issue a temporary/permanent certificate, however, was left at the discretion of the psychiatrist on a case to case basis

Should a private practitioner want a patient to benefit from permanent disability certificate, the calculation as per IDEAS could be documented and then the patient sent to a government center for further procedure.

Income tax exemption

The Government of India provides the facility of tax deduction benefit for the mentally disabled persons under sections 80-U and 80-DD of the Income Tax Act, 1961. While issuing a certificate of disability for tax benefits, it is recommended to use the format as provided by section 80-DD and 80-U. It is preferable to examine the person before issuing the certificate, and the disability in percentage should be mentioned in the certificate.

The certificates listed in Table 1 pertain to mental health alone. However, psychiatrists/medical officers can also issue certificates for the purpose of various acts/administrative requirements. MCI has listed the following certificates and reports to be issued by registered practitioners for various purposes such as (a) under the acts relating to birth, death, or disposal of the dead; (b) under the vaccinations act and the regulations made there under; (c) under the factory act and the regulations made there under; (d) under the education acts; (e) under the public health acts and the orders made there under; (f) under the workman's compensation act and persons with disability act; (g) under the acts and orders relating to the notification of infectious diseases; (h) under the Employee's State Insurance Acts; (i) in connection with sick benefit insurance and friendly societies; (j) under the merchant shipping act; (k) for procuring/issuing of passports; (l) for excusing attendance in courts of justice, in public services, in public offices or in ordinary employment; (m) in connection with civil and military matters; (n) in connection with matters under the control of the department of pensions; (o) in connection with quarantine rules; and (p) for procuring driving license.[23]

CERTIFICATE AND CRIMINAL CASE

Insanity defense

According to section 84 of Indian Penal Code, “Act of a person of unsound mind – Nothing is an offence which is done by a person who, at the time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of the act, or that he is doing what is either wrong or contrary to law.”[20]

The insanity defense is based on the assumption that at the time of the crime, the defendant was suffering from severe mental illness, and therefore, was incapable of appreciating the nature of the crime and differentiating right from wrong, hence making them not legally accountable for the crime. Just the mere presence of a mental disorder is not sufficient to prove insanity.[21]

Psychiatrists are requested to conduct mental health evaluations and treatment. Courts may also request various certifications which include:

Certifying the presence or absence of psychiatric illness

Defendant's mental status at the time of alleged offense retrospectively

Assessment of fitness to stand trial in cases (defendant's present mental status and his competence during adjudication).[2223]

It is prudent for a psychiatrist to consider inpatient admission of the defendant for a detailed evaluation before issuing a certificate. It is imperative for the psychiatrist to educate the court, clarify the psychiatric issues, and provide honest and objective opinions based on facts and sound reasoning.[21]

Fitness to stand trial

Fitness to stand trial is an integral part of criminal proceedings which can influence court proceedings. In India, there are no scales, assessments tools, or schedule to assess fitness to stand trial. The clinician has to look into the following domains to access the fitness to stand trial: (a) cognitive functions, (b) understanding the charges against him/her, (c) understanding the court proceedings, (d) helping the attorney/lawyer, and (e) behavior in the court.[24]

CHALLENGES IN ISSUING CERTIFICATES

Every document issued by a psychiatrist and MHP can be used as an important piece of evidence in the court of law. Hence, utmost care has to be taken while issuing a certificate. The following are a few common challenges a professional face in everyday practice:

Letter asked by one parent without the knowledge of the other parent (one may conceal ongoing legal issues between them). At times, parents may have disagreements about the content of the letter

Patient's request to conceal or change particulars such as name and age or the diagnosis and treatment

Patient's family coming for follow-up visit without patient and asking for a letter

What if the respective consultant in charge of the patient is on leave/has resigned from the establishment?

Adults other than the patient's family (e.g., uncles/grandparents) coming and requesting letters. Some people may go up to the extent of falsely representing themselves as the patient's family

Letters asked by the patient's family without the knowledge of the patient.

There is no standard operating procedure or a protocol provided by appropriate authorities, to be followed while issuing a certificate. Figure 1 details a standard operating procedure which a psychiatrist, medical officer or MHP can follow while issuing a certificate.

Figure 1

Standard operating procedure for issuing a certificate

PREREQUISITES FOR DRAFTING/ISSUING A CERTIFICATE

When the patient/relative approaches for a certificate, the reason for the same needs to be ascertained

A written request for a certificate, stating the purpose, needs to be obtained from the patient (e.g., an extension of leave, rejoining the job/school, medicolegal purpose, transfer to another place) and duly compiled in the patient's file

If a certificate is requested by others on behalf of the patient, the person's identity has to be confirmed, and a written request from the patient for the certificate and a letter authorizing the person to receive the certificate has to be obtained

In case a certificate is required for legal purposes (e.g., custody issues), the request for it must come from the appropriate court of law

If a letter is required by the court/or to be used for legal purposes, it is advisable that it is countersigned by the administrative head of hospital and the Medical Superintendent of the Institute or Teaching Hospital

For a medical fitness certificate, the request for it must come from the concerned authority and the certificate will be issued by a medical board after obtaining the necessary consent from the person to be examined

The issue of any letter needs to be recorded in the file with date, name, and signature of the issuer. The psychiatrist/institute should maintain a copy of the certificate

It is advisable to take signatures of the patient/patient's family in the file when issuing the certificate

It is advisable to take a signature or thumb impression of the patient, along with mentioning the identification marks of the person, on the certificate

Use the correct The International Classification of Diseases of Mental and Behavioural Disorders/Diagnostic and Statistical Manual of Mental Disorders labels for diagnosis. Mention all the objective diagnostic and psychological assessments administered to support the diagnosis

When summoned as “expert witness,” the opposite party could challenge the contents of the certificate. Objective-standardized diagnostic and psychological assessments could add validity to the contents of the certificate

Care needs to be taken while providing details of psychotherapy. Sensitive information revealed as part of psychotherapy should not be mentioned in letters. Confidentiality and anonymity have to be preserved

Drug names should be generic; dose and duration need to be mentioned correctly

Referral letters need to be carefully drafted. Other specialists may not understand psychiatric terminology

In patients who have stressors at the workplace, family, etc., and in those who are victims of abuse/neglect, the letters need to be carefully worded.

Table 2 shows format for issuing a certificate in clinical practice.

Table 2

A well-drafted letter or certificate has to include the following particulars

• Name (should match hospital records)

• Age

• Gender of patient

• Name of the parent/guardian/husband

• Place of residence

• Patient identification number

• Date of registration at the establishment and subsequent dates on which patient is seen

• Medical and psychiatric diagnosis of the patient (preferably after a detailed workup has been done)

• Avoid abbreviations, e.g., BPAD, PTSD, MR, etc., It is preferable to write the full form. Diagnosis should be written in full form, and care needs to be taken about using correct ICD/DSM labels for diagnosis

• Specific information collected over the total number of sessions and/or the number of follow-ups attended by the patient

• How and from whom the information was obtained?

• Mention “At the time of issuance of the letter…” (to highlight the cross-sectional nature of the information). Mention the date and need for follow-up assessment

• Any recommendations

• Purpose of the letter

• The letter issued on whose request?

• Avoid using any disclaimers like “This letter cannot be used as legal evidence” as every document, prescription, etc., issued can be used as legal evidence

• Do not comment on the caregivers’ attitudes or marital harmony without adequate evaluation

• It is a good practice to get the letters typed neatly on a letterhead (preferably A4 size, Arial font: 10–12 size) rather than writing by hand as at times, handwriting may be difficult to decipher

• In letters written for legal purposes, you must mention at least two identification marks of the patients in the file

ICD – International Classification of Disease; DSM – Diagnostic and Statistical Manual; BPAD – Bi-polar affective disorder, PTSD – Post-traumatic stress disorder, MR – Mental retardation

CONCLUSION

Certificates issued by psychiatrists are being increasingly used as evidence in the court of law and are also used for other administrative, bureaucratic, and welfare purposes. MHPs have various ethical, moral, and legal obligations while issuing a certificate. Hence, it is very important to follow minimum standard guideline while issuing a certificate. There is a need to develop guidelines about certification processes at the national level by authorities and institutions. This will help MHPs to follow a uniform standard of practice, without ambiguities while issuing certificates.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.