Disability Certification in Psychiatry.

Rights of disabled persons were first formalized in India with the Persons with Disabilities Act 1995. However, this act was law centric and not person centric. Thus, the Rights of Persons with Disabilities (RPWD) Act 2016 came into being to align with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) 2006 with the intention of creating a person-centric act to protect the rights of persons with disabilities.

The clinical practice guidelines framed here are derived mainly from deliberations arising out of the RPWD Act and implementation of the same. The government systematically released not only the Act but also the framework for assessment of the same. National Institute of Mental Health and Neurosciences (NIMHANS) in the year 2016 in Bangalore and the Disability Task Force of the Indian Psychiatric Society in the year 2018 at Mumbai had two national-level meetings to discuss the rights of disabled individuals, excerpts of which will be included here too.

It is first important to understand the framework of the Act and what it outlines, as compared to the earlier act [Table 1].

Table 1

Differences between Persons with Disabilities Act 1995 and Rights of Persons with Disabilities Act 2016

	PWD 1995	RPWD 2016
Purpose	To give effect to the meeting of “Asian and Pacific Decade of Disabled Persons - 1992”	To give effect to “UNCRPD - 2006” implementation
Motto	Equal opportunities, protection of rights and full participation	Respect for inherent dignity, individual autonomy, freedom to make one’s own choices
Main focus	Social welfare measures, prevention and early detection	Human rights protection along with other two
Total content	74 sections in 15 chapters	102 sections in 17 chapters
Total number of disabilities	7 out of which 2 are mental health related, namely MI and MR	21 out of which 4 are mental health related, namely MI, intellectual disability, MR, ASD and SLD
		More disabilities can be added by Central Government without amendment
Definition of the disabilities	Brief and mentioned along with chapter - 1	More elaborate and given as a separate schedule
Education	Promotion of special schools and special education	5% reservation for higher education. Upper age limit relaxation by 5 years. Promotes inclusive education. No mention about special schools
Job	Reservation (3%), only for visual impairment (1%), hearing impairment (1%) and locomotor (1%) disabilities	Reservation - 4%, (of which 1% for mental illness, ASD, ID, SLD and multiple disabilities including deaf blindness combined)
Grading of disability	Two types	Three types
	Person with no disability (below 40%)	Person with benchmark disability (40% and above)
	Person with disability also known as Benchmark disability (40% and above)	Person with benchmark disability with high support needs
		Person with disability (0%-39%) - cannot avail of benefits
Severity of disability for social benefits	40% and above	40% and above (no change)
Advisory board/committee	Only at central and state level	At central, state and district level
Legal capacity	Not emphasized. Onus upon the PWD	Equal rights as any citizen
		Special courts and public prosecutor for speedy trial
Infrastructure modification	No time limit mentioned	Time limit of 5 years
Incentives for private sector	Incentives for those employing PwD	Those who reserve 5% job for PwDs, incentives from government
Provision for guardianship	Not mentioned	Limited guardianship for PWDs with high support need
Certification	Not much emphasis on procedure	Elaborated and given as a separate chapter. (chapter- 10)
Mental illness as disability	Just included in the list of disability; one among the seven	More elaborate but some of the provisions are in fact harmful to the patient in Indian setup or contradicting with MHCA 2017, e.g., legal capacity

MI – Mental illness; MR – Mental retardation; ASD – Autism spectrum disorder; SLD – Specific learning disability; PWD – Persons with Disabilities Act; RPWD – Rights of Persons with Disabilities Act; UNCRPD – United Nations Convention on the Rights of Persons with Disabilities; MHCA – Mental Healthcare Act

Having understood the differences between the two Acts, Table 2 is a bird’s eye view of the RPWD 2016 (reproduced as it is from the law).

Table 2

Chapters of the Rights of Persons with Disabilities 2016

Chapter number	Content
I	Preliminary
II	Rights and entitlements
III	Education
IV	Skill development and employment
V	Social security, health, rehabilitation and recreation
VI	Special provisions for persons with benchmark disabilities
VII	Special provisions for persons with disabilities with high support needs
VIII	Duties and responsibilities of appropriate governments
IX	Registration of Institutions for persons with disabilities and grants to such Institutions
X	Certification of specified disabilities
XI	Central and State advisory boards on disability and district-level committee
XII	Chief Commissioner and State Commissioners for persons with disabilities
XIII	Special courts
XIV	National fund for persons with disabilities
XV	State fund for persons with disabilities
XVI	Offences and penalties
XVII	Miscellaneous

The detailed Act and chapters are freely available on the following website under the Bare Act – www.indiacode.nic.in Act no. 49, Act Code 201649.[1]

NEED FOR DISABILITY CERTIFICATION

As an ordinary clinician, with minimal interaction with the law, one often wonders what is the real need for us to know about certification and legislation in detail. The need for legislation regarding disability certification opens the following avenues for persons with disabilities (PWD),[2345] to name a few:

Scholarship schemes for students with disability

Rebate in income tax for the caregiver/PwD

Reservation in government jobs

Loan for starting own business

Concession in railway fare

Free travel in state transport buses

Subsidized prosthetic devices, wheelchairs, etc.

Group insurance for government employees with disability

Unemployment allowance to educated disabled persons

Day-care schemes, group homes for adult patients, marketing assistance, health insurance, and caregiver training programs for persons with autism, mental retardation, cerebral palsy, and multiple disabilities.

However, psychiatrists are at times reluctant to process disability certificates. The possible reasons for the delay in disability certification include lack of awareness about disability certification among patients and caregivers, cumbersome bureaucratic process to avail the certificate and welfare benefits, and attitudinal barriers among health professionals to disability certification. Health professionals may feel that it is not their job to educate patients about disability certification and welfare benefits. Due to heavy clinical work, some may prefer to focus on clinical issues rather than spend time on disability certification. There is a need to spread awareness about disability certificate and welfare benefits among patients, caregivers, and health professionals.

TYPES OF DISABILITY CERTIFICATION

The alignment with the UNCRPD and framing a new law is aimed at implementing a policy friendly to PWD. The aim of the disability certificate is for the Government of India to be able to provide benefits and facilities to PWD to reduce their daily stress, which are increased and improved from time to time.

The types of certification that a PwD[23456] can avail of under the Act are shown in Figure 1:

Figure 1

Types of disability certificates under Rights of Persons with Disabilities[35]

Based on severity, disability is grouped into three types (reproduced as it is from the law):

Person with disability: Here, the quantity of disability in percentage is from 0% to 39%. Such persons are disabled but not eligible for any benefits under disability category as of present law

Person with benchmark disability: Disability not less than 40% is grouped under this category. Unfortunately, calculation of percentage of disability in mental health-related disabilities is not easy in contrast to physical disabilities

Person with disability having high support need: Any disabled person with benchmark disability who needs the provision of guardianship or any support comes under this category.

WHO CAN CERTIFY

Medical authority[67]

The certifying medical authority is a medical board, constituted in government-run institutions or medical colleges, one of which is a subject expert, and one usually from the administration.

PROCESS OF CERTIFICATION

District administration shall ensure that PwDs have been issued disability certificate in the standard format prescribed by the Ministry of Social Justice and Empowerment, Government of India, and adopted by the State Governments. Once the application is received in prescribed format, certificate has to be issued within 1 month or inform the party in prescribed format (Form 8) that the person has no specified disability. If the applicant is aggrieved, he can appeal to appellate authority designated for the purpose by the State. After necessary assessment the final certificate can be issued signed by a single medical authority in case of single disability (Form 7). For multiple disabilities, the specialist in the concerned areas to be signed and countersigned by head of medical board (Form 6). For proof of residence apart from usual ones: utility bills with address, a certificate issued by the local body, a gazetted officer, headmaster, or head of rehabilitation center is valid. Individual state authorities can modify the procedures and many states still follow the existing procedure of multiple signatories with Superintendent as the Chairman of the Medical Board for issuing certificate.

A large amount of the above process has become paperless and unified with the UDID application.[48910]

FORMS USED IN THE PROCESS OF DISABILITY CERTIFICATION

The Rules issued (No. 489) on June 15, 2017, by Gazette notification from the Department of Disability Affairs describe eight types of forms to be used in various occasions. The first three forms (1 to 3) are to be used by the employer to have an idea about the number of persons in different categories in his firm with possible vacancies in future. The next five forms are directly associated with disability certification. Of which, the following are pertinent to us:[34]

Form IV: This form is to be used by the person with disability or his guardian as the application for obtaining the certificate [Figure 2]

Figure 2

Process of certification for disability (reproduced as it is from the law)[123]

Form VI: This form is used for issuing the certificate in multiple disabilities. This certificate needs signature from concerned specialists and countersigned by the Chairperson of the Medical Board

Form VII: This form is used for single disability except for conditions mentioned in Form V, namely amputation, blindness, and complete permanent paralysis

Form VIII: This is the form to be used for rejected application. The reasons for rejection have to be clearly mentioned in this form. The PwD has the right to complain to higher authorities in case the person is aggrieved by the rejection of the application and it has to be mentioned with address of appellate authority in this form.

The various forms are attached in the appendix, as a ready reference.

ASSESSMENT OF CHILDREN WITH DISABILITY[11121314]

Intellectual disability[34715]

The process of assessment is thus as follows [Figure 3]:

Figure 3

Assessment of children with intellectual disability replicated from the Rights of Persons with Disabilities 2016 (reproduced as it is from the law)[34]

Screening

Screening following developmental lag or delay. It is important to rule out other co-morbidities hearing/vision/locomotor.

Diagnosis

The recommended tests by MOSJE are as follows (reproduced as it is from the law):

Adaptive functioning: Vineland Social Maturity Scale (VSMS)[16]

IQ testing: Binet-Kamat Test (BKT)/Malin’s Intelligence Scale for Indian Children (MISIC).

Disability calculation:[16] The disability calculation will be done based on VSMS score. The following will be used for disability calculation:

VSMS score 0–20: Profound disability – 100%

VSMS score 21–35: Severe disability – 90%

VSMS score 36–54: Moderate disability – 75%

VSMS score 55–69: Mild disability – 50%

VSMS score 70–84: Borderline disability – 25%.

Age for certification: The minimum age for certification will be 1 completed year. Children 1–5 years shall be given a diagnosis as global developmental delay (GDD). Children less than the age of 5 years shall be given a diagnosis and certificate as Intellectual Disability.

Medical authority: The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified by the State Government shall be the Head of the Medical Board. The Authority shall comprise of:

The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified by the State Government

Pediatrician or Pediatric Neurologist (where available)/Psychiatrist or Physician

(if age >18 years)

Clinical or Rehabilitation Psychologist

Psychiatrist.

Validity of certificate:

Temporary certificate: For children <5 years: The certificate will be valid for maximum 3 years/5 years of age (whichever is earlier).

Renewal certificates: For children >5 years: The certificate will mention a renewal age. The certificate will have to be renewed at the age of 5 years, 10 years, and 18 years.

Permanent certificate: The certificate issued at 18 years of age will be valid lifelong.

The suggested assessment for certification of Children with Suspected Specific Learning Disability adapted from Rights of Persons with Disabilities 2016 (reproduced with minor changes from the law)[34]

Specific learning disability[34] [Figure 4]

The teachers of all public and private schools shall carry out the screening using the “screening tool” mentioned in the guidelines. This screening should be done at 8 years of age/Std III whichever comes earlier

There should be a screening committee in place at every school who will assess the teachers’ referral, and with the principal approach the parents to explain the same to them. With parental consent, the further evaluation can be done

The child shall be referred to the appropriate authorities for assessment.

Medical team and a clinical psychologist would be required for evaluation.

Diagnostic Tool

NIMHANS Battery shall be applied for diagnostic test for specific learning disabilities (SLDs).

Medical authority

The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified by the State Government shall be Head the certification authority. The medical authority will comprise of:

The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified by the State Government

Pediatrician or Pediatric Neurologist (where available)

Clinical or Rehabilitation Psychologist

Occupational Therapist or Special Educator or Teacher trained for assessment of SLD.

Validity of certificate

The certification will be done for children aged 8 years and older

Re-certification should be done at the age of 14 years and at the age of 18 years

The certificate issued at 18 years will be valid throughout life.

AUTISM SPECTRUM DISORDERS[3417]

Autism Spectrum Disorders are to be assessed and diagnosed using the INCLEN tool and Indian Scale for Assessment of Autism (ISAA),[18] which also quantifies disability inherently.

The detailed assessment of the same had been outlined in previous Clinical Practice Guidelines by the Indian Psychiatric Society on Autism, and can be accessed at http://www.indianpsychiatry.org/text.asp?2019/61/8/254/250040.

Children with disabilities form a significant proportion of the child population all over the world, as also in India. Childhood disabilities not only result in significant societal burden but also carry over into adult disabilities. India faces an increasing burden of disability decade on decade. Unless adequate measures of rehabilitation and occupation are made for this population, they will continue to be unemployed and dependent.

There are certain limitations and drawbacks[1920212223] for certification under the Act, and these are discussed below.

EVALUATING CHILDHOOD DEVELOPMENTAL DISABILITY UNDER RIGHTS OF PERSONS WITH DISABILITIES ACT[1920212223]

Evaluating the degree of disability in children is difficult in many cases. The RPWD Act includes only three classes of childhood disability which carry over into adulthood in many cases. Special procedures were laid down to diagnose these conditions in children, but intelligence quotient tests and the ISAA 2009 can be carried out for adults as well.

While the RPWD does include Intellectual Disability (and subsumes Autism and Specific Learning Disabilities – SLD – in the ID section), it does not include a very common disorder – Attention Deficit Hyperactivity Disorder – under its rubric. Moreover, children with Borderline intellectual functioning, who often approach psychiatrists due to academic difficulties, “fall through the cracks” and are not eligible for disability certification under ID or SLD, neither for educational benefits.

CERTIFYING DISABILITY IN SPECIFIC LEARNING DISABILITIES – A CUMBERSOME PROCESS

The Act does recognize that SLDs comprise a heterogeneous set of disabilities which manifest as difficulty to comprehend, speak, read, write, spell language, or to do mathematical calculations and includes such conditions as perceptual disabilities, dyslexia, dysgraphia, dyscalculia, dyspraxia, and developmental aphasia (Section 22.1, Gazette of India no. 61 New Delhi, Friday, January 5, 2018/Pausha 15, 1939) (Ministry of Social Justice and Empowerment, 2018). Admittedly diagnosing these disorders, many of which may coexist in the same child, is a tall order.

The Rules[34192021222324] further state that screening for these disorders is the purview of teachers in and above Class 3 or of children at least 8 years of age. After applying the screening test, the teacher needs to interview the child’s parents for assessing “their involvement and motivation regarding their child’s education.” The Rules appear to suggest that only if the parents are motivated and the screening test is unambiguously positive, should the child be referred for evaluation.

No “screening test” which can be easily used by a primary schoolteacher or above is provided.

The School Screening Committee is headed by the Principal, who is supposed to refer the child in WRITING to the pediatrician. The child has to be first evaluated for neurological hearing vision issues, overseen by a committee consisting of a pediatrician and clinical or rehabilitation psychologist. This is to be followed by an IQ assessment using MISIC or WISCIII (it seems to imply that no other tests for IQ assessment are permissible). Finally, the NIMHANS Battery for SLD shall be applied for diagnostic test for SLD.

The Medical Authority for certifying SLD includes the Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified by the State Government (head), Pediatrician or Pediatric Neurologist (where available), Clinical or Rehabilitation Psychologist, Occupational Therapist, or Special Educator or Teacher trained for assessment of SLD.

PROBLEMS AND ISSUES IN SPECIFIC LEARNING DISABILITY CERTIFICATION[192021222324]

In an obvious omission, psychiatrists who are the best-trained experts for diagnosis, who are most frequently consulted for childhood intellectual or behavioral issues, appear not to be suited to certify SLD.

The rather cumbersome procedures described in this certification process are probably either being followed in the breach or SLD certification is denied to the child altogether. This is because the number of certified (usually government) facilities where pediatricians and psychologists are available together are few and far between. On the other hand, most departments of psychiatry are familiar with the process of certification, and have qualified psychologists as part of their team.

Another lacuna – a scientific one this time – is the lack of standardized screening and assessment tools for Specific Learning Disabilities in India. Most Indian children are bilingual, and several Indian children are trilingual. Beginning with their mother tongue, they go on to learn Hindi and/or English in school, all the while speaking their original language at home. These children need to be assessed in all the languages they know or at least the ones they formally learn in school.[25]

Due to lack of nonproprietary tools suitable in India, the NIMHANS Dyslexia tool has been accepted as a bridge alternative till such time as a free tool suitable for use all over India which is also curriculum free, becomes available. Being curriculum free is important because NIMHANS tool uses ability to read school textbooks as one measure of performance, whereas the child is referred precisely because s/he is not doing well in school. Unless she/he shows typically written symptoms of dyslexia, asking the child to read her or his school textbooks only, to assess dyslexia is not adequate. Moreover, the tool was developed decades ago in a very small sample of children in one center only.

There are other issues – lack of appropriate norms established using a large representative sample and availability in specific languages only (e.g. Marathi, Gujarati, and Kannada). The NIMHANS Index for Specific Learning Disabilities evaluates only English language ability, whereas the large majority of Indian children study in local languages. The items used in these batteries including the NIMHANS Battery, are not standardized, nor are all age groups included (the NIMHANS Battery examines children from 8–12 years only) whereas the Rules for RPWD SLD certification state that re-evaluation needs to be repeated at 14 years and certificates given at age 18 will be permanent. Moreover, all Boards provide special concessions for SLD children, implying that children up to and even above the age of 18 must be evaluated for certification.

Note: NIMHANS’ new scale is constructed to assess the academic difficulties up to tenth grade only. However, those who get academic provisions for a tenth grade can be extended to twelfth grade if the medical authority feels it is essential. Any further application of this battery at degree level or higher grades is not intended. Some experts are of the opinion that benefits of RPWD Act 2016 for students with SLD per se should be only for educational benefits such as extra time, change of subject, and scribe up to the secondary grade of education. After that, the difficulty should be overcome by taking a skill based career.

Suggestions and remedies

As soon as the flawed Rules mentioned above were notified, the Indian Psychiatric Society petitioned both the Ministry of Health (for certification) and the Ministry of Social Justice and Empowerment (MOSJE – nodal for the Act) to amend the Rules to include psychiatrists in the certification process. After several petitions, personal meetings, appeals, and request for interventions, the MOSJE has at last agreed in principle. The Notification in this regard is likely to be published in the near future.

However need for, a simple screening tool which can be used by anyone who knows the child’s academic performance well, and a more detailed one for expert diagnosis still remains. The Ministry of Science and Technology in association with the National Brain Research Centre created the Dyslexia Assessment for Languages of India (DALI) tool available in Hindi, English, Marathi, and Kannada at present (www.dyslexia.tools). The toolkit contains two separate Screening Tests which can be administered by a teacher (who knows the child for at least 2 months), one each for junior and middle school. There is a more detailed Dyslexia Assessment Battery, validated in thousands of Indian schoolchildren, which has to be administered by trained psychologists.

There are other standardized tests being used throughout the country like the Wide Range Achievement Test, the Woodcock–Johnson Test, etc., and curriculum-based tests, which are used by experts across the country, to assess the same. These deserve a mention as an option in the guidelines. Further, even among the IQ tests, advanced tests like the WISC-IV are available, and the discretion and option to use it should be left to the expert availability at that point.

Continual efforts need to be made to develop this tool further, and/or create new tools for both screening and diagnosis of not only dyslexia, but also all the other conditions listed under Specific Learning Disabilities in this law.

DISABILITY IN MENTAL ILLNESS[26272829]

Worldwide, mental illness is a leading cause of disability. According to the National Mental Health Survey 2015–2016 done in India, at least 50% of persons with a mental illness reported disability in work, social, and family life (domains covered by Sheehan Disability Scale used in the survey) more than 50% of persons diagnosed with depressive disorder, bipolar affective disorder, schizophrenia, and related psychotic disorders and epilepsy reported disability More than one-fourth of persons with alcohol use disorders and more than 40% of persons with neurosis reported disability.

Among persons with schizophrenia, disability plateaus after 4–5 years. In contrast to schizophrenia, patients with ICD with >5-year duration of illness have more work impairment as compared to those with 2–5-year duration of illness. More research is needed for disability due to other psychiatric disorders.

In the Persons with Disabilities Act 1995,[13] mental illness was included as a seventh disability. The Rehabilitation Committee of the Indian Psychiatric Society developed the Indian Disability Evaluation and Assessment Scale (IDEAS) and field-tested it in 9 centers. Initially, the scale was supposed to measure disability due to 4 mental illnesses, namely schizophrenia, bipolar affective disorder, dementia, and obsessive-compulsive disorder. The instrument was modified and gazetted by the Government of India in 2002 to measure psychiatric disability in any mental condition causing disability. The gazetted draft made the following modifications:

List of mental illnesses was expanded to all mental illnesses. It was not restricted only to 4 disorders

Minimum duration criteria of 2 years were deleted

“Months disabled in the last 2 years” was replaced with “duration of illness.”

While mental illness is disabling, not every person with mental illness has benchmark disability to avail welfare benefits. In India, a person with mental illness who scores 7 and above as per IDEAS is considered to have benchmark disability. The recent “Rights of Persons with Disabilities Act 2016” has also recommended IDEAS (Ministry of Law and Justice, Government of India, 2016; Ministry of Social Justice and Empowerment, 2018) [Figure 5].

Figure 5

Flowchart for certifying disability due to mental illness[34]

Although IDEAS was gazetted in 2002, mental illness accounts for 4.8%–39.2% of certificates issued from psychiatric hospitals [Table 3]. The number of disability certificates issued for persons with intellectual disability is with several times higher. This may be due to multiple reasons.

Table 3

Indian studies on profile of disability certificates issued for psychiatric disorders[9343536373839]

Study	Setting	Number of disability certificates	Time period	Mental illness disability certificates, n (% of disability certificates issued)	Mental illness certified for disability (n)
Balhara et al., 2011	RML Hospital, New Delhi	173	April 2009 to March 2010	66 (38.2)	Schizophrenia (54)
					Dementia (5)
					Bipolar affective disorder (4)
					Obsessive-compulsive disorder (3)
Kashyap et al., 2012	Wenlock Hospital, Mangalore (certificates issued in hospital and disability assessment camps)	2079	2006-2008	285 (13.7)	Schizophrenia (186)
					Bipolar affective disorder (36)
					Chronic psychosis (33)
					Others (including dementia) 30
Yadav et al., 2017	Safdarjung Hospital, New Delhi	231	January 2015 to May 2016	11 (4.8)	Schizophrenia (10)
					Obsessive-compulsive disorder (1)
Jadhav et al., 2020	NIMHANS, Bengaluru	2376	January 2017 to December 2018	931 (39.2)	Schizophrenia and related psychotic disorders (505)
					Mood disorders (260)
					Obsessive-compulsive disorder (32)
					Dementia (39)
					Other mental illness (95)

NIMHANS – National Institute of Mental Health and Neurosciences

Intellectual disability is a lifelong condition diagnosed early in the life

There is more awareness among parents of persons with intellectual disabilities about disability certificate and welfare benefits. This includes admission in special schools and schemes like Niramaya Health Insurance scheme under National Trust Act 1999

Unlike mental illness, families of persons with intellectual disability may approach the hospital specifically for disability certificate

Intelligence quotient assessment done as part of detailed workup of Intellectual disability can be used to issue disability certificate

As there is no medical intervention for ID per se, the management plan is more likely to include discussion of welfare benefits available with DC.

Schizophrenia and related psychotic disorders[30] account for the majority of disability certificates issued for mental illness. In the UK, common mental disorders (including depressive disorder and anxiety disorders) account for more than two-thirds of persons with mental illness availing welfare benefits. This may be due to stigma or lack of awareness among Indian public about common mental disorders as mental illness and its eligibility for disability certification and reluctance among mental health professionals to certify common mental illness for disability. Many patients with mental illness actively prevent their caregivers from applying for certification, perhaps due to stigma or lack of insight. It is the psychiatrist’s duty to inform both patient and caregiver of facilities and advantages that the government offers after disability certification. Families are often conscious of the genetic or familial nature of mental illnesses and, therefore, want to conceal it in a family member.[31]

Some patients with mental illness refuse to apply for a disability certificate due to paranoia associated with mental illness. Some patients may not apply for disability due to stigma. As disability certificate is a legal document, family/patient may consider it as a “label” which will affect marital and other prospects of the patient as well as family members. The process of availing welfare benefits requires that the person with disability must share the disability status to the concerned officer. Persons with mental illness may be reluctant to disclose their illness status for availing benefits.[103233]

Disability certification for mental illness is done only at government-listed or government-approved medical centers or district or taluk hospitals. It is a matter of concern that psychiatrist and psychologist may not be available at all taluk or district hospitals across the country for certification [Figure 6].

Figure 6

Issuing of disability certificate for mental illness[34]

MULTIPLE DISABILITIES (REPRODUCED AS IT IS FROM THE LAW)

Calculation of multiple disabilities

The disability[36] with the highest score (major) is taken into consideration. The lower score (minor) is telescopically added to the highest score based on the following formula to get the final disability score.[1833]

Total disability in percentage = a + [b (90 − a)/90]

a = major disability; b = minor disability.

E.g.: If a person has 80% disability of vision (a), and

20% disability of locomotor (b)

Then, the total disability is 80+ [20 (90 − 80)/90] =82%.

Subsequent disabilities can be added in the same way after getting each telescopic sum up. The same formula can be used for combining values of different components in a single disability.

UNIQUE DISABILITY ID[10]

The unique disability ID or UDID, was a special project started by the Ministry of Social Justice and Empowerment, by the Department for Empowerment of Persons with Disabilities. It forms a unified and single-point network to deal with digitized application, issuing, and renewal of certificates for individuals with disabilities.

The process is fairly simple:

The said candidate/guardian has to make an online application on www.swavlambancard.gov.in

In the said application, automatically options for nearby centers issuing certificates are generated. Thus, a said candidate can apply only within the geographical jurisdiction of her/his residential area. This will prevent overburdening in key districts, and also facilitate easy tracking. Once the options are chosen, the candidate can take a physical copy and approach the concerned center (which would have received a digital update of the said candidate)

The documents are verified and/or tests initialized at the said center

Once the assessment process is done, a digital entry of the same is carried out, a final nod by the medical board (usually comprising of 3 members – one of who is a subject expert)

The digital certificate with signature and the card are sent directly to the candidate at the address mentioned in the records. Usually, a hard copy is also handed over by the institution issuing the certificate.

The process is fairly simple and streamlined. The government conducts training at various district-level fora, to empower more people to use this and unify the database for PWD. The format for application is attached in the appendix.

As a psychiatrist, the knowledge helps us reach out to patients and help guide them through the process of application.

DO’S AND DON’TS FOR CERTIFYING DISABILITY DUE TO MENTAL ILLNESS

According to guidelines for evaluation and procedure for certification of disabilities under “Right to Persons with Disabilities Act 2017,” mental illness means “a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognize reality or ability to meet the ordinary demands of life, but does not include retardation which is a condition of arrested or incomplete development of mind of a person, especially characterized by subnormality of intelligence.” This definition includes all ICD-10 mental and behavioral disorders,[4041] except F 70–79 (mental retardation). This covers personality disorders and substance use disorders also. The medical authority can take a final call depending on the individual case.

The medical authority certifies disability due to mental illness. A psychiatrist and a clinical psychologist are part of the board to certify disability due to mental illness.

The case record should have all necessary details. Note down marks of identification, identity, and address proof. The current disability certification process through UDID makes Aadhaar card mandatory.

Where possible, collect information about patients’ self-care, interpersonal activities, communication and understanding, and work from multiple sources (patient, family, employer, etc.). It is desirable that the reported information is verified objectively by mental state examination and behavioral observation in OPD or ward.

As per law, disability due to mental illness can be certified even during the first consultation regardless of whether the patient availed treatment or not. The recent government guideline is silent about treatment status at the time of certifying disability due to mental illness [Table 4]. Some states, like Uttar Pradesh, mandate treatment before certifying disability due to mental illness (Government of Uttar Pradesh.[33] Disability certificate for persons with mental illness. vide letter no. 1466/5-7-2003. Government of Uttar Pradesh; 2003). An expert committee constituted by the Indian Psychiatric Society had suggested 3 months of treatment before disability certification for mental illness, but till date, this recommendation has not been accepted or gazetted by the Government of India. As per the RPWD Act, it is necessary to follow the State guidelines for disability certification. The medical authority can take the final call on treatment status at the time of disability certification.[33]

Table 4

Do’s and don’ts while certifying for disability

Dos’	Don’ts
• Verify ID proof, marks of identification and address proof	• Rely only on old records
• Maintain case record of assessments done and old treatment records	• Rely on verbal reports alone to certify. Documents, if available, are important. If not, the psychiatrist will need to generate and maintain records supporting her/his decision of disability
• Clinically verify the diagnosis and assessments done	• Base judgment on someone else’s diagnosis and evaluation
• Specify diagnosis and percentage of disability (with UDID, this problem gets sorted out as the software forces you to enter these fields)	• Keep multiple diagnosis and differentials that can cause problems while certifying
• Is the certificate permanent or temporary (with UDID, this problem gets sorted out as the software forces you to enter these fields)	• Undated certificates and certificates without duration of validity can be very problematic
• Issue disability certificate in correct format given by respective state government from designated hospitals alone (sorted out in UDID as only designated hospitals get the login details to use it)	• Issue disability certificates if you are not a designated hospital to issue disability certificates

UDID – Unique disability ID

The time duration for the administration of IDEAS (for example, last 1 month or 1 year or period of hospitalization) has not been specified. The draft IDEAS proposed by the Rehabilitation Committee of Indian Psychiatric Society had recommended scoring the number of months disabled in the last 2 years. The World Health Organization-Disability Assessment Schedule (WHO-DAS)[42434445] assesses disability over the previous 30 days only. This needs to be clarified by authorities. The medical authority issuing the certificate can take a call on the same.[3046]

As disability can vary according to phase of illness and treatment, the medical authority can decide if a “temporary” or “permanent” disability certificate should be issued.

If the treating psychiatrist is in private sector, the patient can be advised to apply for a disability certificate to UDID. The treating psychiatrist can share details of diagnosis, duration of illness, treatment given, medication adherence, and impression about IDEAS score on her/his letter pad. The medical authority can independently verify the IDEAS score and decide if the person has benchmark disability

AS A FINAL NOTE

Most psychiatrists are truly hesitant to get into disability certification as the onus largely rests with government institutes. However, with the UDID and increasing benefits due to patients, the process is worthwhile exploring and understanding, to help guide patients. Further, for temporary certification and renewal, it is the primary psychiatrist who can keep track and guide the patient accordingly.

At times, the psychiatrist may be called in as an expert witness to testify, and at that time, an understanding of the process of certification, goes a long way in helping both the patient and the judicial proceedings.

Psychiatrists in government institutes undoubtedly will, through the process of training, familiarize and update themselves with the formats under the RPWD 2016 and UDID; it is also suggested that bodies like the Indian Psychiatric Society organize regular online training programs/CMEs to ensure that psychiatrists are updated and trained for the same.

This document hopes to be a ready reckoner to aid that process.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.