Sociodemographic and clinical profile of patients receiving disability certificates for psychiatric disorders: An Indian Psychiatric Society Multicentric study.

Aim: To study the sociodemographic and clinical profile of subjects receiving disability certificates (DCs) issued for psychiatric disorders across multiple centres in India. Materials and
Methods: Eleven centres, including ten government and one non-governmental organization spread across the country, participated in the study. Data on the sociodemographic and clinical profiles of patients who were issued DC in the calendar year 2019 were collected on a proforma designed for the study.
Results: Overall, 2018 patients were issued DC for various psychiatric disorders across 11 centres in 2019. The number of certificates issued across different centres varied from 34 to 622. In terms of diagnostic profile, intellectual disability accounted for most of the certificates issued. In terms of psychiatric diagnosis, schizophrenia was the most common psychiatric diagnosis, followed by bipolar disorder, for which a DC was issued. When the diagnosis was considered, centre wise, intellectual disability (6 centres), mental illness (MI; 4 centres), and autism and specific learning disability (1 centre) accounted for the most DCs issued. Schizophrenia (9 centres), bipolar affective disorder (1 centre), and dementia (1 centre) were the most common MI for which DC was issued. Across centres, more than two-thirds of DC were issued to males.
Conclusion: There is a wide variation in the number and clinical profile of DC issued across centres. Copyright:

INTRODUCTION

The Persons with Disabilities (PWD) Act 1995 recognized seven disabilities, including mental retardation [old term for intellectual disability (ID)] and mental illness (MI).[1] In 2016, the PWD Act 1995 was replaced with the Rights of Persons with Disabilities (RPWD) Act 2016.[2] The Act recognizes four psychiatric disabilities: mental illness (MI), intellectual disability (ID), autism [autistic spectrum disorder (ASD)] and specific learning disability (SLD).[2]

In 2018, the Government of India notified guidelines for evaluation and procedure for certification of disabilities under the RPWD Act 2016.[3] As per the guidelines, if the person fulfils the criteria for benchmark disability, the medical board in the authorized hospital issues a disability certificate (DC). The DC with benchmark disability is required to avail various welfare benefits. Currently, only government hospitals are authorized to issue DC in most states.[4] However, in Tamil Nadu, some non-governmental organizations (NGOs) are permitted to issue DC.

Published studies from Delhi, Mangalore and Bengaluru report that more DCs are issued for ID than MI.[56789] In contrast, a study from Puducherry reports that more certificates were issued for MI followed by ID.[10] All these studies were carried out in government hospitals, and the sample size of DC issued across centres varied from 169 to 2448 over 1 to 5-year periods.[5678910] One study focused on DC issued for adult patients only.[8] Other common trends are seen in the published studies from tertiary centres, and more males were issued DC than females,[678910] unlike community study.[5] Most of these studies were carried out before the latest government guidelines[4] were issued.[567] None of the studies published after the notification of guidelines reported DC issued for SLD[8910] and ASD[810] except in one study.[9]

All the studies have been from single centres, have not included all the psychiatric disorders eligible for disability certification,[3] and do not provide a comprehensive national picture as per RPWD Act, 2016. Accordingly, this study aimed to assess the sociodemographic and clinical profile of patients receiving DC for psychiatric disorders in several centres spread across different regions of India.

MATERIALS AND METHODS

The Indian Psychiatric Society funded this study. Initially, 13 centres showed interest in participating in the study, but finally, 11 centres participated. There were three centres (Kashmir, Chandigarh and Bikaner) from the North zone, one centre (Lucknow) from the central zone, two centres (Ranchi and Kolkata) from the east zone, two centres (Vadodara and Mumbai) from the west zone and three centres (Bengaluru, Puducherry and Madurai) from the south zone. Seven centres were in general hospital psychiatry settings, including two centrally funded institutes (Chandigarh and Puducherry) and five from state government medical colleges (Bikaner, Lucknow, Kolkata, Vadodara and Mumbai). Two centres were from centrally funded mental hospital settings (Bengaluru and Ranchi). One centre was from an NGO setting (Madurai). As private clinics/hospitals are not allowed to issue DC in India, they were not included in the study.

Data was collected on a predesigned uniformly used datasheet across centres for the calendar year 2019. The sociodemographic and clinical details of patients issued DC in 2019 were retrieved from hospital records. All data were entered and analyzed with Microsoft Excel software. The study was approved by the IPS Ethics Committee and local ethics committees of the respective centres.

Statistical analysis

Descriptive analysis was computed using mean and standard deviation with range for continuous variables and frequency with percentage for ordinal and nominal variables. The Chi-square test was applied to check the relationship between categorical variables. However, the Kruskal–Wallis test is the non-parametric equivalent of an analysis of variance used as the assumption of homogeneity of variance between the groups is not met.

RESULTS

Table 1 shows the distribution of DC issued across 11 centres from January 2019 to December 2019. The number of DC issued varied across centres: the highest number of DC were from Bengaluru, followed by Kashmir. The least was from Puducherry. Of the 2018 DC included, 500 were from the north zone, 219 from the central zone, 320 from the east zone, 223 from the west zone and 756 from the south zone.

Table 1

Distribution of DCs across centres in 2019

Centres	Disability certificates (n=2018)
Bengaluru	622 (31%)
Bikaner	213 (10.5%)
Chandigarh	38 (2%)
Kashmir	249 (12%)
Kolkata	123 (6%)
Lucknow	219 (11%)
Madurai	100 (5%)
Mumbai	117 (5.5%)
Puducherry	34 (2%)
Ranchi	197 (10%)
Vadodara	106 (5%)

Table 2 shows the sociodemographic profile of patients issued DC. The mean age was 26.82 years. Most DCs (90%) were issued to those <50 years of age. Two-thirds of DC were issued to males. More than half of the DC were issued to residents of the same district as the hospital. Only a third of patients receiving DC belonged to rural areas. Nearly all except 9 (0.5%) DCs were issued for benchmark (≥40%) disability.

Table 2

Sociodemographic profile of patients issued DCs in 2019

Variables	Mean (SD)/n (%)
Age in years	26.82 (15.58)
Age group
Up to 18 years	807 (40%)
18-60 years	1160 (57%)
61 years and above	51 (3%)
Gender
Male	1371 (68%)
Female	647 (32%)
Residence
Same district	1092 (54%)
Same state	703 (35%)
Different state	153 (8%)
Missing	70 (3%)
Locality
Urban	950 (47%)
Semi-urban	402 (20%)
Rural	596 (30%)
Missing	70 (3%)
Socioeconomic status
Below poverty line	955 (47%)
Above poverty line	795 (39%)
Missing	268 (14%)
Education
Not formally educated	704 (35%)
Primary	390 (19%)
Secondary	160 (8%)
Preuniversity college	19 (1%)
Graduation and higher	42 (2%)
Missing	703 (35%)
Marital status
Single	1054 (52%)
Married	237 (12%)
Widow	8 (1%)
Separated	18 (1%)
Missing	650 (32%)
Percentage of illness
40-74	1193 (59%)
75-90	684 (33.5%)
91-99	16 (1%)
100	116 (6%)
<40	9 (0.5%)

Table 3 shows the clinical and sociodemographic profile of patients issued DC for various psychiatric disorders. More than two-thirds of DC were issued for males. The mean age was lowest for ASD (12.51 years), followed by SLD (15.56 years). The mean age for issuing DC was highest for MI (39.2 years). The majority of DC for ASD, SLD and multiple disabilities were issued for patients aged <18 years. Unlike MI and ID, most patients receiving DC for ASD, SLD and multiple disabilities were above the poverty line.

Table 3

Sociodemographic and clinical profile of DCs issued for various psychiatric disorders across 11 centres

	Mental illness (%)	Intellectual disability (%)	Autistic spectrum disorder (%)	Specific learning disorder (%)	Multiple disabilities (%)	Chi-square test/analysis of variance (P)
n	727 (36%)	962 (47.5%)	74 (3.5%)	96 (5%)	159 (8%)
Age (mean±SD)	39.20 (13.56)	21.46 (12.3)	12.51 (6.68)	15.56 (6.11)	16.57 (12.27)	Kruskal–Wallis test P<0.05
Up to 18 years	45 (6.19%)	481 (50%)	66 (89%)	94 (98%)	116 (73%)
19-60 years	637 (87.62%)	474 (49.2%)	8 (11%)	2 (2%)	43 (27%)
61 and above	45 (6.19%)	7 (0.8%)	0	0	0
Gender
Male	499 (68.6%)	644 (67%)	58 (78%)	68 (71%)	102 (64%)	0.228
Female	228 (31.4%)	318 (33%)	16 (22%)	28 (29%)	57 (36%)
Residence
Same district	295 (40.5%)	534 (56%)	46 (62.2%)	70 (73%)	147 (92.5%)	<0.05
Same state	310 (42.6%)	334 (34%)	25 (33.8%)	23 (24%)	11 (6.5%)
Different state	81 (11.1%)	67 (7%)	1 (1%)	3 (3%)	0
Missing	41 (5.8%)	27 (3%)	2 (3%)	0	0
Locality
Urban	310 (42.6%)	438 (45.5%)	49 (66.2%)	73 (76%)	80 (50%)	<0.05
Semi-urban	188 (25.9%)	164 (17%)	10 (13.5%)	20 (21%)	20 (13%)
Rural	189 (26%)	332 (34.5%)	13 (17.5%)	3 (3%)	59 (37%)
Missing	40 (5.5%)	28 (3%)	2 (2.8%)	0	0
Socioeconomic status
Below poverty line	450 (61.9%)	439 (45.8%)	10 (13.5%)	14 (15%)	42 (26%)	<0.05
Above poverty line	223 (30.7%)	373 (38.7%)	48 (65%)	78 (81%)	73 (46%)
Missing	54 (7.4%)	150 (15.5%)	16 (21.5%)	4 (4%)	44 (28%)
Education
Not formally educated	174 (24%)	387 (40.2%)	23 (31%)	9 (9.2%)	111 (70%)	<0.05
Primary	126 (17.3%)	166 (17.2%)	20 (27%)	43 (45%)	35 (22%)
Secondary	79 (10.85%)	32 (3.3%)	6 (8%)	42 (43.8%)	1 (0.5%)
Preuniveristy college	12 (1.65%)	6 (0.6%)	0	0	1 (0.5%)
Graduation and higher	39 (5.4%)	3 (0.3%)	0	0	0
Missing	297 (40.8%)	368 (37.3%)	25 (34%)	2 (2%)	11 (7%)
Marital status
Single	256 (35.2%)	564 (58.6%)	50 (67.4%)	51 (53%)	144 (91%)
Married	183 (25.2%)	45 (4.7%)	1 (1.3%)	40 (42%)	6 (3.5%)
Widow	7 (1%)	0	1 (1.3%)	2 (2%)	0
Separated	15 (2.1%)	3 (0.3%)	0	0	0
Missing	266 (36.5%)	350 (36.4%)	22 (30%)	3 (3%)	9 (5.5%)
Percentage of illness
40-74	579 (79.6%)	420 (44%)	52 (70%)	96 (100%)	46 (29%)	< 0.05
75-90	137 (18.8%)	433 (45.4%)	20 (27%)	0	94 (59%)
91-99	5 (0.68%)	4 (0.5%)	0	0	7 (4%)
100	6 (0.83%)	96 (10%)	2 (3%)	0	12 (8%)
<40%	0	9 (0.1%)	0	0	0

Table 4 shows the sociodemographic and clinical profile of DC issued across 11 centres. The mean age for issuing DC was lowest in Bikaner (19.4 years) and highest in Puducherry (40.65 years). A male preponderance among DC issued across centres except for Puducherry (68% vs. 44%). Residents of a different state than the hospital accounted for most DC issued in Puducherry (62%), Chandigarh (53%) and Ranchi (40%). Rural patients accounted for most DC in Lucknow (97%), Bikaner (57%) and Chandigarh (53%). Recipients of DC were primarily single, with less than primary school education across most sites. DC was mainly issued to people below the poverty line except in the Bikaner site. ID accounted for most DC issued across centres except Kashmir, Madurai, Puducherry and Mumbai. In Kashmir (79%), Chandigarh (63%), Madurai (49%) and Puducherry (82%), the most DC issued was for MI. ASD and SLD were the most common conditions certified for disability in Mumbai (26% each). Schizophrenia was the most common MI certified for disability across centres except Kashmir (where bipolar affective disorder was the most common MI to be certified) and Chandigarh (where dementia was the most common MI to be certified).

Table 4

Sociodemographic and clinical profile of DCs issued in 11 individual centres

	Bengaluru	Bikaner	Chandigarh	Kashmir	Kolkata	Lucknow	Ranchi	Madurai	Mumbai	Puducherry	Vadodara
n	622	213	38	249	123	219	197	100	117	34	106
Age (years) (mean±SD)	32.58 (15.4)	19.4 (13.5)	27.24 (13.4)	32.98 (14.51)	21.06 (13.1)	23.84 (12.88)	22.5 (15.58)	33.18 (18.36)	18.15 (10.4)	40.65 (14.6)	20.34 (12.5)
Up to18 years	173 (28%)	129 (61%)	11 (29%)	47 (19%)	63 (51%)	86 (39%)	113 (57%)	27 (27%)	91 (78%)	4 (12%)	63 (59%)
19-60 years	427 (69%)	82 (38%)	26 (68%)	194 (78%)	60 (49%)	131 (60%)	81 (41%)	65 (65%)	26 (22%)	25 (73.5%)	43 (41%)
61 and above	22 (3%)	2 (1%)	1 (3%)	8 (3%)	0	2 (1%)	3 (2%)	8 (8%)	0	5 (14.5%)	0
Gender
Male	411 (66%)	149 (70%)	31 (82%)	173 (70%)	82 (67%)	166 (76%)	138 (70%)	59 (59%)	82 (70%)	15 (44%)	65 (61%)
Female	211 (34%)	64 (30%)	7 (18%)	76 (30%)	41 (33%)	53 (23%)	59 (30%)	41 (41%)	35 (30%)	19 (56%)	41 (39%)
Residence
Same district	322 (52%)	213 (100%)	18 (47%)	112 (45%)	123 (100%)	22 (10%)	54 (27%)	58 (58%)	52 (44%)	12 (35%)	106 (100%)
Same state	210 (34%)	0	0	132 (53%)	0	197 (90%)	64 (33%)	38 (38%)	61 (52%)	1 (3%)	0
Different state	21 (3%)	0	20 (53%)	5 (2%)	0	0	79 (40%)	3 (3%)	4 (4%)	21 (62%)	0
Missing data	69 (11%)	0	0	0	0	0	0	1 (1%)	0	0	0
Locality
Urban	322 (52%)	68 (32%)	18 (47%)	115 (46%)	123 (100%)	5 (2%)	99 (50%)	39 (39%)	66 (56%)	12 (35%)	83 (67%)
Semi-urban	224 (36%)	24 (11%)	0	15 (6%)	0	0	38 (19%)	35 (35%)	48 (41%)	10 (30%)	8 (7%)
Rural	6 (1%)	121 (57%)	20 (53%)	119 (48%)	0	214 (98%)	60 (31%)	26 (26%)	3 (3%)	12 (35%)	15 (26%)
Missing data	70 (11%)	0	0	0	0	0	0	0	0	0	0
Education
Not formally educated	3 (0.5%)	148 (70%)	5 (13%)	168 (68%)	3 (2%)	144 (66%)	128 (65%)	50 (50%)	17 (15%)	5 (15%)	33 (31%)
Primary	37 (6%)	54 (25%)	17 (45%)	49 (20%)	0	75 (34%)	34 (17%)	39 (39%)	16 (14%)	11 (32%)	58 (55%)
Secondary	13 (2%)	0	8 (21%)	19 (8%)	1 (1%)	0	7 (3.5%)	10 (10%)	77 (66%)	13 (38%)	12 (11%)
Preuniveristy college	3 (0.5%)	0	4 (13%)	6 (2%)	0	0	2 (1.5%)	0	3 (2%)	1 (3%)	0
Graduation and higher	0	0	4 (13%)	4 (1%)	0	0	26 (13%)	0	1 (1%)	4 (12%)	3 (3%)
Missing	566 (91%)	11 (5%)	0	3 (1)	119 (97%)	0	0	1 (1%)	3 (2%)	0	0
Marital status
Single	72 (12%)	188 (88%)	27 (71%)	193 (78%)	1 (1%)	194 (89%)	155 (79%)	58 (58%)	104 (89%)	16 (47%)	97 (92%)
Married	23 (3%)	25 (12%)	11 (29%)	54 (20.5%)	0	25 (11%)	39 (20%)	34 (34%)	10 (8.5%)	15 (44%)	1 (0.5%)
Widow	0	0	0	2 (1.5%)	0	0	1 (0.5%)	3 (3%)	2 (2%)	2 (6%)	0
Separated	0	0	0	0	1 (1%)	0	2 (0.5%)	4 (4%)	1 (0.5%)	1 (3%)	8 (7.5%)
Missing	527 (85%)	0	0	0	121 (98%)	0	0	1 (1%)	0	0
Socio-economic Status
Below poverty line	283 (45%)	59 (28%)	12 (32%)	193 (78%)	2 (1.5%)	207 (95%)	100 (51%)	64 (64%)	13 (11%)	22 (65%)	0
Above poverty line	299 (48%)	154 (72%)	26 (68%)	54 (20.5%)	2 (1.5%)	12 (5%)	97 (49%)	36 (36%)	103 (88%)	12 (35%)	0
Missing	40 (7%)	0	0	2 (1.5%)	119 (97%)	0	0	0	1 (1%)	0	106 (100%)
Disability category
Mental illness	273 (44%)	20 (9%)	24 (63%)	196 (78.6%)	18 (14%)	21 (9.5%)	65 (33%)	50 (50%)	28 (24%)	28 (82%)	9 (8%)
Intellectual disability	284 (45.5%)	108 (51%)	14 (37%)	36 (15%)	84 (68%)	195 (89%)	127 (64%)	19 (19%)	29 (25%)	6 (12%)	55 (52%)
Autism	10 (1.5%)	2 (1%)	0	1 (0.4%)	12 (10%)	1 (0.5%)	2 (1.5%)	13 (13%)	30 (25.5%)	0	3 (3%)
Specific learning disorder	51 (8%)	0	0	0	2 (2%)	0	0	11 (11%)	30 (25%)	0	2 (2%)
Multiple disability	4 (0.5%)	83 (39%)	0	16 (6%)	7 (6%)	2 (1%)	3 (1.5%)	7 (7%)	0	0	37 (35%)
Percentage disability
40-74%	331 (53%)	122 (57%)	15 (39%)	228 (91.6%)	41 (33%)	86 (39%)	100 (51%)	86 (86%)	104 (88%)	26 (82%)	54 (51%)
75-90%	251 (40%)	76 (36%)	22 (58%)	20 (8%)	69 (56%)	113 (52%)	61 (31%)	13 (13%)	4 (12%)	8 (18%)	47 (44%)
91-99%	0	9 (4%)	0	0	1 (1%)	6 (3%)	0	0	0	0	0
100%	40 (3%)	6 (3%)	1 (3%)	1 (0.4%)	12 (10%)	14 (6%)	36 (18%)	1 (1%)	0	0	5 (5%)
<40%	0	0	0	0	0	0	0	0	9	0	0
Psychiatric diagnosis
Intellectual disability	284 (46%)	108 (51%)	14 (37%)	48 (19%)	84 (68%)	194 (88.5%)	130 (66%)	18 (18%)	20 (17%)	6 (18%)	54 (51%)
Autism	10 (1.5%)	2 (1%)	0	2 (1%)	12 (10%)	1 (1%)	2 (1%)	12 (12%)	30 (26%)	0	3 (3%)
Specific learning disorder	51 (8%)	0	0	0	2 (2%)	0	0 ()	12 (12%)	30 (26%)	0	2 (2%)
Multiple disability	2 (0.5%)	84 (40%)	0	12 (5%)	6 (5%)	2 (1%)	1 (0.5%)	7 (7%)	0	0	37 (35%)
Schizophrenia	180 (29%)	10 (4%)	6 (16%)	45 (19%)	14 (11%)	17 (7%)	35 (18%)	33 (33%)	11 (9%)	18 (49%)	10 (9%)
Bipolar affective disorder	60 (10%)	9 (4%)	2 (5%)	64 (26%)	3 (2%)	0	23 (11.5%)	6 (6%)	2 (2%)	2 (6%)	0
Obsessive compulsive disorder	4 (0.5%)	0	0	9 (4%)	2 (2%)	2 (1%)	2 (1%)	0	3 (2.5%)	0	0
Dementia	16 (2.5%)	0	12 (31.5%)	10 (4%)	0	3 (1.5%)	3 (1.5%)	0	0	6 (18%)	0
Persistent delusional disorder	1 (0.3%)	0	0	0	0	0	0	0	0	0	0
Major depressive disorder	6 (1%)	0	0	25 (10%)	0	0	0	12 (12%)	7 (6%)	1 (3%)	0
Dysthymia	4 (1%)	0	0	0	0	0	0	0	0	0	0
Recurrent depressive disorder	1 (0.3%)	0	0	13 (5%)	0	0	0	0	0	0	0
Schizo-affective disorder	1 (0.3%)	0	0	13 (5%)	0	0	1 (0.5%)	0	0	0	0
Substance use disorder	0	0	0	4 (2%)	0	0	0	0	1 (0.5%)	0	0
Others	2 (0.6%)	0	1 (2.5%)	4 (2%)	0	0	0	0	4 (3%)	1 (3%)	0
Borderline intellectual disability	0	0	0	0	0	0	0	0	9 (8%)	0	0
Traumatic brain injury	0	0	3 (8%)	0	0	0	0	0	0	0	0

Table 5 shows the breakup of DC issued for various MI across 11 centres. Schizophrenia, bipolar affective disorder, dementia and obsessive-compulsive disorder accounted for 86% of DC issued for MI across 11 centres.

Table 5

Psychiatric diagnosis for patients issued DCs as a MI in 11 individual centres

MI category (n=727)	n (%)
Schizophrenia	379 (52.13%)
Bipolar affective disorder	171 (23.52%)
Obsessive compulsive disorder	22 (3.03%)
Dementia	50 (6.88%)
Schizoaffective disorder	15 (2.06%)
Persistent delusional disorder	1 (0.14%)
Major depressive disorder	51 (7.02%)
Recurrent depressive disorder	14 (1.92%)
Dysthymia	4 (0.55%)
Substance use disorders	5 (0.69%)
Traumatic brain injury	3 (0.41)
Others (anxiety disorders, acute transient psychotic disorder)	12 (1.65%)

DISCUSSION

Our multicentric study investigated the sociodemographic and clinical profile of persons with MI who were issued DC (n = 2018) in 2019. The study was conducted across 11 centres distributed across different zones/regions of the country.

There is a wide variation in the number of DC issued across centres. Variation may be due to differences in the catchment area, the population of the city, presence of other centres issuing DC in the locality, certification in camps, frequency of meeting of the disability board at different centres, patient-related factors (such as poor awareness), procedural factors (such as the tedious process of getting welfare benefits, patients approaching tertiary centres for second or third opinion) and health professional-related factor (such as poor awareness among mental health professionals, focus on clinical issues rather than disability certification) may also account for the differences.[9]

Nearly all except nine DCs were issued for benchmark (≥40%) disability. These nine DCs were issued by the Mumbai centre to facilitate local train concessions.

Females accounted only for a third of DC issued. Under-representation of females has been reported by previous studies from tertiary centres[678910] except Puducherry[10] and has been attributed to geographic and sociocultural factors.[8] Males receive preference in access to healthcare and, thereby, the treatment of psychiatric disorders. Earlier studies reported that males received treatment earlier and had better follow-up and regular treatment than their female counterparts.[11] Due to cultural, social and economic reasons, psychiatric disability in a male may be considered more disabling to the family than in a female. Therefore, female patients may be relatively ignored. Anecdotally, families are reluctant to avail DC for females as it is a record of a disability and may affect future marital prospects. The reasons for the under-representation of DC among females need to be studied prospectively.

Overall, rural areas accounted only for a third of DC issued. The present study was conducted in tertiary care centres located in urban areas which may have contributed to the under-representation of patients from rural areas. In addition, those from the rural areas may have availed DC in nearby district/taluk hospitals primarily through disability certification camps. Interestingly, rural areas accounted for 97% of DC issued in Lucknow, and half of DC issued from Bikaner, Chandigarh and Kashmir. The catchment area of respective centres may also have contributed to the difference.

The mean age at the time of certification for developmental disabilities (ID, ASD and SLD) is lower than MI. These neurodevelopmental disorders are diagnosed early in childhood.[9] Early certification of disability in these conditions may be due to increased awareness and a limited scope of achieving remission.[12] As per the Government of India office memorandum dated 08/05/2020 (File no 38-01/2020-DD-III), persons diagnosed with SLD on NIMHANS SLD battery shall be considered persons with benchmark disability, i.e., ≥40% disability. Hence, all persons with SLD have been shown as having 40% disability across centres.

For Puducherry, Chandigarh and Ranchi, residents of a different state than the hospital that accounted for most DC issued could be due to the catchment areas of these hospitals. Chandigarh and Puducherry are Union Territories and serve states surrounding them. In addition to being a Union Territory, city and district, Chandigarh also serves as the capital for Punjab and Haryana. In the past, Ranchi catered to the mental health needs of undivided Bihar. It is now the capital of Jharkhand state, carved from Bihar. However, it continues to serve Bihar.

ID accounted for most DC issued across seven centres. Many parent organizations and special schools have created awareness about DC and associated welfare benefits, which could be the reason.[4] Early referral through teachers/schools, school health programmes (for scholastic difficulties) and doctors (for delayed milestones) could also have contributed to the findings. In addition, IQ assessment is part of the workup of a person with ID.[9] The DC also entitles the person to avail a range of benefits under the National Trust Act 1999.[9] In Puducherry, the departments of paediatrics and psychiatry issue DC for children with ID separately.[10] This may account for the low number of DC issued from the department of psychiatry in Puducherry. The Mumbai centre is renowned for child mental health services, and this might have led to ASD and SLD being the most common condition certified for disability, followed by ID. Both Kashmir and Madurai centres issued more DC to MI than ID. This may be due to differences in the catchment area and the profile of services offered. ASD and SLD are new disabilities that are included recently in the RPWD Act 2016 and are under-represented in the number of DC issued across centres. Lower numbers may also be due to difficulties assessing these conditions for disability certification like expertise available, tools available and demand for such certificates. The NIMHANS SLD battery is not available in all Indian languages.

The original Indian Disability Evaluation and Assessment Scale (IDEAS) drafted by the rehabilitation subcommittee of the Indian Psychiatric Society had proposed limiting DC to four MI: schizophrenia, bipolar affective disorder, obsessive-compulsive disorder and dementia. The Gazette of India notification on disability assessment using IDEAS defines MI as 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.[3] Hence, IDEAS can be used for disability quantification in any MI except ID. This includes conditions like substance use disorders. Kashmir and Mumbai centres [Table 4] have been issuing DC for SUD to avail benefits. Notably, the original set of four MI accounts for 86% of DC issued for MI across centres. Schizophrenia (9 centres), bipolar affective disorder (1 centre) and dementia (1 centre) were the most common MIs for which DC was issued. However, many disorders, including obsessive-compulsive disorder, are under-represented in DC issued across centres. Unlike developed countries like the United Kingdom, where common MIs account for 70% of those with welfare benefits,[12] common MIs like depression and anxiety disorders account for only a tiny subset of DC across centres (except Kashmir). A similar observation is made by previous studies also. Lack of awareness among the public and the tendency of mental health professionals to certify severe MI, which may be perceived as more disabling, may have contributed to such a trend.

Strengths

The present study reported the profile, on a predesigned uniformly used datasheet across centres, of DC issued in 2019 from 11 tertiary care centres across the country, had a large sample size and reported differences in the profile of DC issued across centres.

Limitations of the study

As this was a retrospective study, we could not verify if the DC was issued for the first time or renewed. The profile of patients for whom DC was issued in tertiary care centres may be different from community settings. Some data on education status, marital status, residence, locality and socioeconomic status was missing from some centres as these details were not maintained in a uniform format.

CONCLUSION

This study suggests wide variation in the number and clinical profile of DC issued across centres. Overall, males account for two-thirds of DC issued across centres. ID accounts for the most number of DC issued, and schizophrenia is the most common MI for which DC is issued. There is a need to study welfare benefits availed with DC prospectively.

Financial support and sponsorship

This study was funded by the Indian Psychiatric Society (funded amount: Rs 2 lakhs).

Conflicts of interest

There are no conflicts of interest.