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 MetricsMental illness was included as the seventh disability in the Persons with Disabilities (Equal Opportunities, Protection of Rights, and Full Participation) Act, 1995 (PwD Act, 1995).^[1] Other disability groups opposed this. An amendment committee reviewed and concluded that mental illness should be retained.^[2] One argument was the lack of an objective tool to quantify disability due to mental illness.Evolution of Conceptualization and Measurement of Disability: Has India Kept Up with the Times?The International Classification of Impairment, Disability, and Handicap (ICIDH, 1980) assumed that medical impairment inevitably resulted in disability and handicap.^[3] Each impairment led to a unique disability and handicap. All physical disabilities in the PwD Act 1995 were quantified by medical impairment.The International Classification of Functioning, Disability, and Health (ICF, 2002) recognized that though impairment is necessary, personal and environmental factors influence if impairment results in activity limitation or participation restriction.^[4] Disability was an umbrella term that included impairment, activity limitation, and participation restriction. ICF influenced the United Nations Convention for Rights of Persons with Disability (UNCRPD)^[5] and the World Health Organization Disability Assessment Schedule (WHO DAS) 2.0.^[6] As India ratified UNCRPD, existing legislations were harmonized, leading to the Rights of Persons with Disabilities Act (RPWD), 2016,^[7] and the Mental Health Care Act, 2017.^[8]Paradoxically, the quantification of disability in the RPWD Act 2016^[9] follows the medical impairment-based ICIDH, not the latest ICF!Indian Disability Evaluation and Assessment Scale Avatars over the YearsIn 2001, the rehabilitation committee of the Indian Psychiatric Society (IPS) developed and field-tested the Indian Disability Evaluation and Assessment Scale (IDEAS) among 1078 patients across eight centers nationwide.^[2,10,11] In February 2002, the Government of India modified IDEAS and gazetted it.^[12] The subsequent gazette revisions were in 2018^[9]and 2024.^[13] The different versions are compared in the Appendix 1.The Functional Assessments: Mind, Body, or Human Being?IDEAS was influenced by ICIDH-2 (later renamed as ICF) field trials but left out domains such as mobility, which were irrelevant to mental illness.^[2]The National Mental Health Survey (2015–16) also considered several WHO DAS 2.0 variables irrelevant to mental health. Sheehan Disability Scale was used, and IDEAS was not considered.^[14]Interestingly, DSM-5 has suggested studying WHO DAS 2.0 and abandoned the popular Global Assessment of Functioning scale.^[15]The ICF conceptualizes disability as an etiology-neutral universal human experience where all domains of functioning are relevant.^[4] For example, patients with mental illness can have osteoarthritis, and sometimes, osteoarthritis may disable them more than mental illness. If mobility is not assessed, this would not be quantified. Assessing the overall functioning of human beings seems wiser than splitting individual medical impairments among specialists!Metamorphosis of the Definition of Mental IllnessThe operational definition of mental illness has changed over gazette revisions. IPS version was developed, field-tested, and finalized for schizophrenia, bipolar affective disorder, dementia, and obsessive–compulsive disorder.^[2] The 2002 gazette operationalized it as “any mental disorder other than mental retardation,” which can even include nicotine dependence syndrome.^[12] The 2018 gazette excluded substance use disorders.^[9] The 2024 gazette reverted to the IPS version.^[13] In a recent IPS multi-centric study, 86% of disability certificates for mental illness were for the original 4 disorders in the IPS version.^[16]Mathematical WonderAccording to 2002 and 2018 gazette versions, the threshold for benchmark disability was 7 out of 20, not 40% mathematically.^[9,12]Mandating Documentation of Medical RecordsA psychiatrist working alone in a less-resourced government setting like a district hospital faces challenges while certifying disability due to mental illness. There is no way to confirm the diagnosis when the patient reports symptoms of mental illness, claims having consulted another psychiatrist in the past, and has no treatment records. The 2024 gazette mandates “appropriate evidence-based treatment“ and “documentation of medical records” for certification, which helps psychiatrists in such situations.^[13]Treatment Status and Disability due to Mental IllnessThe UNCRPD defines persons with disabilities as having “long-term physical, mental, intellectual, and sensory impairments.” In India, disability certificates are not issued for physical conditions that can be “cured” or “controlled.” For example, only chronic drug-refractory epilepsy can be certified for disability.^[13] If the medical condition is cured or controlled and does not affect the patient’s daily life, it cannot be considered a “long-term impairment.”Severe mental illness improves with treatment.^[17]The IPS, 2002, and 2018 gazette versions did not mandate “treatment” before certification.^[2,9,12] The medical board could issue permanent disability certificates even to “treatment-naïve” patients with mental illness. However, some states, like Uttar Pradesh, mandated treatment in their gazette.^[18]The 2024 gazette mandates the need for “appropriate evidence-based treatment” without specifying the likely duration required, which varies across patients.^[13]The Logic in Considering “Residual Disability” Despite TreatmentIt is not fair if a patient with schizophrenia with predominant primary negative symptoms requiring a caregiver’s presence must compete for rights and entitlements with another patient in symptomatic remission on regular treatment. The 2024 gazette takes this stance in mandating “residual disability” despite “appropriate evidence-based treatment” for permanent certification.^[13] In physical disabilities, demarcating “residual impairment” from other personal and environmental factors is objective. This can be challenging in mental illness.Impairment versus Personal and Environmental FactorsWork status is commonly inquired in clinical practice as a barometer of functioning. While health is a prerequisite, several personal and environmental factors determine whether a person fulfills work and household responsibilities. When a patient with mental illness is not working, mental illness need not be the only explanation. Personal (including social background, education, coping, personality, expectations from work profile, work environment, and remuneration) and environmental factors (including available opportunities, role models, family expectations, family-accommodating patient’s needs, and economic status) must be considered. The psychiatrist who has longitudinally followed up with the patient is usually aware of these factors.Ethical Dilemma or Conflict of InterestWhen the treating psychiatrist certifies disability, there is an ethical dilemma between beneficence (what is best for the patient) and justice (ensuring fairness for all). For example, a patient with bipolar affective disorder in remission on treatment knows that the family will take care, is unemployed, and leads a “stress-free” life. The family wants a permanent disability certificate to help the patient avail of the parent’s pension after their lifetime to secure his future. How should the psychiatrist interpret “residual disability?” As “symptom remission” (according to ICIDH) or “functioning” (according to ICF)? If it is “symptom remission,” the patient is not eligible. If it is “functioning,” the patient will score 4 in the IDEAS work domain!Some countries does not involve the treating doctor in disability assessment to avoid conflict of interest.^[19]Should Illness Duration be Considered?The IPS version considered “months of illness in last 2 years” as equating the duration of illness of episodic and chronic disorders was inappropriate. Disability was to be reassessed every 2 years and recertified.^[2]The 2002 and 2018 gazette versions specified only the “total duration of illness,” meaning a patient with a single manic episode 20 years ago would score 4.^[9,12] The 2024 gazette reverted to the IPS version but permits permanent certification.^[13] As the clause on mandatory 2, yearly periodic reassessments was dropped, the “months of illness in last 2 years” domain could have been deleted altogether!Conceptually, the illness duration is irrelevant to quantifying disability and is not considered by other assessment instruments.Utilization of Indian Disability Evaluation and Assessment Scale in PracticeIDEAS made disability certification for mental illness possible. This has not been utilized as expected.^[10]Highly resourced tertiary government hospitals issue more disability certificates for intellectual disability than mental illness.^[16,20]The Case for WHO DAS 2.0 and Practical ConsiderationsWHO DAS 2.0 was developed collaboratively and field-tested in 19 countries, including India. The 12-item version takes only 5 min to administer.^[6] If India shifts to WHO DAS 2.0, long-term impairment(s) must be confirmed by medical doctors. Subsequently, other health professionals can perform functioning assessments. The threshold for benchmark disability can be determined based on normative Indian data and resources earmarked by the government for this purpose.^[6]As WHO DAS 2.0 evaluates functioning over the last 30 days, periodic re-evaluation may be required. India must have systems for periodic functional assessments before abandoning the current medical impairment-based certification system, which may be a one-time affair for many adult patients. This is a policy decision with financial implications and requires political will and consultations with various stakeholders.The Way ForwardCurrently, disability assessments are limited to medical boards in government hospitals. Patients with mental illness can apply for a Unique Disability ID Card, a digitally generated disability certificate, either from a notified hospital in their district or another hospital where they seek treatment.^[21]The government needs demonstrable evidence of the magnitude of disability due to mental illness to do more for patients disabled with mental illness and their family caregivers. Most patients and caregivers are not aware that mental illness can be certified as a disability. Mental health professionals can do a better job of identifying eligible patients in clinical practice, educating them about the disability certification, encouraging them to apply, and facilitating the process. A journey of a thousand miles must start with this single step.References1. Ministry of Law, Justice, and Company Affairs. Government of India. The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act 1995; 1996. Available from: