Redefining disability certification for mental illness in India: Towards global standards and functional assessments

VIEWPOINT

Om Prakash

Geriatric Mental Health Division, Department of Psychiatry, Institute of Human Behaviour and Allied Sciences (IHBAS), New Delhi, India

ABSTRACT

This viewpoint advocates for significant reforms in the disability certification guidelines for mental illnesses in India. Currently, two years duration of illness is required before certification, which delays essential support. The proposed model emphasizes assessing the functional impact of conditions, aligns with global standards, and suggests regular reassessments to improve accessibility and inclusivity in mental health services.

Key words: Comparative health systems, disability certification, functional impact assessment, inclusive health policy, mental illness

INTRODUCTION

The Rights of Persons with Disabilities Act (RPWD) of 2016[1] represents a significant commitment by the Indian Government to improve the social integration and empowerment of individuals with disabilities. This Act, aligning with the United Nations Convention on the Rights of Persons with Disabilities, has expanded the definition of disability and strives to ensure equal rights, dignity, and inclusivity for all disabled persons. However, when it comes to the certification of disabilities due to mental health conditions, the Act reveals critical shortcomings that undermine its efficacy and intent.[2]

A notable issue within the recently launched revised guidelines[3] is the requirement for a mental illness to be

Address for correspondence: Prof. Om Prakash,

Geriatric Mental Health Division, Department of Psychiatry, Institute of Human Behaviour and Allied Sciences (IHBAS), New Delhi, India.

E‐mail: drjhirwalop@yahoo.co.in

Submitted: 12‐May‐2024, Revised: 17‐Aug‐2024, Accepted: 27‐Aug‐2024, Published: 19‐Sep‐2024

present for at least two years before an individual qualifies for a permanent disability certificate. This duration requirement is intended to confirm the chronic nature of the condition but often results in delaying necessary support and services. This delay can be detrimental as it postpones access to essential resources that could otherwise assist in improving the living conditions and overall well-being of individuals affected. Such delays can exacerbate the conditions they aim to mitigate.[4]

Moreover, this two-year criterion starkly contrasts with global best practices that prioritize the immediate functional impact of a mental health condition over the duration of the illness. Countries like the United States, the United Kingdom, and others in the Western hemisphere do not enforce such duration-based criteria but instead focus on assessing how a mental health condition affects an individual’s daily activities and full participation in society.

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How to cite this article: Prakash O. Redefining disability certification for mental illness in India: Towards global standards and functional assessments. Indian J Psychiatry 2024;66:863-7.

The insistence on a prolonged duration before certification can also inadvertently reinforce the stigma surrounding mental health, perpetuating a misconception that only long-term or chronic mental illnesses are severe and, thus, deserving of recognition and support. This aspect of the RPWD Act’s guidelines necessitates a critical re-evaluation to align more closely with international standards that emphasize functional impact and immediate needs assessment, ensuring that support mechanisms are responsive and accessible when most needed.

CURRENT INDIAN GUIDELINES AND THEIR LIMITATIONS

The RPWD Act mandates that mental illnesses must persist for at least two years before a permanent disability certificate can be issued. This requirement aims to ensure that only chronic and severe conditions are recognized for disability support. However, this stipulation may inadvertently delay critical interventions that could mitigate the worsening of an individual’s mental and social functioning. Such delays are especially harmful during periods when timely support could prevent further deterioration.

Additionally, the emphasis on extensive treatment records to establish the longevity of a mental illness poses significant challenges, particularly in rural or underserved areas. In these regions, consistent and quality mental health care is often scarce, making it difficult for individuals to meet the documentation requirements for disability certification. This focus not only creates barriers to accessing necessary support but also perpetuates stigma around mental health, implying that conditions are only severe if they are long-term, which can discourage early reporting and treatment-seeking. Interestingly, these guidelines are silent about treatment status at the time of certifying disability.

While the primary benefit of a disability certificate for many individuals in India currently is access to a small pension, there is a need to advocate disability certification for offering more comprehensive support beyond the pension. It is noteworthy to mention that a disability certificate is necessary for accessing treatment. Instead, certification is intended to aid in obtaining additional support services for those with mental health conditions.[5]

India’s current disability assessment system predominantly relies on a medical impairment-based approach, focusing on clinical diagnosis rather than the functional impact on daily life. This method, while standardized, often overlooks the practical challenges faced by individuals. To address this, a gradual transition toward incorporating functional assessments is essential, aligning with global best practices. This shift should be implemented step-by-step to ensure feasibility and sustainability within India’s socioeconomic

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context, avoiding abrupt changes and allowing for necessary infrastructure development.[6]

The current approach under the RPWD Act, with its stringent duration and documentation requirements, does not adequately accommodate the dynamic nature of mental health conditions, whose impacts can be profound regardless of the duration. The insistence on a two-year duration and extensive medical records fails to recognize the immediate needs of individuals experiencing significant mental health challenges, thereby delaying their access to crucial disability benefits and services.

It is noteworthy to mention that an expert committee constituted by the Indian Psychiatric Society (IPS) did indeed suggest a 3-month treatment period before disability certification for mental illness. This recommendation was aimed at ensuring that the disability certification process accurately reflects the persistent and severe nature of the mental illness after an adequate period of treatment.[7]

To address these limitations, there is a pressing need to reform how mental health disabilities are certified in India. Recommendations include removing the two-year duration requirement and focusing on the current functional impact of the mental illness. This change would align India’s practices with international standards that emphasize assessing the immediate functional limitations caused by mental health conditions rather than their duration or the completeness of treatment records. Such reforms would not only facilitate timely and appropriate support for individuals with mental health conditions but also help in reducing stigma and improving overall mental health care accessibility, especially in underserved areas.

COMPARISON WITH WESTERN GUIDELINES AND LAMIC PRACTICES

Western countries like USA, UK, Canada, and Australia emphasize the functional impact of mental health conditions rather than their duration. For instance, the US Social Security Administration and the UK’s Personal Independence Payment system assess how mental health conditions affect daily activities and work capabilities, focusing on immediate needs rather than the duration of illness. This approach is more responsive and inclusive, recognizing the dynamic nature of mental health conditions.

In the United States, the Social Security Administration (SSA) provides an illustrative example of this approach. The SSA evaluates disability claims based on the severity and documented effects of mental health conditions on an individual’s functional capacities, particularly focusing on their ability to engage in substantial gainful activity. The assessment involves detailed criteria that examine the specific challenges an individual faces, such as difficulties in

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social functioning, concentration, or adapting to changes in the work environment, without requiring the condition to have lasted for any predetermined period.[8]

Similarly, the United Kingdom employs the Personal Independence Payment (PIP) system, which assesses the impact of mental health conditions on daily activities and mobility. This system uses a points-based assessment to determine how conditions like depression, anxiety, or other psychiatric disorders affect abilities such as cooking, managing medication, or moving around. The PIP focuses on the actual impact of the mental health condition at the time of assessment rather than the length of time the individual has been affected, enabling a more flexible and responsive support system.[9]

Canada and Australia share similar practices, where disability benefits and assessments are grounded in how mental health conditions affect an individual’s current life. In Canada, the disability determination process under programs like the Canadian Pension Plan Disability (CPP-D) does not fixate on the duration of the illness. Instead, it assesses whether the condition results in a substantial reduction in the individual’s capacity to perform regular work or daily activities based on current health status and medical evidence.

India’s disability assessment process, which primarily relies on medical impairment-based evaluations conducted by government hospital boards, significantly differs from the practices in high-income countries where third-party assessments and comprehensive support systems are more common. These differences can lead to inconsistencies and challenges, particularly in resource-constrained areas.[10]

In contrast, low- and middle-income countries (LMICs) such as Brazil, South Africa, and Uganda face unique challenges in disability certification due to resource constraints and varying levels of healthcare infrastructure.[11] These countries often adopt community-based and decentralized approaches, focusing on the functional limitations imposed by disabilities and leveraging available local resources. For instance, in Brazil, the certification process is integrated within the public health system and involves assessments by community health workers and local health facilities, with a focus on how the disability affects the individual’s daily functioning. This decentralized approach allows for regional differences in resources and infrastructure to shape how disabilities are assessed. Similarly, South Africa utilizes a multidisciplinary team approach, including doctors, social workers, and other healthcare professionals, to assess the functional limitations caused by mental health conditions, linking this assessment closely to eligibility for disability grants administered by the South African Social Security Agency (SASSA). This process emphasizes functional assessments over purely medical diagnoses. In Uganda, the

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certification process is more community-oriented, relying heavily on local health centers and community health workers, particularly in rural areas. The process is less formalized and focuses on how the disability impacts daily activities, often lacking the standardized criteria seen in high-income countries.[12]

These international practices underscore a shift toward more dynamic and nuanced approaches to disability certification, which are sensitive to the complexities and variability of mental health. They recognize that the disabling impact of mental conditions can fluctuate and do not necessarily correlate with a fixed timeline. This more flexible approach allows for adjustments in support and services based on the actual needs of the individual at the point of assessment rather than on a rigid criterion of illness duration.

PROPOSED REVISIONS FOR INDIAN GUIDELINES [TABLE 1]

To enhance the disability certification process for mental illnesses in India, comprehensive reforms are proposed to align with international standards that prioritize functional impact rather than the duration of illness. The following detailed proposals aim to refine the approach and ensure more effective support systems for individuals with mental health conditions:

(a) Shift to Functional Impact Assessment: To better address the challenges faced by individuals with mental illnesses, it is crucial to adopt a functional impact assessment model. This approach would evaluate how mental health conditions affect an individual’s daily activities and their ability to maintain personal independence. Transitioning to this model would involve a reassessment of the current assessment tools and possibly the development of new metrics tailored to the specific nuances of mental health impacts. Adopting such a model would not only align with global best practices but also provide a more accurate and immediate understanding of the individual’s needs.

(b) Regular and Dynamic Reassessments: Given the inherently fluctuating nature of mental health conditions, it is essential to establish a system for regular and dynamic reassessments. This would ensure that the support provided to individuals with mental health conditions is continuously aligned with their current needs. Periodic reviews should be sensitive to changes in the individual’s condition, with mechanisms in place to adjust their disability status and support plans as necessary. This adaptive approach would facilitate responsive care that can effectively address the evolving nature of mental health challenges.

(c) Enhanced Access to Mental Health Services: Implementing these changes requires a significant enhancement of the mental health service infrastructure across India. This includes expanding the availability of mental

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Table 1: Revised Disability Assessment guidelines for Mental illness (2024)[3] and proposed guidelines

Revised Disability Assessment guidelines

F. The duration of the mental illness should be determined from the onset of the mental illness. For certifying permanent disability, a minimum duration of at least 2 years of mental illness is required.

A. For any mental illness with a duration of less than 2 years, only certificate with time validity may be allowed, the degree depending on the extent of disability. In case the disability is severe or profound, the medical board may consider permanent certification.

B. For persons with mental

illness (PWMI), who have not received standard-of-care treatment, only disability certificate with time validity up to 2 years may be issued by the board.

C. The disability board may recommend for treatment from any mental health establishment (MHE) and then may issue permanent disability certificate only after the PWMI has received the treatment for adequate duration as determined by the Board.

D. Permanent Disability Certification

will be issued based on assessment of

the residual disability despite appropriate evidence-based treatment as documented on medical records

E. Treatment-naïve patients of Mental Illness/their caregivers must be advised to seek appropriate treatment to empower them and advised to seek disability certification of disability despite adequate treatment.

F. For persons with Mental Illness who have taken psychiatric treatment but do not have any treatment records, disability certificate with time validity may be issued with advice to seek appropriate psychiatric treatment, preserve medical records, and repeat disability certification after 2 years.

Proposed guidelines

Remarks

In contrast to India’s 2-year minimum duration requirement for certifying permanent disability due to mental illness, countries like the United States, the United Kingdom, Canada, and Australia do not impose such fixed timelines, focusing instead on the functional impact of the condition.

In countries like the United States and the United Kingdom, disability certification focuses more immediately on the functional impact and severity of the mental illness at any point in time without a prerequisite duration, allowing for both temporary and permanent disability determinations based on current assessments rather than fixed time frames.

In countries like the UK and Canada, the focus is more on current functional assessments and the immediate needs of the individual, rather than on treatment history. This approach allows for more flexible and immediate support, regardless of previous care standards.

This ensures that certification is more aligned with the individual’s current health status and respects the variability in treatment responses among persons with mental illness

The new guidelines that condition the issuance of permanent disability certificates for mental illness on undergoing treatment for a set duration may restrict timely access

to essential support and undermine patient autonomy by coercing treatment for certification purposes, rather than health improvement. The suggested guidelines prioritize functional assessments and consider all aspects of an individual’s ability to engage in daily activities, ensuring a more holistic and equitable evaluation process.

The new guideline approach may inadvertently delay disability recognition and support until after treatment has been attempted, which could place unnecessary hurdles in the path of individuals seeking immediate help and support for disabilities caused by mental illness. The proposed guideline ensures that disability certification is based purely on need and the direct impact of the disability, uncoupled from the patient’s treatment journey.

The new guideline imposes that individuals with mental illness who lack formal treatment records may only receive a temporary disability certificate, with a directive to secure treatment and maintain medical records for future reassessment. This approach could potentially delay permanent support for individuals who might have faced barriers in accessing consistent psychiatric care, thus placing them at a disadvantage compared to systems that prioritize immediate and condition-based assessments.

24.2. Diagnosis:

F. The duration of the mental illness should be determined from the onset of the mental illness.

24.3. Validity of Certificate:

A. Disability certification for mental illnesses should be based solely on the severity and functional impact at the time of assessment, without reference to the duration of the condition. Certificates can be temporary or permanent, depending on the individual’s needs, ensuring timely and appropriate support.

This section may be OMITTED.

C. The disability board can recommend treatment from any qualified MHE as part of its assessment process. However, the issuance of a permanent disability certificate should be based on a comprehensive evaluation of the individual’s functional impairment and needs, rather than solely on the duration of treatment received.

D. Permanent Disability Certification should

be based on a comprehensive assessment of

an individual’s current functional capabilities and the impact of their mental health condition, rather than solely on the documented response to treatment.

E. Treatment-naïve patients of Mental Illness and their caregivers should be encouraged to seek treatment to manage symptoms effectively. However, eligibility for disability certification should be evaluated independently based on

the actual functional limitations imposed by the mental illness, not on the treatment status or history.

This section may be OMITTED.

health professionals and facilities, especially in rural and underserved areas, to ensure that all individuals have access to the care they need. Moreover, integrating mental health services with broader health and social service networks is critical to providing comprehensive support. Such integration would help in reducing stigma, improving accessibility, and ensuring that mental health care is a component of the general health care system.

(d) Education and Awareness Programs: Alongside these structural changes, there should be a concerted effort to increase public awareness and education about mental health. This involves training for healthcare providers on the new functional impact assessment model and educating the public to reduce stigma associated with mental health conditions. Awareness campaigns could help change societal attitudes, making the environment

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more supportive for individuals with mental health

challenges.

(e) Legislative Amendments: Legislative changes are necessary

to facilitate these proposed reforms. Amendments to the RPWD Act to remove the 2-year duration requirement and to officially adopt a functional impact assessment approach would solidify the commitment to more inclusive and equitable mental health support. Such legislative backing is essential to ensure that these changes are effectively implemented and sustained.

(f) Strengthening Patient Rights and Advocacy: Strengthening the rights of patients and enhancing advocacy for individuals with mental health conditions are crucial. This would involve establishing clear guidelines for patient rights within the disability certification process and promoting advocacy groups that can provide support and guidance to individuals navigating this system. These measures would help ensure that individuals receive fair and respectful treatment throughout the certification process.

By adopting these revisions, India could transform its disability certification process into a more equitable and effective system.[13] This reform would not only better support individuals with mental health challenges but also foster a more inclusive society. Recognizing and addressing the diverse needs of those with mental health conditions would significantly improve health outcomes and enhance the quality of life, contributing to overall societal health and cohesion.[14]

CONCLUSION

The proposed reforms to India’s disability certification process for mental illnesses are aimed at creating a more equitable, responsive, and effective system. By transitioning to a functional impact assessment model, introducing regular and dynamic reassessments, and enhancing access to mental health services, these changes would better support individuals with mental health challenges. This approach would foster a more inclusive society by recognizing and addressing the diverse needs of those with mental health conditions, thereby improving health outcomes and enhancing the quality of life.

Implementing these reforms would not only align India’s practices with global standards but also ensure that individuals receive timely and appropriate support. It is imperative that these changes are accompanied by legislative amendments that reflect an understanding of the dynamic nature of mental health. This would include removing outdated criteria that delay support and replacing

them with guidelines that focus on the present impact of a condition and its management.

Furthermore, these reforms would contribute significantly to the overall mental health infrastructure and cultural perceptions of mental health in India. By improving the certification process, we can reduce the stigma associated with mental health conditions, increase the accessibility of necessary services, and promote a more empathetic understanding within the community. This is crucial not only for the welfare of individuals with mental health issues but also for the broader societal inclusion and cohesion.

The need for reform is clear, and the benefits of such changes are profound. Adopting these proposals would provide a robust foundation for supporting mental health in India, ensuring that every individual has the opportunity to lead a fulfilling life, irrespective of their mental health status. This is not just a health imperative but also a fundamental human right that must be upheld for all citizens.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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