Disability certification for mental illness in India: ‘A bird in the hand is worth two in the bush’

Dear Editor, The viewpoint titled ‘Redefining disability certification for mental illness in India: Towards global standards and functional assessments’[1] discusses disability certification for mental illness and the lacunas in the new 2024 guidelines.[2] We want to highlight the following factual inaccuracies. The new guidelines do not prohibit the medical authority from issuing a temporary disability certificate for a person with mental illness with less than 2 years’ duration of mental illness.[2] Patients are not deprived of any benefits but the emphasis is on appropriate evidence-based treatment. India already follows functional assessment to certify disability due to mental illness. The Indian Disability Evaluation and Assessment Scale (IDEAS) assesses functioning, not medical impairment.[3] However, the assessment and certification can only be done for 4 mental illnesses under new guidelines. Suggestions are proposed for Indian guidelines to enhance access to mental health services and education and awareness programs in the context of disability certification. It would have been pertinent if the legislation in discussion was the Mental Health Care Act, 2017 (MHCA, 2017),[4] which suggests that the government should ensure access to mental health care, education, and awareness programs. Ensuring access to treatment is not linked to disability certification and it does not come under the purview of RPwD 2016.[5] The guideline explicitly mandates ‘appropriate evidence-based treatment’ before going for permanent certification.[2] Even for temporary certification some treatment should have been provided if not the standard of care. Only treatment naïve patients wouldn’t get any certification without treatment. What constitutes ‘appropriate evidence-based treatment’ or ‘standard of care’ is left to individual interpretation. This has rightly been left unspecified so that the medical authority, comprising a psychiatrist, can decide. Conceptually, ‘duration of illness’ is irrelevant to quantifying disability. The ‘duration of illness’ criteria is a vestige from the original Indian Psychiatric Society version of IDEAS, which advocated for temporary certificates and two-year reassessments.[3] Duration criteria could have been done away with to make it at par with other disabilities with the retention of the best treatment outcome. The guideline requires ‘treatment records’ as evidence of treatment taken. The medical authority can exercise its discretion to refer for treatment to a mental health establishment and issue a permanent disability certificate only after adequate treatment for adequate time. These are reasonable safeguards. Any country’s systems and resources have constraints (related to economics, policy, systems, human resources, or a combination of these factors). While we can aspire for global standards in the long term, we should be guided by local reality in the short term. In our daily practice, we should proactively educate, assess, and certify disability due to mental illness within the current framework. Regular and dynamic reassessments to certify disability require more resources. Let us first advocate for higher resource allocation for the health sector. We can cross the bridge when the time comes. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.