Disability Certification in India; More Issues Remain to be Addressed

Sir, This is in response to your editorial titled “Disability assessment and certification for mental illness in India: concept, context and future directions” by Sivakumar and Nishanth.[1] This crisp and clear editorial addresses many issues in the area of disability assessment for mental illnesses in India. I hope this leads to appropriate steps from the concerned authorities. I agree with their suggestion that IDEAS has to be replaced with WHO DAS 2.0 for more accurate quantification of disability, which is best viewed as a global problem in line with the conceptualization of the International Classification of Functioning. This approach is in line with the biopsychosocial model that psychiatry upholds as disability is measured taking all aspects of a person’s living and functioning in the society into consideration (aspects such as activity limitation and participation restriction), in addition to impairment resulting from dysfunction of bodily organs or systems. I may also argue that this also bridges the philosophical problems created by the mind–body dualism, allegedly inherent in medicine and psychiatry to some extent. They have also highlighted the difficulties created by the inclusion of the duration of illness duration as a domain in disability assessment in this editorial. Is the 2018 gazette version with the duration of illness (in total years) to be used for issuing the disability certificate, or the 2024 gazette version (with months of illness in the last 2 years) has to be used needs clarification. Other issues related to the scoring of IDEAS have been discussed in some earlier articles.[2] There are few more conundrums that could have been included in their editorial. One is the confusion in the area of neurodevelopmental disorders. The current editions of both international classification systems – International Classification of Disorders (ICDs) and the Diagnostic and Statistical Manual (DSM) do not use the term “learning disability,” which is used in the Rights of Persons with Disability (RPwD) Act. ICD 10 and DSM 5 named it Specific Learning Disorder. ICD 11 uses the term “Developmental Learning Disorder (DLD).” The confusion using the term “Learning Disability” results in some stakeholders confusing this condition with Disorder of Intellectual Developmental, which was earlier termed “Mental Retardation.” This is because the term Learning Disability is used in this sense in some countries, notably the United Kingdom. This is important as the field of education is mostly dealt with nonmental health professionals such as teachers and educators. The terminological confusion had been highlighted earlier.[3-5] When people glean information from a cursory Internet search, such misinterpretations do occur and, unfortunately, are prevalent. The degree of disability and the intervention needed are different for these two conditions. DLD is a nonprogressive condition that can be remedied using appropriate interventions or changes in the educational methods, but Intellectual Disability needs integrated interventions involving different experts and is often a long-term effort. Whether DLD needs to be treated at par with other more severe conditions is yet another point to be discussed and settled by experts in this field. Another difficulty is the correct assessment and certification in conditions like traumatic brain injury (TBI).[6] The earlier versions of IDEAS were being used to quantify disability and issue certificates for persons suffering from TBI as it did not specify that it covers only four disorders. However, the current revision does not allow this as it restricts the applicability of IDEAS to only four major mental disorders. There is no other disability assessment tool for TBI in the RPwD Act. Therefore, patients who had TBI and have cognitive impairment/behavioral disorders but do not meet the criteria for dementia cannot be certified using IDEAS. There can be issues due to the involvement of additional domains like locomotor disability in patients with TBI, for which guidelines are available. For psychosocial/behavioral disability, IDEAS was being be used. In a country like ours where the services of a neuropsychologist are only available in very few apex institutes, the majority of those suffering from TBI may not get their rightful disability certificates on time. This could be due to lack of manpower or for want of a suitable assessment instrument. In government hospitals without a neurologist and sometimes even when there is a separate department of neurology, such patients usually get referred to a psychiatrist as they are already available in the medical board. They can be certified as “chronic neurological conditions” using the IDEAS tool. But the lack of clarity on duration of illness (whether to apply the 2018 gazette version with a duration of illness in total years or the 2024 gazette version with months of illness in the last 2 years) needs clarification here too. In addition, the restriction of the IDEAS tool for only four major psychiatric conditions makes it difficult to use this useful tool for certifying those with TBI having sequelae that do not fulfill the diagnostic criteria for dementia. These were being issued by psychiatrists using the IDEAS to quantify disability, and now, this cannot be done. Their right to benefits is thereby denied. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.