Guidelines for mental illness

Ministry of Social Justice and Empowerment

Subject – Guidelines for evaluation and assessment of mental illness and procedure for certification.

No. 16-18/97-NI.

1. Mental illness has been recognized as one of the disabilities under Section 2 (i) of the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995. “Mental illness” has been defined under Section 2(q) of the said Act as any mental disorder other than mental retardation.
2. In order to prescribe guidelines for evaluation and assessment of mental illness and procedure for certification, a Committee was constituted by the Department of Health, Government of India vide Order dated 6th August, 2001 under the Chairmanship of Director General of Health Services on the basis of request made by the Ministry of Social Justice & Empowerment. The Committee has submitted its report.
3. After having considered the report of the Committee, the undersigned is directed to convey the approval of the President to notify the guidelines for evaluation and assessment of mental illness and procedure for certification. Copy of the Report is enclosed herewith as ANNEXURE A.
4. The minimum degree of disability should be 40%. in order to be eligible for any concessions/benefits.
5. According to the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Rules, 1996 notified by the Central Government in exercise of the powers conferred by sub-section (1) and (2) of Section 73 of the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 (l of 1996): authorities to give Disability Certificate will be a Medical Board duly constituted by the Central or the State Government. The Committee has recommended that certification of disability for the purposes of the Act may be carried out by a Medical Board comprising of the following members -(a) The Medical Superintendent/Principal/Director /Head of the Chairperson

   Institution or his nominee

   (b) Psychiatrist Member

   (c) Physician Member

6. At least two of the members, including Chairperson of the Board must be present and sign the disability certificate.
7. The State Governments are, therefore, requested to constitute Medical Boards as indicated above immediately.
8. Specified test as indicated in ANNEXURE A should be conducted by the medical board and recorded before a certificate is given.
9. The certificate would be valid for a period of five years for those whose disability is temporary and arc below the age 18 years. For those who acquire permanent disability, the validity can be shown as ‘Permanent in the certificate’.
10. The Director General of Health Services, Ministry of Health and Family Welfare shall be the final authority, should there arise any controversy/doubt regarding the interpretation of the definitions/classifications/evaluation tests etc.

SM-T. RAJWANT SANDHU, Jt. Secy. ANNEXURE A

MINUTES OF THE MEETING

Minutes of the meeting of the committee to review the definition of mental illness and formulating guidelines for assessment of mental illness disability and procedure for certification held on 27th September 20{) I (Thursday) under the Chairmanship of DGHS.

A meeting was held under the Chairmanship of DGHS on 27th September to review the definition of mental illness and formulating guidelines for assessment of mental illness disability and procedure for certification.

1. After detailed discussion consensus was reached on the view that the present definition of “mental illness” as contained in the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 section 2 (q) may be retained unchanged. This will be most suitable for the purpose of PWD Act.
2. With regard to assessment of disability related to mental illness it was agreed that the Indian Disability Evaluation and Assessment Scale (IDEAS) developed by the Rehabilitation Committee of the Indian Psychiatric Society (IPS) through a task force should be used with modifications for the purposes of the Act. The modified scale, IDEAS is appended.
3. The Committee further recommended that certification of disability for the purposes of the Act may be carried out by, a medical board comprising of the following members:
   • The Medical Superintendent /Principal /Director /Head of the institution or his nominee – Chairperson
   • Psychiatrist – Member
   • Physician -Member.

   At least two of the members, including Chairperson of the board must be present and sign the disability certificate.

4. Meeting ended with the vote of thanks to the chair.

Indian Disability Evaluation and Assessment Scale

Indian Disability Evaluation and Assessment Scale (IDEAS) is a scale for measuring and quantifying disability in mental disorders.

Items –

1. I. Self Care: Includes taking care of body hygiene, grooming, health including bathing, toileting, dressing, eating, taking care of one’s health.
2. II. Interpersonal Activities (Social Relationships): Includes initiating and maintaining interactions with others in contextual and social appropriate manner.
3. III. Communication and Understanding: Includes communication and conversation with others by producing and comprehending spoken/written/non-verbal messages.
4. IV Work: Three areas are Employment/Housework/ Education Measures on any aspect.

1. l. Performing in Work/Job: Performing in work/employment (paid) employment/self-employment/ family concern or otherwise. Measure ability to perform tasks at employment completely and efficiently and in proper time. Includes seeking employment.
2. 2. Performing in Housework: Maintaining household including cooking, caring for other people at home, taking care of belongings etc. Measures ability to take responsibility for and perform household tasks completely and efficiently and in proper time.
3. 3. Performing in school/college: Measures performance education related tasks.

Scores for each item:

0- NO disability (none, absent, negligible)

1- MILD disability (slight, low)

2- MODERATE disability (medium, fair)

3- SEVERE disability (high, extreme)

4- PROFOUND disability (total cannot do)

TOTAL SCORE

Add scores of the 4 items and obtain a total score

Weight age for Duration of illness (DOI) :

DOI: < 2 years: score to be added is 1

2-5 years: add 2 .

6-10 years: add 3

> 10 years: add 4

Global Disability –

Total Disability score + DOI score = Global Disability Score Percentages:

0 No Disability = 0%

1-6 Mild Disability = < 40 %

7-13 Moderate Disability = 40 – 70 %

14-19 Severe Disability = 71-99%

20 Profound Disability = l00%

Cut off for welfare measures = 40 %

Manual for “IDEAS” –

In order to score this instrument, information from all possible sources should be obtained. This will include interview of patient, the care given and case notes when available.

I. SELF CARE: This should be regarded as activity guided by social norms and conventions. The broad areas covered are

a. Maintenance of personal hygiene and physical health.

b. Eating habits

c. Maintenance of personal belongings and living space

a. Does he look after himself. wash his clothes regularly, take a bath and brush his teeth?

b. DOES he have regular meals?

c. Does he take food of right quality and quantity?

d. What about his table manners?

e. Does he take care of his personal belongings with reasonable standard of cleanliness and orderliness?

0= No disability

Patient’s level and pattern of self-care are normal, within the social cultural and economic context.

1= Mild

Mild deterioration in self-care and appearance (not bathing. shaving, changing clothes for the occasion as expected). Does not have adverse consequences such as hazards to his health. No embarrassment to family.

2= Moderate

Lack of concern for self-care should be clearly established such as mild deterioration of physical health, obesity, tooth decay &, body odors.

3= Severe

Decline in self-care should be marked in all areas. Patient wearing torn clothes would only wash if made to and would only cat ift6ld. Evidence of serious hazards to physical health. (Malnutrition. infection. patient unacceptable in public).

4= Profound

Total or near total lack of self-care (Example: risk to physical survival, needs feeding, washing, putting on clothes etc., Constant supervision necessary)

II Inter Personal Activities

Includes patient’s response to questions, requests and demands of others, activities or regulating emotions, activities of initiating, maintaining and terminating interactions and activities of engaging in physical intimacy.

Guiding Questions

a. What is his behaviour with others?

b. Is he polite?

c. Does he respond to questions!

d. Is he able to regulate verbal and physical aggression?

e. Is he able to act independently in social inter

actions?

f. How does he behave with strangers?

g. Is he able to maintain friendship?

h. Does he show physical expression of affection and desire?

Scoring

0= No

Patient gets along reasonably well with people, personal relationships No friction in inter-personal relationships.

1= Mild

Some friction on isolated occasions. Patient known to be nervous or irritable but generally tolerated by others.

2= Moderate

Factual evidence that pattern of response to people is unhealthy. May be seen or more than few occasions. Could isolate himself from others and avoid company.

3= Severe

Behaviour in social situations is undesirable and generalized. Causes serious problems in daily living/or work. Patient is socially ostracized.

4= Profound

Patient in serious and lasting conflict, serious danger to problems of others. Family afraid of potential consequences.

III. Communication and Understanding

Understanding spoken messages as well as written and non-verbal messages and ability to reduce messages in order to communicate with others.

1. Questions

a. Does he avoid talking to people?

b. When people come home what does he do?

c. Does he ever visit others?

d. Is he able to start, maintain and end a conversation?

e. Does he understand body language and emotions of others such as smiling, crying, screaming, etc.,

f. Does he indulge in reading and writing?

g. Do you encourage him to be more sociable?

Scoring:

0 = No disability

Patient mixes, talks and generally interacts with people as much as can be expected in his socio-cultural context. No evidence of avoiding people.

1= Mild

Patient described as uncommunicative or solitary in social situations. Signs of social anxiety might be reported.

2= Moderate

A very narrow range of social contacts, evidence of active avoidance of people on some occasions and interference with performance of social rules causes concern to family.

3= Severe

Evidence of more generalized, active avoidance of contact with people (leave the room when visitors arrive and would not answer the door or phone).

4= Profound

Hardly has any contacts and actively avoids people nearly all the time. Eg : may lock himself inside the room. Verbal communication is nil or a bare minimum.

IV. Work

This includes employment, housework and educational performance. Score only one category in case of an overlap.

Employment:

Guiding Questions

a. Is he employed/unemployed?

b. If employed, does he go to work regularly?

c. Does he like his job and coping well with it?

d. Can you rely on him financially?

e. If unemployed, does he make efforts to find job?

Scoring:

0= No disability.

Patient goes to work regularly and his output and quality of work performance are within acceptable levels for the job.

1= Mild

Noticeable decline in patient’s ability to work, to cope with it and meet the demands of work. May threaten to quit.

2= Moderate

Declining work performance, frequent absences, lack of concern about all this. Financial difficulties foreseen.

3= Severe

Marked decline in work performance, disruptive at work, unwilling to adhere to disciplines of work. Threat of losing his job.

4= Profound

Has been largely absent from work, termination imminent. Unemployed and making no efforts to find jobs.

In similar ways, housewives should be rated on the amount, regularity and efficiency in which tasks in the following areas are completed. Consider the amount of help required completing these. Acquiring daily necessities, making, storing and serving of food, cleaning the house, working with those helping with domestic duties such as maids, cooks etc., looking after possessions and valuable in the house.

Students – Assess a score on performance in school/college, regularity, discipline, interest in future

studies, behaviour at the educational institution. Those who had to discontinue education on account of mental disability and unable to continue further should be given a score of 4.

IDEAS SCORING SHEET