certification in psychiatry

1. CERTIFICATION IN PSYCHIATRY
PRESENTED BY : DR AJAZ AHMAD SUHAFF
DEPARTMENT OF PSYCHIATRY
SKIMS MEDICAL COLLEGE, BEMINA

4. Classification of certificates in Psychiatry
Procedural Certification
 Legislation Related:
 Certification of the capacity
assessment as per MHCA 2017.
 Criminal cases related:
 Certification of Insanity defence
(retrospective mental status of the
defendant at the time of the alleged
crime)
 Psychiatric fitness certificate to
stand trial
On Request certification ( civil matters)
 sickness/ illness related certificate.
 Sickness/ illness related (mental
illness) certificate.
 Treatment (Medical treatment)
certificate.
 Dysfunction related certificate.
 Leave (Medical Leave) Certificate.
 Disability Certificate.
 Functional/Ability related Certificates
[psychiatric fitness certificate]
 Employment related PFC.
 Property related PFC (will, testamentary
capacity)
 Marriage related PFC.
 Premedical/surgical procedures related
PFC.

5. Procedure of certification
 Enquiry & Decision Phase.
 Assessment & Documentation Phase.
 Drafting & Issuing Phase.

6. Enquiry & Decision Phase.
1. Who is the certificate seeker.
( patient himself/nominated representative/employer/Investigating
officer/court magistrate.)
2. Purpose/ benefit, why are he/she asking for the
certificate.
(for paid leave / fitness to join a job/social welfare benefit (pension)/income
tax.)
3. Content of the certificate. (what kind of certificate).
4. Timeline for the certificate.
5. Addressor of the certificate.
6. Transport/delivery of the certificate.

8. •Role of RPWD Act (2016) for person with Disability.
•Rights of Persons With Disabilities Act, 2016 (R.P.W.D.) was enacted under
the Article 253 of the Constitution of India read with item No. 13 of the Union
List. Draft Bill of this Act was created in 2011. The Bill was passed by the
Rajya Sabha on 14 December 2016 and by Lok Sabha on 17 December
2016 Rights of Persons With Disabilities Act, 2016 came into effect on 30
December 2016. It replaced the Persons with Disability (P.W.D.) Act that
was enacted way back in 1995.

9. As per the 1995 version of the Act, only 7 disabilities were included
:blindness, low vision, leprosy-cured, hearing impairment, locomotor
disability, mental retardation and other mental illnesses.
• Numbers of types of disabilities have been increased from 7 to
21.
• Speech and Language Disability and Specific Learning Disability
have been added for the first time. Acid Attack Victims have been
included. Dwarfism, muscular dystrophy have has been indicated
as separate class of specified disability. The New categories of
disabilities also included three blood disorders, Thalassemia,
Hemophilia and Sickle Cell disease In addition, the Government
has been authorized to notify any other category of specified
disability.

11. CERTIFICATION OF INTELLECTUAL DISABILITY
• Definition – A condition characterised by significant limitation both in
 intellectual functioning (reasoning, learning, problem solving) and in adaptive
behaviour which covers a range of every day, social and practical skills.
• Diagnosis: The tools that can be used for diagnosis include:
(i) Adaptive functioning: VSMS
(ii) IQ testing: BKT/SFBT
 Based on the above the diagnosis of ID will be confirmed.

15. VSMS score Disability- %
0-20 Profound Disability-100%
21-35 Severe Disability-90%
36-54 Moderate Disability-75%
55-69 Mild Disability-50%
70-84 Borderline Disability-25%
Disability calculation is done based on VSMS score

16. • The minimum age for certification is one (01)
completed year. Children above one year and up to the age of 5 years shall
be given a diagnosis as Global Developmental Delay (GDD).
• Children above the age of 5 years shall be given a diagnosis and certificate
as Intellectual Disability.
Age for certification:

17. Validity of Certificate
• Temporary certificate for children less than 5 years:
The certificate will be valid for maximum 3 years/ 5 years age (whichever is earlier).
For children more than 5 years:
The certificate will mention a renewal age. The certificate will have to be renewed
at age of 5 years, 10 years and 18 years.
• The certificate issued at 18 years age will be valid lifelong.

18. ASSESSMENT OF DISABILITY IN PERSONS WITH MENTAL
RETARDATION (ADPMR)
• IQ as a measure of disability is not appropriate and conceptually it is quite
different (Flynn 1991; ICF 2001).
• ADPMR scale was developed by Nizamie et al, as a unified scale keeping
in view certification purposes laid down by the Government of India.
• Assessment of Disability in Persons with Mental Retardation (ADPMR)
scale assist clinicians in settings where a psychologist is not available.
• It is a 5 point anchored rating scale that can be completed in a short time
(about 10 minutes) in most setups.

19. ITEMS--
a) Perceptual-Motor
b) Self-care
c) Communication & Social
d) Academic
e) Occupational

20. 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= Profounddisability (total, cannot do)

21. Percentages:
• Score of 0 : No Disability= 0%
• 1- 7 : Mild Disability= < 40%
• 8 and above :> 40%
•(8 -13 Moderate Disability; 14 -19 = Severe Disability; 20 = Profound
Disability)
• For the purpose of welfare benefits, 40% will be the cut-off point

22. CERTIFICATION OF MENTALILLNESS
• Definition: A substantial disorder of thinking, mood, perception,orientation
or memory that grossly impairs judgment, behaviour, capacity to recognise
reality or ability to meet the ordinary demands of life, but does not include
retardation which is a condition of arrested or incomplete development of
mind of a person, specially characterised by subnormality of intelligence.
• The examination process consist of components as required namely,
clinical assessment, IDEAS scale and/or IQ assessment.

23. • In some cases where there is suspicion of intellectual deficits or additional
intellectual evaluation is required for any reason, Standardised IQ test may
be carried out.
• Categories on IQ score will be:
a) Mild Mental Disabilities: The range of 50 to 69 (standardised IQ test) is
indicative of mild disability.
b) Moderate Mental Disability: The IQ is in the range of 35 to 49
c) Severe Mental Disability: The IQ is in the range of 20 to 34.
d) Profound Mental Disability: The IQ in this category estimated to be under
20.

24. • In cases where the mental behavioural condition requires only IDEAS, then
only IDEAS can be administered and degree of disability certified.
• In cases where the cognition is impaired and requires only IQ, then a
standardised IQ test shall be used to certify degree of disability.
• In some cases, only one test may not estimate disability comprehensively.
• Such a person may have borderline or normal score on one test with
disability score on the other. In such cases both IQ and IDEAS shall be
used, the score indicating more severe disability should be the degree of
disability for that person.

25. Indian Disability Evaluation and Assessment
Scale
• It includes following items
• -self care,
• -Interpersonal activities,
• -Communication and understanding, and
• -Work.
,
• Each item is scored between 0-4, i.e., from no to profound disability.
• Scores for each item is added to obtain a total score.
• Weightage 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

26. • Global disability score percentages are calculated by adding Total disability
score and DOI.
0 No Disability = 0%
1-6 Mild Disability = < 40%
7-13 Moderate Disability = 40-70%
14-19 Severe Disability = 71-99%
20 Profound Disability = 100%

27. • In cases where other limitations coexist, they are assessed separately as
per the guidelines and the final disability % calculated using the combining
formula: a+b (90-a)/ 90 (a = higher value, b = lower value).
• Total permanent physical impairment/disability % will not exceed 100%.
• Disability is to be certified in relation to the whole body.

28. CERTIFICATION OF DISABILITY CAUSED DUE TO
AUTISM SPECTRUM DISORDERS
• Definition : A lifelong neurological condition typically appearing in the
first three years of life that is marked by pervasive impairment in the areas
of social skills and communication: often associated with hyper-or-hypo-
reactivity to sensory input; unusual interest of stereotypical rituals, or
behaviors; and may or may not be accompanied by intellectual impairment.

29. • Certification of Autism is issued on the basis of Indian Scale for Assessment
of Autism (ISAA).
• The certificate is valid for a period of 5 yrs for those whose disability is
temporary and are below the age 18 yrs.
• For those who acquire permanent disability; the validity can be shown as
“Permanent” in the certificate.

30. INDIAN SCALE FOR ASSESSMENTOFAUTISM
Name of the child:……………………. Gender:……….. Date:……………
D.O.B:……………………….. Age: …………… Examiner: …………….
Directions:
Below are given 40 statements which are divided under six domains, please
tick ( √ ) mark the appropriate rating for each item of the scale by observing
the child and by interviewing the parents in order to assess Autism
Items
Rarely Upto
20%
Score 1
Sometimes 21–
40%
Score 2
Frequently 41 –
60%
Score 3
Mostly 61-
80%
Score 4
Always 81-
100%
Score 5
I. SOCIAL RELATIONSHIP ANDRECIPROCITY
1 Has poor eye contact
2 Lacks socialsmile
3 Remains aloof
4 Does not reach out toothers
5 Unable to relate topeople
6 Unable to respond to social/environmental cues
7 Engages in solitary and repetitive playactivities
8 Unable to take turns in socialinteraction
9 Does not maintain peer relationships
II. EMOTIONAL RESPONSIVENESS
10 Shows inappropriate emotional response
11 Shows exaggeratedemotions
12 Engages in self-stimulatingemotions
13 Lacks fear of danger
14 Excited or agitated for no apparentreason
III. SPEECH-LANGUAGE AND COMMUNICATION
15 Acquired speech and lostit
16 Has difficulty in using non-verbal language or gestures to
communicate
17 Engages in stereotyped and repetitive use of language
18 Engages in echolalicspeech
19 Produces infantile squeals/ unusualnoises
20 Unable to initiate or sustain conversation with others

31. Items
Rarely
Upto20%
Score 1
Sometimes 21
– 40%
Score2
Frequently 41
–60%
Score3
Mostly 61-
80 %
Score 4
Always 81-
100%
Score 5
21 Uses jargon or meaningless words
22 Uses pronoun reversals
23 Unable to grasp pragmatics of communication (real
meaning)
IV. BEHAVIOUR PATTERNS
24 Engages in stereotyped and repetitive motor mannerisms
25 Shows attachment to inanimate objects
26 Shows hyperactivity/ restlessness
27 Exhibits aggressive behavior
28 Throws temper tantrums
29 Engages in self-injurious behavior
30 Insists on sameness
V. SENSORY ASPECTS
31 Unusually sensitive to sensory stimuli
32 Stares into space for long periods of time
33 Has difficulty in tracking objects
34 Has unusual vision
35 Insensitive to pain
36 Responds to objects/people unusually by smelling,
touching or tasting
VI. COGNITIVE COMPONENT
37 Inconsistent attention and concentration
38 Shows delay in responding
39 Has unusual memory of some kind
40 Has ‘savant’ ability

32. ISAA Scores Degree ofAutism
< 70 Normal
70 to 106 Mild Autism
107 to 153 ModerateAutism
> 153 SevereAutism
Score Percentage (%)
70 40
71-88 50
89-105 60
106-123 70
124-140 80
141-158 90
Above 158 100
PERCENTAGE OF DISABILITY AS PER THE SCORE
Norms of ISAA for DiagnosisofAutism

34. A well-drafted letter or certificate has to
include the following particulars
• Name (should match hospital records)
• Age
• Gender of patient
• Name of the parent/guardian/husband
• Place of residence
• Patient identification number
• Date of registration at the establishment and subsequent dates on which patient is seen
• Medical and psychiatric diagnosis of the patient (preferably after a detailed workup has
been done)
• Avoid abbreviations, e.g., BPAD, PTSD, MR, etc., It is preferable to write the full form.
Diagnosis should be written in full form, and care needs to be taken about using correct
ICD/DSM labels for diagnosis
• Specific information collected over the total number of sessions and/or the number of
follow-ups attended by the patient
• How and from whom the information was obtained?
• Mention “At the time of issuance of the letter…” (to highlight the cross-sectional nature of
the information). Mention the date and need for a follow-up assessment
• Any recommendations

35. • Purpose of the letter
• The letter issued on whose request?
• Avoid using any disclaimers like “This letter cannot be
used as legal evidence” as every document, prescription,
etc., issued can be used as legal evidence
• Do not comment on the caregivers’ attitudes or marital
harmony without adequate evaluation
• It is a good practice to get the letters typed neatly on a
letterhead (preferably A4 size, Arial font: 10–12 size)
rather than writing by hand as at times, handwriting may
be difficult to decipher
• In letters written for legal purposes, you must mention at
least two identification marks of the patients in the file

36. CERTIFICATE FOR INVALIDATION FROM
SERVICE (CERTIFICATE OF
UNFITNESS)
• Patients who have been suffering for a long time from psychiatric illness
require unfitness certificate so that his/her family members may get job on
compassionate ground or under service rules in certainorganizations.
Recommendations
• Do not issue certificate for invalidation unless asked by the employer in writing.
• The detailsregardingthe nature of job should be obtained.
• . If necessary,the patientmay be admittedfor observation for at least 10 days.
• Proper documentationof the certificatesissued is desirable.

37. TREATMENT CERTIFICATE
• A document which certifies that a person has been under treatment from a
particular institution for a particular period of time.
• Issued by a medical officer and signifies that the person had been or is
currently receiving treatment from a particular centre without further
making any comment about the nature of illness from which the person is
suffering.
• There is a lack of proper understanding of the mental illnesses in the
general population.

38. • Thus such a certificate is almost equated with certificate of “insanity”, in
institutional setups and even in courtrooms
• So to prevent misuse of this certificate in the form of an evidence in favour
of insane condition of a person it is recommended to mention that- this
certificate does not make any opinion on the nature, extent, duration and
treatment of illness and that clarification if any can be sought from the
issuing authority.

39. MENTAL FITNESS CERTIFICATE
• Psychiatrists are called upon to produce legally binding
documents that are often presented before the courts,
and that can determine the course of an individual's life
and liberty, and his / her life choices.
• A person with a mental disorder should be assumed to
have mental capacity to decide on various matters unless
the contrary can be shown.

40. • The criteria for incapacity are as follows:
1. The person cannot comprehend and retain information relevant to the
decision and its consequences.
2. The person is incapable of believing the information.
3. The person is incapable of weighing up information to reach a decision.

41. • No instrument developed in this area in India, unlike in other countries
where legal incapacity decisions are done under very high statutory
prescription, ethical dialogue and technical development of tools of
assessments.
• Thus, attribution of “fitness” is often a personal judgement and it should be
exercised very carefully.

42. • In India, “fitness certificates” are regularly issued by psychiatrists for the
following:
1. To stand trial
2. To work
3. For marriage
4. To take custody of a child
5. To enter into contract
6. Making a valid will
7.Fitness to discharge certificate is also given for discharging somebody
from mental institutions.

43. FALSE MEDICAL CERTIFICATE: LEGAL CSEQUENCES
Following actions can be taken if a medical certificate issued by a lawful
authority is found to be malafide and false:
• Wilfully and recklessly issuing a false or fake certificate is a professional
misconduct as per Indian Medical Council, punishable by striking the name off the
Medical Register.
• It is treated as false evidence.
• It is treated as forging documents or supplying false evidences under the provisions
of IPC and CrPC (offences under Section 463, 464 IPC, punishable under Section
465IPC.)
FALSE MEDICAL CERTIFICATE: LEGAL CONSEQUENCES

44. • When a certificate is submitted in a court of law as evidence, and proved to be
false, the one who has issued it is liable for the same punishment as giving false
evidence (ranging from three years’ imprisonment and fine/ imprisonment for
life).
• Alternations/ additions in certificate with the intention to deceive is punishable
by charge of forgery where punishment is of two years’ imprisonment and fine.
• A person who suffers damage while acting upon a false Medical Certificate can
charge the issuing authority of civil or criminal negligence.

45. CONCLUSION
• Certificates and reports that are issued by psychiatrists are increasingly
being used as evidence in the court of law and also for other administrative
and welfare measures.
• Psychiatrists have several ethical, moral and legal obligations in the
performance of their duties.
• It is very therefore important that every psychiatrist should understand the
nature of these obligations to the best of their abilities.

46.  Can we provide disability benefit certificate to
a substance abusers??