 disability has been assigned as the umbrella term to include impairments , activity limitations or participation restrictions by the international classification of functioning ( icf ) disability and health .
the older concept of  disability along with the terms  impairment and  handicap , as described by icf , have been subsumed under the concept of  activity and participation. neuropsychiatric disorders continue to be leading contributors to the global burden of disease . as per the world health report , 2001 mental illnesses accounted for 25% of total disability and 16% of the total burden . among women aged 15 - 44 years , mental disorders constitute three of the 10 leading causes of disease burden in low - and middle - income countries , and 4 of the leading 10 in high - income countries . as per the census of india , 2001
there are an estimated 2,263,821 ( for a population of 1,028,610,328 ) people suffering from disability due to mental illness in the country .
mental disorders rank third among the five leading contributors to disability in india . however , a recent community - based study in india found mental disability to be the most common type of disability accounting for 36.7% of total disability .
schizophrenia has been identified as one of the most disabling condition known to mankind . as per the estimates for global burden of a disease study ,
it usually starts during young age and is frequently associated with deterioration from the previous level of functioning .
this deterioration is reflected in various functional deficits leading to social isolation and poor occupational functioning .
it is also being increasingly recognized that disability is one of the outcome indices for chronic illnesses such as schizophrenia .
the indian literature on disability in schizophrenia has focused on patients seeking treatment in out - patient setting , in patient setting and community setting . however , till recently there was no published literature on disability certification seeking behavior of patients diagnosed with schizophrenia . a recent study from karnataka explored the utilization of disability benefits by those who have been issued disability certificates . the current study aimed at understanding the profile of patients diagnosed with schizophrenia seeking disability certification for a tertiary level multispecialty hospital in india .
the findings of this study are expected to provide valuable information on various socio - demographic and illness related variables of these individuals .
the current study aimed at assessing the profile of subjects diagnosed with schizophrenia seeking disability certification . additionally it aimed at assessing the various socio - demographic and illness related variables among these individuals .
the study was carried out at the psychiatry department for a tertiary care hospital in india .
we here present the findings form review of cases seeking disability certification over a 5 year period .
the evaluation of the subjects was carried out in the presence of a primary care giver .
detailed history taking and mental status examination was carried out as part of this evaluation process .
the evaluation board comprised of three qualified psychiatrists with at least 3 years of post - senior residency experience in psychiatry .
first , the diagnosis was established using icd-10 ( international statistical classification of diseases and related health conditions ) .
subsequently , the disability was assessed using indian disability evaluation assessment scale ( ideas ) .
socio - demographic information from all the subjects was collected using a pre - approved semi - structured proforma .
ideas are approved by the government of india for documenting the level of disability due to mental illness .
it assesses disability under four domains : self - care , interpersonal activities ( social relationships ) , communication and understanding , and work .
each item is scored between 0 and 4 , i.e. , from no to profound disability , adding scores on 4 items gives the  total disability score. global disability score is calculated by adding the  total disability score and mi2y score ( months ill in 2 years- a score ranging between 1 and 4 , depending on the number of months in the last 2 years the patient exhibited symptoms ) .
global disability score of 0 corresponds to  no disability , a score between 1 and 7 corresponds to  mild disability , and a score of 8 - 13 corresponds to 
severe disability , and a score of 20 corresponds to  profound disability. an ideas is a well - validated instrument and is being used across the country for disability evaluation in psychiatric disorders .
the alpha value for the scale has been found to be 0.8682 , indicating good internal consistency between the items .
criterion validity of the scale has been established by comparing ideas with schedule for the assessment of psychiatric disability which has been standardized in india .
data were analyzed using spss ( statistical package for social sciences ) software version 17 .
categorical variables were analyzed using chi - square test and continuous variables were analyzed using parametric tests .
these included independent sample t - test for in - between group differences for male and female subjects ; and family history positive / negative subjects .
further , correlation between different illness variables and ideas scores was carried out using pearson 's correlation coefficient .
conditions of anonymity and confidentiality as recommended were strictly adhered to during the course of the study and data reporting .
socio - demographic information from all the subjects was collected using a pre - approved semi - structured proforma .
ideas are approved by the government of india for documenting the level of disability due to mental illness .
it assesses disability under four domains : self - care , interpersonal activities ( social relationships ) , communication and understanding , and work .
each item is scored between 0 and 4 , i.e. , from no to profound disability , adding scores on 4 items gives the  total disability score. global disability score is calculated by adding the  total disability score and mi2y score ( months ill in 2 years- a score ranging between 1 and 4 , depending on the number of months in the last 2 years the patient exhibited symptoms ) .
global disability score of 0 corresponds to  no disability , a score between 1 and 7 corresponds to  mild disability , and a score of 8 - 13 corresponds to 
severe disability , and a score of 20 corresponds to  profound disability. an ideas is a well - validated instrument and is being used across the country for disability evaluation in psychiatric disorders .
the alpha value for the scale has been found to be 0.8682 , indicating good internal consistency between the items .
criterion validity of the scale has been established by comparing ideas with schedule for the assessment of psychiatric disability which has been standardized in india .
data were analyzed using spss ( statistical package for social sciences ) software version 17 .
categorical variables were analyzed using chi - square test and continuous variables were analyzed using parametric tests .
these included independent sample t - test for in - between group differences for male and female subjects ; and family history positive / negative subjects .
further , correlation between different illness variables and ideas scores was carried out using pearson 's correlation coefficient .
conditions of anonymity and confidentiality as recommended were strictly adhered to during the course of the study and data reporting .
a total of 169 subjects seeking disability certification over the study period of 5 years were diagnosed with schizophrenia .
out of 169 subjects 132 ( 78.1% ) were male and 37 ( 21.9% ) were female .
the mean age of male subjects and female subjects were 36.89 ( standard deviation ( sd ) 9.67 ) years and 39.56 ( sd11.79 ) years , respectively .
majority of the study subjects were literate [ table 1 ] . only around 5.3% of males and 10% of females were illiterate .
majority of the study subjects ( 93.9% males and 86.4% females ) were from an urban setting .
in - between group differences for male and female subjects for socio - demographic variables there was a statistically significant difference ( chi - square=25.27 , df=4 , p<0.05 ) in the marital status of the male and female study subjects . while the majority of male subjects were unmarried ( 62.1% ) and an equal proportion of female subjects were married and unmarried ( 35.1% each ) .
also , 18.9% of the female subjects were either separated or divorced . in comparison ,
there was a statistically significant difference in the employment status of the male and female subjects ( chi - square=7.84 , df=2 , p=0.02 ) .
while 17.4% of male subjects were employed , none of the female subjects was currently employed . around 56.7% of the female subjects were from a lower socio - economic background .
the rest belonged to middle socio - economic status . in comparison , 15.9% of the male subjects belonged to lower socio - economic status , with the rest belonging to middle socio - economic status .
this difference was not statistically significant ( chi - square=3.23 , df=1 , p=0.07 ) .
a significantly higher ( chi - square=8.99 , df=2 , p=0.01 ) percentage of male subjects ( 10.6% ) were the primary earning member of the family as compared to female subjects ( none ) .
family history of psychiatric illness was positive in 9.8% of male subjects and 10.8% of female subjects [ table 2 ] .
of these , around 76.4% of the family members were suffering from schizophrenia . in - between group differences for male and female subjects for illness
related variables there was no significant difference between male and female subjects for the duration of illness ( t=1.20 , p=23 , 95% ci-4.62 - 1.12 ) and duration of being on treatment ( t=0.86 , p=38 , 95% ci-4.03 - 1.57 ) .
the mean global score on ideas were 12.29 sd2.67 and 11.78 sd2.82 for male and female subjects , respectively [ figure 1 and table 3 ] .
* statistically significant difference at p<0.05 in - between group differences for male and female subjects for age , illness related and ideas variables male and female subjects did not differ significantly on the ideas global score ( t=1.01 , p=31 , 95% ci-0.48 - 1.51 ) , personal care ( t=0.68 , p=0.49 , 95% ci-0.20 - 0.41 ) , interpersonal interaction ( t=0.35 , p=0.72 , 95% ci-0.33 - 0.22 ) , and understanding and communication ( t=0.16 , p=0.87 , 95% ci-0.33-.28 ) domains of ideas .
the two groups differed significantly on the work domain ( t=3.92 , p<0.05 , 95% ci-0.43 - 1.30 ) .
the disability on work domain was higher for male ( mean=3.38 sd1.21 ) as compared to female ( mean=2.51 sd1.09 ) subjects .
around 59.8% of male subjects and 56.7% of female subjects were suffering from moderate level of disability .
severe disability was found in 34.8% of male subjects and 35.1% of female subjects [ table 2 ] . there was a significant positive correlation between total duration of illness and global ideas score ( r=0.287 , p=0.001 ) and duration for seeking treatment and global ideas score ( r=0.242 , p=0.005 ) for male subjects [ table 4 ] .
correlation between socio - demographic , illness variables and ideas score for the male subjects however , no such correlation was observed for female subjects [ table 5 ] .
correlation between socio - demographic , illness variables and ideas score for the female subjects additionally , the subjects with or without a family history of psychiatric illness did not differ on various domains of ideas scale as well as global ideas score [ table 6 ] . in - between group differences for the study variables for subjects with and without a family history of psychiatric illness
the current study aimed at assessing the profile of patients with schizophrenia seeking disability certification at a tertiary care multispecialty hospital in india . additionally it aimed at assessing the various socio - demographic and illness related variables among these individuals .
the existing indian literature on disability among patients diagnosed with schizophrenia has focused on patients seeking treatment in out - patient , in - patient and community settings .
we analyzed a total of a total of 169 subjects seeking disability certification over the study period of 5 years was diagnosed with schizophrenia .
schizophrenia remains the most common diagnosis among previous indian studies on disability among treatment seeking psychiatric patients .
reported 65.3% of the subjects to be diagnosed with schizophrenia in their total sample of 285 over a 3 year period .
however , affective disorders have been found to be the most common cause of disability among not treatment seeking individuals in community based studies . in spite of comparatively lower prevalence than other mental disorders schizophrenia continues to be over represented among treatment seekers in hospitals . in the current study ,
an overwhelming majority of study subjects were male . in a community based epidemiological survey for disability in rural karnataka ,
females constituted 68% of individuals with mental disability . in a recent study from karnataka , females constituted 49.1% of all disability certificate seeking individuals over a 3 year period .
similarly , in a study among long stay patients diagnosed with schizophrenia 67.86% were male . in another study from assam ,
31.6% of the study subjects were female . while previous indian studies have reported relatively later help seeking for female patients suffering from schizophrenia , the same is not reflected in the findings of the current study .
in the present study male and female subjects did not differ significantly with regards to age at presentation , total duration of illness and duration since seeing treatment .
the study by kujur et al . also observed a significant difference in marital status of male and female patients with schizophrenia with majority ( 57.7% ) of women were separated from their husbands . a significantly higher proportion of female subjects were divorced or separated in the current study .
previous studies from the west have documented moderate disability in most of patients diagnosed with schizophrenia irrespective of the setting . in the current study
indian studies have revealed the disability among patients with schizophrenia to moderate to severe as early as 2 - 5 years after illness onset . in a study from assam ,
64% of patients suffering from schizophrenia and 30% of those suffering from bipolar affective disorder had severe disability as per the ideas .
however , an indian study among non - treatment seeking individuals in a community setting found mild disability as the most common . in the present study , the highest disability for both male and female subjects was observed in the work domain of ideas .
previous indian studies have also reported occupational disability as the most disabling of all the categories . additionally , the least disability observed for personal care ( for both male and female subjects ) was also in keeping with similar observations in previous studies .
however , another indian study conducted in a mental hospital setting found the highest level of disability for understanding and communication domain of world health organisation disability assessment schedule ii ( whodas ii ) .
disability in schizophrenia has been found to be affected by characteristics like age of onset and duration of illness among other factors . in a previous indian study from ranchi
it was found that duration of illness has a significant correlation with personal areas of disability and age of onset has significant positive correlation with personal and occupational area of disability .
however , in the current study a significant positive correlation between total duration of illness and global ideas score was observed only for the male subjects .
a previous study by thara et al . found a significantly higher global disability and occupational disability among male patients suffering from schizophrenia as compared to the female patients .
however , the two did not differ for disability on other domains including self - care , social withdrawal and social contact . in the present
also the male and female subjects differed significantly only on the work domain of ideas .
no significant differences were observed for personal care , interpersonal interaction and understanding and communication domains .
also , there was no significant difference on the global ideas score for male and female subjects .
stigma , poor knowledge about the ideas , fear of misuse of certificates , discomfort to approach government hospitals , time constraints , rigid negative thinking about legal issues , denial of disability have been specified as some of reasons for underutilization of disability certification .
lack of education among disabled is an important barrier for effective delivery of services . according to national sample survey organization , 2002
gender has been found to be an important determinant of help seeking for mental disorders .
women with common mental disorders were more likely to have sought some form of help than men in studies from western setting .
however , the situation is different in developing countries such as india . due to socio - cultural factors women
researchers has revealed that those closest to the individual play an influential role in whether or not an individual seeks mental health services when experiencing distressing symptoms .
multi - ethnic studies have reported that asian patients with psychiatric illness tend to show the longest delay in help seeking .
more intensive , extended and persistent family involvement is a possible reason for the delay in seeking help by these individuals .
the present study offers some interesting and important insights in to disability certification seeking behavior of patients diagnosed with schizophrenia .
there is a relatively long gap between the onset of illness and disability certification . in spite of regulatory threshold of 2 years ,
also , all the female subjects in the present study were not gainfully employed and were financially dependent on the family . also , a significant greater proportion of them were either divorced or separated .
the findings also suggest a relatively early stabilisation of disability among females as the duration of illness was not found to be correlated with global ideas score .
however , there was a significant correlation between these two variables for male subjects . relatively later impact of disorder on employment status is a likely possible reason for this observation .
lack of impact of presence of psychiatric illness in another family member does not impact the disability seeking behavior of the study subjects .
this is a worrisome finding and it reflects poor education of family with regard to the provisions of disability certification and disability benefits available .
there is a need to disseminate information related to impact on disabled , community mobilization , opportunity for education , opportunity for work , transfer skills to community level , program activities , and involvement of disabled people .
also , research with respect to services , fund allocation , cost - effectiveness , manpower , training , and technical aid of disabled people should be strengthened .
a special emphasis should be placed on providing rehabilitation services and disability benefits to the unreached persons with disabilities living in rural areas and small towns of the country .
positive impact of disability assessment camps on disability certification seeking behavior has been documented in india .
even those who have received disability certification do not utilize the disability benefits offered by the government .
the underutilization is even more prominent in rural areas with disability pension being the most utilized benefit .
we included all the subjects diagnosed with schizophrenia seeking disability certification over the study period .
assessment was carried out using a standardized indian instrument that has been used previously in indian settings . however , there are certain limitations as well .
also , the findings need to be replicated in multisite studies before they could be generalized .
also , it would be informative to review these subjects over time to assess the stability of disability level .
additionally , information on the utilization of disability benefits subsequent to certification should also be assessed in future studies .
we included all the subjects diagnosed with schizophrenia seeking disability certification over the study period .
assessment was carried out using a standardized indian instrument that has been used previously in indian settings .
also , the findings need to be replicated in multisite studies before they could be generalized .
also , it would be informative to review these subjects over time to assess the stability of disability level .
additionally , information on the utilization of disability benefits subsequent to certification should also be assessed in future studies .
majority of patients with schizophrenia seeking disability certificate continue to be male . however , male and female subjects tend to differ very little on various socio - demographic and illness related variables .
there are significant difference in the likely impact of schizophrenia on marital status of males and females .
however , the work related disability is relatively higher among males and females continue to be financially dependent on the family members .
 background : schizophrenia has been identified as one of the most disabling condition known to mankind . until recently there was no published literature on disability certification seeking behavior of patients diagnosed with schizophrenia . the current study aimed at understanding the profile of patients diagnosed with schizophrenia seeking disability certification for a tertiary level multispecialty hospital in india.materials and methods : 
 the study was carried out at the psychiatry department for a tertiary care hospital in india . 
 the evaluation of the subjects was carried out in the presence of a primary care giver . 
 first , the diagnosis was established using international statistical classification of diseases and related health conditions ( icd)-10 . 
 subsequently , the disability was assessed using indian disability evaluation assessment scale ( ideas ) . 
 data were analyzed using spss ( statistical package for social sciences ) software version 17.results:a total of 169 subjects seeking disability certification over the study period of 5 years were diagnosed with schizophrenia . out of 169 subjects 132 ( 78.1% ) were male and 37 ( 21.9% ) were female . 
 there was a statistically significant difference in the marital status of the male and female study subjects . 
 family history of psychiatric illness was positive in 9.8% of male subjects and 10.8% of female subjects . 
 there was no significant difference between male and female subjects for the duration of illness and duration of being on treatment . 
 male and female subjects did not differ significantly on the ideas global score , personal care , interpersonal interaction , and understanding and communication domains of ideas . 
 the two groups differed significantly on the work domain.conclusions:majority of patients with schizophrenia seeking disability certificate continue to be male . 
 however , male and female subjects tend to differ very little on various socio - demographic and illness related variables . the levels of disability are also comparable among males and females . 
 however , the work related disability is relatively higher among males and females continue to be financially dependent on the family members . 