3.6.3.50 Guidelines to Table 5 - Mental Health Function

Summary

Table 5 is used to assess the functional impact of a mental health condition. Recurring episodes of mental health impairment should also be assessed under Table 5.

Regardless of the number of mental health diagnoses a person may have, only one rating is to be applied under Table 5 to reflect the overall impairment to mental health function.

Conditions causing impairment commonly assessed using Table 5

These include but are not limited to:

• chronic depressive/anxiety disorders
• schizophrenia
• bipolar disorder
• eating disorders, such as anorexia nervosa and bulimia somatic symptom disorders
• personality disorders
• post-traumatic stress disorder
• attention deficit hyperactivity disorder (ADHD) manifesting with predominantly behavioural problems.

Diagnosis & evidence

The diagnosis of the condition causing the impairment must be made by an appropriately qualified medical practitioner and supported by corroborating medical evidence. This includes a GP or a psychiatrist.

Where the diagnosis has not been made by a psychiatrist, it must be made by an appropriately qualified medical practitioner with corroborating medical evidence from a registered psychologist.

Where possible, diagnosis and evidence should be consistent with a diagnosis or diagnostic category that appears in a recognised diagnostic tool, such the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD). Alternatively, evidence may include reference to the diagnostics and method of diagnosis.

A PERSON'S SELF-REPORTED SYMPTOMS MUST NOT BE SOLELY RELIED UPON in determining functional impacts of the person's condition (impairment). There must be corroborating medical evidence of the person's impairment.

Corroborating medical evidence can be in writing or verbally provided to the assessor. The advice is required to include the name of the practitioner, their qualifications and professional registration, and must be documented and added to the person's customer record. See 3.6.3.03 ‘Corroborating evidence’.

Examples of corroborating evidence for the purposes of Table 5 include, but are not limited to:

• a report from the person’s treating doctor
• supporting letters, reports or assessments relating to the person’s mental health or psychiatric condition
• interviews with the person and those providing care or support to the person.

Note: A person may not have sufficient self-awareness of their mental health impairment or may not be able to accurately describe its effects. This is to be taken into account when discussing issues with the person and reading supporting evidence. If required, interviews with those providing care or support to the person may be considered as corroborating evidence.

For young people applying for DSP between the ages of 16 and 18 years with a mental health condition having onset in childhood, diagnosis from a paediatrician may be regarded as satisfying these requirements in some instances. This would generally apply to conditions such as ADHD. Conditions, such as severe depression, psychotic disorders, or severe eating disorders would usually be diagnosed (and treated) by a child psychiatrist or clinical psychologist.

The diagnosis made by a paediatrician must be relevant at the time of the DSP claim for this to apply. Where the diagnosis of a paediatrician continues to be relevant for young people over the age of 18 years at the time of applying for DSP, these requirements may be satisfied. This is to be determined on a case-by-case basis and in most cases would be referred to the HPAU (1.1.H.60).

Interpretation & application of relevant terms

References to individuals who provide care or support to a person may include formal caregiving arrangements or informal care from a family member, friend or neighbour.

‘Recurring episodes’ refers to the additional episodes of mental health impairment after periods of time with milder symptoms. In these cases, a person may experience milder symptoms for weeks or even years at a time before experiencing another episode, and this will vary from individual to individual.

‘Registered psychologist’ refers to psychologists registered with the Psychology Board of Australia which is governed by the Australian Health Practitioner Regulation Agency (AHPRA). All psychologists must have general registration, which allows psychologists to work in any area of psychology that is within their scope of practice and to use the title Psychologist.

Vulnerable people

There are some rare instances where it may not be possible for diagnosis of a mental health condition to be made as outlined above. Where the person lacks sufficient insight into their mental health condition or the person lives in a remote community with little or no access to health services, a Services Australia psychologist may make a provisional diagnosis of a mental health condition.

However, in these cases, the evidence/case history must be referred to the HPAU so consideration can be given to other medical factors that may be impacting on the person.

Note: This policy applies only to vulnerable people with mental health conditions, to be assessed under Table 5. People who present with an acquired brain injury (Table 7 – Brain Function) or substance use related impairment (Table 6 - Functioning relating to Alcohol, Drug and Other Substance Use) need to be assessed under the appropriate tables with the diagnosis provided by an appropriately qualified medical practitioner as specified on the relevant Table.

This policy is not designed to be used for people who can readily access health services and for whom a psychological or psychiatric assessment has simply not occurred, or an appropriate medical practitioner involved. In these instances, other avenues for obtaining this assessment exist (see below, ‘Use of specialist assessments’).

Use of specialist assessments

In very limited circumstances, an assessor can arrange a specialist assessment (1.1.S.260) to assist in completing a JCA report or an ESAt report. Where a specialist assessment occurs, consideration must still be given to the diagnosis, reasonable treatment options, likely response to treatment, functional impact and the likelihood of significant improvement within 2 years.

Where a specialist assessment is being undertaken and the formal diagnosis is being made for the first time, consideration must be given as to whether the condition is also reasonably treated and stabilised.

Further information on specialist assessments is available in 3.6.2.15.

Determining the level of functional impact - rules

When establishing whether a person’s impairment causes no or minimal (0 points), mild (5 points), moderate (10 points), severe (20 points) or extreme (30 points) functional impact, each descriptor and all its paragraphs for an impairment rating level in the Table must be read as a whole.

The structure of the Tables requires that, in assessing the level of functional impact, a comparison must be made of all the descriptors for each level of impairment. This does not necessarily mean all descriptors must be met, but all must be considered to determine which descriptors apply to the person’s impairment.

Each descriptor in Table 5 contains the same 6 domains of mental health impairment:

• self-care and independent living
• social/recreational activities and interpersonal relationships
• travel and accessing the community
• concentration and task completion
• behaviour, planning and decision-making, and
• work/training capacity.

While every descriptor requires consideration, in order to compare and contrast the descriptors to determine which impairment rating best reflects the level of functional impact resulting from a person’s condition. Each Table provides specific instructions on the number of descriptors to be met in order to assign a particular impairment rating. Determination of a person's impairment level must be based on the corroborating evidence provided by the person, including the person's medical history, investigation results and clinical findings.

The descriptors in each Table follow an incremental hierarchy, which is expressed among other things, by the use of terms indicating increasing levels of difficulty in performing certain activities. These levels are expressed as: no or minimal difficulty, mild difficulty, moderate difficulty, severe difficulty and extreme difficulty. Some Tables also represent an increase in frequency of symptoms, which is reflective of the impairment rating level.

When determining a person's limitations in relation to conducting 'work tasks', consideration must be given to a person's ability to undertake the task, regardless of whether or not it is part of work they do or have done previously. 'Work' is taken to refer to any work that exists in Australia, even if not within the person’s locally accessible labour market.

An assessment starts by considering the descriptors for 0 points, and if a person has more than 'no functional impact', the descriptors for 5 points are then considered, and so on for the descriptors for higher impairment levels. When it is determined that the person meets the required number of descriptors for a certain impairment rating level, but does not meet sufficient required descriptors for the next impairment rating level, the appropriate impairment rating applicable to the person's circumstances will be the rating at which the required number of descriptors are met.

In other cases, a prescribed number of descriptors may be required for that rating to apply (for example, ‘The person has moderate difficulty carrying out at least 4 of the following’).

Note 1: Individual descriptors or their parts must not be applied in isolation from one another.

In determining whether the required descriptors for a specific impairment level are met or not, ALL the descriptors for that level must be considered and applied as set out in the descriptor. NO descriptors or their parts are to be disregarded.

Note 2: The descriptors must be applied sequentially to allocate an impairment rating - the incremental hierarchy of descriptors MUST NOT be ignored. As mentioned above, the assessment process involves applying the 0-point descriptors first and continuing to apply the descriptors for higher impairment levels, until all the required descriptors for a certain impairment rating level are met.

Note 3: If a person's impairment does not meet sufficient required descriptors for a certain impairment level, the person's impairment cannot be rated at that level or at any higher level.

The examples provided in Table 5 are not prescriptive or exhaustive. The examples are not to be treated as a further descriptor. Rather, examples are suggesting one possible impact, which indicates the level of impairment required to meet the descriptor. A person may have impairment in undertaking other activities not listed in examples, to an equivalent degree.

Determination of the descriptor that best fits a person's impairment level must be based on the available medical evidence including the person's medical history, investigation results and clinical findings. A person's self-reported symptoms must not be solely relied on. An impairment rating must not be applied unless a person's self-reported functional impacts are consistent with and supported by the medical evidence available.

In determining the level of functional impact, care should be taken to distinguish between activities that the person does not do as opposed to activities that they have difficulty performing because of their impairment.

An activity listed under a descriptor cannot be taken as being able to be performed if it can only be performed once or rarely - the person needs to be able to usually perform such activity whenever they would normally attempt it or be required to perform it. Where an activity is usually required to be performed repetitively, a person who can only perform such activity once and is then unable to perform the activity again when required will be taken to be unable to perform this activity. Equally, where an activity is normally undertaken infrequently (for example, only once per day or once per week), a person who can perform that activity once per day or once per week, is not unable to perform the activity merely because they are unable to perform the activity repetitively or with greater frequency than would normally be required.

Where a Table refers to a person being unable to perform certain tasks, the term 'unable' is not intended to mean that the task is unable to be performed without some symptoms. When a person experiences some symptoms when performing an activity this does not mean the person is 'unable' to perform the task. The assessment of the symptoms experienced in performing the activity is relevant where they are severe enough for the person to not be physically able to perform the activity on a repetitive or habitual basis, and not once or rarely.

When assessing episodic or fluctuating impairments and conditions (for example, bipolar disorder), a rating must be assigned which reflects the overall functional impact of those impairments, taking into account the severity, duration and frequency of the episodes or fluctuations as appropriate. The signs and symptoms of mental health impairment may vary over time and the person’s presentation on the day of assessment must not solely be relied upon (see 3.6.3.08 ‘Assessing impairments caused by episodic or fluctuating medical conditions’).

In determining the work-related impairment for fluctuating conditions, consideration should be given to the impact on a person's ability to reliably sustain work over a period of 6 months (26 weeks) without excessive leave or work absences. Sick leave or absences of one month or more taken in any 6-month period are considered excessive.

In determining whether the mental health condition has been reasonably treated and stabilised, one should consider whether a person has received reasonable treatment and whether with or without such treatment, the person's level of function is more likely than not, in light of available evidence, to persist for more than 2 years. If, for example, specialist advice is that a person would benefit from treatment with long-term psychotherapy but that significant functional improvement is not expected to occur within the next 2 years, then the mental health impairment may be considered reasonably treated and stabilised and an impairment rating assigned accordingly.

If reasonable treatment has not been undertaken, it should be determined whether a person has a medical or other compelling reason for not doing so. For example, a person may have a psychotic illness that impairs their insight and ability to make sound judgements and this may affect their compliance with treatment. As such, the person's mental health impairment could then be considered stabilised and is more likely than not, in light of available evidence, to persist for more than 2 years. However, if they retain sufficient insight and judgement and their decision to not undertake reasonable treatment is not due to a medical or other compelling reason, the condition cannot be regarded as reasonably treated and stabilised (see 3.6.3.02 ‘Reasonable treatment & compelling reasons for not undertaking reasonable treatment’).

Impairment Ratings for Table 5

0-point impairment rating level

The 0-point descriptor requires that the person have NO OR MINIMAL functional impact on activities involving mental health function.

For this rating to be assigned, the person MUST have NO OR MINIMAL DIFFICULTIES with at least 4 of the descriptors at (1)(a), (b), (c), (d), (e) or (f).

5-point impairment rating level

The 5-point descriptor requires that the person have a MILD functional impact on activities involving mental health function.

For this rating to be assigned, the person MUST have MILD DIFFICULTIES with at least 4 of the descriptors at (1)(a), (b), (c), (d), (e) or (f).

10-point impairment rating level

The 10-point descriptor requires that the person have a MODERATE functional impact on activities involving mental health function.

For this rating to be assigned, the person MUST have MODERATE DIFFICULTIES with at least 4 of the descriptors at (1)(a), (b), (c), (d), (e) or (f).

20-point impairment rating level

The 20-point descriptor requires that the person MUST have a SEVERE functional impact on activities involving mental health function.

For this rating to be assigned, the person MUST have SEVERE DIFFICULTIES with at least 4 of the descriptors at (1)(a), (b), (c), (d), (e) or (f).

30-point impairment rating level

The 30-point descriptor requires that the person have an EXTREME functional impact on activities involving mental health function.

For this rating to be assigned, the person must have EXTREME DIFFICULTIES with at least 4 of the descriptors at (1)(a), (b), (c), (d), (e) or (f).

Avoiding double counting

Double counting of impairments must be avoided (see 3.6.3.06 ‘Rating multiple conditions with common impairments & double counting’).

Examples of Table 5 assessment

Note: Similar supervisory arrangements may also apply to other non-psychiatrist medical practitioners, for example, visiting medical officers and overseas-trained practitioners. Complex decisions may be referred to the HPAU.

Impairments that should not be assessed using Table 5

Lack of personal motivation or apathy that is not considered to be due to a mental health condition should not be assessed using Table 5.

Not all conditions listed in the DSM should be rated under Table 5. For example, while narcolepsy and dementia are listed in the DSM as mental disorders, they are better rated under Table 7 - Brain Function

ADHD manifesting with predominantly concentration problems should be assessed under Table 7 – Brain Function.