3.6.3.50 Guidelines to Table 5 - Mental Health Function

Summary

Table 5 is used where a person has a functional impairment due to a mental health condition. Recurring episodes of mental health impairment should also be assessed under Table 5.

The diagnosis of the medical condition causing the impairment must be made by an appropriately qualified medical practitioner, such as a psychiatrist.

Where this is not a psychiatrist, the diagnosis must be made by an appropriately qualified medical practitioner with evidence from a clinical psychologist. A PERSON'S SELF-REPORTED SYMPTOMS MUST NOT BE SOLELY RELIED UPON in determining functional impacts of the person's permanent condition (impairment). There must be corroborating medical evidence of the person's impairment.

Interpretation & application of relevant terms

A clinical psychologist is a psychologist registered with the Australian Health Practitioner Regulation Agency who holds an area of practice endorsement in clinical psychology as confirmed by the Psychology Board of Australia.

Corroborating evidence for the claim can include professional or clinical reports. It can also include advice from the treating practitioner that a clinical psychologist or a psychiatrist who made or confirmed the diagnosis or provided evidence in support of the diagnosis has seen the person. This advice either can be in writing or verbally provided to the assessor. The advice is required to include the name of the practitioner and must be documented and added to the person's Medical Information File.

In general, a psychiatry or clinical psychology registrar can be found to satisfy the requirements for diagnosis by an appropriately qualified medical practitioner, so long as they are clinically supervised by a fully qualified psychiatrist or clinical psychologist, respectively.

Example: A 52-year-old woman has been treated by her GP for mild depression and anxiety for many years. 12 months before she applies for DSP, she experiences a significant life event. Her depression worsens over the next 6 months, and she is reluctant to leave the house, has lost 5 kg, wakes at 4 am each morning, feels hopeless about the future and cannot concentrate on the TV for more than ½ hour. Her GP commences an antidepressant medication, but there is no improvement within the following 6 weeks. Her GP is concerned that she is continuing to lose weight and is expressing thoughts that her family would be better off without her, and refers her to the local community mental health service. She is seen there by a psychiatric registrar who diagnoses major depressive disorder. The registrar writes a letter to the GP, which indicates this diagnosis and provides a treatment plan. All psychiatric registrars have regular supervision with a consultant psychiatrist and discuss their patients with the psychiatrist. As the psychiatric registrar is under supervision by a psychiatrist this condition can be rated as fully diagnosed.

Example: A 26-year-old woman has a long history of social anxiety, which commenced during adolescence. She left school at age 16 years, as she found social interactions there difficult and reported being bullied. She was seen by a registered psychologist from the ages of 16 to 18 years and had appropriate psychological therapy. She improved following this treatment and was able to complete a 2-year TAFE diploma course. She worked part-time for the next 12 months. However, she had a relapse of her social anxiety when her grandmother died, as her grandmother had been an important support for her. She ceased work at that point. She attended her GP for the next 4 years and was prescribed antidepressant medication. Even though psychological therapies had been helpful previously, she was reluctant to try this again, as it meant leaving her home. She avoided leaving the house unless someone else came with her; she avoided eating in public and had to be persuaded to answer the telephone. She lived with her parents who did her shopping and provided meals. Her GP encouraged her to reconsider psychological therapies and she eventually agreed to attend a psychologist. The GP referral letter indicated a diagnosis of severe social anxiety. A clinical psychology registrar who saw her confirmed the diagnosis. Clinical psychology registrars are registered psychologists who are in training to become clinical psychologists and are required to have regular supervision from a registered clinical psychologist. This clinical psychology registrar discussed this case with their supervisor who agreed with the diagnosis of severe social anxiety, as indicated by the patient's GP, so the condition of social anxiety can be rated as fully diagnosed for the purposes of Table 5.

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 Health Professional Advisory Unit (HPAU).

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 Attention Deficit Hyperactivity Disorder (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 a referral made to the HPAU.

Example: A man applies for DSP at the age of 20 years. He was diagnosed with ADHD by a paediatrician when he was 8 years old when he was prescribed appropriate stimulant medication. His paediatrician last saw him at age 17 years. The man has corroborating evidence of this diagnosis from the paediatrician. The available medical evidence indicates he has a long-standing presentation of predominantly behavioural difficulties including some difficulties with task completion, hyperactive behaviour, irritability and associated anxiety. The evidence also outlines a history of appropriate past, present and future treatment details. The case was referred to the HPAU, and although the diagnosis was made more than 2 years ago and the person is now over age 18 years, this condition continues to impact the person so the diagnosis from the paediatrician was still considered relevant.

The HPAU confirmed that the diagnosis requirements were met and the condition was considered fully diagnosed, treated and stabilised. Under Table 5-Mental Health Function an impairment rating of 5 points from the mental health impairment ONLY (avoiding double counting on Table 7) was allocated, due to the mild impact the condition has on his ability to function. Under the 5-point descriptor, the man would meet (1) (c), (d), (e) and (f).

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 all cases where the above applies, the evidence/case history should 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, as assessed under Table 5. People who present with an acquired brain injury or substance use related impairment need to be assessed under the appropriate tables with the diagnosis provided by an appropriately qualified medical practitioner.

This policy is not designed to be used for people who can readily access health services and for whom a clinical psychological or psychiatric assessment has simply not occurred. In these instances, other avenues for obtaining this assessment exist.

Act reference: Social Security (Tables for the Assessment of Work-related Impairment for Disability Support Pension) Determination 2011 Table 5 - Mental Health Function, Table 6 - Functioning relating to Alcohol, Drug, and Other Substance Use, Table 7 - Brain Function

Use of specialist assessments

In very limited circumstances, an external specialist assessment by a clinical psychologist or psychiatrist may need to be considered where a person is unable to access an assessment via other means. Where a specialist assessment occurs, consideration should be given by the clinical psychologist or psychiatrist 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 should be given as to whether the condition is also fully diagnosed, treated and stabilised.

Example: Joe lives in an isolated community and has experienced severe depression with suicidal ideation for a number of years. He has been treated by his GP with medication for several years and has seen a psychologist for cognitive behavioural therapy. The diagnosis has not been made by a psychiatrist or with the assistance of a clinical psychologist. As Joe lives in an isolated community, a specialist assessment was undertaken, which concurred with the GP diagnosis of major depressive disorder. Joe's condition of major depressive disorder was regarded as unlikely to significantly improve with further treatment due to the limited response to prolonged and reasonable treatment undertaken to date. As such, he was found to be fully diagnosed, treated and stabilised.

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.

Determining the level of functional impact - general rules

When determining which impairment rating applies to a person the rating that best describes the person's abilities or difficulties must be applied.

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

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

Table 5 has 6 descriptor points at each impairment level. Where the descriptor refers to 'most of the following', most is taken to be at least 4.

As in the other tables, the descriptors in Table 5 are interlinked in that they follow a consistent incremental hierarchy, which in this Table is expressed, among other things, by the use of terms indicating increasing levels of difficulty in performing certain activities (i.e. no, mild, moderate, severe, or extreme difficulties). Consequently, as is the case in applying any other table, in establishing whether the impairment causes no (0 points), mild (5 points), moderate (10 points), severe (20 points) or extreme (30 points) functional impact, all the descriptors for each impairment rating level in Table 5 should be read as a whole and compared so the descriptors, their relativity and hierarchy in this Table are understood.

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. 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 all the required descriptors for a certain impairment rating level, but does not meet all the required descriptors for the next impairment rating level, the appropriate impairment rating applicable to the person's circumstances will be the lower of those 2 impairment ratings (i.e. the rating at which all the required descriptors are met).

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: It is inappropriate to allocate an impairment rating without applying the descriptors sequentially - 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.

Explanation: Where a person meets the required descriptors for 10 points but does not meet all the required descriptors for 20 points or 30 points, the correct impairment rating is 10 points. Their impairment CANNOT be regarded as severe or extreme and neither 20 nor 30 points can be allocated.

Each descriptor contains examples of mental health impairment for each domain. The examples reflect a person's expected level of severity of impairment at each rating level. If a similar example applies to a person but is not specifically listed in the descriptor, the person must have an equivalent level of severity of impairment in order for the descriptor to be met.

The examples referred to 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 from a set of possible impacts, which indicate 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. It would be inappropriate to apply an impairment rating based solely on a person's self-reported functional capacity if this level of functional impairment is not consistent with the medical evidence available.

A person with a mental health condition may not have sufficient self-awareness of their mental health impairment and may not be able to accurately describe its effects. This should be kept in mind when discussing issues with the person and reading the supporting evidence. If required, interviews with those providing care or support to the person may be considered as corroborating evidence.

It is particularly important in the assessment of people with mental health conditions that a person's presentation on the day of the assessment should not solely be relied upon. In some mental health conditions, the person may have insufficient insight into their condition and minimise its impacts.

For mental health conditions which are episodic in nature and fluctuate in severity over time (e.g. bipolar disorder), the severity, duration and frequency of the episodes or fluctuations must be taken into account when determining the rating that best reflects the person's overall functional ability (see 3.6.3.05 (G) Assessing impairments caused by episodic or fluctuating medical conditions).

In determining the work-related impairment for such fluctuating conditions, consideration should be given to the impact on a person's ability to reliably sustain work over a period of 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 disorder has been fully 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 will improve within 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 fully treated and stabilised and rated 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 stable and permanent for DSP purposes if it is unlikely that any significant improvement will occur within 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 fully treated and stabilised (see 3.6.3.05 (B) Reasonable treatment and compelling reasons for not undertaking it).

0-point impairment rating level

The 0-point descriptor requires that for this impairment rating to be applied, a person has NO functional impact on activities involving a mental health function, i.e. they can carry out 4 or more activities in descriptor (1).

5-point impairment rating level

The 5-point descriptor requires that for this impairment rating to be applied to a person, they must have MILD DIFFICULTY in performing MOST of the functions in descriptors 1(a), (b), (c), (d), (e) and (f).

10-point impairment rating level

The 10-point descriptor requires that for this impairment rating to be assigned to a person, there is a moderate functional impact on activities involving mental health function.

For this rating to be allocated to a person, they must have MODERATE DIFFICULTY in performing MOST of the descriptor points (1) (a), (b), (c), (d), (e) and (f).

20-point impairment rating level

The 20-point descriptor requires that for this impairment rating to be assigned to a person, there is a severe functional impact on activities involving mental health function.

For this rating to be allocated to a person, they must have SEVERE DIFFICULTY in performing MOST of the descriptor points (1) (a), (b), (c), (d), (e) and (f).

30-point impairment rating level

The 30-point descriptor requires that for this impairment rating to be assigned to a person, there is an extreme functional impact on activities involving mental health function.

For this rating to be allocated to a person, they must have EXTREME DIFFICULTY in performing MOST of the descriptor points (1) (a), (b), (c), (d), (e) and (f).

Some conditions causing impairment commonly assessed using Table 5

These include but are not limited to:

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

Example: A 39-year-old woman has a diagnosed condition of bipolar disorder. The condition was diagnosed by a clinical psychologist. She has undergone various treatment options for this condition, under the guidance of her treating psychiatrist. She regularly experiences fluctuations in her condition. Despite these fluctuations, the corroborating evidence provided by the treating psychiatrist indicates that her condition can be considered stabilised, due to the nature of this condition. She experiences periods of mania followed by periods of deep, prolonged and profound depression. Between these episodes, she is often symptom free. On average, she experiences periods of depressed mood every 3 months and is affected for roughly 1 month. Her periods of mania last a few days.

During the assessment for DSP, the woman presented as highly functioning and confident when communicating. However, the medical evidence outlines that she experiences regular periods of depression where she withdraws from social situations and has very limited contact with family or friends. During these times, her mother visits her every day, as she is often unable to take care of her personal hygiene or cook and clean for herself. During these depressive periods, she is unable to drive as she experiences slowed reaction times. When she is experiencing mania symptoms, she has increased energy and over activity and is often unable to sleep. She is unable to sustain a job for a prolonged period due to her mental health condition, as she has frequent fluctuations in her mood.

The condition is considered fully diagnosed, treated and stabilised and under Table 5, this woman would receive an impairment rating of 20 points due to the severe impact this condition has on her ability to function. The rating has taken into consideration the severity, duration and frequency of fluctuating impairments to arrive at a rating that reflects the overall functional impact of those impairments. Under the 20-point descriptor the woman would meet (1) (a), (c), (d) and (f).

Act reference: Social Security (Tables for the Assessment of Work-related Impairment for Disability Support Pension) Determination 2011 Table 5 - Mental Health Function

Policy reference: SS Guide 3.6.1.67 Sustainability of Work & DSP

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.

Not all conditions listed in Diagnostic and Statistical Manual of Mental Disorders (DSM-5) should be rated under Table 5. For example, narcolepsy and dementia are listed in DSM-5 as mental disorders, however, they are better rated under Table 7 - Brain Function.

Last reviewed: 10 May 2021