By popular demand, here is the Guide to the evaluation of psychiatric impairment for clinicians (G.E.P.I.C) used today to assess permanent primary and/or secondary psychiatric/psychological conditions suffered as a result from or as a consequence of a workplace injury, by insurance doctors and medical panels.
This extremely important Guide was published in the Victoria Government Gazette on 8 May 2008 (G19) but is very difficult to locate on line as it is no longer published on the Victoria Gazette’s website and very few injured workers know about the existence of this vital document!
THE GUIDE TO THE EVALUATION OF PSYCHIATRIC IMPAIRMENT FOR CLINICIANS (G.E.P.I.C.)
Prepared by M.W.N. Epstein, G. Mendelson, N.H.M. Strauss, Revised December 2005 For citation:
Epstein M.W.N., Mendelson G., Strauss N.H.M. The Guide to the Evaluation of Psychiatric Impairment for Clinicians. Melbourne: The Authors, 2005.
Link to document (Pages 40 -)
The Guide to the Evaluation of Psychiatric Impairment for Clinicians (GEPIC) is a revision of the Clinical Guidelines to the Rating of Psychiatric Impairment (Clinical Guidelines), which has been in use for seven years. In general the Clinical Guidelines has performed very well but some concerns have emerged that this revision intends to correct.
The name has been changed to distinguish the new edition from its predecessor, and to provide a convenient acronym. The basic aim of the Clinical Guidelines remains, being to improve the inter-rater reliability of psychiatric impairment assessments.
It has been made explicit that the descriptors associated with each class for a particular mental function are intended to be indicative examples of the type of symptoms one could expect to see in that class range. The list of descriptors is not intended to be all-encompassing, as the Guide is designed to be used only by qualified psychiatrists who have completed the prescribed training course. To provide an exhaustive list of descriptors would be an impossible and ultimately unnecessary task. Furthermore, such a document would be so voluminous as to be practically useless as a handy guide for the clinician, and would amount to a textbook of psychiatry.
There has been some re-wording of the definitions of some mental functions, and some descriptors have been added to provide a more comprehensive range of examples for each class. The changes implemented in this revision are designed to further improve the inter-rater reliability of the GEPIC.
The Clinical Guidelines were developed from the User’s Manual to the second edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, which was prepared by the authors with the assistance of other members of the Psychiatric section of the Victorian WorkCover Medical Panel in 1994.
There had been considerable concern about the lack of reliability of impairment assessment by psychiatrists using the second edition of the AMA Guides. The User’s Manual was an attempt to provide definitions of the terms which were used in the second edition, with an explanation of the various changes that would be observed with increasing levels of impairment. In addition, the User’s Manual developed a method, now known as the ‘median method’, to determine whole person impairment.
The User’s Manual had no official status but was widely used for assessment of psychiatric impairment. The User’s Manual had considerable impact in improving the inter-rater reliability of assessments.
The changeover in various legal jurisdictions from the second to the fourth edition of the AMA Guides proved to be a particular concern with regard to psychiatry. Chapter 14 of the fourth edition of the AMA Guides provides a classification which is impossible to quantify, and it fails to provide any method of maintaining reliability of assessments.
It was with these concerns in mind that the authors of the User’s Manual further refined and developed the Clinical Guidelines to the Rating of Psychiatric Impairment, with the assistance of other members of the Psychiatric Medical Panel.
The GEPIC maintains the principles found in both the User’s Manual and the Clinical Guidelines. The six terms which had originally been used to assess mental function, that is, Intelligence, Thinking, Perception, Judgement, Affect, and Behaviour, have remained substantially the same. (The Clinical Guidelines replaced ‘Affect’, which was technically an inaccurate term, with the word ‘Mood’.)
The final two items in the Table which was adapted from the second edition of the AMA Guides, that is, ‘Ability’ (in terms of ‘Activities of Daily Living’) and ‘Potential’ (in terms of ‘Rehabilitation or Treatment Potential’) were removed in the Clinical Guidelines, as it was considered that they do not reflect impairment. (‘Ability’ is a measure of disability rather than impairment, and ‘potential’ involves a prediction of the future, which is problematical at best, and not a measure of current psychiatric impairment.)
The table in the Clinical Guidelines included a footnote: In evaluating the ‘whole person psychiatric impairment’, intermediate values may be used that are not included in the individual classes.
This footnote has been removed from the GEPIC as it undermined the intention of the authors to force assessors to make clear choices in determining both individual classes and whole person psychiatric impairment.
As with the Clinical Guidelines, the GEPIC must be considered in the context of the fourth edition of the AMA Guides, and any explanatory or other information provided in that edition of the AMA Guides is applicable to the Clinical Guidelines and to the GEPIC.
Psychiatric Impairment Evaluation
The assessment of psychiatric impairment is based on the systematic application of empirical criteria, and takes into consideration both the diagnosis and other factors unique to the individual. It is also relevant to consider motivation, and to review the history of the illness, as well as the treatment and rehabilitation methods. These considerations can be summarised in the following five principles:
In assessing the impairment that results from any mental or physical disorder, readily observable empirical criteria must be applied accurately. The mental state examination, as used by consultant psychiatrists, is the prime method of evaluating psychiatric impairment.
Diagnosis is among the factors to be considered in assessing the severity and possible duration of the impairment, but is by no means the sole criterion.
The evaluation of psychiatric impairment requires that consideration be also given to a number of other factors including, but not limited to, level of functioning, educational, financial, social and family situation.
The underlying character and value system of the individual is of considerable importance in the outcome of the disorder, be it mental or physical. Motivation for improvement is a key factor in the outcome.
A careful review must be made of the treatment and rehabilitation methods that have been applied or are being used. No final judgement can be made until the whole history of the illness, the treatment, the rehabilitation phase, and the individual’s current mental and physical status and behaviour have been considered.
Use of the Guide
The presence and extent of impairment is a medical issue, and is assessed by medical means. This Guide has been designed for use by medical practitioners; in evaluating psychiatric impairment in accordance with this Guide clinical information has to be obtained and assessed, together with an examination of the individual’s mental state.
The evaluation of psychiatric impairment in accordance with the Guide is meant to be informed by clinical judgement, based on appropriate training and experience, and the specific rating criteria are not meant to be used in a ‘cookbook’ fashion.
The descriptors associated with particular classes for each mental function are intended to be indicative only. They are intended to provide an overview of the type and severity of symptoms expected for each particular class. It would be futile to attempt to list all relevant symptoms and would be onerous for the assessor. The absence of a particular symptom in the list of descriptors does not mean that that symptom is to be disregarded. The assessor may be required to justify why that/those symptom(s) is/are associated with a particular class of severity.
It is ultimately for the clinician, and no one else, to make the clinical judgement whether a specific rating criterion is present. If the clinician doubts that a particular symptom or abnormality of mental function is present, even after hearing the patient describe it, the item should be rated as not present. This convention is advocated in the Structured Clinical Interview for DSM-IV Axis I Disorders, and it is important to emphasise that the evaluation of psychiatric impairment, like diagnosis, is based on ‘ratings of criterion items, not of answers to questions’.
The method described in this Guide involves the assessment of the severity of six specific mental functions (listed in the picture above) into five classes of increasing severity. The different classes are combined to produce a total psychiatric impairment. Use is made of a modified form of the table that was in the second edition of the AMA Guides.
How did these new Psychiatric Guides come about?
*Epstein, Michael. 2009. ‘Submission to Comcare, Policy Review of Comcare’s Permanent Impairment Guide.’ www.comcare.gov.au/__data/assets/…/Dr_Epstein_PI_Submission.doc.
Epstein, Michael, George Meldelson, and Nigel Strauss. 2005. ‘The Guide to the Evaluation of Psychiatric Impairment for Clinicians’. Melbourne.
According to Epstein (who developed these Guides), The American Medical Association Guides to the Evaluation of Permanent Impairment4th Edition (currently used in Victoria)(as well the 5th edition) are “useless” when it comes to dealing with mental and behavioural impairment. The 2nd Edition had a system that used the basic building blocks of any psychiatric examination, the mental state examination. That method was just workable and with considerable development, an amended version and its successors have been in use in Victoria since 1985. This method has been workable, equitable and without controversy. However that process was abandoned starting with the 3rd Edition This and the next 2 Editions have a system that is unusable. Because of this, every jurisdiction which uses the AMA Guides has been forced to develop some modification. This has led to a veritable Tower of Babel in terms of methods of assessing psychiatric impairment.
It is important to differentiate between impairment and disability. Impairment is the reduction or loss of a physical/mental function and is a matter for determination by clinicians.
By contrast disability is the reduction in ability arising from an impairment and is a matter for the courts. These definitions have been developed by the World health Organization.
The classical example of the difference is amputation of a little finger. This is a 5% whole person impairment according to the AMA Guides but may lead to 100% disability for a concert pianist and 0% disability for a construction worker.
Why Measure Psychiatric Impairment?
All statutory schemes that provide benefits for claimants such as workers’ compensation schemes, transport accident schemes, personal injury schemes, pension and superannuation schemes require some method of measurement of impairment of health. Impairment measurements are used in two ways.
1. To provide a threshold so that claimants with impairments that lie below the threshold cannot proceed.
2. To provide a level of whole person impairment using a percentage to determine the level of benefits provided.
Various legislatures that implement and control these schemes have shown considerable uncertainty and ambivalence about dealing with psychiatric injury. This concern arises from a number of sources. There is some prejudice against the people experiencing a psychiatric injury, at times with disbelief that such injuries occur. There are also concerns that since psychiatric injury is regarded as subjective it is capable of being misused by fraudulent claims, so-called gaming.
Most jurisdictions have developed methods of limiting claims for psychiatric injury. Some jurisdictions simply exclude psychiatric injury from benefits. Other schemes require claimants with a psychiatric injury to meet a higher level of threshold of impairment before they can access the scheme. The third method, used extensively in Australia, is to reject claims for psychiatric injury which are
secondary to physical injury, for example depression arising from a chronic back injury. Successful claimants have to demonstrate that they have an injury arising from the incident itself, such as a post traumatic stress disorder. In a number of jurisdictions in Australia the latter two methods are combined.
A reliable means of measuring psychiatric percentage impairment is critical for courts, tribunals, and claimants.
Requirements of Any Method of Psychiatric Impairment Measurement
- It should measure impairment and not disability. In some methods, which we will see later, disability is used as a surrogate for impairment, this is inappropriate. All psychiatrists are familiar with assessing a person’s mental status. This should be the core of any system of psychiatric impairment.
- It should be easily and rapidly administered using data arising from the clinical interview. This is preferable to a checklist which is susceptible to cheating by claimants.
- It should be able to produce a percentage figure which is reliable. The term reliable in this context means that different examiners, seeing the same claimant, come to a similar identical figure for percentage impairment.
- It should be transparent and readily understood by courts and tribunals and the figures emerging from such a method should make sense. If a method consistently provides claimants who are functioning normally with an impairment of 60%, it would not be credible.
Problems Measuring Psychiatric Impairment
The fundamental problem with measuring psychiatric impairment is that there is no “gold standard”. There is no objective measure such as in physical science. There is a means of accurately determining the length of a metre which is reproducible and is the standard throughout the world. Such a situation cannot apply in psychiatry.
Despite the requirement that any method should only measure impairment and leave disability for the courts and tribunals there is inevitably a blurring between impairment and disability, this is difficult to avoid. Inevitably psychiatrists rely on behaviour to inform their opinion. Behaviour is a manifestation of disability. Furthermore any method relies, to a large degree, on self reporting. This causes problems for people who are deliberately misleading the examiner or who, for a variety of reasons, are unable to provide an accurate account of their situation.
Furthermore there is a fundamental absurdity in collapsing a complex pattern of behaviour into a single number. This is inescapable and is a basic problem with psychiatric impairment.
There are also special problems in psychiatric impairment assessment when dealing with the overlap between psychiatric injury and neurological injury and with assessing pain disorders and psychiatric injury.
Methods of Psychiatric Impairment
There are two basic methods of measuring psychiatric impairment.
Method 1 is to assess specific functions and combine these assessments to determine whole person psychiatric impairment. This is the method used in the American Medical Association Guides.
The second method is to group combinations of symptoms assumed to be present at specific levels of impairment. This is the method used by the the ComCare Guides – Chapter 5 and the Diagnostic and Statistical Manual of the American Psychiatric Association 4th Edition Global Assessment of Functioning Scale (GAF).
Fundamental Problems with Chapter 14 of the AMA Guides (Both 4th and 5th Edition)
The method of impairment assessment described in chapter 14 is summarised by a table. The table assesses 4 areas of functioning including activities of daily living, social functioning, concentration, and adaptation. The impairment for each area lies within one of five classes, ranging from class one, no impairment to class five, extreme impairment. There is a generalised account of what each of these areas involve but no specific descriptors relevant to each class.
There are two basic problems with this table.
- Three of the four areas are measures of disability, not impairment. The only measure of impairment is concentration. This is a fundamental problem.
- From an operational point of view there is no method for combining the overall classes. Guide users have no guidance on how to combine the classes.
- Quite deliberately, the authors have rejected providing percentage impairments.
There are five reasons given for this lack of percentages
- There are no precise measures of impairment in mental disorders.
- The use of percentages implies a certainty that does not exist.
- Percentages are likely to be used inflexibly by adjudicators.
- No data exists that shows the reliability of the impairment percentages.
- It would be difficult for Guides users to defend their use in administrative hearings.
This is not seen to be a problem in other parts of the Guides. The chapter on Pain has a means of producing a score with regard to pain and a percentage increment to be added to a physical impairment for pain. The chapter on musculoskeletal systems provide a system of measuring impairment due to pain.
Arguably, pain is even more elusive than psychiatric injury as it is a totally subjective perception. All these concerns still exist and should have been regarded by the authors as a challenge and not as an excuse for their lack of nerve.
Consequences of the Inadequacy of Chapter 14 – the Australian Experience
Most jurisdictions in Australia have recognized that chapter 14 is unusable. This has led to each jurisdiction in Australia developing its own method of determining psychiatric impairment. There are not only differences between the states and the federal jurisdictions but there are also differences within states for determining psychiatric impairment depending whether a person has a workers compensation claim, a transport accident claim or some other claim.
Differing Methods for Measuring Psychiatric Impairment in Australia (see appendix)
Victoria began using the AMA Guides 2nd edition in 1985, a decade or more before other states. At that time chapter 12, Mental and Behavioural Disorders, did provide for measuring mental status and percentages. Subsequently there have been further amendments to this original method and Victoria now uses the Guide to the Evaluation of Psychiatric Impairment for Clinicians (the GEPIC) which has five different classes of impairment with appropriate descriptors for each of the mental functions assessed and a method of combining these to produce a final percentage impairment. Many thousands of impairment assessments have been done. There have been few concerns about reliability or equity and little controversy.
Most other states who began doing impairment assessment after the publication of the 4th Edition have attempted to use chapter 14 but with significant amendments. These amendments include descriptors of differing levels of impairment for the four areas assessed with appropriate percentages and a means of combining these. The Psychiatric Impairment Rating Scale (the PIRS) developed in New South Wales is one such instance.
Since the PIRS is derived from chapter 14 it measures disability not impairment. It appears to have been specifically designed to meet legislative thresholds and the requirement is that impairment must be attributable to recognized psychiatric conditions. It has subsequently been modified for use in the New South Wales workers compensation system with the addition of more descriptors, the use of employability as part of adaptation and a different method of combining classes. Tasmania also uses the PIRS but ironically, does not provide a percentage rating. Queensland uses the PIRS for assessing psychiatric injury for personal injury claims.
The Northern Territory uses chapter 14 without modification.
In the Commonwealth jurisdictions and some state jurisdictions the methods used have no relationship with the AMA Guides.
Fundamental Criticisms of Chapter 14 of the AMA Guides 4th and 5th Editions
The authors of chapter 14 in the 4th and 5th editions have failed to meet the basic requirements of any system of psychiatric impairment. There is no systematic method to measure impairment. The chapter does not restrict measurement to impairment arising from psychiatric injury. For example, problems with adaptation may relate to a neurological disorder or dementia and not to a psychiatric injury.
The method does not enable a percentage figure to be determined and the method has no inherent reliability. The method is not defensible in court and tribunal settings.
The AMA Guides Sixth Edition
The latest edition is the 6th Edition of the AMA Guides.
This edition appears to have a significant difference in focus. The stated aim in every previous edition was:to provide a response to a public need for a standardized approach to evaluating medical impairments.
On page 20 of this edition is stated:
The primary purpose of the Guides is to rate impairment to assist adjudicators and others in determining the financial compensation to be awarded to individuals who, as a result of injury or illness, have suffered measurable physical and/or psychological loss.
I have already complained at length about the failure of nerve of the authors of chapter 14 – Mental and Behavioural Disorders of the 4th and 5th Editions. Regrettably, the authors of this chapter in the 6th Edition, have reinforced this impression of timidity. In the two previous editions the authors refused to give any percentages for the reasons described above, this made chapter 14 unusable. In an effort to redress the situation the authors of chapter 14 in the 6th Edition have gone in the opposite direction and have used not one but three different methods, each of which has major flaws but the end result is that there is a percentage impairment established. This is an improvement, but at what a cost!
Ironically, in the first part of the chapter assessors are required to do a mental status examination. As described above, the mental status examination is the basis for the table in the 2nd Edition of the AMA Guides. However findings from the mental state examination then play little part in the method discussed in the 6th Edition.
A Brief Summary of the Methods Described in Chapter 14
The process involves using three scales.
- Brief Psychiatric Rating Scale
- Global Assessment of Functioning Scale
- Psychiatric Impairment Rating Scale
Brief Psychiatric Rating Scale (BPRS) adapted from a recent article
Appropriate for: Patients with major psychiatric disorders, particularly schizophrenia
Administered by: Psychiatrists, psychologists or other trained rater
Time to complete: 15-30 minutes
This version of the BPRS is a 24-item scale measuring positive symptoms, general psychopathology and affective symptoms. Some items (eg mannersisms and posturing) can be rated simply on observation of the patient; other items (eg anxiety) involve an element of self-reporting by the patient.
When rating BPRS, it is important to allow unstructured sections in the clinical interview such that conceptual disorganisation in the patient’s thought and speech and unusual thought content can be observed.
Each item is rated on a seven-point scale (1=not present to 7=extremely severe)
- Well established – among the most researched instruments used in psychiatry
- Well known – clinicians tend to be familiar with symptom scores and changes
- Sensitive to change – may be used to rate treatment response
- Broad evaluation – allows rating of severity of a number of different symptoms
- Used in many classic studies of new antipsychotics
- Psychometric properties and underlying factor structure is well-established
- Grouping on item scores allow scoring on distinct factors (tension; emotional withdrawal; mannerisms and posturing; motor retardation; uncooperativeness)
- Limited in scope – focus on positive and general psychopathology. Does not focus on negative symptoms. Needs to be utilised in combination with a negative symptom assessment tool, if negative symptomatology is to be captured
- Ambiguous interpretation – there are several ways symptoms are reported (eg. on a scale of 0 to 6 or a scale of 1 to 7); the dual reporting scale must be taken into consideration when interpreting scores
- Use of 1-7 scale – the non-linearity into the scale can complicate interpretation changes over time, particular with regards to response rates.
- The BPRS contains a mixture of symptoms and behaviours in addition to some considerations of “abnormal mental functioning” but where these are present they are reiterative. The 24 items of the BPRS contain multiple aspects of mood/affect impairment but nothing about formal thought disorder or impairment of judgement – surely fundamental aspects of mental functioning.
Furthermore the BPRS has been tweaked beyond its limits. The authors of chapter 14 have added a percentage impairment score derived from who knows where. This is certainly not the product of research and is an innovation by the authors. The maximum score is only 50%, this for someone who is so impaired as to be grossly dysfunctional requiring institutional care!
The Global Assessment of Functioning Scale
The Global Assessment of Functioning (GAF) is a numeric scale (0 through 100) used by mental health clinicians and physicians to subjectively rate the social, occupational and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living. The scale is presented and described in the Diagnostic and Statistical Manual of the American Psychiatric Association 4th Edition revised (DSM-IV-TR) on page 32.
91-100 Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many qualities. No symptoms.
81-90 Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns.
71-80 If symptoms are present they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning.
61-70 Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.
51-60 Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning.
41-50 Serious symptoms OR any serious impairment in social, occupational, or school functioning.
31-40 Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.
21-30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas.
11-20 Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication.
1-10 Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death.
0 Not enough information available to provide GAF.
The GAF is a measure of disability. It is intended to measure how well or adaptively one is meeting various problems-in-living. The descriptors are very limited. The authors of chapter 14 have added a so-called GAF Impairment Score which is a means of relating the numbers on the left to a percentage score, a totally subjective exercise. For example a score of between 31-40 which seems to indicate very significant problems is scored at 20% impairment. A person who scores between 1-10 is regarded as having only a 50% impairment. The description provided, brief as it is, seems to indicate a person who is very severely disabled.
The authors of chapter 14 state that
The Global Assessment of Functioning Scale has been widely used and accepted but has a significant limitation arising from combining level of functioning and symptom severity into one scale. This may lead to a score indicating a high level of impairment for a well functioning person with a single severe symptom. Alternatively, a person may have a life-threatening mental illness and yet may not rate highly on this scale. It is the intention of the authors of this chapter to remedy this problems by using the GAF with the other two scales
The authors have not mentioned the problems they have caused by the imposition of their percentage table.
The Psychiatric Impairment Rating Scale
As described above the PIRS is also a measure of disability, the scale relies on self reporting and is vulnerable to gaming. This form of the PIRS involves scoring using six different tables.
- self-care, personal hygiene and activities of daily living
- role functioning, social and recreational activities
- interpersonal relationships
- concentration, persistence and pace
- resilience and employability
The table regarding concentration, persistence and pace measures impairment, the others are to do with disability. Each of these is scored from 1 to 5. The scores are arranged in order and the middle two scores are added together. Using a separate table this sum correlates to a specific percentage score.
The percentage scores derived from the BPRS, the GAF and the PIRS are then sorted from low to high, the middle number of the 3 numbers is the final percentage score.
Commentary on Chapter 14
There are significant problems with this method. Not least is the time involved. It is estimated that the BPRS takes between 15-30 minutes, the PIRS involves scoring using six different tables and would probably take a similar period of time. The GAF should derived from the content of the clinical interview and would take it most five minutes. Nevertheless using this method involves a time expenditure of at least 30 minutes and probably longer.
Despite the major drawbacks described above is chapter 14 in the sixth edition an improvement?
One is bemused by the changes from the fourth and fifth edition now seen in the sixth edition. The authors have gone from the sublime to the ridiculous. They have gone from having no method of determining percentages to 3 methods of determining percentages with major questions about whether they are measuring impairment or disability and with real concerns about the means by which they have related particular percentages to particular levels in each of the measures. Despite the obvious advantage in having one AMA guide that can be used by all disciplines nevertheless I cannot endorse this hopeless pastiche.
My own view is that the methods currently used in Australia, chaotic as they are, are better than this.
The method involved is extremely time-consuming, the method involved is appropriate for severe psychiatric illness with regard to the BPRS and the GAF but is not appropriate for most of the psychiatric injuries seen in workers compensation claims.
The GAF and the PIRS are essentially measures of disability and not impairment.
Whatever the reliability of the BPRS and the GAF this reliability has been circumvented by the imposition of arbitrary percentage tables.
Is there a Way Ahead?
The short answer is not yet. The current situation may be confusing, the current chapter, Chapter 5 is very vague and limited in its scope, but the alternatives are worse and less equitable. In Victoria we wish the authors had further developed the method used in the 2nd Edition.
- The American Medical Association Guides to the Evaluation of Permanent Impairment have provided an effective and efficient means of measuring impairment for all organ systems except for Mental and Behavioural Disorders.
- The authors of chapter 14 on Mental and Behavioural Disorders in both the 4th and 5th editions have chosen to measure disability rather than impairment and failed to provide percentages related to different levels of impairment.
- The lack of percentage impairment disadvantages users, claimants, courts, and tribunals.
- This failure has led to every jurisdiction in Australia developing different methods of measuring psychiatric impairment, leading to a veritable Tower of Babel.
- All jurisdictions fear that claims for psychiatric injury will overwhelm the funding of any statutory scheme.
- The consequences of the failure of the authors to do their job has reduced the credibility of psychiatric impairment assessments and has the potential to lead to the exclusion of psychiatric injury from statutory schemes.
- Chapter 14, Mental and Behavioural Disorders in the AMA Guides 6th edition has used a modified form of the PIRS together with two other scales to produce a clumsy, inequitable and in my view unworkable system for determining percentages for different levels of psychiatric impairment and should not be used in any Comcare Guide.
- Any guide for assessing psychiatric impairment should be assessing symptoms arising from a mental health disorder or mental illness in a stepwise fashion according to level of severity.
- Any worthwhile guide to the assessment of psychiatric impairment should not be driven by the need to fit into any specific legislative framework.
- The current chapter in the Comcare Guides, Chapter 5 – Psychiatric Conditions is very vague and limited in its scope, but the alternatives are worse and less equitable.
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