Indian Journal of Social Psychiatry

: 2022  |  Volume : 38  |  Issue : 3  |  Page : 231--236

A comparative study of disability between bipolar affective disorder and schizophrenia using Indian disability evaluation and assessment scale

Kabyashree Borah1, Padmavathi Nagarajan2, Balaji Bharadwaj3,  
1 Department of Psychiatric Nursing, Asian Institute of Nursing Education, Guwahati, Assam, India
2 Department of Psychiatric Nursing, College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Pudhucherry, India
3 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Pudhucherry, India

Correspondence Address:
Dr. Padmavathi Nagarajan
Department of Psychiatric Nursing, College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Pudhucherry


Background: Schizophrenia and bipolar affective disorder (BPAD) have been identified as two severe mental disorders that are associated with a considerable amount of disability. These disorders create significant impairment in many aspects of an individual's life. Objective: This study was undertaken to compare the disability associated with schizophrenia and bipolar affective disorder (BPAD). Materials and Methods: A descriptive cross-sectional study was carried out among patients with a diagnosis of schizophrenia spectrum disorder (F20.0–F20.9) (n = 30) or BPAD (F30.0–F39) (n = 30) as per the International Classification of Diseases-10. The level of disability was assessed by the Indian Disability Evaluation and Assessment Scale. A semi-structured pro forma was used to assess the sociodemographic and clinical parameters. Results: The level of disability was mild in 17 (56.7%) subjects, moderate in 12 (40%) subjects among patients with BPAD. In Schizophrenia, 20 (66.7%) subjects had a mild disability and 10 (33.3%) had a moderate level of disability. The mean global disability score among patients with BPAD was significantly higher than in those with schizophrenia (7.57 + 2.84) versus 6.93 + 2.94, t = 0.846, P = 0.033. Conclusion: The level of disability among individuals diagnosed with BPAD was higher mostly related to self-care and work-related domain disability.

How to cite this article:
Borah K, Nagarajan P, Bharadwaj B. A comparative study of disability between bipolar affective disorder and schizophrenia using Indian disability evaluation and assessment scale.Indian J Soc Psychiatry 2022;38:231-236

How to cite this URL:
Borah K, Nagarajan P, Bharadwaj B. A comparative study of disability between bipolar affective disorder and schizophrenia using Indian disability evaluation and assessment scale. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Dec 5 ];38:231-236
Available from:

Full Text


Disability is an impairment that may be cognitive, developmental, intellectual, mental, physical, and sensory or some combination of these. It limits the performance of an individual related to the roles and tasks that are expected from him/her within a social, cultural, and physical environment such as family, work, recreation, and self-care. Psychiatric disorders cause a considerable amount of disability and create significant impairment in all aspects of one's daily life. In most of people, the disability continues lifelong at different levels that result in a poor quality of life due to the chronic nature of the illness.

According to the International Classification of Impairment, Disability, and Handicap (1980), disability is defined as interference with activities of the whole person with the immediate environment.[1] The current concept of disability has been redefined by the International Classification of Functioning, Disability, and Health (ICF). ICF is the WHO framework for measuring health and disability at both individual and population levels. As the functioning and disability of an individual occur in a context, ICF also includes a list of environmental factors.[2]

Psychiatric disorders account for about 31% of world's disability and these disorders impact negatively on the academic, occupational, social, and familial functioning of the patients.[3] Psychiatric disorders are associated with various patterns of disabilities when compared to that of other chronic physical illnesses. Social and work-related functioning is more likely to be impaired in those with mental illnesses. The stigma and discrimination amalgamated with mental illness were also the reasons for disability among these people.[4]

Indian Disability Evaluation and Assessment Scale (IDEAS) is a well-validated instrument and is being used across the country for disability evaluation in psychiatric disorders. IDEAS is a simple instrument that can be practically used in the clinical area. The government of India has recommended this tool for disability certification in mental disorders through a Gazette notification.[5],[6] Cutoff score of 40% or more are considered for welfare measures and benefits. The gazette version of IDEAS is different from the version proposed by the Rehabilitation Committee of Indian Psychiatric Society (score of 8–13 is moderate disability). According to Government gazette, IDEAS score of 7–13 is moderate disability (40%–70%).

The literature suggests that schizophrenia is the maximally disabling disorder among all other mental disorders.[7],[8] Bipolar disorder affects 2% of the world population.[9] With treatment, approximately 37% of patients relapse into depression or mania within 1 year and 60% within 2 years.[10] Patients also experience psychotic features, impaired functioning, and stigma. BPAD is a major cause of disability around the globe.[9],[10] A chart review by Balhara et al. reported that subjects with schizophrenia and BPAD did not differ significantly on the global IDEAS score and scores on individual items. This finding contradicts to the usual understanding of schizophrenia being a more disabling condition than other major mental disorders like BPAD.[11] Another study conducted in Assam indicated that a significant amount of disability was observed in varying proportions in all disorders such as schizophrenia, BPAD, depression, and dementia.[7] Hence, it can be assumed that all the mental disorders are associated with a considerable amount of disability and is influenced by various illness-related and sociodemographic factors. To gain further insight, the present study aimed to investigate the disability related to mental illnesses such as schizophrenia and BPAD and to identify the differences between these two.

 Materials and Methods

A cross-sectional, comparative study was carried out among adults with a diagnosis of bipolar spectrum disorders (F30–F39) (n = 30) or schizophrenia spectrum disorder (F20.0–F20.9) (n = 30) as per the International Classification of Diseases and related health conditions (ICD-10) (WHO, 1992). Participants were recruited from the outpatient department of Psychiatry unit of a tertiary care hospital, Southern India using convenient sampling technique. This center caters its services to the people from all over Southern India. Special follow-up clinic once a week separately for the patient diagnosed with Bipolar disorder (BPAD) and schizophrenia spectrum disorder.

Sample size calculation

In review of recently issued disability certificates for mental illness, 14 patients with schizophrenia had an average IDEAS score of 14 (mean 13.71), and patients with bipolar disorder had an average IDEAS score of 11 (mean 10.42). The standard deviation was 2.46. With a 95% confidence interval and 95% power to detect a significant difference, it was estimated to include 26 patients in each group. Hence, 30 patients in each group were recruited in the study. Since we wanted to compare the two disorders, in particular, we calculated the sample size based on the IDEAS scores from our own institution.

Ethical approval was obtained from the Institute Ethical Committee for human studies (JIP/IEC/2018/059). Patients aged 18 years and above, both sex, diagnosed with BPAD or schizophrenia according to ICD 10 criteria were included in the study after signing a written informed consent from the patients and the caregivers. Privacy was maintained during data collection, and confidentiality was ensured throughout the study period. Participants were assured the freedom to withdraw at any time during the study period without assigning any reason to do so and without affecting the treatment they are receiving from the institute. Diagnoses in all cases, was ascertained by a qualified psychiatrist and verified from the case record as well as from the primary caregiver. Those patients having organic etiology of mental disorder and having an intellectual disability were excluded from the study.

Socio-demographic data were assessed through a predesigned proforma. Clinical profiles that were assessed in the study include age at onset of illness, duration of illness (DOI), duration of treatment, and number of hospitalization.

The level of disability was assessed by the IDEAS that was developed by the Rehabilitation Committee of the Indian Psychiatric Society in 2002.[12] The disability is being assessed under four domains: Self-care, interpersonal activities, communication and understanding, and work. Each domain is scored as follows: 0 = No disability, 1 = Mild disability, 2 = Moderate disability, 3 = Severe disability and 4 = Profound disability. The score of each domain is added to get the total disability score. The total disability score ranges from 0 to 20.

Weightage for the DOI is calculated as: <2 years: score to be added is 1; 2–5 years: add 2; 6–10 years: add 3; >10 years: add 4.

The Global Disability Score (range 1–20) is calculated as the total disability score + DOI score. Global disability score with the corresponding level of disability category and percentage of disability as suggested by the guidelines are given below:

A score of 0 (No Disability) = 0%; 1–7 (Mild disability) = <40%; 8–13 (Moderate disability) = 40%–70%; 14–19 (Severe disability) = 71%–99% and a score 20 indicates Profound Disability = 100%.

The tool used in this study has been used in many previous studies conducted in India.[13],[14] The alpha value for the scale is 0.8682, indicating good internal consistency between the items.


The comparison of demographic profile of patients with bipolar affective disorder (BPAD) and Schizophrenia is shown in [Table 1].{Table 1}

The comparison of the clinical profile of the participants is illustrated in [Table 2]. The age at onset of illness, the duration of the illness, and the number of hospitalization were found to be statistically different between the two groups (P < 0.05). Among BPAD group, 4 (13.4%) patients were in the depressive phase, 11 (36.7%) were in the manic phase and 15 (50%) were in mixed-phase.{Table 2}

The level of global disability among patients with BPAD indicated that 17 (56.7%) participants had mild disability, 12 (40%) had moderate disability and only one (3.3%) had severe disability. The mean global disability score was 7.57 + 2.84. Comparatively, it was found that 20 (66.7%) participants had a mild disability, and 10 (33.3%) participants had a moderate level of disability among patients with schizophrenia. The mean global disability score was 6.93 + 2.94.

The domain-wise comparison of the level of disability among patients with bipolar affective disorder and schizophrenia is summarized in [Table 3]. The disability associated with self-care was slightly higher among patients with BPAD (1.84 ± 0.973) when compared to schizophrenia (1.40 ± 0.621, P < 0.05). Similarly, the disability related to communication and understanding domain revealed that patients with BPAD had a slightly higher level (1.47 ± 0.819) of disability than patients with schizophrenia (1.37 ± 0.850). Furthermore, the global disability score was significantly more (7.57 ± 2.84) among patients with BPAD than schizophrenia (6.93 ± 2.94).{Table 3}

Further, the results of the study found that a couple of sociodemographic variables such as the educational status and number of days absent from work had a statistically significant association (P < 0.05) with the level of disability among patients with BPAD; the association between the levels of disability among these patients with their selected clinical variables is presented in [Table 4]. The disability was not found to be significantly associated with any of the clinical variables that were assessed in the present study among these patients.{Table 4}

In addition, the association between the levels of disability among patients with schizophrenia with their selected clinical variables is presented in [Table 5]. It was found that the duration of treatment had an association with the level of disability and it was statistically significant (P < 0.05); whereas, the disability was not associated with the demographic variables that were assessed in the present study among these patients.{Table 5}


The present study has assessed a set of patients who are seeking treatment and not patients who have been given disability benefits. There has been sparse literature in this regard. Various researchers had used IDEAS for disability certification among patients with schizophrenia and BPAD.[15]

In a community-based study in rural Karnataka, the prevalence of mental disability was found to be 2.3% and the study also observed that the prevalence was more among females.[16] Similarly, a study conducted in China also demonstrated that rural women had more disability due to schizophrenia.[17] The limited access to health-care facilities in rural area might have contributed for this.

Our findings suggested that male subjects had higher disability than females. This finding is supported by Balhara et al.[11] The authors further stated that work-related disability was relatively higher among males. Our study findings indicated that the scores for work-related disability were higher in both disorders than the other three domains. Determining work disability related to mental disorders is challenging. Part of the difficulty is related to trying to understand the relationship between symptoms and work ability for people experiencing these disorders.

Sahoo et al. stated that patients with schizophrenia had a higher level of disability in the work domain in their study that assessed the global and socio-occupational functioning of patients with residual schizophrenia. The authors also insisted to improve the rehabilitation facilities and to create patient-friendly job opportunities for these patients.[18] Further, a recent study from Karnataka by Philip et al. revealed that severe disability was noted in the areas of social participation and interpersonal relationship among patients with schizophrenia.[19]

The results of the study revealed that the level of global disability among patients with bipolar affective disorder was slightly higher than patients with schizophrenia. In contrast, many other studies found that patients with schizophrenia had significantly higher disability than patients with BPAD.[20],[21],[22] However, a previous study from Malaysia[23] concluded that there was no significant difference in the severity of disability between schizophrenia and chronic mood disorders.[23]

It is known that disability due to schizophrenia plateaus by 5 years.[24] Our findings revealed that patients with schizophrenia who had their DOI for more than 5 years and also when the duration of treatment exceeded more than 5 years had more disability that was statistically significant. Even though the similar findings were seen among patients with BPAD, it did not approach statistical significance. Similar findings were reported by other studies also.[4],[25]

 Limitations of the study

Nonprobability sampling technique, absence of follow-up on identifying work-related disability and utilization pattern of disability certificate. There was no matching of two samples for gender, age, and total DOI as these are likely to influence disability scores. Large samples matched for these will help us unravel different domains of disability domains influenced by specific disorders and reasons behind it.


The level of disability among individuals diagnosed with BPAD was significantly higher than those diagnosed with schizophrenia, especially in self-care and work-related domains. Appropriate strategies are needed to reduce the disability along with pharmacological and other treatment modalities. Rehabilitation measures should focus on employment opportunities and other welfare benefits for those individuals who are eligible for disability certification. Awareness should be created among mental health professionals, general public, and policymakers regarding disability benefits for people with mental illness.


The authors would like to thank and acknowledge Dr. Shivanand Kattimani, Additional Professor, Department of Psychiatry, JIPMER, Puducherry, for his valuable suggestions and significant contributions towards the study

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1World Health Organization. International Classification of Impairment, Disability and Handicap (ICIDH). Geneva: World Health Organization; 1980.
2Stucki G. International classification of functioning, disability, and health (ICF): A promising framework and classification for rehabilitation medicine. Am J Phys Med Rehabil 2005;84:733-40.
3Adegbaju DA, Olagunju AT, Uwakwe R. A comparative analysis of disability in individuals with bipolar affective disorder and schizophrenia in a sub-Saharan African mental health hospital: Towards evidence-guided rehabilitation intervention. Soc Psychiatry Psychiatr Epidemiol 2013;48:1405-15.
4Górna K, Jaracz K, Jaracz J, Kiejda J, Grabowska-Fudala B, Rybakowski J. Social functioning and quality of life in schizophrenia patients-relationship with symptomatic remission and duration of illness. Psychiatr Pol 2014;48:277-88.
5Indian Disability Evaluation and Assessment Scale. Guidelines for Evaluation and Assessment of Mental Illness and Procedure for Certification. Part 1I, Sec. 3 (ii). New Delhi: Published in the Gazette of India (Extraordinary); 5th January 2018. Appendix IV, 112-5. Available from: Guidelines for assessment of various Disabilities under RPwD Act; 2016. [Last accessed on 2020 Jul 24].
6Rights of Persons with Disability Act; 2016. Available from: [Last accessed on 2020 Jun 20].
7Chaudhury KP, Deka K, Chetia D. Disability associated with mental disorders. Indian J Psychiatry 2017;48:95-101.
8Solanki RK, Singh P, Midha A, Chugh K, Swami MK. Disability and quality of life in schizophrenia and obsessive compulsive disorder: A cross-sectional comparative study. East Asian Arch Psychiatry 2010;20:7-13.
9Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry 2011;68:241-51.
10Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. Lancet 2013;381:1672-82.
11Balhara YP, Gauba D, Deshpande SN. Profile difference between male and female psychiatric patients seeking certificate of disability. Oman Med J 2011;26:410-5.
12Abraham KM, Miller CJ, Birgenheir DG, Lai Z, Kilbourne AM. Self-efficacy and quality of life among people with bipolar disorder. J Nerv Ment Dis 2014;202:583-8.
13Bondade S, Sudarshan CY, Begum S. Assessment of disability in bipolar affective disorder and alcohol use disorder – A descriptive study. SL J Psychiatry 2015;6:25-9.
14Swapna B. Burden on Caregivers and Disability in Patients Having Bipolar Affective Disorder and Alcohol Dependence. RGUHS Digital Repository; 2008.
15Balhara YP, Verma R, Deshpande SN. A study of profile of disability certificate seeking patients with schizophrenia over a 5 year period. Indian J Psychol Med 2013;35:127-34.
16Kumar SG, Das A, Bhandary PV, Soans SJ, Harsha Kumar HN, Kotian MS. Prevalence and pattern of mental disability using Indian disability evaluation assessment scale in a rural community of Karnataka. Indian J Psychiatry 2008;50:21-3.
17Liu T, Zhang L, Pang L, Li N, Chen G, Zheng X. Schizophrenia-related disability in China: Prevalence, gender, and geographic location. Psychiatr Serv 2015;66:249-57.
18Sahoo S, Grover S, Dua D, Chakrabarti S, Avasthi A. Concurrent validity of Indian Disability Evaluation and Assessment Scale with sociooccupational functioning scale in patients with schizophrenia. Indian J Psychiatry 2017;59:106-10.
19Philip BV, Cherian AV, Shankar RG, Rajaram P. Severity of disability in persons with schizophrenia and its sociodemographic and illness correlates. Indian J Soc Psychiatry 2020;36:80-6.
20Government of India, Ministry of Social Justice & Empowerment, Simplification and Streamlining the Procedure for Issue of Disability Certificates to the Persons with Disabilities; 2011. Available from: [Last accessed on 2019 Dec 12].
21Shihabuddeen TM, Chandran M, Moosabba. Disability in persons with Schizophrenia correlated to family burden and family distress among their caregivers. Delhi Psychiatry J 2012;15:332-6.
22Sylvia LG, Montana RE, Deckersbach T, Thase ME, Tohen M, Reilly-Harrington N, et al. Poor quality of life and functioning in bipolar disorder. Int J Bipolar Disord 2017;5:10.
23Rahman MB, Indran SK. Disability in schizophrenia and mood disorders in a developing country. Soc Psychiatry Psychiatr Epidemiol 1997;32:387-90.
24Thara R, Rajkumar S. Nature and course of disability in schizophrenia. Indian J Psychiatry 1993;35:33-5.
25Sadath A, Kumari S, Mathew S. Mental disorder and disability: A Cross-sectional study of disability variance in severe mental disorders. Indian J Soc Psychiatry 2018;34:51-6.