Measuring social disabilities in mental health

Social functioning is important in relation to mental illness as it can limit the ability to function independently and because it may vary separately from symptoms. This paper summarises and critically reviews the development of the WHO Classification of Impairments, Disabilities and Handicaps. The value of social role theory is described followed by a classification of the relevant assessment scales in this field. Mental disorders are in general strongly associated with social dysfunctioning, particularly in schizophrenia and the major affective disorders. For a long time social dysfunctioning was considered an epiphenomenon and just a part of the disease process. Criteria for the diagnosis of a mental disorder were and still are often derived from the domains of work and social relationships. There are at least two related reasons why social functioning deserves a closer look: 1. There is an increasing trend to treat patients in the community instead of in the hospital: the changing orientation on community care needs careful evaluation with respect to its consequences. To what extent is survival in the community possible and what is the quality of life like there? Are community programs better than hospital treatment, and for whom? Therefore, separate measurement is justified for evaluation of outcome and costs and benefits. 2. There is growing evidence that the courses of symptomatology and social dysfunctioning may vary relatively independently: social disablement of a patient may be characterized much more by social disabilities than by persistent psychiatric symptoms; the former may call for another kind of action than usually available. For example, psychosocial rehabilitation focuses on cognitive and social abilities of the patient which are crucial for a more or less independent life. Therefore, separate measurement is justified for the sake of the right choice of treatment. The usual diagnostic systems such as the ICD and the DSM offer no adequate solution to the problem of classification and assessment of social dysfunctioning as a consequence of mental disorder. We have to look for other classification systems such as the International Classification Impairments, Disabilities and Handicaps (ICIDH) of the WHO (1980, 1993) which offers a conceptual model to study the long-term consequences in terms of functional disabilities and experienced social handicaps, and the effectiveness of health care to handle these kind of problems.