ICD-11 Revision of Mental Disorders: the Global Standard for Health Data, Clinical Documentation, and Statistical Aggregation
Vujnovic M., Manukhina O., Reed G., Theodorakis P., Fountoulakis K.
Mental health conditions in the World Health Organization (WHO) European Region affect more than 10% of the population, with 140,000 lives lost annually to suicide. Comorbidity with other diseases is high. However, basic mental health care is received by less than a third of patients. The COVID-19 pandemic has revealed the vulnerability of mental health services to disruptions and underscored the need to integrate mental health into response strategies. One of the flagship initiatives of the WHO European Programme of Work (EPW), 2020–2025: 'United Action for Better Health in Europe' is the establishment of a Mental Health Coalition at the European level. In this framework, reporting of health statistics using the International Classification of Diseases 11th Revision (ICD-11) will begin on 1st January 2022. Clinical utility, scientific rigour and wider cultural applicability were all of prime importance in the development of the ICD-11. The 11th Revision was the end product of the most extensive global, multilingual, multidisciplinary and participative process ever undertaken for this task, involving more than 15,000 experts from 155 countries, representing approximately 80% of the world's population. With the adoption of the ICD-11 and the priority being given to mental health, new ideas based on the 30 years of research since the approval of the ICD-10 will be widely adopted and applied.
Consortium Psychiatricum. 2021;2(2):3-6
Cultural Issues Related to ICD-11 Mental, Behavioural and Neurodevelopmental Disorders
Sharan P., Hans G.
The challenge of producing a classificatory system that is truly representative of different regions and cultural variations is difficult. This can be conceptualized as an ongoing process, achievable by constant commitment in this regard from various stakeholders over successive generations of the classificatory systems. The objective of this article is to conduct a qualitative review of the process and outcome of the efforts that resulted in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders becoming a global classification. The ICD-11 represents an important, albeit iterative, advance in the classification of mental, behavioural and neurodevelopmental disorders. Significant changes have been incorporated in this regard, such as the introduction of new, culturally-relevant categories, modifications of the diagnostic guidelines, based on culturally informed data and the incorporation of culture-related features for specific disorders. Notwithstanding, there are still certain significant shortcomings and areas for further improvement and research. Some of the key limitations of ICD-11 relate to the paucity of research on the role of culture in the pathogenesis of illnesses. To ensure a classificatory system that is fair, reliable and culturally useful, there is a need to generate empirical evidence on diversity in the form of illnesses, as well as mechanisms that explain these in all the regions of the world. In this review, we try to delineate the various cultural challenges and their influences in the formulation of ICD-11, along with potential shortcomings and areas in need of more improvement and research in this regard.
Engagement of Russian Mental Health Professionals in the Development of WHO's ICD-11
Rebello T., Kulygina M.A., Krasnov V.N., Pike K., Reed G.
The World Health Organization (WHO) has officially approved the next version of its global diagnostic system, the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11). Processes to implement the ICD-11 are now underway. Developing the ICD-11 chapter on Mental, Behavioural and Neurodevelopmental Disorders, in line with WHO's core priorities to enhance the clinical utility, reliability, and global applicability of the guidelines, necessitated a large-scale scientifically-rigorous research program. Such a program of global field studies engaged mental health professionals from across the world, with substantial contributions from clinicians in the Russian Federation.
This paper systematically highlights the substantive roles played by Russian clinicians in all steps of development of the mental, behavioural, and neurodevelopmental disorder guidelines, including their participation in the following: 1) early formative field studies that informed the organizing principles and overarching structure of the ICD-11; 2) large-scale online studies that used a case-controlled methodology to evaluate the guideline's clinical utility and the accuracy with which the new ICD-11 guidelines could be applied by global clinicians; 3) an online network of mental health professionals who provided direct feedback on the ICD-11 to WHO (also known as the Global Clinical Practice Network, www.globalclinicalpractice.net) with over 16,000 members from 160 countries, and with the Russian Federation being in the top five most represented countries in the network; 4) clinic-based field studies that tested the reliability and clinical utility of the ICD-11 diagnostic guidelines; and 5) development and participation in training programs that prepare clinicians in implementing the diagnostic guidelines in clinical settings.
In these many ways, Russian clinicians have substantively and directly contributed to efforts to maximize the clinical usefulness, consistency, acceptability, and applicability of the ICD-11's mental, behavioural, and neurodevelopmental disorder guidelines. This substantial engagement of clinicians will conceivably facilitate the adoption and use of the guidelines by clinicians in the Russian Federation and other Russian-speaking countries, as the ICD-11 is implemented over the coming years.
Toward ICD-11 Implementation: Attitudes and Expectations of the Russian Psychiatric Community
Kulygina M.A., Syunyakov T.S., Fedotov I.A., Kostyuk G.P.
Background. ICD-11 implementation will start in early 2022 in WHO member countries, including Russia. This process should be preceded not only by the official translation and wide distribution of ICD-11 statistical classification and diagnostic guidelines but also by clinicians' training. For recent years ICD-11 development and innovations in the diagnosis of mental disorders were in the focus of attention of mental health professionals in all over the world.
Objectives. This online survey aimed to identify the current views of the Russian psychiatric community on the upcoming implementation of ICD-11.
Methods. A survey was composed in a Google form and circulated through the website of the Russian Society of Psychiatrists and other professional networks. Statistical and narrative analysis was provided. The sample was represented by 148 psychiatrists working in inpatient or outpatient clinical settings.
Results. Expectations for the classification of mental disorders reported by the respondents were wider than the current purpose of ICD-10. In general, the Russian psychiatrists expressed their interests to forthcoming ICD-11 implementation. Positive attitudes to ICD-11 innovations were associated with the familiarity with the ICD-11 draft.
Conservative or negative views were related to longer years of clinical experience. Early carrier psychiatrists were more practically oriented than 'old school' clinicians.
Conclusion. This survey may help to promote the ICD-11 by focusing on its advantages for clinical practice and develop targeted training programs.
The Use of ICD-10 for Diagnosing Mental Disorders In Russia, According to National Statistics and a Survey of Psychiatrists' Experience
Martynikhin I.A.
Purpose and methods. In order to assess the specifics of practical use of the ICD-10 Diagnostic Guidelines by Russian psychiatrists, official national statistics on the prevalence of a number of mental disorders in Russia in 2019 were compared with the results of meta-analyses of international epidemiological studies of these disorders. In addition, a number of items in the online psychiatrists' survey, relating to the diagnosis of schizophrenia, were analysed; 807 Russian psychiatrists took part in the online survey.
Results. Analysis of national statistics showed that domestic clinicians diagnose some mental disorders significantly less often than might be expected, according to data obtained by international epidemiological studies. The number of cases of bipolar affective disorder registered in Russia is 90–150 times less than that for the prevalence of this disorder, according to meta-analyses of epidemiological studies; for depression, the result is 50–70 times; for anxiety disorders, the number is 25–50 times, and for autism, it is 30 times. Instead of the above disorders, diagnoses of organic non-psychotic mental disorders and schizophrenia might have been used unreasonably often. Between 2005 and 2019, diagnosis of childhood autism changed significantly (an increase of more than 100%), while the frequency of diagnosing other mental disorders remained unchanged. The results of the online survey also showed largely perfunctory use of the ICD-10 Diagnostic Guidelines, with a third of respondents reporting never checking the diagnostic schedules, and another third doing so from time to time. In addition, the low estimates given by survey participants regarding practical utility of the ICD-10 Diagnostic Guidelines, along with a large percentage of respondents who do not directly use diagnostic criteria in their work, indicate the need to improve the clinical usefulness of the diagnostic guidelines in the latest revision of the ICD, including convenience of use in practice.
Conclusion. The results of analysis of the Russian national mental health service statistic indicate that at least some diagnostic categories are not used by Russian psychiatrists exactly as ICD-10 suggests. The revealed discrepancy between the principles of diagnostics observed by domestic clinicians and international criteria may interfere with the use of evidence-based treatment algorithms, negatively affecting the quality of psychiatric care. In light of the upcoming transition to ICD-11 and in order to unify approaches to the diagnosis of mental disorders in our country, it is necessary to update and improve educational programmes for psychiatrists.
Depathologizing Sexual Orientation and Transgender Identities in Psychiatric Classifications
Robles R., Real T., Reed G.
Introduction. This article presents the history and rationales of conceptualization and classification of homosexuality and transgender identity in both ICD and DSM. We review the efforts that have been made (and those that remain pending) to improve psychiatric classifications with new scientific knowledge, changing social attitudes and human rights standards.
Method. We conducted a literature search of the classification of homosexuality and transgender identity as mental disorders.
Result. We provide a historical description of these concepts in ICD and DSM, including fundamental points of disagreement as well as arguments that have been effective in achieving changes in both classifications.
Conclusions. Fundamental changes have been made in the International Classification of Diseases Eleventh Revision (ICD-11) in terms of the classification of sexual orientation and gender identity based on scientific evidence and the ICD's public health objectives. These changes might support the provision of accessible and high-quality healthcare services, and are responsive to the needs, experience and human rights of the populations involved.
Gender Identity Disorders: Current Medical and Social Paradigm and the ICD-11 Innovations
Dyachenko A.V., Perekhov A.Y., Soldatkin V.A., Bukhanovskaya O.A.
Introduction. This article presents a review of current concepts of gender identity under normal and pathological conditions.
Aim. To analyse the impact of the medical and social paradigm shift for clinical practice.
Results and discussion. The modern academic literature devoted to gender identity disorders is characterized by a variety of terminology, a shift in emphasis from clinical judgement to a socially beneficial normocentric approach and a relatively few advanced, evidence-based research. There is also a lack of evidence for the gender theory underlying the new approach, which raises serious doubts about the validity of the medical and social paradigm revision. In the same time, the position of Russian psychiatrists remains to be more clinically oriented.
Conclusion. Patients who declare the desire to reassign their gender have to be assessed by psychiatrists for differential diagnosis to exclude a mental disorder. In such cases, the destigmatization of mental disorders is more critical than the depathologization of gender identity disorders.
The Evolution of Approaches to Schizophrenia Diagnostics: from Kraepelin to ICD-11
Shmukler A.B.
This article presents the evolution of views on schizophrenia diagnostics over the course of 150 years, beginning from the pre-Kraepelin period and ending with concepts developed in recent decades. Consideration is given to the merits and demerits of contemporary official classifications (DSM-5 and ICD-11) as well as to alternative approaches, particularly in relation to scientific research, and their prospects for development. Special attention is paid to the Research Domain Criteria Project (RDoC) of the National Institute of Mental Health (NIMH). Another promising area discussed in this paper relates to network analysis as a method for the investigation of psychotic disorders, particularly schizophrenia.
ICD-11 as a Paradigm Shift Phase in the Classification of Mental Disorders
Krasnov V.N.
Classifications of mental disorders change regularly. This fact requires analysis, taking into account changes in the epidemiological situation and changes in the organizational structure of mental health service, and development of its technical and human resources. The preliminary analysis of these changes presented in the article using the example of ICD-11 gives us reason to believe that they are almost unrelated to the diagnostic process improvement. On the contrary, each new classification is characterized by an increasing formalization and simplification of the criteria for separate clinical forms. The inevitable losses of clinical accuracy in psychopathological assessment of disorder are compensated for increasing opportunities to deliver care to a significantly greater number of patients.
Qatar Community Mental Health Care: Achievements and Challenges
Ahmed M., Ghuloum S.
Guided by international best practice and evidence-based medicine, the Qatar mental health service has undergone a major transformation in the last two decades, replacing the institution-based service with an accessible multidisciplinary community-based service.
In this paper, we provide a brief historical background to mental health services in Qatar, and the progress and development towards community-based mental health-care provision.
We also explore the challenges facing this new model of care in Qatar including social and cultural sensitivities, and the various solutions adopted to overcome these challenges.
We outline the comprehensive plans envisaged to further develop Qatar community mental health services, including the provision of accessible, integrated and multimodal mental health care within primary care settings.
Community Mental Health Care in Serbia: Development and Perspectives
Lecic-Tosevski D., Milosavljevic M.
Community mental health care was developed in Serbia in 1982 at the Belgrade Institute of mental health. Treatment was provided through the primary health care system, with each health centre having its own mental health care team. However, in the process of psychiatric reform and deinstitutionalization, dedicated community centres had to be established, in accordance with the National Strategy for the Development of Mental Health Care. The first community-based mental health centre opened in the southern area of Serbia in 2005 and subsequently, other centres were established. The centres are organized independently of psychiatric hospitals and are located in local, self-government units, providing psychosocial treatment and the continuation of mental health care. In relation to the ongoing reform of psychiatry in the country, there are positive and negative issues. There are 41.41 beds per 100,000 of the population in psychiatric hospitals and 18.33 beds per 100,000 of the population in the psychiatric departments of general hospitals. Day hospitals, established throughout the country, provide patients with good quality care. Mental health care professionals are educated to a high standard and integrative, person-centred treatment is applied in most services. However, the level of stigma directed towards those with mental illness is still high and constitutes a barrier to treatment. Well-developed screening and early detection programmes to identify persons requiring mental health care are lacking, as are the records of patients with mental disorders. The future goal is to further reduce the number of beds in psychiatric hospitals, establish new community mental health care services throughout the country and ensure the prevention of mental disorders, as well as mental health promotion.
Community Mental Health Services in Italy
Sampogna G., Del Vecchio V., De Rosa C., Giallonardo V., Luciano M., Palummo C., Di Vincenzo M., Fiorillo A.
In 1978, in Italy, approval of Basaglia's reform law marked a shift from an asylum-based to a community-based mental health system. The main aim of the reform was to treat patients in the community and no longer in psychiatric hospitals. Following the Italian model, similar reforms of mental health care have been approved worldwide. The community-based model aims to promote integration and human rights for people with mental disorders on the basis of their freedom to choose treatment options.
By 2000, all psychiatric hospitals had been closed and all patients discharged. Mental health care is organized through the Department of Mental Health, which is the umbrella organization responsible for specialist mental health care in the community; this includes psychiatric wards located in general hospitals, residential facilities, mental health centres, and day-hospital and day-care units.
Approval of Law 180 led to a practical and ideological shift in the provision of care to patients with mental disorders. In particular, the reform highlighted the need to treat patients in the same way as any other patient, and mental health care moved from a custodialistic to a therapeutic model.
Progressive consolidation of the community-based system of mental health care in Italy has been observed in the past 40 years. However, some reasons for concern still exist, including low staffing levels, potential use of community residential facilities as long-stay residential services, and a heterogeneity in the availability of resources for mental health throughout the country.