Draft diagnostic guidelines for ICD‐11 mental and behavioural disorders available for review and comment

From the beginning, practicing psychiatrists and other mental health professionals around the globe have played an integral role in the development of the ICD-11 classification of mental and behavioural disorders by the World Health Organization (WHO) Department of Mental Health and Substance Abuse. A central aspect of practitioners' contribution has been their participation in a series of developmental field studies1 conducted by the WHO to gather information about the performance of draft versions of the ICD-11 guidelines. Findings from these studies are being used to improve the reliability, validity and clinical utility of the final versions2. As one specific example, data from a field study in which participants applied the proposed diagnostic guidelines for Disorders Specifically Associated with Stress to standardized case material in the form of vignettes showed that, while the ICD-11 guidelines were generally an improvement over ICD-10, clinicians did not clearly understand the new diagnostic requirement of re-experiencing for post-traumatic stress disorder and also found that the disorder was too narrowly defined3. Based on these results, specific changes were made to the diagnostic guidelines. These field studies are currently being implemented via the Internet in multiple languages through the Global Clinical Practice Network (GCPN)4. The WHO Department of Mental Health and Substance Abuse established the GCPN as a realistic and feasible tool to collect truly global information about whether the proposed ICD-11 diagnostic guidelines lead to more accurate and consistent clinical decision-making than those of ICD-10. The GCPN was partly an extension of an earlier collaboration between the WHO and the WPA on a large international survey of nearly 5,000 psychiatrists in 44 countries regarding their use of and attitudes towards diagnostic classification systems5. The GCPN now consists of more than 12,600 mental health and primary care professionals in nearly 150 countries. The largest group of GCPN participants – over half – are psychiatrists, followed by psychologists (29%). Nearly four in ten GCPN members are from low- and middle-income countries, where the large majority of the world's population lives. The WHO's strong emphasis on participation by the anticipated daily users of the classification has sometimes been taken to suggest that we are managing the ICD-11 development as a popularity contest, making decisions about categories and diagnostic requirements based on whether or not practitioners "like" them. In fact, the proposals made by the ICD-11 Working Groups have been based on a careful consideration of the available scientific evidence. We believe that utility and validity are related and overlapping concepts6, and that a dichotomy between science and practice is false as applied to the approach we are taking to ICD-11 field studies. But the WHO has also gone beyond traditional evidence reviews to develop a robust research agenda that treats the extent to which the ICD-11 can be accurately and easily used by practitioners as a serious scientific question2. For the WHO, the importance of clinical utility is closely related to the key aim of reducing the disease burden of mental and behavioural disorders and to the objectives of the WHO's Mental Health Action Plan of providing comprehensive, integrated and responsive mental health and social care services in community-based settings and strengthening information systems, evidence and research for mental health7, 8. If the ICD-11 is too cumbersome to use and fails to provide mental health professionals with clinically useful information, they simply won't apply it consistently. In that case, information collected at the health encounter level will not provide a valid basis for health policy or resource allocation at the system, national or global level. Data collection is now beginning for multi-site ecological implementation field studies that will assess the clinical utility and diagnostic reliability of the ICD-11 guidelines in the global clinical settings in which they will ultimately be implemented. One arm of these clinic-based studies will involve the participation of major international field study centers. A second arm will provide the opportunity for GCPN members to contribute data regarding the implementation of the guidelines in the context of their own clinical practices. The general proposed structure of the entire ICD-11, covering all health conditions, as well as brief glossary definitions for all categories are available for public review on the ICD-11 beta platform (http://apps.who.int/classifications/icd11/browse/l-m/en). Registered users may comment on the categories and definitions provided. However, the information available on the beta platform constitutes the statistical version of the classification, designed primarily for use by government health statistics agencies and coders of medical records and death statistics. The WHO does not consider this information to be sufficient for application of the ICD-11 by mental health professionals9. The latter is the purpose of the diagnostic guidelines. Previously, we described the structure, nature and rationale for the ICD-11 diagnostic guidelines being developed for use by mental health professionals in global health care settings10. The complete guidelines are too lengthy to be practical for field studies, so an abbreviated version of the guidelines is being used for that purpose that consists of three core sections. Essential features provide explicit guidance regarding the symptoms or characteristics needed to confidently make the diagnosis. Their format is intended to conform to the way clinicians actually make psychiatric diagnosis, i.e., with the flexible exercise of clinical judgment. The field studies version of the guidelines also contains a section on Boundary with other disorders and with normality, which indicates those disorders that should be considered in the differential diagnosis and provides specific guidance related to each, as well as regarding the differentiation from normal variation in characteristics that may underlie or be similar to the disorder. Additional information provides a description of other features that are relevant in helping the clinician to recognize variations in presentation of the disorder, but are not diagnostically determinative. The final, published version of the guidelines will include additional information (e.g., information on features related to culture, gender and development). The WHO Department of Mental Health and Substance Abuse is interested in receiving comments on the proposed diagnostic guidelines from their intended users. To receive these comments, the Department has created a new Internet platform for members of the GCPN, called GCP.Network (http://gcp.network). This platform will make several sets of guidelines available per month until all of them are included. All mental health or primary care professionals who are legally authorized to provide services to people with mental and behavioural disorders in their countries are eligible to join the GCPN and to provide comments on the proposed diagnostic guidelines. At a later time, the draft guidelines will also be made available for review by the general public. A variety of additional resources for registered GCPN members are available at GCP.Network. These include brief reports on the results of GCPN field studies, access to articles related to the development of ICD-11 mental and behavioural disorders, and a variety of relevant training resources. We invite you to visit http://gcp.network, to register if you are not already a member, to provide comments on the proposed ICD-11 guidelines, and to take advantage of the other resources we have and will continue to develop. Geoffrey M. Reed1,2, Michael B. First3, María Elena Medina-Mora4, Oye Gureje5, Kathleen M. Pike6, Shekhar Saxena1 1Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland; 2INPRFM-UNAM Center for Global Mental Health Research, Mexico, DF, Mexico; 3Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY, USA; 4National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico, DF, Mexico; 5Department of Psychiatry, University of Ibadan, Ibadan, Nigeria; 6Global Mental Health Program, Columbia University, New York, NY, USA G. Reed and S. Saxena are members of the Secretariat, WHO Department of Mental Health and Substance Abuse. M. First is a consultant to the Secretariat. M.E. Medina-Mora, O. Gureje and K. Pike are members of the Field Studies Coordination Group and/or the International Advisory Group for ICD-11 Mental and Behavioural Disorders. The views expressed here are those of the authors and, unless specifically stated, do not represent the official views or positions of the WHO.