Jared W. Keeley

Do mental health professionals use diagnostic classifications the way we think they do? A global survey

We report on a global survey of diagnosing mental health professionals, primarily psychiatrists, conducted as a part of the development of the ICD‐11 mental and behavioural disorders classification. The survey assessed these professionals use of various components of the ICD‐10 and the DSM, their attitudes concerning the utility of these systems, and usage of “residual” (i.e., “other” or “unspecified”) categories. In previous surveys, most mental health professionals reported they often use a formal classification system in everyday clinical work, but very little is known about precisely how they are using those systems. For example, it has been suggested that most clinicians employ only the diagnostic labels or codes from the ICD‐10 in order to meet administrative requirements. The present survey was conducted with clinicians who were members of the Global Clinical Practice Network (GCPN), established by the World Health Organization as a tool for global participation in ICD‐11 field studies. A total of 1,764 GCPN members from 92 countries completed the survey, with 1,335 answering the questions with reference to the ICD‐10 and 429 to the DSM (DSM‐IV, DSM‐IV‐TR or DSM‐5). The most frequent reported use of the classification systems was for administrative or billing purposes, with 68.1% reporting often or routinely using them for that purpose. A bit more than half (57.4%) of respondents reported often or routinely going through diagnostic guidelines or criteria systematically to determine whether they apply to individual patients. Although ICD‐10 users were more likely than DSM‐5 users to utilize the classification for administrative purposes, other differences were either slight or not significant. Both classifications were rated to be most useful for assigning a diagnosis, communicating with other health care professionals and teaching, and least useful for treatment selection and determining prognosis. ICD‐10 was rated more useful than DSM‐5 for administrative purposes. A majority of clinicians reported using “residual” categories at least sometimes, with around 12% of ICD‐10 users and 19% of DSM users employing them often or routinely, most commonly for clinical presentations that do not conform to a specific diagnostic category or when there is insufficient information to make a more specific diagnosis. These results provide the most comprehensive available information about the use of diagnostic classifications of mental disorders in ordinary clinical practice.

The ICD-11 developmental field study of reliability of diagnoses of high-burden mental disorders: results among adult patients in mental health settings of 13 countries.

Reliable, clinically useful, and globally applicable diagnostic classification of mental disorders is an essential foundation for global mental health. The World Health Organization (WHO) is nearing completion of the 11th revision of the International Classification of Diseases and Related Health Problems (ICD‐11). The present study assessed inter‐diagnostician reliability of mental disorders accounting for the greatest proportion of global disease burden and the highest levels of service utilization – schizophrenia and other primary psychotic disorders, mood disorders, anxiety and fear‐related disorders, and disorders specifically associated with stress – among adult patients presenting for treatment at 28 participating centers in 13 countries. A concurrent joint‐rater design was used, focusing specifically on whether two clinicians, relying on the same clinical information, agreed on the diagnosis when separately applying the ICD‐11 diagnostic guidelines. A total of 1,806 patients were assessed by 339 clinicians in the local language. Intraclass kappa coefficients for diagnoses weighted by site and study prevalence ranged from 0.45 (dysthymic disorder) to 0.88 (social anxiety disorder) and would be considered moderate to almost perfect for all diagnoses. Overall, the reliability of the ICD‐11 diagnostic guidelines was superior to that previously reported for equivalent ICD‐10 guidelines. These data provide support for the suitability of the ICD‐11 diagnostic guidelines for implementation at a global level. The findings will inform further revision of the ICD‐11 diagnostic guidelines prior to their publication and the development of programs to support professional training and implementation of the ICD‐11 by WHO member states.

Internetbasierte Untersuchungen zur diagnostischen Klassifikation und Kodierung psychischer Störungen im Vergleich von ICD-11 und ICD-10

The German Society for Psychiatry, Psychosomatics and Psychotherapy (DGPPN,) conducted a comprehensive field study (principal investigator WG) funded by the German Federal Ministry of Health in cooperation with 4 other German medical societies in the field of mental health (DGPM, DGPPR, DeGFS, DGfS) * to support WHOs development of the ICD-11 (Chapters 6 and 17). The objective of the web-based field study was to compare ICD-10 and ICD-11 (beta draft) for selected mental disorders, regarding consistency, accuracy and assessment of utility. The first study (TP1) focused on the diagnostic classification and the second (TP2) on assignment of diagnostic codes.In TP1, clinicians used either the ICD-10 Clinical Descriptions and Diagnostic Guidelines (CDDG) version or a draft version of the ICD-11 CDDG to evaluate 10 case vignettes in a randomized study implemented through the WHO GCPN **. As hypothesized, consistency was in favor of the ICD-11 (p = .02; n = 319 expert participants) though there was some variability across the different diagnostic categories. In addition, time for diagnosis was shorter (p = .01) and clinicians judgment of utility (ease of use; goodness of fit) was better for ICD-11 (p = .047 and p < .001 respectively).TP2 focused on consistency of diagnostic code assignment for 25 short case descriptions (including explicit diagnosis and additional clinical information) using both ICD-10 and ICD-11 in a randomized web-based field study which was run on the WHO ICD-FiT *** platform. Based on 531 code assignments by120 expert clinicians, consistency for ICD-11 was significantly lower compared to ICD-10 (71 % vs. 82 %, p < .001) contrary to study hypothesis, and time required was significantly higher for ICD-11 (p < .001). Nevertheless, utility assessments were in favor of ICD-11 (p < .005).In summary, in TP1, given vignettes with more complex clinical descriptions more similar to clinical cases, ICD-11 showed advantages in the consistency of correct diagnoses among clinicians, time required to reach a diagnosis, and clinicians ratings of clinical utility. These results provide evidence for quality improvement of the diagnostic process due to the revision of the more complete diagnostic guidelines for ICD-11. In the coding task of TP2, coding by clinicians using the ICD-10 was more consistent and faster than coding using the ICD-11. This may be a result of the greater complexity for coding use of the ICD-11 (e. g., due to post-coordination), as well as greater familiarity with the ICD-10 system (which German clinicians currently use) and lack of practice with the new ICD-11 codes and tools. In spite of this, users assessed the ICD-11 system as more useful than the ICD-10, in part also because of ICD-11s more systematic and comprehensive coding tools. In addition, time needed for coding improved with practice, indicating need for intense education and training initiatives when ICD-11 is adopted and implemented into clinical practice.

Psychotic disorder symptom rating scales: Are dichotomous or multi-point scales more clinically useful?—An ICD-11 field study

Classifications of psychotic disorders are moving towards utilizing dimensional symptom domains as the preferred mechanism for describing psychotic symptomatology. The ICD-11 has proposed six symptom domains (Positive symptoms, Negative symptoms, Depressive symptoms, Manic symptoms, Psychomotor symptoms, and Cognitive symptoms) that would be rated in addition to providing a psychotic disorder diagnosis. This study investigated clinicians use of dichotomous versus multi-point scales for rating these six domains. Global mental health professionals (nu202f=u202f273) rated case vignettes using both a 2-point and 4-point version of a rating scale for the six domains. Clinicians were more accurate using the 2-point scale in absolute terms, but after correcting for chance guessing and disagreements, the two versions of the scale were equally accurate. Clinicians believed the 2-point scale would be easier to use, although they also indicated that the 4-point scale would provide richer clinical information. Participants were able to detect the presence of psychotic symptom domains in the vignettes with good reliability with no special training using either scale. We recommend that clinicians and researchers use the version of the scale that best matches their purpose (i.e., to maximize accuracy or enhance case description). Future work should develop the implementation characteristics of the scale to improve its potential for global application.

Clinical utility of ICD-11 diagnostic guidelines for high-burden mental disorders: results from mental health settings in 13 countries: Clinical utility of ICD-11 diagnostic guidelines for high-burden mental disorders: results from mental health settings in 13 countries

In this paper we report the clinical utility of the diagnostic guidelines for ICD‐11 mental, behavioural and neurodevelopmental disorders as assessed by 339 clinicians in 1,806 patients in 28 mental health settings in 13 countries. Clinician raters applied the guidelines for schizophrenia and other primary psychotic disorders, mood disorders (depressive and bipolar disorders), anxiety and fear‐related disorders, and disorders specifically associated with stress. Clinician ratings of the clinical utility of the proposed ICD‐11 diagnostic guidelines were very positive overall. The guidelines were perceived as easy to use, corresponding accurately to patients’ presentations (i.e., goodness of fit), clear and understandable, providing an appropriate level of detail, taking about the same or less time than clinicians’ usual practice, and providing useful guidance about distinguishing disorder from normality and from other disorders. Clinicians evaluated the guidelines as less useful for treatment selection and assessing prognosis than for communicating with other health professionals, though the former ratings were still positive overall. Field studies that assess perceived clinical utility of the proposed ICD‐11 diagnostic guidelines among their intended users have very important implications. Classification is the interface between health encounters and health information; if clinicians do not find that a new diagnostic system provides clinically useful information, they are unlikely to apply it consistently and faithfully. This would have a major impact on the validity of aggregated health encounter data used for health policy and decision making. Overall, the results of this study provide considerable reason to be optimistic about the perceived clinical utility of the ICD‐11 among global clinicians.

Accounting for Social Processes in the Development of Diagnostic Classification Systems: Commentary on the “Standards and Guidelines for the Development of Diagnostic Nomenclatures and Alternatives in Mental Health Research and Practice”

Diagnostic classifications of mental disorders are complex systems that integrate both scientific and social priorities. The Task Force on Developing Humanistic Approaches to Psychological Diagnosis of the Society for Humanistic Psychology has released a set of guidelines intended to guide the development of mental health classifications. This commentary argues that the attention paid in the guidelines to social processes is a desirable and inherent component of the development of any classification. Social influences regarding the definition of the concepts and the processes by which people develop them are integrally intertwined, contrary to the common view that nonscientific factors should be excluded from classification systems as much as possible. These guidelines offer a much needed resource for developing future mental health classifications.

A case-controlled field study evaluating ICD-11 proposals for relational problems and intimate partner violence

Background/Objective: Intimate partner relationship problems and intimate partner abuse and neglect — referred to in this paper as “relational problems and maltreatment” — have substantial and well-documented impact on both physical and mental health. However, classification guidelines, such as those found in the International Classification of Diseases (ICD-10), are vague and unlikely to support consistent application. Revised guidelines proposed for ICD-11 are much more operationalized. We used standardized clinical vignette conditions with an international panel of clinicians to test if ICD-11 changes resulted in improved classification accuracy. Method: English-speaking mental health professionals (N = 738) from 65 nations applied ICD-10 or ICD-11 (proposed) guidelines with experimentally manipulated case presentations of presence or absence of (a) individual mental health diagnoses and (b) relational problems or maltreatment. Results: ICD-11, compared with ICD-10, guidelines resulted in significantly better classification accuracy, although only in the presence of co-morbid mental health problems. Clinician factors (e. g., gender, language, world region) largely did not impact classification performance. Conclusions: Despite being considerably more explicated, raters’ performance with ICD-11 guidelines reveals training issues that should be addressed prior to the release of ICD-11 in 2018 (e. g., overriding the guidelines with pre-existing archetypes for relationship problems and physical and psychological abuse).

Global Collaborative Team Performance for the Revision of the International Classification of Diseases: A Case Study of the World Health Organization Field Studies Coordination Group

Background/Objective: Collaborative teamwork in global mental health presents unique challenges, including the formation and management of international teams composed of multicultural and multilingual professionals with different backgrounds in terms of their training, scientific expertise, and life experience. The purpose of the study was to analyze the performance of the World Health Organization (WHO) Field Studies Coordination Group (FSCG) using an input-processes-output (IPO) team science model to better understand the teams challenges, limitations, and successes in developing the eleventh revision of the International Classification of Diseases (ICD). Method: We thematically analyzed a collection of written texts, including FSCG documents and open-ended qualitative questionnaires, according to the conceptualization of the input-processes-output model of team performance. Results: The FSCG leadership and its members experienced and overcame numerous barriers to become an effective international team and to successfully achieve the goals set forth by WHO. Conclusions: Research is necessary regarding global mental health collaboration to understand and facilitate international collaborations with the goal of contributing to a deeper understanding of mental health and to reduce the global burden of mental disorders around the world.

What Constitutes Poor Teaching? A Preliminary Inquiry Into the Misbehaviors of Not-So-Good Instructors:

Across three phases, we investigated college students’ perceptions of poor college teaching to develop a typology of poor teaching behaviors. In Phase 1, students generated a list of qualities representative of poor teaching. In Phase 2, another group of students assigned behavioral correspondents to these qualities, resulting in a list of 15 poor teaching qualities and their attendant misbehaviors. Finally, in Phase 3, yet another group of students generated a “top 5” list of qualities and behaviors that their most ineffective teachers have exhibited. Across participants in Phase 3, the top 5 list included, in order, being disrespectful, offering unrepresentative and unfair student learning assessments, having unrealistic expectations for student learning, being less than knowledgeable on course content, and having poor communication skills. These findings provide practical guidance on which particular behaviors teachers should avoid adopting in their instructional repertoires.