Rebeca Robles

Vignette methodologies for studying clinicians’ decision-making: Validity, utility, and application in ICD-11 field studies ☆

Vignette-based methodologies are frequently used to examine judgments and decision-making processes, including clinical judgments made by health professionals. Concerns are sometimes raised that vignettes do not accurately reflect “real world” phenomena, and that this affects the validity of results and conclusions of these studies. This article provides an overview of the defining features, design variations, strengths, and weaknesses of vignette studies as a way of examining how health professionals form clinical judgments (e.g., assigning diagnoses, selecting treatments). As a “hybrid” of traditional survey and experimental methods, vignette studies can offer aspects of both the high internal validity of experiments and the high external validity of survey research in order to disentangle multiple predictors of clinician behavior. When vignette studies are well designed to test specific questions about judgments and decision-making, they can be highly generalizable to “real life” behavior, while overcoming the ethical, practical, and scientific limitations associated with alternative methods (e.g., observation, self-report, standardized patients, archival analysis). We conclude with methodological recommendations and a description of how vignette methodologies are being used to investigate clinicians’ diagnostic decisions in case-controlled field studies for the ICD-11 classification of mental and behavioural disorders, and how these studies illustrate the preceding concepts and recommendations

Disorders specifically associated with stress: A case-controlled field study for ICD-11 mental and behavioural disorders

As part of the development of the Eleventh Revision of International Classification of Diseases and Related Health Problems (ICD-11), the World Health Organization Department of Mental Health and Substance Abuse is conducting a series of case-controlled field studies using a new and powerful method to test the application by clinicians of the proposed ICD-11 diagnostic guidelines for mental and behavioural disorders. This article describes the case-controlled field study for Disorders Specifically Associated with Stress. Using a vignette-based experimental methodology, 1,738 international mental health professionals diagnosed standardized cases designed to test key differences between the proposed diagnostic guidelines for ICD-11 and corresponding guidelines for ICD-10. Across eight comparisons, several proposed changes for ICD-11, including the addition of Complex PTSD and Prolonged Grief Disorder, produced significantly improved diagnostic decisions and clearer application of diagnostic guidelines compared to ICD-10. However, several key areas were also identified, such as the description of the diagnostic requirement of re-experiencing in PTSD, in which the guidelines were not consistently applied as intended. These results informed specific revisions to improve the clarity of the proposed ICD-11 diagnostic guidelines. The next step will be to further test these guidelines in clinic-based studies using real patients in relevant settings.

A global clinicians' map of mental disorders to improve ICD-11: analysing meta-structure to enhance clinical utility.

Abstract Enhancing clinical utility is an emphasis of the World Health Organizations development of the mental and behavioural disorders chapter of the next International Classification of Diseases (ICD-11). Understanding how clinicians conceptualize the structure of mental disorders can enable a more clinically intuitive classification architecture that will help professionals find the categories they need more efficiently. This study examined clinicians’ conceptualizations of the relationships among mental disorders and the dimensions they use in making these judgements. Psychiatrists and psychologists from 64 countries (n = 1,371), participating in English or Spanish, rated the similarity of mental and behavioural disorders presented as paired comparisons. Data were analysed by multidimensional scaling procedures (INDSCAL) and by analyses of consistency. Participants used three distinctive dimensions to evaluate the similarity among disorders: internalizing versus externalizing, developmental versus adult onset, and functional versus organic. Clinicians’ conceptual map of mental disorders was rational and highly stable across profession, language, and country income level. The proposed ICD-11 structure is a moderately better fit with clinicians’ conceptual model than either ICD-10 or DSM-IV. Clinician judgements can be used to improve clinical utility of the ICD-11 without sacrificing validity based on a scientific approach to enhancing a logically organized classification meta-structure.

Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11

BACKGROUND The conceptualisation of transgender identity as a mental disorder has contributed to precarious legal status, human rights violations, and barriers to appropriate health care among transgender people. The proposed reconceptualisation of categories related to transgender identity in WHOs forthcoming International Classification of Diseases (ICD)-11 removes categories related to transgender identity from the classification of mental disorders, in part based on the idea that these conditions do not satisfy the definitional requirements of mental disorders. We aimed to determine whether distress and impairment, considered essential characteristics of mental disorders, could be explained by experiences of social rejection and violence rather than being inherent features of transgender identity, and to examine the applicability of other elements of the proposed ICD-11 diagnostic guidelines. METHODS This field study used a retrospective interview design in a purposive sample of transgender adults (aged >18 years or older) receiving health-care services at the Condesa Specialised Clinic in Mexico City, Mexico. Participants completed a detailed structured interview focusing on sociodemographic characteristics, medical history related to gender identity, and, during a specific period of adolescence, key concepts related to gender identity diagnoses as proposed for ICD-11 and from DSM-5 and ICD-10, psychological distress, functional impairment, social rejection, and violence. Data were analysed with descriptive statistics and univariate comparisons and multivariate logistic regression models predicting distress and dysfunction. FINDINGS Between April 1, 2014, and Aug 17, 2014, 260 transgender adults were approached and 250 were enrolled in the study and completed the interview. Most (n=202 [81%]) had been assigned a male sex at birth. Participants reported first awareness of transgender identity at a mean age of 5·6 years (SD 2·5, range 2-17), and 184 (74%) had used health interventions for body transformation, most commonly hormones (182 [73%)], with the first such intervention at a mean age of 25·0 years (SD 9·1, range 10-54). 84 (46%) of those who had used hormones did so initially without medical supervision. During adolescence, distress related to gender identity was very common, but not universal (n=208 [83%]), and average level of distress was quite high among those who reported it (79·9 on a scale of 0 [none at all] to 100 [extreme], SD 20·7, range 20-100). Most participants (n=226 [90%] reported experiencing family, social, or work or scholastic dysfunction related to their gender identity, but this was typically moderate (on a scale of 0 [not at all disrupted] to 10 [extremely disrupted], family dysfunction mean 5·3 [SD 3·9, range 0-10]; social dysfunction mean 5·0 [SD 3·8, range 0-10]; work or scholastic dysfunction mean 4·8 [SD 3·6, range 0-10]). Multivariate logistic regression models indicated that distress and all types of dysfunction were strongly predicted by experiences of social rejection (odds ratios [ORs] 2·29-8·15) and violence (1·99-3·99). A current male gender identity also predicted distress (OR 3·90). Of the indicators of gender incongruence, only asking to be treated as a different gender was a significant predictor, and only of work or scholastic dysfunction (OR 1·82). INTERPRETATION This study provides additional support for classifying health-related categories related to transgender identity outside the classification of mental disorders in the ICD-11. The reconceptualisation and related reclassification of transgender-related health conditions in the ICD-11 could serve as a useful instrument in the discussion of public health policies aimed at increasing access to appropriate services and reducing the victimisation of transgender people. FUNDING National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico.

Depresión: estado del conocimiento y la necesidad de políticas públicas y planes de acción en México

Depression is an important public health problem. It is the fourth cause of disease in the world in terms of lost years of healthy life. In Mexico, it ranks first in terms disability for women and ninth for men. There is a high comorbidity between depression and other mental disorders such as anxiety and substance abuse, as well as other serious and chronic physical conditions (e.g. diabetes, and heart disease). Despite the impact of depressive disorders in the quality of life of the population, there is a large proportion of people who don’t get treatment, delaying seeking help and thus don’t receive adequate assistance. The aim of this paper is to present an analysis of depression status in the Mexican population from a public health perspective; it includes prevalence and associated factors, gaps in care, characteristics of the use of services and treatments available. The paper concludes with a presentation of the implications for research and mental health policy in Mexico.

Screening for anxiety, depression, and anxious depression in primary care: A field study for ICD-11 PHC

BACKGROUND In this field study of WHOs revised classification of mental disorders for primary care settings, the ICD-11 PHC, we tested the usefulness of two five-item screening scales for anxiety and depression to be administered in primary care settings. METHODS The study was conducted in primary care settings in four large middle-income countries. Primary care physicians (PCPs) referred individuals who they suspected might be psychologically distressed to the study. Screening scales as well as a structured diagnostic interview, the revised Clinical Interview Schedule (CIS-R), adapted for proposed decision rules in ICD-11 PHC, were administered to 1488 participants. RESULTS A score of 3 or more on one or both screening scale predicted 89.6% of above-threshold mood or anxiety disorder diagnoses on the CIS-R. Anxious depression was the most common CIS-R diagnosis among referred patients. However, there was an exact diagnostic match between the screening scales and the CIS-R in only 62.9% of those with high scores. LIMITATIONS This study was confined to those in whom the PCP suspected psychological distress, so does not provide information about the prevalence of mental disorders in primary care settings. CONCLUSIONS The two five-item screening scales for anxiety and depression provide a practical way for PCPs to evaluate the likelihood of mood and anxiety disorders without paper and pencil measures that are not feasible in many settings. These scales may provide substantially improved case detection as compared to current primary care practice and a realistic alternative to complex diagnostic algorithms used by specialist mental health professionals.

Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO's revised classification of mental disorders in primary care settings

OBJECTIVE A World Health Organization (WHO) field study conducted in five countries assessed proposals for Bodily Stress Syndrome (BSS) and Health Anxiety (HA) for the Primary Health Care Version of ICD-11. BSS requires multiple somatic symptoms not caused by known physical pathology and associated with distress or dysfunction. HA involves persistent, intrusive fears of having an illness or intense preoccupation with and misinterpretation of bodily sensations. This study examined how the proposed descriptions for BSS and HA corresponded to what was observed by working primary care physicians (PCPs) in participating countries, and the relationship of BSS and HA to depressive and anxiety disorders and to disability. METHOD PCPs referred patients judged to have BSS or HA, who were then interviewed using a standardized psychiatric interview and a standardized measure of disability. RESULTS Of 587 patients with BSS or HA, 70.4% were identified as having both conditions. Participants had an average of 10.9 somatic symptoms. Patients who presented somatic symptoms across multiple body systems were more disabled than patients with symptoms in a single system. Most referred patients (78.9%) had co-occurring diagnoses of depression, anxiety, or both. Anxious depression was the most common co-occurring psychological disorder, associated with the greatest disability. CONCLUSION Study results indicate the importance of assessing for mood and anxiety disorders among patients who present multiple somatic symptoms without identifiable physical pathology. Although highly co-occurring with each other and with mood and anxiety disorders, BSS and HA represent distinct constructs that correspond to important presentations in primary care.

Categories That Should Be Removed From Mental Disorders Classifications: Perspectives and Rationales of Clinicians From Eight Countries

OBJECTIVE To explore the rationales of mental health professionals (mainly psychiatrists and psychologists) from 8 countries for removing specific diagnostic categories from mental disorders classification systems. METHOD As part of a larger study, 505 participants indicated which of 60 major disorders should be omitted from mental disorders classification systems and provided rationales. Rationale statements were analyzed using inductive content analysis. RESULTS The majority of clinicians (60.4%) indicated that 1 or more disorders should be removed. The most common rationales were (a) problematic boundaries between normal and psychopathological conditions (45.9% of total removal recommendations), (b) problematic boundaries among mental disorders (25.4%), and (c) problematic boundaries between mental and physical disorders (24.0%). The categories most frequently recommended for deletion were gender identity disorder, sexual dysfunction, and paraphilias, usually because clinicians viewed these categories as being based on stigmatization of a way of being and behaving. A range of neurocognitive disorders were described as better conceptualized as nonpsychiatric medical conditions. Results were analyzed by country and country income level. Although gender identity disorder was the category most frequently recommended for removal overall, clinicians from Spain, India, and Mexico were most likely to do so and clinicians from Nigeria and Japan least likely, probably because of social and systemic factors that vary by country. Systematic differences in removal rationales by country income level may be related to the development, structure, and functioning of health systems. CONCLUSION Implications for development and dissemination of the classification of mental and behavioral disorders in WHOs ICD-11 are discussed.

Gender-related issues in the diagnosis and classification of alcohol use disorders among Mexican patients seeking specialized services

OBJECTIVE The objective of the study was to examine the role of gender in the endorsement of symptoms included in both the International Classification of Diseases-10th Edition and the Diagnostic and Statistical Manual of Mental Disorders-4th Edition. METHOD Six hundred patients treated for alcohol-related problems in outpatient services in Mexico were evaluated with the Substance Abuse Module of the Composite International Diagnostic Interview. RESULTS Confirmatory factor analyses using the International Classification of Diseases-10th Edition and Diagnostic and Statistical Manual of Mental Disorders-4th Edition criteria produced two factors that included a combination of abuse/harmful alcohol use and dependence symptoms, which explained 40% and 49.2% of the total variance, respectively. In the abuse/harmful use groups of patients, symptoms and social consequences differed according to gender: withdrawal syndrome, lack of control and legal problems were more frequent in men, while women exhibited higher rates of attempts to give up alcohol and difficulties to accomplish daily activities. Specific gender-related factors differentiated abuse/harmful use from dependence, such as loss of control and time spent to drink in the case of men and desire to drink among women, according to the Diagnostic and Statistical Manual of Mental Disorders-4th Edition dependence criteria; and presence of physical symptoms in men and family/social problems, craving, and futile effort to stop drinking in women, according to the International Classification of Diseases-10th Edition dependence criteria. CONCLUSION Future classification systems of substance abuse disorders should take into account differences between genders in order to help closing the treatment gap for women.

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.