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The ICD-11 CDDR: benefits to health systems and clinical care
World Psychiatry ( IF 60.5 ) Pub Date : 2024-09-16 , DOI: 10.1002/wps.21250
Oye Gureje 1
Affiliation  

At their most basic level, classification systems provide health professionals with tools to assist them in identifying people in need of health services and deciding which treatments are most likely to be effective. Moreover, the World Health Organization (WHO) expects the ICD-11 chapter on mental, behavioural and neurodevelopment disorders to provide its member states with a tool to help them reduce the disease burden associated with these disorders.

The development of the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR)1 was guided by current scientific evidence and best clinical practices. An overarching goal was to enhance the capability of the tool to serve as a global common language to facilitate communication among: a) health workers, who not only make decisions about the nature of mental health problems and what treatment to offer, but also consult and refer to one another; b) service users and caregivers, to help them be informed about the nature of their conditions and engage in decisions about their care; and c) member states, who need to collect and collate data from health encounters in the form of health statistics that are crucial for evidence-based health policy and planning.

To perform these functions, the CDDR must be valid, reliable, and fit for purpose, that is, have clinical utility. Even though advances in neurogenetics and psychophysiology have not provided sufficient basis for new characterizations of mental health conditions, the diagnostic validity of those conditions – that is, the evidence to affirm that the constructs are what they purport to be – has nevertheless been supported by empirical studies of responsiveness to treatment and patterns of clinical outcomes2. In retaining or including new diagnostic categories for the CDDR, this evidence was comprehensively reviewed and drawn upon to establish validity. The reliability of the diagnosis of highly burdensome conditions was evaluated by clinician raters of differing levels of experience across diverse country settings.

The WHO also devoted major effort to ensuring that the categories and diagnostic guidance contained in the ICD-11 and CDDR had adequate and demonstrable clinical utility3. Drawing on previous work4, the WHO used a more elaborate definition of clinical utility that included: a) conceptualization (the extent to which the construct or category helps in understanding the patient's health condition); b) goodness of fit (the extent to which the guidelines accurately capture patients’ symptomatic presentations and help the clinician to select interventions and make relevant clinical management decisions); and c) ease of use (the feasibility of using the guidelines, especially in clinical settings where, typically, clinicians are often pressed for time).

To facilitate the global use of the CDDR, their applicability across diverse cultures was also a key consideration. First, given its reliance on empirical sources, psychiatric nosology is influenced by where the data come from. A classification that is limited in the sources of data for its development will be constrained in its breadth of applicability. The diversification of sources of data is therefore an important requirement for global applicability. Equally important is an effort to ensure that multiple perspectives are brought to bear in delineating the boundary between normative experiences and clinically significant deviations5. Second, an international classification must have flexibility for cultural responsiveness and sensitivity, given that cultures influence the pattern, form and presentation of most mental health conditions.

Diversification of the sources of data was ensured through conducting clinic-based studies in a network of international field study centers. These studies evaluated the clinical utility and usability of the proposed CDDR in natural conditions, as well as the reliability of diagnoses that most commonly bring people to seek care. The settings for the field studies were in 13 countries across all WHO global regions, with the studies conducted in the local language of each country. Complementarily, the WHO established the Global Clinical Practice Network (GCPN), which participated directly in the development of the ICD-11 CDDR through Internet-based field studies.

Irrespective of the quality of the data derived from these studies and the existing scientific literature, judgements still had to be made in defining what constitutes a mental health condition. That is, given the lack of sensitive and specific biomarkers to provide precise delineation of most mental disorders, it is hardly possible that decisions on the classification of these disorders can be made on the sole basis of the strength of the available research evidence. It was therefore imperative that, to enhance the relevance and global applicability of the CDDR, the decisions guiding the classification were made through consensus judgements in which diverse stakeholder groups were involved. Inclusiveness means that these stakeholder groups provided perspectives on what constitutes a deviation from normality5.

This consideration led the formation of multidisciplinary ICD-11 working groups, with each specifically composed to include representatives from all WHO regions – Africa, the Americas, Europe, the Eastern Mediterranean, Southeast Asia, and the Western Pacific. As in the selection of the field study sites – which included those based in Brazil, China, India, Mexico and Nigeria, countries representing about 43% of the world's population – each of the working groups also had a substantial proportion of experts from low- and middle-income countries.

As noted, cultural factors influence the presentation of mental health conditions, as well as how treatment options are negotiated and accepted by service users. Consideration of cultural factors improves decision-making during the clinical encounter and facilitates the delivery of holistic person-centred care. Attention was therefore given to how to enhance the relevance of the CDDR to the diverse cultural contexts in which they would be used.

Developing a culturally sensitive classification without detracting from the central goal of facilitating global communication required careful attention. The WHO constituted a Working Group on Cultural Considerations6, which conducted an extensive review of existing evidence about cultural influences on diagnosis and psychopathology for each diagnostic category, including relevant cultural formulations in the ICD-10 and DSM-5. The result is a section on “culture-related features” for each diagnostic category in the CDDR. Designed to be practical and actionable, this section seeks to highlight contextually relevant cultural issues that can support clinicians in making informed decisions about the patient's condition and lived experience, as well as negotiating appropriate intervention options. It does this without detracting from the ability to communicate clinical findings and decisions among providers within and outside the particular cultural setting.

At the beginning of its work, the WHO International Advisory Group – mandated to organize the program of revision activities – noted that, to facilitate access to appropriate mental health services, the identification and treatment of health conditions for which people seek care need to be supported by a classification system that is precise, valid and clinically useful7. The results of the field studies show that common and high-burden disorders were diagnosed reliably using the CDDR, and that the requirements can be interpreted consistently across a wide range of countries8. Importantly, the CDDR's approach of describing the essential features of each disorder – to reflect real-life patterns of clinical decision-making and avoiding the reification of arbitrary cutoffs or symptom counts – was found to have high clinical utility9.

更新日期:2024-09-21
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