Feature

For the first time, psychologists are playing a key role in the revision of the International Classification of Diseases (ICD).

A part of the mission of the World Health Organization (WHO), the ICD is the global standard for diagnostic classification of all health conditions for clinical, health management and epidemiological purposes. At the national level, WHO’s member countries use the ICD in morbidity and mortality statistics, while individual practitioners use its codes for reimbursement purposes. The Health Insurance Portability and Accountability Act’s electronic transactions rule requires psychologists and other U.S. health-care providers to use ICD codes for billing.

WHO is revising the ICD for the first time in two decades and the 11th time since it was first published in 1893 — a process that will have major implications for U.S. psychologists.

Psychologist Geoffrey M. Reed, PhD, a senior project officer in WHO’s Department of Mental Health and Substance Abuse, is coordinating the revisions to the ICD’s section on mental and behavioral disorders. He’s also centrally involved in revising the section on diseases of the nervous system, which include Alzheimer’s, sleep disorders and headaches.

Psychologists from around the world are serving on the working groups that are reviewing and proposing changes to specific sections, such as intellectual disabilities, mental disorders in children and adolescents and personality disorders, within the ICD’s current revision effort. More will join in as additional working groups are formed, Reed predicts.

“With previous revisions, the revision of the mental health section has been led by psychiatrists and has not been open to other professions,” says Lynn Bufka, PhD, assistant executive director for practice research and policy in APA’s Practice Directorate. “This is a first. It’s a big deal.”

A multidisciplinary approach

What accounts for the shift from a purely psychiatric approach to a more multidisciplinary one? Reed credits his boss, psychiatrist Shekhar Saxena, MD, who was promoted to director of the Department of Mental Health and Substance Abuse in March. Saxena decided to involve psychology, nursing, primary care and other disciplines in the revision because psychiatrists provide less than 10 percent of the care for people with mental disorders in the world.

The ICD system must be usable by a variety of professionals if it is to help WHO’s 193 member countries reduce the disease burden associated with mental disorders, says Reed. Eighty-five percent of the world’s population lives in countries with few resources and often very few specialist providers, he points out.

“Often, efforts to diagnose and then treat mental disorders are being initiated by primary-care people, who in some cases might be a nurse in a village,” says John E. Lochman, PhD, a University of Alabama clinical psychology professor who serves on the work group examining the section on mental disorders among children and adolescents. “It’s important to have a diagnostic system accessible enough to be used by nonspecialists.”

The end product of this revision, expected in 2014, will be an electronic database in addition to the customary book. Researchers, mental health specialists and nonspecialists will be able to use the publicly accessible database to create customized versions of the classifications depending on the level of detail they need.

Epidemiologists might want very specific diagnostic criteria to use as they recruit study participants, for example. Primary care clinicians, on the other hand, could just download the basics as they decide whether or not a patient needs further treatment.

Possible changes

While the focus will shift from specialists to nonspecialist users of the ICD, Reed doesn’t foresee major changes in the content of the mental and behavioral disorders section.

“There’s not the degree of scientific, neuroscientific or genetic evidence that would cause us to make major changes in the classifications at this point,” he says. “That’s part of why we think this is a big opportunity to improve the classification’s clinical utility.”

In addition to convening multidisciplinary, international work groups on such diagnostic categories as psychotic disorders and substance abuse disorders, Reed and his colleagues plan to launch a series of field studies to explore how clinicians themselves view mental and behavioral disorders. The goal is to make the revision more user-friendly by ensuring that its diagnostic categories align with actual clinical experience.

One area that probably will change is the way personality disorders are classified, predicts Roger K. Blashfield, PhD, a psychology professor at Auburn University in Auburn, Ala., who serves on the personality disorders work group. Current diagnostic criteria for personality disorders suffer from extensive overlap, says Blashfield, who emphasizes that his opinions are his own and not WHO’s official policy. Since about a quarter of patients who meet the criteria for one personality disorder will meet criteria for five or more, he says, some streamlining may be in order. Another problem the working group plans to address is the fact that clinicians in the developing world are often reluctant to use these diagnoses.

“The question is whether they are Western cultural stereotypes,” says Blashfield. “Or are they being avoided because they’re stigmatizing terms?”

In the work group on mental health disorders in children and adolescents, one major concern is the soaring rate of bipolar disorder diagnoses in children.

“We’ll be thinking about alternate diagnoses that could be given that could capture at least a portion of those children who receive bipolar disorder diagnoses, but may not truly be bipolar,” says Lochman.

Another issue the group will tackle is whether to include callous and unemotional traits within the conduct disorder diagnosis or make them a separate diagnosis.

Because the Diagnostic and Statistical Manual of Mental Disorders (DSM) is also being revised, Reed and the various work groups are in close contact with the American Psychiatric Association as both groups grapple with these and other issues. The DSM’s fifth edition will be published in 2013.

The work group on children and adolescents has a liaison who is involved in the DSM revision, for instance. “We’ve received a lot of the working documents that have been developed by the DSM work groups,” says Lochman.

Implications for practitioners

Even when psychologists use DSM codes for making diagnoses, these must be converted to ICD codes for purposes of billing, reimbursement and health statistics reporting.

But, while the United States is still using ICD-9, most of the rest of the world uses the current version — ICD-10. The United States is set to adopt the ICD-10 in 2013 — just as everyone else starts preparing to use the ICD-11.

“The ICD-10 has been around for almost 20 years, and the U.S. has never converted to it — mostly because there are so many payers, so many systems, so many places where the conversion would need to happen,” says Bufka. “Everyone has always argued it would take too long and be too difficult.”

The shift to the ICD-10 and then the ICD-11 will require learning the new codes and possibly new diagnostic categories, depending on the extent of the revision.

“It may be that the final version of ICD-11 will look very different because of the greater involvement of more professions with different perspectives,” says Bufka.

APA will work with WHO and the U.S. Center for National Health Statistics to ensure that U.S. psychologists won’t have to undergo two big learning curves. This could happen through annual updates of ICD-10-Clinical Modification (ICD-10-CM) to bring it into line with ICD-11.

Everybody thinks that instead of having these dramatic revisions every 10 years, it would be better to have a more regular sort of updating process, says Reed. “This way,” he says, “within five or six years, the ICD-10-CM would have caught up to ICD-11, so there will be gradual changes rather than a big, sudden shift.”


Rebecca A. Clay is a writer in Washington, D.C.