Classification of mental disorders: a global mental health perspective

Mental disorders are common in all countries, affect every community and age group, contribute substantially to the overall burden of disease, and have major economic and social consequences and effects on human rights. However, the greatest inequities are cross-national: 80% of people affected by mental disorders live in low-income and middle-income countries, which benefit from scarcely 10% of global mental health resources. Global mental health initiatives attempt to improve the availability of, access to, and quality of services for people with mental disorders worldwide. Diagnostic categories and a classification of mental disorders, which are essential to achieve objectives of global mental health, are needed for a range of stakeholders: for health-care practitioners to make treatment decisions and implement clinical guidelines; for policy makers to make decisions about allocation of resources; and for patients and their families to gain an understanding of their disorders. But can contemporary psychiatric classifications meet these needs?

Non-specialist health professionals working in routine health-care settings deliver more than 90% of mental health care worldwide. Psychiatric disorders are frequently diagnosed in epidemiological surveys in community and primary care populations, in particular the common mental disorders of depression, anxiety, somatoform, and stress-related disorders (all of which are distinct categories in contemporary classifications). However, a large gap often exists between the numbers reported in surveys and those recorded by primary care workers. The response of psychiatry has traditionally been to assume that these workers are not well informed about contemporary psychiatric concepts. Many strategies, such as the use of simple diagnostic algorithms, straightforward management guidelines, training programmes to improve skills, and advocacy campaigns, were developed and implemented to address this gap.1 However, these approaches did not seem to substantially change primary care worker behaviour, or improve detection rates or outcomes in developed nations or low and middle-income countries.2, 3, 4 Indeed, one of us (VP) had proposed that even the term “mental” needed to be dropped altogether from such training.4

The American Psychiatric Association, who produced the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV), and WHO, who produced the International Classification of Diseases tenth revision (ICD-10), also published concise versions of these classifications for use in primary care (DSM-IV PC and the ICD-10 PHC).5, 6 They reduced the number of categories (eg, from hundreds of ICD-10 categories to 26 in ICD-10 PHC), the many categories of depressive and anxiety disorders were reduced into single categories, and the more obscure diagnostic categories (eg, dissociative stupor) were dropped altogether. However, these simplified schemes remained virtually unknown and unused in primary care worldwide. Nevertheless, there are plans to release similar primary care versions (DSM-5 PC and ICD-11 PHC) to correspond to the latest revisions of these classifications. Given the allegiance that these classifications owe to their parent classifications, we doubt that they will be suitable for the global mental health cause.

The vast differences in settings, patient populations, and perspectives between psychiatrists and primary health-care professionals demand caution in the translation of specialist concepts and classifications for use in primary care. Primary care workers typically see patients with mild and non-specific symptoms, subsyndromal and mixed presentations, often clustered around the case threshold and frequently associated with psychosocial adversity and with physical health problems.7, 8, 9 They recognise the importance of psychosocial circumstances (eg, stress, personal resources, coping, social supports, and culture) and their effect on mental health. They prefer not to use mental disorder labels because of the high rates of spontaneous remission and placebo response and the absence of improvement with antidepressant drugs in those with mild disorders.10A related serious concern for primary care workers is the medicalisation of human distress.11, 12 They contend that the use of symptoms to diagnose mental disorders, without consideration of context, in particular psychosocial adversity, essentially flags non-clinically significant distress, especially at lower degrees of severity.

Although psychiatrists prefer to use disorder labels, primary care workers often favour dimensions of distress for presentations of common mental disorders. Primary care workers seem to be uncomfortable with the use of the notion of mental disorder, with its disease halo, which sidesteps the disease–illness dichotomy while attempting to encompass both disease and distress. Consequently, these practitioners mostly do not use psychiatric categories at all, preferring to avoid potentially stigmatising and meaningless labels, or use categories like “mixed anxiety–depression” and “adjustment disorders”. However, mixed anxiety and depression is not included in DSM-5,13 ICD-11-PHC,14 or in the recent WHO guidelines, which are designed explicitly for primary care.15Adjustment disorders are also excluded from ICD-11-PHC and the WHO Mental Health Gap Action Programme and have a subordinate status in the DSM-5. Dimensional approaches to distress and categories that are most common and useful in primary care are poorly addressed in contemporary classifications. Psychiatry has also reified common symptoms of disorders frequently seen in specialist settings, while primary care workers, who understand local contexts, acknowledge several variants of distress. Perhaps the most outstanding example of this discrepancy is the diagnosis of depression: not surprisingly, people with depression who consult a mental health specialist proffer their emotional and cognitive symptoms, but those in primary care almost never do so, and instead prefer to discuss their somatic and behavioural symptoms.

These discrepancies force primary care workers to favour the recording of reasons for the clinical encounter or the recognition of broader clinical presentations instead of using specific psychiatric labels. This situation is a key reason why primary care workers use the International Classification of Primary Care-2,16 which focuses on reasons for clinical encounters, patient data, and clinical activity. Although primary care workers do make specific diagnoses for medical disorders when reliable, valid, and laboratory diagnoses are available, they tend to focus on reasons for the clinical consultation, distress, and functioning in other contexts. Primary care workers argue that psychiatric syndrome labels are unsuitable because most of their patients have mild, subsyndromal, and mixed presentations,7, 8, 9, 17 which are often associated with psychosocial adversity. They reject the mechanistic application of psychiatric hierarchies, which subordinate adjustment problems to mental disorders by discounting psychosocial contexts. Consequently, specialist perspectives, which dominate the academic discourse and official classifications, are rarely used in primary care practice. Despite buy-in by academic primary care workers who endorse psychiatric approaches in primary care, there seem to be very few takers in front-line primary care, especially in low-income and middle-income countries. The many differences in patient populations and perspectives suggest a so-called category fallacy when specialist cultures are blindly imposed on primary care.

Most evidence argues that contemporary classifications (eg, DSM-IV/5 and ICD-10/11) and their diluted versions for primary care will be of little use in global mental health. Poor agreement between the diagnostic approaches adopted by psychiatry and those that are useful in primary care will also result in a failure of policy and health system strategies to improve mental health care. The DSM is a context-bound classification unique to the health system characteristic of psychiatric care in the USA. Conversely, the ICD for mental disorders is bound to the specialist culture of international psychiatry. In view of the enormous barriers to their application in most mental health consultations worldwide, primary care workers, although cautious about expressing resistance, openly use a different dialogue among themselves, which then dictates their practice. However, any resistance or challenge to specialist perspectives on mental disorders in primary care usually generates incredulity among psychiatrists and a reinforcement of their belief that re-training of primary care workers is the solution. We disagree. Our experience shows the problem is not just about the skills of primary care workers but also the approach adopted in contemporary classifications.

Global mental health needs a pragmatic classification that addresses the prevalent disorders in primary care and community settings, acknowledges both the dimensional and categorical nature of common mental health symptoms, addresses contextual issues, and that can easily be incorporated into routine health-care platforms across diverse settings. This aim does not just mean reduction in the number of labels or in their complexity, but the creation of categories relevant to and frequently seen in primary care. The fact that labels will vary across languages and cultures should be explicitly acknowledged, and diagnostic practices must be adapted to suit these variations. Put bluntly, if very few patients report feeling depressed, then the value of imposing the label “depression” is questionable; unsurprisingly, most global mental health interventions targeting depression in low-income and middle-income countries avoid the use of the label altogether.18

Many narratives of mental distress and disorder across settings exist that argue against one authentic version of these complex accounts. Their diversity and contradictions are a testimony to the pluralism of mental health-care traditions. Consequently, primary care needs to consider its own reality and devise a classification for mental distress and disorder that is usable in routine clinical practice, rather than work with a handed-down, diluted version of specialist approaches. Mental disorders in primary care need to be understood and theorised independently of specialist perspectives.19 The process of the identification of common presentations and development of a classification system and management protocols in primary care needs to be led and owned by primary care workers, and this process needs to engage with communities, donors, or policy makers who are major stakeholders for global mental health.

Declaration of interests

The views expressed in this Viewpoint are those of the authors. KSJ is a member of WHO’s Primary Care Consultation Group involved in the revision of the International Classification of Diseases of Mental Disorders tenth revision for primary care. VP is supported by a Wellcome Trust Senior Research Fellowship in Clinical Science, and by grants from the National Institute of Mental Health, the Department of International Development, Grand Challenges Canada, Autism Speaks, and the Sir Jamsetji Tata Trust. He was cochair of the DSM-5 working group on somatoform disorders. The authors declare that they have no other competing interests.

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