Abstract
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.
Keywords: Classifications of mental disorders, ICD‐11, ICD‐10, DSM‐5, Global Clinical Practice Network, ordinary clinical practice, psychiatric diagnosis, use for administrative purposes, clinical utility, residual diagnostic categories
For the past ten years, the World Health Organization (WHO) has been revising the Mental and Behavioural Disorders chapter as part of the development of the 11th edition of the International Classification of Diseases and Related Health Problems (ICD‐11). A major focus of the proposed changes for ICD‐11 has been to improve the clinical utility of the classification for use by frontline mental health professionals, including psychiatrists1.
A first step in efforts to improve the clinical utility of a classification is to collect baseline information about how the classification is currently being used2, 3. Two surveys were conducted by the WHO at the outset of the ICD‐11 revision process in order to determine psychiatrists'4 and psychologists'5 attitudes towards, and usage of, mental health classifications. Survey questions were primarily directed towards assessing respondents' views about the classification of mental disorders, covering topics such as their opinions about the main purposes of a classification system, the ideal number of diagnostic categories, the desired level of flexibility in application of the criteria, the best way to address concepts of severity and functional status, whether disorders should be rated dimensionally or categorically, and whether the current classification system is difficult to apply cross‐culturally. The minority of questions focusing on classification usage included how often a formal classification was used in day‐to‐day clinical work, which classification was used most, and which diagnostic categories were most used in daily clinical practice. For those diagnoses used at least once per week, respondents provided ratings of their ease of use and goodness of fit.
In those surveys, 79% of participating psychiatrists and 60% of participating psychologists reported that they “often” or “almost always” use a formal classification system as part of their everyday clinical work, with an additional 14% of psychiatrists and 18% of psychologists indicating that they “sometimes” use one. However, these results do not tell us precisely how clinicians use formal classification systems in their practices. For example, such use might involve employing only the diagnostic labels or the diagnostic codes, using diagnostic prototypes embodied in the classification's definitions, or applying diagnostic guidelines or criteria6. In fact, conventional wisdom about psychiatrists' use of classification systems suggests that ICD is often used only as a coding system to meet administrative requirements, so that the impact of revisions of that system may be lower than usually realized.
In fact, very little is known about the global implementation of either the ICD or DSM classifications by psychiatrists and other mental health professionals in their clinical practices. Most of the limited information we have about clinicians' reported clinical usage of psychiatric classifications comes from surveys7, 8, 9, 10, 11. Those surveys, however, have focused almost entirely on respondents' attitudes and preferences about classification systems, rather than on collecting information about their usage. For example, a survey developed by Mellsop et al in 200612, administered to psychiatrists in seven different countries13, 14 included only one general question about usage, asking respondents how often (i.e., routinely, sometimes, or never) they used each of the five DSM‐IV axes, ICD‐10, and the International Classification of Functioning (ICF) in their clinical practice. An exception was a 1991 survey of American child psychiatrists attending a national meeting, which included several specific questions regarding how respondents used the DSM‐III‐R criteria for childhood disorders15. The survey found that, depending on the diagnosis, 47 to 66% of the respondents reported that they generally assessed all applicable DSM‐III‐R criteria when making a diagnosis and that 28 to 49% often referred to the manual before assigning a diagnosis.
The present paper reports on a detailed survey of global mental health professionals' actual usage of the ICD‐10 and the most recent two editions of the DSM. Its purpose was to shed light on clinicians' use of the various components of ICD and DSM (i.e., diagnostic codes, diagnostic guidelines/criteria, descriptive text) as a part of their routine clinical practice, as well as to compare clinicians' patterns of use of these two classifications. The survey also queried clinicians about their attitudes concerning the utility of the ICD and DSM for various purposes (e.g., communication, treatment selection), as well as collecting information about their usage of the “residual” categories (i.e., other specified, unspecified, not otherwise specified).
Both the ICD and DSM include such “residual categories” for use in situations where the patients' clinical presentation does not meet the definitional requirements for any specific disorder or when there is insufficient information available for the clinician to make a specific diagnosis (for example, in an emergency department setting). However, it has been suggested that the relatively high rates of the use of these categories may in fact be an indirect clue that clinicians find the ICD/DSM categories difficult to use or not accurately descriptive of their patients16, or that providing specific diagnostic information in a patient's medical record may be harmful to the patient (e.g., stigmatizing).
The survey was conducted with clinicians registered as a part of the Global Clinical Practice Network (GCPN)17, 18, which was established by the WHO Department of Mental Health and Substance Abuse for the purpose of direct participation by clinicians around the world in field studies related to the development of the ICD‐11 chapter on Mental and Behavioural Disorders. GCPN members are mental health professionals who have completed their training and are qualified to practice in their country of residence (https://gcp.net). The GCPN consists now of more than 14,000 mental health professionals from 154 countries, more than half of whom are psychiatrists. Although the network was initially established for the purpose of conducting ICD‐11 field studies via the Internet19, it also provides an opportunity to survey clinicians from a range of professional backgrounds and from all over the world on other related topics. The present survey of classification usage is the first of the network to study a topic other than the new ICD‐11 diagnostic guidelines.
METHODS
Participants
Participants were recruited from the GCPN. At the time of study sample selection, there were 11,707 registered GCPN members from 139 countries, across nine registration languages. It was determined that the study would be conducted in six languages: Chinese, English, French, Japanese, Spanish and Russian. Language selection was based on an adequate number of GCPN members who are proficient in that language and the availability of appropriate translation resources.
The Internet‐based survey used in the study was programmed in the six languages using the Qualtrics survey software. The survey contained questions related to classification use followed by a separate module on technology use. The original survey was developed in English, assessed for global applicability and relevance (e.g., examples used in questions), and then translated into the other five languages using a rigorous process including validation by bilingual content experts19.
Survey invitations were sent directly via Qualtrics to 9,792 registered GCPN members who, based on information provided at the time of registration, were proficient in one of the study languages and were actively providing clinical services or direct clinical supervision. Reminder e‐mails were sent two and four weeks after the first invitation to all those who had not yet completed the survey. Data collection in each language was closed two months after the initial invitation.
Of the 9,792 GCPN members invited to participate, 2,960 (30.2%) clicked on the embedded link in the survey invitation and explicitly agreed to participate in the study by confirming consent in the first survey question. This participation rate is comparable to the diagnostic field studies conducted using the GCPN.
At the beginning of the survey, consenting participants were asked to state whether they: a) were currently providing direct mental health services to patients for at least one hour per week, b) were usually responsible for assigning a mental disorder diagnosis to patients, and c) had often or routinely used the ICD‐10 or a version of the DSM (DSM‐5, DSM‐IV or DSM‐IV‐TR) during the past year, which was determined based on their response to a four‐point scale (never/rarely, sometimes, often, routinely). Individuals who did not meet the above criteria were not asked the remaining questions about classification use, but instead taken directly to the technology module.
Participants who indicated that they had often or routinely used only one of the target classification systems during the past year were asked a series of detailed follow‐up questions for that particular classification system. Participants who indicated that they had often or routinely used both the ICD‐10 and some edition of the DSM during the last year (“mixed users”) were asked to indicate those purposes for which they used the ICD and DSM classifications often or routinely. If they indicated that they used either the ICD or DSM for clinical purposes, they were then asked to answer detailed questions regarding that system. Participants who indicated that they used both the ICD‐10 and some edition of the DSM for clinical purposes were assigned to answer detailed questions about ICD‐10. Participants who indicated that they used the DSM for clinical purposes were instructed to answer detailed questions on the version of the DSM they were using, with preference given to the DSM‐5 if they were using more than one version. Meaningful differences in patterns of use were not found between users of the DSM‐5, DSM‐IV or DSM‐IV‐TR, so DSM users were combined in the analyses.
Survey content
Once assigned to either the ICD‐10 or a DSM use module, participants were asked to indicate which version(s) they had used over the past year in either printed or electronic format. A unique feature of the ICD‐10 is the existence of different versions20, including the Clinical Descriptions and Diagnostic Guidelines21, intended for use by mental health professionals in clinical practice, the Diagnostic Criteria for Research22, and the statistical version of the classification, used for the collection and reporting of health information by WHO member states, which contains only brief definitions of mental and behavioural disorders23. ICD‐10 users were asked to indicate whether they had used each of these three versions within the past year and, if they had not used a particular version, whether they had ever seen it. Participants were presented with samples of each system so that they would report as accurately as possible regarding their use of specific versions. Both ICD‐10 and DSM users were asked questions about their use of printed and electronic formats of the relevant system.
Participants were then asked to provide detailed information about how frequently they used the assigned diagnostic system in specific ways (e.g., systematically going through the diagnostic guidelines or criteria, reviewing other parts of available text in addition to diagnostic guidelines or criteria) and for specific purposes (e.g., administrative and billing uses, communicating with patients and family members). Frequency of usage was assessed using a four‐point scale (never/rarely, sometimes, often, routinely) for the initial diagnostic phase and during the ongoing treatment of patients. Participants were also asked to rate the utility of the relevant diagnostic system for specific purposes (e.g., selecting a treatment, assessing probable prognosis) using the following four‐point scale: not at all/slightly useful, moderately useful, very useful, extremely useful.
Finally, participants were asked how often they used “other specified” or “unspecified” categories in the ICD‐10 or “not otherwise specified” categories in the DSM, and offered a range of reasons for using these categories. In order to determine whether the respondents were using these categories appropriately, the range of reasons included some that would be considered legitimate (e.g., for presentations that do not conform to any specified category) and others that would be more questionable (e.g., to prevent more specific diagnostic information from being entered into the patient's record).
RESULTS
Sample demographics
After excluding participants who did not meet the eligibility requirements for the survey and 13 individuals who agreed to participate and met the eligibility requirements but did not provide sufficient data for analysis, the final sample for the study consisted of 1,764 GCPN members. As shown in Table 1, these included 1,335 participants who were assigned the ICD‐10 version of the survey (75.7% of the sample) and 429 participants who were assigned the DSM version of the survey (24.3%).
Table 1.
Demographic characteristics of the sample
| Completed ICD‐10 version of survey (N=1,335) | Completed DSM version of survey (N=429) |
Total (N=1,764) |
|
|---|---|---|---|
| Age at time of network registration, years (mean±SD) | 45.4 ± 10.7 | 48.6 ± 12.6 | 46.2 ± 11.3 |
| Years of experience after training completion (mean±SD) | 15.6 ± 10.1 | 17.5± 11.7 | 16.1 ± 10.5 |
| Gender, N (%) | |||
| Male | 877 (65.7) | 242 (56.4) | 1,119 (63.4) |
| Female | 457 (34.2) | 187 (43.6) | 644 (36.5) |
| Other or not available | 1 (<0.1) | 0 | 1 (<0.1) |
| Professional discipline, N (%) | |||
| Medicine | 1,102 (82.5) | 214 (49.9) | 1,316 (74.6) |
| Psychology | 198 (14.8) | 144 (33.6) | 342 (19.4) |
| Nursing | 2 (0.1) | 1 (0.2) | 3 (0.2) |
| Social work | 4 (0.3) | 27 (6.3) | 31 (1.8) |
| Counseling | 13 (1.0) | 23 (5.4) | 36 (2.0) |
| Sex therapy | 0 | 4 (0.9) | 4 (0.2) |
| Speech therapy | 1 (<0.1) | 0 | 1 (<0.1) |
| Occupational therapy | 14 (1.0) | 0 | 1 (<0.1) |
| Other | 16 (3.7) | 30 (1.7) | |
| Country income level, N (%) | |||
| High | 781 (58.5) | 284 (66.2) | 1,065 (60.4) |
| Upper‐middle | 404 (30.3) | 106 (24.7) | 510 (28.9) |
| Lower‐middle | 136 (10.2) | 27 (6.3) | 163 (9.2) |
| Low | 14 (1.0) | 11 (2.6) | 25 (1.4) |
| Language of participation, N (%) | |||
| Chinese | 254 (19.0) | 10 (2.3) | 264 (15.0) |
| English | 429 (32.1) | 204 (47.6) | 633 (35.9) |
| French | 144 (10.8) | 59 (13.8) | 203 (11.5) |
| Japanese | 137 (10.3) | 63 (14.7) | 200 (11.3) |
| Russian | 229 (17.2) | 0 | 229 (13.0) |
| Spanish | 142 (10.6) | 93 (21.7) | 235 (13.3) |
| WHO global region, N (%) | |||
| Africa | 27 (2.0) | 15 (3.5) | 42 (2.4) |
| Americas ‐ North | 11 (0.8) | 131 (30.5) | 142 (8.0) |
| Americas ‐ South | 128 (9.6) | 78 (18.2) | 206 (11.7) |
| Eastern Mediterranean | 24 (1.8) | 31 (7.2) | 55 (3.1) |
| Europe | 644 (48.2) | 71 (16.6) | 715 (40.5) |
| South‐East Asia | 92 (6.9) | 15 (3.5) | 107 (6.1) |
| Western Pacific ‐ Asia | 395 (29.6) | 74 (17.2) | 469 (26.6) |
| Western Pacific ‐ Oceania | 14 (1.0) | 14 (3.3) | 28 (1.6) |
Demographic characteristics of the sample are shown in Table 1. Nearly two‐thirds of the sample (63.4%) were male and three‐quarters (74.6%) were physicians, approximately 90% of whom were psychiatrists. Participants were from 92 countries, and 39.5% were practicing in low‐ or middle‐income countries. All global regions were represented; while the representation of regions appears imbalanced, it closely resembles the representation of mental health professionals across the world24. A substantial majority (64.1%) completed the survey in a language other than English. The average age of participants was 46.2 ± 11.3 years, with a mean of 16.1 ± 10.5 years of experience following completion of their training.
Classification usage
When asked about which version of the classification they were using during the past year, almost three‐quarters of the ICD‐10 users (73.8%) reported that they had used the Clinical Descriptions and Diagnostic Guidelines, while 26.4% had used the Diagnostic Criteria for Research, and 32.0% had used the statistical version (percentages are non‐exclusive). Only 7.6% of ICD‐10 users indicated that they had never seen the Clinical Descriptions and Diagnostic Guidelines. A majority of the DSM users (86.9%) reported using the full version (i.e., diagnostic criteria plus descriptive text), 47.3% used the version containing only the diagnostic criteria and 11.7% used a listing of DSM disorders and codes without diagnostic criteria (percentages are non‐exclusive).
Despite the availability of electronic sources of the diagnostic codes and diagnostic guidelines or criteria, respondents primarily relied on printed versions as their sources. With respect to obtaining diagnostic codes, while 93.3% of ICD‐10 users and 84.6% of DSM users reported obtaining them from printed versions, only 44.1% of ICD‐10 users and 30.5% of DSM‐5 users obtained them from electronic sources (e.g., WHO or American Psychiatric Association websites, drop‐down menus in electronic health records or other software). The breakdown of sources for obtaining diagnostic guidelines or criteria was similarity tilted towards printed versions, with 92.5% of ICD‐10 users and 84.8% of DSM users obtaining them from hardcopy sources and around 35% of both ICD‐10 and DSM‐5 users obtaining them electronically (percentages are non‐exclusive).
The usage pattern for various components of the diagnostic classifications (i.e., diagnostic codes, diagnostic guidelines/criteria, descriptive text) is presented in Table 2. Clinicians reported using diagnostic classifications most often for administrative or billing purposes, with 68.1% reporting that they used them often or routinely for the initial evaluation.
Table 2.
Overall classification usage pattern (N=1,764)
| Never/Rarely | Sometimes | Often | Routinely | |
|---|---|---|---|---|
| Frequency of use of diagnostic codes for administrative/billing purposes (%) | ||||
| Initial diagnosis | 18.4 | 13.5 | 19.2 | 48.9 |
| Ongoing treatment | 18.4 | 18.5 | 22.6 | 40.5 |
| Frequency of systematically going through diagnostic guidelines/criteria to determine whether they apply to individual cases (%) | ||||
| Initial diagnosis | 5.2 | 37.4 | 33.9 | 23.5 |
| Ongoing treatment | 8.8 | 43.2 | 31.3 | 16.7 |
| Frequency of making diagnosis without referring to diagnostic guidelines/criteria (%) | ||||
| Initial diagnosis | 18.2 | 32.0 | 36.8 | 13.0 |
| Ongoing treatment | 17.2 | 32.8 | 35.9 | 14.1 |
| Frequency of referring to relevant additional text sections outside diagnostic guidelines/criteria (%) | ||||
| Initial diagnosis | 16.8 | 46.9 | 26.1 | 10.1 |
| Ongoing treatment | 21.4 | 50.5 | 21.3 | 6.9 |
| Frequency of using the diagnostic system to communicate or share information with patient and/or family (%) | ||||
| Initial diagnosis | 25.9 | 39.2 | 21.1 | 13.8 |
| Ongoing treatment | 26.6 | 41.0 | 20.9 | 11.5 |
With respect to diagnostic practices, the survey asked respondents to indicate how often they systematically go through diagnostic guidelines or criteria to determine whether they apply to individual patients, as well as how often they make a diagnosis without referring to guidelines or criteria. These were not presented as mutually exclusive questions. A bit more than half (57.4%) of the respondents reported going through the diagnostic guidelines or criteria often or routinely during the initial assessment of individual patients, dropping to 48.0% during ongoing treatment. Approximately half of the clinicians reported often or routinely making a diagnosis without referring to the diagnostic guidelines or criteria, which was essentially the same during the initial diagnostic assessment and during ongoing treatment (49.8% and 50.0%, respectively). Usage of the additional text sections was much less common, with only 36.2% reporting that they referred to the text often or routinely during the initial evaluation, and only 28.2% during ongoing treatment.
Usage of the classification system for the purpose of communicating or sharing information with the patient or family was not frequent, with 34.9% using it often or routinely for that purpose during the initial evaluation and 32.4% during ongoing treatment.
In order to facilitate the comparison of usage patterns and utility ratings among ICD‐10 and DSM users, Likert scale frequency tables were converted to standard weighted frequencies. This was done by assigning a value of 1 to never/rarely, 2 to sometimes, 3 to often, and 4 to routinely, and multiplying the frequency of each response option by its point value. The resulting scores were then transformed into a standard weighted frequency by summing all the values for a question, subtracting that value from the minimum possible sum, and dividing the total by the range of possible scores. Using this method, the resulting values range from 0 to 1, are roughly on the same scale, and the magnitude of each individual response is taken into account.
Comparative usage patterns for ICD‐10 and DSM users during initial diagnosis and ongoing treatment are shown in Table 3. ICD‐10 users were more likely than DSM users to use it for administrative and billing purposes, especially during initial diagnosis. DSM users were less likely to indicate that they make diagnoses without referring to the diagnostic guidelines or criteria and more likely to indicate that they go through the diagnostic guidelines or criteria systematically to determine whether they apply to individual cases, but these differences were small in absolute terms. For both systems, participants indicated that they were more likely to go through the guidelines or criteria and to refer to additional text sections during the initial diagnostic assessment than during ongoing treatment.
Table 3.
Comparison of usage patterns for ICD‐10 and DSM users (standard weighted frequencies)
|
ICD‐10 (N=1,335) |
DSM (N=429) |
χ2 (df=3) | |
|---|---|---|---|
| Frequency of use of diagnostic codes for administrative/billing purposes | |||
| Initial diagnosis | .7021 | .5369 | 58.83*** |
| Ongoing treatment | .6557 | .4965 | 57.41*** |
| χ2 (df=3) | 28.66*** | 0.14 | |
| Frequency of systematically going through diagnostic guidelines/criteria to determine whether they apply to individual cases | |||
| Initial diagnosis | .5643 | .6511 | 32.79*** |
| Ongoing treatment | .5101 | .5478 | 7.18 |
| χ2 (df=3) | 24.28*** | 27.46*** | |
| Frequency of making diagnosis without referring to diagnostic guidelines/criteria | |||
| Initial diagnosis | .4961 | .4390 | 11.68** |
| Ongoing treatment | .4979 | .4639 | 4.33 |
| χ2 (df=3) | 1.61 | 1.99 | |
| Frequency of referring to relevant additional text sections outside diagnostic guidelines/criteria | |||
| Initial diagnosis | .4215 | .4646 | 8.63 * |
| Ongoing treatment | .3810 | .3722 | 1.98 |
| χ2 (df=3) | 14.55** | 23.77*** | |
| Frequency of using the diagnostic system to communicate or share information with patient and/or family | |||
| Initial diagnosis | .4010 | .4343 | 4.93 |
| Ongoing treatment | .3868 | .4017 | 2.50 |
| χ2 (df=3) | 3.49 | 2.15 | |
*p < 0.05, **p <0 .01, ***p <0.001
Utility of the classifications
Participants' ratings of the utility of the ICD‐10 and DSM during the past year for a variety of different purposes are shown in Table 4. Both systems received the highest ratings of utility for meeting administrative requirements, assigning a diagnosis, communicating with other health care professionals, and teaching trainees or students, and the lowest ratings for selecting a treatment and assessing probable prognosis.
Table 4.
Utility of ICD‐10 and DSM in the past year (standard weighted frequencies)
|
ICD‐10 (N=1,335) |
DSM (N=429) |
χ2 (df=3) | |
|---|---|---|---|
| Meeting administrative requirements | .7486 | .5066 | 236.71*** |
| Assigning a diagnosis | .6777 | .6589 | 4.85 |
| Selecting a treatment | .3658 | .3388 | 4.99 |
| Educating patient and/or family about diagnosis | .3910 | .4406 | 11.32 * |
| Assessing probable prognosis | .3870 | .3916 | 0.95 |
| Communicating with other health care professionals | .6449 | .6426 | 0.77 |
| Teaching trainees or students | .6275 | .6535 | 3.52 |
*p < 0.05, ***p < 0.001
ICD‐10 users rated that system as more useful for meeting administrative requirements as compared to ratings of the DSM by DSM users, and the DSM was judged by its users as slightly more useful for educating the patient and/or family about the diagnosis, although this latter difference was small in absolute terms. Otherwise, utility ratings by ICD‐10 and DSM users were similar.
Results concerning “mixed users”, i.e., those who reported that they often or routinely used both the ICD‐10 and some editions of the DSM, are shown in Table 5. In our experience, there is widespread confusion among US and Canadian professionals about whether they are using the ICD‐10 or the DSM for making diagnoses or for administrative purposes, due to the existence of US and Canadian clinical ICD modifications. For this reason, 55 survey participants from the US and Canada were not included in the analysis.
Table 5.
Usage of ICD‐10 and DSM by “mixed users” (N=605)
| ICD‐10 | DSM | χ2 (df=1) | |
|---|---|---|---|
| Fulfilling administrative requirements, N (%) | 428 (70.7) | 127(21.0) | 115.27*** |
| Assigning diagnoses in clinical practice, N (%) | 445 (73.6) | 458 (75.7) | 0.11 |
| Research, N (%) | 246 (40.7) | 475 (78.5) | 46.23*** |
| Education, N (%) | 347 (57.4) | 498 (82.3) | 15.97*** |
***p < 0.001
Mixed users were substantially more likely to report using the ICD‐10 (70.7%) than the DSM (21.0%) for fulfilling administrative requirements. However, they were equally likely to report using the ICD‐10 and the DSM for assigning diagnoses in clinical practice. Mixed users more frequently use the DSM for research and education.
Usage of “residual” categories
A total of 67.5% of ICD‐10 users and 72.7% of DSM users indicated that they at least sometimes employed “residual” categories, with 11.6% of ICD‐10 users and 19.3% of DSM users reporting that they employed these categories often or routinely. The reasons that participants endorsed for using these categories, expressed as standard weighted frequencies to facilitate comparisons, are shown in Table 6.
Table 6.
ICD‐10 and DSM users' reasons for employing “residual” categories (standard weighted frequencies)
|
ICD‐10 (N=916) |
DSM (N=317) |
χ2 (df=3) | |
|---|---|---|---|
| Because the patient's presentation does not conform to any of the specific categories | .6001 | .6090 | 1.61 |
| Because there is insufficient information to make a more specific diagnosis | .4554 | .4733 | 4.56 |
| To indicate that it cannot be determined whether the symptoms are due to a primary condition or are secondary | .2882 | .2863 | 0.11 |
| Because the patient meets the requirements for more than one diagnosis in a grouping | .2926 | .2265 | 17.64*** |
| To prevent more specific diagnostic information from being entered into the patient's record | .1850 | .1795 | 0.66 |
| Because making a more specific diagnosis is not useful for patient care | .1709 | .1934 | 2.75 |
***p < 0.001
The most commonly endorsed reasons for both ICD‐10 and DSM users were clinical presentations that do not conform to any specific diagnostic category and insufficient information to make a more specific diagnosis. There were no significant differences between the responses of ICD‐10 and DSM users except that the former were somewhat more likely to indicate that they employ these categories when the patient meets the diagnostic requirements for multiple categories in a grouping.
DISCUSSION
Clinicians make mental and behavioural disorder diagnoses in everyday clinical practice for a variety of reasons: a) a diagnosis is generally required in order to meet administrative requirements; b) diagnostic labels provide a convenient shorthand for communicating the patient's clinical presentation to other clinicians; c) a diagnosis is often important for determining the patient's prognosis and selection of treatment; and d) the diagnosis can facilitate the education of the patient and family about the illness. Diagnostic classification systems provide clinicians with tools intended to meet these needs: diagnostic codes for meeting administrative requirements, diagnostic guidelines or criteria to facilitate accurate and reliable diagnoses, and accompanying text to facilitate differential diagnosis and the appreciation of the role of developmental and culture‐related features in the clinical presentation. However, the extent to which clinicians make use of these elements of diagnostic systems in clinical practice is unknown3.
Several aspects of the results of this survey of GCPN users confirm conventional wisdom about patterns of classification usage. In particular, the most frequently reported use of a classification system is to obtain diagnostic codes for administrative or billing purposes. This almost certainly reflects the fact that the provision of a diagnostic code is a requirement for clinical encounters in most countries. Nonetheless, 18.4% of respondents reported that they rarely or never use a classification for that purpose, which likely reflects the fact that in some practice settings the responsibility for looking up the appropriate diagnostic code is not the clinician's but instead falls on non‐clinical personnel (e.g., medical billing and coding specialists).
A majority of GCPN clinicians (57.4%) reported that they often or routinely go through diagnostic guidelines or criteria systematically during the process of making an initial diagnosis, which is at variance with the widespread belief that clinicians only use the classification, in particular the ICD‐10, for the purpose of obtaining diagnostic codes. Only 5.2% of GCPN clinicians reported that they never or rarely go through the diagnostic guidelines or criteria systematically during the initial diagnostic process. The practice of making a diagnosis without referring to the diagnostic guidelines or criteria was a bit less common, with just less than half of GCPN clinicians reporting often or routinely doing this during the initial evaluation. The use of the classification for ancillary purposes was less frequent, with only 34.9% reporting often or routinely using it to communicate or share diagnostic information with patients and their families.
A comparison of usage patterns between ICD and DSM users reveals that the ICD classification is used much more commonly among this sample for administrative and billing purposes as compared to the DSM classification. This is unsurprising, because the ICD is required for administrative use in most countries in which documentation of diagnoses for clinical encounters is needed. The only other significant difference between ICD and DSM users is the pattern of usage of the diagnostic guidelines or criteria, with DSM users being more likely to go through the diagnostic criteria to determine whether they apply as compared to the ICD users, who were correspondingly more likely to make psychiatric diagnoses without referring to the diagnostic guidelines, although these differences were small in magnitude. This may reflect a difference in the perceived utility of the ICD diagnostic guidelines vs. the DSM criteria, but it could also reflect the greater complexity of the DSM criteria, which makes them more difficult to recall as compared to the ICD guidelines. Slightly greater usage of the DSM additional text as compared to the ICD‐10 text likely reflects the much more extensive text sections in the DSM. In recognition of the unevenness of the ICD‐10 text, the newly developed ICD‐11 text is more extensive and follows a uniform template from disorder to disorder20.
Clinicians' ratings of the utility of the ICD and DSM classifications for various purposes were highest for applications such as meeting administrative requirements, assigning a diagnosis, communicating with other health care professionals, and teaching trainees or students, and lowest for selecting a treatment and assessing probable prognosis. This result likely reflects long‐identified weaknesses of descriptive categorical classification systems25, 26, namely the diagnostic heterogeneity of the categories and the lack of a one‐to‐one relationship between diagnostic categories and treatment options. Several previous surveys of clinicians' attitudes towards mental health classification (including the WPA‐WHO study undertaken early in the development of the ICD‐114) included a question which asked respondents to indicate the single most important purpose of a diagnostic classification. In each of these surveys, the two top‐prioritized purposes were to facilitate communication among clinicians and to inform treatment decisions. From this perspective, the ICD and DSM classifications get a mixed grade: their utility for communication with other health care professionals was one of the three use types in the top tier of ratings, whereas utility for selecting treatment was one of three use types in the bottom tier. Clinicians also do not consider the classifications to be particularly useful in communicating with the patient or family, although the DSM was rated slightly higher in this regard than the ICD.
Finally, the question on the use of the “residual” (other specified, unspecified, and not otherwise specified) categories indicated that these categories are employed relatively often (more so by DSM than ICD‐10 users), although a substantial minority (around 32% of ICD‐10 users and 27% of DSM users) reported that they rarely or never employed them. The survey results suggest that, for the most part, clinicians are using these categories appropriately: the top three most commonly endorsed reasons were those that would be considered to be legitimate (i.e., presentations that do not conform to specific diagnoses, insufficient information to make a more specific diagnosis, and inability to determine whether symptoms are primary or secondary).
Although the higher usage of these residual categories by DSM users might suggest that the ICD‐10 classification has better diagnostic coverage (i.e., that the ICD‐10 categories are overall more broadly defined and more likely to cover patient presentations in clinical settings than the more narrow DSM categories), there was no difference in frequency between the two classification systems in respondents' answers with respect to the reason that best corresponds to differences in coverage (i.e., “because the patient's presentation does not conform to any of the specific categories”). The only reason for using residual categories that was given more frequently by ICD‐10 users was to indicate that the patient's presentation met the requirements for more than one diagnosis in a grouping, which is an inappropriate use of these categories, given that the convention in ICD‐10 (and DSM) is to give multiple comorbid diagnoses in such cases.
The main strengths of this study are the inclusion of survey questions specifically focusing on classification usage rather than just on attitudes about usage, and its diverse sample, which included clinicians from a wide variety of geographical locations, languages, and country income levels. All participants were individuals who indicated that they customarily assigned diagnoses in clinical practice.
The main limitation of the survey is that the sample is not representative of the whole population of mental health clinicians in terms of their level of interest in diagnosis and classification, given that GCPN members joined the network specifically to participate in studies of diagnostic classification and thus were likely to be more interested in diagnostic and classification issues and more proficient in the use of classification systems than the average clinician. Thus, the relatively high frequency of systematically reviewing diagnostic guidelines or criteria in order to determine whether they apply to individual cases may not generalize to a population of clinicians with a wider range of levels of interest in diagnosis and classification. However, it should be noted that this generalizability problem is inherent to all surveys, even those that randomly select participants, since response rates are traditionally low, and people who agree to participate are those most interested in the topic covered by the survey.
Additionally, some answers in the present survey may have been subject to a social desirability bias, as clinicians could have wanted to present their diagnostic practice in the best possible light.
CONCLUSIONS
If it were the case, as suggested by conventional wisdom, that clinicians' use of the ICD and DSM classifications is largely confined to the diagnostic labels and codes, then current efforts to improve the clinical utility of the ICD diagnostic guidelines and DSM diagnostic criteria would have a limited impact on clinical practice. Although the survey sample of GCPN members was likely self‐selected to use diagnostic guidelines or criteria more often than the average clinician, the results of this survey suggest that clinicians do use the diagnostic guidelines and criteria in routine clinical practice and that efforts to revise and update them is likely to have an impact on that practice.
Because of limitations in using self‐report methodology to examine actual behaviour, it would be useful to employ additional methodologies in the future2, 3, such as direct observation of clinician's classification usage in clinical settings. Such research would help not only to improve classification systems, but also to enhance the function of classification as the interface between clinical practice and health information.
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