International classification systems: views of early career psychiatrists

Classification systems are an important part of medical education and clinical practice. A classification system that is reliable, clinically useful, and globally applicable provides an essential foundation for the diagnosis of mental disorders, helping to identify the patients with higher mental health needs, and ensuring the best care provi­sion ¹ . A system that is not clinically useful will likely not be implemented by clinicians ² .

The World Health Organization (WHO) developed the Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD‐10 Mental and Behavioural Disorders ³ for clinical, educational and service use. Surveys undertaken as a part of the development of ICD‐11 suggested that many clinicians regularly use this material, reviewing it systematically when making an initial diagnosis ⁴ .

The WPA‐WHO Global Survey of Psychiatrists’ Attitudes Towards Mental Disorders Classification was an international study published in 2011, reporting responses by 4,887 psychiatrists from 44 countries ⁵ . Respondents regarded communication among clinicians as the most important purpose of a diagnostic classification system, followed by informing treatment and management decisions. The use of classification systems was very common, and the ICD‐10 was by then the most widely used classification system across the world. Since one of the inclusion criteria of the survey was that participating psychiatrists had completed their training, the study did not cover the views of those still in training. This is particularly important, as much of the clinical practice worldwide is done by psychiatrists in training, who are responsible for making clinical diagnoses for their patients to the best of their knowledge.

The WPA Early Career Psychiatrists (ECPs) Section developed an online survey based on questions from a prior WHO survey ⁶ and asked ECPs across the world to respond about their experience and opinions on ­classification systems. The survey was circulated through the online platforms of the WPA ECPs Section to its members between August and September 2019. The included questions explored: the frequency of providing direct mental health services to patients, the responsibility for ­assigning a psychiatric diagnosis to patients, the frequency of using different classification systems, the purpose of such usage and its usefulness, as well as their interest in classification systems, and suggestions for the involvement of ECPs in the implementation of ICD‐11.

Responses were collected from 52 countries across Europe, Asia, Africa, Americas and Australia. The sample consisted of 202 ECPs (52.5% female; mean age: 33 years, range 25‐59 years). Of the respondents, 41.1% were psychiatrists in training, and the rest were still in their early career.

An overwhelming majority of 86.6% of respondents reported that they usually assign psychiatric diagnosis themselves, 0.5% that they assign it together with their supervisor, 9% that diagnosis is assigned by another health professional, and 0.5% that a consultant psychiatrist assigns it in a weekly meeting.

During a typical work week, the majority of respondents (33.7%) spent 40 hours or more providing direct mental health services to patients, while 18.3% spent between 30 and 39 hours, 14.9% 20 to 29 hours, 12.4% 10 to 19 hours, 13.9% 4 to 9 hours, 5.4% 1 to 4 hours, and 1.5% less than one hour.

The majority of respondents (63.9%) used ICD‐10 routinely; the DSM‐5 was sometimes used by 35.6% of participants. When inquired about the main purpose of use of classification systems, the ICD‐10 ranked first with respect to assigning diagnoses for administrative purposes (81.7%) and clinical practice (74.3%), whereas the DSM‐5 ranked first for teaching and education (66.4%) and research (56%).

Most ECPs were interested (47.0%) or very interested (41.6%) in classification systems, with only very few (0.5%) not at all interested. ECPs were very interested (55.0%) or interested (36.1%) in the ICD‐11, and very interested (38.1%) or interested (48.5%) in the DSM‐5. Many ECPs reported their wish and availability to be involved in the implementation of and training for the ICD‐11, and suggested the use of technology (e.g., smartphone apps, videos and webinars) for these purposes.

These findings document the important role of ECPs in assigning psychiatric diagnosis in routine clinical practice worldwide. When developing the ICD‐11 CDDG, the importance of clinical utility has been emphasized as a core principle ¹ , and field studies conducted in 13 countries in clinical settings reported that clinicians considered the clinical utility of ICD‐11 to be high ⁷ . While the Global Clinical Practice Network, through Internet‐based field studies, allowed mental health and primary care professionals worldwide to contribute to the development of the ICD‐11 ² , there was little involvement of ECPs.

The WHO is now working with its Member States, health professionals, academic centers, and professional organizations such as the WPA on ICD‐11 implementation and training. Based on the findings of this survey, the WPA Secretary for Education will convene a new Task Force with members from the WPA ECPs Section and the International Federation of Medical Student Associations, who will advise on the key strategic implementation steps in enabling competent use of ICD‐11 classification.

With the launch of the new WPA learning management system in the WPA web­site8, 9, online training and discussion forums can be conducted and disseminated to ECPs working in any part of the world. We hope that voicing the views of ECPs will raise awareness of their critical role in clinical practice, and support them in utilizing current and future psychiatric classification systems across the world.