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Book Review

Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders: Refining the Research Agenda for DSM-5 and ICD-11

Frederick G. Guggenheim, MD

Published: July 15, 2013

Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders: Refining the Research Agenda for DSM-5 and ICD-11

edited by Shekhar Saxena, MD; Patricia Esparza, PhD; Darrel A. Regier, MD, MPH; Benedetto Saraceno, MD; and Norman Sartorius, MD, PhD. American Psychiatric Association and the World Health Organization, Arlington, VA, APPI, 2012, 273 pages, $70.00 (paper).

This book presents 9 fascinating technical reviews stemming from the World Health Organization (WHO)-American Psychiatric Institute for Research and Education (APIRE) conference on the public health implications of diagnosis and classification of mental disorders. Given the book’s 5 editors and 80 contributors from 26 countries, one might think that readability/quality would be uneven. However, the chapters flow nicely. Since this reviewer comes from a perspective of diagnostic consistency, disablements, and an interest in public health, I found the book both scholarly and highly entertaining. The book was not meant to be a beach read. But if one judges a book by the number of pages one underlines with important points or interesting new information (on review, I discovered I underlined more pages than not) and the number of dog-eared pages, then this book is a winner. It also meets its goal of being fundamental to the history of psychiatric classification and functional impairment in patient populations from around the world.

Did you know that there are an estimated 450,000,000 people with mental and behavioral disorders worldwide? That there are several classification systems in use, including the International Classification of Diseases (ICD), the Diagnostic and Statistical Manual of Mental Disorders (DSM), the Chinese Classification of Mental Disorders, and the Latin American Guide for Psychiatric Diagnosis? That successive classification revisions need to keep in mind (vertical) compatibility while the WHO and the United Nations families of international classifications need to work on mutual (horizontal) compatibility? That the term schizophrenia has been removed from legal and medical language in Japan through the joint efforts of the Japanese Society of Psychiatry and Neurology plus families and consumers? That, in the United States, up to half of all young people who fail to complete secondary school have mental illness? That, in Europe, 74% of people with mental illness, but only 8% of people with diabetes mellitus, do not receive care? That almost half of all sickness certificates are due to mental disorders and that mental illness predicts a longer period of illness certification than most physical disorders?

One cannot do justice in summarizing some of the chapters in a short review, but here goes: Chapter 1, by Diana Rose (from King’s College) and colleagues, focuses on diagnosis as it relates to consumers, the treatment gap, and stigma. Chapter 2, by Shekhar Saxena (from WHO) and colleagues, focuses on prevention and topics such as primary through tertiary prevention of mental illness, proximal and distal factors associated with mental illness, the nonlinear relationship between risk factors and outcomes, predisposing and precipitating factors in mental illness, the distinction between subthreshold and full mental diagnoses as having little relationship to level of disability, the benefits of categorical versus dimensional diagnoses, and broad versus narrow categories of illness. The authors recommend the following multiaxial system: Axis I, categorical diagnoses; Axis II, dimensions related to mental disorders; Axis III, protective and risk factors; Axis IV, function and dysfunction; and Axis V, quality of life.

Chapter 3, by Linda Gask (from University of Manchester) and colleagues, focuses on capturing complexity of diagnosis in a primary care versus a specialty care setting. Subthreshold symptoms seen in primary care do not readily fit into current diagnostic systems. Of 100 patients in primary care with mental illness, only 3 were seen in specialty care. Evidence is presented that severity and impairment should be considered separately. There is a need in primary care for a diagnostic system that is simple (some generalists are seeing 70 patients a day, 1 every 3-5 minutes) and one that deals with anxiety-depression spectrum and subsyndromic conditions.

Chapter 4, by Julio Arboleda-Florez (of Queen’s University in Ontario), Paul Applebaum (of Columbia), and colleagues, is equally interesting, focusing on the ways in which psychiatric diagnosis often does not overlap with the legal definition of mind state/functional impairment at the time of the crime. Dimensional information would be more helpful than categorical. In many countries, untreatable criminals are flocking to mental institutions to be "treated" while treatable regular patients are piling up in prisons to be "managed." Chapter 5, by Howard Goldman (of the University of Maryland), Darrel Regier (of the American Psychiatric Association), and colleagues, focuses on economic consequences of revising the diagnostic nomenclature. It reminds us that, of the 486 Medicare diagnosis-related groups, 15 were for psychiatric illnesses. But psychiatric providers were exempted from the prospective payment system because psychiatric diagnosis was only imperfectly associated with the course of illness or resource utilization; social and legal characteristics also accounted for much of the cost of care.

Chapter 7, by Walter Gulinat (Manager of the Global Network for Research in Mental and Neurologic Health from Lichtenstein) and colleagues, gives a great primer on how information services can assist (or be frustrated with) the multiple electronic health records and the multiplicity of classifications of mental illness to serve as a tool for improving mental health. Chapter 8, by Alberto Minoletti (from Chile) and colleagues, sums up very nicely the translational task of putting psychiatric classification into public health usage.

No book is perfect, and this one is no exception. Published in 2012, the book is the product of a 2007 conference (with prepared background papers). Most references stop there, although some Web references are updated to 2009 and a few to 2012. But the work is heavily referenced, and except for those on the cutting edge of the impact of classification, the lack of more recent references should not be much of a problem for the interested reader.

Frederick G. Guggenheim, MD

Author affiliation: Warren Alpert Medical School of Brown University, Providence, Rhode Island.

Potential conflicts of interest: None reported.

Volume: 74

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