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Year : 2018  |  Volume : 34  |  Issue : 5  |  Page : 75-78

International classification of Diseases-11: Primary care perspective

Institute of Psychiatry, WHO collaborating Center, Benazir Bhutto Hospital, Rawalpindi, Pakistan

Date of Web Publication20-Nov-2018

Correspondence Address:
Prof. Bushra Razzaque
Institute of Psychiatry, WHO collaborating Center, Benazir Bhutto Hospital, Rawalpindi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_77_17

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The World Health Organization, Department of Mental Health and Substance Abuse is currently revising the international classification of disease10 (ICD-10) chapter on mental, behavioral, and neurodevelopmental disorders. This revision aims to improve the clinical utility of the ICD-primary health-care (ICD-PHC) classification system in the primary health-care settings, where the presentation of common mental health conditions vary from that of the specialist centers. The salient changes proposed in the ICD-11 PHC version are the category of anxious depression, health anxiety, and bodily stress syndrome. The ICD-11 PHC field trails have positively supported the proposed changes. The changes in the classification will have to be widely disseminated, complemented with training, and supervision for it to be of use to the people suffering from common mental health conditions in the community.

Keywords: Anxious depression, bodily stress syndrome, health anxiety, international classification of disease-11 primary care version, international classification of diseases

How to cite this article:
Razzaque B, Minhas FA. International classification of Diseases-11: Primary care perspective. Indian J Soc Psychiatry 2018;34, Suppl S1:75-8

How to cite this URL:
Razzaque B, Minhas FA. International classification of Diseases-11: Primary care perspective. Indian J Soc Psychiatry [serial online] 2018 [cited 2022 May 26];34, Suppl S1:75-8. Available from: https://www.indjsp.org/text.asp?2018/34/5/75/245837

  Background Top

Mental, neurological, and substance use disorders (MNS) are highly prevalent, with 14% of the global burden of disease attributed to neuropsychiatric disorders.[1] Mental healthcare is a low-priority area in low- and middle-income countries (LMICs). It has been estimated that >75% of those identified with serious anxiety, mood, impulse control, or substance use disorders in the World Mental Health surveys in LMICs received no care.[2]

The World Health Organization (WHO) has recognized the need for action to reduce the mental health disease burden and the huge treatment gap associated with these disorders. To deal with this growing mental health burden, the WHO devised the Mental Health Gap Action Program (mhGAP)[3] for the purpose of scaling up of services, ensuring provision, and availability of evidence-based treatment for MNS conditions at the grass root level of primary health-care facilities. To address the mental health gap, the WHO considers the development of more accessible and less stigmatized services which can reach masses of the population in need and increase the population impact of services for mental health and substance abuse disorders to be an urgent priority. It is in this background that provision and availability of evidence-based, scientific, cost-effective, and readily accessible services need to be made available at the grass root level in the community.

Primary care setting is the most accessible opportunity for the provision of mental health services. It provides an essential point of contact for identification, assessment, and provision of effective mental health treatment for the masses in the community. This conduit of service makes the provision of mental health services widely accessible and less resource intense as globally only a small percentage of individuals get the opportunity to be seen by specialists. It is estimated that <1/10,000 psychiatrist is available for the population of low- and middle-income countries and about two psychiatrists per 10,000 in middle-income countries.[4]

The diagnostic system being employed at the encounter level in the community needs to be user-friendly and have good clinical utility. The parent international classification of disease (ICD) classification was considered unsuitable to the common mental disorders presenting in the primary care settings in the community.[5] Primary care differs considerably from specialist mental health settings, the presentation of common mental health problems varies considerably from the specialist mental health settings, at times presenting in undifferentiated form, as subthreshold symptomatology, and their possible presentation with various comorbid states.[5] This made the case of a classification system having better clinical utility for the primary care setting. The WHO, therefore, produced a separate classification system for the assessment and management of the mental health issues presenting in the primary care setting, the ICD-10 PHC.[6]

The WHO, Department of Mental Health and Substance Abuse is currently revising the ICD chapter on mental, behavioral, and neurodevelopmental disorders, with the aim to review the current classification with a central goal of improving the clinical utility of the classification system. In addition, ICD-10 mental health classification system designed for the primary care settings is currently also being reviewed for improving the diagnostic utility, effective assessment, and better management of patients presenting with mental health disorders in the primary care settings.[7]

ICD is the global standard in diagnostic classification for health reporting and clinical applications for mental disorders as well as for all other medical diagnoses.[8] A study of nearly 5,000 psychiatrists in 44 countries sponsored by the WHO and the World Psychiatric Association showed that >70% of the world's psychiatrists use WHO's ICD most in day-to-day practice while just 23% turn to the DSM.

Clinical Utility of Classification Systems and Revision of International Classification of Diseases-10 Primary Health Care Classification

The diagnostic classification systems present clinicians with a set of outline, a framework, and guiding principles, thereby assisting in establishing a diagnosis and bringing uniformity and homogeneity in diagnosing disorders not only across individuals but also across regions. The various diagnostic classification systems are advantageous and useful in assisting physicians, and their utility cannot be undermined. Despite this, issues are still being raised regarding the clinical utility of the classification systems. The salient criticisms to various diagnostic systems have been numerous. First, clinically many patients tend to present with a range of symptoms either meeting the criteria of one or more conditions or these presentations may represent varying aspects of the same underlying condition. Moreover, many a times, the diagnostic systems give the categories of unspecified or not otherwise specified categories creating difficulties in the usage of classification systems by the physicians.[9] It is also advocated that many psychiatric conditions might have overlapping pharmacological and psychotherapeutic managements, thereby making the clinical relevance in categorizing patients of little relevance. Moreover, the classification systems have become complex with many categories, specifiers, and subtype further adding to the complexity of the diagnostic systems.

Diagnostic classification provides a basis for efficiently identifying people with the greatest mental health needs, in addition, ensuring that they have access to appropriate and cost-effective forms of treatment. The classification must be comprehensively practical so that it can be applied across settings even with limited resources, mental health professionals, and nonspecialty health professionals, especially primary care settings. To meet these requirements, it is unlikely that one size will fit all.[10]

The Diagnostic and Management Guidelines for Mental Disorders in Primary care (WHO, 1996) was given to improve the clinical utility of the diagnostic process in the primary care setting.[11] This classification system is the simplified version comprising 27 diagnostic categories relating to the common mental health conditions presenting in the primary health-care centers and general medical care settings in the community. The classification system is structured to be simple making it easy to use in the primary care setting; the document additionally includes management guidelines for comprehensive management of common mental health disorders in nonspecialist settings.

Provision of Mental Health Service in the Community – Experiences and Perspectives from Pakistan

The Institute of Psychiatry, located in a tertiary care hospital setting, is the academic unit of Rawalpindi Medical University, Pakistan. It is also WHO Collaborating Centre for mental health research and training for the whole of the Eastern Mediterranean Region. The Institute being a WHO Collaborating center is a forerunner in the provision of community mental health services in the country. The community mental health program was initiated in 1983 in one district (an administrative division) in the country. This involved training of around 800 primary care physicians and 3500 newly identified health-care providers; in addition, a community education project was set up with schools being the principal point of entry. The community mental health program had the following objectives: integration of mental health in primary health care, training the staff in the detection of common mental health disorders, thereby enhancing the capacity of the primary health-care staff, and bringing forth mental health awareness in the community.

The WHO Collaborating Centre in Pakistan has over the years undertaken the initiative to train PHC workers, health and field administrators at the district level, and developing training modules. In Pakistan, the majority of the mentally ill tends to seek care at the local level, accessing traditional practitioners, local private providers, faith healers, and those within the primary health-care system. Training of the primary health care staff in the common mental health conditions formed an important component of the community mental health. These trainings aimed to to impart basic mental health skills of identification, assessment, and management to the health-care providers. ICD-10 PHC classification formed the pivot of the training curriculum. The years of experience has shown us that the trainings remarkably improved the skill, knowledge base and improved the recognition, referral, and management of common mental disorders.

This training program was deemed to be a success and with the support of the WHO, this program was expanded nationwide in two phases; in the first phase, it was extended to five pilot districts in the country, following the success of the first phase; in the second phase, the community mental health program was extended to another 15 administrative districts in the country. During the span of 14 years from (from the years 2000–2014), 15000 training workshops for primary care physicians, 20,000 workshops for paramedics, and 1600 trainings for national coordinators were carried out. The lessons learnt from the community program in Pakistan have taught us that the primary care staff frequently expressed that the clinical presentations of common disorders varied extensively due to the possible cultural differences, for example, patients frequently presented with extensive somatic symptomatology or with presentation of concomitant depressive symptoms with symptoms of anxiety or even subthreshold presentation of various disorders, thereby creating a diagnostic confusion for the primary care staff. The recommendations given were to make possible revisions in the curriculum, thereby making the diagnostic process simpler, and less time-consuming. In addition, for complicated cases that posed a diagnostic confusion, more rigorous supervision was requested.

  Proposed Revision of the Primary Care Classification System Top

In view of the clinical utility of the classification in a primary care setting, it has been continually highlighted that owing to the variable presentations of common mental health conditions in the community, many a times the common mental health disorders are missed from being diagnosed in the primary care setting. The reasons highlighted for this are mainly the difficulties encountered in the assessment and management of the categories of anxiety, depressive illness, and that of unexplained somatic symptoms.

One of the salient issues pointed out with the ICD-10 PHC diagnostic system is that the parent classifications that have been developed for specialist settings tend to diagnose the anxiety once it has been present for several months, whereas the presence of depressive symptoms are required only if they have been present for 2 weeks. This diagnostic framework is not the perfect fit for the patients presenting in general medical and primary care settings since a substantial number of patients in primary care settings present either with comorbid depressive and anxiety symptoms or subthreshold symptomatology making the diagnosis and management difficult.[12]

It has been documented that patients usually present with anxiety and depressive symptoms in the primary care settings in one of the three forms;[9] either as comorbid presence of anxiety and major depressive disorder, depressive disorder presenting with subthreshold anxiety, or presence of subthreshold symptoms of depression with subthreshold symptoms of anxiety. All these presentations are of considerable significance owing to the implications in assessment and difficulty in management.

One of the changes proposed for the ICD-11 PHC is the inclusion of the category of anxious depression.[11] This category is deemed to be clinically useful in primary care settings as most patients present with a mix of both symptoms, and this new proposed category is characterized by simultaneous presentation of anxiety and depressive symptoms. Moreover, in the revised ICD-11 PHC, the duration requirement of diagnosis for depression was reduced to 2 weeks instead of several months as in ICD-10 PHC.[12]

To test the clinical utility of this classification, field trials were carried out in Pakistan along with other countries; these trails were carried out to determine the efficacy and clinical utility of the ICD-11 PHC version. The trials showed that co-occurrence of depression with anxiety was common in the primary care setting across Pakistan and also that the diagnostic category of Anxious depression fared well in the primary care settings. The postfield trial focus group interviews conducted with the primary care physicians established that they found the diagnostic category practically useful, less confusing, and saved clinicians time.

Another significant matter is that considerable proportion of patients presenting in primary care settings complain of physical symptoms not attributable to any known conventionally defined disorder; these presentations are generally called medically unexplained or functional somatic symptoms. The second category revised in the ICD-11 PHC is the category relating to this somatic symptomatology. ICD-10 PHC contained a diagnostic entity called “medically unexplained somatic complaints”; a condition characterized by the presentation of multiple physical symptoms without any known physical explanation and frequent medical visits despite negative investigations. This diagnosis underwent reviewing owing to the body of research work conducted by Fink et al.,[13] which recommended the presence of three or more symptoms as a limit for primary care population. The working ICD-11 PHC group replaced the diagnostic category of medically unexplained symptoms with the proposed category of bodily stress syndrome, characterized by the presence of three or more somatic symptoms not explained by known physical pathology associated with distress, and/or problems with the daily functioning.[14]

In the primary care setting, a significant proportion of patients also present with fear and suspicion of various illnesses. A category of health anxiety (HA) was therefore included in ICD-11 PHC characterized by the presence of either or both of the following, persistent idea or a fear of having an illness, intense worry or preoccupation with bodily sensations or problems, and misinterpreting them as a serious illness.[14]

  Discussion Top

In view of the issues with the clinical utility and practical use of the prevalent ICD-10 primary care diagnostic classification system, there was a need to revise the current classification system. It is in this background that the WHO Department of Mental Health and Substance Abuse organized the revision of the ICD parent classification of mental, behavioral, and neurodevelopmental Disorders. In addition, they are also coordinating the revision of classification of mental disorders for the use in primary care settings, the ICD-11 PHC.

The working group has proposed the revision of three categories; they have made improvement in nomenclature and the revision in diagnostic criteria. The revision process comes in the background of difficulties in implementing the diagnostic classification system at the primary health-care settings. The revised categories included anxious depression, body somatic syndrome, and HA.

The revision of the diagnostic classification has simplified the diagnostic categories, in view of the feedback received in the utility of the diagnostic system in the primary care setting, thereby making the classification user-friendly, less time intense, and clarifying the diagnostic confusion in possible clinical presentations of various conditions. All this will prove to be beneficial in efficient patient management.

The recommendations in the revision of nomenclature and diagnostic framework were emanating from the difficulties in variations in presentation of patients across primary health settings. The ICD-11 PHC revision has been widely tested across the various cultures in the world with field testing carried out across five countries, thereby making the revision more widely acceptable across cultures. This makes the newly implemented revisions more feasible for implementation across varied cultures and across a range of primary health care settings. More efficient recognition and identification of various disorders will result in effective management, thereby decreasing the treatment gap for mental health conditions and in turn decreasing the disease burden.

Although the benefits of the revised classification seem to be plentiful, effective implementation, and efficient clinical utility of the revised version will require effective dissemination of the revised material, trainings of the primary care staff in the revisions, and effective supervisions of the possible problems encountered in the implementation. In order to increase the clinical utility of the new ICD-11 primary care version in practice at the primary care level, it might be imperative to integrate the ICD-11 PHC classification system in he mhGAP trainings that are to be held country wide.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007;370:859-77.  Back to cited text no. 1
Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization world mental health surveys. JAMA 2004;291:2581-90.  Back to cited text no. 2
Mental Health Gap Action Program. Scaling up Care for Mental Neurological and Substance use Disorders. Geneva: World Health Organization; 2008.  Back to cited text no. 3
Reed GM. Toward ICD-11: Improving the clinical utility of WHO's international classification of mental disorders. Prof Psychol Res Pract 2010;41:457-64.  Back to cited text no. 4
Gask L, Klinkman M, Fortes S, Dowrick C. Capturing complexity: The case for a new classification system for mental disorders in primary care. Eur Psychiatry 2008;23:469-76.  Back to cited text no. 5
World Health Organization. Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD-10 Primary Care, Version. Ch. 5. Germany: Hogrefe & Huber, Göttingen; 1996.  Back to cited text no. 6
Goldberg DP, Prisciandaro JJ, Williams P. The primary health care version of ICD-11: The detection of common mental disorders in general medical settings. Gen Hosp Psychiatry 2012;34:665-70.  Back to cited text no. 7
The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1996.  Back to cited text no. 8
Silverstone PH, von Studnitz E. Defining anxious depression: Going beyond comorbidity. Can J Psychiatry 2003;48:675-80.  Back to cited text no. 9
International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. A conceptual framework for the revision of the ICD-10 classification of mental and behavioural disorders. World Psychiatry 2011;10:86-92.  Back to cited text no. 10
Diagnostic and Management Guidelines for Mental Disorders in Primary Care. ICD-10 Primary Care Version. Ch. 5. Hogrefe & Huber, Göttingen, Germany: World Health Organization; 1996.  Back to cited text no. 11
Goldberg DP, Reed GM, Robles R, Minhas F, Razzaque B, Fortes S, et al. Screening for anxiety, depression, and anxious depression in primary care: A field study for ICD-11 PHC. J Affect Disord 2017;213:199-206.  Back to cited text no. 12
Fink P, Rosendal M, Olesen F. Classification of somatization and functional somatic symptoms in primary care. Aust N Z J Psychiatry 2005;39:772-81.  Back to cited text no. 13
Goldberg DP, Reed GM, Robles R, Bobes J, Iglesias C, Fortes S, et al. Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO's revised classification of mental disorders in primary care settings. J Psychosom Res 2016;91:48-54.  Back to cited text no. 14


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