NEW DELHI, INDIA / 10 – 12 APRIL 2015
Meeting of the Field Studies Coordination Group
Progress of ICD-11
Development since
September 2014 Meeting
Geoffrey M. Reed
DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE
Why is the ICD part of WHO’s core constitutional
responsibilities and why do countries use it?
• Countries agree to use the ICD as a framework for
health information and reporting:
 To monitor epidemics/threats to public health/disease
burden
 To assess progress toward meeting public health
objectives
 To define obligations of WHO Member States to provide
free or subsidized health care to their populations
 To facilitate access to appropriate health care services
 As a basis for guidelines for care and standards of
practice
 To facilitate research into more effective treatments
and prevention strategies
Field Studies Coordination Group
10 – 12 April 2015
2
In other words . . .
• The mandate of the ICD is a pragmatic one,
based on public health and clinical
objectives
• Based on the best evidence that we have
available today, what health categories
should the world’s global health authority tell
its Member States are important to track as a
basis for public health reporting and as a
basis for structuring clinical care?
• How should those categories be defined and
operationalized?
Field Studies Coordination Group
10 – 12 April 2015
3
ICD-11 MENTAL AND BEHAVIOURAL DISORDERS
Public Health Considerations
Field Studies Coordination Group
10 – 12 April 2015
4
Mental Health in a Global Context
•
Neuropsychiatric disorders account for 12.3%
of total disease burden
•
Mental and substance use disorders
responsible for loss of 184 million disabilityadjusted life years (DALYs) worldwide in 2010
•
They are the leading cause of disability, in
terms of years of life-lived with disability (YLDs)
Global Burden of Disease Study (2010); Whiteford et al, (2013)
Field Studies Coordination Group
10 – 12 April 2015
5
Global Causes of Disability
GBD, 2010
Field Studies Coordination Group
10 – 12 April 2015
6
Health of People with Schizophrenia
and other Severe Mental Disorders - I
• Disproportionately high rates of mortality
– Cardiovascular disease
– Metabolic diseases
– Respiratory diseases
• Mortality rates are 2 – 2.5 times higher than
general population
• Life expectancy is 10 – 25 years less
• Behaviour factors, and also intervention
factors
Field Studies Coordination Group
10 – 12 April 2015
7
Physical health disparities [among
people with schizophrenia and other
severe mental disorders] have rightfully
been stated as contravening
international conventions for the 'right
to health’
WORLD HEALTH ORGANIZATION, 2014
Field Studies Coordination Group
10 – 12 April 2015
8
Adopted by the World Health Assembly in May 2013
Field Studies Coordination Group
10 – 12 April 2015
9
Goal
• To promote mental well-being, prevent mental
disorders, provide care, enhance recovery, promote
human rights and reduce the mortality, morbidity and
disability for persons with mental disorders.
Time frame
2013 to 2020
Field Studies Coordination Group
10 – 12 April 2015
10
Objectives
1. To strengthen effective leadership and
governance for mental health
2. To provide comprehensive, integrated and
responsive mental health and social care services
in community-based settings
3. To implement strategies for promotion and
prevention in mental health
4. To strengthen information systems, evidence and
research for mental health
Field Studies Coordination Group
10 – 12 April 2015
11
Field Studies Coordination Group
10 – 12 April 2015
12
Why does the ICD matter?
People are only likely to have access to the most
appropriate mental heath services when the
conditions that define identification, eligibility
and treatment selection are supported by a
precise, valid and clinically useful classification
system.
INTERNATIONAL ADVISORY GROUP FOR THE REVISION
OF ICD-10 MENTAL AND BEHAVIOURAL DISORDERS,
WORLD PSYCHIATRY, 2011
Field Studies Coordination Group
10 – 12 April 2015
13
Most important aims of ICD-11 MBD
• To provide WHO Member States with better tool
to help them reduce the disease burden of
mental and behavioural disorders
• To provide health professionals with better tools
for identifying people in need of mental health
services and which treatments are most likely to
be effective, at the point at which they are most
likely to encounter opportunities for care.
Field Studies Coordination Group
10 – 12 April 2015
14
Scarcity of Human Resources
(N = 157 – 183 countries)
35
32.95
30
Psychiatrists
25
Psychologists
20
15.70
15
14.00
10.50
10
Psychiatric
Nurses
5.35
5
0
Social
Workers
2.70
0.05 0.04 0.04 0.16
Low Income
1.05 0.60
1.05
0.28
Lower Middle
Income
1.80 1.50
Upper Middle
Income
Field Studies Coordination Group
High Income
10 – 12 April 2015
15
Does one size fit all?
Field Studies Coordination Group
10 – 12 April 2015
16
Current focus of development
•
Statistical version of ICD-11 contains hierarchical
structure, category names, code numbers, brief
definitions, inclusion and exclusion terms; mostly
complete for MBD, available on ICD-11 beta platform
•
Current focus is on Clinical Descriptions and Diagnostic
Guidelines (CDDG), intended for use in clinical settings
by global mental health professionals
•
Primary care version being developed simultaneously,
for use by a broad range of global primary care
professionals
•
Research version to be developed later; currently in
discussions with relevant parties to formulate work plan
Field Studies Coordination Group
10 – 12 April 2015
17
CDDG: Focus on clinical utility
• The ideal: scientific validity and clinical utility
• At present, neuroscience and genetics evidence is
limited in its ability to support support major changes for
individual conditions or a specific classification structure
• Where evidence exists, should be considered
• WHO views current revision as major opportunity to
improve clinical utility of the diagnostic manual
• Field studies of ICD-11 Mental and Behavioural Disorders
guidelines focus on:
1. Diagnostic consistency
2. Clinical utility
Field Studies Coordination Group
10 – 12 April 2015
18
Why does clinical utility matter?
• Health encounters are the source of aggregated
health information that provide a basis for health
policy decisions at system, national, and global levels
• Health classifications are the interface between health
encounters and health information
• A classification that is too cumbersome to use at the
encounter level or does not provide clinically useful
information will not be used, and can’t provide valid
data for health policy and decision-making
• Opportunities for practice improvement will be lost
Field Studies Coordination Group
10 – 12 April 2015
19
Global applicability
• WHO International Advisory Group and all WHO
Working Groups include representation of all
WHO global regions and high proportion of
representatives from low- and middle-income
countries
• All ICD-11 field studies are multidisciplinary and
multilingual
– Case controlled studies in Chinese, English,
French, Japanese, Russian, Spanish
– Capacity for Arabic, German, Portuguese for
ecological implementation (clinic-based studies)
Field Studies Coordination Group
10 – 12 April 2015
20
CURRENT ENROLLMENT AND CHARACTERISTICS
Global Clinical Practice Network
TO REGISTER IN 9 LANGUAGES, VISIT:
www.globalclinicalpractice.net
Field Studies Coordination Group
10 – 12 April 2015
21
11,707 GCPN Registrants from 139 Countries
(As of 1 March 2015)
Americas
Europe
North: 1,636
South & Central: 1,223
4,302
Western
Pacific
Asia: 2,980
Oceania: 331
Africa
242
Eastern
Mediterranean
Southeast
Asia
573
361
Field Studies Coordination Group
10 – 12 April 2015
22
Global Registrants:
Distribution by Country Income Level
Lower-middle
8%
Upper-middle
29%
Low
1%
High
62%
Global Mental Health
Professionals by Region
40%
35%
37% 37%
GCPN
34%
MH ATLAS
28%
30%
25%
25%
20%
13%
15%
9%
10%
5%
3%
2% 1%
5%
5%
0%
AFRO
AMRO
EMRO
Field Studies Coordination Group
EURO
SEARO
10 – 12 April 2015
WPRO
24
Case-Controlled Field Studies:
Current Status
Field Studies Coordination Group
10 – 12 April 2015
25
International Field Study Centres
(Countries represent more than 50% of world’s population)
•
•
•
•
•
•
•
•
•
•
•
•
•
Brazil: Universidade Federal de São Paulo
China: Shanghai Mental Health Center
France: Etablissement Public de Santé Mental, Lille-Métropole
Germany: Heinrich-Heine University, Düsseldorf
India: All India Institute of Medical Sciences
Japan: Tokyo Medical University
Lebanon: American University of Beirut
Mexico: Instituto Nacional de Psiquiatria
Nigeria: University of Ibadan
Russian Federation: Moscow Research Institute of Psychiatry
Spain: Universidad Autónoma de Madrid
USA: University of Kansas
Data Coordinating Center: Columbia University
Field Studies Coordination Group
10 – 12 April 2015
26
Ecological Implementation Field Studies
• Evaluate clinical utility and usability of the
proposed ICD-11 diagnostic guidelines in
natural conditions, in the settings in which they
are intended to be used
• Will also evaluate reliability of diagnoses that
account for greatest proportion of disease
burden and mental health services utilization
Field Studies Coordination Group
10 – 12 April 2015
27
Use of Field Studies Results
• Identify areas of lower diagnostic agreement
• Identify specific diagnostic features that contribute to
confusion
• Identify lack of clarity regarding diagnostic threshold and
specific differential diagnoses
• Identify features that are and are not considered to be
clinically useful
• Results across languages compared to identify cultural
differences and translation issues
• Will lead to specific revisions in ICD-11 diagnostic
guidelines as well as targeted educational programs
Field Studies Coordination Group
10 – 12 April 2015
28
Scholarly output related to ICD-11
Mental and Behavioural Disorders
• Over 200 published articles related to development of
ICD-11 Mental and Behavioural Disorders
• Includes publications in top journals in the field (e.g.,
Lancet, World Psychiatry)
• Focus on:
– Proposals for ICD-11; evidence and rationale
– Conceptual issue in ICD-11 development
– Results of formative fields testing
– Methodological issues for field testing
– Current focus on results of evaluative field testing
Field Studies Coordination Group
10 – 12 April 2015
29
Work Plan
2014
Q1 & Q2
2014
Q3 & Q4
2015
Q1 & Q2
2015
Q3 & Q4
2016
Q1 & Q2
2016
Q3 & Q4
Complete draft diagnostic
guideline for field studies
Case-controlled field studies
Ecological implementation
field studies
Review and comment on
draft guidelines
Prepare additional material
for CDDG
Revise guidelines per field
studies and comments
Finalize CDDG
Translations, educational,
implementation material
Field Studies Coordination Group
10 – 12 April 2015
30