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EDITORIAL 1

Dementia and the International Classification of Diseases-11 (Beta Version)

Sathyanarayana Rao, T. S; Jacob, K. S.1; Shaji, K. S.2; Raju, M. S. V. K3; Bhide, Ajit V.4; Rao, G. Prasad5; Saha, Gautam6; Jagiwala, Mukesh7

Author Information
Indian Journal of Psychiatry: Jan–Mar 2017 - Volume 59 - Issue 1 - p 1-2
doi: 10.4103/psychiatry.IndianJPsychiatry_66_17
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The World Health Organization (WHO) recently uploaded the International Classification of Diseases-11 (ICD-11)(beta version) on its website.[1] The draft had a major shock for the mental health and psychiatric community. The ICD-11 version has moved the syndromal diagnosis of dementia from the chapter on mental and behavioral disorders to the chapter on diseases of the nervous systems. The sudden and unexpected change in the WHO's position on diagnosis and coding was a clear departure from its previously stated position on the subject and its previous classifications. The new scheme is a sharp deviation from the long-standing consensus and approach employed by the WHO and international psychiatry. Many national and international psychiatric associations, including the Indian Psychiatric Society, have sent their serious concerns and arguments against the move. This editorial highlights the arguments and position of the Indian Psychiatric Society.

The earlier beta versions of the ICD-11 and that of the ICD-10[2] and the Diagnostic and Statistical Manual-5[3] included syndromal codes for dementia and its associated behavioral and psychological symptoms under the chapter on mental and behavioral disorders with diagnosis of dementia with specific neurological etiologies included in the chapter on diseases of the nervous system. The current approach suggested in the latest beta version of ICD-11 is problematic for psychiatrists, particularly for those working in low-resource settings in India and low- and middle-income countries (LMICs) for the following reasons:

The general population in many LMICs often consider cognitive impairment and decline in older people as part of normal aging.[45] Consequently, the majority of people who are brought to medical attention have behavioral psychological symptoms of dementia and consult psychiatrists and mental health workers, only when their relatives have behavioral and psychological problems associated with dementia. The removal of syndromal codes for dementia and its associated behavioral and psychological symptoms is problematic as psychiatrists and mental health professional play a crucial role in the management of majority of people with dementia in LMICs.[6] The suggested system is clearly disadvantages for clinical care. The shortage of neurology specialists and their limited expertise in managing behavioral and psychological symptoms does not help. The neurologists could always use specific codes for dementia in the ICD-10, and a similar system can be continued in the ICD-11.

The diagnostic facilities and resources in LMICs may not always allow for elucidating specific etiologic diagnosis/categories of dementia, and so the syndromal approach is useful and should be retained in the chapter of mental and behavioral disorder, while specific dementias are listed in the chapter on diseases of the nervous system.

This new approach is inconsistent with the fact that behavioral disorders secondary to general medical conditions are included in the chapter on mental and behavioral disorders in the beta version of ICD-11.[1] Behavioral disorders secondary to endocrine, cardiovascular, infectious disease, and a diagnosis of delirium have codes in the chapter on mental and behavioral disorders. For example, delusional, psychotic, and depressive disorders secondary to general medical conditions continue to have codes in the chapter on mental and behavioral disorders.

The current beta version goes against the explicit aims of the WHO and the American Psychiatric Association's Diagnostic and Statistical Manual-5's attempt harmonization of the two approaches.

The new approach will also create problems related to insurance reimbursement for psychiatrists working in LMICs as insurance companies may insist on a neurologist's assessment, if syndromal codes for dementia are exclusively in the chapter on diseases of the nervous system. It will create unnecessary difficulties related to financing the costs of care for people with dementia. This is particularly relevant at a time when health insurance options are increasingly being used for meeting the health-care needs and costs in LMICs.

The new approach to classification will also have an adverse impact on financing of care in LMICs as official disease classifications are often employed for budgeting resources. The already meager budgets for mental health care[78] could face further reductions if the syndromal diagnosis of dementia is taken out the chapter on mental and behavioral disorders. With specialist neurological care nonexistent outside tertiary care facilities, older people with dementia receive practically no neurological care in community and primary and secondary care settings. On the other hand, India, which currently has the district mental health program, will be able to manage such conditions in primary and secondary care.

Different national mental health agencies can disagree with the WHO's official classification resulting in nonuniform implementation of mental health policies.

Normal cognition, perceptions, and emotions have a biological representation in the brain. Mental and behavioral disorders and emotional distress will also have similar representation. Those who divide disorders into neurological diseases and mental disorders have wrongly bought into the Cartesian dichotomy, with its strict dichotomous alternatives of body and mind. The WHO, with its current approach to the coding of dementia in the ICD-11 beta version, has internalized Cartesian beliefs.

Recent advances in genetics, molecular biology, and imaging have revealed the potential of the newer approaches to identify the biological basis of mental disorders. The newer approaches using the Research Domain Criteria have tried to identify the many dimensions, which form the basis of mental disorders.[9] The current approaches study positive and negative valence systems, cognitive mechanisms, and social processes. They use a dimensional matrix, which includes genes, molecules, cells, neural circuits, physiology, behaviors, and psychological issues. Removing categories from the psychiatric diagnostic repertoire, every time the biological basis of specific diseases is been identified, is a retrograde step. It suggests that the overall approach to classification is not taking into account the current research approaches and their potential to unravel mental disorders. It is not in keeping with current evidence and implies a lack of vision.

The Indian Psychiatric Society, representing 5800 of its members, strongly opposes the move to exclude syndromal dementia from the chapter on mental and behavioral disorder section of the proposed beta version of the ICD-11. The Society is of the opinion that any such move will be detrimental to the provision of dementia care and services in India and LMICs. The Society urges the WHO to reconsider its decision and retain syndromal codes for dementia in the chapter on mental and behavioral disorders. The Society is willing to discuss these and related issues with the WHO so that older people with mental health concerns and conditions will benefit from appropriate, easily accessible, and available care.

REFERENCES

1. World Health Organization. ICD-11 Beta Draft (Mortality and Morbidity Statistics). 2017Last accessed on 2017 Feb 10 Geneva World Health Organization Available from: http://www.apps.who.int/classifications/icd11/browse/l-m/en
2. World Health Organization. International Classification of Diseases: Mental and Behavioural Disorders. 199210th ed Geneva World Health Organization
3. American Psychiatric Association. Diagnostic and Statistical Manual. 20135th ed Arlington, VA American Psychiatric Association
4. Patel V, Prince M. Ageing and mental health in a developing country: Who cares? Qualitative studies from Goa, India Psychol Med. 2001;31:29–38
5. Jacob KS. Dementia: Toward contextual understanding Int Psychogeriatr. 2012;24:1703–7
6. Alzheimer's Disease International. World Alzheimer Report 2016: Improving Healthcare for People Living with Dementia: Coverage, Quality and Costs now and in the Future. 2016Last accessed on 2017 Feb 08 London Alzheimer's Disease International (ADI) Available from: https://www.alz.co.uk/research/WorldAlzheimerReport2016.pdf
7. Jacob KS. Mental health services in low-income and middle-income countries Lancet Psychiatry. 2017;4:87–9
8. Jacob KS. Repackaging mental health programs in low- and middle-income countries Indian J Psychiatry. 2011;53:195–8
9. Cuthbert BN, Insel TR. Toward the future of psychiatric diagnosis: The seven pillars of RDoC BMC Med. 2013;11:126
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