The WPA‐WHO Global Survey of Psychiatrists’ Attitudes Towards Mental Disorders Classification
Authors: GEOFFREY M. REED, JOÃO MENDONÇA CORREIA, PATRICIA ESPARZA, SHEKHAR SAXENA, MARIO MAJ
Journal: World Psychiatry (2011)

The World Health Organization (WHO) is in the process of revising the International Classification of Diseases and Related Health Problems, currently in its tenth version (ICD-10) 1. The WHO Department of Mental Health and Substance Abuse has technical responsibility for the development of the classification of mental and behavioural disorders for ICD-11, and has appointed an International Advisory Group to advise it throughout this process. The WPA is a key partner for WHO in developing the new classification, and as such is officially represented on the Advisory Group. The conceptual framework that has been articulated by the Advisory Group for the development of ICD-11 mental and behavioral disorders is described in another article in this issue of World Psychiatry 2. That article highlights the improvement of the classification's clinical utility as a key goal of the current revision process, an issue that has been discussed in more detail elsewhere 3. The WHO has also emphasized the revision's international and multilingual nature, along with the intention to engage in a serious examination of the cross-cultural applicability of categories, definitions, and diagnostic descriptions. If improving global clinical utility and cross-cultural applicability represent important goals of the revision, then it is clearly important to obtain information from professionals who come into daily contact with people who require treatment for mental and behavioural disorders in the various countries. Because of the relative scarcity of psychiatrists in many parts of the world, psychiatrists cannot accomplish WHO's public health goals of reducing the global disease burden of mental and behavioural disorders without the collaboration of other groups. Nonetheless, psychiatrists represent a critical professional group in the diagnosis and management of mental disorders, whose role is essential in all regions of the world. International surveys represent one of the most feasible methods for obtaining relevant information from professionals. Several studies have used surveys to assess the views of psychiatrists and other mental health professionals regarding the classification of mental disorders. However, previous surveys have been relatively limited in scope, geographically specific, and sometimes characterized by sampling methods that make conclusions difficult. A previous WPA survey including psychiatrists from 66 different countries 4 reported that psychiatrists' top recommendations for future diagnostic systems concerned broader availability of diagnostic manuals, more effective promotion of diagnostic training, and a wider use of multiaxial diagnosis. However, the reported conclusions were based on only 205 completed questionnaires. In addition, the sample's representativeness was restricted by only including psychiatrists who were part of the WPA Classification Section, presidents and secretaries of WPA Member Societies, officers of other WPA Sections and "pertinent" network members. Mellsop et al 5,6 used more widely targeted surveys to assess the use and perceived utility of diagnostic systems among psychiatrists in New Zealand, Japan, and Brazil. The techniques for implementing the surveys varied across countries, partly due to an effort to encourage local ownership of the survey and its results. Based on this work, a similar survey was implemented in Japan, Korea, China and Taiwan 7. Across regions, psychiatrists indicated that they wanted simple, reliable and user-friendly diagnostic tools, although there were significant regional differences in psychiatrists' views of the cross-cultural applicability of existing classifications, including both the ICD-10 and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) 8. Zielasek et al 9 conducted a survey of German-speaking psychiatrists in Germany, Austria and Switzerland regarding their perceptions of mental disorders classification and needs for revision. They investigated the extent to which the ICD-10 adequately reflected actual clinical practice, including its understandability and ease of use. The majority of respondents reported that they were satisfied with the mental disorders chapter of the ICD-10. However, the response rate was low, making it difficult to generalize the results of the survey. The purpose of the WPA-WHO Global Survey was to expand on the international scope and content of prior surveys to generate information about psychiatrists' views and attitudes about the classification of mental disorders that would be of direct relevance to the WHO Department of Mental Health and Substance Abuse in the revision of the ICD-10. In line with the priorities identified above, the survey was specifically intended for a broad spectrum of practicing psychiatrists, rather than organized psychiatry leadership or individuals with a specific interest in classification. In order to reach this population, the WPA and the WHO partnered with 46 WPA Member Societies (national psychiatric societies) in 44 countries, in all regions of the globe. Through this collaboration, the survey was administered in 19 languages, in order to maximize the participation of international psychiatrists. The survey focused on major practical and conceptual issues in mental disorders classification as encountered in the day-to-day psychiatric practice, as well as the characteristics of a classification system that international psychiatrists would find most useful. These included the most important purpose of a classification system, the number of categories that should be included for maximum clinical utility, whether the classification should also be useable by other mental health professionals and understandable to relevant non-professionals, what sort of classification system should be used by primary care professionals, whether a system with strict or specified criteria for all disorders or more flexible guidance would be most useful, the best way to conceptualize severity and the relationship between diagnosis and functional status, whether psychiatrists believed that a dimensional component would be a useful addition, and the cross-cultural applicability of existing classifications systems and the perceived need for national classifications. Participating psychiatrists who used the ICD-10 in their day-to-day clinical work were also asked to indicate which specific categories they used frequently, and to provide ratings of the ease of use and goodness of fit of those specific categories. Participating psychiatrists were contacted via their national psychiatric societies, and told that the purpose of the survey was to provide input to the WHO related to the revision of the ICD-10 classification of mental and behavioural disorders. Although it was expected that the survey would also produce information that would be relevant to the ongoing revision of the DSM-IV, unlike some previous surveys 4,10, comparing and contrasting the ICD-10 and the DSM-IV was not a major purpose of the study. We decided that the most efficient way to implement the survey would be electronically via the Internet, although preserving the option to use a paper-and-pencil methodology for those Societies whose members could not participate in an Internet-based study. At the outset, there was some concern that conducting the survey over the Internet would limit the ability of psychiatrists from low-resource countries to participate. Some previous surveys 5,7 have been conducted via the Internet, but this has tended to be in high-income countries. However, access to the Internet in developing countries has dramatically expanded in recent years, especially among the types of professionals who were the target participants in this survey. If this type of international, multilingual study could be effectively conducted electronically, particularly among low- and middle-income countries, this would have major implications for expanding access and participation in other field studies as a part of the development of ICD-11. In late 2009, the WPA and the WHO (Maj and Saxena) wrote jointly to the Presidents of all WPA Member Societies inquiring about their interest in participating in various aspects of the revision process for the ICD-10 classification of mental and behavioural disorders. One of the participation options presented was to participate in a global survey of psychiatrists' experiences and attitudes regarding the ICD-10 and other mental disorders classifications. Societies were asked to indicate whether they were interested in participating, had the capacity to implement the survey systematically, whether their members could participate in an English-language survey and, if not, whether the Society could translate the survey into the language used by most of its members. Fifty-two Societies responded that they were interested in participating in such a survey. The survey was developed by Reed, Maj, and Saxena, with input from G. Mellsop (Waikato Hospital, New Zealand) and W. Gaebel and J. Zielasek (University of Düsseldorf, Germany), from whose prior surveys 5,6,9 some questions in the current survey were adapted. Questions on goodness of fit were adapted from the field trial 11 of the Clinical Descriptions and Diagnostic Guidelines for ICD-10 Mental and Behavioural Disorders 12. Feedback on the survey was also provided by the WPA Executive Committee (see Acknowledgements). Following development of the survey in English, the WHO undertook translation of the survey into French and Spanish, using experts from multiple countries (see Acknowledgements) and an explicit translation methodology that included forward and back translation. The WPA Member Societies which had indicated that they wished to translate the survey into their local languages were provided with a set of translation materials and a translation methodology that included instructions on semantic and conceptual equivalence, forward translation, back translation, and resolution of differences among translators. WPA Member Societies produced item-by-item translations according to these instructions in 16 additional languages (see). The survey was prepared for administration in all languages via the Internet using the Qualtrics electronic survey platform (see www.qualtrics.com). The survey was programmed to present only those questions that were relevant to a particular respondent, depending on his or her prior responses. For example, questions related to use of specific ICD-10 categories were skipped for respondents who indicated they do not use the ICD-10 in their clinical practice. Survey packets were sent to all participating Societies, including instructions for administration, and initial solicitation and reminder messages to send to their members. Messages were provided in English, French and Spanish to the appropriate Societies, and other Societies were asked to translate the solicitation and reminder messages into their local language. Participating WPA Member Societies were informed that the survey data collected from their membership would be jointly owned by the WPA, the WHO and the Society, that they would be provided with the survey results from their own membership, and that they would be free to publish the survey results from their own membership after publication of the international data by the WPA and the WHO. Those WPA Member Societies that according to WPA records had more than 1,000 members were asked to randomly select 500 eligible members to solicit for participation. Member Societies that had fewer than 1,000 members were asked to solicit all eligible members. Eligible members were defined as all psychiatrist members of the Society who had completed their training. Participating WPA Member Societies were asked to send a standard initial solicitation message by e-mail or regular mail to the selected sample, and reminder messages to the entire selected sample at 2 weeks and 6 weeks following the initial solicitation. After the second reminder message had been sent, participating Societies were asked to return a Participation Tracking Form, indicating the number of members in the Society, the number of members solicited, the number of solicitations sent by e-mail and by regular mail, the number of solicitation messages returned as undeliverable, and the dates that the initial and reminder solicitations were sent. The initial solicitation and reminder messages contained a link (Internet address) to the online survey that was unique to each participating Member Society. When the respondent clicked on the link (or entered the Internet address in his or her web browser), he or she was directed to a page that explained the purpose of the survey, its anonymous and voluntary nature, the time required, and its exemption by the WHO Research Ethics Review Committee, and provided relevant contact information in the event of questions or comments. In order to proceed to the survey, the respondent had to affirm that he or she was a psychiatrist who had completed his or her training and that he or she wished to participate in the study. After receiving the survey packets, two Societies — the Cuban Society of Psychiatry and the Pakistan Psychiatric Society — contacted the WPA and indicated that they felt that their members would be unable to participate in an Internet-based survey. A paper-and-pencil version of the survey, with exactly the same content, was provided to these Societies for their use. The solicitation message to accompany the paper-and-pencil survey gave potential respondents the option of participation via the Internet or by completing the paper-and-pencil survey and returning it to their Society by regular mail. Data are presented here for the 46 WPA Member Societies in 44 countries that implemented the survey. Participation by Member Societies took place over a period of 11 months, due to the time necessary for Societies to complete translations, make other preparations, and implement the survey. The data presented here were collected between 3 May 2010 and 1 April 2011. A total of 4,887 psychiatrists worldwide participated in the survey. A list of participating WPA Member Societies, countries, languages of administration, number of participants from each Society, response rate, mean age of respondents, mean number of years of professional experience, and ratio of men to women for each is provided in Responses in are also aggregated according to the six WHO global regions — AFRO (primarily sub-Saharan Africa), AMRO (the Americas), EMRO (Eastern Mediterranean/North Africa), EURO (Europe), SEARO (Southeast Asia), and WPRO (Western Pacific) — and across the global sample. Weighted totals presented in and elsewhere in this article represent averages of totals by country divided by the number of respondents for that country, so that each country is weighted equally, thus controlling for differences in sample size among countries. A comparison of the unweighted and weighted statistics provides an indication of whether Societies with large samples contributed disproportionately to the overall result. Response rates for each WPA Member Society participating in the Internet-based survey were calculated by dividing the total number of psychiatrists from that Society who accessed the survey website and agreed to participate by the total number of participants solicited by that Society less any returned e-mail or regular mail solicitations. For the paper-and-pencil surveys in Cuba and Pakistan, the response rate represents the number of surveys completed and returned divided by the total sent less any returned as undeliverable. Response rates for each participating Society and aggregated response rates by region and overall are shown in Table 1. As shown in Table 1, the weighted overall global response rate was 34%. However, response rate varied dramatically by Society, from 7% (Slovenian Psychiatric Association, Spanish Neuropsychiatric Association) to 93% (Kyrgyzstan Psychiatric Association). By WHO region, weighted response rates were lowest for SEARO (25%) and highest for EMRO (51%). To examine the impact of country income level on participation in the Internet-based survey, based on the possibility that lower-resource countries would be less technologically able to participate, weighted response rates were calculated for countries grouped by World Bank country income level 13. The mean weighted response rate was 58% for low-income countries, 48% for lower-middle income countries, 30% for upper middle-income countries, and 24% for high-income countries. Because the survey was administered electronically, it was possible to capture the amount of time required for each participant to complete it. For the global sample, the mean response time was 21.8 min (weighted mean 21.8 min). Response times of less than 5 min were excluded from this calculation, as were response times of greater than 2 hours (the survey platform made it possible to leave the survey unfinished and come back at a later time to complete it, so using a maximum of 2 hours likely resulted in an overestimation of response time). The average response time was shortest for Italy (13.5 minutes), and longest for Nigeria (34.8 minutes). Response time would be influenced both by speed of Internet connectivity and by the pattern of participants' responses. For example, respondents who reported that they did not use a formal classification system were not asked subsequent questions about use of specific diagnostic categories. Globally, 96.7% of the participating psychiatrists reported that they currently saw patients (97.0% weighted by country). Subsequent questions regarding day-to-day clinical work were not presented in the electronic survey to psychiatrists who did not see patients. Of those who reported that they did see patients, 13.8% reported that they saw patients for between 1 and 9 hours during a typical week, 22.3% for between 10 and 19 hours, 44.9% for between 20 and 40 hours, and 18.8% for more than 40 hours. In order to facilitate comparisons across Societies and regions, categorical responses to this question were transformed into a continuous variable by setting "between 1 and 9 hours" to 5, "between 10 and 19 hours" to 15, "between 20 and 40" to 30 and "more than 40 hours" to 50. Table 1 shows the resulting transformed mean number of patient hours per week by Society, by WHO region, and for the global sample. All participants who reported they saw patients were asked: "As part of your day-to-day clinical work, how much of the time do you use a formal classification system for mental disorders, such as the ICD, the DSM, or a national classification?". Overall, use of classification systems among psychiatrists participating in the survey was high, with 79.2% of psychiatrists in the global sample who see patients (83.3% weighted) reporting that they "often" or "almost always/always" use a formal classification system as part of their day-to-day clinical work. An additional 14.1% (11.7% weighted) indicated that they "sometimes" use a formal classification system as part of their day-to-day clinical work. The proportion of participants for each Society who reported using a formal classification system "often" or "almost always/always", as opposed to those who only "sometimes", "rarely" or "never" did so, is shown in Table 1, as are unweighted and weighted aggregated results by WHO region and globally. Participants who saw patients were asked: "In your day-to-day clinical work, which classification system for mental disorders do you use most?" Overall, 70.1% of the global sample (63.9% weighted) reported that ICD-10 is the classification system they use most in their daily clinical work. Most of the remaining participants (23.0% unweighted, 29.9% weighted) reported that the system they use most frequently is the DSM-IV, but 5.6% (5.2% weighted) reported using another classification system, such as the Chinese Classification of Mental Disorders, the Cuban Glossary of Psychiatry, or the French Classification of Child and Adolescent Mental Disorders, and 1.3% (1.0% weighted) reported that they use the ICD-9 or the ICD-8. Table 1 shows the percentage of participating psychiatrists from each WPA Member Society who reported that the ICD-10 is the classification system they use most in daily clinical work, as well as aggregated totals by region and for the global sample. All participating psychiatrists, including those who do not see patients, were asked: "From your perspective, which is the single, most important purpose of a diagnostic classificatory system?". Overall global responses are shown in Figure 1. The most important purpose of a diagnostic classification system, from the respondents' perspective, is communication among clinicians, followed by informing treatment and management decisions. Percentage of participating psychiatrists endorsing six response options for the single, most important purpose of a diagnostic classificatory system of mental disorders All participants were asked: "In clinical settings, how many diagnostic categories should a classificatory system contain to be most useful for mental health professionals?". The overwhelming majority favored a system with dramatically fewer categories than current classification systems: 40.4% responded that a classification system with between 10 and 30 categories would be most useful (39.5% weighted), 47.1% preferred a classification system with 31 to 100 categories (46.9% weighted), 9.2% a classification system with 101–200 categories (9.6% weighted), and only 3.3% a system with more than 200 categories (4.0% weighted). Both the ICD-10 and the DSM-IV contain more than 200 categories. Overall, 79.5% of respondents (79.6% weighted) said that they completely or mostly agreed with the statement "A diagnostic classification system should serve as a useful reference not only for psychiatrists but also for other mental health professionals (e.g., psychologists, social workers, psychiatric nurses)", and 15.5% (15.6% weighted) said they agreed somewhat. Similarly, 60.4% (61.6% weighted) completely or mostly agreed that "a diagnostic classification system should be understandable to service users, patient advocates, administrators, and other relevant people as well as to health professionals", and 28.2% (27.3% weighted) agreed somewhat. Approximately two-thirds of respondents (66.1% unweighted, 64.8% weighted) said that primary care practitioners should have a modified/simpler classification system of mental disorders, while approximately one-third (33.9% unweighted, 35.2% weighted) felt that primary care practitioners should use the same classification system as specialist mental health professionals. Only a minority of participants (30.7% unweighted, 31.1% weighted) indicated that for maximum utility in clinical settings a diagnostic manual should contain clear and strict (specified) criteria for all disorders. The large majority (69.3% unweighted, 68.9% weighted) said they would prefer diagnostic guidance that is flexible enough to allow for cultural variation and clinical judgment. This is one of the main differences between the approach taken by the ICD-10 Clinical Descriptions and Diagnostic Guidelines 12 and that of the DSM-IV, so it was relevant to compare the responses of ICD-10 users and DSM-IV users to this question. A slightly higher proportion of global DSM-IV users (72.3%) compared to ICD-10 users (68.3%) expressed a preference for flexible guidance rather than strict criteria (p<0.05). All participating psychiatrists were asked their view of the best way for a diagnostic system to address the concept of severity. On this issue there was no majority opinion. Because this is an important issue for both the ICD-10 and the DSM-IV revisions 14, results for respondents who most frequently use the ICD-10 as compared to those who most frequently use the DSM-IV are presented in Figure 2. The responses of these two groups were significantly different from one another (p<0.01), with DSM-IV users more likely than ICD-10 users to favor a separate axis allowing an overall assessment of severity that could be used for all diagnoses, and less likely to say that a classification should provide subtypes of relevant diagnostic categories (e.g., mild, moderate or severe depressive episode) based on the number and/or severity of symptoms present. Percentage of global ICD-10 and DSM-IV users endorsing four options for the best way to address severity in mental disorders classification systems Participants were asked: "What is the best way for a diagnostic system to conceptualize the relationship between diagnosis and functional status (e.g., impairment in self-care or occupational functioning)?". Again, because of the relevance of this issue for both the ICD-10 and DSM-IV revisions 15, responses to this question for ICD-10 users as compared to DSM-IV users are shown in Figure 3. Responses of ICD-10 and DSM-IV users were significantly different from one another (p<0.0001). Although the most frequent response for both groups was that "functional status should be a diagnostic criterion for some mental disorders, when it is necessary to infer the presence of a disorder from its functional consequences", ICD-10 users more frequently endorsed this option. ICD-10 users were also more likely to say that "functional status should not be included in diagnostic criteria" at all, whereas DSM-IV users were more likely to say that "functional impairment should be a diagnostic criterion for most mental disorders; if there is no functional impairment, then a disorder should not be diagnosed". This result parallels the difference in the way that issues of functional status and clinical significance are currently treated in the two systems. Percentage of global ICD-10 and DSM-IV users endorsing three options for diagnostic classification systems to conceptualize the relationship between diagnosis and functional status Participants were asked to indicate whether they felt that a diagnostic system should incorporate a dimensional component, where some disorders are rated on a scale rather than just as present or absent. Responses for ICD-10 and DSM-IV users are shown in Figure 4. Although responses of these two groups are significantly different (p<0.05), the patterns are the same. The majority of both groups were favorable to the inclusion of a dimensional component, either because it would make the diagnostic system more detailed and personalized or because it would be a more accurate reflection of the underlying psychopathology. Only a minority said that a dimensional system would be too complicated for use in most clinical systems or that there was insufficient evidence regarding the reliability of such an approach. Percentage of global ICD-10 and DSM-IV users endorsing four options for whether a diagnostic classification system should incorporate a dimensional component Participants were asked to indicate whether they thought that a diagnosis of depression should be assigned when the depressive symptoms are a proportionate response to an adverse life event (e.g., loss of job or home, divorce). Nearly two-thirds (64.1% unweighted, 64.3% weighted) said yes, that if the full depressive syndrome is present, the diagnosis should be made regardless of whether there are life events that can potentially explain it, with the remaining respondents indicating that a proportionate response to an adverse life event should not be considered a mental disorder. Participants who see patients were asked to rate their level of agreement with the statement "The diagnostic system I use is difficult to apply across cultures, or when the patient/service user is of a different cultural or ethnic background from my own". Nearly three-quarters of respondents (74.8% unweighted, 71.3% weighted) said that they at least somewhat agreed with this statement. The proportion of psychiatrists by WHO region who mostly or completely agreed with the statement is show in Figure 5. For this analysis, the USA (AMRO North) was separated from Latin America (AMRO South), and Australia and New Zealand (WPRO Oceania) were separated from Asia (WPRO Asia). As shown in Figure 5, there was significant regional variation in agreement with this statement, with over 30% of participating psychiatrists in Latin America and Asia, and nearly 30% of those in Southeast Asia indicating that they mostly or completely agreed, in contrast to only 10% of psychiatrists in the USA. Percentage of psychiatrists by global region indicating they mostly or completely agreed with the statement "The diagnostic system I use is difficult to apply across cultures, or when the patient/service user is of a different cultural or ethnic background from my own" A related question asked of all participants was whether they saw the need for a national classification of mental disorders (i.e., a country-specific classification that is not just a translation of ICD-10). Participants in the USA were not asked this question. Figure 6 shows the percentage of psychiatrists, by country and within WHO region, indicating that they saw such a need in their countries. For presentations of country-level data, data from the two participating Societies in France were combined, as were data from the two participating Societies in Spain. Data for Hong Kong and the People's Republic of China are presented separately, because of historically different training and practice traditions that may have direct implications for attitudes toward classification. The overwhelming majority of participating Cuban psychiatrists had indicated that the diagnostic system they use most frequently is the Third Cuban Glossary of Psychiatry 16, a Cuban adaptation of the ICD-10 Clinical Descriptions and Diagnos