Future changes in psychiatric classification systems

1. Future changes in psychiatric classification systems Terry Brugha Leicestershire Partnership NHS Trust and University of Leicester

2. Overview History and present status From chaos to categories Dimensions The example of depression Top down classification (clinical experience) vs bottom up (taxonomic) classification Anything new in adult psychiatry? � developmental disorders and the example of the autism spectrum

3. History and present state Emergence of broad distinct groupings Intellectual disability; acute and chronic organic brain/�organic� disorders; addictions; functional disorders � neurosis/psychosis; personality/developmental disorders Clinical perspectives From the Kraepelinian distinction to the DSM/ICD workgroups Empirical perspectives Epidemiological data; large heterogeneous (not diagnosis specific) clinical series

4. From Chaos to Categories US-UK Project � chaotic transatlantic agreement on what is schizophrenia Robins and Guze (1970) Research based Diagnostic Criteria and DSM-III etc Establishment of reliability Payment by diagnosis (US health economies) Certainty in the witness box Competition with other branches of medicine: or pseudoscience?

5. Priorities for DSM-V Excessive comorbidity Poor correlation of diagnosis with genetic and neuroscience measures Potential for dimensional approaches to diagnosis

6. Dimensions Ref: Dimensional Approaches in DIAGNOSTIC CLASSIFICATION Refining the Research Agenda for DSM-V, Helzer, Kraemer, Krueger, Wittchen, Sirovatka, Regier. American Psychiatric Association, 2008. THE EXAMPLE OF DEPRESSION

7. �The end of the beginning: a requiem for the categorisation of mental disorder?� Background dimension free classification: a step too far? does not reflect reality (epidemiological data)? one solution / threshold fits all? Reification of categories - fallacy or deceit? But clinical decision making is binary and the criterion item pool is invaluable

8. Chosen points Selective epidemiological evidence Exemplar marriages of dimensions and categories in clinical decision making A marriage of existing categories and new dimensions

9. Data source UK Adult psychiatric morbidity surveys SN 4653 -Psychiatric Morbidity among Adults Living in Private Households, 2000 Full details including reports, detailed documentation etc are at: http://www.data-archive.ac.uk/findingData/snDescription.asp?sn=4653 Papers cited: Brugha et al, 2004, Br J Psychiat, 185, 378-84, and Melzer et al, 2002, Psychological Medicine, 32, 1195-1201.

15. NICE Depression Guideline Management of depression in primary and secondary care Clinical Guideline 23 Developed by the National Collaborating Centre for Mental Health, December 2004 www.nice.org.uk/CG023distributionlist

16. Guidance Good practice points relevant to the care of all people with depression: Stepped care Step 1: recognition of depression in primary care and general hospital settings Step 2: recognised depression in primary care � mild depression Step 3: recognised depression in primary care � moderate or severe Step 4: specialist mental health services � treatment-resistant, recurrent, chronic, atypical and psychotic depression, and those at significant risk Step 5: depression needing inpatient care

18. Adding dimensions Proposal to augment DSM-V with dimensional measures Proposal to specify measurement scales Up side: enhances clinical practice decision making Down side: chaos could return because dimensions also highlight the lack of discontinuity between existing categories

19. Top down (clinical experience) vs bottom up (taxonomic) Criteria driven by clinical experience � the clinician perspective bias Multiplicity of ever more subcategories of subcategories Population data fit better with parsimony� Classification based on statistical analysis of large dataset item pools� the contribution of numerical taxonomy Example taken from Slade & Watson, 2006, Psychological Medicine.

21. Anything new in adult psychiatry? � developmental disorders and the example of the autism spectrum Categorically: 1 in 100 children meet criteria for an ASD of whom half are not intellectually disabled (LD) Baird et al Lancet, 2006 Autistic criteria are also dimensionally distributed, are commoner in people with another mental disorder, complicate and go largely unseen within clinical presentations Refs on request.

22. Pervasive developmental disorder criteria (DSM/ICD) PDD criteria require information on early development (age of speech development) Older adults: no informant sources Existing PDD/ASD criteria do not consider the needs of older adults Epidemiology of ASD is now being studied in 3rd Adult Psychiatric Morbidity Survey DH Ministerial announcement 8/5/2008. DoH press Release: http://nds.coi.gov.uk/Content/Detail.asp?ReleaseID=366876&NewsAreaID=2 National Autistic Society Press Release http://www.nas.org.uk/nas/jsp/polopoly.jsp?d=824&a=16356

23. Conclusions So some specific criteria require updating But more fundamental problems remain The survival of existing categorical top down classification is pragmatic Dimensional perspective more likely to augment than replace categorical approaches The development of our evidence base and clinical practice must be soundly based How prepared is our discipline for the necessary changes?

24. Future changes in psychiatric classification systems Terry Brugha Leicestershire Partnership NHS Trust and University of Leicester