Psychiatric Diagnosis and Classification - part 9 ppsx

developing a brief disability measure (WHODAS II) that should be applicable for use in primary care (www.who.int/icidh/whodas). Many primary care physicians will not find it easy to use either of these scales and there are two questions that can be asked of patients that correlate with the scores on these two measures. They are: Beginning yesterday and going back four weeks, how many days out of the past four weeks were you totally unable to work or carry out your normal activities because of your health? Record this number as total disability days. The next question is: Apart from those days, how many days in the past four weeks were you able to work and carry out your normal activities, but had to cut down on what you did, or did not get as much done as usual because of your health? Record this as ``cut down days''. The sum of cut down days and total disability days is the disability days attributed to illness. The disability day measure correlates highly with the formal SF-12 and DAS-II question- naires. Normative data on disability days for the common mental disorders are displayed in Table 9.4. Why bother about assessing disability? The usual reply is that such measures provide a basis for sickness certificates and the like. But doctors have been writing sickness certificates for years without feeling the need for external measures. The proper answer is that a reduction in disability, especially in the number of cut down days, is a very good indication that the patient is responding to treatment, and is a much better indicator of Tableable 9.4 Self-reported disability by one-month ICD-10 diagnosis. Data from the Australian National Survey of Mental Health and Wellbeing (Andrews et al. [39]) Disability by diagnosis Short Form 12 (SF-12) Mental health summary score Disability days Mean (SE) Mean (SE) One-month ICD-10 diagnosis Affective disorder 33.4 (0.7) 11.7 (0.7) Anxiety disorder 39.2 (0.5) 8.9 (0.7) Substance use disorder 44.4 (0.7) 5.2 (0.5) Personality disorder 42.0 (0.6) 7.4 (0.5) Neurasthenia 34.6 (1.3) 14.1 (1.3) Psychosis 39.7 (1.1) 6.3 (1.9) Worse disability is indicated by lower SF-12 mental health summary scores and higher disability days. PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION IN PRIMARY CARE 235 improvement than a question about symptom severity. Disability assess- ment has another advantage: it acts as a qualifier on complaints of symp- toms. That is, a person who complains of many and varied symptoms, but who is not disabled, is probably in need of less treatment than their symp- toms would indicate. Conversely, a person who says stoically ``I'm just a bit down and find it hard to get started'', has no other symptoms but has missed days at work and has had to cut down on most other days in the past month, is certainly in need of treatment. SPECIAL GROUPS Children and Adolescents Children and adolescents do have emotional and behavioral disorders that should be recognized and treated. The recognition of the externalizing or acting out youth requires little skill, the parents or school will complain about the behavior, but the recognition of the internalized anxious or de- pressed child is difficult. Epidemiological surveys in many countries have shown that one in five children and adolescents will have experienced significant emotional problems in the previous six months. At any point in time, one in ten children will meet criteria for a mental disorder and warrant treatment if education and vocational choice is not to be impaired by what may well be a chronic mental disorder. Thus, the task for the clinician is to decide whether the symptoms being reported by the parent or complained of by the older child are evidence of normal variation, are problems related to intercurrent stressors, or are evidence of an ICD-10 or DSM-IV-PC de- fined mental disorder. There are well established risk factors that should raise the index of suspicion in clinicians that the child is at risk of developing a mental disorder. Mental disorders are more frequent in children of low intelligence, and in children with chronic physical disease, especially if that disease involves the central nervous system, e.g. epilepsy. Temperament, evident from infancy, is another good predictor. Easy children tend to be happy, regular in feeding and sleeping patterns, and they adapt easily to new situations. Difficult children are irritable, unhappy, intense, and have diffi- culty adjusting to change. Children with difficult temperaments are at higher risk of developing emotional and behavioral problems. Children are very sensitive to their direct family environment and, while the preced- ing factors are intrinsic to the child, poor family environments are not. Clinicians must be alert to families that are characterized by lack of affec- tion, parental conflict, overprotection, inconsistent rules and discipline, families in which there is parental mental illness such as depression or 236 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION substance use disorders, and above all to families in which physical or sexual abuse of the child is a possibility. When the index of suspicion is high, clinicians should attempt to obtain information from several informants: the child, the parents and sometimes the teachers or other family members. The following is a checklist of areas that should be covered, differentiating between symptoms and behaviors that are within normal variation, or consistent with problems that are likely to remit, or indicative of mental disorder [40]: . Achievement of developmental milestones . Fears, phobias and obsessions . Depressive symptoms, including suicidal thoughts . Inattention, impulsivity, excessive activity . Aggressive, delinquent and rule breaking conduct . Problems with learning, hearing, seeing . Bizarre or strange ideas or behavior . Use of alcohol or drugs . Difficult relationships with parents, siblings or peers. Studies indicate that less than 30% of children with substantial dysfunc- tion are recognized by primary care physicians. Recognition of conduct or attention problems is reasonably good because of the clarity of the parental complaint or school report, but recognition of the anxiety and depressive syndromes or of physical or sexual abuse is poor. There is a 35 item Pediatric Symptom Checklist (PSC) that has demonstrated reliability and validity as a screening instrument for use with cooperative parents. According to the author [41], it can be given to parents in the waiting room and completed in a few minutes before seeing the doctor. The scale is reproduced in Table 9.5. The PSC is scored by assigning two points for every ``often'' response, one point for every ``sometimes'' response and no points to the ``never'' answers. Adding the points yields the total score. If the PSC score is 28 or above, there is a 70% likelihood that the child has a significant problem. If the score is below this, then there is a 95% likelihood that the child does not have serious difficulties. Interested clinicians should consult the original articles or access the website (www.healthcare.partners. org/psc). Diagnosis in the Elderly Across all ages, common mental disorders are much more likely to present in primary care than in specialist clinics. Among the elderly, primary care accounts for an even greater proportion of mental health care [42]. Even in PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION IN PRIMARY CARE 237 Tableable 9.5 Pediatric Symptom Checklist (PSC; Jellinek [41], reproduced by permission) Please mark under the heading that best describes your child: Never Sometimes Often Complains of aches and pains ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Spends more time alone ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Tires easily, has little energy ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Fidgety, unable to sit still ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Has trouble with a teacher ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Less interested in school ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Acts as if driven by a motor ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Daydreams too much ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Distracted easily ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Is afraid of new situations ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Feels sad, unhappy ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Is irritable, angry ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Feels hopeless ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Has trouble concentrating ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Less interested in friends ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Fights with other children ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Absent from school ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ School grades dropping ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Is down on him or herself ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Visits doctor with doctor finding nothing wrong ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Has trouble sleeping ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Worries a lot ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Wants to be with you more than before ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Feels he or she is bad ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Takes unnecessary risks ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Gets hurt frequently ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Seems to be having less fun ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Acts younger than children of his or her age ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Does not listen to rules ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Does not show feelings ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Does not understand other people's feelings ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Teases others ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Blames others forhisorher troubles ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Takes things that do not belong to him or her ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Refuses to share ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ those countries relatively well supplied with mental health specialists, ini- tial presentation to specialist care is relatively rare. Consequently, the need to improve recognition and diagnosis of mental disorders in primary care 238 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION applies even more to older adults. A few diagnostic issues specific to the elderly deserve mention. Community and primary care surveys typically show that prevalence rates for anxiety and depressive disorders are lower among the elderly than in middle age [43, 44]. While this pattern is seen for a wide range of disorders, most attention has been directed at age differences in rates of depressive disorders. Application of standard DSM or ICD criteria for depressive episode leads to the conclusion that depressive disorders are only half as frequent above age 60 as below. This has led to questions regarding the validity of DSM and ICD criteria in the elderly [45, 46]. Some have proposed that older adults are less likely to endorse emotional symptoms such as depressed mood or sadness, leading to an under-estima- tion of the true prevalence of depression [46]. Others have found that elders are less likely to report symptoms of all types, and that this may reflect a general tendency to under-report distressing experience [47]. Either of these views would suggest use of a somewhat lower threshold for diagnosis of depression in the elderly. Primary care physicians in the United States and Western Europe may, in fact, already use such an adjustment. Though epi- demiological data suggest a decreasing prevalence of depressive disorder with age, rates of antidepressant prescription are generally as high or higher in the elderly [48]. The overlap between depressive symptoms and symptoms of chronic medical illness has also led to questions regarding appropriateness of de- pression diagnostic criteria in the elderly. Symptoms such as fatigue, loss of weight or appetite, and poor concentration may reflect medical illness rather than depression, especially among older primary care patients. This concern has led to development of alternative depression measures that rely more on ``psychic'' and less on ``somatic'' symptoms [49]. Such a change in emphasis, though, would probably be inappropriate for a primary care classification. Depressed primary care patients are especially likely to pre- sent with somatic symptoms or complaints. Given concerns about under- diagnosis of depression in primary care, changes to decrease diagnostic sensitivity would probably be ill-advised. CROSS-NATIONAL ADAPTATION OF DIAGNOSTIC SYSTEMS Adaptation of a diagnostic system for use in different countries and cultures must consider several of the same issues important to adaptation from specialist to primary care practice. First, the form or structure of mental disorders may differ significantly across countries or cultures. Second, the prevalence of specific disorders may vary. Finally, the importance of PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION IN PRIMARY CARE 239 specific clinical questionsÐand specific diagnostic distinctionsÐmay differ widely according to the resources available. Available evidence does not suggest that the form or structure of common mental disorders in primary care varies widely across countries or cultures. The common anxiety and depressive syndromes originally defined in West- ern Europe and the United States are also seen among primary care patients in economically developing countries [10]. Consequently, adaptation of a classification system should not usually require redefinition of core syn- dromes or development of new diagnostic criteria. Cross-national epidemiological data, however, find some areas of signifi- cant variation. Overall morbidity rates show significant variability across countries and cultures. Both community and primary care surveys find that overall rates of psychiatric morbidity are typically highest in Latin America and lowest in Asia, with intermediate rates in North America and Western Europe [10, 50]. When a primary care classification is adapted for local use, some disorders may require less emphasis (or be omitted altogether). In addition, the typical presentation of anxiety and depressive disorders varies across countries and cultures [7]. While somatic presentations of psycho- logical distress are the norm worldwide, overtly psychological presenta- tions may be relatively common in some settings and quite rare in others. Local adaptation of a generic classification must consider culture-specific somatic presentations. Variation across countries and health systems in availability of treatments has important implications for the utility of a primary care classification. In some cases, resource limitations may argue for simplification of a diagnostic classification. If antidepressant drugs are unavailable, the distinction between major depressive episodes and less severe depression becomes less import- ant. In other cases, resource limitations may require an expanded scope of primary care practice. When no specialist services are available, management of psychotic disorders becomes a primary care responsibility. In this situation, distinguishing among various agitated or psychotic states (delirium, mania, and schizophrenia) becomes more relevant to primary care practice. TRAINING AND IMPLEMENTATION Accurate diagnosis of mental disorders in primary care is a multi-step process involving initial recognition, diagnostic assessment, and (in some cases) diagnostic confirmation. Each of these steps has unique requirements and potential difficulties. Quality improvement efforts will need to address each of these stages differently. The initial stage in diagnosis is recognition of the presence of psycho- logical distress or mental disorder. Abundant evidence suggests that a large 240 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION number of anxiety and depressive disorders go unrecognized in the typical primary care visit. Recognition is strongly related to presenting complaint, so the most straightforward approach to improving recognition is to en- courage the presentation of psychological complaints [5, 6]. Presentation of psychological complaints is associated with specific physician behaviors, and those behaviors are modifiable through training [8]. In some cases, a focus on physician awareness and interviewing style may be sufficient. Even the most skillful physician, however, will fail to recognize some cases of significant psychological disorder. Any systematic program to increase recognition should be inexpensive, convenient, and acceptable to patients. Ideally, this initial stage of diagnosis should require little or no time from physicians and minimal time from other clinical staff. Theleastexpensive and intensive approachisa passive screening program allowing patients to self-screen and self-identify. Examples include pamphlets or posters in the waiting room or consulting room. These ap- proaches are probably the least expensive and least intrusive, but evidence of effectiveness is lacking. A range of options is available for active screening. While visit-based screening is the most common approach, mail screening allows a clinic or practice to target specific high-risk groups or screen those who make infrequent visits. Various modes of administration are available: paper and pencil, computer screen, telephone, or face-to-face live interview. The choice of methods should depend on local availability and acceptability to patients. Finally, a large number of measures have been proved sufficien- tly sensitive and specific for primary care screening. The PRIME-MD [9] and SDDS-PC [51] described above are examples of multipurpose meas- ures intended to screen for a number of specific mental and substance use disorders. The General Health Questionnaire (GHQ) [52] and the Men- tal Health Inventory (MHI-5) [53] are examples of a ``broad spectrum'' screener for common anxiety and depressive disorders. The Center for Epi- demiologic Studies Depression Scale (CES-D) [54] and the Alcohol Use Dis- orders Identification Test (AUDIT) [55] are examples of disorder-specific screeners. A substantial literature suggests that screening alone (or simple recogni- tion of psychological distress) is probably not sufficient to improve outcomes [56±59]. Screening must be followed by specific diagnosis and effective treat- ment [12, 60, 61]. Several studies have examined the diagnostic performance of trained primary care providers [8, 9]. Specific diagnostic tools (algorithms, criteria, semi-structured interviews) are acceptable to primary care providers and feasible for use in busy primary care practices. Diagnoses made by trained primary care staff agree well with those made by mental health specialists [9, 35]. Research supports the accuracy of diagnoses by trained physicians and nurses, with no data necessarily favoring one type of provider over the other. Two recent studies with the PRIME-MD system [29, 34] PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION IN PRIMARY CARE 241 suggest that completely automated administration may agree well with a face-to-face assessment by a trained physician. Despite this evidence, it seems unlikely that most primary care physicians (or mental health specialists) would choose to initiate treatment on the basis of an automated assessment. Computerized assessment tools may be most useful for ``ruling out'' a spe- cific diagnosis among those with positive screening results. In the case of less common or more severe disorders, the primary care physician or practice should focus on screening with referral to specialist services for diagnostic confirmation. In the case of rare disorders (such as Tourette's syndrome), training primary care physicians or nurses in specific diagnosis (or treatment) does not seem a worthwhile investment. In the case of more severe disorders (such as bipolar disorder or schizophrenia), definitive diagnosis and management will usually be the responsibility of specialist services. When specialist consultation is available, training of the primary care team should focus on screening for severe disorders rather than definitive diagnostic evaluation (i.e. sensitivity rather than diagnostic specificity). Training Other Primary Care Staff Receptionists and Practice Nurses It is difficult to attend a primary care physician for a regular check-up and not have blood and urine tests, and one's blood pressure estimated. So it should be. It should be equally difficult to attend and not have one's emotional well- being estimated. Unfortunately it is not. The GHQ is probably the world standard measure used for this purpose [62]. All patients, apart from those on regular repeat visits, should be given a GHQ (and for that matter an SF-12) by the receptionist or practice nurse on arrival. If parents are bringing chil- dren to see the doctor, they should be asked to fill in the parent screening for children (PSC) before the consultation begins. All receptionists and practice nurses should be trained to score these questionnaires and to flag, with a discrete code, whether the score is above the established threshold, exactly as abnormal laboratory tests are flagged to aid easy recognition by the doctor who is responsible for diagnostic decisions. Psychologists Psychologists are, or should be, mental health specialists. They should be capable of administering and interpreting the standard diagnostic tests, including the Composite International Diagnostic Interview (CIDI) 242 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION [63], a structured diagnostic interview for DSM-IV and ICD-10 that includes the Mini Mental State Examination [64], the Equivalent Diagnostic Inter- view Schedule for Children [65] and the Child Behavior Checklist [66]. They should be able to administer the Wechsler Intelligence Scale for Chil- dren [67] to any child who has a problem at school. In addition, the psych- ologist should be familiar with a range of questionnaires used to identify symptoms specific to the various mental disorders. Once such self-report measures are established in a clinic, the practice nurse can administer and score most of them. In fact, in many practices, clinical information systems can be used to administer most of the tests used to assess mental well-being. Volunteers, NGO Staff and other Multipurpose Care Workers These people, who often function with people at considerable risk of mental abnormality, need ways of identifying people who should be referred to a primary care physician for further assessment. Again, they should be trained to administer and score the GHQ and the SF-12, and to recognize when a person's score is above the accepted threshold. Furthermore, because their clientele are underserviced, they may need some understanding of the ways that people with the common mental disorders behave. The Manage- ment of Mental Disorders is a very accessible workbook (see www.crufad. org/books) that is published in the UK, Australia, New Zealand and Canada, with Italian and Chinese language versions in preparation. All primary care staff, from doctors to care workers, should have access to this resource. CONCLUSIONS We have shown that primary care needs to use a simplified system of classification, aimed at choosing appropriate management for the indi- vidual patient. The main problems in the development of the mental health aspect of primary care are finding the time to deal with the sheer mass of psychological problems in primary care, and training suitable staff in the specific skills they need to deal with the various problems that are of high prevalence in this setting. Across the world, many patients can now be offered treatment where previously no help would have been forthcoming, and there is a growing appreciation of the contribution that can be made by other staff, with the doctor responsible for initial triage. PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION IN PRIMARY CARE 243 REFERENCES 1. Jaspers K. (1963) General Psychopathology. Manchester University Press, Man- chester. 2. World Organization of National Colleges, Academies and Academic Associ- ations of General Practitioners (WONCA) (1988) ICHPCC-2-Defined International Classification of Health Problems in Primary Care, 3rd edn. Oxford Medical Publi- cations, Oxford. 3. NHS Information Authority (2000) The Clinical Terms (The Read Codes). Version 3 Reference Manual. NHS Information Authority, Loughborough. 4. Jenkins R., Smeeton N., Shepherd M. (1988) Classification of mental disorders in primary care. Psychol. Med., Suppl. 12. 5. Bridges K.W., Goldberg D.P. (1985) Somatic presentations of DSM-III psychi- atric disorders in primary care. J. Psychosom. Res., 29: 563±569. 6. Goldberg D.P., Bridges K. (1988) Somatic presentations of psychiatric illness in primary care. J. Psychosom. Res., 32: 137±144. 7. Simon G.E., VonKorff M., Piccinelli M., Fullerton C., Ormel J. (1999) An inter- national study of the relation between somatic symptoms and depression. N. Engl. J. Med., 341: 1329±1335. 8. Scott J., Jennings T., Standart S., Ward R., Goldberg D. (1999) The impact of training in problem-based interviewing on the detection and management of psychological problems presenting in primary care.Br. J. Gen. Pract., 443: 441±445. 9. Spitzer R.L., Williams J.B.W., Kroenke K., Linzer M., deGruy F.V., Hahn S.R., Brody D., Johnson J.G. (1994) Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA, 272: 1749±1756. 10. U È stu È n T., Sartorius N. (1995) Mental Illness in General Health Care. Wiley, New York. 11. Goldberg D.P., Huxley P.J. (1991) Common Mental DisordersÐA Biosocial Model. Routledge, London. 12. Goldberg D.P., Privett M., U È stu È n T.B., Gater R., Simon G. (1998) The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities. Br. J. Gen. Pract., 48: 1840±1844. 13. Kroenke K., Spitzer R.L., Williams J.B.W., Linzer M., Hahn S.R., deGruy F.V., Brody D. (1994) Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch. Fam. Med., 3: 774±779. 14. Simon G.E., VonKorff M. (1991) Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area Study. Am. J. Psychiatry, 148: 1494±1500. 15. Wells K.B., Stewart A., Hays R.D., Burnam M.A., Rogers W., Daniels M., Berry S., Greenfield S., Ware J. (1989) The functioning and well-being of depressed patients: results from the Medical Outcome Study. JAMA, 262: 914±919. 16. Simon G.E., VonKorff M., Barlow W. (1995) Health care costs of primary care patients with recognized depression. Arch. Gen. Psychiatry, 52: 850±856. 17. Penninx B.W., Geerlings S.W., Deeg D.J., van Eijk F.T., van Tilburg W., Beek- man A.T. (1999) Minor and major depression and the risk of death in older persons. Arch. Gen. Psychiatry, 56: 889±895. 18. Penninx B.W., Leveille S., Ferrucci L., van Eijk J.T., Guralnik J.M. (1999) Explor- ing the effect of depression on physical disability: longitudinal evidence from the established populations for epidemiologic studies of the elderly. Am. J. Public Health, 89: 1346±1352. 244 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION [...]... published in the form of a handbook of 238 pages It contains operationalized criteria for all diagnostic categories and the equivalent or closest ICD -9 and ICD-10 codes alongside the diagnostic headings The CCMD-2-R strategy of classification is both aetiological and symptomatological Zheng et al [85] have demonstrated that the reliability and validity of the CCMD-2 and the DSM-III-R were closely compatible... al ( 199 5) Brief diagnostic interviews (SDDS-PC) for multiple mental disorders in primary care Arch Fam Med., 4: 208±211 246 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION Mulrow C.D., Williams J.W., Gerety M.B., Ramirez G., Montiel O.M., Kerber C ( 199 5) Case-finding instruments for depression in primary care settings Ann Intern Med., 122: 91 3 92 1... (depressive syndrome) without 264 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION any sub -classification Although the CCMD-2-R duration criterion (two weeks or more) for the diagnosis of depression is the same as that of the ICD-10 and DSM-IV, depressed mood is required as the ``main characteristic'' of the condition Neurosis and psychogenic mental disorders are preserved in the CCMD2-R, which emphasizes as their... T.L., Rose T.L ( 198 3) Development and validation of a geriatric depression screening scale J Psychiatr Res., 17: 37± 49 Weissman M.M., Bland R.C., Canino G.J ( 199 6) Cross-national epidemiology of major depression and bipolar disorder JAMA, 276: 293 ± 299 Weissman M.M., Broadhead W.E., Olfson M., Faravelli C., Greenwald S., Hwu H.G., Joyce P.R., Karam E.G., Lee C.K., Lellouch J., et al ( 199 8) A diagnostic... and psychosocial problems They are a   Psychiatric Diagnosis and Classification Edited by Mario Maj, Wolfgang Gaebel, Juan Jose Lopez-Ibor and Norman Sartorius # 2002 John Wiley & Sons, Ltd 250 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION large and heterogeneous group Some of them use magical and occult practices They may make astrological predictions, use trance-like experience in which spirits are supposed... amount of information on the diagnosis and classification is available from cross-cultural studies of groups of patients with the same diagnosis Though there were some studies in this area prior to 199 0 [55±60], the number of studies during the last decade is remarkable This could be a reflection of the availability of the ICD-10 and DSM-IV for comparative studies The pre- 199 0 studies have focused on:... episode 24%, generalized anxiety disorder 15%, and epilepsy 9% ) and there was little agreement between the faith healers' classification and DSM-III-R diagnosis [4] A limited number of case reports of Amok [70], brain-fag syndrome [71], and culture bound syndromes from South Africa have been published Saxena and Prasad [31] applied DSM-III criteria to 123 Indian psychiatric outpatients with predominantly... psychologists, psychiatric social workers, psychiatric nurses and occupational therapists [77] Though mental health care in primary health care is a widely accepted approach in developing countries, systematic studies of psychiatric diagnosis and classification at that level are scarce [78, 79] PSYCHIATRIC DIAGNOSIS IN DEVELOPING COUNTRIES 263 EXPERIENCES OF APPLYING AND USING MODERN PSYCHIATRIC CLASSIFICATION. .. DEVELOPING COUNTRIES China China has a national system of psychiatric classification called the Chinese Classification of Mental Disorders (CCMD) [80±84] The first published classificatory scheme appeared in 197 9 This was revised and named the CCMD-1 in 198 1, and was further modified in 198 4 The CCMD-1 was subsequently revised and tested on 22 285 outpatients and 8061 inpatients in 77 mental health facilities... London American Psychiatric Association ( 199 5) Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV), Primary Care Version American Psychiatric Association, Washington Spitzer R.L., Kroenke K., Williams J.B ( 199 9) Validation and utility of a selfreport version of PRIME-MD: the PHQ primary care study JAMA, 282: 1737±1744 First M., Spitzer R., Gibbon M., Williams J ( 199 7) Structured . J. ( 199 9) An inter- national study of the relation between somatic symptoms and depression. N. Engl. J. Med., 341: 13 29 1335. 8. Scott J., Jennings T., Standart S., Ward R., Goldberg D. ( 199 9). D. ( 199 4) Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch. Fam. Med., 3: 774±7 79. 14. Simon G.E., VonKorff M. ( 199 1) Somatization and psychiatric. Kerber C. ( 199 5) Case-finding instruments for depression in primary care settings. Ann. Intern. Med., 122: 91 3 92 1. 37. Mathers C., Vos T., Stevenson C. ( 199 9) The Burden of Disease and Injury