A qualitative analysis on what Brazilian psychiatrists expect from current diagnostic classifications

Abstracts

INTRODUÇÃO: Pretende-se analisar o perfil de respostas qualitativas a um questionário padronizado anônimo, com itens abertos e fechados, sobre a percepção dos psiquiatras brasileiros acerca do uso dos sistemas diagnósticos multiaxiais CID-10 e DSM-IV e de suas expectativas quanto às próximas revisões (CID-11 e DSM-V). MÉTODO: O questionário, elaborado por Graham Mellsop (Nova Zelândia), foi traduzido e enviado para 1.050 psiquiatras afiliados à Associação Brasileira de Psiquiatria. RESULTADOS: Retornaram 160 questionários (15,2%). Nestes, 71,1% das questões abertas foram respondidas. As principais qualidades julgadas necessárias ou desejadas em uma classificação psiquiátrica foram: simplicidade, clareza de critérios, objetividade, compreensibilidade, confiabilidade e facilidade de uso. O eixo I da CID-10 foi citado como o mais utilizado pelo caráter instrumental e pelo fato de ser a classificação oficial, inclusive para fins burocráticos e legais. O DSM-IV também é bastante utilizado no cotidiano, sobretudo para ensino e pesquisa, por psiquiatras com afiliações acadêmicas. O uso menos frequente de sistemas multiaxiais foi justificado pela falta de treino e de familiaridade, pela sobrecarga de informações e pelo fato de não serem obrigatórios. Avaliou-se que algumas categorias diagnósticas, entre outras, devem ser revistas, como: retardo mental, transtornos alimentares, de personalidade, do sono, da infância e adolescência, quadros ansiosos, afetivos, esquizoafetivos. CONCLUSÃO: O material fornece um panorama sobre as opiniões e expectativas dos psiquiatras a respeito dos instrumentos diagnósticos dos quais se servem ativamente em sua prática diária e cujas revisões estão em pleno processo de elaboração.

Classificação; diagnóstico; utilidade clínica; sistemas multiaxiais

A qualitative analysis on what Brazilian psychiatrists expect from current diagnostic classifications

Amilton dos Santos Júnior^I;Luiz Fernando Almeida Lima e Silva^II; Cláudio Eduardo Muller Banzato^III; Mário Eduardo Costa Pereira^III

^IMédico psiquiatra. Mestrando, Saúde da Criança e do Adolescente, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil

^IIMédico psiquiatra, Unidade de Emergência Referenciada, Hospital das Clínicas, Faculdade de Ciências Médicas, Unicamp

^IIIProfessor livre-docente, Faculdade de Ciências Médicas, Unicamp

Apoio financeiro e logístico: Associação Brasileira de Psiquiatria (ABP)

Correspondence

ABSTRACT

INTRODUCTION: The objective of the present study was to analyze the qualitative answers of an anonymous standardized survey including qualitative and quantitative questions about the Brazilian psychiatrists' perceptions on their use of the multiaxial diagnostic systems ICD-10 and DSM-IV and about their expectations regarding future revisions of these classifications (ICD-11 and DSM-V).

METHODS: The questionnaire, elaborated by Graham Mellsop (New Zealand), was translated into Portuguese and sent through mail to 1,050 psychiatrists affiliated to the Brazilian Psychiatry Association. The quantitative analysis is presented elsewhere.

RESULTS: One hundred and sixty questionnaires returned (15.2%). From these, 71.1% of the open questions where answered. The most needed and/or desirable qualities in a psychiatric classification were found to be: simplicity, clarity of criteria, objectivity, comprehensibility, reliability, and ease to use. Axis I of the ICD-10 was reported to be the most used due to its instrumental character in addition to being the official classification also for legal and bureaucratic purposes. The DSM-IV was also used in the everyday practice, mostly for education and research purposes, by psychiatrists with academic affiliations. The less frequent use of the multiaxial systems was explained by the lack of training and familiarity, the overload of information and by the fact they are not mandatory. Based on the respondents' answers, we concluded that some diagnostic categories must be revised, such as: mental retardation, eating disorders, personality disorders, sleeping disorders, child and adolescent disorders, affective, and schizoaffective disorders.

CONCLUSION: This material offers a systematic overview of the psychiatrists' opinions and expectations concerning the diagnostic instruments used in their daily practice.

Keywords: Classification, diagnosis, clinical utility, multiaxial systems.

INTRODUCTION

At this moment, when the first steps towards the International Statistical Classification of Diseases and Related Health Problems (ICD), 11th revision, and the Diagnostic and Statistical Manual of Mental Disorders (DSM), fifth revision, are taken, the discussion about the future of diagnostic classifications in psychiatry has developed around two basic parameters: validity and utility.^1-3 Although the scientific ambition that animates the diagnostic classifications - notably the DSM system - has received more attention from the specialized literature, there has always been a concern over the clinical and educational impact of the adoption and use of such systems.^1,4-7 Since the launch of the DSM-III (1980), a landmark on psychiatry for being the first classification based on explicit diagnostic criteria and the first which officially adopted a multiaxial system,⁸ several surveys have been conducted, mainly in the US and Canada, on the use and clinical impact and on the teaching of the DSM-III and its successors with different populations and in different contexts.^1,4-6,9,10

This study aims to investigate the Brazilian psychiatrists' use and perceptions on the utility of the main current diagnostic classifications (ICD-10 and DSM-IV) and to identify their expectations about the future classificatory systems. More specifically, it intends to check the desirable attributes of a diagnostic classification according to the respondents. Previous surveys had only focused on the use and perceived utility of diagnostic classifications. In this study, the expectations and some of the taxonomic preferences of psychiatrists regarding the classification systems are also considered.

METHOD

The questionnaire used is the translation into Portuguese of the English original instrument elaborated by Graham Mellsop (New Zealand). An independent back-translation into English and a comparison to assess its semantic equivalence with the original questionnaire were performed. Revisions of the translation were carried out when necessary.

A detailed analysis of the Brazilian psychiatrists' answers to this questionnaire was performed.¹ Another study including these data combined with those collected by Graham Mellsop in New Zealand and with the results from a third survey was carried out in Japan using the same questionnaire.¹¹ That study was conducted in order to identify the global characteristics of diagnostic systems and the preferred classificatory systems of professionals from three culturally, socioeconomically and geographically diverse countries.¹¹

In the present report, only the Brazilian psychiatrists' answers to the open questions of the questionnaire were considered, which are articulated with quantitative elements of the questionnaire, and respondents were asked to list the qualities and attributes considered necessary or desirable in a psychiatric classification; to comment about the reasons why each respondent routinely uses or never uses certain axes of the DSM-IV and ICD-10; and to comment on any specific diagnoses in the DSM-IV or ICD-10 that should be withdrawn or moved to another section.

From the mailing list provided by the Department of Psychiatric Diagnosis and Classification of the Brazilian Psychiatry Association (DDCP-ABP), including the names of 3,062 associated psychiatrists, 1,050 names were randomly selected to receive the questionnaire, together with a stamped envelope for the return of the questionnaire. After sending out the questionnaires, two electronic messages were sent (in the second and in the fifth subsequent weeks) to the e-mail addresses of the psychiatrists included in the original list, reinforcing the request of its fulfillment. No personal data of the psychiatrists was included in the questionnaire form.

RESULTS

From the total sample of 1,050 questionnaires, 21 could not be delivered because of the receivers had moved or due to incomplete addresses.¹ One hundred and sixty questionnaires returned, which represents a response rate of 15.2%.^1,11 Among these, 71.1% of the open questions were answered.

When asked to list the qualities or attributes needed or wanted from a psychiatric classification, most psychiatrists (75% - 120 of the 160 returned questionnaires) agreed on the importance of clear, simple, objective, understandable, reliable, and easy to use criteria. These were considered important items to better explain symptoms and psychopathological structures, to inform treatment and to indicate possible etiology and pathogenesis. Some examples of the most frequent answers included:

Clarity, objectivity, guidance of choices, prognosis, and therapy.

Good validity and reliability, easy implementation, understanding, and clear criteria.

Simplification, with emphasis on the main/core symptoms of the pathology.

After an inquiry about the use of each axis of the DSM-IV and ICD-10 (Table 1), the psychiatrists were asked to comment on why they routinely use these instruments. For five out of 160 respondents (3.1%), the question was not applicable because they informed they do not routinely use any of the axes listed in Table 1. Among the others, the request was discussed by 134 psychiatrists (86.5%). Axis I of the ICD-10 was cited as the most used. The most often cited reason was related to the fact that it is the official classification, as well as an "instrument of communication with other professionals, lay people, justice, health insurance," which "enables communication with all the team throughout the service."

The DSM-IV is also widely used (mainly axis I), often by the same professional who also declared to use the ICD-10. Those who make routine use of DSM-IV mentioned the following reasons: academic affiliations, working together with students and residents (because it is the classification found in many sources of the literature), or being a system that allows broader diagnosis formulation.

Concerning to reasons for not using some psychiatric axes of the classification systems, 30 respondents mentioned the occasional use of all the axes of the ICD-10 and DSM-IV. Therefore, such question did not apply to them. Among the other 130 psychiatrists who answered this item, 97 (74.6%) made comments about the request, mentioning lack of training and familiarity, lack of knowledge about the classification criteria, and little practicality as the most important reasons for not using the mentioned axes. Such comments were more frequently presented as an explanation for the non-use of multiaxial classifications.

The last open question inquired if there were any diagnostic categories that psychiatrists thought should be either deleted altogether or moved to another section of the DSM-IV and ICD-10. According to the 104 interviewees who answered this question (65% of the returned questionnaires), 33 (31.7%) psychiatrists replied "no" and 12 (11.5%) answered did not have an opinion about it, did not feel able to comment on that, or had never thought about it. The other 59 psychiatrists (56.7%) considered some diagnostic categories as problematic and believed that they should be revised. The most cited ones were:

- neurotic disorders, stress related and somatoform (many categories, with overlapping frames and considerable association with mood disorders);

- personality disorders (difficulties in diagnosing and delimitating subtypes);

- persistent mood disorders (dysthymia/cyclothymia);

- obsessive-compulsive disorder (with several suggestions for separating it from other anxiety disorders);

- schizoaffective disorder (questionings about the validity of the construct);

- schizotypal disorder (lack of consensus: clinical axis diagnosis of the disorder in the ICD versus personality disorder in axis II of the DSM-IV);

- bipolar mood disorder (separation from unipolar depression, debates over the construct of the "bipolar spectrum");

- other: disorders starting in childhood; impulse control disorder, mental retardation, simple schizophrenia, eating and sleep disorders.

DISCUSSION

Simplicity, clarity of criteria, objectivity, reliability, understandability, and ease of use are among the key attributes considered necessary in a psychiatric classification.

The most used diagnostic system for the Brazilians psychiatrists is the ICD-10 (at least axis I), for being an international classification and the one officially adopted in the country for bureaucratic and legal purposes. Axis I of the DSM-IV is routinely used for teaching and in research settings. The lower use of the other axes of the current multiaxial systems was explained by lack of training and familiarity with them, lack of knowledge about classificatory criteria, and less practice.

Most respondent psychiatrists considered that certain diagnostic categories should be revised or moved to another section, based on the current systems of classifications.

Although it is not possible to claim that these answers are representative of the views of all Brazilian psychiatrists given the relatively low rate of returned questionnaires, for the first time in the country, these data provide a broad and fertile overview of the opinions and expectations of Brazilian psychiatrists on the diagnostic tools available in their daily practice and whose revisions are under underway.^1,11

CONCLUSION

It seems that clinicians prefer simple, useful and user-friendly diagnostic criteria in their daily practice, which somehow goes against the splitting trend of contemporary psychiatry and its ever increasing number of diagnostic labels.

REFERENCES

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Publication Dates

• Publication in this collection
  11 Mar 2010
• Date of issue
  2009