Engagement of Russian Mental Health Professionals in the Development of WHO’s ICD-11

INTRODUCTION

On May 2019, the World Health Organization (WHO) approved the newest version of its global diagnostic classification system, the International Classification of Diseases and Related Health Problems (Eleventh Revision; ICD-11). Although implementation processes are still underway, the ICD-11 is considered as the official classification system of all 194 WHO Member States, including the Russian Federation. This approved statistical version of the ICD-11 features a chapter on Mental, Behavioural and Neurodevelopmental Disorders, whose development was led by the WHO’s Department of Mental Health and Substance Abuse (MSD). The development of this chapter and the related Clinical Descriptions and Diagnostic Guidelines (CDDG) — a version of the ICD-11 chapter that provides comprehensive and detailed diagnostic guidance on mental, behavioural and neurodevelopmental disorders — was a decade-long, scientifically-rigorous process that involved mental health professionals from across the globe, with appreciable participation of clinicians from the Russian Federation and from other Russian-speaking countries.1-5 The substantive participation of mental health professionals from the Russian Federation, and those from across the globe, in developing the ICD-11 was essential in enabling the WHO to ensure that the ICD-11 diagnostic guidelines were in line with its three core priorities.2,6

The first priority was to enhance the clinical utility of the guidelines, which reflects their usefulness when applied in the clinical context (e.g., how easily clinicians can apply the guidelines, how well the guidelines fit real-life patients, and how clear and understandable they are to clinicians). Clinical utility is a particular focus, as the ICD has important clinical uses, such as serving as a framework for diagnosis and as a basis for development of guidance on clinical management and standards of practice as well as facilitating research into more effective treatments and prevention. Improved clinical utility is also arguably crucial to the broader public health uses of ICD to facilitate the accurate collection and tracking of health data, to monitor mortality and morbidity, to assess disease burden, and to hold WHO Member States accountable for addressing this burden.

The second core priority was to validate the clinical consistency or reliability of the guidelines, and the third priority was to maximize the applicability and acceptance of the diagnostic guidelines to clinicians working in diverse clinical, geographical, and cultural contexts around the world. In this way, the ICD-11 would serve as a relevant and useful tool that can be used by global mental health professionals upon its implementation. Ensuring that the ICD-11 adhered to these three core priorities prompted a global research program led by MSD, which substantively engaged scientists, clinicians, and researchers from across the globe. Here we specifically highlight the important contributions of Russian mental health professionals in the development and field testing of the ICD-11 guidelines for mental, behavioural, and neurodevelopmental disorders.

FORMATIVE ICD-11 FIELD STUDIES

First, clinicians from the Russian Federation contributed to the early formative field studies of the ICD-11,7-9 allowing them to provide WHO with important feedback and data, which influenced the overarching architecture and linear structure of the ICD-11 chapter on Mental, Behavioural and Neurodevelopmental Disorders. This included a study in which WHO collaborated with Member Societies of the World Psychiatric Association (WPA)7 in order to assess global psychiatrists’ attitudes regarding mental disorder classifications, such as what they considered to be the most important purpose of a classification system of mental disorders, how they conceptualized severity and the relationship between functional impairment and diagnosis, and their attitudes toward the inclusion of dimensionality in a classification system. The study was conducted in 19 languages, including Russian, allowing for the participation of 4,887 clinicians from 44 countries. A noteable number (n = 298) of study participants were members of the Russian Society of Psychiatrists, making the Russian Federation the fourth most represented country in the study sample. In this way, the overall structure and organization of the ICD-11 chapter on Mental, Behavioural and Neurodevelopmental disorders was influenced by feedback from Russian clinicians and others from around the world.7

EVALUATIVE ICD-11 FIELD STUDIES

A second notable way in which Russian clinicians contributed to the development of the ICD-11 is through their participation in WHO MSD’s large-scale global program of evaluative field studies, which tested whether the proposed versions of the ICD-11 guidelines met the standards of clinical utility, reliability, and global applicability set by WHO.10 This research program was overseen by international experts with the relevant clinical and research experience to be able to provide scientific leadership throughout the ICD-11 field testing process. These experts formed the ICD-11 Field Studies Coordinating Group and included members from the Russian Federation (authors VK and MK). The international representation in this leadership body overseeing the field testing was one of the mechanisms through which WHO aimed at ensuring that the final ICD-11 guidelines would reflect a version that was most useful and applicable to clinicians working in diverse contexts around the world, including the Russian Federation.2

Global Clinical Practice Network as a platform for ICD-11 case-controlled field studies

The first subset of evaluative studies, through which Russian clinicians contributed to the ICD-11, used a case-controlled methodology to test how accurately clinicians could apply the proposed ICD-11 guidelines to standardized case vignettes and also captured their assessment of the clinical utility of the guidelines.11,12 These studies were implemented online via the WHO’s Global Clinical Practice Network (GCPN). The GCPN is a disciplinarily, geographically, and lingually diverse practice-based research network devoted to mental health, composed of individual mental health professionals who have registered to participate in WHO field studies on ICD-11 and related areas of inquiry.13 As of February 2021, the GCPN has over 16,000 members from 160 countries. Over a thousand members (about 80% of whom are psychiatrists, representing 6.3% of the total network) are Russian, thus placing the Russian Federation in the top five most represented countries in the network. The GCPN also includes Russian-speaking mental health professionals residing in 24 other countries. GCPN members have an average 19 years of professional experience (SD = 10.8; range 0 to 68 years), and 92% actively see patients and engage in clinical activities. As such, they serve as ideal participants with the relevant clinical experiences to contribute to the online case-controlled studies that test whether the ICD-11 guidelines can be accurately applied in a clinically useful manner.

Case-controlled field studies in Russia

As part of this evaluative program of field studies, clinicians in the Russian Federation first participated in a comprehensive process of translating the ICD-11 guidelines into Russian. This process involved forward translation (English to Russian) by experts with relevant clinical training and content expertise to be able to capture the technical details and clinical terminology included in the guidelines. This was followed by a back-translation (Russian to English) conducted by other experts. Any areas of confusion or differences in translations were reconciled through a consensus process so that the final version of the Russian ICD-11 guidelines can best capture the clinical nuance intended by the WHO Working Groups and other global experts who developed them.

In this field-testing phase, hundreds of Russian and Russian-speaking mental health professionals participated in major ICD-11 case-controlled studies that cover many of the key mental disorder areas including mood disorders, schizophrenia or other primary psychotic disorders, anxiety or fear-related disorders, obsessive-compulsive or related disorders, and dissociative disorders.14-16 Russian mental health professionals demonstrated their special diagnostic opinions based on their own clinical traditions and nosological approaches.17 Additional case-controlled studies are expected to be implemented in such areas as personality disorders and substance use disorders.

Another related online study that looked into how clinicians used classification systems and technology was also done in Russian,18 enabling WHO to better understand how the ICD-11 would likely be eventually used in clinical practice (e.g., which ICD version(s) do clinicians use and how do they access this content). In turn, this allowed WHO to potentially plan for additional or supplemental resources on ICD-11, which could be made available to clinicians, thus facilitating the adoption and use of the new classification system in the Russian Federation and in other parts of the world.

Clinic-based (ecological implementation) field studies in Russia

A second subset of evaluative field studies that allowed Russian clinicians to provide further contributions to CDDG development involved clinic-based field studies (also referred to as “ecological implementation” field studies), which tested how reliably the ICD-11 guidelines could be applied to real patients in natural clinical settings across the world.2,11 This study also examined clinicians’ ratings of the utility of the guidelines when applied to patients in the clinical context, rather than the standardized cases as was done with the online case-controlled studies.19

Clinicians at two study sites in the Russian Federation (Moscow Research Institute of Psychiatry and the First St. Petersburg City Mental Hospital named after PP Kaschenko) participated in the clinic-based study protocol, which specifically tested the reliability of the ICD-11 diagnostic guidelines relevant to psychotic, mood, anxiety, and stress disorders as applied to adult patients. Results demonstrated high ratings of clinical utility and other implementation characteristics of the guidelines.19,20 Data from these studies were used to further improve the guidelines by identifying potential areas that require clarity or elaboration. In doing so, the improved guidelines can be more reliably and consistently applied in clinical practice in the Russian Federation, and across the world.

ICD-11 TRAINING ACTIVITIES IN RUSSIA: EXPERIENCE AND FUTURE INITIATIVES

With the participation of Russian clinicians and mental health professionals from around the world in the development and testing of the ICD-11 guidelines for mental, behavioural, and neurodevelopmental disorders, the CDDG is now close to being finalized and made broadly available. A next key step in the adoption of the ICD-11 is to train clinicians on the guidelines so that they are prepared to effectively use them in clinical practice when the ICD-11 is fully implemented. In-person trainings, led by world experts who had leadership roles in the ICD-11’s development, such as members of the Field Studies Coordinating Group, have already taken place globally at scientific meetings or via webinars hosted by professional societies, such as the WPA and the European Psychiatric Association (EPA), and at WHO Collaborating Centers and other affiliated clinical or research institutions around the world. The objectives of these trainings are to orient clinicians regarding key principles, scientific foundations, and innovations introduced in the CDDG; to give clinicians in-depth knowledge of the guidelines and provide clinically-relevant rationales for the ICD-11’s diagnostic approach, especially in areas where there may be noticeable differences with the ICD-10; and to expand clinicians’ knowledge about psychopathology and the ICD-11 diagnostic classification. Trainings encourage active participation, provide an opportunity for clinicians to apply their knowledge of the ICD-11 guidelines to standardized cases, and offer clinicians the space in which to discuss and clarify diagnostic dilemmas and questions about the guidelines with both training facilitators and other colleagues in attendance. In the Russian Federation, the ICD-11 training activities have been ongoing, with the first programs linked to training clinicians who participated in the clinic-based reliability field studies of the ICD-11. Trainings have also been conducted through workshops as part of several local and national conferences and symposia throughout the Russian Federation.

The first workshop in Moscow was organized in May 2019 under the auspices of Professor George Kostyuk, Chief Expert in Psychiatry of the Moscow Healthcare Department, with the assistance of author MK, and led by authors GMR, KMP, and Professor/Past President of the EPA Dr. Wolfgang Gaebel. The program of this two-day training focused on the new ICD-11 diagnostic guidelines and key changes for several areas, namely, schizophrenia or other psychotic disorders, mood disorders, obsessive-compulsive disorders, anxiety or fear-related disorders, and disorders specifically associated with stress and personality disorders, followed by the application of new knowledge to standardized cases.

The workshop was held at the Civic Chamber of the Russian Federation in Moscow, conducted in English with simultaneous translation, and was attended by 144 Russian clinicians from 27 cities from diverse regions of the Russian Federation. Attendees included senior specialists or opinion leaders in psychiatry, such as chief doctors, directors, and the heads of departments at research or clinical institutions across the country, as well as postdoctoral trainees or medical residents. Qualitative data collected at the end of the workshop validated that Russian clinicians found the training valuable and that they were willing to serve as ambassadors of the ICD-11 by themselves facilitating broader training and adoption of the ICD-11 guidelines in Russia. The participants also mentioned the necessity of such events in supporting Russian clinicians as they implement the ICD-11 into clinical practice, with an emphasis on the need to consider the ICD-11 diagnostic approaches within the context of Russian clinical traditions. These data will be used to strengthen future training programs, such as the development of online ICD-11 trainings that are currently being pilot-tested and finalized for broader access.

CONCLUSION

As is evident, mental health professionals from the Russian Federation have played a substantive role in many key phases of the ICD-11’s development. Not only have Russian specialists served on the ICD-11 scientific leadership group that guided the ICD-11 field testing process, but thousands of Russian clinicians working in diverse contexts all across the Russian Federation have participated in WHO MSD’s large-scale program of global field studies. In this way, Russian clinicians have directly contributed to efforts to maximize the clinical utility, reliability, acceptability, and applicability of the CDDG guidelines. Such efforts can conceivably facilitate the adoption and use of the guidelines by clinicians in the Russian Federation and other Russian-speaking countries as the ICD-11 is implemented over the coming years.

Authors contribution: Tahilia J. Rebello: conception, design and writing of article, analysis and interpretation of data, leadership of studies mentioned in article; Maya A. Kulygina: conception, design and writing of article, leadership of studies mentioned in article; Valery N. Krasnov: review and final approval of article, leadership of studies mentioned in article; Kathleen M. Pike: article review and leadership of studies mentioned in article; Geoffrey M. Reed: article writing, review and final approval of article, leadership of studies mentioned in article.