The Lancet
Apr 19, 2014 Volume 383 Number 9926 p1359 – 1436
http://www.thelancet.com/journals/lancet/issue/current

Classification of mental disorders: a global mental health perspective
Prof K S Jacob a, Prof Vikram Patel b c d
Excerpt
Mental disorders are common in all countries, affect every community and age group, contribute substantially to the overall burden of disease, and have major economic and social consequences and effects on human rights. However, the greatest inequities are cross-national: 80% of people affected by mental disorders live in low-income and middle-income countries, which benefit from scarcely 10% of global mental health resources. Global mental health initiatives attempt to improve the availability of, access to, and quality of services for people with mental disorders worldwide. Diagnostic categories and a classification of mental disorders, which are essential to achieve objectives of global mental health, are needed for a range of stakeholders: for health-care practitioners to make treatment decisions and implement clinical guidelines; for policy makers to make decisions about allocation of resources; and for patients and their families to gain an understanding of their disorders. But can contemporary psychiatric classifications meet these needs?

Non-specialist health professionals working in routine health-care settings deliver more than 90% of mental health care worldwide. Psychiatric disorders are frequently diagnosed in epidemiological surveys in community and primary care populations, in particular the common mental disorders of depression, anxiety, somatoform, and stress-related disorders (all of which are distinct categories in contemporary classifications). However, a large gap often exists between the numbers reported in surveys and those recorded by primary care workers. The response of psychiatry has traditionally been to assume that these workers are not well informed about contemporary psychiatric concepts. Many strategies, such as the use of simple diagnostic algorithms, straightforward management guidelines, training programmes to improve skills, and advocacy campaigns, were developed and implemented to address this gap.1 However, these approaches did not seem to substantially change primary care worker behaviour, or improve detection rates or outcomes in developed nations or low and middle-income countries.2—4 Indeed, one of us (VP) had proposed that even the term “mental” needed to be dropped altogether from such training.4…

…Global mental health needs a pragmatic classification that addresses the prevalent disorders in primary care and community settings, acknowledges both the dimensional and categorical nature of common mental health symptoms, addresses contextual issues, and that can easily be incorporated into routine health-care platforms across diverse settings. This aim does not just mean reduction in the number of labels or in their complexity, but the creation of categories relevant to and frequently seen in primary care. The fact that labels will vary across languages and cultures should be explicitly acknowledged, and diagnostic practices must be adapted to suit these variations. Put bluntly, if very few patients report feeling depressed, then the value of imposing the label “depression” is questionable; unsurprisingly, most global mental health interventions targeting depression in low-income and middle-income countries avoid the use of the label altogether.18
Many narratives of mental distress and disorder across settings exist that argue against one authentic version of these complex accounts. Their diversity and contradictions are a testimony to the pluralism of mental health-care traditions. Consequently, primary care needs to consider its own reality and devise a classification for mental distress and disorder that is usable in routine clinical practice, rather than work with a handed-down, diluted version of specialist approaches. Mental disorders in primary care need to be understood and theorised independently of specialist perspectives.19 The process of the identification of common presentations and development of a classification system and management protocols in primary care needs to be led and owned by primary care workers, and this process needs to engage with communities, donors, or policy makers who are major stakeholders for global mental health