Copyright
©The Author(s) 2022.
World J Psychiatry. Dec 19, 2022; 12(12): 1335-1355
Published online Dec 19, 2022. doi: 10.5498/wjp.v12.i12.1335
Published online Dec 19, 2022. doi: 10.5498/wjp.v12.i12.1335
| Principles and priorities | ICD-11-CDDR | DSM-51 |
| Public health imperative | The guidelines should be useful in alleviating the global mental health burden, especially the burden in the low-and middle-income countries | The manual is meant to be used as a tool for collecting and communicating accurate public health statistics on mental disorders |
| Clinical imperative | Clinical and public health utility were accorded the greatest priority followed by scientific validity | Clinical utility was accorded the highest priority followed by the scientific evidence |
| Stakeholders | The guidelines are meant for use in all countries, for all professionals, and for all service users | The manual is meant for all professionals and service users |
| Multiple uses | The guidelines are meant for clinical, research, teaching, and training purposes, and for collecting data | The manual is meant for clinical, research, teaching, and training purposes, and for collecting data |
| Settings | The guidelines are meant for all settings including specialist and primary-care settings, with special emphasis on primary-care settings in low-and middle-income countries | The manual should be applicable to all settings including specialist, primary-care, community, and forensic settings |
| Cross-cultural applicability | The revision should be relevant and acceptable to clinicians from all cultures | Cultural aspects relevant to the diagnosis was a key consideration |
| Priorities | ||
| Global applicability | Global and universal applicability: The guidelines should be relevant for all countries, all stakeholders, and in all settings | Professionals from 39 countries were involved in developing the scientific basis of the diagnostic criteria |
| Clinical utility | Clinical and public-health utility was accorded the highest priority during the process of revision | The manual is primarily intended for clinical use and should be feasible for clinical practice |
| Scientific validity | The scientific basis should be based on best available evidence. Compromises for the sake of utility should be avoided | The revision was guided by a thorough review of the best scientific evidence |
| Harmonization | Efforts to harmonize the ICD-11 revision with the DSM-5 involved enhancing similarities and minimizing arbitrary differences between the two systems | The APA collaborated with the WHO to develop a common and globally applicable research base for the DSM-5 and the ICD-11 disorders |
Table 2 Comparison of diagnostic criteria for manic and hypomanic episodes
| ICD-11-CDDR | DSM-5 | |
| Gate/entry level criteria | Both extreme and persistent mood changes (euphoria, irritability, expansiveness, mood lability) and abnormally increased activity or subjective experience of increased energy | Both abnormal and persistent mood changes (elevated, expansive, or irritable) and abnormal and persistent increase in goal-directed activity or energy1 |
| Accessory criteria | Significant changes in several of the following seven areas: talkativeness/pressured speech, flight of ideas/racing thoughts, increased self-esteem/grandiosity, decreased need for sleep, distractibility, impulsive/reckless behaviour, increased sexual or social drive/increased goal directed activity | Significant and noticeable changes in three of the seven accessory symptoms; four if mood is only irritable; accessory criteria almost identical to the ICD-11 definition |
| Persistence and duration | Symptoms present most of the day, nearly every day for a minimum of one week unless shortened by treatment | Symptoms present most of the day, nearly every day for a minimum of one week unless shortened by hospitalization |
| Functional impairment | Significant impairment in all the areas of functioning; the patient may require intensive treatment/hospitalization to prevent self-harm or violence; the episode may be accompanied by psychotic symptoms | Significant impairment in all the areas of functioning; the patient may require hospitalization to prevent self-harm or violence; the episode may be accompanied by psychotic symptoms |
| Exclusions | Mania secondary to medical conditions or substance use; mixed episodes excluded | Mania secondary to medical conditions or substance use; manic episodes with mixed features allowed |
| Effects of antidepressant treatment | The episode should be considered a manic one if all the criteria are met even after the effects of treatment have diminished | The episode should be considered a manic one if all the criteria are met even after the effects of treatment have diminished |
| Grading of severity | Severity not graded | Severity graded as mild, moderate, or severe based on the number of symptoms, their intensity, and functional impairment |
| Psychotic symptoms | No distinction between mood-congruent and incongruent symptoms | Mood-congruent and incongruent symptoms distinguished |
| Hypomanic episode | ||
| Gate/entry criteria | Both persistent mood changes (elevation, irritability, mood lability) and abnormally increased activity or subjective experience of increased energy that are significantly different from the usual mood state; changes are apparent to others and do not include changes that are appropriate to the circumstances2 | Both abnormal and persistent mood changes (elevated, expansive, or irritable) and abnormal and persistent increase in activity or energy; changes in mood differ significantly from the usual state and are apparent to others |
| Accessory criteria | Significant changes in several of the seven accessory symptoms that are identical to the definition of mania; these changes are apparent to others | Significant and noticeable changes in three of the seven accessory symptoms, four if mood is only irritable; accessory criteria are the same as those for mania and almost identical to the ICD-11 definition |
| Persistence and duration | Symptoms present most of the day, nearly every day for at least several days | Symptoms present most of the day, nearly every day for a minimum of four consecutive days |
| Functional impairment, hospitalization, and psychotic symptoms | Socio-occupational functioning is not markedly impaired; the patient does not require intensive treatment or hospitalization to prevent self-harm or violence; the episode is not accompanied by psychotic symptoms | Clear change in socio-occupational functioning from the usual state apparent to others, but functioning is not markedly impaired; the patient does not require hospitalization to prevent self-harm or violence; the episode is not accompanied by psychotic symptoms |
| Exclusions | Hypomania secondary to medical conditions or substance use; mixed episodes are excluded | Hypomania secondary to substance use3; hypomanic episodes with mixed features allowed |
| Effects of antidepressant treatment | The episode should be considered a hypomanic one if all the criteria are met even after effects of treatment have diminished | The episode should be considered a hypomanic one if all the criteria are met even after effects of treatment have diminished; however, full syndromal manifestation of hypomania is necessary |
Table 3 Prevalence of bipolar disorder according to the International Classification of Diseases, 11th version and the Diagnostic and Statistical Manual of Mental Disorder, 5th edition criteria
| Ref. | Criteria sets | Patients | Bipolar types | Type of prevalence | Results regarding the prevalence of BD |
| Fassassi et al[55], 2014 | DSM-5 | Community-based | BP-I, BP-II, Other BD1 | 12-mo and lifetime | Prevalence similar to earlier studies of BD |
| Calvó-Perxas et al[56], 2015 | DSM-5 | Community-based | BP-I, BP-II, Other BD | Lifetime | Prevalence was within the range of previous reports of BD |
| Blanco et al[57], 2017 | DSM-5 | Community-based | BP-I | Lifetime | Prevalence was within the range of previous reports of BD |
| Gordon-Smith et al[58], 2017 | DSM-IV and DSM-5 | Community-based and outpatients | BP-I, BP-II | Lifetime | Up to 94% of the patients with DSM-IV BD also met the DSM-5 criteria |
| Decrease in the prevalence of bipolar disorder | |||||
| Angst et al[53], 20132 | DSM-5 | Analysis based on a previous community study (BRIDGE) | BD | Lifetime | About 22% reduction in prevalence |
| Machado-Vieira et al[38], 2017 | DSM-IV and DSM-5 | Outpatients | Maniaand hypomania | Point prevalence | The prevalence of mania and hypomania according to the DSM-5 criteria was reduced by about 50% |
| Fredskild et al[59], 2019 | DSM-IV TR and DSM-5 | Outpatients | Maniaand hypomania | Point prevalence | A reduction of 35% in the prevalence of mania and hypomania with the DSM-5 criteria was noted |
| Faurholt-Jepsen et al[60], 2020 | DSM-5 | Patients taking part in trials | Mania and hypomania | Smartphone-based activity assessments over 6-9 mo | The prevalence of hypomania according to the DSM-5 criteria was substantially less (0.12%) than patients not meeting these criteria (24%) |
| Fredskild et al[61], 2021 | DSM-IVand DSM-5 | Outpatients | Mania and hypomania | Assessments at baseline and at 3-year follow-up | The prevalence of mania and hypomania according to the DSM-5 criteria was reduced by 62% at baseline and by 50% on follow-up |
| Increase in the prevalence of type II bipolar disorder | |||||
| Angst et al[53], 20133 | DSM-5 | Analysis based on a previous community study (BRIDGE) | BP-II | Lifetime | Prevalence of BP-II disorder will be twice as much with the DSM-5 than earlier |
| Angst et al[31], 20204 | ICD-10, DSM-5, and ICD-11 | Analysis based on an earlier community study (Zurich cohort study) | Mania (BP-I) and hypomania (BP-II) | Lifetime | Prevalence of hypomania (BP-II) will be doubled with the ICD-11 criteria compared to the ICD-10 and the DSM-5 criteria; no change in the prevalence of mania (BP-I) is likely |
Table 4 Changes to the diagnostic guidelines for bipolar depression in the International Classification of Diseases, 11th version
| ICD-11-CDDR | DSM-5 | ICD-10 | |
| Core symptoms | One of the following: Depressed mood or diminished interest or pleasure | One of the following: Depressed mood or loss of interest or pleasure | Two of the following: Depressedmood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability, diminished activity, and marked tiredness |
| Reported or observed changes | Reported or observed changes | ||
| Change from usual functioning | Change from usual functioning | ||
| Accessory symptoms | Eight symptoms including the new symptoms of hopelessness, fatigue, and agitation/retardation | Seven symptoms: Hopelessness is not included, but fatigue and psychomotor changes are included | Seven symptoms: Bleak and pessimistic views of future instead of hopelessness, no psychomotor changes or fatigue that are part of the core symptoms |
| Other symptoms (unchanged) are inattentiveness, changes in sleep and appetite, low self-worth or guilt, and suicidal ideation | Other symptoms are the same as in the ICD-11 | Other symptoms are the same as in the ICD-11 | |
| Persistence and duration | Symptoms occur most of the day, nearly every day during a minimum period of two weeks | Symptoms occur most of the day, nearly every day during a minimum period of two weeks | Minimum duration of two weeks usually required but shorter periods suffice if symptoms are unusually severe and of rapid onset |
| Diagnostic threshold | Five out of ten symptoms | Five out of nine symptoms | Four out of ten symptoms |
| Functional impairment | Part of the diagnostic criteria | Part of the diagnostic criteria | Used to rate severity |
| Exclusions | Depression secondary to medical conditions or substance use and mixed episodes; mixed episodes excluded | Depression secondary to medical conditions or substance use; diagnosis of depressive episodes with mixed features possible | No clear exclusions |
| Bereavement exclusion | Operationalized definition present | Only an explanatory note that advises the use of clinical judgement in such instances | Not mentioned as a part of the diagnostic guidelines |
| Severity ratings | Mild, moderate and severe depressive episodes based on symptom-severity and functional impairment; no requirement for a minimum number of symptoms | Grading similar to the ICD-11; no requirement for a minimum number of symptoms | Grading similar to the ICD-11, but a minimum number of symptoms required for grading different levels of severity; clinical judgement also advised |
| Psychotic symptoms | Moderate depression with psychotic symptoms is a new category | Mood congruent and incongruent symptoms distinguished | Mood congruent and incongruent symptoms distinguished |
| Description of melancholia | Descriptions similar to the ICD-10, but no requirement for a minimum number of symptoms | Description more elaborate; a minimum of four symptoms required | Descriptions similar to the ICD-11; a minimum of four symptoms required |
| Additional specifiers | With prominent anxiety, panic attacks, chronicity, seasonal pattern, puerperal onset | Similar to the ICD-11; additionally mixed features, atypical features, and catatonia | No other specifiers |
Table 5 Controversies about type two bipolar disorder
| Controversy | For retaining BP-II disorder | Against retaining BP-II disorder |
| The definition of hypomania | Current definitions of BP-II disorder in the ICD-11 and the DSM-5 represent an optimal balance between sensitivity and specificity; they will prevent the over-diagnosis and harmful effects of inappropriate treatment of a false positive diagnosis[30,38,42,43] | Current criteria are too restrictive and under-diagnose hypomania and BP-II disorder. The minimum duration required is not evidence-based and should be shorter[32,113,114,120,121] |
| Prevalence of BP-II disorder | The prevalence of BP-II disorder is as high as BP-I disorder, or even higher than the BP-I subtype[98,108-110] | Data on prevalence are mixed. Prevalence is also influenced by factors such as broader definitions, improved recognition, and increased awareness[111,114] |
| Course of BP-II disorder | Compared to BP-I disorder, BP-II disorder has a more chronic course, greater syndromal and subsyndromal depressive symptoms, and higher episode frequency[98,107-109,112] | The seemingly adverse course of BP-II disorder could be a function of confounding factors such as symptom-severity, comorbidity, and the effects of treatment[32,70,99,114] |
| Diagnostic stability of BP-II disorder | The diagnosis of BP-II disorder remains the same for several years. Only 5%-15% of the patients with BP-II disorder develop BP-I disorder[6,98,105,109] | The boundaries between BP-II and BP-I disorder, between BP-II disorder and cyclothymia, and between BP-II disorder and personality disorders are unclear[70,99,113,115] |
| The prevalence of psychotic symptoms | Patients with BP-I disorder are more likely than those with BP-II disorder to have psychotic symptoms[66,111,115] | Psychosis is also associated with hypomania, especially in longitudinal community studies[68,69,113] |
| Suicidal behaviour | Suicide rates are higher in BP-II disorder than BP-I disorder[107-109,120,121] | The higher suicide rates in BP-II disorder could be a function of comorbid personality disorders and comorbid substance use[98] |
| Family-genetics | BP-II disorder runs in families. Genetic studies help distinguish BP-II disorder from BP-I disorder[98,110,116,118,121] | Genetic studies show that BP-II and BP-I disorders lie on a continuum of genetic risk without any distinction between the two subtypes[106,112,114,120] |
| Neuroimaging | Some studies suggestquantitative or qualitative differences between the two subtypes[116,123] | There are no differences in neuroimaging between the two subtypes[98,111,112,114,120] |
| Neurocognition | Patients with BP-II disorder are less impaired on neuropsychological tests than those with BP-I disorder[98] | There is a great degree of overlap in the neurocognitive performance between the two subtypes[114,116] |
| Treatment response | The treatment requirements of patients with BP-II disorder are different[115,118,119] | There is no difference in treatment response between the two subtypes[98,108,111,114,120] |
Table 6 Changes to the diagnostic guidelines in the International Classification of Diseases, 11th version for cyclothymic disorder
| ICD-11-CDDR | DSM-5 | ICD-10 | |
| Core features | Chronic mood instability of more than two years consisting of several hypomanic and depressive periods (irritability in children and adolescents) | Several hypomanic or depressive symptoms for more than two years | A persistent instability of mood, involving numerous periods of mild depression and mildelation (No duration mentioned) |
| Hypomanic symptoms may meet the criteria for hypomanic episodes | Symptoms do not meet the criteria for hypomanic or major depressive episodes | None of these symptoms meet criteria for mania/BD or depressive episode/recurrent depressive disorder | |
| Symptom-free periods | Symptom-free periods are no longer than two months during the course of the disorder | Hypomanic and depressive symptoms are present at least half of the time during the course of the disorder | Mood state may be normal and stable for months (No minimum duration for symptom-free periods specified) |
| Symptom-free periods are no longer than two months during this period | |||
| Children and adolescents | Duration of one year is appropriate | Duration of one year sufficient | No mention of duration in children and adolescents |
| Manic mixed, and depressive episodes | Criteria for manic and mixed episodes are never met. Depressive episodes cannot be diagnosed during the first two years of cyclothymia. After that, they can be diagnosed if criteria are met | Criteria for manic, hypomanic, or major depressive episodes are never met during the first 2 years. If the person subsequently experiences major depression, mania, or hypomania, the diagnosis is changed to major depressive disorder, BP-I disorder, or other specified or unspecified bipolar and related disorders | Criteria for manic, mixed, and depressive episodes are never met |
| Criteria for BP-I or BP-II disorder are never met | Criteria for BD or recurrent depressive disorder are never met | ||
| Exclusions | Cyclothymia secondary to medical conditions or substance use | Cyclothymia secondary to medical conditions or substance use | No exclusions |
| Functional impairment | Symptoms result in significant distress and/or functional impairment | Symptoms result in significant distress and/or functional impairment | Symptoms are so mild that patients often do not seek treatment |
| Progression to BD | Mentioned | Mentioned | Mentioned |
| Inclusion of additional personality features | Not included-unlike personality disorders, cyclothymia does not include persistent self and interpersonal dysfunction | Included-the person may be temperamental, moody, unpredictable, inconsistent, or unreliable | Included-in some instances, mood changes are less prominent than cyclical disturbances of activity, self-confidence, and social behaviour |
Table 7 Considerations guiding the notion of clinical utility in the International Classification of Diseases, 11th version
| Concept | Application to the ICD-11 CDDR |
| Working definition | Clinical utility of the classification and its categories includes the ability to facilitate communication among clinicians, having characteristics that help clinical practice (diagnostically accurate, easy to use, and feasible), and containing guidance for appropriate treatment choices[141,142] |
| Why clinical utility? | Validity is not a pragmatic goal; enhanced diagnostic reliability has not led to increased validity[143,144]. Current classifications have several shortcomings and are not useful in real-world settings[11,37,142] |
| Levels of utility | Clinical utility has two levels including the architectural or organizational level and the category level[24,141], utility should focus on both the levels and emphasize coverage, description of attributes, and ease of use[145] |
| Application to healthcare settings | The need for utility is the greatest during clinical encounters in routine practice settings. The classification must provide information of value to the clinician in these situations[9-11,13,146] |
| Public health utility | Consideration must be given to the features of the classification that enhance global applicability and reduce global mental health burden[9,147] |
| Contextual aspects | Utility is context-specific; it depends on the purpose for which a classification is used, clinical, research, or for public health[9,10,146] |
| Utility and scientific validity | Clinical utility has to go hand-in hand with the scientific evidence. Moreover, compromising the scientific basis of the classification to meet the needs of clinical utility has to be avoided as far as possible. There is considerable overlap between clinical utility and predictive validity and sometimes it is difficult to distinguish between them[105,145,147] |
| Greater emphasis on clinical utility in the ICD-11 | 1Clinical utility as the ultimate organizing principle is not a new notion, but the ICD-11 has paid the greatest systematic attention to this aspect[10,147,148] |
| Improving clinical utility in the ICD-11 | Clinical utility has been the guiding principle at all the stages, from the evidence review, to content formation, and to the field trials. The standardized template or content-form was structured to enhance clinical utility. Working Groups were asked to consider the clinical utility of the changes suggested. The protype-based approach contributed to enhanced clinical utility. Cross-cultural usefulness was addressed. The ICD-11 field-trial studies used methodology specifically designed to examine clinical utility in naturalistic settings. The results of these studies have been used to improve the revision further[9-13] |
Table 8 The International Classification of Diseases, 11th version field trials on reliability and clinical utility of bipolar disorder1
| Ref. | Manuscript type | Results |
| Formative field trials | ||
| Surveys of mental health professionals: Opinions and utilization patterns | ||
| Reed et al[22], 2011 | Internet-based survey | The ICD-10 category of BD had considerable clinical utility and was commonly used. The category of single depressive disorder was commonly used and should be retained. Functional impairment should be a diagnostic criterion for mood disorders |
| Evans et al[151], 2013 | Internet-based survey of psychologists | The ICD-10 category of BD was not as commonly used. BD was rated to have low clinical utility, especially regarding its ease of use |
| Avasthi et al[152], 2014 | Internet-based survey | The ICD-10 category of BD was commonly used and was easy to diagnose (high ease of use) |
| Robles et al[153], 2014 | Internet-based survey | The ICD-10 category of BD was considered a problematic diagnosis by about 4% of the participants because of its non-specificity. Only about 1% of the participants felt that BP-II disorder should be included in the current version |
| Maruta et al[154], 2013 | Internet-based survey | A majority (69%) of the participants felt that BD should be included in a separate category of mood disorders |
| Studies on the clinicians’ organizational map for classifications | ||
| Roberts et al[23], 2012 | Internet-based survey | Clinicians’ concepts were in keeping with the current evidence and similar across all groups and countries. BP-I, BP-II, and cyclothymic disorders were considered to be adult rather than developmental onset disorders. Clinicians’ views about the organizational structure corresponded more to the ICD-11 classification than the ICD-10 or the DSM-5 |
| Reed et al[24], 2013 | Clinic-based FTC study | Clinicians’ concepts were in keeping with the current evidence and similar across all groups and countries. Mood disorders including BP-I, BP-II, cyclothymic, depressive, and dysthymic disorders were grouped together by clinicians. This group was also among the most cohesively organized groups. The results supported the ICD-11 organization of the mood disorders group |
| Evaluative field trials | ||
| Studies of clinical vignettes | ||
| Gaebel et al[155], 2020 | Internet-based based field study | Diagnostic accuracy of the ICD-11 BP-II disorder category was significantly higher than a modified ICD-10 BP-II category. However, regarding disorders already existing in the ICD-10, e.g., BD, there were no differences between the ICD-11 and the ICD-10. There were no significant differences in overall clinical utility of BD between the ICD-11 and the ICD-10 |
| Kogan et al[156], 2021 | Internet-based based field study | Greater diagnostic accuracy was found for the ICD-10 categories of BP-I disorder and a modified category of BP-II disorder on initial analysis. However, there were no significant differences on re-analysis. There were no significant differences between the ICD-11 and the ICD-10 categories of cyclothymic disorder. Clinical utility was somewhat lower for the ICD-11 category of BP-I disorder. Ratings of severity of depression were better with the ICD-10 |
| Clinic-based FTC studies | ||
| Reed et al[142], 2018 | ICD-11 diagnoses-reliability and utility | The clinical utility of BP-I disorder was higher than schizophrenia, schizoaffective disorder, and depressive disorders on all three parameters including diagnostic accuracy, ease of use, and clarity. Agreement between the raters was also the highest for BP-I disorder (k = 0.85)2,3 |
| Reed et al[157], 2018 | ICD-11 diagnoses-reliability | Agreement between the raters was one of the highest for BP-I disorder (k = 0.84). It was relatively low though adequate for BP-II disorder (k = 0.62)3,4 |
| Hackmann et al[158], 2019 | Qualitative study on patient perceptions of BP-I disorder | The patients commented on several additional features that were missing from the description of BP-I disorder in the ICD-11 CDR. They preferred native language and idioms. A lay language version of the diagnostic descriptions was preferred |
| Medina-Mora et al[159], 2019 | ICD-11 diagnoses-reliability and utility | Inter-rater reliability of the mood disorders category was high (percentage agreement-87%). This was higher than schizophrenia and most of the other disorders. Clinical utility was also high |
| Onofa et al[160], 2019 | ICD-11 diagnoses-reliability and utility | Inter-rater reliability of BP-I disorder (k = 0.83) was high. Ratings of diagnostic accuracy and ease of use were also high, but the descriptions were felt to be less useful in selecting treatment |
- Citation: Chakrabarti S. Bipolar disorder in the International Classification of Diseases-Eleventh version: A review of the changes, their basis, and usefulness. World J Psychiatry 2022; 12(12): 1335-1355
- URL: https://www.wjgnet.com/2220-3206/full/v12/i12/1335.htm
- DOI: https://dx.doi.org/10.5498/wjp.v12.i12.1335