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|Year : 2014
: 56 | Issue : 4 | Page
|Indian Psychiatric Society-World Psychiatric Association - World Health Organization survey on usefulness of International Classification of Diseases-10
Ajit Avasthi1, Sandeep Grover1, Mario Maj2, Geoffrey Reed3, M Thirunavukarasu4, Uttam Chand Garg5
1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, Punjab, India
2 Department of Psychiatry, University of Naples SUN, Naples, Italy
3 Department of Psychiatry, SRM Medical College Hospital and Research Center, Kattankulathur, Kanchipuram, Chennai, Tamil Nadu, India
4 Department of Mental Health and Substance Abuse (MER/MSD), World Health Organization 20, Revision of ICD 10 Mental and Behavioural Disorders, Geneva, Switzerland
5 Consultant Psychiatrist, Agra, Uttar Pradesh, India
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|Date of Web Publication||8-Dec-2014|
| Abstract|| |
Background: World Health Organization (WHO) is in the process of revising the International Classification of Diseases 10 (ICD-10). For increasing the acceptability of the ICD-11, WHO along with World Psychiatric Association (WPA), conducted a survey of psychiatrists around the world, in which 386 psychiatrists from India participated.
Aim: To present the findings of "WPA-WHO Global Survey of Psychiatrists' Attitudes toward Mental Disorders Classification" for Indian psychiatrists who participated in the survey as members of Indian Psychiatric Society.
Methodology: The online survey was sent to qualified psychiatrists who are members of Indian Psychiatric Society and are residing in India.
Results: Of the 1702 members who were urged to participate in the survey, 386 (22.7%) participated. Most(79%) of the psychiatrists opined that they use formal classificatory systems in their day-to-day clinical practice. ICD-10 was the most commonly (71%) followed classificatory system. Nearly half (48%) felt the need for only 10-30 categories for use in clinical settings and another 44% opined that 31-100 categories are required for use. Most of the participants (85%) suggested that a modified/simpler classificatory system should be designed for primary care practitioners. Similarly, the same number of participants (89%) argued that for maximum utility of a nosological system diagnostic criteria should provide flexible guidance that allows cultural variation and clinical judgement. About 75% opined that the diagnostic system they were using was difficult to apply across cultures.
Conclusion: Findings of the survey suggest that classificatory systems are routinely used in day-to-day practice by most of the participating psychiatrists in India and most expect that future classificatory system should provide flexible guidance that allows cultural variation and clinical judgement.
Keywords: India, nosology, ICD-11
|How to cite this article:|
Avasthi A, Grover S, Maj M, Reed G, Thirunavukarasu M, Garg UC. Indian Psychiatric Society-World Psychiatric Association - World Health Organization survey on usefulness of International Classification of Diseases-10. Indian J Psychiatry 2014;56:350-8
|How to cite this URL:|
Avasthi A, Grover S, Maj M, Reed G, Thirunavukarasu M, Garg UC. Indian Psychiatric Society-World Psychiatric Association - World Health Organization survey on usefulness of International Classification of Diseases-10. Indian J Psychiatry [serial online] 2014 [cited 2020 Feb 25];56:350-8. Available from: http://www.indianjpsychiatry.org/text.asp?2014/56/4/350/146522
| Introduction|| |
The tenth revision of International Classification of Diseases and Related Health Problems (ICD-10) was published by World Health Organization (WHO) in 1992.  Currently, WHO is in the process of revising the current nosological system and in the process of developing ICD-11. One of the goals of WHO in the process of development of ICD-11 is to improve its clinical utility and to fulfil the same WHO is laying emphasis on developing definitions and diagnostic descriptions which will have cross-cultural applicability.  For fulfilling this goal, there is a need to have information on the cross-cultural applicability of the existing classificatory system from professionals who are using the same while evaluating and managing the patients in their day-to-day practice.
Unfortunately, there is limited data in the form of surveys of psychiatrists and other mental health professionals which have assessed their views about the classificatory systems. One of the earlier surveys conducted by the WHO Committee on Evaluating and Updating the ICD-10 Mental Health Component and the World Psychiatric Association (WPA) Section on Classification and Diagnostic Assessment, which included 205 psychiatrists from 66 countries concluded that compared to Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV), ICD-10 was more valued for clinical diagnosis and training and DSM-IV was given more importance for research purposes. The survey also revealed that access to the diagnostic manuals and training for the same was limited. Some of the important recommendations of psychiatrists for future diagnostic systems were related to broader availability of the diagnostic manuals, better promotion of diagnostic training and wider use of multiaxial diagnosis.  However, this survey was limited by the fact that it only included those psychiatrists who were part of the WPA classification section, office bearers (i.e, presidents and secretaries of the WPA member societies and other office bearers of the WPA various sections and pertinent network members.
Another study surveyed 569 psychiatrists from 3 geographically different countries, that is, Brazil, Japan and New Zealand for the use and perceived utility of ICD-10 and DSM-IV and reported varied views for the two diagnostic systems from the psychiatrists across the different countries. Psychiatrists opined that they prefer a classification with <100 diagnostic options. However, the sampling technique in the three countries varied and authors mentioned that the samples may not be representative. 
For the development of ICD-11, WHO Department of Mental Health and Substance Abuse appointed an International Advisory Group, of which WPA is a constituent, to advise it during the process of development of ICD-11.
Keeping the goals of the revision of ICD in mind, minimal existing data and lack of representativeness of the existing data, WPA conducted a survey of 4887 psychiatrists belonging to 44 countries across the globe to assess the uses and attitude of psychiatrists toward the classifications used for mental disorders which has been published earlier. 
Indian Psychiatric Society (IPS) as a member organization of WPA also participated in the survey. This paper aims to present the results of the survey of members of IPS and compare the same with the opinion of the psychiatrists from other part of the world.
| Materials and Methods|| |
Detailed methodology of the survey has been described in an earlier paper published by the WPA.  We would briefly discuss the methodology here, and those interested can refer to the WPA paper for a detailed methodology. This was an online survey using the Qualtrics electronic survey platform (see www.qualtrics.com) in which all the member countries of WPA participated. The survey intended to know the experiences of the psychiatrists with regards to ICD-10 and their attitude toward ICD-10 and other classificatory systems. The survey was developed by WPA and details of the development of this survey have already being published by the WPA.  The survey was designed in such a way that only those questions which were relevant to a particular respondent, depending on his or her prior responses were presented to her/him. For example, those participants who indicated that they were not using ICD-10 in their clinical practice, questions related to use of specific ICD-10 categories were not presented to these respondents.
Indian Psychiatric Society was one of the participant countries of this survey. The survey link was sent to 1702 members of IPS (whose E-mail addresses were available with the society), and they were requested to participate in the survey. Eligible members were defined as all psychiatrists who were members of IPS who had completed their training. Survey reminders were sent at the predetermined time, that is, at 2 and 6 weeks after the initial solicitation request.
The initial and the reminder mails contained a link for the online survey. Whenever a person interested to participate in the survey visited the survey link page, initially they were explained about the purpose of the survey, mentioned that the participation is voluntary, and responses would be kept anonymous and that the survey had received exemption from the WHO Research Ethics Review Committee. The link also informed the participants as to whom to contact, in case they had any questions or comments. Before proceeding to the survey questions, a participant had to confirm that she/he was a qualified psychiatrist, and he wished to participate in the study. The data for IPS was collected during the period of June 5, 2010-September 9, 2010.
| Results|| |
Of the 1702 members of the IPS who were sent the survey link, 413 signed in to participate in the survey, of whom 386 completed the survey, giving a response rate of 22.7%. On average, the participants took 19 min to complete the survey with a range of 5-117 min. The mean age of the participants was 43.5 (standard deviation [SD]: 11.4; range: 27-78) years and majority of the participants (87%) were male. The mean duration of professional experience of the participants was 12.8 (SD: 10.8; range: 0-46 years) and almost all (99%) the participants were actively seeing patients.
All the participants were spending 32.3 h/week in seeing patients with more than 70% spending at least 20 h/week in seeing patients [Table 1]. About four-fifth (79%) of the participants were often/always using formal classificatory system in their day-to-day clinical work. Among the different classificatory systems, 71% were using ICD-10 and about one-fourth (27%) were using DSM-IV classification. About the question evaluating the single most important purpose of a diagnostic classificatory system, about one-third (32%) reported that the communication among clinicians was the most important purpose, 44% reported that the most important purpose is to inform treatment and management decisions, and 16% reported that the most important purpose of classification is to aid communication between clinicians and patients. When asked "how many diagnostic categories should a classificatory system contain to be most useful for mental health professionals?" nearly half (48%) of the participants opined that 10-30 categories were sufficient, and another 44% opined that 30-100 categories were sufficient. Very few participants opined that there is a need for a classificatory system with more than 100 categories. Regarding separate classification for primary care practitioners, the majority of the participants (85%) opined that there should be a modified/simpler classificatory system for them. Regarding the question of whether "a diagnostic classification system should serve as a useful reference not only for psychiatrists, but also for other mental health professionals (e.g, psychologists, social workers, psychiatric nurses)" most of the participants (90%) answered as completely/mostly agree. Similarly most of the participants (71%) answered as "completely/mostly agree" to the question of "a diagnostic classification system should be understandable to service users, patient advocates, administrators, and other relevant people as well as to health professionals." In term of flexibility versus clear and strict diagnostic criteria, 89% reported that the nosological system should provide flexible guidance, which allows for cultural variation and clinical judgement. There was the lack of consensus about the concept of severity, with one-fourth (27%) considered that subtypes should be defined based on the number and severity of symptoms, 29% opined that subtypes should be based on functional impairment, and 30% opined that there should be a separate severity axis for all diagnoses.
When the psychiatrists were asked about their opinion regarding the relationship between diagnosis and functional status, nearly half (48%) reported that "functional status should be part of diagnostic criteria when necessary to infer the presence of disorder," whereas another one-third (28%) reported that the disorder should not be diagnosed if there is no functional impairment.
About dimensional approach, 40% opined that following a dimensional approach would reflect a "more accurate psychopathology" and 32% reported that the dimensional approach would help in making more detailed and personalized diagnosis.
About the diagnosis of depression, 72% of the participants opined that a diagnosis of depression should be assigned even when the depressive symptoms are a proportionate response to an adverse life event(e.g. loss of job or home, divorce).
Only one-fourth of the participants were satisfied with the diagnostic system they were using in terms of its applicability "across cultures, or when the patient/service user was of a different cultural or ethnic background from my own." A good proportion of participants answered to the question as "agree somewhat (44%)", "mostly agree (26%)" or "completely agree (6%)."
In terms of the influence of United States of America and European culturally-derived concepts and values on the nosological system currently used by the participants, most of the participants agreed with the same, however the level of agreement varied, that is, "agree somewhat (43%)" , "mostly agree (28%)" or "completely agree (10%)."
Those who were using ICD-10, were asked specifically about the ICD system diagnostic categories and about half of the patients reported that there were categories in the ICD-10 with which they were "dissatisfied or believed that there were categories which were problematic in terms of their goodness of fit in clinical settings?." With regard to need for removal of specific diagnostic categories from ICD-10, 25% felt that there were categories which should be removed or moved to another section. However, a higher proportion (43%) felt that there is a need to add specific diagnoses to another section of ICD-10.
More than four-fifth (82%) of the participants did not feel that there were "terms" used in current diagnostic systems which were stigmatizing in their language or cultural context. Similarly three-fourth (74%) felt that there was no need of having a national classification.
As part of the survey question number-21, the participants who answered to prior questions that they were using ICD-10 in day-to-day clinical practice were given a list of 44 ICD-10 diagnostic categories and were asked to select the diagnostic categories they used at least once a week in their day-to-day clinical practice. The 10 most commonly indicated categories were: F20-Schizophrenia, F32-Depressive episode, F31-Bipolar affective disorder, F41.1-Generalized anxiety disorder, F10-Mental and behavioural disorders due to use of alcohol, F42-Obsessive compulsive disorder, F45-Somatoform Disorders, F23-Acute and transient psychotic disorders, F30-Manic episode and F41.2 Mixed anxiety and depressive disorder. Similarly certain diagnoses were used very less frequently [Figure 1]. This diagnostic profile was slightly different from that from other parts of the world, for example, higher use of diagnosis of acute and transient psychosis and alcohol dependence by psychiatrists from India.
|Figure 1: Response to Q-21: Of the ICD-10 diagnostic categories listed, please indicate which ones you use once a week or more in your day to day clinical practice|
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For the each ICD-10 category that a participant indicated to be using at least once a week, he or she was asked to rate the category in clinical practice in terms of ease of use and goodness of fit or accuracy of the ICD-10 definition, clinical description and diagnostic guidelines in describing patients seen in clinical practice. Ratings were done on a 4-point scale from 0 ("not at all easy to use in clinical practice" or "not at all accurate") to 3 ("extremely easy to use" or "extremely accurate"). Responses are shown in [Figure 2] and [Figure 3]. The responses suggested good correlation between "goodness of fit" and "ease of use" for more commonly used categories.
|Figure 2: Response to Q-22: Ease of use of the ICD-10 diagnostic guidelines|
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|Figure 3: Response to Q-22: goodness to fit or accuracy of ICD-10 definition, clinical description, and diagnostic guidelines in describing the patients you see in clinical practice|
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Comparison with the global data
When the data from India was compared with the data from other countries  across with globe, certain differences were noticed. The response rate from India (22.7%) was less than the global average response rate of 34%. The mean response time of Indian psychiatrists (19 min) was nearly equal to the global response time of 21.8 min. The amount of patient contact of 99% among Indian psychiatrists was also similar to the global average of 96.7%. Compared to the psychiatrists from other parts of the world, significantly higher percentage of psychiatrists from India were spending more than 40 h/week in providing patient care. However, compared to psychiatrists from other parts of the world, psychiatrists from India, significantly less frequently reported using classificatory system -"almost always" in routine clinical practice.
In terms of most commonly used classificatory system, use of ICD-10 by the Indian Psychiatrists was at par with the psychiatrists from other parts of the world.
The global data suggested that the most important purpose of diagnostic classification system, from the respondents' perspective, was communication among clinicians, followed by informing treatment and management decisions. However, from the Indian psychiatrists point of view the reverse was true, and the difference was statistically significant.
In terms of number of diagnostic categories desired, compared to the responses from the psychiatrists from other part of the world, significantly higher percentage of psychiatrists from India were of the opinion that a classificatory system with 10-30 diagnostic categories would be most useful for mental health professionals. Similarly, significantly higher proportion of psychiatrists from India were of the opinion of having separate classificatory system for primary care practitioners; diagnostic system should serve as a useful reference not only for psychiatrists, but also for other mental health professionals (e.g, psychologists, social workers, psychiatric nurses), diagnostic classification system should be understandable to service users, patient advocates, administrators, and other relevant people as well as to health professionals; classificatory system to provide flexible guidance that allows for cultural variation and clinical judgment; the concept of severity to be addressed in the form of subtypes based on functional impairment; to have dimensional component rather than having "present/absent" for rating some of the disorders; should not diagnosed depression when the depressive symptoms are a proportionate response to adverse life event (e.g. loss of job or home, divorce) and considered that the diagnostic system which they were using was problematic because it is over-embedded in U.S. and European culturally-derived concepts and values.
Compared to psychiatrists from other part of the world, significantly higher proportion of psychiatrists from India opined that there is a need to add specific diagnosis to another section in ICD-10 and less proportion of them opined that the terminology in the current diagnostic system were stigmatizing. Compared to the psychiatrists from other part of the world, the higher proportion of Indian psychiatrists were of the opinion that there should be national classificatory system.
The opinion of psychiatrists from India, did not differ significantly from psychiatrists from other part of the world, in terms of conceptualizing the relationship between diagnosis and functional status; cross-cultural application of classification and dissatisfaction with certain diagnostic categories for their goodness of fit in clinical setting.
| Discussion|| |
Survey of users is an important tool in understanding the limitations and usefulness of classificatory systems. None of the surveys from India had obtained the opinion of the psychiatrists about the use of ICD-10. Participation in this survey provided a unique opportunity in understanding the views of psychiatrists across the country. Further, as there are limited numbers of surveys across the world which has assessed the usefulness and application of current nosological system. We would try to understand some of the differences in the responses to the survey between psychiatrists from India and rest of the world. In doing so, we would try to hypothesize the reasons for these differences.
Although the response rate was 23% for the psychiatrists from India, which was significantly less than the global survey response rate, the percentage of responses contributed by psychiatrists from India amounted to 8.6% of the total responses for the survey across the globe. Finding of the survey reflects that compared to psychiatrists from other parts of the world, psychiatrist from India were spending higher number of h/week in seeing patients. This is understandable considering the fact most of the psychiatrists in this country work for 6-7 days a week compared to some of the countries from Europe and America, were the usual working is limited to 5 days a week. About four-fifth of the participants from India were often/always using formal classificatory system in their day-to-day clinical work, and this was similar to the pooled percentage of the response from other parts of the world. However, when it came to the "almost always" response, the percentage of Indian psychiatrists with this response were less that the psychiatrists from the other parts of the world. This relatively lesser use of formal classification could be understood from various perspectives. First, there is marked shortage of psychiatrists in India and the ratio of psychiatrist per lakh population is dismal. Because of this the psychiatrists have to deal with higher patient load compared to their counterparts in other parts of the world. Due to this it is always not possible for some of the practicing psychiatrists to establish the exact subtype of a particular disorder. Second, the huge patient load also impacts the training and due to this, less emphasis is laid on the nosology in the busy outpatient practice. These hypotheses are supported by the fact that in the present survey, compared to their counterparts from other parts of the world, significantly higher percentage of psychiatrists from India opined the need to have a classificatory system with only 10-30 diagnostic categories, which can help in categorizing the patients in broad diagnostic categories. Overall the response of 'often' and 'almost always' by about 80% of the psychiatrists from India indicate that a formal classificatory system is an integral part of the psychiatric practice in India.
A significantly large proportion of psychiatrists from India mostly used the ICD-10 in their clinical practice and this was similar to the profile reported for the rest of the world. A reasonable proportion of psychiatrists also rely on DSM-IV. However, compared to psychiatrists from other parts of the world, significantly lesser proportion of psychiatrists from India used diagnostic systems other than ICD-10 and DSM-IV. Possible reasons for these could be a variation in the emphasis on different nosological systems in the different training centres across the country along with the absence of any national level classification. This was also reflected in the responses of this survey in which compared to the psychiatrists from other parts of the world a significantly higher proportion of psychiatrists reported the need for having national level classification. This would possibly an important challenge for the IPS to address in future. Although psychiatrists from India, agreed on the two most common purposes of classification is "communication among clinicians" and "inform treatment and management decisions," significantly higher proportion of psychiatrists laid emphasis on the later compared to the former and this lead to a significant difference in findings from India compared to the psychiatrists from other parts of the world. A possible reason for this difference could be lack of organized health care system in our country in which there is no formal referral system. In many western countries, the health care system is organized, and the patient had to first see a general physicians before seeing a psychiatrists, who refer back the patient to a general physician after providing the appropriate care. In India, patients have the liberty to seek treatment from a physician or psychiatrist of their own choice and can shift from one treating psychiatrist to the other, without asking for a formal referral letter. This possibly leads to the relative lack of communication between the clinicians. Further, compared to the responses from psychiatrist across the globe, significantly lower proportion of psychiatrists from India opted for the response that the purpose of classification is "generating national statistics," because of lack of national registries, compared to some of the countries like Sweden, which have national registries.
Compared to psychiatrists from other parts of the world, significantly higher proportion of the psychiatrists reported the need to have modified or simpler classification for the primary care practitioners and having a classificatory system which can also be used by other mental health professionals and other stake holders like service users, patient advocates, administrators, and other relevant people as well as to health professionals. Higher proportion of psychiatrists from India advocated having simpler classification for primary care practitioners, because of lack of emphasis on training in psychiatry at the undergraduate level and resultantly many physicians and surgeons have poor knowledge about psychiatry. More complicated nosological system possibly acts as a demotivating factor for the primary care physicians to learn and use the complex nosological system. Need for having a nosological system to suit other mental health professionals and stake holder possibly reflects the need to broaden the base of mental health professionals. Again the need to have nosological system that can be used easily by other stakeholder possibly reflect the perception, which possibly is true too, is a lack of knowledge about different mental illness among different stakeholders.
Compared to psychiatrists from other parts of the world, significantly higher proportion of psychiatrists from India opined that the nosological system should provide flexible guidance that will allow for cultural variation and clinical judgement. This possibly reflects that in routine clinical practice it is not possible to fit the entire patient population to specific diagnostic categories if clear and strict diagnostic criteria are followed. Significantly higher proportion of psychiatrists from India opined that the concept of severity should be addressed in the form of subtypes based on functional impairment, rather than subtypes based on number and severity of symptoms or separate axis for severity. This possibly is in tune with the need for the have flexible system which can help in addressing the cultural issues rather than the system based on symptom count. Further nonpreference for separate severity axis possibly reflects that this would further make the practice cumbersome, which will require separate evaluation and possibly lead to lack of use of the same.
With regards to the diagnosis of depression, majority of the psychiatrists opined that the diagnosis of depression should be assigned when the depressive symptoms are a proportionate response to adverse life event (e.g. loss of job or home, divorce), and this was in line with the opinion with the psychiatrists from other parts of the world. However, the proportion of psychiatrists from India was much more than the psychiatrists from other parts of the world. Possibly this reflect the traditional cultural belief according to which many people in the community consider these as normal reactions to stress and as a result do not seek treatment till late, which leads to delay in onset of treatment, higher disability and suffering and higher indirect cost to the society.
Most of the psychiatrists from India responded as "agree somewhat" to the question of "the diagnostic system I use is difficult to apply across cultures, or when the patient/service user is of a different cultural or ethnic background from my own" reflects the need to take into consideration the cultural aspects while formulating classification. This possibly reflect the fact that current classification system does not take all cultural aspects into consideration and due to the same, at times it is not possible to understand and label all the symptoms of the patients according to the current nosological system.
The level of dissatisfaction with the current nosological system among psychiatrists from India was at par with the responses of psychiatrists from other part of the world. This possibly reflect the general level of dissatisfaction among psychiatrists with the current nosological systems and the requirement for having a system which would be more user friendly and have better goodness of fit with the description of the syndrome by the patients in a clinical setting. This was further supported by the fact that compared to psychiatrists from other parts of the world significantly higher proportion of psychiatrists from India responded affirmatively to the question asking as to adding a diagnosis to another section.
Significantly lesser proportion of psychiatrists from India considered that there was terminology in the current nosological system which was stigmatizing in language or current cultural context. No specific hypothesis can be proposed for this difference. Although most of the psychiatrists opined that there was no need to have a separate national level of classification, as discussed earlier, compared to psychiatrists from other part of the globe, higher proportion of psychiatrists from India felt the need to have national level classificatory system. This can be understood from the differences in the responses of psychiatrists from India and other parts of the world. This possibly reflects the need to have a classification which can suit the busy practicing Indian psychiatrists who spend much more time than psychiatrist in other parts of the world, providing services in the resource poor country.
Compared to the other parts of the world, the diagnoses of acute and transient psychosis and alcohol dependence syndrome were more commonly used in the Indian context. These possibly reflect the cultural differences as many patients in India do present with an acute onset short lasting psychosis, which usually have a good prognosis. Higher use of alcohol dependence syndrome diagnosis, possibly reflects higher intolerance for use of alcohol in the Indian society compared to the west and presence of the family which possibly brings the patients who are using excessive alcohol to the hospital.
Overall, average ease of use and goodness of fit ratings were reasonably high for psychiatrists from India, at times higher than the average reported by the psychiatrists from other parts of the world suggesting that psychiatrists from India found the current system to be user friendly and relatively accurate in describing the patients in their clinical practice.
| Conclusion|| |
The findings of the survey suggests that the opinion of the psychiatrists from India is consistent with the psychiatrists from other parts of the world in terms revision of ICD, but for certain differences. Psychiatrists from India expect that the ICD-11 would have fewer diagnostic categories, would be more simplified, with flexible and dimensional approach that would allow cultural variations to making a diagnosis and applying the same in a clinical practice.
| References|| |
World Health Organization. ICD-10 Classification of Mental and Behavioural Disorders. Geneva: World Health Organization; 1992.
International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. A conceptual framework for the revision of the ICD-10 classification of mental and behavioural disorders. World Psychiatry 2011;10:86-92.
Mezzich JE. International surveys on the use of ICD-10 and related diagnostic systems. Psychopathology 2002;35:72-5.
Mellsop G, Banzato C, Shinfuku N, Nagamine M, Pereira MEC, Dutu G.
An international study of the views of psychiatrists on present and preferred characteristics of classifications of psychiatric disorders. Int J Ment Health 2008;36:18-26.
Reed GM, Mendonça Correia J, Esparza P, Saxena S, Maj M. The WPA-WHO global survey of psychiatrists' attitudes towards mental disorders classification. World Psychiatry 2011;10:118-31.
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012, Punjab
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]