世卫组织 ICD-11 灵活访谈(FLII-11)

IF 73.3 1区 医学 Q1 Medicine
World Psychiatry Pub Date : 2024-09-16 DOI:10.1002/wps.21227
Geoffrey M. Reed, Karen T. Maré, Michael B. First, T.S. Jaisoorya, Girish N. Rao, John-Joe Dawson-Squibb, Christine Lochner, Mark van Ommeren, Dan J. Stein
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For example, the Research Diagnostic Criteria were used to develop a Schedule for Affective Disorders and Schizophrenia<span><sup>1</sup></span>, while the DSM-III criteria were incorporated into the Structured Clinical Interview for DSM (SCID)<span><sup>2</sup></span>. In addition, the Diagnostic Interview Schedule<span><sup>3</sup></span> was developed for use by non-clinician interviewers in epidemiological surveys of mental disorders. These instruments have been widely used in research on mental disorders.</p>\n<p>Structured diagnostic interviews have subsequently been developed or adapted for successive revisions of the DSM and the ICD. The SCID, a semi-structured interview – meaning that the interviewer probes unclear responses and makes certain clinical judgments – has been updated with each edition of the DSM<span><sup>4</sup></span>. The briefer and fully structured Mini International Neuropsychiatric Interview (MINI)<span><sup>5</sup></span> has also been widely employed. The Composite International Diagnostic Interview (CIDI)<span><sup>6</sup></span> incorporated both DSM and ICD diagnostic requirements and was used in the National Comorbidity Survey and the World Mental Health Surveys. Similarly, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), based on the Present State Examination, assessed for both DSM and ICD requirements<span><sup>7</sup></span>. Structured diagnostic interviews for children have also been developed, as have a range of more focused interviews that cover specific conditions or diagnostic groupings.</p>\n<p>Based on an extensive program of field testing, the reliability of the diagnostic guidance provided in the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR)<span><sup>8</sup></span> was found to be higher than that of other mental disorder classification systems, ranging from moderate to almost perfect according to the specific category. This finding was perhaps counterintuitive, insofar as the CDDR avoid highly prescriptive symptom counts and duration requirements, unless these are specifically supported scientifically, in order to facilitate clinical use.</p>\n<p>These results, therefore, challenge the assumed relationship between operational precision and diagnostic reliability. They also suggest that the diagnoses based on the CDDR would be sufficiently reliable for certain types of research projects (e.g., studies focusing on diagnostic groups in health care settings). However, in other types of research, standardized diagnostic assessments are desirable to control clinician-level variability associated with different skill levels, interviewing styles, and clinical judgment. For example, in pharmacological trials that select participants based on certain diagnostic requirements, the ability to document specific symptom patterns reliably and reproducibly is often important. Epidemiological or other population-based surveys involving lay (i.e., not clinically trained) interviewers also require pre-scripted questions and strict decision rules, because they cannot rely on the interviewer's clinical knowledge to determine whether specific features are present.</p>\n<p>Diagnostic interviews have therefore been a part of the work plan related to the CDDR nearly from the beginning. The relevant work has employed a rigorous development process and included international experts in the fields of nosology and diagnostic interviews. Work on the Structured Clinical Interview for ICD-11 (SCII-11) has been ongoing since 2014. This is a semi-structured diagnostic interview – designed to be administered by a trained clinician – that provides a standardized set of questions, each assessing a specific diagnostic requirement for the purpose of formulating a differential diagnosis. Though developed for research applications, the SCII-11 will also be useful for training purposes and in clinical settings.</p>\n<p>Due to the CDDR's more clinically-oriented framing of diagnostic requirements, additional operationalization has been necessary in developing the SCII-11. Specifically, the SCII-11 substitutes more precise diagnostic thresholds for less prescriptive terms in the CDDR (e.g., at least three rather than “several” symptoms; at least three months rather than “persistent”). In addition, specific questions have been developed for elements of the CDDR that may manifest in a variety of different ways (e.g., “persistent delusions” in schizophrenia).</p>\n<p>The World Health Organization (WHO) Flexible Interview for ICD-11 (FLII-11) is being developed as an open-access tool to support national epidemiological investigations and other population-based and clinical studies of mental disorders. It is a fully structured diagnostic interview that can be administered by trained lay interviewers and assesses mental disorders associated with the greatest global disease burden. It builds on the operationalization work completed for the SCII-11. Like the SCII-11, the FLII-11 is modular and customizable to assess a subset of disorders, and can evaluate current and lifetime diagnostic status. Available modules include psychotic, mood, anxiety, obsessive-compulsive and related, post-traumatic, eating, addictive behaviour, and substance use disorders, and attention deficit hyperactivity disorder. An adaptation for adolescents aged 13-17 has also been developed.</p>\n<p>There has been a high level of interest in the FLII-11, due to the increasing global importance given to mental disorders, and the desire of WHO member states to use an open-access measure that is consistent with the current official global diagnostic system. The FLII-11 is being prepared for feasibility testing, including review by people with lived experience, as a part of an international collaboration that involves Brazil, China, India, Liberia, Mexico, South Africa, Sri Lanka, Tunisia and Uganda. This is occurring in tandem with its use in national mental health surveys in several of these countries.</p>\n<p>The FLII-11 is being translated into multiple languages and employed in a broad range of settings around the globe. It is therefore critical that complex concepts be phrased in readily understandable and culturally appropriate ways. This has necessitated the development of a standardized cultural adaptation and translation process. The WHO aims to develop an online platform that will facilitate the collection, analysis and sharing of international data and become a resource for international mental health epidemiology.</p>\n<p>Diagnostic interviews based on the ICD-11 CDDR promise to be useful for both clinicians and researchers. At the same time, several concerns should be borne in mind as this work proceeds. A first concern relates to the limitations of an approach to diagnostic assessment of mental disorders that relies primarily on direct self-report of their essential features. There are also concerns about areas in which interviewees may have an incentive to minimize or deny their symptoms (e.g., when they relate to illegal or highly stigmatized behaviours), or when an aspect of the presentation is poor or absent insight or a distorted view of their own behaviour and functioning. Validation of diagnostic interviews in these areas requires particular attention.</p>\n<p>Another ongoing question is how best to validate an interview undertaken by an experienced clinician. Spitzer proposed using a “longitudinal expert all data (LEAD) standard”<span><sup>9</sup></span>, which is difficult and burdensome to do and still subject to clinician bias. New diagnostic measures are more commonly validated against other measures; for example, results of the lay-administered FLII-11 could be compared to those of the clinician-administered SCII-11, rather than against a measure not based on the ICD-11. The issue of false positives in epidemiological research remains a concern and must be evaluated, but may be ameliorated by training.</p>\n<p>Establishing the cross-cultural feasibility and validity of structured diagnostic interviews for the ICD-11 will provide an important foundation for international mental health research.</p>","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":null,"pages":null},"PeriodicalIF":73.3000,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"The WHO Flexible Interview for ICD-11 (FLII-11)\",\"authors\":\"Geoffrey M. Reed, Karen T. Maré, Michael B. First, T.S. 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In addition, the Diagnostic Interview Schedule<span><sup>3</sup></span> was developed for use by non-clinician interviewers in epidemiological surveys of mental disorders. These instruments have been widely used in research on mental disorders.</p>\\n<p>Structured diagnostic interviews have subsequently been developed or adapted for successive revisions of the DSM and the ICD. The SCID, a semi-structured interview – meaning that the interviewer probes unclear responses and makes certain clinical judgments – has been updated with each edition of the DSM<span><sup>4</sup></span>. The briefer and fully structured Mini International Neuropsychiatric Interview (MINI)<span><sup>5</sup></span> has also been widely employed. The Composite International Diagnostic Interview (CIDI)<span><sup>6</sup></span> incorporated both DSM and ICD diagnostic requirements and was used in the National Comorbidity Survey and the World Mental Health Surveys. Similarly, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), based on the Present State Examination, assessed for both DSM and ICD requirements<span><sup>7</sup></span>. Structured diagnostic interviews for children have also been developed, as have a range of more focused interviews that cover specific conditions or diagnostic groupings.</p>\\n<p>Based on an extensive program of field testing, the reliability of the diagnostic guidance provided in the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR)<span><sup>8</sup></span> was found to be higher than that of other mental disorder classification systems, ranging from moderate to almost perfect according to the specific category. 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引用次数: 0

摘要

从 DSM-III 开始的以症状为基础的描述性诊断系统的发展,在一定程度上是为了回应人们对精神病诊断可靠性的广泛关注和批评。这促使人们开始强调诊断结构和标准的日益精确的可操作性,并假定这将使诊断的可靠性不断提高。例如,"研究诊断标准 "被用于制定 "情感障碍和精神分裂症时间表 "1 ,而 "DSM-III 标准 "则被纳入了 "DSM 结构化临床访谈(SCID)"2。 此外,还制定了 "诊断访谈时间表 "3,供非临床医师访谈者在精神障碍流行病学调查中使用。这些工具已被广泛应用于精神障碍的研究中。结构化诊断访谈随后被开发或改编用于 DSM 和 ICD 的历次修订。SCID 是一种半结构化访谈--即访谈者对不明确的回答进行试探并做出某些临床判断--已随着 DSM4 的每一版进行了更新。更简短、完全结构化的迷你国际神经精神病学访谈(MINI)5 也被广泛采用。国际综合诊断访谈(CIDI)6 纳入了 DSM 和 ICD 的诊断要求,并被用于全国发病率调查和世界精神健康调查。同样,基于现状检查的神经精神病学临床评估表(SCAN)也同时评估了 DSM 和 ICD 的要求7。根据一项广泛的现场测试计划,《ICD-11 精神、行为和神经发育障碍临床描述和诊断要求》(CDDR)8 提供的诊断指导的可靠性高于其他精神障碍分类系统,根据具体类别从中等到几乎完美不等。这一结果可能与直觉相反,因为 CDDR 避免了高度规范化的症状计数和持续时间要求,除非这些要求得到科学的具体支持,以方便临床使用。这些结果还表明,基于 CDDR 的诊断对于某些类型的研究项目(例如,以医疗机构中的诊断群体为重点的研究)来说是足够可靠的。然而,在其他类型的研究中,标准化的诊断评估是可取的,以控制与不同技能水平、面谈风格和临床判断相关的临床医生层面的变异性。例如,在根据特定诊断要求选择参与者的药理学试验中,可靠、可重复地记录特定症状模式的能力往往非常重要。流行病学调查或其他基于人群的调查中,涉及非专业(即未接受过临床培训)访谈者时,也需要预设问题和严格的决策规则,因为这些调查不能依靠访谈者的临床知识来判断是否存在特定特征。因此,诊断访谈几乎从一开始就是 CDDR 相关工作计划的一部分。因此,诊断性访谈几乎从一开始就是 CDDR 相关工作计划的一部分。相关工作采用了严格的开发流程,并邀请了分类学和诊断性访谈领域的国际专家参与。自 2014 年以来,ICD-11 结构化临床访谈(SCII-11)的工作一直在进行。这是一个半结构化的诊断访谈--旨在由训练有素的临床医师进行--提供了一套标准化的问题,每个问题评估一个特定的诊断要求,以形成鉴别诊断。尽管 SCII-11 是为研究应用而开发的,但它也可用于培训目的和临床环境。由于 CDDR 对诊断要求的设定更加面向临床,因此在开发 SCII-11 时有必要增加可操作性。具体来说,SCII-11 用更精确的诊断阈值取代了 CDDR 中不那么规范的术语(例如,至少有三个而不是 "几个 "症状;至少有三个月而不是 "持续")。此外,还针对 CDDR 中可能以各种不同方式表现出来的内容(如精神分裂症中的 "持续妄想")开发了特定的问题。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
The WHO Flexible Interview for ICD-11 (FLII-11)

The movement to a descriptive, symptom-based diagnostic system that started with the DSM-III was in part a response to widespread concerns and criticisms regarding the reliability of psychiatric diagnoses. This fueled an emphasis on increasingly precise operationalization of diagnostic constructs and criteria, based on the assumption that this would produce successive improvements in reliability.

Clinician-administered structured diagnostic interviews were subsequently developed. For example, the Research Diagnostic Criteria were used to develop a Schedule for Affective Disorders and Schizophrenia1, while the DSM-III criteria were incorporated into the Structured Clinical Interview for DSM (SCID)2. In addition, the Diagnostic Interview Schedule3 was developed for use by non-clinician interviewers in epidemiological surveys of mental disorders. These instruments have been widely used in research on mental disorders.

Structured diagnostic interviews have subsequently been developed or adapted for successive revisions of the DSM and the ICD. The SCID, a semi-structured interview – meaning that the interviewer probes unclear responses and makes certain clinical judgments – has been updated with each edition of the DSM4. The briefer and fully structured Mini International Neuropsychiatric Interview (MINI)5 has also been widely employed. The Composite International Diagnostic Interview (CIDI)6 incorporated both DSM and ICD diagnostic requirements and was used in the National Comorbidity Survey and the World Mental Health Surveys. Similarly, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), based on the Present State Examination, assessed for both DSM and ICD requirements7. Structured diagnostic interviews for children have also been developed, as have a range of more focused interviews that cover specific conditions or diagnostic groupings.

Based on an extensive program of field testing, the reliability of the diagnostic guidance provided in the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR)8 was found to be higher than that of other mental disorder classification systems, ranging from moderate to almost perfect according to the specific category. This finding was perhaps counterintuitive, insofar as the CDDR avoid highly prescriptive symptom counts and duration requirements, unless these are specifically supported scientifically, in order to facilitate clinical use.

These results, therefore, challenge the assumed relationship between operational precision and diagnostic reliability. They also suggest that the diagnoses based on the CDDR would be sufficiently reliable for certain types of research projects (e.g., studies focusing on diagnostic groups in health care settings). However, in other types of research, standardized diagnostic assessments are desirable to control clinician-level variability associated with different skill levels, interviewing styles, and clinical judgment. For example, in pharmacological trials that select participants based on certain diagnostic requirements, the ability to document specific symptom patterns reliably and reproducibly is often important. Epidemiological or other population-based surveys involving lay (i.e., not clinically trained) interviewers also require pre-scripted questions and strict decision rules, because they cannot rely on the interviewer's clinical knowledge to determine whether specific features are present.

Diagnostic interviews have therefore been a part of the work plan related to the CDDR nearly from the beginning. The relevant work has employed a rigorous development process and included international experts in the fields of nosology and diagnostic interviews. Work on the Structured Clinical Interview for ICD-11 (SCII-11) has been ongoing since 2014. This is a semi-structured diagnostic interview – designed to be administered by a trained clinician – that provides a standardized set of questions, each assessing a specific diagnostic requirement for the purpose of formulating a differential diagnosis. Though developed for research applications, the SCII-11 will also be useful for training purposes and in clinical settings.

Due to the CDDR's more clinically-oriented framing of diagnostic requirements, additional operationalization has been necessary in developing the SCII-11. Specifically, the SCII-11 substitutes more precise diagnostic thresholds for less prescriptive terms in the CDDR (e.g., at least three rather than “several” symptoms; at least three months rather than “persistent”). In addition, specific questions have been developed for elements of the CDDR that may manifest in a variety of different ways (e.g., “persistent delusions” in schizophrenia).

The World Health Organization (WHO) Flexible Interview for ICD-11 (FLII-11) is being developed as an open-access tool to support national epidemiological investigations and other population-based and clinical studies of mental disorders. It is a fully structured diagnostic interview that can be administered by trained lay interviewers and assesses mental disorders associated with the greatest global disease burden. It builds on the operationalization work completed for the SCII-11. Like the SCII-11, the FLII-11 is modular and customizable to assess a subset of disorders, and can evaluate current and lifetime diagnostic status. Available modules include psychotic, mood, anxiety, obsessive-compulsive and related, post-traumatic, eating, addictive behaviour, and substance use disorders, and attention deficit hyperactivity disorder. An adaptation for adolescents aged 13-17 has also been developed.

There has been a high level of interest in the FLII-11, due to the increasing global importance given to mental disorders, and the desire of WHO member states to use an open-access measure that is consistent with the current official global diagnostic system. The FLII-11 is being prepared for feasibility testing, including review by people with lived experience, as a part of an international collaboration that involves Brazil, China, India, Liberia, Mexico, South Africa, Sri Lanka, Tunisia and Uganda. This is occurring in tandem with its use in national mental health surveys in several of these countries.

The FLII-11 is being translated into multiple languages and employed in a broad range of settings around the globe. It is therefore critical that complex concepts be phrased in readily understandable and culturally appropriate ways. This has necessitated the development of a standardized cultural adaptation and translation process. The WHO aims to develop an online platform that will facilitate the collection, analysis and sharing of international data and become a resource for international mental health epidemiology.

Diagnostic interviews based on the ICD-11 CDDR promise to be useful for both clinicians and researchers. At the same time, several concerns should be borne in mind as this work proceeds. A first concern relates to the limitations of an approach to diagnostic assessment of mental disorders that relies primarily on direct self-report of their essential features. There are also concerns about areas in which interviewees may have an incentive to minimize or deny their symptoms (e.g., when they relate to illegal or highly stigmatized behaviours), or when an aspect of the presentation is poor or absent insight or a distorted view of their own behaviour and functioning. Validation of diagnostic interviews in these areas requires particular attention.

Another ongoing question is how best to validate an interview undertaken by an experienced clinician. Spitzer proposed using a “longitudinal expert all data (LEAD) standard”9, which is difficult and burdensome to do and still subject to clinician bias. New diagnostic measures are more commonly validated against other measures; for example, results of the lay-administered FLII-11 could be compared to those of the clinician-administered SCII-11, rather than against a measure not based on the ICD-11. The issue of false positives in epidemiological research remains a concern and must be evaluated, but may be ameliorated by training.

Establishing the cross-cultural feasibility and validity of structured diagnostic interviews for the ICD-11 will provide an important foundation for international mental health research.

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来源期刊
World Psychiatry
World Psychiatry Nursing-Psychiatric Mental Health
CiteScore
64.10
自引率
7.40%
发文量
124
期刊介绍: World Psychiatry is the official journal of the World Psychiatric Association. It aims to disseminate information on significant clinical, service, and research developments in the mental health field. World Psychiatry is published three times per year and is sent free of charge to psychiatrists.The recipient psychiatrists' names and addresses are provided by WPA member societies and sections.The language used in the journal is designed to be understandable by the majority of mental health professionals worldwide.
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