World Health Organization (WHO) ICD-11
13 February 2017
Dr. Shekhar Saxena
Department of Mental Health & Substance Abuse
World Health Organization
CH-1211, Geneva, Switzerland
Dear Dr. Saxena:
The International Psychogeriatric Association (IPA) has recently learned of the proposal to transfer the diagnostic categories of dementia in ICD-11 from the Mental or Behavioral Disorders section to Diseases of the Nervous System section.
The IPA Executive/Board of Directors has discussed this issue and has decided to express its great concern for such a proposal, both for the harm it can cause to the field of psychiatry and for the enormous prejudice that will undoubtedly cause patients with dementia and their families in many countries in the world, as well as the incoherence it introduces into a long-established tradition of WHO documents published along decades with a broad consensus base.
From the conceptual point of view, the measure attacks the concept of psychiatry as a science that has its roots in the three biological, psychological and social components of the human being and therefore incorporates all the knowledge of medicine and social sciences. It is paradoxical, even if it is not the first time this has occurred in the history of psychiatry, that when the knowledge of the biological basis of a mental illness develops, in the name of "science", considers it has arrived the time for detaching such condition from the group of all other mental illnesses. By reduction to the absurd, if this measure were taken, the entire block of mental disorders described in ICD-10 as "Organic, including symptomatic, mental disorders" should have to be removed from the category of mental disorders and included in the classifications of other medical specialties. The rest of the mental illnesses would expect the same fate...in a more or less distant future. Psychiatrists know that there are advocates of this approach, but we certainly did not expect it would receive the support of the WHO.
Moreover, the measure does not help to clarify anything about the nature of the disease. The biological, and specifically neurological component of dementia has not been called into question by any modern psychiatric school. As the field of dementia research is an interdisciplinary field in which there are many leaders with training in psychiatry, neurology or both medical specialties, it is difficult to understand that a measure of this nature can contribute to enhance the interdisciplinary investigation of dementias. We rather fear the opposite.
If the foregoing arguments could lead to an exciting academic debate on the epistemology of dementia, we want to emphasize and concern ourselves even more closely with the negative, practical and immediate consequences that such a measure might have for the care of people with dementia and their families around the world.
In developed countries, psychiatry, neurology and geriatrics are the medical specialties that give the greatest attention to dementia, varying their leadership and the involvement of the respective services according to the different countries. Psychiatry and geriatrics deal with continuity of patients with dementia, while neurology services usually focus on the diagnosis and initial treatment of the condition.
In many developed countries, the specialty of Old Age Psychiatry or Geriatric Psychiatry is recognized or there are a large number of professionals who are grouped under this denomination, and its services pay special attention to patients with dementia and their caregivers, which is consistent with the psychiatrist model of services organization that emphasizes interdisciplinary and community care, very different from that of neurology services.
The International Psychogeriatric Association is a scientific association with members who are psychiatrists, geriatricians, neurologists and representatives of other medical specialties, psychologists, nurses, social workers and other professionals concerned with the mental health of the elderly. Many of them are grouped in the 27 IPA affiliated societies. These thousands of professionals exercise their clinical, research and teaching activities in all continents and provide IPA with a wealth of social and cultural perspectives. We therefore have no doubt about the important role that psychiatric services play in developed and developing countries in addressing dementia and other mental illness worldwide.
IPA has been the scientific entity that two decades ago conceptualized the so-called Behavioral and Psychological Symptoms of Dementia (BPSD). Its congresses and seminal publications created a concept that is now definitively established as nuclear in the clinic of dementia, and which is often the element that most concerns the caregivers of these patients. Psychiatrists and mental health professionals of the elderly who work in psychiatric services are characterized by their special training in dealing with problems of this nature.
In some countries, such as the United States, failing to conceptualize dementia as a mental illness would mean that psychiatrists could not charge their services to these patients, whereas there are not enough neurologists to care for these patients and their training is different than what is received by psychiatrists.
In short, the measure could have several other paradoxically perverse unintended effects:
- the sociological confrontation of neurology and psychiatry, a paradox at a time when it seemed that both historically sister disciplines were approaching each other again, at least in the field of research;
- trying to "de-stigmatize" the patient with dementia by avoiding categorizing dementia with other mentally illnesse, deprives the patient of access to the services and professionals specially qualified to attend them. One of the WHO publications, "Reducing stigma and discrimination against older people with mental disorders. A Technical Consensus Statement" (http://www.who.int/mental_health/media/en/499.pdf), is worth recalling here, that the best way to deal with the stigma of mental illness in the older population is creating excellent psychogeriatric services. In addition, such controversial measure would contribute to stigmatize the whole of psychiatry, by questioning its training and undermining its services.
Finally, this measure is inconsistent with a long list of official WHO documents or published under the auspices of the WHO, which have always stated as essential the role of psychiatry in the care, research and prevention of dementia, among which we can cite:
- Draft global action plan on the public health response to dementia. Report by the Director-General, 23 December 2016.
- Dementia: a public health priority http://www.who.int/mental_health/publications/dementia_report_2012/en/
- Global Action Against Dementia http://www.who.int/mental_health/neurology/dementia/ministerial_conference_2015_report/en/
- Psychiatry of the Elderly. A consensus statement http://www.who.int/mental_health/media/en/17.pdf?ua=1
- Comprehensive mental health action plan 2013-2020 http://www.who.int/mental_health/action_plan_2013/en/
- WHO Mental Health Gap Action Programme, Diagnosis of dementia http://www.who.int/mental_health/mhgap/evidence/dementia/q6/en/
- WHO iSupport: e-programme for caregivers of people living with dementia http://www.who.int/mental_health/neurology/dementia/isupport/en/
- WHO Mental health atlas 2014 http://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2014/en/
- WHO assessment instrument for mental health systems (AIMS), Version 2.2, http://www.who.int/mental_health/evidence/WHO-AIMS/en/
- WHO Service availability and readiness assessment http://www.who.int/healthinfo/systems/sara_introduction/en/
For all the foregoing reasons, we request that dementia continue to be considered a mental illness in the ICD-11 disease classification.
We take this opportunity to reiterate to the WHO the availability and interest of the IPA to continue collaborating in all matters related to the mental health of the older population.
Raimundo Mateos, MD
President, International Psychogeriatric Association; Professor of Psychiatry, Coordinator of the Psychogeriatric Unit; University of Santiago de Compostela, Spain
CC: Members, IPA Board of Directors
- Mary Sano, Director, ADRC Professor, Department of Psychiatry, Mount Sinai School of Medicine, United States
- Huali Wang, Associate Professor, Institute of Mental Health, Peking University; P.R. China
- Kate Zhong, Chief Strategy Office, Global Alzheimer's Platform Foundation, United States
- Henry Brodaty, Director and Professor, Academic Department for Old Age Psychiatry, University of New South Wales, Australia
- Daisy Acosta, 10/66 Dementia Research Group, Dominican Republic
- David Conn, Vice President of Education, Baycrest Centre for Geriatric Care, Canada
- Brian Draper, Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Australia
- Manabu Ikeda, Kumamoto University, Japan
- Raymond T. Koopmans, Professor of Elderly Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
- Wendy Moyle, Professor and Program Director, Griffith University, Australia