By Jeannine Mjoseth
Monitor staff

APA is helping the World Health Organization (WHO) revise its international diagnostic system that recognizes the importance of treating a disease?s emotional, social and occupational consequences.

The International Classification of Impairments, Activities and Participation (ICIDH) aims to capture the ways in which diseases, injuries or disorders affect individuals? functions and provide a systematic way of communicating these impacts. For example, the ICIDH (the acronym applies to the system?s former name) can distinguish between two people with cardiovascular disease who have markedly different behavioral disabilities, such as one who is unable to perform domestic chores and the other who has a language impairment. WHO released a trial version of the document in 1980 and began revisions in 1994 after some problems were identified in the original version. The final revision, known as the ICIDH-2, will be completed in 2000.

The ICIDH has the potential to offer a much richer framework for psychological interventions and research than do existing classification systems, APA officials say. ICIDH is a functionally based classification system, in direct contrast to the traditional medical model that focuses exclusively on the disease agent, says Russ Newman, PhD, JD, APA?s executive director for practice. Many psychologists find that psychiatric diagnoses, such as those in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV), fail to fully capture the problems that bring patients to treatment.

ICIDH is designed to mesh with the International Classification of Diseases (ICD), the dominant diagnostic system that also classifies mental health and behavioral disorders. Representatives of 14 countries who serve on the ICIDH Committee of Experts also have helped revise the ICIDH.

ICIDH-2?s success depends largely on its acceptance by governments and third-party payers, which now are experimenting with the classification system, explains Stanley Berent, PhD, chairman of APA?s ICIDH-2 working group, which reports to the APA?s Committee for the Advancement of Professional Practice (CAPP).

Psychologists? contributions

WHO and the National Institute of Mental Health have encouraged psychologists? participation in the ICIDH-2 process to develop valid and reliable behavioral classifications, produce appropriate names for such classifications and establish links to effective behavioral interventions.

In the last 18 months, APA has contributed a psychological perspective to the ICIDH-2 revision. For example, APA suggested that the guidelines include psychometric tools such as those measuring intelligence or anxiety. Psychologists? involvement in the revision is expected to yield an instrument capable of distinguishing among mental health disabilities with greater reliability, says a CAPP report.

APA?s involvement in ICIDH-2 is extremely important because of the increasing awareness of the interactions between behavior and changes in health status, says Berent. He spent a week at WHO headquarters in Geneva last spring working directly on the ICIDH document, and says that APA?s work on the revision increases the likelihood that psychologists? role will be recognized, documented and institutionalized in and by the ICIDH-2.

The guidelines also must be practical in the field because ?at some point, a third-party payer is going to tell a psychologist to assign an ICIDH-2 code to receive reimbursement,? says Berent. ?If the ICIDH-2 codes don?t fit the psychologist?s treatment, it?ll be difficult to adjust the codes once the revision process is complete.?

Once revised, ICIDH-2 may help clinicians provide a more sensitive assessment of individuals? problems and permit a more comprehensive evaluation of their treatment, the ICIDH-2 draft document says. It also might permit researchers to document use of services, hospitalization and discharge plans and evaluate outcomes, allowing them to assess the effectiveness of interventions, develop health-care policies and determine community needs.

In addition to psychologists, ICIDH-2 can be used by those working on social security, insurance, education, labor and legislative issues to produce statistics on disease, track epidemiological trends and make projections for services. By providing functional descriptions, quantifiable data and numerical coding regardless of the language of origin, ICIDH-2 can permit comparison of data across countries, health-care disciplines and services to better describe and respond to the needs of people with disabilities.

ICIDH-2?s shortcomings

The ICIDH-2 draft has some shortcomings, Berent says. To create a system that will be useful all over the world, ICIDH-2 authors sometimes have overlooked characteristics that are unique to a single culture. For example, the usual socioeconomic distinctions found in the section on economic self-sufficiency sometimes cannot be used because the lowest level in one country may be relatively high in another.

There are other problems that might be fixed during the revision period: Operational definitions focusing on how an individual?s functions are affected by mental or emotional disorders are scarce or nonexistent; there is little or no identification of tools or methods of functional assessment and there are few empirically verified methods to measure individual satisfaction, emotional response or quality of life, Berent says. In addition, there are few identified links between psychological treatments and subsequent changes in a person?s ability to function.

Definitions need to be standardized and other weaknesses need to be addressed so ICIDH-2 classifications and code numbers mean the same thing from country to country, Berent says. WHO is writing a companion text to ICIDH-2 of standard operational definitions, he says.

APA has discussed the possibility of developing its own classification system as an alternative to DSM-IV. Many APA officials believed a system that emphasizes psychological and behavioral functioning rather than diagnoses would be more helpful to association members.

But the practical and financial obstacles in developing an alternative classification system made such a project seem unrealistic, Newman says.

?Through our involvement with ICIDH, psychology may be able to accomplish most of what we would have gained by developing our own classification system,? he says. ?And we?ll have a much higher likelihood of acceptance in the current health-care system.?