The purpose of this article was to examine the application of the International Classification of Functioning, Disability, and Health (ICF) in the field of psychiatry in ...
Authors: Ana Sabela A´lvarez, MSc, MA, BSc (Hons)
MURINET
Affiliations: From the Department of Neurology, Public Health and Disability Unit, Scientific Directorate, Neurological Institute Carlo Besta IRCCS Foundation, Milan, Italy, and Department of Psychiatry and Psychotherapy II, Ulm University, Gu¨nzburg, Germany.
Correspondence: All correspondence and requests for reprints should be addressed to: Ana Sabela A´lvarez, MSc, Neurology, Public Health and Disability Unit, Scientific Directorate, Neurological Institute Carlo Besta, Via Celoria 11, Milan 20131, Italy.
Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. Supported by MURINET, European Commission project within the Sixth Framework Programme for the period 2007Y2010 (number: MRTN-CT-2006-035794). 0894-9115/12/9102(Suppl)-0S69/0 American Journal of Physical Medicine & Rehabilitation Copyright * 2011 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0b013e31823d4f1c
REVIEW & ANALYSIS
The Application of the International Classification of Functioning, Disability, and Health in Psychiatry Possible Reasons for the Lack of Implementation ABSTRACT A´lvarez, AS: The application of the International Classification of Functioning, Disability, and Health in psychiatry: possible reasons for the lack of implementation. Am J Phys Med Rehabil 2012;91(suppl):S69YS73. The purpose of this article was to examine the application of the International Classification of Functioning, Disability, and Health (ICF) in the field of psychiatry in the last 10 yrs since the ICF was launched. The hypothesis is that the application of the ICF in the field of psychiatry has not been yet much explored. Therefore, the objective of this article was to provide reasons to explain the difficult implementation of the ICF in this field, which in turn, might account for the lack of studies. A literature search was conducted using the terms ICF AND mental illness OR mental disorders OR psychiatry in titles, abstracts, and key words of articles collected in the databases ISI Web of Knowledge, ScienceDirect and Medline from 2001 to 2010. A total of 64 full-length articles were retrieved and reviewed, and among them, 13 were eventually included in this review because they were related to the ICF in psychiatry. Of the 13 studies identified concerning the ICF and mental disorders, 7 focus on the implementation of the ICF in the clinical practice, and 6 are theoretical papers discussing the potential benefits of the ICF for the field of psychiatry. A number of reasons can be suggested to explain the paucity of studies on the use of the ICF in psychiatry in the last 10 yrs: (1) the novelty of the ICF and the dominance of the medical model, (2) the belief that disability is just about physical conditions, (3) the influence of medication on capacity and performance, (4) the complex structure of the ICF, (5) the intrinsic limitations of the ICF, and (6) limitations in the accessibility of the ICF to some medical professionals. Key Words:
Mental Health, Professional Practice, Psychiatry, Interdisciplinary Studies
BACKGROUND AND OBJECTIVES The International Classification of Functioning, Disability and Health (ICF) was published by the World Health Organization (WHO) in 2001.1 The ICF is a model of disability that actually operationalizes biopsychosocial ideas and provides a conceptual framework for understanding disability. At the core of the ICF www.ajpmr.com
Application of the ICF in Psychiatry
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conceptual model is the notion that disability is a multidimensional and universal phenomena placed on a continuum with health. Human functioning is understood as a continuum of health states, and every human being exhibits one or another degree of functioning in each domain, at the body, person, and society levels.2 The ICF does not itself develop instruments to describe and to measure functioning and disability related to health conditions but researchers and clinicians might use the ICF to do so. The ICF was developed as an international language to describe the consequences of health conditions at the individual and societal levels.3
METHODOLOGY FOR THE LITERATURE SEARCH To reach the above objective, a literature search was conducted using the terms ICF AND mental illness OR mental disorders OR psychiatry in the titles, abstracts, and key words of articles collected in the databases ISI Web of Knowledge, ScienceDirect, and Medline from 2001 to 2010. To our knowledge, this is the first literature review of studies that examine the use of the ICF in the study of mental disorders.
RESULTS A total of 64 full-length articles were retrieved and reviewed, and among them, 13 were eventually included in this review because they were related to the ICF in psychiatry. Of the 13 studies identified concerning the ICF and mental disorders, 7 focus on the implementation of the ICF in the clinical practice,4Y10 and 6 are theoretical papers discussing the potential benefits of the ICF for the field of psychiatry.11Y16 The literature shows that mental disorders are associated with high rates of disability.17 Among those psychiatric diagnoses that are considered Bsevere and persistent[ and cited as contributing to disability are schizophrenia and schizoaffective disorder. Bipolar disorders, major depression, some anxiety disorders, and borderline personality disorder also are often associated with severity and high treatment costs.12 Episodic and unpredictable fluctuations in symptoms of these psychiatric disorders contribute to variability in functioning. The seven studies applying the ICF in psychiatry4Y10 specifically show the areas of activity and participation that these disorders affect most acutely. These studies can be classified in the following categories according to the specific disorders explored: attention-deficit hyperactivity disorder,
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anxiety, depression, bipolar disorders, and schizophrenia. The contexts in which functioning and disability were mostly studied were recreational activities, everyday life activities, work-related attitudes, and sick leave. Tenorio-Martinez et al.8 shows that the level of incapacity experienced by patients with schizophrenia can be appreciated in a clinical situation as being more serious than the situation of patients with anxiety and depression. Daremo and Haglund6 illustrate how patients in psychiatric institutional care perceive and conceive their opportunities to be actively involved in their own treatment. This study points out the distinction between the factors that patients perceive as important for their good care and the environmental factors that allow the patients to participate in their care. In a similar study4 related to mental disorders, the ICF is used as a point of reference for the identification of the concepts contained in the assessment of the outcome of clinical trials on depressive disorders.
DISCUSSION The potential benefits of the ICF in the field of psychiatry have been already described in several studies,11Y16 but few of them actually implement the ICF in clinical practice. Here, the possible reasons why the ICF has been little implemented in real practice are examined. A number of reasons can be suggested to explain the paucity of studies on the use of the ICF in psychiatry in the last 10 yrs. 1. The novelty of the ICF and the dominance of the medical model. The current application of the ICF is still limited because the WHO endorsement is very recent; consequently, the earliest references using the ICF date back to 2001.1 The ICF was officially endorsed by all 191 WHO member states in the Fifty-Fourth World Health Assemby on 22 May 2001 (resolution WHA 54.21).18 In addition to the novelty of the ICF, a second problem arises from the prevailing medical model over the ICF biopsychosocial model of health and disability, which takes into consideration the biologic, social, and psychologic dimensions within the individual. As Reed et al.11 points out, in most parts of the world is, unfortunately, still a common belief that serious mental illness is incurable and that any care beyond simple custody is a waste of resources, so any form of treatment beyond the medical model might be more difficult to be implemented. In line with this position, political and economic policies are also hindering the application of the ICF in psychiatry because it involves higher costs for the public
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health system than the application of the medical model. 2. The belief that disability is just about physical conditions. Even if it is known that mental disorders are one of the major causes for disability,11,16 it remains a misconception that disability refers mainly to physical conditions because of the visibility of these last ones. The overall burden of nonfatal disabling conditions is dominated by a relatively short list of causes, particularly a number of neuropsychiatric conditions and sense organ disorders.19 Kennedy13 states that the concept of disability has been long associated with physical impairments rather than mental conditions. 3. The influence of medication on capacity and performance. The assessment of severe mental illness is also affected by the effects of some pharmacologic treatment. In this respect, it could be difficult for the ICF to discriminate in a person the real capacity from the real performance because the medication that a patient takes might be influencing his capacity and performance. So far, there are not enough data available to assess the improvement of psychosocial functioning with antipsychotic medication.20 4. The complex structure of the ICF. Because of its complex structure and the difficulties in applying the ICF as a whole in clinical settings, the ICF might not be the most suitable tool to describe the functioning and disability of psychiatric patients. For this reason, Baron and Linden16 developed the BMini-ICF for mental disorders,[ a short practical instrument workable in psychiatry. The main focus of the Mini-ICF20 is on the limitations resulting from psychopathology in assessing the abilities of a person to fulfill his or her roles and functions. The idea behind the elaboration of the Mini-ICF is to develop a short list of ICF categories that contains the most frequent and relevant aspects of functions that are consistent with mental disorders. By using the Mini-ICF, it is possible to assess and quantify the ability disorders of people with mental disorders independently from psychopathology.20 Other specific measures of functioning and disability in mental disorders have been developed.21 5. Intrinsic limitations of the ICF. The ICF presents the following limitations that affect its implementation in clinical practice: (1) the lack of definition and development of the domain BPersonal Factors.[ In the field of mental health, personal factors such as coping strategies or skills, and personality traits, are the goal of most psychosocial interventions. (2) Although the ICF is based on a www.ajpmr.com
modern concept of disability, that is, its Universality Principle, the ICF is still focused on a deficit model. Nowadays, concepts such as Brecovery[ from mental illness have captured the attention of most researchers and clinicians, as they involved elements beyond symptoms and functioning, and it entails a more optimistic view of the mental illness, its treatment, and its outcomes. Even more, the understanding and promotion of human strengths is having an impact on clinicians and researchers. This perspective, which assumes the strengths and positive values of people with mental illness, is poorly included in the ICF. (3) A universal model of capacity is needed in the field of mental illness. As far as the ICF does not explicitly develop a universal taxonomy of capacities, it would be difficult to implement the ICF model as the framework for classifying Babilities[ and Bdisabilities.[ (4) The domain BParticipation in society[ is a key element in assessing mental health problems and designing individuals’ plans of treatment (e.g., community approach for treating schizophrenia), and it is also related to concepts such as social or public stigma, and self-stigma. (5) From a methodologic perspective, useful and flexible instruments to capture both Bdisabilities[ and Bcapabilities[ are needed. The ICF-related instruments seem to have difficulties in capturing relevant domains for the understanding of mental disorders such as personal factors, contextual barriers, or strengths. 6. Accessibility. The ICF might be an instrument currently more accessible to medical doctors than other mental health practitioners and allied professionals, such as psychologists and social workers, given that the ICF is based on the biopsychosocial ideas, which in turn, were born as a reaction to the dominant medical model and is also taught in the medical undergraduate programs. However, nonmedical doctors might be more prone to the use of the ICF because it includes biopsychosocial ideas focused on the context of the individual and the social enviroment, whereas medical doctors could be still a bit more reluctant to its entire application because of their medical training being more focused on biology and pharmacology, and therefore, their bias to overlook the personal and social aspects of the individual. The perspective that each professional has regarding the etiology of mental disorders guides in turn his clinical practice, and consequently, the instruments and treatments that they will apply to it. The following limitations regarding this literature review should be acknowledged. This is not a systematic literature review about the application Application of the ICF in Psychiatry
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of the ICF into the field of psychiatry. First, a review on the ICF for each type of mental disorder was not performed but for all mental disorders in general; a review of each one of the mental disorders should be done in further studies because it could provide specific patterns on functioning and disability depending on each specific disorder. Second, not all the databases were searched. Third, the review included publications written only in English language, and there are related publications written in other languages, such as German and Japanese, that were not reviewed. Last, the focus of this article is on studies carried out in adult population, whereas there are also studies regarding the clinical application of the ICF in childhood disability.22
are members of the so-called family of WHO classifications.16 Further research could support this conclusion. Further research can be recommended to widen the spectrum of the present review and to examine the ICF for each single disorder, both in children and adults, and the contributions retrievable from databases not included in the present work and from contributions published in languages other than English. The ICF could be a valuable tool in identifying specific patterns of functioning and disability according to the different disorders. This article adds the relevant contribution to the debate in the field of the application of the ICF in psychiatry because it indicates the solution how to make the ICF really useful in psychiatric settings, that is, using the ICD and ICF jointly.
CONCLUSIONS This literature review shows that in the 10 yrs the ICF was published by the WHO in 2001,1 13 studies have been found in relation to mental disorders. The potential benefits of the ICF in psychiatry has been described in several studies11Y16; the paucity of studies that implement the ICF in these settings and the number of possible reasons outlined make it difficult to explain whether the ICF can really be useful in psychiatric settings. This article consistently and clearly provides the reasons why the implementation of the ICF in the field of psychiatry is difficult: the novelty of the ICF and the dominance of the medical model, which involves lower costs for the public health system than does the application of the biopsychosocial one; the assumption that disability is about physical conditions, the nature of mental illness itself, the influence of medication on capacity and performance, the complex structure of the ICF and difficulties in accessibility for mental health practitioners and allied health professionals. One possible solution to this issue would be the one suggested by Kostanjsek et al.,3 which consist of the joint use of the International Statistical Classification of Diseases (ICD) 10 and the ICF. Therefore, the integration of the ICF into the ICD-11 could become the gateway for the actual implementation of the ICF in different clinical settings, including psychiatry. Kostanjsek et al.3 suggests the joint use of the ICD and the ICF through the list of functioning properties, which are in course of development for the new ICD-11, as it captures the valuable synergy of the two classifications. The ICD-10 chapter 5 (BMental and Behavioral Disorders[)23 is one of the major classifications that are used in the diagnosis of mental disorders. The ICF and the ICD
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ACKNOWLEDGMENTS
I thank Dr. Pavel Ptyushkin (Department of Health Sciences and Health Policy, University of Lucerne, Switzerland, and the Switzerland Swiss Paraplegic Research, Nottwil, Switzerland) for his time in revising this manuscript and providing useful comments. This article would have not been possible without all of his valuable contributions. REFERENCES 1. World Health Organization: International Classification of Functioning, Disability and Health (ICF). Geneva, Switzerland, World Health Organization, 2001 2. Kostanjsek N: Use of the International Classification of Functioning, Disability and Health (ICF) as a conceptual framework and common language for disability statistics and health information systems. BMC Public Health 2011;11:S3 3. Kostanjsek N, Rubinelli S, Escorpizo R, et al: Assessing the impact of health conditions using the ICF. Disabil Rehabil 2011;33:1475Y82 4. Brockow T, Wohlfahrt K, Hillert A, et al: Identifying the concepts contained in outcome measures of clinical trials on depressive disorders using the ICF as a reference. J Rehabil Med 2004;44:49Y55 5. Nieto-Moreno M, Gimeno Blanco P, Ada´n J, et al: Applicability of the ICF in measuring functioning and disability in unipolar depression in primary care settings. Actas Esp Psiquiatr 2006;34:393Y6 6. Daremo A, Haglund L: Activity and participation in psychiatric institutional care. Scand J Occup Ther 2008;15:131Y42 7. Sanderson K: Mental health in the workplace: Using the ICF to model the prospective associations between symptoms, activities, participation and environmental factors. Disabil Rehabil 2008;30:1289Y97
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Application of the ICF in Psychiatry
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