Clinical complexity and person‐centered integrative diagnosis

Clinical complexity is emerging as a pointed indicator of the conceptual and empirical richness of psychiatry and general medicine and of the intricate challenges faced by our field. This complexity needs to be appraised, understood and formulated in attention to its various aspects and levels in order to inform adequately the development of crucial clinical tools such as an effective diagnostic model. A broad model relevant to this concern is being outlined under the term of person-centered integrative diagnosis (PID) 1,2. Clinical complexity is a protean term encompassing multiple levels and domains. Illustratively, a prominent concern in health care involves multiplicity of disorders and conditions experienced by a person along with their cross-sectional and longitudinal contexts. Also relevant are the diversity of severity levels and courses of clinical conditions. Financial-related complexity includes case-mix definitions and their implications for reimbursement. Further noteworthy are the plurality of values of people experiencing health problems and seeking help for them 3. A major form of clinical complexity is comorbidity, which is widely recognized as a common feature of regular clinical care. While recognizing the spurious use that has been made sometimes of this term, as when two facets of the same condition have been taken as separate disorders, there are many situations where clearly different clinical conditions, such as circulatory problems and depression, are identified as requiring specific attention. The need to systematically address comorbidity in general medicine was highlighted by Feinstein 4, who is credited with coining this term. He defined it as “any distinct additional clinical entity that has existed or that may occur during the clinical course of a patient who has the index disease under study”. The broadness of “additional clinical entities” under his concept of comorbidity reached physiological conditions requiring clinical attention such as pregnancy. Comorbidity can be noted among conditions in the same chapter of the International Classification of Diseases (ICD), such as that on mental disorders. It can be noted as well among conditions in different ICD chapters. It can be argued that comorbidity can also apply to the concurrence of disorders and social conditions of clinical significance, such as trauma and child abuse. The intricacy of comorbidity may also be extended to the involvement of multiple sectors such as mental disorders, general medical disorders, and clinically relevant social conditions, a situation that has been referred to as hypercomorbidity by the Workgroup on Comorbidity of the World Health Organization (WHO) 5. The US National Comorbidity Survey 6 revealed that 79% of all ill people had comorbid disorders, and that over half of the lifetime disorders identified were concentrated in 14% of the population studied. Comorbidity is particularly common in the elderly, and with worldwide advancing of population age it is becoming a major global health concern. Comorbidity is associated with serious implications for clinical care, due to its impact on both diagnosis and treatment. Comorbidity may interfere with the identification of the index disease by creating significant difficulty in symptom attribution, leading to delay or incorrect nosological diagnosis. The course of the index disorder may be adversely affected by comorbid conditions, leading to increased disability and mortality as well as to higher family and societal burden and suffering. Comorbidity may also lead to limitations in treatment planning, implementation and outcome. Conventional health care paradigms focusing just on disease and immediate care are often regarded as inadequate. This is particularly true when comorbid conditions are noted. The WHO Comorbidity Workgroup concluded that person-centered care offers the most promising approach when comorbid conditions are involved, by facilitating coordination and integration of services. A person-centered approach would also facilitate attention to the positive aspects of health, such as resilience, resources, and quality of life. This is important for clinical treatment, prevention, rehabilitation and health promotion. The need for person-centered care in response to clinical complexity (from comorbidity to patient values) and other developments in the health field has been recently addressed by the WPA through an Institutional Program on Psychiatry for the Person (IPPP) 7,8. The program is aimed at promoting a psychiatry of the person, for the person, by the person, and with the person. One of its components involves clinical diagnosis, dedicated to collaborating with WHO in the development of ICD-11 and to the design of PID 1. To be noted as background of these developments is WPA's extensive record on classification and diagnosis. An illustrative contribution is the International Guidelines for Diagnostic Assessment (IGDA) 9). The record also encompasses long-standing collaboration with the WHO, which has been displayed through a number of major conferences and congresses and the publication of two monographs in Psychopathology 10,11. Collaboration has also taken place with national and regional psychiatric associations, such as the American Psychiatric Association 12, the Chinese Psychiatric Society (CCMD-3) 13, the Cuban Psychiatric Society (GC-3) 14, the French Psychiatric Federation, and the Latin American Psychiatric Association (GLADP) 15. The construction of the PID theoretical model has been carried out by the IPPP workgroup through a number of meetings in 2006 and 2007, most recently a major conference in London co-organized by the UK Department of Health. Emerging features of the PID model include its being a diagnosis of health (of both illness and positive aspects of health), involving collaborative and empowering engagement of patients, and serving as informational basis for prevention, treatment, rehabilitation, and health promotion. Strategically, the PID model has a bio-psycho-socio-cultural framework, articulates science and humanism, utilizes all pertinent descriptive tools (categories, dimensions, and narratives) in a multilevel structure, and engages clinicians, patients and families in a diagnostic partnership. Building on the above mentioned PID model, a PID guide or manual will be developed with the following phases: preparation of the first draft of the PID guide (during 2008), evaluation (reliability, validity and feasibility) of the draft (2009), completion and publication of the PID guide (2010), and its translation, implementation and training (2011 and following years). Clinical complexity denotes the richness of our field and represents a pointed challenge to our professional responsibilities. WPA is responding to it through the IPPP and the PID model and guide, in collaboration with all its institutional components, including the Global Network of National Classification and Diagnosis Groups, and growing links with major international medical and health organizations.