Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021EditorialA5A6TRKorayBAŞAR127010.5080/u27029

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021The Mental Health of Healthcare Professionals During the COVID-19 PandemicCovid-19 Pandemisinde Sağlık Çalışanlarının Ruh Sağlığı22523410.5080/u25827ENTRMesutIŞIKUmutKIRLIPınar GüzelÖZDEMİR127110.5080/u25827Objective: The aim of this study is to investigate the anxiety, depression, insomnia and post traumatic stress disorder (PTSD) symptoms and the assocaited sociodemographic, clinical and professional factors during the COVID-19 pandemic in healthhcare workers. Method: A total of 509 participants joined an online survey to complete the data acquisition tools consisting of a Sociodemographic and Clinical Questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Insomnia Severity Index (ISI) and the Post Traumatic Stress Disorder- Short Scale (PTSD-SS). Results: The 509 participants of the study consisted of physicians (69.2%) and nurses (30.8%). On the basis of the scores above the cut-off points of the pscyhometric scales used, the mental symptoms of the participants were ranked as 54.2% on depression, 26.3% on anxiety, 20.8% on insomnia and 8.8% on PTSD. The corresponding scores of the 20-30 year old, the female and the nursing participants were significantly higher as compared to the others (p<0.001, for all). Significant differences were not found in these scores with respect to working or not working directly with COVID-19 patients, or having a family member with or without COVID-19 infection (p>0.05). Having a history of suspected COVID-19 infection was significantly associated with insomnia (p=0.026 and PTSD (p=0.008). Also, the anxiety and PTSD scores of the participants with a history of mental disorder diagnosis were significantly higher in comparison to the others (p<0.001). Conclusion: The results indicated that females, nurses, participants in the 20-30 year age group and with a history of mental disorder diagnosis were in the high risk group for impaired mental health, irrespective of their professional positions. Close monitoring and early intervention are essential for these high-risk individuals.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021The Relationship between Alcohol-Cannabis Use and Stressful Events with the Development of Incident Clinical Psychosis in a Community-Based Prospective CohortToplum Tabanlı Bir Örneklemin İleriye Dönük İzleminde, Alkol- Esrar Kullanımının ve Stresli Yaşam Olaylarının Klinik Psikoz Gelişimi ile İlişkisi23524510.5080/u26410ENTRUmutKIRLITolgaBİNBAYKöksalALPTEKİNBülentKAYAHANHayriyeELBİ127210.5080/u26410Objective: The aim of this study is to evaluate the associations between alcohol-cannabis use and forensic/stressful events with the risk of incident clinical psychosis during follow-up. Method: A community-based sample (n: 2142) was screened for clinical psychosis (schizophrenia and other psychotic disorders, affective disorders with psychotic features) at baseline and follow-up. Thus, incident clinical psychosis cases to develop during follow-up (individuals with no clinical psychosis at the baseline assessment and with clinical psychosis at the follow-up assessment) were detected (n: 27). These cases and the controls who did not report any psychotic symptoms at the follow-up assessment (n: 1691) were compared for exposure to environmental risk factors during follow-up (total n: 1718). Results: Individuals reporting heavy alcohol drinking or cannabis use during follow-up had significantly higher risk of incident clinical psychosis. The monthly frequency of drinking and cannabis use was also associated with the risk. Higher number of stressful life events exposed predicted higher risk of incident clinical psychosis. The risk of incident clinical psychosis was significantly higher in case of coexistence of two risk factors (heavy drinking, cannabis use, ≥3 stressful events), in comparison with the existence of a single risk factor (17.7 vs. 1.6%, p<0.001). Conclusion: Heavy drinking, cannabis use, forensic events and stressful events were associated with the risk of incident clinical psychosis. The coexistence of multiple stressful events and disorders related to abuse of alcohol/cannabis should be considered as a warning for the development of clinical psychosis.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021Clinical Characteristics, Comorbid Medical Diagnoses, and Causes of Death of Individuals with Severe Mental Illness Who Died During Follow-up in Community Mental Health Centers: A Multicenter, Retrospective StudyToplum Ruh Sağlığı Merkezlerinde Takipleri Sırasında Ölen Şiddetli Ruhsal Hastalığı Olan Bireylerin Klinik Özellikleri, Ek Tıbbi Tanıları ve Ölüm Nedenleri: Çok Merkezli, Geriye Dönük Bir Araştırma24625210.5080/u25685ENTRDursun HakanDELİBAŞMemduhaAYDINTülaySATI-KIRKANElif GülşahOĞUZUmutKARASUYaseminŞİMŞEKCananKILIÇSedaKIRCI-ERCANAdemBAYRAKÇIAnılTALAS-ÖZÇİMENSüleymanGÜNDÜZArdaYEŞİLMustafaYILDIZ127310.5080/u25685Objective: In this study, it was aimed to define the clinical characteristics, causes of death, disease and treatment of patients who died while being followed for severe mental illness. Method: The study was carried out in ten community mental health centers from six provinces. The clinical characteristics, causes of death, course of the illness and treatment characteristics of the patients who had a death report from the date the community mental health centers were opened until the start date of the study were analyzed by retrospective file scanning method. Results: In an average of 52 months, files of 3715 patients were examined. There were death declarations for 106 patients. The diagnosis of most patients with death declarations was schizophrenia (78%), most of them were male (66%), mean age was 57, mean disease duration was 24 years. The rate of multiple antipsychotic medication use was 61%. The most common comorbidities were metabolic syndrome (36%), hypertension (22%), diabetes (18%) and chronic obstructive pulmonary disease (15%). The most frequently reported causes of death were cardiovascular diseases (39%), infectious diseases (14%) and cancer (11%). Conclusion: Individuals with severe mental illness followed up in community mental health centers are mostly die due to preventable natural causes of death. Therefore, a sensitive approach should be taken to evaluate psychiatric and other medical conditions together. In our country, there is a need for natural follow-up studies investigating the average age of death and causes of death of individuals with severe mental illness.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021The Relationship Between Peritraumatic Dissociation and Anxiety Level, Perceived Stress, Anxiety Sensitivity and Coping with Earthquake Stress in Post-Earthquake Acute Stress Disorder PatientsDeprem Sonrası Akut Stres Bozukluğu Olanlarda Travma Esnasındaki Çözülmenin, Anksiyete Düzeyi, Algılanan Stres, Anksiyete Duyarlılığı ve Deprem Stresiyle Baş Etme ile İlişkisi25326010.5080/u25892ENTRKerimUĞURFatmaKARTALBurakMETELutTAMAMMehmet EminDEMİRKOL127410.5080/u25892Objective: The present study aims to determine the effects of anxiety sensitivity, anxiety level, perceived stress and coping strategies on peritraumatic dissociation in post-earthquake acute stress disorder (ASD) patients. Method: Sociodemographic data form, Beck Anxiety Index (BAI), Perceived Stress Scale (PSS), Anxiety Sensitivity Index-3 (ASI-3), Coping with Earthquake Stress Scale, and Peritraumatic Dissociation Scale (PDEQ) were applied to 477 patients diagnosed with ASD. Results: Anxiety sensitivity cognitive sub-dimension explained 31.5%, anxiety explained 7%, and perceived stress explained 1% of the variation in peritraumatic dissolution development. A moderate positive correlation was determined between peritraumatic dissolution and anxiety, a weak positive correlation was found between peritraumatic dissolution and perceived stress, a weak positive correlation was determined between peritraumatic dissolution and positive thinking, and a very weak negative correlation was determined between peritraumatic dissolution and seeking social support. A moderate positive correlation was determined between peritraumatic dissolution and physical, cognitive and social sub-dimensions of anxiety sensitivity. Conclusion: The most important finding in the study was the fact that the highest contribution to the development of peritraumatic dissolution was by the cognitive sub-dimension of anxiety sensitivity. It could be suggested that individuals with high anxiety sensitivity may experience higher peritraumatic dissolution and these individuals could have a higher risk of PTSD later on.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021Validity and Reliability of the Turkish Version of the Weiss Functional Impairment Rating Scale- Self Report Form (WFIRSS- TR)Weiss İşlevsellikte Bozulma Ölçeği-Özbildirim Formu Türkçe Güvenilirliği ve Geçerliliği26126610.5080/u25086ENTRŞerminYALIN-SAPMAZDilekERGİNNesrinŞEN-CELASİNÖznurBİLAÇMasumÖZTÜRKDuyguKARAARSLANMahmut CemTARAKÇIOĞLUÖmerAYDEMİR127510.5080/u25086Objective: The aim of this study was to demonstrate the validity and reliability of the WFIRS-S-TR, Turkish version of the Weiss Functional Impairment Rating Scale-Self Report form. Method: The study comprised two groups of participants of 15-18 years of age, one consisting of 35 children diagnosed with attention deficit and hyperativity disorder (ADHD) based on the DSM-IV criteria and the other, 510 healthy volunteers attending high school. Apart from the WFIRS-S-TR, the Health Questionnaire for Children and Adolescents (KIDSCREEN-10 Index) which is a general quality of life and functionality measurement instrument, was used to check the concurrent validity of the WFIRS-S-TR. Results: The Cronbach’s alpha coefficient for the total scale was 0.939. The test-retest reliability assessed by repeated measurements two weeks apart gave a high correlation between the results (r=0.804, p<0.0001). Total mean score of the WFIRS-S-TR showed significant correlation with the KIDSCREEN-10 Index total mean score (r= -0.467, p<0.0001). Confirmatory factor analysis was carried out for the construct validity of the WFIRS-S-TR. The RMSEA and the CFI values were found to be 0.065 and 0.68, respectively. Conclusion: The WFIRS-S-TR can be used as a valid and reliable tool both in clinical practice and for research purposes.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021Adaptation and the Psychometric Properties of Turkish version of the Structured Clinical Interview for the DSM-5-Personality Disorders - Clinician Version (SCID-5-PD/CV)DSM-5 Kişilik Bozuklukları için Yapılandırılmış Klinik Görüşme (SCID-5-PD)’nin Türkçeye Uyarlanması ve Psikometrik Özellikleri26727410.5080/u25484ENTRSerkanBAYADÖzgeALP-TOPBAŞTuğbaKOCABAŞMügeELBİRDenizGÖKTEN-ULUSOYUlaşKORKMAZOğuzhanARAZAyşeERGÜNER-ARALAytülKARABEKİROĞLUÖmerAYDEMİR127610.5080/u25484Objective: The aim of this study is to demonstrate the validity and reliability of the Categorical and Dimensional Psychometric Properties of the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) after its translation to the Turkish. Method: The study was carried out with 102 volunteers from two university hospitals. The SCID interview was conducted by two experienced psychiatrists who interchanged positions as interviewer and observer; and completed the research forms without discussing the patient. The diagnostic agreement between the interviewers and the Kappa coefficient were calculated. Divergent and convergent validity analyses were carried out for diagnostic validity and the scores obtained from the self-report form as well as the dimensional evaluation scores were used in the statistical analyses. Results: The group mean age for volunteers was 39.6±11.6 years and 66.7% consisted of females. The Kappa values for personality categories were 0.79 for avoidant personality structure, 0.64 for dependent personality structure, 0.81 for obsessive-compulsive personality structure, 0.76 for paranoid personality structure, 0.49 for schizotypal personality structure, 0.90 for histrionic personality structure, 0.66 for narcissistic personality structure, 0.89 for borderline personality structure and 0.71 for antisocial personality structure. Dimensional evaluation showed significant correlation with the diagnostic agreement between the interviewers and also with the scores of the self-report forms completed by the participants. Conclusion: The results demosntrated that the Turkish version of the Structured Clinical Interview for DSM-5 Personality Disorders (SCID- 5-PD-CV-TR) is valid and reliable.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021Role of the Telemental Health Services During the COVID-19 Pandemic: A Systematic ReviewCOVID-19 Pandemisi Sırasında Tele-Psikiyatri Hizmetlerinin Rolü Hakkında Sistematik Derleme27528210.5080/u26021ENTRNaureen AKBERALIAdeelKHOJAFizzahKAZIM127710.5080/u26021Objective:: The COVID-19 pandemic has directed the use of telemedicine and digital mental health services to meet the needs of people in order to maintain physical distancing by preventing person to person contact. The aim of this review is to highlight the role of telemental health services during the COVID-19 pandemic. Method: An electronic search was carried out between January 01, 2020 and October 31, 2020 to explore the utilization of telehealth services for mental health problems among adults during the COVID-19 pandemic. The primary source of literature was the structured search of major electronic databases from the MEDLINE (PubMed), CINAHL Plus, Science Direct and the Web of Science. We included nine published studies meeting the the eligibility criteria. Results: The role of telehealth identified in this review mainly focused on the applicability of this modality for assessing and managing various mental health problems in these unprecedented times. It also pointed out that the provision of telemental health support reduced the burden of mental health diseases and promoted the wellbeing of the individual. Further, it was witnessed that patients preferred remote consultation as compared to face-to-face visits in order to avoid contracting the virus and found online mental health interventions and psychological counseling very helpful to cope up with the current crisis. Conclusion: The current COVID-19 lockdown has changed the management of the mental health problems of patients. The use of this innovative modality prevents transmission of infection and provides timely treatment to the community members most in need.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021Double-Edged Sword: A Case with Withdrawal-Emergent Dyskinesiaİki Ucu Keskin Bıçak: Nöroleptik Kesilmesiyle Gelişen Diskinezi Olgusu28328510.5080/u25613ENTRHidayet EceARAT-ÇELİKBurcuKÖK-KENDİRLİOĞLUBuğraÇETİNSuatKÜÇÜKGÖNCÜ127810.5080/u25613Tardive dyskinesia is defined as involuntary athetoid or choreiform movements that develop due to the use of neuroleptic drugs for at least a few months. Tongue, lower face, jaw, upper and lower extremities are the most affected parts of the body in tardive dyskinesia. Quality of life is negatively affected because of the low remission rates. Besides tardive dyskinesia, involuntary movements may appear after discontinuation, change or a reduction in the dose of antipsychotic medications, which is called withdrawal-emergent dyskinesia (WED). Unlike tardive dyskinesia, the involuntary movements involve mainly the neck, trunk, and limbs and regress in shorter period of time in WED. A consensus has not yet been reached for the treatment of WED. Restarting the previous antipsychotic agent with slow titration or switching to an atypical antipsychotic with low affinity for dopamine D2 receptors are among the primary options for treatment. As WED is one of the predictors of tardive dyskinesia development, early detection and treatment is believed to have positive effect on the quality of life. In this report, the case of a patient followed up for bipolar disorder type I (BD-I) and started on clozapine for WED after discontinuation of haloperidol on account of adverse effects is discussed. It is necessary for clinicians to consider these types of complications when discontinuing or changing treatment. Further research is needed in order to reach a common approach for the treatment of WED.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021A Case of Chronic Functional Parkinsonism Treated Over 10 Years for the Diagnosis of Juvenile ParkinsonismJuvenil Parkinsonizm Tanısıyla 10 Yılı Aşkın Süre Tedavi Gören Kronik Bir Fonksiyonel Parkinsonizm Olgusu28629010.5080/u25540ENTRNecati SerkutBULUTNeşeYORGUNERGresaÇARKAXHIU-BULUTEmine NeşeTUNCER127910.5080/u25540Functional (psychogenic) movement disorders (FMD) constitute a cluster of heterogeneous diagnoses involving motor symptoms that cannot be explained by organic pathology and are often associated with underlying psychological problems. In psychiatry, patients with FMD are often placed within the scope of somatoform disorders and conversion disorders. Functional Parkinsonism (FP) is a rare form of FMD seen in 1.5% of all patients presenting with symptoms of parkinsonism. Although almost all symptoms of parkinsonism can be present in FP, clinical features such as sudden onset and a nonprogressive course, inconsistent response to pharmacotherapy, and atypical findings in neurological examination are considered as important clues of psychogenic aetiology. Limited data in the literature on FP indicate that the average age of onset is between 37-53 years of age, whereas the average onset age of Idiopathic Parkinson’s Disease (IPD) is around 60; and Juvenile Parkinsonism, a rare condition presenting before the age of 21, is often familial and more closely related to genetic mutations. Here, we present the case of a female patient, who, after the diagnosis of Juvenile Parkinsonism at the age of 17, had been treated with antiparkinsonian medications for about 14 years in the neurology clinic. Even though the age of onset of this case was far earlier than expected for both IPD and FP and the symptoms became chronic despite close monitoring, it is believed that this case is a striking example for the importance of the recognition of FP and early intervention.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021Letter to the Editor: EDUCATIONAL ACTIVITIES RELATED TO THE ICD-11 CHAPTER ON MENTAL DISORDERSEditöre Mektup: ICD-11’İN RUHSAL BOZUKLUKLAR BÖLÜMÜ ÜZERİNE EĞİTİM FAALİYETLERİ29129210.5080/u26898ENTRVincenzoGIALLONARDO128010.5080/u26898Dear Editor, The 11th revision of the International Classification of Diseases and Related Health Problems (ICD-11), including the chapter on mental, behavioural and neurodevelopmental disorders, has been adopted unanimously by the 72nd World Health Assembly in Geneva on May 25, 2019. The endorsement of the new classification will not come into effect until January 1, 2022. Until that date, the Member States of the World Health Organization (WHO) will keep on using the ICD-10 for reporting data. The most significant innovations in the ICD-11 chapter, and the most important differences from the DSM-5, have been detailed elsewhere (Reed et al. 2019). Several issues debated in the process of development of the chapter – including the role of a dimensional component within a system that remains mainly based on categories, and the need for a further clinical characterization of the individual patient, in addition to the diagnosis, in order to guide the formulation of the prognosis and the management plan, have been also covered in the recent literature (Clark et al. 2017, Rebello et al. 2019, Fuss et al. 2019, Gureje et al. 2019, van Os et al. 2019, Fusar-Poli et al. 2019, Forbes et al. 2019, Gaebel et al. 2019, Patel 2019, Kotov et al. 2020, Maj et al. 2020, Sanislow et al. 2020). The training of professionals in the use of the ICD-11 chapter is now ongoing worldwide, under the coordination of a WHO International Advisory Group led by G.M. Reed. Educational courses have been conducted at the 18th and 19th World Congresses of Psychiatry (Mexico City, Mexico, September 27-30, 2018; and Lisbon, Portugal, August 21-24, 2019) (Giallonardo 2019, Pocai 2019, Perris 2020). A more comprehensive online 20-hr training course has been organized by the Naples WHO Collaborating Centre on Research and Training in Mental Health and the European Psychiatric Association from 9 to 30 April, 2021. The course has been coordinated by G.M. Reed and M. Maj, and has covered all the main sections of the ICD-11 chapter on mental disorders. W. Gaebel, M. Cloitre, M. Maj, C.S. Kogan, P. Monteleone, M. Swales, J.B. Saunders and N.A. Fineberg composed the Faculty. The live course has been attended by 120 psychiatrists, selected from almost 500 applicants, representing 78 different countries. A further group of 250 psychiatrists have had access to the course on demand. Two ICD-11 training sessions have been organized by the Psychiatric Association of Turkey within its 24th Clinical Education Symposium, held from 2 to 6 June 2021. One covered psychotic disorders and mood disorders, with the participation of W. Gaebel and M. Maj and the chairmanship of S. Vahip and C. Atbasoglu. The other dealt with trauma-related, fear-related and obsessive-compulsive disorders, with the participation of M. Cloitre and D.J. Stein and the chairmanship of R. Tukel and C. Kilic. Each session had more than 150 participants. An ICD-11 training event has been also organized by the UK Royal College of Psychiatrists from 25 to 26 May 2021. One further educational event is now going to be held by the World Psychiatric Association from 8 to 29 November 2021 (www.wpanet.org). A training course with exclusive access to the members of the WHO Global Clinical Practice Network (https://gcp.network) has been recently set up by the WHO Collaborating Centre on Mental Health at the Columbia University, in collaboration with the WHO Department of Mental Health and Substance Use. The course consists of 15 online training units, each focusing on a different disorder grouping and EDUCATIONAL ACTIVITIES RELATED TO THE ICD-11 CHAPTER ON MENTAL DISORDERS 292 Received: 13.09.2021, Accepted: 15.09.2021, Available Online Date: 30.11.2021 MD., University of Campania L. Vanvitelli, WHO Collaborating Centre for Research and Training in Mental Health, Naples, Italy. Dr. Vincenzo Giallonardo, e-mail: enzogiallo86@gmail.com https://doi.org/10.5080/u26898 taking from one to one and a half hours. Each unit provides a description of the relevant diagnostic grouping and the main innovations with respect to the ICD-10. Knowledge check questions are included to test the outcome of training. Participants have the opportunity to practice by applying diagnostic guidelines to clinical case examples. This training course is going to be available also in Spanish, and additional translations are planned. The WHO Global Clinical Practice Network now includes more than 16.000 clinicians from 159 countries (51% psychiatrists, 30% psychologists; 40% from Europe, 25% from Western Pacific, 24% from the Americas, 5% from Southeast Asia, 3% from Eastern Mediterranean, and 3% from Africa; 63% from high-income countries, 37% from middle- and low-income countries). The Network contributed significantly to the development of the ICD-11 chapter on mental disorders, in particular through its participation in the Internet field trials of the diagnostic system. It is now further serving as a catalyst for scientific and clinical research collaborations. All health professionals working in mental health or primary care are welcome to join the Network. Vincenzo GİALLONARDO REFERENCES Clark L, Cuthbert B, Lewis-Fernández R et al (2017). Three approaches to understanding and classifying mental disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC) Psychol Sci Public Interest 18:72-145. Forbes MK, Wright AGC, Markon KE et al (2019) The network approach to psychopathology: promise versus reality. World Psychiatry 18:272-3. Fusar-Poli P, Solmi M, Brondino N et al (2019) Transdiagnostic psychiatry: a systematic review. World Psychiatry 8:192-207. Fuss J, Lemay K, Stein DJ et al (2019) Public stakeholders’ comments on ICD-11 chapters related to mental and sexual health. World Psychiatry 18:233-5. Giallonardo V (2019) ICD-11 sessions within the 18th World Congress of Psychiatry. World Psychiatry 18:115-6 Gaebel W, Reed GM, Jakob R (2019) Neurocognitive disorders in ICD-11: a new proposal and its outcome. World Psychiatry 18:232-3. Gureje O, Lewis-Fernandez R, Hall BJ et al (2019) Systematic inclusion of culture-related information in ICD-11. World Psychiatry 18:357-8. Kotov R, Jonas KG, Carpenter WT et al (2020) Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): I. Psychosis superspectrum. World Psychiatry 19:151-72. Maj M, Stein DJ, Parker G et al (2020) The clinical characterization of the adult patient with depression aimed at personalization of management. World Psychiatry 19:269-93. Patel V (2019) Reimagining outcomes requires reimagining mental health conditions. World Psychiatry 18:286-7. Perris F (2020) ICD-11 sessions at the 19th World Congress of Psychiatry. World Psychiatry 19:263-4. Pocai B (2019) The ICD-11 has been adopted by the World Health Assembly. World Psychiatry 18:371-2. Rebello TJ, Keeley JW, Kogan CS et al (2019) Anxiety and fear-related disorders in the ICD-11: results from a global case-controlled field study. Arch Med Res 50:490-501. Reed GM, First MB, Kogan CS et al (2019) Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry 18:3-19. Sanislow CA (2020) RDoC at 10: changing the discourse for psychopathology. World Psychiatry 19:311-2. van Os J, Guloksuz S, Vijn TW et al (2019) The evidence-based group-level symptom-reduction model as the organizing principle for mental health care: time for change? World Psychiatry 18:88-96.

Türkiye Sinir ve Ruh Sağlığı DerneğiTurk Psikiyatri Derg1300-21633242021Letter to the Editor: CONVERGENCES AND DIVERGENCES IN THE ICD-11 VS. DSM-5 CLASSIFICATION OF MOOD DISORDERSEditöre Mektup: DUYGUDURUM BOZUKLUKLARININ ICD-11 VE DSM-5 SINIFLANDIRMALARINDA ORTAK NOKTALARI VE FARKLILIKLARI29329510.5080/u26899ENTRArcangelo DICERBO128110.5080/u26899Dear Editor, The chapter on mental, behavioural and neurodevelopmental disorders of the 11th revision of the International Classification of Diseases and Related Health Problems (ICD-11) has been now finalized. Reporting of health statistics by Member States to the World Health Organization (WHO) using the new diagnostic system will begin in 2022. The section on mood disorders of the ICD-11 is overall consistent with the corresponding section of the ICD-10. However, the definitions of a depressive and a manic episode have been slightly changed, making them consistent with the DSM-5 (see below), and an independent category of bipolar II disorder has been introduced. A significant effort has been made by the WHO and the American Psychiatric Association to harmonize the diagnostic systems they produce (the ICD-11 and the DSM-5). Indeed, the organizational framework (“metastructure”) is now the same in the two systems. Nonetheless, several intentional differences between the two classifications remain, or have emerged as a consequence of changes made in the DSM- 5. Here we briefly summarize the convergences and the divergences between the ICD-11 and the DSM-5 regarding the section on mood disorders (see Table 1). A major convergence between the two diagnostic systems regards the minimum number of symptoms required for the diagnosis of major depression (“depressive episode” in the ICD-11). In the ICD-11, contrary to the ICD-10, the threshold for the diagnosis of depression is the same as in the DSM: at least five depressive symptoms. However, the ICD-11 requires at least five symptoms out of a list of ten (instead of nine as in the DSM-5). The additional symptom is “hopelessness”, which has been found to outperform more than half of DSM symptoms in differentiating depressed from non-depressed people (McGlinchey et al. 2006). Table 1. Some Main Differences Between ICD-10, ICD-11 and DSM-5 Concerning the Diagnosis Of Mood Disorders ICD-10 ICD-11 DSM-5 Threshold for diagnosis of depressive episode At least four out of ten symptoms, two of which must be depressed mood, loss of interest and enjoyment, or increased fatigability At least five out of ten symptoms, one of which must be depressed mood or diminished interest or pleasure At least five out of nine symptoms, one of which must be depressed mood or diminished interest or pleasure The threshold for the diagnosis of depression is higher if the person is bereaved Not made explicit Yes No Antidepressant-related mania qualifies as a manic episode No Yes Yes Mixed episode is a separate diagnostic entity Yes Yes No Dysthymia is a separate diagnostic entity Yes Yes No Bipolar II disorder is a separate diagnostic entity No Yes Yes “Qualifiers” (“specifiers”) for the diagnoses of mood disorders are provided No Yes Yes CONVERGENCES AND DIVERGENCES IN THE ICD-11 VS. DSM-5 CLASSIFICATION OF MOOD DISORDERS 294 The ICD-11 is also following the DSM-5 in requiring the presence of increased activity or a subjective experience of increased energy, in addition to euphoria (or irritability or expansiveness), for the diagnosis of a manic episode, in order to reduce the chance of false positive cases. The two diagnostic systems also converge in considering that a manic or hypomanic syndrome arising during antidepressant treatment, and enduring beyond the known physiological effects of that treatment, qualifies as a manic or hypomanic episode. Bipolar II disorder has become an independent category in the ICD-11 (it was just mentioned as an example of “other bipolar affective disorders” in the ICD-10). Furthermore, for the first time, the ICD follows the DSM in introducing “qualifiers” (corresponding to DSM-5 “specifiers”) to the diagnoses of mood disorders, based on specific aspects of symptomatology or course. There are, however, three important aspects in which the two diagnostic systems diverge. All of them are a consequence of changes made in the DSM-5 that the relevant ICD-11 Committee has regarded as not sufficiently supported by the available research evidence. The first of these divergences concerns the issue of bereavement. In the ICD-11, in line with the DSM-IV and ICD-10 approach, it is stated that “a depressive episode should not be considered if the depressive symptoms are consistent with the normative response for grieving within the individual’s religious and cultural context”. However, the diagnosis of depression is not excluded if the person is bereaved; the diagnostic threshold is just raised, exactly as it happens in ordinary clinical practice. A depressive episode during bereavement is suggested by the persistence of symptoms for at least one month, and the presence of at least one symptom which is unlikely to occur in normal grief (such as extreme beliefs of low self-worth or guilt not related to the lost loved one, presence of psychotic symptoms, suicidal ideation, or psychomotor retardation). In contrast, the special status conferred by the DSM-IV to bereavement among life stressors has been eliminated in the DSM-5. However, two independent follow-up studies (Mojtabai 2011, Wakefield and Schmitz 2012) have reported that, in people with baseline bereavement-related depression, the risk for the occurrence of a further depressive episode during follow-up is significantly lower than in individuals with baseline non-bereavement-related depression, and not significantly different from the risk of people without a baseline history of depression to develop a first depressive episode during follow-up. This research evidence strongly supports the ICD-11 (and DSM-IV) approach. Furthermore, an intensive public debate has highlighted the consequences that the DSM-5 approach to the bereavement issue could have in several cultures, including a high rate of false positives and a trivialization of the concept of depression and consequently of mental disorder (Kleinman 2012). A second divergence between the ICD-11 and DSM-5 sections on mood disorders concerns mixed states. The category of mixed episode is kept in the ICD-11, defined by several prominent manic and depressive symptoms which either occur simultaneously or alternate very rapidly (from day to day or within the same day) during a period of at least two weeks. The mood state is altered throughout the episode (i.e., the mood should be depressed, dysphoric, euphoric or expansive for at least two weeks). When depressive symptoms predominate, common contrapolar symptoms are irritability, racing or crowded thoughts, increased talkativeness, and increased activity. When manic symptoms predominate, common contrapolar symptoms are dysphoric mood, expressed beliefs of worthlessness, hopelessness, and suicidal ideation. This definition is in line with the ICD-10 and completely consistent with both classic and recent research evidence, as well as with clinical experience. In contrast, the DSM-5 solution to eliminate the category of mixed episode and to introduce a specifier “with mixed features”, applicable to manic, hypomanic and depressive episodes, has had the consequence to reduce the visibility of “mixity” in ordinary clinical practice (especially since the specifier is not codable, and is therefore at risk of not being recorded in clinical settings). Moreover, the DSM-5 definition of major depression with mixed features, requiring the presence of at least three “classic” manic symptoms (such as elevated mood, grandiosity, and increased involvement in risky activities) has been criticized for being inconsistent with the concept of mixed depression as delineated in both the classic and recent literature (e.g., Koukopoulos and Sani 2014). A third divergence between the two diagnostic systems consists in the fact that the ICD-11 has not followed the DSM-5 in combining dysthymic disorder and chronic major depressive disorder into a single category (“persistent depressive disorder”). In fact, the relevant ICD-11 Committee expert considered that the evidence that the two disorders represent the same condition, to be addressed therapeutically in the same way, is insufficient. The category of dysthymic disorder is kept in the ICD-11, while a qualifier “current episode persistent” is to be used when the diagnostic requirements for depressive episode have been met continuously for at least the past two years. For a discussion of other aspects of the classification of mood disorders, with the relevant therapeutic implications, as well as for information about the differences between the ICD-11 and the DSM-5 concerning other sections of the classification of mental disorders, we refer the reader to previous contributions (Demyttenaere et al. 2015, Fried et al. 2016, Haroz et al. 2017, Boschloo et al. 2019, Bryant 2019, Forbes et al. 2019, Fusar-Poli et al. 2019, Gureje et al. 2019, 295 Received: 13.09.2021, Accepted: 19.09.2021, Available Online Date: 30.11.2021 MD., University of Campania L. Vanvitelli, WHO Collaborating Centre for Research and Training in Mental Health, Naples, Italy. Dr. Arcangelo Di Cerbo, e-mail: ardice77@gmail.com https://doi.org/10.5080/u26899 Reed et al. 2019, Kendall 2019, van Os et al. 2019, Cuijpers et al. 2020, Fava and Guidi 2020, Gaebel et al. 2019, 2020, Hasler 2020, Jarrett 2020, Kato et al. 2020, Maj et al. 2020, Reynolds 2020, Sanislow 2020, Stein et al. 2020). An International Advisory Group has been established to supervise the activities of translation, training of professionals and implementation of the ICD-11 chapter on mental disorders (see Giallonardo 2019, Pocai 2019, Perris 2020). The experience in the field will tell whether the above divergences from the DSM-5 in the ICD-11 classification of mood disorders are justified. Indeed, divergences in the description of the same mental health condition may sometimes be useful in order to allow the empirical comparison of different approaches to issues that are controversial. Arcangelo DI CERBO REFERENCES Boschloo L, Bekhuis E, Weitz ES et al (2019) The symptom-specific efficacy of antidepressant medication vs. cognitive behavioral therapy in the treatment of depression: results from an individual patient data meta-analysis. World Psychiatry 18:183-91. Bryant RA (2019) Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges. World Psychiatry 18:259-69. Cuijpers P, Noma H, Karyotaki E et al (2020) A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry 19:92-107. Demyttenaere K, Donneau AF, Albert A et al (2015) What is important in being cured from depression? Discordance between physicians and patients (1). J Affect Disord 174:390-6. Fava GA, Guidi J (2020) The pursuit of euthymia. World Psychiatry 19:40-50. Fried EI, Epskamp S, Nesse RM et al (2016) What are “good” depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis. J Affect Disord 189:314-20. Forbes MK, Wright AGC, Markon KE et al (2019) The network approach to psychopathology: promise versus reality. World Psychiatry 18:272-3. Fusar-Poli P, Solmi M, Brondino N et al (2019) Transdiagnostic psychiatry: a systematic review. World Psychiatry 8:192-207. Gaebel W, Reed GM, Jakob R (2019) Neurocognitive disorders in ICD-11: a new proposal and its outcome. World Psychiatry 18:232-3. Gaebel W, Stricker J, Riesbeck M et al (2020) Accuracy of diagnostic classification and clinical utility assessment of ICD-11 compared to ICD-10 in 10 mental disorders: findings from a web-based field study. Eur Arch Psychiatry Clin Neurosci 270:281-9. Giallonardo V (2019) ICD-11 sessions within the 18th World Congress of Psychiatry. World Psychiatry 18:115-6. Gureje O, Lewis-Fernandez R, Hall BJ et al (2019) Systematic inclusion of culture-related information in ICD-11. World Psychiatry 18:357-8. Haroz EE, Ritchey M, Bass JK et al (2017) How is depression experienced around the world? A systematic review of qualitative literature. Soc Sci Med 183:151-62. Hasler G (2020) Understanding mood in mental disorders. World Psychiatry 19:56-7. Jarrett RB (2020) Can we help more? World Psychiatry 19:246-7. Kato TA, Kanba S, Teo AR (2020) Defining pathological social withdrawal: proposed diagnostic criteria for hikikomori. World Psychiatry 19:116-7. Kendall T (2019) Outcomes help map out evidence in an uncertain terrain, but they are relative. World Psychiatry 18:293-5. Kleinman A (2012) Culture, bereavement, and psychiatry. Lancet 379:608-9. Koukopoulos A, Sani G (2014) DSM-5 criteria for depression with mixed features: a farewell to mixed depression. Acta Psychiatr Scand 129:4-16. Kotov R, Jonas KG, Carpenter WT et al (2020) Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): I. Psychosis superspectrum. World Psychiatry 19:151-72. Maj M, Stein DJ, Parker G et al (2020) The clinical characterization of the adult patient with depression aimed at personalization of management. World Psychiatry 19:269-93. McGlinchey JB, Zimmerman M, Young D et al (2006) Diagnosing major depressive disorder VIII. Are some symptoms better than others? J Nerv Ment Dis 194:785-90. Mojtabai R (2011) Bereavement-related depressive episodes: characteristics, 3-year course, and implications for the DSM-5. Arch Gen Psychiatry 68:920-8. Perris F (2020) ICD-11 sessions at the 19th World Congress of Psychiatry. World Psychiatry 19:263-4. Pocai B (2019) The ICD-11 has been adopted by the World Health Assembly. World Psychiatry 18:371-2. Reed GM, First MB, Kogan CS et al (2019) Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry 18:3-19. Reynolds CF 3rd (2020) Optimizing personalized management of depression: the importance of real-world contexts and the need for a new convergence paradigm in mental health. World Psychiatry 19:266-8. Sanislow CA (2020) RDoC at 10: changing the discourse for psychopathology. World Psychiatry 19:311-2. Stein DJ, Szatmari P, Gaebel W et al (2020) Mental, behavioural and neurodevelopmental disorders in the OCD-11: an international perspective on key changes and controversies. BMC Med 18:21. van Os J, Guloksuz S, Vijn TW et al (2019) The evidence-based group-level symptom-reduction model as the organizing principle for mental health care: time for change? World Psychiatry 18:88-96. Wakefield JC, Schmitz MF (2012) Recurrence of bereavement-related depression: evidence for the validity of the DSM-IV bereavement exclusion from the Epidemiologic Catchment Area Study. J Ment Dis 200:480-5.