According to the results of a professional online survey of Russian psychiatrists, about a half of them rely on outdated diagnostic and treatment criteria in their work. The situation is aggravated by the recent refusal of the Russian Ministry of Health to adopt ICD-11: an update of the international classification of diseases, which is compiled by the World Health Organization (WHO) on the basis of modern medical achievements. Previously ICD 10 has been used (adopted by WHO in 1990 and introduced in Russia in 1999), The refusal to switch to ICD-11 is a giant leap into the past and needs to be understood in the context of the conservative turn in Russian social policy. It will inevitably affect medical education, resulting in a return to reactionary policies and outdated approaches to the diagnosis of many conditions.
Why is it so important to update to ICD-11?
WHO published ICD11, a new classification of diseases, in 2018. This is a normative document that reflects the most important changes and global trends in medicine. The taxonomy of medical conditions that it describes is much wider than in the previous version, with four times as many items. Various types of diabetes, immune system disorders, sleep-wake cycle disorders are described in greater detail. Several diagnoses were added, such as gambling addiction, attention deficit hyperactivity disorder, dysmorphic disorder. There is also a new category “Conditions related to sexual health”. Gender incongruence is now a separate subcategory and conditions related to it are no longer considered mental disorders. Pedophilia, instead of “sexual attraction to children”, is now codified as “pedophilic disorder”.
The transition to ICD-11 would keep Russian doctors up to date with modern advancements and achievements of scientists around the world. It would create an opportunity to be more precise in diagnoses, to choose attenuated and modern methods of treatment. It would make possible, for instance, to diagnose young patients with “autism spectrum disorder (ASD)” instead of the outdated diagnoses of “psychosis” and “schizophrenia”; to help people with transsexuality or hermaphroditism by correcting their sex; to select the latest psychotropic drugs with minimal side effects for patients with mental disorders instead of those used decades ago. Switching to a new classification of diseases would make it possible for Russian doctors to refer to the work of their foreign colleagues who use ICD-11. Due to the difference in vocabularies and codes, this will now be problematic.
Why was ICD-11 abandoned in Russia?
ICD-11 in Russia officially came into force on January 1, 2022, with three years allotted for transition period. However, in January 2024, Russian Prime Minister Mikhail Mishustin signed an order to suspend the transition. The primary reason for objections was the section on conditions related to sexual health. Members of the Duma, civic organizations, and clergy actively spoke out against the new classification and in defense of traditional values. The transition to ICD-11 has not been legally canceled, only suspended; but suspended indefinitely.
A blow to psychiatry
Psychiatry will be affected more than any other field by the refusal to adopt the new classification. For doctors in other areas of specialization, the ICD is helpful when it comes to encoding diagnoses for the purposes of discharging a patient, keeping statistics and calculating insurance deductions. Psychiatrists, on the other hand, need the classification to make a diagnosis. Psychiatrist and psychotherapist Ivan Matrynikhin explains:
“It had been noted since the 1960s that completely different approaches to psychiatry were being used in different regions of the world. Patients who had the same problem were given completely different diagnoses. This hindered the advancement of our area. Also during that time pharmacological treatment was being introduced. Diagnostics had to be more reliable, which led first to creating glossaries of terms, then to the development of DSM, the American classification that already had diagnostic criteria; later a comprehensive guide for diagnosing mental conditions was introduced in the ICD-10.”
Because of the suspension of the ICD-11, psychiatrists have been deprived of more than just a modern statistical list of terms. They will have to make diagnoses and prescribe medications according to outdated classifications. Thus, patients will be treated according to the standards of the last century. In addition, there will not be congruency between Russian and international diagnoses. This means that when moving to another country or being treated abroad, patients will have to re-collect an anamnesis, establish a diagnosis, and select treatment anew.
Russian lawmakers claim that the refusal to switch to ICD-11 will not affect the quality of treatment and plan to develop their own classification of diseases. The Russian Ministry of Health is now reviewing the draft of new clinical recommendations on autism, which were prepared by the Russian Society of Psychiatrists.
The draft has drawn serious criticism from progressive psychiatrists, educators and parents of children with autism, who describe the draft now proposed for approval by the Ministry of Health as anti-scientific. For example, it claims that autism is overdiagnosed, ABA behavioral programs are useless and even harmful in some cases, PECS alternative communication is ineffective, while haloperidol is recommended for children with ASD from the age of 2. (This older-generation drug, developed back in 1958, is infamous for its widespread use in Soviet punitive psychiatry). We have yet to see whether officials will eventually accept the project.
It seems that Russian lawmakers are not averse to adapting earlier classifications of psychiatric conditions that were used back in the 1970s. These outdated views go back to the works of German psychiatrists of the late 19th century, who assumed that all mental disorders, like syphilis or tuberculosis, had a biological cause, and that the doctor’s job was to discover it. Here is how Ivan Martynikhin comments on this:
What was so revolutionary about the ICD-10 and its predecessor DSM-III of 1980? A group of authors who created it, representing scientific collectives from around the world, abandoned the old concept of mental disorders. They basically said: in reality we have no reliable methods to establish the causes of mental disorders, so we are not guessing anymore. Here, we have an agreement that we call these things this way and these things another way, and these are all clinical syndromes, just a general framework. This framework of diagnostic criteria can be revised depending on what scientific evidence accumulates about the usefulness of diagnoses made in this way. But those doctors who were trained in the previous approaches are unwilling to abandon the previous concepts, they say: no, let’s better go back to these old German-Soviet approaches, which are based on the hypotheses of the late 19th century.”
Before the appearance of ICD-10 Russian psychiatrists used guidelines developed domestically. The most famous of them belongs to the major Soviet psychiatrist Andrei Snezhnevsky. He made a great contribution to the study of schizophrenia, but he was also infamous for his involvement for psychiatric examinations of dissidents and forced hospitalizations of healthy people. It is one thing to study Snezhnevsky’s works at university as part of the history of psychiatry; it is quite another to be guided by them in practice today. Ivan Martynikhin talks about the state of psychiatric diagnostics today:
“We did a survey at the Russian Society of Psychiatrists, asking what approaches the members use to diagnose schizophrenia. We asked: do you use the ICD-10? 96% answered, yes, we do. The next question was, how would you proceed in a case? It turns out that they only say that they use ICD-10, because it is required by law to give a diagnosis code. But they follow the diagnostic criteria set forth in the ICD only loosely, often substituting their own ideas of how and what to diagnose.”
The results of the above-mentioned survey indicate that approximately 50% of Russian psychiatrists use the 1976 edition of ICD-9 in their work. For example, the description of autism in ICD-10 is close enough to modern standards, including concepts like infantile autism and Asperger’s syndrome. In ICD-9, autism is classified as psychosis and schizophrenia, and there is no concept of neural development. However, in modern medicine there have been no shortage of descriptions and studies in neurodevelopmental disorders: these can be disorders of intellectual development, speech and communication, motor coordination, attention deficit and hyperactivity disorder. Treating each of these disorders requires an individual approach, individually selected medications and sessions with specialists. A doctor who uses ICD-10 will correctly diagnose a patient with one of these disorders, while their colleague who sticks to ICD-9 is likely to diagnose psychosis or intellectual deficit. If psychiatrists are able to use at least ICD-10 in their work, it will be a big step forward.
Doctors against ICD-11?
The suspension of the transition to ICD-11 in Russia was a gradual process. It was preceded by discussions among public opinion makers and clergy, with the sections related to transgenderism and pedophilia receiving backlash. Doctors’ opinions were also presented to the public. For this purpose, the analytical company RNC Pharma together with the Medvestnik portal conducted a study of the Russian medical workers’ evaluation of the new ICD. They surveyed 375 doctors of 75 specialties from 120 Russian cities.
According to the study, 34.4% of doctors fully support the abandonment of ICD-11, precisely because of its LGBT agenda. 18.4% are ready to switch to the new classification if controversial sections are excluded from it. 36% of doctors do not agree with the abolition of the transition, and another 10.4% of the survey participants believe that there are more important problems in the Russian healthcare system. The survey itself can hardly be described as independent. First of all, Medvestnik is a specialized portal for healthcare professionals backed by a company with direct ties to the Ministry of Health. There is therefore no reliable information about the attitude of Russian doctors to the cancellation of the transition to the new system of classification of diseases. It should perhaps be noted that even in a biased survey, the share of doctors who disagree with the authorities’ decision is quite significant.
The state of the field
Oksana Ivanenko, the mother of a child with autism from St. Petersburg, says that it took several years to get a correct diagnosis for her son. With autism, it is especially important to start therapy as early as possible, preferably before the age of three. At first, the public clinic’s psychiatrist denied the presence of autistic traits in the child and said the boy just had “obnoxious character”, which would “amend with age”. When the diagnosis was made after all, the doctor prescribed two rounds of nootropics (drugs aimed at activating metabolism in the brain whose effectiveness in autism has not been proven). This is how Oksana describes the situation:
“The doctors at general clinics are unprepared to work with such children, so they often refuse to diagnose ASD or autism, arguing that there is no such diagnosis in our country. Instead, most often they go with intellectual deficit and assign a degree of deviation. We claimed disability with a diagnosis of intellectual deficit, despite being diagnosed with ASD by more progressive psychiatrists.”
At universities, general practitioners are given only basic knowledge of psychiatry, for which only about three weeks of classes are assigned. For a doctor who has had no other training in this field and never revisited the little knowledge they received, it may indeed be difficult to see the first signs of a disorder in time and diagnose it correctly.
Independent initiatives acquire increased importance in such circumstances. Charities like Exit, Naked Hearts and OUTside provide assistance in various forms to people with autism. The charity foundation Anton’s Right Here organizes educational lectures on ASD for pediatricians. The Foundation’s specialists together with psychiatrists hold seminars for pediatricians, teaching them about early diagnosis of RAS. Since 2013, The charity has organized a system of support for people with autism, from early diagnosis and inclusive preschool education to employment and independent life in society.
There is now the risk, however, that years of work by charities, educators, psychologists and psychiatrists will be undone by the draft with the new recommendations from the Russian Society of Psychiatrists.
Pediatricians, whose workload is already heavy, in this case will have to face a dilemma. On the one hand, respectable modern experts will teach them about early detection of ASD, the importance of behavioral programs and alternative communication, and on the other hand, the Ministry of Health recommendations will explicitly instruct them not to over-diagnose autism and to give preference to drug treatment.
Patients with other mental disorders also often face difficulties in receiving a diagnosis. Tatiana from Moscow [name changed at her request] has been admitted several times to a psychiatric hospital since she was 27, receiving a new diagnosis each time. This is how she describes her experiences:
“The first time I was diagnosed with a manic episode. The second time I was admitted, a very young doctor diagnosed a personality disorder. However, a couple of days later, another psychiatrist showed up and crossed everything out and diagnosed me with bipolar disorder and schizophrenia on no clear grounds (he did not interview me, did not examine me, and had no contact with me at all). I tried to receive an explanation for this verdict and to find out if this diagnosis could be removed in the future, but the doctors only said: do you really care what it says here? They surely seemed like they couldn’t care less. In any case, you always get prescribed some neuroleptic. As one comedian joked, the psychiatrist will prescribe you whatever it says on his pen. I was given an ancient neuroleptic drug for a year. I couldn’t work or think straight or move. Every time I said: please change my medication, I don’t feel well, I need to be able to work. But they just ignored it.”
A few years later, Tatiana’s mother found information about an expensive modern drug that psychiatrists use for such mental disorders and got it prescribed. Tatiana returned to work, started a family and lives a normal life. One injection is enough for three months, and the medicine is given free of charge in the pharmacy’s discount department. However, the pharmacists are worried that this drug will no longer be supplied from abroad and prescribe two packs at once each time, so that there is always one in reserve.
Tatiana’s story is an example of how carefully selected modern drugs can bring a person back to normal life. Psychiatrists make a tremendous impact on their patients’ future by way of diagnoses and prescriptions; even if complete recovery is not always possible, one can return to a comfortable and fulfilling life when treatment is right. It is paramount that a person who enters a psychiatrist’s office is not transported decades into the past, into the time when mental disorders were perceived differently, associated with fear, neglect and despair.
Hope for doctors
Neglect of people with mental disorders has been common in institutions around the world. Overt paternalism has been widely manifest in teachings of various psychiatric schools and more importantly, in medical practice. The status of doctors and of medical knowledge is a big part of it. In the case of psychiatry, however, additional complication comes from the status of the condition itself that supposedly limits the patient’s capacity, will and rationality. It has been widely believed that the doctor knows best how to treat the patient and may choose whether to inform the patient of their diagnosis or not and whether to listen to their complaints and requests or not. As a result, patients have been disempowered, hindering the advancement of psychiatry: if the doctor is always right, then there is no need for them to improve. Ivan Martynikhin comments:
“As cardiologists, neurologists, obstetricians, everyone had been trying to improve for their patients, psychiatrists weren’t much interested in new scientific knowledge and modern approaches until only about 10-15 years ago. Before that, they were very conservative and did not try to update their education.”
According to a 2019 study, one in eight people on the planet suffers from a mental health disorder. Anxiety and depressive disorders are believed to be the most common. That is a total of 970 million people: a huge number. This is not some insignificant group of people that could be warded off with the walls of psychiatric institutions. However, the new developments in the Russian health care system linked to the abandonment of ICD-11 are unlikely to help to ensure a decent life for people with mental difficulties.
Inadequate treatment and using outdated medications increase the burden on the health care system. Problems that could have been prevented with timely intervention and/or the right medication will exacerbate the condition of patients and stigmatize them in society. If neuroleptics remain the first-choice treatment of children with ASD instead of early diagnosis and behavioral correction, it will be virtually impossible to integrate such children into society in the future.
For other mental disorders, the burden on the health care system will also increase. If an adult with a mental disorder is treated incorrectly for years according to 19th- and 20th-century guidelines, they are unlikely to go into remission and more likely to end up in psychiatric hospitals (where a patient spends an average of 1.5 to 3 months per admission). If people with BAR (bipolar affective disorder) type 2 are treated for depression, their condition will worsen to the point of disability and incapacity. Ignoring conditions like burnout will lead to an increase in depression and anxiety disorders.
Finally, the stigmatization of mental health problems in society leads to the adoption of a reclusive lifestyle by the patients themselves and their loved ones who may prefer to stay inside more often, to keep away from playgrounds where they could face hostile reactions, to avoid even trying to build a professional life or a relationship.
These are problems of any individual who seeks medical help and lives with and among people. The disempowerment of patients inevitably leads to the disempowerment of healthy people. If the minority is not protected, no one is protected. This is only part of the difficulties that society will face due to the suspension of the transition to ICD-11. In this sense, psychiatric illnesses are the area in which the problems and the socio-political ramifications of abandoning the classification are the most salient.
A number of psychiatrists and specialized charities are now trying to prevent this setback. Psychiatrists have been increasingly following the developments in international psychiatry, adopting the global experience of their colleagues, and holding training seminars for pediatricians. Patients and their relatives have been increasingly aware of modern approaches and demand that they are talked to on equal footing. Finally, the English version of ICD-11 is freely available, and it is not forbidden to use it as reference. However, the diagnosis will still have to be made according to the older classification. Using unapproved phrasing may lead to disciplinary responsibility or dismissal. Nevertheless, the hope is in doctors who will be ready to work in spite of cancellations and bans.
