Skip to main content Accessibility help
Hostname: page-component-684899dbb8-489z4 Total loading time: 0.672 Render date: 2022-05-21T13:10:48.620Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true }

Capturing complexity: The case for a new classification system for mental disorders in primary care

Published online by Cambridge University Press:  05 September 2008

Linda Gask*
National Primary Care Research and Development Centre, 5th Floor, Williamson Building, University of Manchester, Oxford Road, ManchesterM13 9PL, UK
Michael Klinkman
Departments of Family Medicine and Psychiatry, University of Michigan Medical School, 1018 Fuller Street, Ann Arbor, MI48109-0708, USA
Sandra Fortes
Medical Science Faculty, University of Rio de Janeiro State, Av. 28 de setembro, 177, sala 107, Vila Isabel, Rio de Janeiro, RJ20000.000, Brazil
Christopher Dowrick
Primary Medical Care, School of Population, Community & Behavioural Sciences, 2.11 Whelan Building, University of Liverpool, Liverpool, L69 3GB, UK
*Corresponding author Tel.: +44 161 275 1848; fax: +44 161 256 1070. E-mail address: (L. Gask), (M. Klinkman), (S. Fortes), (C. Dowrick).
Get access


Primary care differs considerably from specialist mental health settings: problems are presented in undifferentiated forms, with consequent difficulties in distinguishing between distress and disorder, and a complex relationship between psychological, mental and social problems and their temporal variations.

Existing psychiatric diagnostic systems, including ICD-10-PHC and DSM-IV-PC, are often difficult to apply in primary care. They do not adequately address co-morbidity, the substantial prevalence of sub-threshold disorders or problems with cross-cultural applications. Their focus on diagnosis may be too restrictive, with a need to consider severity and impairment separately.

ICPC-2, a classification system created specifically for use in primary care, provides advantages in that it allows for simple linkage between reason for encounter, diagnosis and intervention.

It is both necessary and feasible to develop a classification system for mental health in primary care that can meet four basic criteria: (1) characterized by simplicity; (2) addressing not only diagnosis but also severity, chronicity and disability; (3) feasible for routine data gathering in primary care as well as for training; and (4) enabling efficient communication between primary and specialty mental health care.

Original article
Copyright © Elsevier Masson SAS 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)



Tel.: +1 734 998 7120x309; fax: +1 734 998 7335.


Tel.: +55 21 25876469.


Tel.: +44 151 794 5821; fax: +44 151 794 5604.


Agency for Healthcare Research and Quality US Preventive Services Task Force Scholar
American Psychiatric Association Diagnostic and statistical manual of mental disorders 4th ed. 1995 American Psychiatric Association Washington, DCGoogle Scholar
Arroll, B.Goodyear-Smith, F.Kerse, N.Fishman, T.Gunn, J.Effect of the addition of a ‘help’ question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study British Medical Journal. 331 2005 884CrossRefGoogle ScholarPubMed
Balint, M.The doctor, his patient and the illness 1964 Pitman LondonGoogle Scholar
Bernstein, R.M.Hollingworth, G.R.Viner, G.Shearman, J.Labelle, C.Thomas, R.Reliability issues in coding encounters in primary care using an ICPC/ICD-10 based controlled clinical terminology Journal of the American Medical Informatics Association Symposium Supplement. 21 1997 843Google Scholar
Britt, H.Bridges-Webb, C.Sayer, G.P.Neary, S.Charles, J.Traynor, V.The diagnostic difficulties of abdominal pain Australian Family Physician. 23 1994 375381Google ScholarPubMed
Brody, D.S.The DSM-IV-PC: toward improving management of mental disorders in primary care [Editorial] Journal of the American Board of Family Practice. 9 1996 300302Google Scholar
Casey, P.Dowrick, C.Wilkinson, G.Adjustment disorders: fault line in the psychiatric glossary [Editorial] British Journal of Psychiatry. 179 2001 479480CrossRefGoogle Scholar
Chang, D.F.Myers, H.F.Yeung, A.Zhang, Y.Zhao, J.Yu, S.Shenjing shuaruo and the DSM-IV: diagnosis, distress and disability in a Chinese primary care setting Transcultural Psychiatry. 42 2005 204218CrossRefGoogle Scholar
Chwastiak, L.A.Von Korff, M.Disability in depression and back pain: evaluation of the World Health Organization Disability Assessment Schedule (WHO DAS II) in a primary care setting Journal of Clinical Epidemiology. 56 2003 507514CrossRefGoogle Scholar
Coyne, J.C.Klinkman, M.S.Gallo, S.M.Schwenk, T.L.Short-term outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients General Hospital Psychiatry. 19 1997 333343CrossRefGoogle ScholarPubMed
Coyne, J.C.Schwenk, T.L.Relationship of distress to mood disturbance in primary care and psychiatric populations Journal of Consulting and Clinical Psychology. 65 1997 167168CrossRefGoogle ScholarPubMed
deGruy, F.V.3rd Pincus, H.The DSM-IV-PC: a manual for diagnosing mental disorders in the primary care setting Journal of the American Board of Family Practice. 9 1996 274281Google ScholarPubMed
Dowrick, C.Beyond depression: a new approach to understanding and management 2004 Oxford University Press OxfordGoogle Scholar
Dowrick, C.Buchan, I.Twelve month outcome of depression in general practice: does detection or disclosure make a difference? British Medical Journal. 311 1995 12741276CrossRefGoogle ScholarPubMed
Foley, D.Neale, M.C.Gardner, C.O.Pickles, A.Prescott, C.A.Kendler, K.S.Major depression and associated impairment: same or different genetic and environmental risk factors? American Journal of Psychiatry. 160 2003 21282133CrossRefGoogle ScholarPubMed
Garcia-Campayo, J.Lobo, A.Perez-Echeverria, M.J.Campos, R.Three Forms of somatisation presenting in primary care settings in Spain Journal of Nervous and Mental Disease. 186 9 1998 554560CrossRefGoogle Scholar
Gask, L.Is depression a chronic illness? Chronic Illness. 1 2005 101106CrossRefGoogle ScholarPubMed
Gilbody, S.M.House, A.O.Sheldon, T.A.Routinely administered questionnaires for depression and anxiety: systematic review British Medical Journal. 322 2001 406409CrossRefGoogle ScholarPubMed
Goldberg, D.Huxley, P.Common mental disorders 1992 Tavistock LondonGoogle Scholar
Goldberg, D.Williams, P.A user's guide to the General Health questionnaire Windsor, UK: NFER-Nelson. 1988Google Scholar
Goldberg, D.P.Bridges, K.Duncan-Jones, P.Grayson, D.Dimensions of neuroses seen in primary-care settings Psychological Medicine. 17 1987 461470CrossRefGoogle ScholarPubMed
Institute of Medicine Primary care: America's health in a new era Washington DC 1996Institute of MedicineGoogle Scholar
Janca, A.Tacchini, G.Isaac, M.WHO international study of somatoform disorders: an overview of methods and preliminary resultsKeio University Symposia for Life Science and Medicine. Somatoform disorders: a worldwide perspective 1999 Springer TokyoGoogle Scholar
Jenkins, R.Goldberg, D.Kiima, D.Mayeya, J.Mayeya, P.Mbatia, al.Classification in primary care: experience with current diagnostic systems Psychopathology. 35 2002 127131CrossRefGoogle ScholarPubMed
Judd, L.L.Akiskal, H.S.Maser, J.D.Zeller, P.J.Endicott, J.Coryell, al.A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders Archives of General Psychiatry. 55 1998 694700CrossRefGoogle ScholarPubMed
Katerndahl, D.Variations on a theme: the spectrum of anxiety disorders and problems with DSM classification in primary care settingsGower, P.L.New research on the psychology of fear. 2005 NovaScience Publishers, Inc Hauppauge NYGoogle Scholar
Katerndahl, D.Larne, A.C.Palmer, R.F.Amodei, N.Reflections on DSM classification and its utility in primary care: case studies in ‘mental disorders’ Primary Care Companion to the Journal of Clinical Psychiatry. 7 2005 9199CrossRefGoogle Scholar
Kessler, R.C.Berglund, P.Demler, O.Jin, R.Merikangas, K.R.Walters, E.E.Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication Archives of General Psychiatry. 62 2005 593602CrossRefGoogle ScholarPubMed
Kessler, R.C.Nelson, C.B.McGonagle, K.A.Liu, J.Swartz, M.Blazer, D.G.Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey British Journal of Psychiatry. 168s 30 1996 1730CrossRefGoogle Scholar
Kirmayer, L.J.Robbins, J.M.Three forms of somatization in primary care: prevalence, co-occurrence and socio-demographic characteristic Journal of Nervous and Mental Disease. 179 1991 647655CrossRefGoogle Scholar
Kisely, S.Simon, G.An international study of the effect of physical ill-health on psychiatric recovery in primary care Psychosomatic Medicine. 67 2005 116122CrossRefGoogle Scholar
Korten, A.Henderson, S.The Australian National Survey of Mental Health and Well-Being: common psychological symptoms and disablement British Journal of Psychiatry. 177 2000 325330CrossRefGoogle ScholarPubMed
Kroenke, K.Spitzer, M.Williams, J.B.The PHQ-9: validity of a brief depression severity measure Journal of General Internal Medicine. 16 2001 606613CrossRefGoogle ScholarPubMed
Kroenke, K.Spitzer, M.Williams, J.B.The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms Psychosomatic Medicine. 64 2002 258266CrossRefGoogle ScholarPubMed
Lamberts, H.The use of the International Classification of Primary Care as an episode-oriented databaseBarber, B.Coa, D.Qin, D.Wagner, G.Medinfo 89. 1989 Elsevier North-Holland Amsterdam835839Google Scholar
Lamberts, H.Hofmans-Okkes, I.M.Classification of psychological and social problems in general practice Huisarts en Wetenschap. 36 1993 513Google Scholar
Lamberts, H.Schade, E.Surveillance systems from primary care data: from a prevalence-oriented to an episode-oriented epidemiologyEylenbosch, W.J.Noah, N.D.Surveillance in health and disease. 1988 Oxford University Press Oxford7589Google Scholar
Lamberts, H.Wood, M.Hofmans-Okkes, I.The international classification of primary care in the European Community, with a multi-language layer. 1993 Oxford University Press OxfordGoogle Scholar
Leduc, Y.Cauchon, M.Emond, J.G.Oueliet, J.Utilisation d'un systeme informatise de classification pour les soins de premiere ligne: trois annees d'experience Canadian Family Physician. 41 1995 13381345Google Scholar
Leon, A.C.Shear, K.Portera, L.Klerman, G.L.Assessing impairment in patients with panic disorder: the Sheehan Disability Scale Social Psychiatry and Psychiatric Epidemiology. 27 1992 7882CrossRefGoogle ScholarPubMed
MaGPIe Research Group. The nature and prevalence of psychological problems in New Zealand primary healthcare: a report on mental health and general practice investigation (MaGPIe); 2003 (URL: Scholar
Mari, J.J.Williams, P.A comparison of the validity of two psychiatric screening questionnaires (GHQ-12 and SRQ-20) in Brazil using relative operating characteristic (ROC) analysis Psychological Medicine. 15 1985 651659CrossRefGoogle ScholarPubMed
Mezzich, J.E.Kirmayer, L.J.Kleinman, A.Fabrega, H. Jr.Parron, D.L.Good, al.The place of culture in DSM-IV Journal of Nervous and Mental Disease. 187 1999 457464CrossRefGoogle ScholarPubMed
Nease, D.E.Aikens, J.E.DSM depression and anxiety criteria and severity of symptoms in primary care: cross sectional study British Medical Journal. 327 2003 10301031CrossRefGoogle ScholarPubMed
Nease, D.E. Jr.Green, L.A.ClinfoTracker: a generalizable prompting tool for primary care Journal of the American Board of Family Practice. 16 2003 115123CrossRefGoogle ScholarPubMed
Nease, D.R. Jr.Klinkman, M.A.Volk, R.J.Improved detection of depression in primary care settings through severity detection Journal of Family Practice. 51 2002 10651070Google Scholar
Okkes, I.M.Becker, H.W.Bernstein, R.M.LambertsThe, H.update of the electronic version of ICPC-2. A step forward to the use of ICD-10 as a nomenclature and a terminology for ICPC-2 Family Practice. 2002 19 March 2002 543546CrossRefGoogle Scholar
Okkes, I.M.Groen, A.Oskam, S.K.Lamberts, H.Advantages of long observation in episode-oriented electronic patient records in family practice Methods of Information in Medicine. 40 2001 229235Google ScholarPubMed
Okkes, I.Jamoulle, M.Lamberts, H.Bentzen, N.ICPC-2-E: the electronic version of ICPC-2. Differences from the printed version and the consequences [see comments] Family Practice. 17 2000 101107CrossRefGoogle Scholar
Okkes, I.Oskam, S.K.Lamberts, H.The probability of specific diagnoses for patients presenting with common symptoms to Dutch family physicians Journal of Family Practice. 51 2002 3136Google ScholarPubMed
Olfson, M.Broadhead, W.E.Weismann, M.M.Leon, A.C.Farber, L.Hoven, al.Subthreshold psychiatric symptoms in a primary care group practice Archives of General Psychiatry. 53 1996 880886CrossRefGoogle Scholar
Patel, V.Mann, A.Etic and Emic criteria for non-psychotic mental disorder: a study of the CISR and care provider assessment in Harare Social Psychiatry and Psychiatric Epidemiology. 32 1997 8489CrossRefGoogle ScholarPubMed
Piccinelli, M.Rucci, P.Ustun, B.Simon, G.Typologies of anxiety, depression and somatization symptoms among primary care attenders with no formal mental disorders Psychological Medicine. 29 1999 677688CrossRefGoogle Scholar
Pincus, H.A.Vettorello, N.E.McQueen, L.E.First, M.Wise, T.N.Zarin, al.Bridging the gap between psychiatry and primary care. The DSM-IV-PC Psychosomatics. 36 1995 328335CrossRefGoogle ScholarPubMed
Pingitore, D.A.Sansone, R.A.Using DSM-IV primary care version: a guide to psychiatric diagnosis in primary care American Family Physician. 1998 58Google Scholar
Rogers, W.H.Adler, D.A.Bungay, K.M.Wilson, I.B.Depression screening instruments made good severity measures in a cross-sectional analysis Journal of Clinical Epidemiology. 58 2005 370377CrossRefGoogle ScholarPubMed
Rogers, W.H.Wilson, I.B.Bungay, K.M.Cynn, D.J.Adler, D.A.Assessing the performance of a new depression screener for primary care (PC-SAD©) Journal of Clinical Epidemiology. 55 2002 164175CrossRefGoogle Scholar
Santor, D.A.Coyne, J.C.Evaluating the continuity of symptomatology between depressed and nondepressed individuals Journal of Abnormal Psychology. 110 2001 216225CrossRefGoogle ScholarPubMed
Santor, D.A.Coyne, J.C.Examining symptom expression as a function of symptom severity: item performance on the Hamilton Rating Scale for Depression Psychological Assessment. 13 2001 127139CrossRefGoogle ScholarPubMed
Sartorius, N.Ustun, T.B.Lecrubier, Y.Wittchen, H.U.Depression comorbid with anxiety: results from the WHO study on psychological disorders in primary health care British Journal of Psychiatry. 30 Suppl 1996 3843CrossRefGoogle Scholar
Sheehan, D.V.The anxiety disease 1983 Scribner New YorkGoogle Scholar
Sherbourne, C.D.Wells, K.B.Meredith, L.S.Jackson, C.A.Camp, P.Co-morbid anxiety and the functioning and well-being of chronically ill-patients of general medical providers Archives of General Psychiatry. 53 1996 889895CrossRefGoogle Scholar
Simon, G.E.Goldberg, D.P.Von Korff, M.Ustun, T.B.Understanding cross-national differences in depression prevalence Psychological Medicine. 32 2002 585594CrossRefGoogle ScholarPubMed
Sinclair, P.A.Lyness, J.M.Kind, D.A.Cox, C.Caine, E.D.Depression and self-reported functional status in older primary care patients American Journal of Psychiatry. 158 2001 416419CrossRefGoogle ScholarPubMed
Slade, T.Andrews, G.Latent structure of depression in a community sample: a taxonmetric analysis Psychological Medicine. 35 2004 489497CrossRefGoogle Scholar
Spitzer, R.L.Kroenke, K.Williams, J.B.Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire Journal of the American Medical Association. 282 1999 17371744CrossRefGoogle ScholarPubMed
Spitzer, R.L.Kroenke, K.Williams, J.B.Lowe, B.A brief measure for assessing generalized anxiety disorder: the GAD-7 Annals of Internal Medicine. 166 2006 10921097CrossRefGoogle ScholarPubMed
Spitzer, R.L.Williams, J.B.Kroenke, K.Linzer, M.deGruy, F.V.3rd Hahn, al.Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study Journal of the American Medical Association. 72 1994 17491756CrossRefGoogle Scholar
The Mental Health and General Practice Investigation (MaGPIe) Research Group General practitioner recognition of mental illness in the absence of a ‘gold standard’ Australia and New Zealand Journal of Psychiatry. 38 2004 789–794CrossRefGoogle Scholar
Toft, T.Fink, P.Oernboel, E.Chriensen, K.Frostholm, L.Olesen, F.Mental disorders in primary care: prevalence and co-morbidity among disorders: results from the functional illness in primary care (FIP) study Psychological Medicine. 35 2005 11751184CrossRefGoogle ScholarPubMed
Tyrer, P.Nur, U.Crawford, M.Karlsen, S.McLean, C.Rao, al.The Social Functioning Questionnaire: a rapid and robust measure of perceived functioning International Journal of Social Psychiatry. 51 2005 265275CrossRefGoogle ScholarPubMed
Upton, M.W.Evan, M.Goldberg, D.P.Sharpe, D.J.Evaluation of ICD-10 PHC mental health guidelines in detecting and managing depression within primary care British Journal of Psychiatry. 175 1999 476482CrossRefGoogle ScholarPubMed
Ustun, T.B.Goldberg, D.Cooper, J.Simon, G.E.Sartorius, N.New classification for mental disorders with management guidelines for use in primary care: ICD-10 PHC chapter five British Journal of General Practice. 45 1995 211215Google ScholarPubMed
Üstün, T.B.Sartorius, N.Mental illness in general health care 1995 John Wiley & Sons ChichesterGoogle Scholar
Van Weel-Baumgarten, E.van den Bosch, W.van den Hoogen, H.Zitman, F.G.Ten year follow-up of depression after diagnosis in general practice British Journal of General Practice. 48 1999 16431646Google Scholar
Vuorilehto, M.Melartin, T.Isometsa, E.Depressive disorders in primary care: recurrent, chronic and co-morbid Psychological Medicine. 35 2005 673682CrossRefGoogle ScholarPubMed
Wolraich, M.L.Diagnostic and statistical manual for primary care (DSM-PC) child and adolescent version: design, intent, and hopes for the future Journal of Developmental and Behavioral Pediatrics. 18 1997 171172CrossRefGoogle ScholarPubMed
WONCA international classification committee international classification of primary care 2nd ed. 1998 Oxford University Press Oxford [ICPC-2]Google Scholar
Zigmond, A.S.Snaith, R.P.The hospital anxiety and depression scale Acta Psychiatrica Scandinavica. 67 1983 361370CrossRefGoogle ScholarPubMed
Zimmerman, M.Coryell, W.Wilson, S.Corenthal, C.Evaluation of symptoms of major depressive disorder: self-report vs. clinician ratings Journal of Nervous and Mental Disease. 1986 50153CrossRefGoogle Scholar
Zinsbarg, R.Barlow, D.Liebowitz, M.Street, L.Broadhead, E.Katon, al.DSM-IV field trial for mixed anxiety-depression American Journal of Psychiatry. 151 1994 11531162Google Scholar
Submit a response


No Comments have been published for this article.
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Capturing complexity: The case for a new classification system for mental disorders in primary care
Available formats

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Capturing complexity: The case for a new classification system for mental disorders in primary care
Available formats

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Capturing complexity: The case for a new classification system for mental disorders in primary care
Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *