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For many years, there has been dissatisfaction with the nomenclature widely employed to classify the medicines used in the treatment of psychiatric disorder. It has lurched between the obscure, the inconsistent and the incomprehensible. To start with the obscure, a WHO symposium in Oslo in 1969 agreed a consensus that an international system of drug classification was needed and the Drug Utilisation Research Group (DURG) was established. It created the WHO ATC (Anatomical Therapeutic Chemical) classification system, first published in 1976, and in use to this day to present drug utilisation data and so make national and international comparisons of drug utilisation, evaluate long-term trends in drug use, assess the impact of external events on drug use and provide denominator data in investigations of drug safety.
The ATC system sorts drugs initially into a target organ system (the nervous system, for psychotropics obviously) and then permits an ad hoc further subdivision between therapeutic indication (antidepressant for example) and/or pharmacology (e.g. SSRI, selective serotonin reuptake inhibitor) and/or chemistry (e.g. tricyclic). The result has been a growing mishmash, which has cried out for a systematic rationalisation. So we have antipsychotics and anti-epileptics used to treat patients with bipolar disorder who are neither psychotic nor epileptic. We have SSRIs and SNRIs, but SNRIs are not selective noradrenaline reuptake inhibitors, but instead serotonin/noradrenaline reuptake inhibitors and finally we have a growing majority of antidepressants classed simply as ‘other’.
The taskforce on nomenclature of the four colleges – ECNP, ACNP, CINP and AsCNP is pleased to announce that we have reached a further stage of consultation on developing pharmacologically-based principles for categorising the most frequently used psychotropic drugs. This proposal is a work in progress. Our expectation is that with input from the expert wisdom of our colleagues, using the same principle as Wikipedia, but with careful supervision and editing by the taskforce, it can and will be improved.
We are proposing a multi-axial system which seems to us to offer advantages for clinicians, informed patients, researchers, regulators and industry. It means we can do justice to the pharmacological complexity of drugs and emphasize what they do at molecular, cellular and systems levels, while also recognising their clinical actions and adverse effects. To some extent, this multi-axial approach logically echoes the desire enshrined in the NIMH Research Domain Criteria project (RDoC) to find new ways of classifying psychopathology based on dimensions of observable behaviour and neurobiological measures. If RDoC works, we can imagine how the classification of treatments might logically combine with classification of psychopathology, but that is for the future.
In the present, RDoC may stimulate research and initiate revisions of diagnostic practice but it cannot replace DSM-5, which has left us with a parallel system of (mostly) familiar diagnoses, which we will continue to use to communicate with ourselves and our patients and estimate societal morbidity. The nomenclature project must also leave clinicians with something logical and familiar in how we group different medicines, whatever their multi-axial complexity. I do not think we are over the line on the latter challenge. Nor is the detail of the multi-axial system complete. It is a large project, which is still only presenting a tiny summary of the available evidence.
Accordingly, please, go to the link below and make your contribution to what is a landmark project of international cooperation for our field.
Call for feedback
Best regards,
Guy Goodwin, ECNP President |
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