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Objective: This study aims to compare ICD-10 and putative ICD-11 classifications of personality disorder in different clinical populations., Design: Prospective recording of ICD-10 and ICD-11 personality disorder classifications was carried out in (1) an anxious medical population, (2) an acute psychiatric in-patient population and (3) a retrospective recording of a mixed anxiety depression cohort in which all baseline data were scored from baseline information using the ICD-11 classification and compared with the original ICD-10 assessments., Method: Comparison of ICD-10 and ICD-11 prevalence of personality disorder in each population was carried out., Results: Data from 722 patients were recorded. Using the ICD-10 criteria, the prevalence of generic personality disorder was 33.8% compared with 40.4% using the ICD-11 ones (χ2  = 6.7; P < 0.01), with 103 (14.3%) discordant assessments. Using the severity definitions in ICD-11, 34.3% of patients had personality difficulty. Severity level varied greatly by population; severe personality disorder was five times more common in the inpatient group. The four domain traits originally denoted as qualifying severity in ICD-11, negative affective, dissocial, anankastic and detached, were linked to anxious, borderline, dissocial, anankastic and schizoid personality disorders in ICD-10. Many patients had pathology in two or more domains., Conclusions: The ICD-11 classification of personality disorder yields somewhat higher levels of personality dysfunction than ICD-10, possibly because the age range for the onset of diagnosis is now flexible. The range of severity levels make the classification more useful than ICD-10 in clinical practice as it identifies the greater pathology necessary for intervention., (Copyright © 2014 John Wiley & Sons, Ltd.)

Background: Mixed anxiety and depressive disorder (MADD) is common yet ill-defined, with little known about outcomes., Aims: To determine MADD outcomes over 1 year., Method: We recruited 250 adults attending seven London general practices with mild-moderate distress. Three groups were defined using a diagnostic interview: MADD, other ICD-10 psychiatric diagnosis, no psychiatric diagnosis. We assessed symptoms of distress (General Health Questionnaire-28), quality of life (12-item Short Form Health Survey), general practitioner (GP) diagnosis and consultation rate at baseline, 3 months and 1 year., Results: Two-thirds of participants with MADD had no significant psychological distress at 3 months (61%) or 1 year (69%). However, compared with those with no diagnosis, individuals had twice the risk of significant distress (incidence rate ratio 2.39, 95% CI 1.29-4.42) at 3 months but not 1 year, and persistently lower quality of life (mental health functioning). There was no significant difference in GP consultation rate/diagnosis., Conclusions: The majority with MADD improved, but individuals had an increased risk of significant distress at 3 months and a lower quality of life. As we cannot currently predict those with a poorer prognosis these patients should be actively monitored in primary care.

Background: Despite strong evidence for its effectiveness, cognitive-behavioural therapy (CBT) remains difficult to access. Computerised programs have been developed to improve accessibility, but whether these interventions are responsive to individual needs is unknown. We investigated the effectiveness of CBT delivered online in real time by a therapist for patients with depression in primary care., Methods: In this multicentre, randomised controlled trial, 297 individuals with a score of 14 or more on the Beck depression inventory (BDI) and a confirmed diagnosis of depression were recruited from 55 general practices in Bristol, London, and Warwickshire, UK. Participants were randomly assigned, by a computer-generated code, to online CBT in addition to usual care (intervention; n=149) or to usual care from their general practitioner while on an 8-month waiting list for online CBT (control; n=148). Participants, researchers involved in recruitment, and therapists were masked in advance to allocation. The primary outcome was recovery from depression (BDI score <10) at 4 months. Analysis was by intention to treat. This trial is registered, number ISRCTN 45444578., Findings: 113 participants in the intervention group and 97 in the control group completed 4-month follow-up. 43 (38%) patients recovered from depression (BDI score <10) in the intervention group versus 23 (24%) in the control group at 4 months (odds ratio 2.39, 95% CI 1.23-4.67; p=0.011), and 46 (42%) versus 26 (26%) at 8 months (2.07, 1.11-3.87; p=0.023)., Interpretation: CBT seems to be effective when delivered online in real time by a therapist, with benefits maintained over 8 months. This method of delivery could broaden access to CBT., Funding: BUPA Foundation.

Background: Most evidence for associations between childhood adversity and adult mental illness is retrospective., Aims: To evaluate prospective evidence of associations between poor parent-child relationships and common psychiatric disorders in later life., Method: Systematic review of studies published between 1970 and 2008 including: (a) more than 100 participants; (b) measures of relationships in the home during childhood; (c) at least 10 years between assessment of exposures; and (d) measures of anxiety, depression, suicide, suicidal ideation or post-traumatic stress disorder (PTSD). Analysis was by narrative synthesis., Results: Twenty-three papers were identified reporting data from 16 cohorts. Abusive relationships predicted depression, anxiety and PTSD. Maternal emotional unavailability in early life predicted suicide attempts in adolescence. Results of studies investigating less severe relationship problems were suggestive but not conclusive of causal association, due partly to methodological heterogeneity., Conclusions: Given the prevalence and disabling nature of common psychiatric problems, these studies highlight the need to minimise harm associated with dysfunctional parent-child relationships.

Background: Undertreatment of depression in primary care is common. Efforts to address this tend to overlook the role of patient attitudes. Our aim was to validate and describe responses to a questionnaire about attitudes to depression and its treatment in a sample with experience of moderate and severe depressive episodes., Method: Cross-sectional survey of 866 individuals with a confirmed history of an ICD-10 depressive episode in the 12 months preceding interview, recruited from 7271 consecutive general practitioner (GP) attendees in 36 general practices in England and Wales. Attitudes to and beliefs about depression were assessed using a 19-item self-report questionnaire., Results: Factor analysis resulted in a three-factor solution: factor 1, depression as a disabling, permanent state; factor 2, depression as a medical condition responsive to support; and factor 3, antidepressants are addictive and ineffective. Participants who received and adhered to antidepressant medication and disclosed their depression to family and friends had significantly lower scores on factors 1 and 3 but higher scores on factor 2., Conclusions: People with moderate or severe depressive episodes have subtle and divergent views about this condition, its outcome, and appropriate help. Such beliefs should be considered in primary care as they may significantly impact on help seeking and adherence to treatment.

Background: Depression is prevalent, costly and often undertreated., Aims: To test the hypothesis that people with low socio-economic status are least likely to receive and adhere to evidence-based treatments for depression, after controlling for clinical need., Method: Individuals with an ICD-10 depressive episode in the past 12 months (n=866) were recruited from 7271 attendees in 36 general practices in England and Wales. Depressive episodes were identified using the 12-month Composite International Diagnostic Interview. Treatment receipt and adherence were assessed by structured interview, and rated using evidence-based criteria., Results: We identified 332 individuals (38.3%) who received and adhered to evidence-based treatment. There were few socio-economic differences in treatment allocation. Although those without educational qualifications were least likely to receive psychological treatments (OR = 0.55,95% CI 0.34-0.89, P = 0.02), this association was not statistically significant after adjusting for depression severity., Conclusions: We found no evidence of inverse care in the treatment of moderate and severe depression in primary care in England and Wales.

Background: Low socio-economic status is associated with a higher prevalence of depression, but it is not yet known whether change in socio-economic status leads to a change in rates of depression., Aims: To assess whether longitudinal change in socio-economic factors affects change of depression level., Method: In a prospective cohort study using the annual Belgian Household Panel Survey (1992-1999), depression was assessed using the Global Depression Scale. Socio-economic factors were assessed with regard to material standard of living, education, employment status and social relationships., Results: A lowering in material standard of living between annual waves was associated with increases in depressive symptoms and caseness of major depression. Life circumstances also influenced depression. Ceasing to cohabit with a partner increased depressive symptoms and caseness, and improvement in circumstances reduced them; the negative effects were stronger than the positive ones., Conclusions: The study showed a clear relationship between worsening socio-economic circumstances and depression.

Background: Prevention of depression must address multiple risk factors. Estimating overall risk across a range of putative risk factors is fundamental to prevention of depression. However, we lack reliable and valid methods of risk estimation. This protocol paper introduces PREDICT, an international research study to address this risk estimation., Methods/design: This is a prospective study in which consecutive general practice attendees in six European countries are recruited and followed up after six and 12 months. Prevalence of depression is assessed at baseline and each follow-up point. Consecutive attendees between April 2003 and September 2004 who were aged 18 to 75 were asked to take part. The possibility of a depressive episode was assessed using the Depression Section of the Composite International Diagnostic Interview. A selection of presumed risk factors was based on our previous work and a systematic review of the literature. It was necessary to evaluate the test-retest reliability of a number of risk factor questions that were developed specifically, or adapted, for the PREDICT study. In a separate reliability study conducted between January and November 2003, consecutive general practice attendees in the six participating European countries completed the risk factor items on two occasions, two weeks apart. The overall response rate at entry to the study was 69%. We exceeded our expected recruitment rate, achieving a total of 10,048 people in all. Reliability coefficients were generally good to excellent., Discussion: Response rate to follow-up in all countries was uniformly high, which suggests that prediction will be based on almost a full cohort. The results of our reliability analysis are encouraging and suggest that data collected during the course of PREDICT will have a satisfactory level of stability. The development of a multi-factor risk score for depression will lay the foundation for future research on risk reduction in primary care. Our data will also provide the necessary evidence base on which to develop and evaluate interventions to reduce the prevalence of depression.

It is still not known whether the places that people live affect their mental health. The principal aim of this 1991 study was to quantify simultaneously variance in the prevalence of the most common mental disorders, anxiety and depression, in Britain at the individual, household, and electoral ward levels. Data from a cross-sectional, nationally representative survey of 8,979 adults aged 16-74 years living in private households nested within 642 electoral wards in England, Wales, and Scotland were analyzed by using multilevel logistic and linear regression. Common mental disorders were assessed by using the General Health Questionnaire. Less than 1% of the total variance in General Health Questionnaire scores occurred at the ward level. This variance was further reduced and was no longer statistically significant after adjustment for characteristics of persons. By contrast, the proportion of total variance at the household level (14.4%, 95% confidence interval: 11.4, 17.5 in the null model) (p < 0.001) was statistically significant and remained so after adjustment for individual- and household-level exposures. While these findings suggest that future interventions should target persons and households rather than places, further research is first required to establish whether other (particularly smaller) areas lead to similar results.

Background: Little is known about the effects of the physical environment on individual health., Aims: The present study tested the hypothesis that the prevalence of depression is associated with independently rated measures of the built environment, after adjusting for individuals' socio-economic status and the internal characteristics of their dwellings., Method: Cross-sectional survey of 1887 individuals aged 16 years and over in two electoral wards in north London. Depression was ascertained using the Center for Epidemiologic Studies Depression scale (CES-D). The built environment was rated independently, using a validated measure., Results: After adjusting for socio-economic status, floor of residence and structural housing problems, statistically significant associations were found between the prevalence of depression and living in housing areas characterised by properties with predominantly deck access (odds ratio=1.28, 95% CI 1.03-1.58; P=0.02) and of recent (post-1969) construction (odds ratio=1.43, 95% CI 1.06-1.91; P=0.02)., Conclusions: The prevalence of depression was associated with independently rated features of the built environment, independent of individuals' socio-economic status and internal characteristics of dwellings.

There are few reliable measures of place with which to study the effects of socio-economic context on health. We report on the development and inter-rater reliability of a 27-item observer-rated built environment site survey checklist (BESSC). Across eleven 'housing areas' (defined as areas of homogeneity in housing form) and two raters, kappa coefficients were > or =0.5 for fifteen categorical items, and intra-class correlation coefficients exceeded 0.6 for a further three continuous measures. Ratings on several BESSC items were associated to a statistically significant degree with the prevalence of depression and residents' dissatisfaction with 'their area as a place to live'. BESSC items may prove to be valuable descriptors of the urban built environment in future studies.