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Aims\ud To examine the factors that associated with changes in depression in people with type 2 diabetes living in 12 different countries.\ud Methods\ud People with type 2 diabetes treated in out-patient settings aged 18-65 years underwent a psychiatric assessment to diagnose Major Depressive Disorder (MDD) at baseline and follow-up. At both time points participants completed the Patient Health Questionnaire (PHQ-9), the WHO 5-item Well-being scale (WHO-5) and the Problem Areas in Diabetes (PAID) scale which measures diabetes-related distress. A composite stress score (CSS) (the occurrence of stressful life events and their reported degree of 'upset') between baseline and follow-up was calculated. Demographic data and medical record information were collected. Separate regression analyses were conducted with MDD and PHQ-9 scores as the dependent variables.\ud Results\ud In total there were 7.4% (120) incident cases of MDD with 81.5% (1317) continuing to remain free of a diagnosis of MDD. Univariate analyses demonstrated that those with MDD were more likely to be female, less likely to be physically active, more likely to have diabetes complications at baseline and have higher CSS. Mean scores for the WHO-5, PAID and PHQ-9 were poorer in those with incident MDD compared with those who had never had a diagnosis of MDD. Regression analyses demonstrated that higher PHQ-9, lower WHO-5 scores and greater CSS were significant predictors of incident MDD. Significant predictors of PHQ-9 were baseline PHQ-9 score, WHO-5, PAID and CSS.\ud Conclusion\ud This study demonstrates the importance of psychosocial factors in addition to physiological variables in the development of depressive symptoms and incident MDD in people with type 2 diabetes. Stressful life events, depressive symptoms and diabetes-related distress all play a significant role which has implications for practice. A more holistic approach to care, which recognises the interplay of these psychosocial factors may help to mitigate their impact on diabetes self-management as well as MDD, thus early screening and treatment for symptoms is recommended.

Universal health coverage, comprehensive access to affordable and quality health services, is a key component of the newly adopted 2015 Sustainable Development Goals. Prior to the UN resolution, several countries began incorporating elements of universal health coverage into their domestic policy arenas. In 2013, the newly elected President of Kenya announced initiatives aimed at moving towards universal health coverage, which have proven to be controversial. Little is known about how frontline workers, increasingly politically active and responsible for executing these mandates, view these changes. To understand more about how actors make sense of universal health coverage policies, we conducted an interpretive policy analysis using well-established methods from critical policy studies. This study utilized in-depth semi-structured interviews from a cross section of 60 nurses in three health facilities (public and private) in Kenya. Nurses were found to be largely unfamiliar with universal health coverage and interpreted it in myriad ways. One policy in particular, free maternal health care, was interpreted positively in theory and negatively in practice. Nurses often relied on symbolic language to express powerlessness in the wake of significant health systems reform. Study participants linked many of these frustrations to disorganization in the health sector as well as the changing political landscape in Kenya. These interpretations provide insight into charged policy positions held by frontline workers that threaten to interrupt service delivery and undermine the movement towards universal health coverage in Kenya.

Reply by the current authors to the comments made by John G. Gunderson et al. (see record 2011-25063-003); John Livesley (see record 2011-25063-004); Joel Paris (see record 2011-25063-005); Anthony W. Bateman (see record 2011-25063-006); Andrew M. Chanen (see record 2011-25063-007); Erik Simonsen (see record 2011-25063-008); Kenneth R. Silk (see record 2011-25063-009); and Antonia S. New (see record 2011-25063-010) on the original article (see record 2011-25063-002). We welcome the opportunity to respond to the commentaries on our proposed revised classification of personality disorder. We argue that our revised classification, despite all the limitations imposed by the absence of independent biomarkers or other yardsticks, is a good empirical classification that synthesizes the advances that have been made in the past 30 years. These advances are not mere statistical developments that are esoteric and arcane; they show that there are several personality dimensions that together underpin diagnosis and explain pathology, which can be formulated simply and can be incorporated into a clinically useful nosological system. We agree that this represents only a start in defining a new classification, and we need to bring our proposals and those of the current DSM-5 system closer together. But we hope that our continued field studies and, indeed, the work of our commentators and other researchers will assist this in the next few years.

Nineteen years have elapsed since the 10th revision of the International Classification of Diseases (ICD-10), and many advances have been made in the field of personality disorders since that time. This paper reflects these advances and presents the first proposals of the ICD-11 working group for the reclassification of personality disorders. The essential changes from ICD-10 are to make the primary classification of personality disorder one of five levels of severity, including one of personality difficulty below the severity of disorder, to replace the existing categories of personality disorder with five monothetic trait domains of asocial, emotionally unstable, obsessional (anankastic), anxious/dependent and dissocial groups and to provide a simple algorithm for classification that can be used in ordinary psychiatric practice. It is argued that the proposed changes will improve the clinical utility of the diagnosis of personality disorder, reduce its stigma and help in the development and selection of appropriate treatment.

Background: When a patient presents with mental illness and displays psychotic symptoms which are not clearly delineated, a clinical diagnosis of psychosis is usually entertained. Aim: To determine the underlying Diagnostic and Statistical Manual of Mental Disorders-Fourth edition (DSM-IV) disorders in clinical entities admitted with a working diagnosis of \"psychosis\" at Mathari Psychiatric Hospital, Nairobi, Kenya. Study Design: Descriptive cross-sectional quantitative study Method: A total of 138 patients with a working diagnosis of \"psychosis\" on admission at Mathari Hospital during the period of this study were recruited over a one-month period. Their DSM-IV diagnoses were made using the Structured Clinical Interview for DSM-IV (SCID). Analysis of the results was done using SPSS version 11.5. Results: Nearly three quarters (72.5%) of the patients were male, 68.5% were aged between 20 and 34 years and 63.7% reported that they were single. Nearly half (49.2%) had attained up to 12 years of formal education and 90% were dependants of a member of the family. The most common DSM-IV diagnoses were schizophrenia, bipolar disorder, substance abuse, depression and anxiety disorders. Co-morbidity was recorded with an average of three DSM-IV disorders. Conclusion: \"Psychosis\" as a working diagnosis was reported in relatively young adults. The patients whose working clinical diagnosis was \"psychosis\" met the criteria for an average of three DSM-IV diagnoses. There is need for a proactive policy in clinical practice so that definitive diagnoses rather than just \"psychosis\" are made and appropriate management initiated as early as possible. African Health Sciences Vol. 7 (4) 2007: pp. 197-201