There is controversy about whether mental health services should be provided in community or hospital settings. There is no worldwide consensus on which mental health service models are appropriate in low-, medium- and high-resource areas.

To provide an evidence base for this debate, and present a stepped care model.

Cochrane systematic reviews and other reviews were summarised.

The evidence supports a balanced approach, including both community and hospital services. Areas with low levels of resources may focus on improving primary care, with specialist back-up. Areas with medium resources may additionally provide out-patient clinics, community mental health teams (CMHTs), acute in-patient care, community residential care and forms of employment and occupation. High-resource areas may provide all the above, together with more specialised services such as specialised out-patient clinics and CMHTs, assertive community treatment teams, early intervention teams, alternatives to acute in-patient care, alternative types of community residential care and alternative occupation and rehabilitation.

Both community and hospital services are necessary in all areas regardless of their level of resources, according to the additive and sequential stepped care model described here.

Advances in the ability to identify people at high risk of developing psychosis have generated interest in the possibility of preventing psychosis.

To evaluate the efficacy of cognitive therapy for the prevention of transition to psychosis.

A randomised controlled trial compared cognitive therapy with treatment as usual in 58 patients at ultra-high risk of developing a first episode of psychosis. Therapy was provided over 6 months, and all patients were monitored on a monthly basis for 12 months.

Logistic regression demonstrated that cognitive therapy significantly reduced the likelihood of making progression to psychosis as defined on the Positive and Negative Syndrome Scale over 12 months. In addition, it significantly reduced the likelihood of being prescribed antipsychotic medication and of meeting criteria for a DSM – IV diagnosis of a psychotic disorder. Analysis of covariance showed that the intervention also significantly improved positive symptoms of psychosis in this population over the 12-month period.

Cognitive therapy appears to be an acceptable and efficacious intervention for people at high risk of developing psychosis.

The psychosis phenotype is generally thought of as a categorical entity. However, there is increasing evidence that psychosis exists in the population as a continuum of severity rather than an all-or-none phenomenon.

To investigate the prevalence and correlates of self-reported psychotic symptoms using data from the 2000 British National Survey of Psychiatric Morbidity.

A total of 8580 respondents aged 16–74 years were interviewed. Questions covered mental health, physical health, substance use, life events and socio-demographic variables. The Psychosis Screening Questionnaire (PSQ) was used to identify psychotic symptoms.

Of the respondents, 5.5% endorsed one or more items on the PSQ. Factors independently associated with psychotic symptoms were cannabis dependence, alcohol dependence, victimisation, recent stressful life events, lower intellectual ability and neurotic symptoms. Male gender was associated with paranoid thoughts, whereas female gender predicted hallucinatory experiences.

Self-reported psychotic symptoms are less common in this study than reported elsewhere, because of the measure used. These symptoms have demographic and clinical correlates similar to clinical psychosis.

Little is known about what characteristics of teams, staff and patients are associated with a favourable outcome of severe mental illness managed by assertive outreach.

To identify predictors of voluntary and compulsory admissions in routine assertive outreach services in the UK.

Nine features of team organisation and policy, five variables assessing staff satisfaction and burn-out and eleven patient characteristics taken from the baseline data of the Pan-London Assertive Outreach Study were tested as predictors of voluntary and compulsory admissions within a 9-month follow-up period.

Weekend working, staff burn-out and lack of contact of the patient with other services were associated independently with a higher probability of both voluntary and compulsory admission. In addition, admissions in the past predicted further voluntary and compulsory admissions, and teams not working extended hours predicted compulsory admissions in the follow-up period.

Characteristics of team working practice, staff burn-out and patients' history are associated independently with outcome. Patient contact with other services is a positive prognostic factor.

We set out to determine whether anorexia nervosa exists in a culture where the pressure to be thin is less pervasive.

To determine whether there were any cases of anorexia nervosa in female students attending two secondary schools in the north-east region of Ghana.

The body mass index (BMI) of consenting students was calculated after measuring their height and weight. Those with a BMI ⩽19 kg/m2 underwent a structured clinical assessment including mental state, physical examination and completion of the Eating Attitudes Test and the Bulimic Investigatory Test, Edinburgh. Participants nominated a best friend to serve as a comparison group, and these young women underwent the same assessments.

Of the 668 students who were screened for BMI, 10 with a BMI <175 kg/m2 appeared to have self-starvation as the only cause of their low weight. All 10 viewed their food restriction positively and in religious terms. The beliefs of these individuals included ideas of self-control and denial of hunger, without the typical anorexic concerns about weight or shape.

Morbid self-starvation may be the core feature of anorexia nervosa, with the attribution for the self-starvation behaviour varying between cultures.

No study has directly assessed the need for mental health care among those consulting in general practice.

To make a direct assessment of the needs for mental health care in people with non-psychotic disorders consulting their general practitioner.

In a two-phase study design, consecutive general practice attenders aged 17–65 years were interviewed using the Structured Clinical Interview for DSM–IV Axis I Disorders. Needs for care were assessed using the community version of the Medical Research Council Needs for Care Assessment Schedule.

Three hundred and thirty-six people were interviewed. The overall prevalence of need was 27.3%. More than half of the consulters (59.6%) had unmet needs and a further 6.2% had partially met needs. Needs were met in 28.1% and unmeetable in 6.2%. The prevalence of unmet need in those with anxiety disorders was 13.9% and depressive disorders 9.5%.

The unmet need for mental health treatment in primary care attenders is high.

Most studies of post-traumatic stress disorder following terrorist attacks are of small samples in industrialised nations and take place months or years after the incident.

To describe reactions following the US embassy bombing in Nairobi and the characteristic features of and risk factors for post-traumatic stress symptoms in a large, non-Western sample soon after the attack.

A self-report questionnaire which assessed potential risk factors and identified symptoms matching DSM–IV criteria for post-traumatic stress disorder was answered by 2883 Kenyans, 1–3 months after the bombing.

Symptoms approximating to the criteria for post-traumatic stress disorder occurred in 35%. Factors associated with post-traumatic stress included female gender, unmarried status, lack of college education, seeing the blast, injury, not recovering from injury, not confiding in a friend, bereavement and financial difficulty since the blast. Many other factors were not significant.

Specific factors often cited to predict marked short-term post-traumatic stress were confirmed in this large, non-Western sample.

The assessment and reporting of national patterns of psychiatric hospital admissions is important for strategic service development and planning.

To investigate patterns of psychiatric hospital admissions of patients aged 16–64 years in England.

We used the Department of Health's national Hospital Episode Statistics data on admissions to National Health Service hospitals in England between April 1999 and March 2000, to investigate patterns by region, gender, age and diagnosis.

The annual admission rate for England was 3.2 per 1000 population. There were marked regional variations and rates were higher in males than in females. Depression and anxiety together were the most common (29.6%) reason for admission. Length of stay exceeded 90 days in 9.2% of admissions and 1 year in 0.9% (highest in London and for psychoses).

Depression and anxiety together were the most frequent diagnoses leading to hospitalisation. There has been a reversal of the previously reported predominance of female admissions. Regional variations in activity and the significant numbers of patients remaining for long periods in acute’ in-patient care have important policy implications.

Little is known about the efficacy of educational interventions for reducing the stigma associated with depression.

To investigate the effects on stigma of two internet depression sites.

A sample of 525 individuals with elevated scores on a depression assessment scale were randomly allocated to a depression information website (BluePages), a cognitive–behavioural skills training website (MoodGYM) or an attention control condition. Personal stigma (personal stigmatising attitudes to depression) and perceived stigma (perception of what most other people believe) were assessed before and after the intervention.

Relative to the control, the internet sites significantly reduced personal stigma, although the effects were small. BluePages had no effect on perceived stigma and MoodGYM was associated with an increase in perceived stigma relative to the control. Changes in stigma were not mediated by changes in depression, depression literacy or cognitive–behavioural therapy literacy.

The internet warrants further investigation as a means of delivering stigma reduction programmes for depression.