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.

Patients with psychosis have activation of the hypothalamic-pituitary-adrenal (HPA) axis during the acute phase of the psychosis. Whether this has any morphological consequences for the pituitary gland is currently unknown.

To examine pituitary volume variation in people at different stages of psychotic disorder.

Pituitary volume was measured using 1.5 mm, coronal magnetic resonance images in 24 people with first-episode psychosis, 51 with established schizophrenia and 59 healthy controls.

Compared with the control group, the people with first-episode psychosis had pituitary volumes that were 10% larger, whereas those with established schizophrenia had pituitary volumes that were 17% smaller. In both of the groups with psychosis, there was no difference in pituitary volume between those receiving typical antipsychotic drugs and those receiving atypical antipsychotics.

The first episode of a psychosis is associated with a larger pituitary volume, which we suggest is due to activation of the HPA axis. The smaller pituitary volume in the group with established schizophrenia could be the consequence of repeated episodes of HPA axis hyperactivity.

ICD–10 has introduced the diagnostic group acute and transient psychotic disorders (ATPDs; F23). Aims To validate the nosological distinctiveness of ICD–10 ATPDs by following up an inception cohort with first-episode psychosis. Method All patients with first-episode psychosis identified in Nottingham between 1992 and 1994 and diagnosed using ICD–10 criteria were reassessed 3 years later. ATPD outcomes were compared with schizophrenia and affective psychosis. Multivariate analyses were conducted to determine whether acute onset and early remission predicted favourable 3-year outcome in first-episode psychosis. Results Of 168 cases of first-episode psychosis, 32 (19%) received an intake diagnosis of ATPD. The diagnosis of ATPD was stable in women over 3 years, but not in men. Outcomes in ATPD were better than in schizophrenia and similar to affective psychosis. In non-affective psychoses, favourable outcomes were a function of gender and premorbid functioning rather than acute onset and early remission. Conclusions The ICD–10 criteria for ATPDs identify a diagnostically unstable group of disorders. Acute onset and early remission do not independently predict favourable outcome over 3 years in first-episode psychosis.

Disturbances in the central nervous system originating during foetal life may increase the risk of schizophrenia.

To illuminate the hypothesis that prenatal exposure to analgesics may affect foetal neurodevelopment, leading to increased risk of schizophrenia in adulthood.

Using data from the Copenhagen Perinatal Cohort and from the Danish Psychiatric Central Register, we studied the relationship between prenatal exposure to analgesics and the risk of schizophrenia. The effect of prenatal exposure was adjusted for parental history of schizophrenia, second-trimester viral infections, concomitant drug treatment during pregnancy, an index of pregnancy complications, parental social status and parental age.

In a risk set of 7999 individuals, 116 cases of schizophrenia were found (1.5%). Prenatal exposure to analgesics in the second trimester was associated with an elevated risk (adjusted odds ratio 4.75, 95% CI1.9–12.0). Independent of the covariates, the effect remained statistically significant.

Independent of a wide range of possible confounders, a significant association between second-trimester exposure to analgesics and increased risk of schizophrenia was observed.

Stressful life events are established as risk factors for the onset of mood disorders, but few studies have investigated their impact on the development of mood disorders in adolescents.

To study the effect of life events on the development of mood disorders in the offspring of parents with bipolar disorder, with respect to the possibility of a decay effect and modification by familial loading.

In a high-risk cohort of 140 Dutch adolescent offspring of parents with bipolar disorder, we assessed life events, current and past DSM–IV diagnoses and familial loading. To explore their interaction and impact on mood disorder onset, we constructed four different models and used a multivariate survival analysis with time-dependent covariates.

The relationship between life events and mood disorder was described optimally with a model in which the effects of life events gradually decayed by 25% per year. The effect of life event load was not significantly stronger in the case of high familial loading.

Independent of familial loading, life events increase the liability to mood disorders in children of patients with bipolar disorder but the effects slowly diminish with time.

Psychosis associated with stimulant use is an increasing problem, but there is little research evidence about the nature of the problem and its management.

To critically review the literature on stimulant psychosis and sensitisation.

Systematic review of studies that have investigated stimulant use and psychosis in humans. The main outcome measures were increases in psychosis with stimulant use, and differences between stimulant users and non-users.

Fifty-four studies met the inclusion criteria. Experimental studies show that a single dose of a stimulant drug can produce a brief increase in psychosis ratings (a ‘response’) in 50–70% of participants with schizophrenia and preexisting acute psychotic symptoms, unaffected by the presence of antipsychotic medication. Those with schizophrenia who do not have acute psychotic symptoms respond, but less frequently (30%). There has been little research into the longer-term effects of use.

Compliance with antipsychotic medication by someone with schizophrenia will not prevent a relapse or worsening of psychotic symptoms if stimulants are used. Low-dose antipsychotic treatment may be beneficial in stimulant users, to prevent sensitisation.

No study outside the UK has examined the diagnostic stability of psychotic disorders in a population-based sample.

To determine diagnostic stability in a Dutch population-based psychosis incidence cohort, to examine the frequencies of diagnostic shifts to and from schizophrenic disorders and to report the revised relative risks of schizophrenic disorders for immigrants.

A 30-month follow-up study assessed the cohort (n=181) by means of face-to-face diagnostic interviews.

Diagnostic stability of schizophrenic disorders was high (91%), but lower for other psychotic disorders. At follow-up, the initial diagnosis was adjusted to schizophrenic disorder more often than that the reverse occurred. Almost half (49%) of the patients who were not initially diagnosed as having a schizophrenic disorder received this diagnosis at follow-up. The relative risks for most immigrant groups were stable.

Schizophrenic disorders are underdiagnosed, rather than overdiagnosed, at first presentation.

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.

Newer antidepressants have increasingly been used during the past decade. These drugs may increase compliance and reduce the risk of cycle acceleration in affective disorders.

To investigate the naturalistic longitudinal course of illness in patients with depressive or bipolar disorder following the use of recently introduced drugs.

The rates of relapse leading to hospitalisation after successive episodes were calculated in a case register study including all hospital admissions of patients with primary affective disorder in Denmark during 1994–1999. Altogether, 9417 patients had a diagnosis of depressive disorder and 1106 patients had a diagnosis of mania or bipolar disorder, at first-ever discharge.

The rate of relapse leading to hospitalisation increased with the number of previous episodes in both depressive and bipolar disorders. However, the effect of episodes was not significant for men. The rate of relapse did not decline during the study period.

The course of severe depressive and bipolar disorders has remained roughly the same despite introduction of new treatments.