Many service users and professionals are not satisfied with current hospital care: they call for a safer and more friendly environment, with greater freedom and less social distance between staff and patients. Phase 2 of the Alternatives Study was designed to improve the evidence base for such residential alternatives. Findings suggest that offering a more acceptable environment increases satisfaction with treatment, although it does not improve the clinical outcome. This set of coordinated studies also suggest that we should listen (and talk) more to our patients, and make our style of working in hospital and community facilities less paternalistic.

The UK healthcare economy is facing an unprecedented downturn, mental health services being particularly vulnerable. The Royal College of Psychiatrists' Fair Deal campaign is a potentially important tool to help protect services. However, like the College itself, it is only as strong as the membership, and requires individual commitment and involvement if it is to be effective.

The limitations of current diagnostic categories are well recognised but their rationale, advantages and utility are often ignored. The scientific support for a ‘continuum of psychosis' is limited, and the examination of whether categories, a continuum or more than one continua, and alternatives such as subtypes or hybrid models, best account for the distributions of symptoms in populations has simply not been done. There is a lack of discussion, let alone consensus, about the critical aspects of psychosis to measure, the best ways to quantify those and how these would be applied in clinical practice. Systematic studies are needed to evaluate which of a range of plausible approaches to the classification of psychosis is most useful before change could be justified.

British hospital alternatives inherit some of their most valuable features, such as the use of small, domestic environments and the avoidance of coercion and confinement, from the early 19th-century moral management movement. The North American experience illustrates that these advantages can be lost if clinical benefits are overridden by cost and other practical concerns.

Our ideas about the intrinsically pathological nature of hallucinations and delusions are being challenged by findings from epidemiology, neuroimaging and clinical research. Population-based studies using both self-report and interview surveys show that the prevalence of psychotic symptoms is far greater than had been previously considered, prompting us to re-evaluate these psychotic symptoms and their meaning in an evolutionary context. This non-clinical phenotype may hold the key to understanding the persistence of psychosis in the population. From a neuroscientific point of view, detailed investigation of the non-clinical psychosis phenotype should provide novel leads for research into the aetiology, nosology and treatment of psychosis.

Allen Shand works as a general adult psychiatrist at Royal Cornhill Hospital, Aberdeen. He has always been an enthusiastic artist but only took up photography in 2004 while living in Melbourne, Australia where he worked as a registrar in psychiatry. He describes Recovery as follows:

Greater income inequality is associated with higher prevalence of mental illness and drug misuse in rich societies. There are threefold differences in the proportion of the population suffering from mental illness between more and less equal countries. This relationship is most likely mediated by the impact of inequality on the quality of social relationships and the scale of status differentiation in different societies.