Research on aetiology three levels and three designs

Epidemiological methods can be applied at any of three levels: to disorders as these present in hospitals and specialist health services, in primary care, or in the general population. These three levels are represented diagrammatically in Fig 1 as a three-dimensional cone, derived from the seminal volume on pathways to care by Goldberg and Huxley.(l4) The base of the cone consists of those in the general population who have clinically significant psychological symptoms (Stage 1). When these symptoms become unmanageable to self or to others, people seek help from their doctor or other health practitioners (Stage 2). But only some of them are recognized by the professional to have significant mental health problems (Stage 3). A small proportion may be referred to mental health services (Stage 4), of whom an even smaller fraction are admitted to inpatient care (Stage 5). Note that undergraduate teaching and the diagnostic criteria in international use are largely based on Stages 4 and 5!

Fig. 1 Pathways to care. (Adapted from Goldberg and Huxley.(14))
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