Since the beginning of the nineteenth century, society has struggled to meet the ever-growing needs for psychiatric services from an ever-growing population with ever-growing demands for better standards of care. During the nineteenth century, mental hospitals were built outside the urban areas; these hospitals were organised in accord with the best standards of care of that time, But because of progressive overcrowding and understaffing, the care of the patients in these hospitals became inhumane and humiliating. These conditions led to an ideological movement intending to give back to patients their dignity and autonomy. This movement has been encouraged by changed perceptions of an individual's rights and dignity which have blossomed during the twentieth century.
At the present time the ideological assumptions guiding the development of policy in the care of the mentally ill have been joined with economic considerations. As a consequence, the reduction in the availability of psychiatric beds has not been sufficiently balanced by an increase in community services for the mentally ill. Among the most visible social consequences of these changes are the homeless mentally ill wandering the streets of metropolitan areas and the unacceptably high numbers of people with mental illness who remain in prisons. To address these deficits, changes in service must both improve standards of care and at the same time be cost-effective. It is no longer acceptable for well-intentioned, humanitarian professionals alone to be involved in planning decisions; the caregivers, the service users and their relatives must also be involved. Consequently it is now necessary to set clear goals for services, to develop new, more effective treatments, and to develop services which are based on evidence.
But research and practice in mental health are not straightforward. The complexity of society must be reflected in the complexity of the research. The care of the severely mentally ill patient involves more than the patient, his or her relatives and the psychiatrist. The social welfare system, volunteer organisations, primary health care staff and the criminal justice system all play key roles in the pattern of care. Their joint impact must be a part of the overall assessment of the effectiveness of the care of the patient.