Schizophrenia continues to challenge services: recent advances in antipsychotic drug treatment and psychosocial interventions are hindered by non-adherence, disengagement and substance misuse. Furthermore, new side-effect concerns attach to atypical drugs, and psychosocial interventions may be underresourced or of unproven benefit. It is important to address all issues with which patients, families and carers need assistance, and to take a well-informed, creative approach to pharmacological treatment, using medication according to individual patient need rather than mechanistic adherence to guidelines. Psychiatrists should be realistic in their expectations of patient outcome, accepting outcomes that fall short of recovery and imply long-term supportive care, and insisting that this care be available to their patients. Psychiatrists should support early diagnosis and intervention as being possibly the only means to alleviate the burden of long-term schizophrenia for patients, families and services.