In the 50 years that have passed since I entered medical school, psychiatry has made great progress. It has developed effective drugs, and practical forms of psychotherapy. Slowly but surely, research is illuminating the causes of mental illness. While we can be frustrated about a slow rate of progress, many psychiatric treatments have been shown to be both efficacious (supported by clinical trials) and effective (working in the real world of practice).

Yet when not enough is known, we can fall victim to hubris. Psychiatry has sometimes embraced premature closure and easy answers. The 21st century began with great expectations for breakthroughs in both theory and treatment. Following ‘the decade of the brain’ in the 1990s, we prepared for a brave new world of specific biomarkers and bedside functional magnetic resonance imaging. One of the latest hopes is for personalised treatment based on genome analysis (Roberts et al, 2012). None of these things has come to pass, and one can only be sceptical that they lie just over the horizon. Psychiatry faces a long journey, and few of us will live to see it arrive at its destination.

In the meantime, the standard of mental healthcare offers grounds for both hope and concern. On the plus side, psychiatrists do a good job of caring for patients with severe illnesses. In the psychoses, clinical guidelines are evidence based and followed almost everywhere. But as soon as one moves into the realm of common mental disorders, patients can no longer be sure of receiving predictable treatment. The absence of a well-established standard of care leaves mental health practice open to faddishness.

A portrait of modern mental health services

Fewer patients today go directly to specialists. Those with common mental disorders usually pass through a gateway of primary care. But the treatments offered in that setting are also determined by the culture of contemporary psychiatry.