Mental health and illness in the 21st century is in the same position that Clinical Medicine occupied in the late 19th century-the science imperfect, the laboratory of limited usefulness, the therapeutic armamentarium limited and the mode of action of therapies ill understood.

In the 19th Century there was however a considerable skill in history taking, examination and the description of disease.

This ignorance with diagnosis based on clinical skills and treatment on empiricism is changing rapidly. Today there is an increased understanding of brain biochemistry and the ability to visualize brain-activity in health and disease with Computerized Tomography (CT scans), Magnetic Resonance imaging ( MRI) and Positron Emission Tomography(PET). In turn this leads to a rational therapeutics.

It is much more difficult to define mental illness than renal failure. There is no convenient laboratory test to distinguish the ill from the not ill.

A rational,pragmatic approach has been effective and even successful with the advent of new medications in the 1950’s , the closure of large institutions-the feared asylums, the development of community support services, a realization of the chronicity of illness and the need for treatment over months or years.