Professor Tom Burns, in his special article on community psychiatry's achievements (Burns, 2014, this issue), provides a magisterial overview of the field. Against the background of welfare state reforms in Western societies, he reviews community care pre-1980 as a ‘clinically driven, relatively a theoretical and highly localised evolution’ with a focus on multidisciplinary community mental health teams and geographic sectorisation of services, and he goes on to characterise post-1980 community mental health care as the period of evidence-based mental health services (Burns, 2014, this issue). There is ample evidence of the viability of reprovision of care following mental hospital closure and of the efficacy of alternative provision, with a focus on the assertive community treatment (ACT) model. Burns describes the surge of interest in psychosocial treatment approaches (e.g. adherence therapy, social skills training and supported employment) as part of community care reforms. However, with a strong trend towards specialisation in community mental health care (see early intervention, assertive outreach and crisis intervention services), with a strengthening of advocacy, recovery and the user movement he maintains that the current perspective of community psychiatry and the direction of movement cannot easily be discerned. Burns is clearly right in characterising community care as ‘an idea of its time’ (Burns, 2014, this issue). However, this leaves the task of determining what new ideas will reshape community mental health care or take its place.

Currently, there are some issues that require research effort. Burns (Reference Burns2014, this issue) highlights the fact that more recent trials of the assertive community treatment (ACT) model have shown less superiority over control conditions than earlier studies. In a previous editorial, Burns has challenged research designs that compare innovative interventions with ‘treatment as usual’ considering it an ill-defined term and calling for a shift to ‘head-to-head’ comparisons of equally well-defined services in taking the field forward (Burns, Reference Burns2009). Clearly, with some evidence of attrition of effectiveness over time (Burns et al. Reference Burns, Catty, Dash, Roberts, Lockwood and Marshall2007) it is fair to ask whether there has been a spillover of elements of innovative community care to just ‘any serious psychiatric practice’. With this happening there is a danger of loss of innovative potential in the community care paradigm, and the field needs to avoid inertia and stalemate.

Some recent high-quality randomised controlled trials found psychosocial interventions not to be effective. This applies to community treatment orders that were put to test in the OCTET study (Burns et al. Reference Burns, Rugkåsa, Molodynski, Dawson, Yeeles, Vazquez-Montes, Voysey, Sinclair and Priebe2013). There has been some debate on the OCTET study (Burns, Reference Burns2013; Segal, Reference Segal2013; Light, Reference Light2014) and, more widely, on community treatment orders but the finding remains of no convincing evidence in this and other trials on outpatient commitment (Swartz et al. Reference Swartz, Swanson, Wagner, Burns, Hiday and Borum1999; Steadman et al. Reference Steadman, Gounis, Dennis, Hopper, Roche, Swartz and Robbins2001). Also, there has been a large-scale randomised controlled trial of advance directives (joint crisis plans, JCP) in improving treatment provision in mental health crises (CRIMSON study, Thornicroft et al. Reference Thornicroft, Farrelly, Szmukler, Birchwood, Waheed, Flach, Barrett, Byford, Henderson, Sutherby, Lester, Rose, Dunn, Leese and Marshall2013) that failed to reduce the number of patients sectioned during follow-up (primary outcome). There were no differences in secondary outcomes either, with the exception of an improved secondary outcome of therapeutic relationships in the patient group who had a JCP. Findings, in the CRIMSON study, were inconsistent with two earlier JCP studies (that had been positive), and the authors concluded that, in their RCT, the JCP intervention was not significantly more effective than treatment as usual. Deficiencies in JCP implementation in some study sites were discussed by the authors, and questions of implementation of new interventions in routine treatment settings were raised. Similarly, Becker & Puschner (Reference Becker, Puschner, Thornicroft, Ruggeri and Goldberg2013), in discussing RCTs of psychosocial interventions, i.e. outcome monitoring and management (EMM study), discharge planning (NODPAM study) and antipsychotic medication adherence therapy (QUATRO study) that failed to significantly improve outcome, raised the pivotal role of (a) study context and of (b) the organisational and clinical determination in implementing trial interventions as key factors in the failure to achieve superiority over control conditions. Interestingly, there is also a systematic review reporting the failure to find differences in outcome in studies for clients receiving statutory mental health services from consumer-providers compared to professionals (Pitt et al. Reference Pitt, Lowe, Hill, Prictor, Hetrick, Ryan and Berends2013). These findings may reflect difficulties, in a highly developed and well-resourced community mental health care setting, to further improve on current routine practice. This would fit in well with the caution voiced by Burns in addressing the future ‘road’ for community psychiatry. Clearly, there is currently strong interest in non-professional input in mental health care systems and alternative care approaches such as the peer-support model (Mahlke et al. Reference Mahlke, Krämer, Becker and Bock2014).

An aspect that requires attention is the issue of cross-country and regional variation. Burns rightly states that there have been developments towards community mental health care in different European countries, and he refers to law 180 (passed in 1978) for Italy and the ‘Psychiatrie-Enquête’ for the Federal Republic of Germany (published in 1975). Although he is clearly right in stating that the paradigm shift towards community care has applied to all three countries mentioned, narrative descriptions of community mental health reform in European countries highlight that mental health and community care are highly variable, and that they can only be understood following the study of historical, societal, cultural and legislative background and that this underlines the caution in concluding from findings in one country on efficacy, feasibility and routine implementation in another country (de Girolamo et al. Reference de Girolamo, Bassi, Neri, Ruggeri, Santone and Picardi2007; Glover, Reference Glover2007; Salize et al. Reference Salize, Rössler and Becker2007; Verdoux, Reference Verdoux2007).

Also, limiting our discourse to high-income country settings with high funding levels, we need to acknowledge that society, culture and socioeconomic conditions are in a continuous process of change, and this is likely to impinge on the way community mental health services are provided and how paradigms and concepts in community care evolve. Changes that are likely to affect community mental health care include:

• • the tremendous increase in migration that shapes European society and culture (with ensuing socioeconomic and welfare issues) and the epidemiology of mental health problems and poses challenges to the care system (Bhugra et al. Reference Bhugra, Gupta, Schouler-Ocak, Graeff-Calliess, Deakin, Qureshi, Dales, Moussaoui, Kastrup, Tarricone, Till, Bassi and Carta2014);

• • a strengthening of the involvement of mental health service users in the debate around community care, adequate care systems, issues of coercion, social inclusion and human right issues in psychiatry (Wykes, Reference Wykes2014);

• • an intense interest in the potential of a (non-clinical) subjective recovery approach to mental illness in building adequate care systems (Slade et al. Reference Slade, Adams and O'Hagan2012);

• • a strong human rights focus in mental health care around the issues of coercion and involuntary treatment (Thornicroft & Tansella, Reference Thornicroft and Tansella2014);

• • a parallel trend, across Europe, of a rise in places in institutional care settings (re-institutionalisation (Priebe et al. Reference Priebe, Badesconyi, Fioritti, Hanson, Kilian, Torres-Gonzales, Turner and Wiersma2005);

• • a strong trend towards commodification of health care in high-resource Western societies;

• • a trend towards medicalisation across Western societies with a tendency to increasingly attribute emotional and unspecific states of ill-health to mental health problems and mental disorders, and with a corresponding increase in mental health service utilisation, pressure on resources and adequate allocation of care (Clark, Reference Clark2014); and

• • strong trends (with some debate around their existence) towards increasing inequity in rich societies, data pointing towards an increased poverty divide in Western societies and growing population subgroups in precarious living conditions across Europe (de Vogli, Reference de Vogli2014; Piketty & Saez, Reference Piketty and Saez2014).

In this societal setting and the lack of clarity around where community psychiatry should be heading, Thornicroft & Tansella (Reference Thornicroft and Tansella2014) provide a clear framework of reference that may be useful in moving the field forward. Against the very background described in the review by Burns (Reference Burns2014, this issue) they define nine proposals that formulate the challenges for our field. First, mental health services need to address a number of deficiencies that are of great ethical concern: they should increase the proportion of people with mental illness who receive effective care, reducing the considerable treatment gap; they need to address the far lower life expectancy among persons with mental disorders; and they should include programmes to reduce stigma and discrimination associated with mental illnesses. Second, mental health services need to provide more accessible and acceptable care; a careful balance between hospital- and community-based services; and finally should abandon ineffective or even harmful services. Third, shared decision making, the knowledge and practice of non-western practitioners as well as a focus on citizenship and recovery should play a greater role and be integrated into our services. Since the authors plausibly argue that most of these goals can be pursued in community psychiatric better than in inpatient settings, there is no shortage of exciting challenges for community psychiatry which may have a bright future after all.