Psychiatry has an image problem. The anti-psychiatry movement of the 60s is still thriving and clearly takes a dim view of the bio-medical management of mental disorder. The image of psychiatrists outside psychiatry (particularly amongst GPs) is all too often one of staid, rigid, unhelpful, protocol bound, catchment area defined, "10 'till 4" inflexibility. As a profession we must accept some culpability for these views. Psychiatrists are not very good at getting their message across. Despite important evidence-based advances in the treatment of mental illness, including the advent of safer, better-tolerated medications as well as cognitive-behavioural therapies which work, psychiatry still gets a bad press and patients continue to turn to complimentary therapies. The prominent media "shrinks" avoid the sensitive and difficult issues facing psychiatry.

Patients like to talk and, by and large, psychiatrists like listening. Diagnosing and treating mental illness without recourse to gadgets or complex tests, employing clinical skills acquired through experience and training, these are among the joys of psychiatry. Sadly today, if our patients need "talking to" they usually have to be referred to someone else; we barely have the time to clarify the treatment and record the "care plan", and our appointment schedules are little better than those of the average GP. This lack of "face to face" contact time has been highlighted by the report of the Confidential Enquiry into Homicides and Suicides as a common denominator of the lack of care for seriously ill patients. Despite this constrained availability, we are still expected to act as society's policeman, accepting virtually unlimited responsibility for "supervising" the mentally ill in the community.

Against this background psychiatrists increasingly feel they are not doing the job for which they were trained. How can patients be properly managed when so many factors - poverty, housing, under-staffed social service departments - are entirely beyond our control?

A variety of measures could be introduced that would significantly improve the present situation and would require little additional expenditure:

Perhaps the biggest challenge of all facing psychiatry the battle against stigma and prejudice. Until society stops excluding the severely mentally ill, then any amount of policy, resources or legislation will fail and the dream of community care will remain a Utopian fantasy. Psychiatrists must make public education a greater priority although there are few incentives to do this.

Psychiatric treatment still all too often takes place in unsuitable and even anti-therapeutic surroundings. Priority should be given to improve the environment of hospital as well as community mental health facilities. More so than other areas of medicine, psychiatrists have an absolute ethical duty to draw attention to short-falls in service provision especially because so many patients lack choice, this is the ethical principle of reciprocity. Mental Health Act section rates have risen year on year and it is hard to escape the conclusion that some of this increase must at least be attributable to the poor conditions of many acute psychiatric units. Can we ethically or morally countenance continuing to work in a service where we would be unwilling to see ourselves, friends or loved ones treated? Perhaps by passively accepting and working in such conditions we have unwittingly done more than anyone to perpetuate stigma and discrimination against the mentally ill. The current timely debate about access to the new "atypical" antipsychotic drugs for the treatment of schizophrenia (currently the subject of "postcode rationing") and under consideration by NICE has illuminated this debate: more than 90 per cent of psychiatrists surveyed wanted these drugs for themselves or their families in the event of a psychotic breakdown and yet less than 66 per cent actually prescribe them for their patients. Perhaps Health Commissioners and Purchasers should be made to actually take the older (and cheaper) alternatives and see for themselves what it is to suffer the disabling neurological side-effects associated with these drugs.

Defeating stigma is a matter of international concern. In too many nations the mentally ill and handicapped are treated little better than livestock. Perhaps if we as a profession did more to stand up for our patients we might go some way to regain some of our professional self-respect, dignity and public support which has been lost in recent years. Psychiatric research has done much to win the battle for the minds of the patient. The challenge facing us is the fight for the battle of the minds of the public.