Clearly, the introduction of lithium and then chlorpromazine, closely followed by other first generation antipsychotic medications, heralded a new era in psychiatry. This was referred to as the ‘Golden Age’ of psychopharmacology, rivalling the period of discovery, for instance, of antibiotics or antihypertensives (Lieberman et al 2000). There was, henceforth, a treatment for symptoms of psychosis that promised to give new hope to people who previously had had little relief from an almost continuous presence of symptoms and the related distressing emotions and behaviours they often brought. The introduction of medications that were able to control many of these symptoms contributed to a change in the care of people with mental illness, moving increasingly from large psychiatric institutions out into the community. In 1990, the ever-increasing focus on research and development in pharmacological treatments led to a declaration of the ‘decade of the brain’ (Floersch 2003). Neuroscience was becoming an ever more prominent force in understanding the structure and function of the brain, and how disturbances in neurochemical functioning could impact upon a person’s thoughts, feelings and behaviours.

More recently, there have been further additions to the range of psychotropic medications. The second generation antipsychotics or atypicals were introduced initially in the 1950s and quickly withdrawn due to concerns over the side effects of clozapine. They were re-introduced in the 1980s and have brought with them comparable effectiveness to the first generation medications, yet with fewer side effects (Epstein et al 2007). This is a significant development, as the side effects of many of the psychotropics have been a major factor in consumer dissatisfaction and non-adherence. Similar developments occurred with the antidepressant group of medications. The tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) were introduced in the 1950s and were followed from the 1980s onwards by the newer and better tolerated selective serotonin reuptake inhibitors (SSRIs), for example fluoxetine, and the noradrenaline serotonin reuptake inhibitors (NSRIs), such as venlafaxine. However, concerns about the increasing costs of many of these medications and the social stigma and discrimination associated with the diagnosis and treatment of mental health problems, along with high side effect profiles, have contributed to consumers becoming increasingly vocal about perceived over-reliance on these forms of treatment. These concerns have existed within the context of a debate about the dominance of the scientific approach in the understanding and management of mental health problems.

The field of psychopharmacology is based on a model of understanding that considers that the development of symptoms of mental health problems is caused primarily by biochemical disturbances in the brain. The focus is on diagnosing the disorder/s in the individual, with the aim to cure or remediate symptoms through the use of somatic treatments such as psychotropic medications or electro-convulsive therapy. This has become the major paradigm in the care and treatment of people with mental health problems (Select Committee on Mental Health 2006). Yet, such an approach does not focus on the individual’s experience of their illness and tends to emphasise their deficits rather than strengths. While biochemical causes are significant, there is an increasing understanding of the multifactorial influences of psychosocial factors on the development of mental health problems.

The treatment context in whichpsychotropic medications are administered

As discussed, pharmacological treatments for mental disorders were extremely limited prior to the discoveries of the efficacies of psychotropic medications in the 1950s. As a consequence of these discoveries as well as changing sentiment regarding the treatment of mentally ill persons globally, reforms were implemented that led to a period where alternatives to institutionalisation for the care and treatment of people with severe mental illness were instigated. Known as ‘deinstitutionalisation’, this period led to the closure of most of the large psychiatric facilities in both Australia and New Zealand. In their place we now have mental health units attached to general hospitals, an approach referred to as ‘mainstreaming’, and a greater emphasis on community-based services.

As a direct result of deinstitutionalisation, the number of inpatient beds in public psychiatric facilities in Australia fell from around 30,000 in the 1960s to around 6,000 by 2005 (Department of Health and Ageing 2005). Inpatient services for people with severe mental illness in Australia and New Zealand are now mainly provided in general hospitals in intensive care, acute care and longer term care wards. Community services include psychiatric emergency services and 24-hour crisis teams, continuing care and consultancy teams and mobile intensive community treatment teams (MITT) and others (Muir-Cochrane et al 2005), although the terms used to describe the services may differ between areas, regions and countries. However, the investment in community mental health services promised at the time of deinstitutionalisation has not eventuated, resulting in a paucity of services for people experiencing a mental illness. In Australia, there continues to be an over-reliance on acute inpatient facilities as the primary, and sometimes only, source of support for people living with a serious mental illness and experiencing an acute episode (Mental Health Council of Australia 2006). This is a problem given that Australia and New Zealand both need more services for people requiring psychosis care. At present there are many such people who need to go to hospital but cannot because the acute units are full of people with chronic conditions (Andrews 2006).

Initiatives in Australia and New Zealand have been implemented in recent years in an attempt to improve the range of services available to people experiencing mental illness. In Australia, the National Mental Health Strategy launched a national reform agenda in recognition of the significant impact of mental illness on individuals, their families and the wider community. Under this strategy, the National Mental Health Policy (Australian Health Ministers 1992b) outlined the broad aims and goals designed to guide reform. The policy addressed important areas such as consumer rights, service mix, promotion and prevention. It also outlined the key principles underlying service developments, including the creation of opportunities for consumer participation in such developments and the need for responsiveness of the mental health services to the needs of consumers.

The National Mental Health Plan (Australian Health Ministers 1992a) set out a 5-year plan (1993–1998), which expressed commitment to the overarching principles of mainstreaming and integration. The Second National Mental Health Plan (1998–2003) and the National Mental Health Plan (2003–2008) have moved the reform agenda further, taking particular account of the range of settings in which health promotion and community education could occur, acknowledging that different people require different types of services and interventions, focusing on improving the quality and effectiveness of mental health services, supporting the development of partnerships between service providers and consumers and carers, increasing service responsiveness and fostering research, innovation and sustainability (Ash et al 2006). Regardless of the reform agenda, widespread dissatisfaction with mental health services in Australia continued and the Senate Select Committee was established in 2006. Its first report, A National Approach to Mental Health; From Crisis to Community, outlined many issues such as the failure of deinstitutionalisation, recognition of the limitations of mainstreaming, the ineffective use of available resources, variability of the quality of mental health care, and how the dominant medical model continues to hinder improvement in the quality of services and care.

In New Zealand, deinstitutionalisation also led to recognition that community services were inadequate. As a result, the National Mental Health Strategy was launched in 1994 with the publication of Looking Forward: Strategic Directions for the Mental Health Services (Ministry of Health 1994). This publication outlined two goals: to decrease the prevalence of mental illness and mental health problems within the community; and to improve the health status of and reduce the impact of mental disorders on consumers, their families, caregivers and the general community. The directions of the strategy were to: implement community-based services; encourage Maori involvement in the planning, development and delivery of services; improve quality of care; balance personal rights with protection of the public; and develop a national drug and alcohol policy (Muir-Cochrane et al 2005). However, in 1996 the Mental Health Commission was established with the recognition that services had not achieved the desired outcomes and that a process of independent monitoring of mental health policy and service delivery was required to improve services. The Commission is guided by the 1998 document Blueprint for Mental Health Services and is charged with facilitating the implementation of the National Mental Health Strategy as well as reviewing aspects of services. The future direction for the delivery of mental health services in New Zealand is now guided by the Te Tahuhu New Zealand Mental Health Plan 2005–2015.

Within these treatment contexts, where there has been a push for the development and delivery of more services within the community, psychotropic medications have become increasingly important even though their use remains contentious (Frank et al 2005). However, disadvantaged social groups, such as Australian Indigenous peoples and New Zealand Maori and Pacific Islanders, are amongst those who have lower rates of access to mental health services and are therefore less likely to receive treatment, including psychotropic medication (O’Brien et al 2007, Wells et al 2006). The achievements of psychotropic medication research and development, however, have generally enabled people experiencing mental disorders to spend less time in hospital and to be troubled less by the deleterious side effects of the earlier psychotropic medications, making contemporary medicines much more acceptable to consumers (Epstein et al 2007).