We review the origins and history of community psychiatry and the challenges posed to it by advancing technology and the neoliberal political economy and society that have prevailed since the 1990s. We summarise both achievements and shortcomings and argue that the term ‘community’ fails to acknowledge the gap between its original ambition and the outcomes of its implementation. We argue that, because of the changes that have taken place, the implementation of community psychiatry's objectives as conceived originally is likely to continue to fail. To sharpen current awareness and thinking and optimise future policy discourse and service strategies we revisit the concept of ‘metacommunity’. This is a historical descriptive label that aims to encapsulate the fundamental transformations that have taken place. These in turn demand of psychiatrists and other mental health providers both more socially critical thinking and mental health activism in the public sphere. Ultimately, beyond both community and metacommunity psychiatry, what is required is a democratic psychiatry.

In Continental Philosophy of Psychiatry: The Lure of Madness Alastair Morgan surveys the contributions of a loosely conceived school of psychiatrists, philosophers and social theorists to understanding and responding to madness during the years 1910–1980. Taking my cue from him, I highlight some of the contributors discussed in Morgan's book and reflect that although madness may be difficult or even impossible to articulate effectively in discourse it remains a ‘limit experience’ which demarcates and illuminates the contours of other thinking and being, including reason and activism. I discuss social and cultural factors that have dulled clinicians’ sensitivities to the sounds of madness in recent decades and advocate the need for a reappraisal of our expertise and for a new activism today. What may at first appear as a failed clinical-philosophical tradition remains of professional relevance in today's rapidly transforming circumstances of practice both as inspiration and as cautionary tale.