What emerges across the world is a picture of contrasts and commonalities. Cultural contexts, expenditure levels, availability of trained manpower, and extent of central service coordination differ widely. Yet mental illness itself and the needs of the seriously mentally ill are remarkably consistent. Hospital care is the single largest budget item in each of the mental health systems described, and, in each, savings from the reduction of inpatient beds are applied to develop community-based hospital alternatives. These include residential care, day treatment, rehabilitation, community domiciles, and nonhospital acute care programs. Along with a worldwide shift away from the large institution is the widespread organization of families, patients, consumers, and users for greater participation in the planning, design, and operation of new services.