Reading the first part of this book presents a striking contrast between current preoccupations in healthcare systems and the science presented here. In other words, between extant public concerns about entitlement to, funding of, and delivering healthcare in the second decade of the twenty-first century and the contents of Chapters 2, 3 and 4.

Healthcare systems and the people who fund, run and deliver them are, arguably, necessarily acutely sensitive to the socio-economic environment in which countries sit. The potential capabilities of healthcare continue to develop at increasingly rapid rates. By contrast, we live in a world in which the resources available are affected by austerity and in which the spread of affluence between the most advantaged people and the least affluent continues to grow. This is contributing to an increasing gap between potential capability and actual capacity, which appears to be expanding rapidly.

While there is great optimism for healthcare to be gained from developments in neuroscience, genetics and epigenetics, the social contexts and social approaches revealed by research, including much that we cover in this book, are also very powerful contributors to our health and recovery from ill health. As Nestler et al. say, ‘Psychiatric disorders are complex multifactorial illnesses … While genetic factors are important in the etiology of most mental disorders, the relatively high rates of discordance among identical twins … clearly indicate the importance of additional mechanisms’ (Nestler et al., 2016, p. 447).

This book focuses on social and environmental mechanisms; this chapter draws together a selection of the topics raised in Sections 1 and 2. We link facets of the social science that have come up thus far with concepts that are implicit in public physical and mental healthcare, and we summarise the concept of mental health recovery.

This book has considered the nature of health and mental health using the definition of the World Health Organization (WHO) and other definitions in Chapter 6. We now move to considering what the term ‘parity of esteem’ means. This chapter brings together thoughts about parity of esteem for mental health and mental healthcare with physical health and physical healthcare, and the way in which that reflects the contents and values in this book. I have spoken at international events about this topic on many occasions.

This practical guide is a very welcome and, dare I say, overdue contribution towards giving the physical health needs of people with mental health problems a higher priority.

As a medical discipline with its own specialty areas, psychiatry inevitably focuses on the mental health needs of patients. But as our mission is to improve the lives of people with mental illness, ‘improving lives’ should include physical as well as mental health and well-being.

This marvellous book makes it clear that this is not just an issue for psychiatrists, but is also an area for general practitioners, nurses and other health professionals to consider.

Even a cursory examination of some of the statistics reveals the huge cost of poor physical illness to those with severe mental illness. For example, men with a diagnosis of psychosis live 20 years less than the general population, while women with the diagnosis live 15 years less, with evidence that this ‘mortality gap’ may be widening.

Of the 7500 people who develop a psychosis in England each year, many face a future compromised by poor physical health as well as psychological difficulties. Antipsychotic drugs often lead to rapid weight gain and increases in cholesterol, compromising broader health and well-being. We also know that, for a wide variety of reasons, smoking prevalence among those with a diagnosis of schizophrenia is much higher than it is in the general population.

But behind the human tragedy of premature mortality is the reality that mental and physical disorders frequently coexist, often intertwined with social exclusion, restricted opportunities and disadvantage. People with an enduring physical illness are also more likely to experience mental health problems.

With chapters covering a wide range of health issues and common problems that may affect psychiatric patients, I am sure this book will be a great help to mental health professionals and psychiatrists everywhere. I am proud that the Royal College of Psychiatrists has published it.

Introduction

Young people at the interface of the criminal justice system and mental health services face social exclusion, alienation and stigmatisation (Bailey, 1999). The definition of this group varies across and within agencies; their needs are diverse and require a range of mental health services that can be effective only if integrated with the services of other agencies.

Young people account for almost a quarter of all persons arrested in a single year (Home Office, 2007). The psychosocial and biological factors placing young people at risk of both offending and mental health problems are well established (Junger-Tas et al, 1994; Kazdin, 1995; Rutter & Smith, 1995; Shepherd & Farrington, 1996; Rutter et al, 1998; Rutter, 1999).

Definitions

Forensic mental health has been defined as an area of specialisation that involves the assessment and treatment of those who are both mentally disordered and whose behaviour has led or could lead to offending (Mullen, 2000). Defining forensic psychiatry in terms of the assessment and treatment of the mentally disordered offender delineates an area of concern that could engulf much of mental health.

Offending behaviour is common in the whole community and among adolescents it is approaching the universal, with just under 40% of all known offenders being under the age of 21, and 24% of all offenders being aged 10–17 (Home Office, 2007). Males are more likely to have committed an offence, with 30% of males saying they had committed an offence in the past year (Home Office, 2006).

Antisocial behaviour is also prevalent with 23% of all young people having committed at least one act of antisocial behaviour in the previous year (Home Office, 2006). In practice, patients often gravitate to forensic services when the nature of their offending or the anxiety and apprehension created by their behaviour is such as to overwhelm the tolerance or confidence of professionals in the general mental health services.

In part, these cases are also driven by the emerging culture of blame, in which professionals fear being held responsible for failing to protect their fellow citizens from the violent behaviour of those who have been in their care. Mullen (2000) stresses that mental health expertise should address the mental health component of social problems, and highlights the importance of rigorous risk assessments and management.