Authors' reply

We are indebted to Caan for an opportunity to further debate the potential of preventive psychiatry within a public health context. A failure to address inequalities reflects not only a failure of leadership but also lack of commitment by all sectors to recognise potential benefits in human capital and economic savings over the next decades. The Royal College of Psychiatrists’ position statement, ¹ which informed the Department of Health strategy No Health without Mental Health, sets out the evidence base and the need for further research. Recognising the role of psychiatrists and specialists in primary, secondary and tertiary prevention as well as the need for further development to include a role for specialists with appropriate training and accreditation processes is vital.

Preventive psychiatry is not new and remedying the consequences of adversity and vulnerabilities are but one of a number of preventive activities that already take place within existing psychiatric practice. The editorial sets this out alongside the new challenges facing specialists but also the wider public health community. ² The prevention of violence and hostility between adults and young people has been long recognised as a core task of preventive psychiatry. ³ As set out in the College’s position statement, ¹ protecting and promoting health and optimal maturation of young people while taking account of complex interactions between biology and the environment are key objectives and are also at the heart of more complex approaches to medicine in general; ⁴ preventing gender violence, sexual exploitation and abuse, promoting best parenting, nutrition, exercise, and education, protecting mental capital and physical health, and delivering interventions that develop mature adults who enjoy the responsibilities of adulthood while still enjoying the pleasures of life over the life-course are clearly important objectives. These policy priorities, although challenged by the need for more evidence and related research questions, are as important in low- and middle-income countries as in their higher-income neighbours. ⁵

These ambitious frameworks require local adaptations and actions, which incorporate an understanding of people’s lifestyle, attitudes, beliefs, cultures and status reflected in the delivery of interventions. ⁵ Existing universal and global policies are being challenged by socially excluded groups and by people with multiple health problems, as well as those presenting with novel phenotypes. ⁴ There is a role for specialists to be central to both policy and delivery, and to inform other stakeholders of the many varieties of personal distress and illness that are often lumped together under the title of mental health; an approach that would not be acceptable, say, for infectious diseases (see Lemkau ⁶ ). Inclusive and progressive policies and practices must protect the health and well-being of the population as a whole but also of the most vulnerable, including those victim to inequalities and social exclusion or those with complex needs that do not conform to unitary concepts of what constitutes mental health, illness and mental disorder; ⁷ these opportunities must be seized while also dealing with economic and financial crises that have an adverse impact on population mental health.