Health inequalities in psychiatry are well established, with people living in poverty and those from minoritised groups receiving different care and experiencing worse health outcomes. Psychiatric patients experience significant differences in life expectancy compared with the general population. This article explores changes within psychiatric services and public health interventions that could address health inequalities and asks why this has not happened yet.

When I reached Seychelles to start my new job with the Ministry of Health as a consultant psychiatrist at the Victoria Hospital I had hardly any idea about the islands, let alone its mental health service. But I decided to take the job partly out of curiosity and an interest to see what psychiatry would be on a tourist island in the middle of the Indian Ocean.

Contemporary psychiatry in the UK is practised in an era where the deinstitutionalisation programme is virtually complete. The vast majority of the large mental hospitals (once called asylums) that dominated mental healthcare have closed to be replaced by a complex network of community services (including a ‘virtual asylum’ of residential and nursing home provision). Psychiatrists of past generations recall the excitement (and concern) associated with the concepts of ‘community psychiatry’ and ‘community care’: some, including me, were appointed to post as a consultant community psychiatrist. In the era of ubiquitous community care is the community psychiatrist an anachronism? Or does the recent call for in-patient psychiatry to be recognised as a specialism (Dratcu, 2006) imply its obvious corollary, the specialist community psychiatrist?

Physicians caring for people with severe learning disabilities are frequently faced with the problem of self-injurious behaviour, which often takes a chronic course. Among neurotransmitter systems the serotonergic system in particular is thought to be involved in the initiation and maintenance of self-injurious behaviour, and pharmacological treatment with serotonin enhancers or serotonin reuptake inhibitors has been shown to reduce impulsive aggressive behaviour.

The Law Commission report on Mental Incapacity was published in 1995 and examines how decisions can be made on behalf of those who are unable to make decisions for themselves. It has far reaching implications for psychiatrists and recommends the introduction of new legislation. Research with those unable to consent, advance treatment directives, decisions about medical treatment and public law protection of vulnerable Incapable people are areas covered in the document. Although there are some concerns for psychiatrists, many of the proposals can be welcomed.