SYNOPSIS This paper describes the referral pathways taken by 1554 patients newly referred to the mental health services in 11 countries, and documents factors associated with delays in referral. The pathways in centres relatively well provided with psychiatric staff were dominated by general practitioners and to a lesser extent hospital doctors: the relatively less well resourced centres showed a variety of pathways with native healers often playing an important part. Delays were remarkably short in all centres regardless of psychiatric resources, but in some centres we found longer delays on pathways involving native healers. Somatic problems were a common presentation in all centres, and in some centres there was a tendency for patients presenting with somatic problems to have longer delays than those with symptoms of depression or anxiety. The implications of these findings are discussed in the context of an ongoing programme of WHO research activities aimed at improving the quality of mental illness care available in community settings.

The prevalence of psychiatric morbidity (PM) was studied among general hospital out-patients in a rural and in a semi-urban area of Kenya. There were no significant differences in the demographic features of psychiatric patients from the two areas, so the results were pooled: this gave a PM prevalence rate of 29 per cent among 388 patients. Anxiety and depression were the most frequent diagnostic categories. Alcoholism was more common in the rural than in the semi-urban area. There was no sex difference in the prevalence of PM and possible reasons for this, which is in contrast to western findings, are discussed. Psychiatric symptoms could be readily elicited when present. Patients showing them had been ill longer than non-PM patients. The study suggests that clinic staff not psychiatrically trained should be able to identify and treat psychiatric morbidity, even when it is presented as somatic illness.

Characteristics of patients absconding from an open psychiatry ward in a developing country may be different from both those in developed countries and a mental hospital setting. The aim of this paper is to study the incidence and characteristics of patients absconding from an open psychiatric ward in a general hospital-based psychiatric unit in India. We studied patients consecutively admitted to an open psychiatric ward over a 2-month period. We compared those who absconded with those who did not. Out of 231 patients admitted, 33 absconded. Among those who absconded, 15 had bipolar disorder, 11 had schizophrenia and five had substance-related disorders. Nine had indicated their intention to do so at admission. Ten patients had absconded by the second day. The treatment cost was the likely influencing factor for seven patients who absconded after deemed fit for discharge on clinical grounds. Only 10 patients were readmitted to the hospital within 2 weeks of absconding. The risk of absconding is highest in the early days following. Absconding patients did not differ significantly from others in many socio-demographic and clinical features. Treatment costs are an important consideration in India.

Four case reports are presented of psychotic patients seen in clinical practice in Nairobi over a period of one year, who inflicted serious bodily harm to themselves during that period. Possible psychopathological basis for this self-damage is briefly considered. A review of the literature reveals paucity of similar reports from Africa and the third world. Reasons for this paucity are hard to come by.

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