Review of the forensic psychiatry service at Zomba Mental Hospital and a comparison of forensic psychiatry services in Malawi and Scotland.

This retrospective case-note study describes the demographic details, offences and diagnostic characteristics of 283 patients admitted to Zomba Mental Hospital, Malawi, after early diversion from the Criminal Justice System between May 1997 and February 2007. Given the historical links between Malawi and Scotland and the ongoing involvement of Scottish psychiatrists in the development of psychiatry in Malawi, a comparison is drawn between the provision of secure psychiatric treatment in these low- and high-income countries. Consistent with Scottish prison mental health team referrals and Scottish high secure psychiatric patients, the Malawian patients were predominantly men, poorly educated and drug misusing, but alcohol was less often a problem. Affective disorders were rarely diagnosed, as is also the case in the equivalent Scottish populations. In Malawi, there appears to be a problem with aftercare because many of the patients had been detained before. The length of detention was very short, other than an exceptional finding for substance misuse--a mental disorder with no Mental Health Act equivalence in the UK. Absconding was the commonest outcome. Malawian patients diverted from the Criminal Justice System are treated on general adult psychiatry wards where few secure measures can be offered. Further, there is little capacity for follow-up, no community compulsion legislation exists and psychiatric expertise is limited to a few disparate sites. However, the service is developing and the data in this study represent a small part of that ongoing programme.