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Uganda has passed through political and bloody civil strife stretching over 40 years. Since 1987 the HIV/AIDS pandemic has compounded the problems of the country. The present paper describes some initiatives to develop mental health services in one district of the country. A bottom-up approach in the district resulted in the formation of a community-led mental health program with strong support from two self-help groups, district political leaders and district representatives in parliament. Primary health care providers at all levels of health care in the district were trained in order to make services accessible to the rural population. Further plans based on initial exploratory discussions aim to involve the education department, the welfare and probation office, prisons and police, the military, church and cultural leaders and traditional healers. These initiatives show that it is possible to empower communities to participate in the development of mental health programs in a low-income country.

Referrals for psychological treatment have been problematic for many years. Even though GPs have attempted to limit access into the small psychological treatment services, long waiting lists have developed which have deterred referrals and deferred psychological care. GPs have understandably been frustrated. In addition, the consultation rate for psychological problems is low when compared with the rate of identified mental health problems in population surveys. Possible reasons include patients' failure to recognise the problem as psychological and thus not consulting one's GP, and/or the problem not being detected by the GP. While a self-referral system may be seen as a way of trying to allow non-consulters to receive treatment, this has been viewed with some scepticism since it may allow the 'worried well' to access already limited services. However, a study has shown that those self-referring to advertised psychological workshops had high levels of psychological morbidity and also were more representative of the population, in terms of ethnicity, than GP referrals. The government has set up the Increasing Access to Psychological Therapies (IAPT) programme to address some of the service shortfalls by expanding the provision of psychological therapists. Notably, the IAPT programme is allowing self-referrals such that any member of the public can access the service directly, bypassing general practice. Although not available at all the sites, this represents a radical shift from the present system in which access to talking therapy is generally only available through direct referral by the GP. The implications of this new development are discussed.