About one in three people with schizophrenia in South Africa relapse within a year, with clinicians saying this is driven by multiple interacting factors, and calling for the beefing up of primary-level mental healthcare, a more reliable supply of medication, and expanded vocational support programmes, among other things.
Schizophrenia relapse is a common, troubling reality affecting about one in every 100 people in SA, and with a notable percentage of those who have the chronic and debilitating condition experiencing a recurrence within the first year of diagnosis.
Yet while relapse is often blamed on patients not taking their medication as prescribed, recent research suggests experts view this as a symptom of deeper structural challenges rather than a root cause.
In a study published in Global Mental Health, Dr Retha Smit and colleagues from Stellenbosch University’s Department of Psychiatry examined public-sector clinicians’ perspectives on why these relapses occur.
“Our findings show that clinicians do not see relapse as a single-cause event, but rather as the result of multiple interacting factors,” said lead author Smit.
“They describe how clinical vulnerabilities intersect with social pressures, economic hardship, stigma, and constraints within the healthcare system. In this way, the environment in which care is delivered plays a major role in shaping relapse trajectories.”
Relapse can be a major challenge in lower- and middle-income countries, where mental health services are almost always overstretched and under-resourced.
And although it’s frequently framed in terms of individual behaviour – particularly treatment non-adherence – this perspective overlooks the broader social and systemic barriers influencing patients’ ability to remain well.
The researchers conducted three focus groups in South Africa with 14 public-sector clinicians, including psychiatrists, medical officers, psychiatric registrars, and psychiatric nurses, all with experience in schizophrenia care.
While participants consistently identified medication non-adherence as the immediate trigger for relapse, this behaviour is often driven by inadequate social and healthcare support systems. Apart from stigma and erratic and fragmented service delivery, other contributing factors include poverty, unemployment, and safety concerns.
Healthcare system constraints also play a significant role. Clinicians highlighted limited access to newer-generation antipsychotic medications, medication stockouts, early discharge because of bed shortages, and lack of adequate post-discharge rehabilitation and follow-up support.
At the same time, they noted, family support systems are often strained by financial pressures and competing responsibilities, reducing their ability to assist individuals suffering schizophrenia effectively.
In addition, high levels of crime and gang violence in some areas may discourage people from attending clinic appointments, while stigma in both communities and within the healthcare setting can erode trust and reduce engagement with care.
“In our lower middle-income country context, relapse prevention depends on strategies that combine clinical management as well interventions addressing structural and social factors,” said Smit.
She added that policy priorities should include strengthening primary-level mental healthcare, ensuring reliable supply of medication, expanding supervised care and vocational support programmes, implementing stigma-reduction initiatives, and fostering collaboration across sectors to address safety concerns and inequities in service provision.
Study details
Beyond treatment non-adherence: A qualitative study of clinicians’ perspectives on structural and social determinants of schizophrenia relapse in South Africa
Anna Margaretha Smit, Sanja Kilian, Hilmar Klaus Luckhoff, Lebogang Simon Phahladira, Robin Emsley and Laila Asmal.
Published in Global Mental Health on 5 May 2026.
Abstract
The objective of this study is to explore public sector clinicians’ perspectives on factors associated with relapse in schizophrenia within a South African context, focusing on structural, social and environmental contributors beyond treatment non-adherence. Three focus groups were conducted with 14 public-sector clinicians (psychiatrists, medical officers, psychiatric registrars and psychiatric nurses) with ≥5 years’ experience in schizophrenia care. Data were analysed using reflexive thematic analysis to identify themes relating to relapse risk. Clinicians consistently described medication non-adherence, often the immediate trigger for relapse, as emerging from interrelated health system and socio-structural constraints, including poverty, unemployment, unsafe communities, fragmented services and stigma. Limited access to newer-generation antipsychotics, medication stockouts, early discharges due to bed shortages and scarce post-discharge rehabilitation compounded relapse risk. Family support was frequently undermined by financial strain and competing demands, while crime and gang violence discouraged clinic attendance. Stigma within both communities and healthcare settings reduced trust and engagement. In this lower-middle-income country context, relapse prevention depends on integrated strategies that combine clinical management with interventions addressing structural and social determinants. Policy priorities include strengthening primary-level mental healthcare, ensuring medication supply continuity, expanding supervised care and vocational programmes, implementing stigma-reduction initiatives and fostering intersectoral collaboration to address safety and spatial inequities in service provision.
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