Schizophrenia relapse is a common and troubling reality in South Africa, with approximately one in three people living with the condition experiencing a recurrence within the first year after diagnosis.

While relapse is often blamed on individuals not taking their medication as prescribed, new research suggests healthcare workers view this as a symptom of deeper structural challenges rather than a root cause.

Schizophrenia is a chronic and debilitating disorder affecting about one in every 100 South Africans. Relapse can have profound psychological and social consequences and may lead to serious medical complications, including reduced responsiveness to treatment over time.

In a study published in Global Mental Health, Dr Retha Smit and colleagues from Stellenbosch University’s (SU) 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,” says Smit, the lead author. “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 continues to pose a major challenge in lower- and middle-income countries, where mental health services are often overstretched and under-resourced. Although relapse is frequently framed in terms of individual behaviour – particularly treatment non-adherence – this perspective overlooks the broader social and systemic barriers that influence individuals’ 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 of whom have experience in schizophrenia care.

While participants consistently identified medication non-adherence as the immediate trigger for relapse, they emphasised that this behaviour is often driven by inadequate social and healthcare support systems. Contributing factors include poverty, unemployment, stigma, safety concerns, and fragmented service delivery.

Healthcare system constraints also play a significant role. Clinicians highlighted limited access to newer-generation antipsychotic medications, medication stockouts, early discharge due to bed shortages, and lack of adequate post-discharge rehabilitation and follow-up support.

At the same time, 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 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,” says Smit. 

She adds 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.