Gang violence, poverty and drug abuse fuel schizophrenia relapses

High levels of crime and gang violence in some South African communities are discouraging people living with schizophrenia from attending clinic appointments, contributing to relapses and worsening health outcomes.

This is one of the key findings of a study published in the journal Global Mental Health, in which researchers from Stellenbosch University’s department of psychiatry explored public-sector clinicians’ perspectives on why patients with schizophrenia relapse.

The study, led by Dr Retha Smit, found that clinicians viewed relapse not as the result of a single factor but rather as the outcome of multiple interconnected social, economic and healthcare challenges.

According to the research, high crime rates, community violence and gang activity were frequently cited as barriers preventing patients from accessing treatment.

“Patients don’t go to clinics because they are scared,” Smit said.

Schizophrenia affects about 1% of South Africans and typically emerges during late adolescence or early adulthood. The chronic mental health condition can severely disrupt a person’s thoughts, emotions and behaviour.

Relapse remains a major challenge, particularly in low- and middle-income countries where mental healthcare services are often overstretched. Researchers warn that repeated relapses can have profound psychological and social consequences and may also reduce patients’ responsiveness to treatment over time.

Smit said clinicians consistently described working within significant structural constraints that make it difficult for patients to remain stable.

“While non-adherence and substance use were noted, poverty, stigma, crime and systemic under-resourcing were emphasised as key disruptions to continuity of care and client agency,” the study found.

Medication non-adherence emerged as the most frequently identified trigger for relapse. Clinicians reported that many patients stop taking their medication once they begin feeling better, unaware that the improvement is due to the treatment itself.

We often have to send patients back to settings where they are exposed to stressors and substances. Sometimes we even have to send patients to shelters because there is limited support and limited options available. That creates a therapeutic sense of futility and failure and contributes to the revolving-door phenomenon.

—  Clinician

One clinician quoted in the study said: “They are not even long out of hospital. The minute they start feeling better, they feel like they don’t need to take any medication, not knowing that it is because of the medication they are taking that makes them feel better.”

Substance abuse was also identified as a significant contributor to relapse. Clinicians described drug and alcohol use as both a coping mechanism and a barrier to treatment adherence, often reinforced by peer pressure and linked to unemployment, boredom and a lack of recreational opportunities.

Beyond individual behaviour, the study highlighted several social determinants that undermine continuity of care. These include unstable housing, food insecurity, inadequate family supervision and transport difficulties that make it harder for patients to access services consistently.

Clinicians also pointed to weaknesses within the healthcare system itself. Staff shortages, fragmented care, gaps in primary healthcare integration, early discharge from psychiatric facilities and limited access to rehabilitation services were all identified as factors that increase the risk of relapse.

Medication shortages emerged as another recurring concern.

According to clinicians, some patients are turned away from facilities when medication is unavailable, while others are given substitute treatments that they may not tolerate well.

“We often have to send patients back to settings where they are exposed to stressors and substances,” one clinician said. “Sometimes we even have to send patients to shelters because there is limited support and limited options available. That creates a therapeutic sense of futility and failure and contributes to the revolving-door phenomenon.”

The study concluded that relapse prevention requires more than simply ensuring patients take their medication. Instead, it calls for integrated interventions that address the broader social and structural factors shaping mental health outcomes.

South Africa currently manages schizophrenia through the National Mental Health Policy Framework and Strategic Plan 2023–2030, which promote community-based care, patient rights and the integration of mental healthcare into primary healthcare services.

Smit said policymakers should prioritise strengthening primary-level mental healthcare, ensuring a reliable supply of medication, expanding supervised care and vocational support programmes, implementing stigma-reduction initiatives, and fostering cross-sector collaboration to address safety concerns and inequalities in service delivery.

The researchers said future studies will incorporate the perspectives of patients, families and healthcare administrators to develop more practical and context-specific approaches to preventing relapse.