Letter

To the Editor: Adherence to psychiatric treatment is a major challenge to mental health care worldwide ( 1 ). Most studies of treatment adherence have been conducted in high-income countries ( 2 ). The question arises as to whether there are structural barriers to adherence that are particular to—but underresearched in—areas with poor resources.

Research on mental health in low- and middle-income countries highlights many challenges to optimal care. Such challenges include what may be termed global social factors ( 3 ), such as poverty, high rates of violence, and a lack of basic infrastructure, often in the context of rapid urbanization and high rates of substance abuse. At the health-system level are challenges such as the lack of sufficient numbers of trained staff, interruptions in the supply of drugs and absence of appropriate drugs ( 4 ), and chaotic and overcrowded health facilities ( 4 ). In keeping with international trends, mental health care in developing countries is increasingly being integrated into primary health care, with the aim of providing nonstigmatizing, holistic, and accessible services ( 5 ).

A recent qualitative study examining the impact of changes in service delivery on families living with mental disorders in poor South African communities has highlighted potential contextual barriers to treatment adherence. As part of this study, ten case studies were conducted in households with members who were caring for a household member who had schizophrenia and living in poor urban environments.

Several themes emerged that may have implications for adherence to psychiatric treatment. The themes were related to the community clinic from which medication was dispensed. Several logistic problems were described by patients and relatives, including having to queue in darkness outside the clinics from as early as 4 a.m. and having to wait for many more hours before they could collect their medication. Participants spoke of the high risk of being mugged and attacked while waiting in the queues. Participants also told stories of how patients waiting in queues would become impatient and leave before collecting their medication, thus defaulting on their treatment. One coping strategy used by patients was not taking the correct dosage of their medication—for example, taking one pill instead of two, so that a clinic visit was required every two months instead of every month.

Our anecdotal experience from other clinical service experience is that these problems are widespread and represent significant barriers to care. These findings highlight possible contextual barriers to treatment adherence in a context of high levels of poverty, violence, and crime and few resources. Such conditions represent challenges to implementation of new mental health policy.

Although limited data were collected and the findings are not generalizable, this study highlights areas of concern that are in need of further investigation. Such research may have implications for our understanding of challenges to adherence in the context of mental health policy reform, high levels of poverty and violence, and poor infrastructure.

The authors report no competing interests.

Ms. Breen and Dr. Swartz are with the Department of Psychology at Stellenbosch University, Cape Town, South Africa. Dr. Swartz is also with the Human Sciences Research Council, Cape Town. Dr. Joska is with the Department of Psychiatry and Mental Health and Dr. Flisher is professor and head of the Division of Child and Adolescent Psychiatry, University of Cape Town. Dr. Flisher is also adjunct professor, Research Centre for Health Promotion, University of Bergen, Bergen, Norway. Dr. Corrigall is with the School of Public Health, University of Cape Town, and the Western Cape Department of Health.