Deng et al.

BMC Psychiatry (2022) 22:22

https://doi.org/10.1186/s12888-021-03681-6

RESEARCH Open Access

Factors influencing medication adherence

among patients with severe mental disorders
from the perspective of mental health
professionals
Mengjie Deng1, Shuyi Zhai2, Xuan Ouyang1*, Zhening Liu1 and Brendan Ross2

Abstract
Background: Medication adherence is a common issue influenced by various factors among patients with severe
mental disorders worldwide. However, most literature to date has been primarily quantitative and has focused on
medication adherence issue from the perspective of patients or their caregivers. Moreover, research focused on medi-
cation adherence issue in China is scarce. Present study aims to explore the influential factors of medication adher-
ence among patients with severe mental disorders form the perspective of mental health professionals in Hunan
Province, China.
Methods: A qualitative study was performed in Hunan Province, China with 31 mental health professionals recruited
from October to November 2017. And semi-structured interviews or focus group interviews were conducted along
with audio recordings of all interviews. Interview transcripts were then coded and analyzed in Nvivo software with
standard qualitative approaches.
Results: Three major themes influencing medication adherence among patients with severe mental disorders were
identified as: (1) attitudes towards mental disorder/treatment; (2) inadequate aftercare; (3) resource shortages.
Conclusions: This qualitative study identified the factors influencing medication adherence among patients with
severe mental disorders in China. As a locally driven research study, it provides practical advice on medication adher-
ence promotion for mental health workers and suggests culturally tailored models that improve the management of
patients with severe mental disorders in order to reduce economic burden on individual and societal level.
Keywords: Medication adherence, Severe mental disorders, Qualitative research

Background patients with severe mental disorders, such as schizo-

Medication adherence is defined as a patient’s medication phrenia, bipolar disorder and major depressive disor-
taking behavior that complies with recommendations der, to keep taking their medications continuously over
from healthcare providers [1]. To maintain treatment the long term [2–4]. However, the rates of medication
effectiveness and prevent relapse, it is important for nonadherence among schizophrenia patients, bipolar
disorder patients and patients with major depressive dis-
order in China were approximately 56, 48 and 51% at the
*Correspondence: [email protected]
1
National Clinical Research Center for Mental Disorders, and Department beginning of 21st century, respectively [5–8]. As a result
of Psychiatry, The Second Xiangya Hospital of Central South University, of this poor adherence, 60% of patients with severe men-
Changsha, Hunan, China tal disorders have experienced high rates of disability,
Full list of author information is available at the end of the article

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Deng et al. BMC Psychiatry (2022) 22:22 Page 2 of 11

rehospitalization and suicide [9, 10], which has increased treatment. The disability-adjusted life-year (DALYs)
the burden on the healthcare system [11]. Therefore, it is rate per 100,000 of schizophrenia and bipolar disorder
worthwhile to carefully examine the issue of medication are 322.8 and 109.3 respectively [27]. Considering fac-
adherence, which plays a key role in the management and tors such as disparities in mental health services, mental
improvement of clinical outcome in patients with severe health workforce scarcity, and weaknesses in community-
mental disorders. based management, medication adherence is a key factor
Medication adherence among patients with severe that determines performance in managing severe mental
mental disorders is a complex issue determined by a disorders as well as an important indicator of the overall
multitude of factors, such as treatment effect, patient quality of care. To the best of our knowledge, qualitative
insight, attitudes toward medication, financial and emo- research focused on the medication adherence situation
tional support from family members, income situation, in China is insufficient. Using a qualitative approach with
side effects, cultural context, level of therapeutic alli- semi-structured interviews and focus groups, this study
ance with therapists, and aftercare environment after explores influential factors of medication adherence in
discharge [12–18]. With respect to China, a shortage in Hunan, China, with a particular focus on the perspec-
the mental health workforce has also been observed by tive of mental health professionals from urban and rural
Xiang et al. [19] , which may contribute to medication areas. The study may also provide useful information for
nonadherence [14]. Moreover, according to the World improving the management of severe mental disorders.
Health Organization (WHO)’s report in 2018 [20], a lack
of mental health resources, including mental health facil- Methods
ities, government expenditure on mental health, and the Participants
mental health workforce, is a prominent issue worldwide Participants were enrolled by mental health profession-
that negatively impacts rates of medication adherence. als in mental health institutions from October to Novem-
Although researchers have used various methodologies ber 2017 and included psychiatrists based in mental
to study medication adherence in patients with severe health hospitals, directors of psychosocial rehabilitation
mental disorders, most studies to date have focused on services (also called clubhouses), researchers of public
the perspectives of patients or their caregivers (usually mental health, social workers, and psychological counse-
their family members) [21–24]. The limitation of these lors. According to previous studies [26, 30], we defined
papers lies in the potential omission of the opinion from that all participants should have at least 2 years working
other important parties in the process of care, who may experience related to mental health. We conducted in-
also provide insights into our understanding of the issue. depth semi-structured interviews and focus groups, and
Mental health professionals such as psychiatrists, psy- performed participant observation as well. After the first
chiatric nurses, psychologists, and social workers are interview, we identified the next participant(s) by means
all valuable sources to seek opinions from, as they are of the snowball sampling method [31]. The number of
experienced in handling adherence issues and are also participants enrolled was based on data saturation, that
knowledgeable in identifying other contributing factors is, data collection was terminated once no new themes
on the pharmaceutical, psychosocial, and systemic level. were identified and a theoretical end point of saturation
However, to the best of our knowledge, only two quali- was reached [32, 33]. Ultimately, a total of 31 participants
tative studies had focused on mental health profession- were recruited: 14 psychiatrists, 2 researchers of public
als’ attitudes towards medication adherence, with one mental health, 7 directors of clubhouses, 7 psychological
conducted in rural China [25] and the other conducted counselors, and 1 social worker were included. In addi-
in 4 European countries (England, Germany, Italy and the tion, we conducted 22 individual interviews as well as
Netherlands) [26]. Thus, qualitative research that explore 2 focus groups (including 3 psychiatrists and 6 psycho-
their perspectives on medicine adherence is key to tack- logical counselors). Detailed demographic information of
ling this issue comprehensively. participants is displayed in Table 1. All participants were
China, one of the world’s most rapidly developing coun- subsequently numbered during the process of data analy-
tries, also faces a serious mental health burden, of which sis to aid in organization and analysis.
severe mental disorders [27] constitute a significant part.
In China, lifetime prevalence of schizophrenia, bipolar Data collection
disorder and major depressive disorder have reached 0.7, One researcher conducted all interviews in Mandarin
0.6 and 3.4%, respectively [28]. A meta-analysis, how- and each interview averaged 45-60 minutes. Observa-
ever, reported that the treatment rate of schizophrenia tional field notes were collected as well. In addition, all
in psychiatric institutions was only 31% [29]. It implies interviews were audio-recorded and were conducted
that nearly 70% of schizophrenia patients did not receive with a list of pre-determined open-ended questions
Deng et al. BMC Psychiatry (2022) 22:22 Page 3 of 11

Table 1 Respondent information Data analysis

Demographic characteristics Number of Percentage (%)
Coding was performed using NVivo software (version
participants 11). To minimize bias, each of the two coders coded the
two interviews independently and differences were dis-
Sex
cussed to determine the initial coding framework. Cod-
Female 18 58.06
ing and thematic analysis of remaining interviews was
Male 13 41.94
then conducted by one researcher. To increase the valid-
Work
ity of the study, themes and subthemes were reviewed
Psychiatrist 14 45.16
and verified by other researchers. Finally, researchers
Director of clubhouse 7 22.58
translated themes, subthemes and representative quota-
Psychological counselor 7 22.58
tions into English. In addition, quotations were edited to
Researcher of public mental health 2 6.45
correct grammar or remove content of repeated words
Social worker 1 3.23
and stutters.
Workplace
Hospital 14 45.16
Results
Rehabilitation service 8 25.81
We extracted three themes that were likely related to
University 7 22.58 the challenges of medication adherence in patients with
Public health institution 2 6.45 severe mental disorders: 1) attitudes towards mental
Location disorders/treatment; 2) inadequate aftercare; and 3)
Urban area 23 74.19 resource shortages. The themes and subthemes were vis-
Rural area (western part of Hunan 8 25.81 ualized in Table 3.
Province)

Attitudes towards mental disorders/treatment

Inadequate knowledge about mental disorders
(Table 2). The audio records of all interviews were tran- and treatment
scribed verbatim in Mandarin by other researchers Mental health professionals stated that some patients
unfamiliar with this study. All of the participants signed or their families did not hold a correct or scientific
informed consent before the interview. The study understanding of mental disorders and treatment. As a
was approved by the ethics committee of the Second result, patients or their families thought that medication
Xiangya Hospital of Central South University. could be discontinued once the symptoms disappeared
after a period of treatment. Additionally, some of these
patients might only continue treatments such as Chinese

Table 2 Interview guide

Open-ended questions about medication adherence among patients with severe mental disorders

1. What is your current position at work and what are your clinical responsibilities?
2. In your daily work, have you ever encountered problems that patients with severe mental disorders, such as schizophrenia, bipolar disorder and
major depressive disorder, discontinue the medications prescribed by psychiatrists?
3. Do you suggest/help these patients to continue their medications? How do you do that?
4. Do you face with any difficulties when suggesting/helping these patients to continue medications?
5. Are there any other people (family members/friends/other caregivers/other healthcare providers?) assisting these patients taking medications?
How do they help?
6. Besides mental health hospitals or psychiatry department in general hospitals, are there any other mental health services that can help these
patients continue medication treatment? What roles do they play specifically?
7. How is community-based mental health care organized to help these patients continue medication?
8. Did the government propose any policy or implement any programs to help these patients continue medication treatment? How do they help?
9. Are there any religious/cultural customs that may influence these patients to continue medication treatment?
10. Besides the points you just mentioned, what other situations/factors can you think of that may influence these patients to continue medication
treatment?
11. What other things do you think could be done to help these patients continue medication treatment?
12. Is there anything else you would like to add that may help me better understand your perspective?
13. Do you have any questions for me?
Deng et al. BMC Psychiatry (2022) 22:22 Page 4 of 11

Table 3 Themes and subthemes about challenges of medication adherence in patients with severe mental disorders
Themes Percentages (%) Subthemes Percentages (%)

1. Attitudes towards mental disorders/ 67.74 (1) Inadequate knowledge about mental disorders 16.13
treatment and treatment
(2) Insight 19.35
(3) Side effect of treatment 12.90
(4) Stigma 19.36
2. Inadequate aftercare environment 45.16 (1) Aftercare from family 22.58
(2) Aftercare from community 22.58
3. Resource shortage 35.48 (1) Financial resource 16.13
(2) Mental health workforce 9.68
(3) Public resource 9.67

traditional medicine or psychotherapy. Moreover, some Some patients with severe mental disorders, however,
patients or families from rural areas believed in super- had poor insight into their conditions. This lack of aware-
natural etiologies of mental disorders, which led them ness probably led many of them to resist medication
to embrace alternative methods that were considered as treatment.
more effective cures.
“We use medication to treat patients. For example,
“Some members (patients) thought that they do not schizophrenia patients with delusions and abnor-
need to take medicine, they are normal. ... They think mal behaviors might refuse to accept that they had
I don’t need to take medicine anymore, I’m alright. mental disorder. But, after antipsychotic treatment,
They definitely think that not taking medicine is nor- they might realize their own mental health prob-
mal and good. Many of them expressed that I don’t lems, be more willing to take antipsychotics, … and
need to take medicine tomorrow, I will be fine. I can finally return to their daily life.” (#1, psychiatrist)
do whatever I want.” (#19, directors of clubhouse)
“First of all, it is necessary to control their (patients)
“Some patients’ families thought that their children symptoms, … the drug compliance is better, and the
were different from other children. They think that side effects are lighter, so that they might maintain
previously their children (patients) were stressed, medication treatment more readily.” (#15, researcher
and if they could pay more attention to their chil- of public mental health)
dren, then they could try to see if it can be effective
without taking medicine. (#2, psychiatrist)
Side effects of treatment
“Some patients’ families were reluctant to accept It concerned some patients or their families that medica-
that their children (patients) had a mental illness. tions had side effects that might influence everyday life.
I saw a patient with severe psychotic symptoms … For example, some patients might become overweight, or
and suggested his family to take him to hospital. But present with an even more severe metabolic syndrome,
they thought that their kid was healthy and just pos- and other patients might feel drowsy and indolent the
sessed by a ghost. They thought he would get better if whole day which led them to believe that medication
they used some ritual methods.” (#25, psychological was harmful for them. Obviously, they worried about the
counselor) side effects of medication and neglected to appreciate the
drugs’ effectiveness.
“Some of them (patients) might discontinue medica-
Insight
tion because it made them fat. … However, most of
Insight means that the patient’s understanding of their them relapsed after they discontinue their medica-
symptoms, illness, prognosis and treatment aligns with tion treatment.” (#25, psychological counselor)
that of their healthcare professionals [34]. In general,
patients with good insight might be more likely to be “Without supervision of parents, some students
compliant with their mental health providers’ plan and (patients) might discontinue medication because of
maintain medication treatment as prescribed. side effects, then the symptoms might relapse.” (#30,
psychological counselor)
Deng et al. BMC Psychiatry (2022) 22:22 Page 5 of 11

Stigma record book. Lastly, we will tell patients’ families to

Carrying the fear that other people might know about keep the medication in a secure location.” (#2, psy-
their diagnosis of a mental health disorder, some patients chiatrist)
refused to continue taking medication in a public space.
For a similar reason, some of the patients or their fami-
Aftercare from community
lies would rather receive treatment from internal medi-
Aftercare from community mostly referred to rehabilita-
cine outpatient departments in general hospitals than
tion clubhouses and the 686 Project in this study. In 2004,
outpatient departments of psychiatry in general hospitals
the 686 Project was initiated to provide comprehensive
or mental hospitals. Therefore, stigma about mental dis-
mental health services to patients with severe mental dis-
orders might constrain the use of available mental health
orders [35, 36]. This project aimed to improve medica-
resources and might eventually affect the level of medica-
tion adherence in patients with severe mental disorders
tion adherence.
by providing free medication routinely and conveniently.
“There are many reasons that patients with severe Members of clubhouses were patients with severe mental
mental disorders may be reluctant to take medi- disorders. Referring to patients as members in the club-
cation, such as stigma, severe side effects or poor house could reduce stigma and be helpful in creating an
insight.” (#15, researcher of public mental health) appropriate atmosphere for the rehabilitation of patients.
The clubhouse staff would ask members everyday if they
“We can find certain forms of social discrimina- have taken their medication. And members would dis-
tion of mental disorders, … some patients’ families cuss with each other the results and practice of taking
thought it might be disgraceful to send patients to a medication. Additionally, lectures on medication adher-
mental health hospital, so they might procrastinate ence were provided from time to time to create a virtuous
treatment for couple years, ten years, or even a cou- cycle for better recovery.
ple decades.” (#10, psychiatrist)
“In the clubhouse, members would discuss together,
… they would often ask other members’ views about
Inadequate aftercare medication. … The result of our survey last time
Aftercare from families showed that 90% of our members continued medi-
Almost all patients with severe mental disorders dis- cation treatment. However, probably 50% of patients
charged from hospital were taken care of by their families or even lower continued medication treatment out in
at home. Therefore, the burden of rehabilitation was pri- the community. Good medication adherence might
marily born by patients’ families. In fact, most of the fam- be helpful to reduce the relapse rate for patients. …
ilies needed to supervise the patients to ensure they take The environment in the clubhouse could help mem-
medication every day. Sometimes, families even needed bers keep a stable state.” (#17, directors of clubhouse)
to deceive patients into taking medication, although
some of the them failed at this. “For one thing, members will be optimistic (in the
clubhouse). For another, members will realize the
“From our point of view, due to traditional notions
importance of medication adherence and hold a
or conventions, … it is patients’ families that have
global perspective about mental disorders as well as
been faced with the heaviest burden in support-
medication adherence.” (#18, directors of clubhouse)
ing this kind of (rehabilitation) work. … Therefore,
the role and values of patients’ families in manag-
“They provide them (patients with severe mental dis-
ing medication adherence in severe mental disorders
orders) medication for free in community. This is the
cannot be underestimated.” (#6, psychiatrist)
686 Project.” (#1, psychiatrist)
“Generally, due to the close relationship among fam-
ily members in traditional Chinese culture, we will Resource shortages
tell patients’ families that patients’ recovery requires Financial resources
a certain period of supervised care and that the Some patients might discontinue treatment due to the
medication treatment needs to be continued. And financial burden. For example, most patients and their
we will also write down some important points, such families from rural areas or county-level areas would
as when to make a follow-up visit and what kind of seek out the top hospitals in urban areas in order to
medical examination needs to be completed at the pursue better treatment, which might cost them a great
next visit, noted on patients’ outpatient medical expense for transportation and accommodation. Even if
Deng et al. BMC Psychiatry (2022) 22:22 Page 6 of 11

the expense of hospitalization could be covered by their our country.” (#5, psychiatrist)
healthcare insurance, policies often limited the coverage
rate of non-local patients mentioned above. Addition-
Social resources
ally, expenses incurred in the outpatient department,
Social resources, especially from government sources,
based on a related policy, were likewise not included in
are likely to improve psychiatric patients’ medication
the healthcare insurance plan. Therefore, patients might
adherence. Currently, the management of patients with
need to use more expensive medications with more side
mental disorders, especially those in the community, is
effects.
underdeveloped. However, the government did imple-
“Although huge amounts of patients come to our out- ment some measures, such as the 686 Project, a series of
patient department for treatment, the expense is not mental health policies and various mental health services
entirely covered by healthcare insurance. … Without designed to meet the needs of psychiatric patients in the
the subsidy of healthcare insurance, they may take community.
on too great of a financial burden. This is because
“In our country, most mental health professionals
most of them (patients with severe mental disorders)
only focus on the management of patients in mental
have no job and they depend on their families to sup-
health hospitals. This may require the government to
port them financially. Some of them have to travel a
implement measures allowing psychiatrists to go to
great distance to come here, and it costs them many
communities and to treat patients there. And it has
fees for transportation and accommodation, which
been promoting such measures. For example, psy-
is even more expensive than the medical expenses.”
chiatrists, nurses and other related mental health
(#7, psychiatrist)
professionals may organize a team, then go to com-
munities and distribute medications to patients
“Some patients (from rural or county-level areas)
with severe mental disorders. This is the 686 Project
relapsed many times due to lots of reasons. First of
which is in process.” (#1, psychiatrist)
all, previous treatment of this illness already caused
them to spend so much money, which made future
“The most important thing is that they (patients
treatment seem even more unaffordable. … In other
with severe mental disorders) need social support. …
words, they were just lacking money (for treatment).”
It is a tough issue that has caused some of them to
(#10, psychiatrist)
relapse many times. Therefore, in order to see more
positive results in medication adherence, the gov-
Mental health workforce ernment needs to actively intervene and our society
Several interviewees mentioned that supervision and needs to adopt some measures.” (#10, psychiatrist)
education of medication adherence required a profes-
sional workforce. However, due to limited mental health
Discussion
workforce in the community mental health system and a
In our study, we identified that attitudes towards mental
large flow of patients in outpatient departments in recent
disorders/treatment, inadequate aftercare environment,
years, psychiatrists were often too busy to explain or
and resource shortages might affect medication adher-
promote medication adherence to patients in outpatient
ence in patients with severe mental disorders in the Chi-
departments. In addition, it remains difficult to estab-
nese context.
lish a relatively mature system of supervision for mental
health management, especially to address medication
Attitudes towards mental disorders/treatment
adherence.
Multiple studies have shown that psychiatric patients’ or
“There are not enough psychiatrists in our country. their family members’ attitudes towards mental disor-
During patients’ early stages of severe mental disor- ders and treatment can impact medication adherence to
ders, there needs to be a large related workforce to various degrees [16, 26, 37, 38]. Additionally, results of
manage patients when their symptoms are stable a cross-sectional study revealed that Asians held more
and to check if they take medication regularly. All of negative beliefs towards taking medication compared
this labor requires a relatively large mental health to Europeans [39]. In our qualitative research, we found
workforce to support it. … If there are social workers, that knowledge about mental disorders and treatment,
and an adequate mental health workforce in this patients’ levels of insight, awareness of the side effects of
field, they can supervise the symptoms and the treat- the treatment, and social stigma could also influence psy-
ment of patients. … However, there is a shortage in chiatric patients’ medication adherence.
Deng et al. BMC Psychiatry (2022) 22:22 Page 7 of 11

In the Chinese context, patients or their family mem- patients with poor insight as the recovery of insight was
bers’ inadequate knowledge about mental disorders may difficult and time consuming [24]. In this case, psychoed-
lead to misconceptions about the care received, which ucation could also be employed to spread the knowledge
results in poor medication taking behaviors. Consist- about mental disorders and treatment, enhance insight,
ent with previous studies, we found inadequate knowl- and manage side effects, and reduce stigma, which may
edge about mental disorders and treatment being one ultimately improve medication adherence [14, 26, 50–53].
of the risk factors of medication nonadherence [17, 18].
In China, a large number of patients with mental health Inadequate aftercare
disorders and their family members perceive that con- Aftercare refers to mental health care given outside the
tinuous psychotropic medication use can be harmful hospital. It consists of supervision of medication use,
and addictive [16, 40]. Many of them sought help from follow-up of recurrence, rehabilitation of social function
traditional Chinese medicine or superstitious meth- as well as work skills training. Due to the clinical charac-
ods [29, 41]. Additionally, previous literature suggested teristics of severe mental disorders (e.g., chronic course
that poor insight into mental disorders, concerns over and impaired social function), aftercare is one of the key
the side effects of medications, and perceived stigma factors that determines the prognosis of severe men-
about mental disorders constrained proper adherence tal disorders. In China, patients with mental disorders
to medications [22, 25, 42]. First, patients with severe mostly live with or have close connection with their fam-
mental disorders who have poor insight into their con- ily members, so the burden of aftercare often falls on the
ditions are less willing to continue medication or to fol- latter. However, as their family members’ knowledge of
low their psychiatrist’s medication plan rigorously [25]. and time dedicated to aftercare is often limited, the after-
Second, psychotropic medications like antipsychotics or care burden experienced by patients’ family members
antidepressants may introduce certain side effects, such was inversely correlated with patients’ medication adher-
as drowsiness, weight gain, diabetes, or sexual dysfunc- ence, as shown in a previous study [54]. Another research
tion, which might impact patients’ daily functioning and study in China also demonstrated that patients with
directly decrease their medication adherence [43]. Last, severe mental disorders heavily relied on the aftercare
as stigma toward patients with severe mental disorders from their family members [55], which urged the spread
is quite common in China [44, 45], Saxena et al. inves- and development of community-based mental health
tigated that stigma towards mental disorders could con- programs for patients and caregivers. As a large part of
strain the use of available mental health resources [46]. community-based mental health services still requires
Worried about being discriminated by others, many family participation [56], it is understood that aftercare
patients might avoid taking medications in public space from patients’ families and rehabilitation both play sig-
or even discontinue their medications. Even their family nificant roles in maintaining medication adherence [14].
members might also discourage them for the same rea- In China, the government has launched a program
son [45, 47]. in 2004 called the 686 Project to improve community-
Several researchers concluded that collaborative deci- based mental health services. The 686 Project was initi-
sion making, also termed therapeutic alliance, enables ated to provide comprehensive monitoring, key mental
patients with mental disorders to be more involved in health treatment, rehabilitation, and prevention services
choosing their medication regime, which is a key factor to patients with severe mental disorders from a wide
for better medication adherence [42, 48, 49]. A shared range of urban and rural communities [35, 36, 57, 58].
decision-making process could empower patients to Additionally, an increasing number of rehabilitation ser-
actively communicate with their mental health provid- vices have been emerging including the rehabilitation
ers and help providers be aware of the difficulties that a clubhouse model, farming programs, and workstation
patient faces during treatment. As a result of this thera- programs [50, 59, 60]. In this qualitative research, we
peutic collaboration, patients and their family members’ mainly focused on the rehabilitation clubhouse as one of
attitudes towards mental health and treatment would the community-based mental health services currently
be more positive and their stigma could be reduced as offered. Previous literature identified the positive influ-
well. Moreover, with better communication with their ence of mental health rehabilitation services on preven-
psychiatrists, patients might be more satisfied with their tion, treatment, and rehabilitation of mental disorders
treatment and report fewer side effects due to timely [50, 61]. Consistent with these studies, we found that
management [22]. Noordraven et al. demonstrated that mental health aftercare played an essential role in medi-
insight was less strongly associated with medication cation adherence in patients with severe mental disor-
adherence than motivation for treatment, so it may be ders. However, the aftercare offered by patients’ family
more important to improve motivation as the first step in members and their communities is currently inadequate.
Deng et al. BMC Psychiatry (2022) 22:22 Page 8 of 11

Therefore, besides improving caregivers’ knowledge of resource scarcity may constrain the availability of men-
mental health aftercare, multiple types of community- tal health services and essential medication for patients,
based mental health services or innovative service mod- which eventually hinders the medication adherence in
els are needed. For example, Xu et al. demonstrated that patients with severe mental disorders.
mobile text messaging was an effective way to integrate In the past two decades, the Chinese govern-
family-based aftercare into community-based aftercare, ment implemented several effective interventions to
leading to improvements in medication adherence in strengthen and integrate mental health resources. First,
patients with severe mental disorders [62]. the 686 Project, initiated in 2004, was a comprehensive
service delivery model aiming to integrate hospital ser-
Resource shortages vices, community case management, prevention and
In the present study, we found that the shortage of finan- monitoring services, treatment, and rehabilitation ser-
cial resources, the mental health workforce, and social vices [36]. Second, as suggested by one of our previous
resources may be among the main factors that affected studies, the rehabilitation clubhouse model has been in
medication adherence in patients with severe mental dis- use in Hunan Province, China, and both the central and
orders. In China, there are currently many challenging provincial governments took active steps to promote
issues causing this resource shortages for mental health. its development in more areas [50, 66]. Third, along-
For example, in considering financial resource short- side strategies to improve undergraduate and graduate
ages, the health insurance system in China has devel- medical education [67], one of the most efficient steps
oped separate reimbursement models in urban and rural taken to advance mental health workforce development
areas, which might increase inequity of mental health was the psychiatrist licensing program announced by
resources offered across different areas [63]. Even with the National Family Planning and Health Commission
health insurance coverage, many families cannot afford in 2015 [68]. This program allows physicians who were
the expenses of treatment for severe mental disorders already in practice to receive further training in psychia-
due to the chronicity of the disease. Therefore, some of try and to be licensed as psychiatrists. Finally, a series of
them used less expensive medications with more side mental health policies has been launched since 2000 [69],
effects, which might increase the risk of medication non- including the Mental Health Law of the People’s Republic
adherence. Second, medication adherence in patients of China was released on 2011 and came into effect from
with severe mental disorders requires adequate super- 2013 [19, 70, 71]. Although the government has initiated
vision and education from mental health professionals. a series of steps to reinforce mental health resources,
However, in 2015, there were 27,733 licensed psychia- their uneven distribution still persists [72]. Furthermore,
trists (2.02 per 100,000 population) and 57,591 psychiat- Thornicroft et al. demonstrated that a balanced approach
ric nurses (4.19 per 100,000 population) in China [36]. In in planning community-based and hospital-based men-
contrast, according to the mental health atlas of WHO in tal health services was effective in both urban and rural
2014 [64], there were 7 psychiatrists per 100,000 popula- areas [73]. By gradually strengthening community-based
tion and 24.1 psychiatric nurses per 100,000 population services, medication adherence is expected to improve in
in European regions, while there were 0.1 psychiatrists patients with severe mental disorders that often require
per 100,000 population and 0.6 psychiatric nurses per more supervision and nearby assistance.
100,000 population in African regions. This stretched Adequate mental health resources are one of the foun-
workforce may affect the medication adherence in dations to improving medication adherence in patients
patients with severe mental disorders and may limit the with severe mental disorders. Due to the challenges of
access for patients to seek help. The limited mental health lacking mental health resources that China has con-
workforce constitutes an important barrier to proper fronted, it is vital to implement measures that are well
mental health service delivery, which in turn, slows down adapted to the local context. First, the government
the process of services integration [65]. Finally, different should mobilize existing mental health resources, both
levels of social resources were scarce or fragmented in to improve access to and increase the capacity of men-
distribution, including mental health policies, non-gov- tal health services. Second, in order to reduce inequity
ernmental organization support, mental health services and fragmentation of mental health resources between
(especially community-based services) and support from urban and rural areas, we can designate mental health
social networks. All of these may provide substantial sup- professionals from urban areas to rural areas periodi-
port in the integration of mental health resources, spread cally as well as make use of telemedicine. For example,
of psychoeducation, case management and so on, which online consultation is considered efficient in balanc-
are vital to improve the medication adherence in patients ing the distribution of mental health resources between
with severe mental disorders. In a word, mental health urban and rural areas, and even between first-tier cities
Deng et al. BMC Psychiatry (2022) 22:22 Page 9 of 11

and second-tier cities. Third, to implement mental health is a purposive sampling. Nevertheless, as purposive
policies efficiently from top to bottom, local-level execu- sampling is widely used in qualitative studies to iden-
tion and national-level promotion are equally important. tify and select information-rich participants related
Fourth, despite the heavy economic burden of mental to the phenomenon of interest, snowballing sampling
disorders, equitable allocation of financial resources in method is a highly-efficient way to identify potential
mental health should still be emphasized, as it not only participants from whom researchers may explore more
improves medication adherence in patients with severe useful information [31]. Another limitation is that the
mental disorders but also reduces the overall cost of present study only looked at rehabilitation clubhouses
mental health. Finally, non-psychiatric mental health and the 686 Project as examples of community-based
professionals, including psychologists, counselors, social mental health services, which may not reflect the whole
workers, and occupational therapists are also currently in picture nationally. The occurrence of data saturation
high demand [68]. Diversifying the mental health work- in our case may be due to the location of our research,
force is therefore urgently needed to relieve psychiatrists’ since the rehabilitation clubhouses and 686 Project
and psychiatric nurses’ burden and provide comprehen- were both in Hunan Province and more successful in
sive care. promoting medication adherence than other forms of
mental health aftercare in community settings. Along
Implications the same lines, in considering the provincial differences
The issue of medication nonadherence in patients with in mental health services across the country, the fact
severe mental disorders has its own unique circum- that our findings were entirely generated from Hunan
stances in different settings, and this qualitative study province may limit the data applicability when general-
provided evidence based on the Chinese context to illu- ized to the national level. But given that we have inves-
minate the effects of local conditions on clinical work. In tigated medication adherence in patients with severe
clinical work, psychiatrists and nurses should pay more mental disorders in both urban areas and rural settings,
attention to the therapeutic alliance with patients and it may still provide useful information to researchers
patients’ families, which can assist them in identifying in the field. Furthermore, it may also provide support
patients’ insight and addressing the side effects of treat- for this kind of research in other Asian countries with a
ment in a timely manner to improve clinical outcomes. cultural context similar to that of China. However, as a
Moreover, psychiatrists and nurses should strengthen qualitative study, there may be limited generalizability
psychoeducation regarding mental disorders and treat- beyond our setting.
ment in patients and their families to reduce their mis-
conceptions. Considering the importance of psychiatric
community rehabilitation in medication adherence, gov- Conclusion
ernments should establish local community-based men- In summary, the present study focused on the perspec-
tal health services. As some mental health projects (e.g., tives of mental health professionals to identify fac-
686 Project) and mental health policies have achieved tors influencing medication adherence among patients
certain improvement in medication adherence in some with severe mental health disorders in Hunan Province,
areas of China, governments should promote the suc- China. Our findings provide practical advice for men-
cessful and culturally adapted mental health models tal health providers on the promotion of medication
to other areas in China as well as integrate the mental adherence among patients with severe mental disorders.
health workforce at all levels to implement the mental Moreover, this locally driven research also suggests cul-
health models efficiently. With the aforementioned effec- turally tailored models that improve the management of
tive steps, the future mental health system may improve patients with severe mental disorders in order to reduce
the medication adherence in patients with severe mental economic burden on individual and societal level. Future
disorders and reduce the economic burden for patients researchers could further explore the medication adher-
and society at large in China. ence among patients with severe mental disorders in
other cultural contexts.
Limitation
One limitation of this qualitative study is that the sam- Abbreviations
ple size is relatively small. However, saturation did WHO: World Health Organization; DALYs: Disability-adjusted life-year.
occur during the process of participant enrollment, Acknowledgements
which suggested the adequacy of the sample size in We would like to thank all the mental health professionals who participated
this particular study. In addition, there is potential bias in the study. We would also like to thank Xinran Hu and Wen Zhang for their
support and help with recruitment.
caused by the snowballing sampling method which
Deng et al. BMC Psychiatry (2022) 22:22 Page 10 of 11

Authors’ contributions depressive disorder: A report on the National Survey on Symptomatology

ZL supervised the study. MD and XO designed the study, conducted the of Depression in China. CNS Neurosci Ther. 2019;25(2):215–22.
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Post-graduate (CX20190087) and the National Natural Science Foundation of 2010;362(17):1553–5.
China (81801353 and 82071506). The funding institution played no part in the 12. Novick D, Montgomery W, Treuer T, Aguado J, Kraemer S, Haro JM.
design and conduction of the study and did not influence the analysis and Relationship of insight with medication adherence and the impact on
interpretation of the data or writing of the manuscript. outcomes in patients with schizophrenia and bipolar disorder: results
from a 1-year European Outpatient Observational Study. Value Health.
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