Co-production, a model that actively involves patients as partners in designing, delivering and evaluating their treatment, has gained traction across global health systems as a relational and implementation strategy. It positions patients as active design partners in the delivery and evaluation of care, improving satisfaction, adherence and long-term outcomes.^1,2,3 For psychiatrists treating adult attention-deficit/hyperactivity disorder (ADHD), the paradox is clear: Even with accurate diagnoses and effective medications, meaningful, sustained outcomes often remain elusive.^4,5,6,7 Despite notable advances in psychiatric diagnostics and pharmacological interventions, mental health outcomes in adults with ADHD remain persistently poor.^8,9,10 Increasingly, international mental health discourse recognises that treatment success depends not only on clinical efficacy but also on how care is experienced, particularly the extent to which patients feel heard, involved, and respected.^11,12,13

In South Africa, only about 1.09% of adults in the private healthcare sector have received a formal ADHD diagnosis,^5,6,7 a figure widely considered to be a significant underestimation. The country’s dual healthcare system is characterised by marked inequities in access to specialist psychiatric services, particularly in the public sector.¹⁴ Access to a diagnosis of ADHD and treatment is often constrained by language, geographic, and financial barriers.¹⁵ This suggests a large population of undiagnosed adults, particularly in the public sector and underserved communities.¹⁶ Despite this diagnostic gap, people in the private sector remain largely absent from the design of mental health services.^8,17,18 Psychiatric care continues to operate in silos, with clinical decisions primarily shaped by provider perspectives, rather than being co-informed by patients’ insights.^9,19 This approach poses risks, particularly in chronic mental health conditions where engagement and continuity of care are essential for long-term outcomes.^20,21 These challenges, however, are not merely technical; patterns of treatment disengagement, reports of feeling unheard, and strained therapeutic relationships suggest that they may extend beyond the technical.^8,18,22 They hint at a deeper relational gap in how care is co-constructed between clinicians and patients. As highlighted by the Life Esidimeni tragedy, where 144 psychiatric patients died after being transferred from licensed care facilities to inadequately resourced non-profit organisations as part of a cost-cutting project, the consequences of excluding patient voices from mental health planning and delivery can be severe.^17,23,24

To conceptualise this relational component more holistically, Bronfenbrenner’s ecological systems theory offers a valuable framework. It illustrates how individual functioning is shaped through interconnected systems, ranging from the immediate doctor-patient relationship (microsystem) to family and community networks (mesosystem) and broader factors such as healthcare design and clinician workload (exosystem).^25,26,27 At the macrosystem level, cultural norms, workplace demands, and healthcare policies influence how patients experience care.^21,28 Failure to consider these layers can lead to fragmented treatment and missed opportunities for co-production.²⁹

Psychiatrists and other mental healthcare workers are well-positioned to use patients’ insights and perspectives to personalise care, improve engagement, and address barriers to continuity of care.^30,31,32 Understanding the lived experience of adults with ADHD, including what they value in care, what they struggle with, and how they define success, is essential for developing responsive, value-based healthcare interventions.^33,34,35 However, as confirmed by McCalman et al., specifics of patient involvement and the factors influencing its effectiveness remain largely unexplored.²³

Although co-production has become a core tenet in high-income countries, its empirical application within South African psychiatric services remains underexplored, particularly in adult ADHD care.^16,36 This study addresses this gap and explores how adults with ADHD in South Africa perceive their involvement in care and what clinicians can learn from their experiences to improve adherence and outcomes. The insights on embedding co-production principles into psychiatric practice could challenge traditional, top-down models of care in favour of more responsive, collaborative, patient-informed approaches and interventions. By highlighting how co-production can operate as a relational and implementation practice, this study contributes to the global conversation on reconfiguring mental healthcare toward more responsive, collaborative, and sustainable models.

The diversity in participant age, professional background and duration since diagnosis of ADHD contributes to a rich dataset, allowing for exploration of how these factors may influence patient involvement in co-production within mental healthcare. While the study ensured diversity, it did not collect detailed information on psychiatric comorbidities. This is relevant as ADHD frequently co-occurs with other conditions such as mood disorders, anxiety disorders, substance use disorders, and personality disorders, which may influence patient experiences of care and treatment engagement.

Notably, although treatment adherence was not an inclusion criterion, two participants had disengaged or dropped out of care. Their perspectives contributed valuable insights into the challenges of continuity of care and added depth to the emerging conversation on service co-production in mental healthcare.

As outlined in Table 1, this demographic variation provides context for understanding the personalised nature of patient care and patients’ involvement across different settings.

The final code list consisted of 45 codes, representing 351 comments. The codes were then grouped into 11 subthemes, from which four key themes emerged: Patient agency and involvement, Trust in healthcare providers, Satisfaction with care and outcomes, and accessibility and continuity of care. These themes represent the participants’ reflections and offer insight into the relational dynamics and structural barriers shaping their experiences of care. Results will be reported as participant: quote; for example, (P4:Q3) refers to participant 4, quote 3.

Drawing on the results, Figure 1 presents a patient-centred care framework where these four interrelated themes, namely patient agency, provider trust, satisfaction with care, and continuity, form a relational cycle that underpins co-production in psychiatric care.

Based on the findings, the patient-centred care framework aligns with prior research, highlighting the importance of patient agency in promoting collaborative clinical decision-making and therapeutic partnership.³⁴ For some participants, agency was a defining feature of their treatment journey. Others described limited engagement with care decisions, often shaped by the quality of communication with their psychiatrist. These reflections illustrate that patient involvement is neither uniform nor guaranteed.

Notably, trust in provider expertise influenced perceived involvement, aligning with Higgins et al.’s suggestion that trust is foundational to collaborative care.^33,52,53 Trust, a core element in mental healthcare, was influenced by how providers acknowledged patients’ lived experiences, echoing Sunkel and Sartor’s emphasis on the need for relational approaches in mental health.^13,19,22 Therefore, trust emerged as a key factor in determining engagement.

Participants who described their providers as approachable and consistent were more likely to report active participation, while those who experienced poor communication described disengagement. This finding aligns with Charles et al. who emphasise the relationship between agency and collaborative satisfaction.^31,32,33,34

It was noted that increased involvement was linked to greater satisfaction, empowerment, and adherence. Participants highlighted how co-developed care plans enhanced their sense of control and autonomy. At the same time, others noted that involvement helped them better understand and commit to treatment. These experiences reflect the benefits of shared decision-making.^11,54 Empathy and support structures also played a crucial role, as Ong et al. argue that empathetic communication fosters engagement and enhances treatment outcomes.^31,49,55 Participants who experienced co-production described higher satisfaction and improved outcomes, particularly when supported by increased accessibility and consistent follow-up. These insights align with evidence that co-production and continuity of care improve patient outcomes and satisfaction.^9,30,56

Similar patterns have been reported in high-income contexts such as Canada, the UK, and the Netherlands, where shared decision-making and relational continuity are central to national mental health policies. In these settings, co-production has been linked to patient satisfaction, as well as reduced service utilisation and improved cost-effectiveness, underscoring its value beyond individual engagement.^2,32,57 Accessibility and continuity of care are influenced not only by clinician availability but also by the organisational processes that support patient access to services. In many healthcare settings, reception and administrative staff represent the first point of contact for patients and therefore play an important role in shaping patients’ experiences of access and continuity.⁵⁸ Administrative processes related to appointment scheduling, prescription renewals and communication with clinicians can either facilitate timely engagement with care or contribute to delays and frustration for patients managing chronic conditions such as ADHD.

However, unlike in contexts where co-production is increasingly institutionalised, South Africa lacks formal structures and policy frameworks that embed patient involvement in psychiatric service delivery. This disparity highlights a pressing implementation gap, especially in areas such as adult ADHD, which remains underdiagnosed and poorly integrated into public mental health strategies.^13,59

By positioning co-production as both a relational and system-level intervention, this study contributes to global discussions on adapting participatory care models to under-resourced settings.⁶⁰ The cyclic interplay between involvement, trust, satisfaction, and continuity aligns with the ecological systems framework,^4,27 suggesting that interventions should address individual and systemic levels to sustain engagement.

This study contributes to a growing body of literature that moves beyond clinical efficacy to explore the relational and structural dimensions of care. The findings demonstrate that a dynamic interplay of agency, trust, satisfaction, and continuity shapes patient involvement in adult ADHD care. Qualitative methods enabled a deep exploration of lived experience, revealing how small relational moments, such as empathetic communication or consistent follow-up, can influence long-term engagement. The SERVPERF-informed interview approach elicited perceptions of care quality in a psychiatric setting.

For practitioners, this study emphasises the importance of fostering trust, encouraging patient agency, and ensuring continuity in provider relationships. For health system managers, it underlines the value of incorporating patient-reported experiences into quality improvement strategies. For researchers, it signals the need to investigate further how relational cycles operate across diverse clinical contexts. Theoretically, the findings affirm the utility of Bronfenbrenner’s ecological systems model as a lens for understanding patient engagement. Future research should test the framework in under-resourced or public sector contexts.

Empirically, they offer patient-informed evidence to guide the integration of co-production principles into psychiatric care. Ultimately, advancing outcomes in adult ADHD care requires both clinical excellence and a deliberate, relational approach, care that listens, evolves and remains consistently engaged.