The key finding
A 2025 realist review analyzing 106 documents found that shared decision-making (SDM) — where doctors and patients choose treatments together — remains rare in psychosis care, especially when prescribing antipsychotics. Researchers identified five core mechanisms that increase prescriber engagement: reducing their fear of sole responsibility for patient harm, lowering the perceived time burden of SDM conversations, building confidence in negotiating treatment discussions, enhancing their ability to safely give patients more autonomy, and creating supportive team environments. The review suggests that when these psychological and organizational barriers are addressed, prescribers become significantly more willing to involve patients in medication decisions.
What the study looked like
This was a realist review — a type of analysis that doesn’t just ask “does SDM work?” but “when, how, and why does it work?” Researchers searched nine databases including PubMed, PsycINFO, and Google Scholar for studies examining SDM interventions in antipsychotic prescribing contexts. They analyzed 106 documents to understand the relationship between intervention design, local implementation contexts, and prescriber behavior change. Unlike traditional systematic reviews that focus on measuring outcomes, this realist approach traced causal pathways: identifying which features of SDM programs triggered specific mechanisms in prescribers’ thinking, and how organizational contexts either facilitated or blocked these mechanisms. The review specifically focused on meso-level (service delivery) and micro-level (individual prescriber) contexts.
Why researchers think this happened
The authors explain that prescribers face substantial psychological barriers when considering SDM in psychosis care. Many fear that giving patients with psychosis more decision-making authority could lead to medication non-adherence and subsequent relapse — and that they alone would bear responsibility for negative outcomes. This fear is compounded by time pressures: SDM conversations appear more burdensome than directive prescribing. The review found that successful interventions worked by redistributing responsibility across multidisciplinary teams rather than placing it solely on individual prescribers. When SDM became a team responsibility, prescribers felt safer engaging patients in decisions. Additionally, interventions that built specific negotiation skills helped prescribers feel competent rather than overwhelmed during complex treatment conversations. The authors note that fragmented care systems — where patients see different prescribers at each visit — undermine trust-building necessary for productive SDM.
How to read this carefully
This is a realist review synthesizing existing literature rather than a controlled trial measuring SDM outcomes directly. The findings describe associations between intervention features and prescriber engagement, not proof that these strategies definitively cause behavior change in all settings. The 106 included documents likely varied substantially in quality, setting, and population. The review focuses specifically on antipsychotic prescribing in psychosis — findings may not generalize to other medical decisions or patient populations. Additionally, the analysis examines what increases prescriber willingness to engage in SDM, but doesn’t directly measure whether increased SDM improves patient outcomes like medication adherence, quality of life, or symptom management. Cultural and healthcare system differences across included studies may limit applicability to specific local contexts.
What this means for everyday life
If you or someone you know lives with psychosis and takes antipsychotic medications, this research suggests the decision-making dynamic with prescribers might improve if certain conditions exist. Continuity of care — seeing the same prescriber over time — appears important for building the trust necessary for collaborative decisions. Having a multidisciplinary team involved in your care, rather than a single prescriber making all decisions, may create more space for your preferences to be heard. If you’ve felt your psychiatrist seems rushed or directive, this review suggests they may lack training in shared decision-making conversations or fear being blamed if you choose a medication that doesn’t work well. While you can’t change system-level factors alone, knowing these barriers exist might help you explicitly ask for time to discuss treatment options and express your preferences, potentially triggering more collaborative conversations even in imperfect systems.