From Idealist to Realist-Designing and Implementing Shared Decision-Making Interventions in the Choice of Antipsychotic Prescription in People Living with Psychosis (SHAPE): A Realist Review.

Background: Shared decision-making (SDM) implementation remains limited in psychosis management, particularly within antipsychotic prescribing. When and why prescribers engage in SDM within these contexts is largely unknown. Part 1 of this two-part realist review aimed to understand the impact of structural and contextual factors on prescriber engagement in SDM within antipsychotic prescribing.

Study design: CINAHL Plus, Cochrane Library, Embase, PsycINFO, PubMed, Scopus, Sociological Abstracts, Web of Science, and Google Scholar were searched for evidence to develop realist program theories outlining the relationship between macro-level contexts and their impact on prescriber behaviors.

Study results: From 106 included documents, five program theories explaining relationships between (i) leadership and governance, (ii) workforce development, and (iii) service delivery contexts and their impact on reducing prescriber engagement with behaviors required of SDM application were developed. No facilitative macro-level contexts were identified. Key mechanisms reducing prescriber engagement in desired behaviors include fear of individual blame for adverse outcomes and exposure to liability, pressure from service environments to prioritize decreasing risk of harm, devaluing of experiential knowledge, and beliefs that SDM conflicts with duties of beneficence and non-maleficence.

Conclusion: Even empirically efficacious interventions will be difficult to implement at scale within real-world settings due to misalignment with complex cultural, legal, and professional realities prominent therein. Mechanisms responsible for reducing prescriber engagement in SDM should be the target of structural interventions necessary to support contextual integration into psychosis management. Part 2 outlines features of service delivery contexts, workforce development, and technology that can increase prescriber engagement in SDM.