A realist review of medication optimisation of community dwelling service users with serious mental illness

Abstract Background Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly anti-psychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterized by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI. Objective Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community? Methods A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations. Results Our programme theory represents a continuum from a service user’s initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation. Conclusions Supported decision-making and trust are foundational to overcoming stigma and establishing ‘safety’ and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers. What is already known on this topic Medication optimisation is challenging for both people living with SMI and their prescribing clinicians; medication non-adherence is common. What this study adds Effective medication optimisation requires a person-centred approach embedded throughout a service user’s journey from initial diagnosis to effective medication co-management with practitioners. How this study might affect research, practice or policy Research is needed in multiple aspects of medication optimisation, including transition from acute care to community, the role of trained peer support workers, and practitioner awareness of unique needs for individuals from ethnic and cultural minority groups.

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