RT Journal Article SR Electronic T1 A realist review of medication optimisation of community dwelling service users with serious mental illness JF BMJ Quality & Safety JO BMJ Qual Saf FD BMJ Publishing Group Ltd SP bmjqs-2023-016615 DO 10.1136/bmjqs-2023-016615 A1 Howe, Jo A1 MacPhee, Maura A1 Duddy, Claire A1 Habib, Hafsah A1 Wong, Geoff A1 Jacklin, Simon A1 Oduola, Sheri A1 Upthegrove, Rachel A1 Carlish, Max A1 Allen, Katherine A1 Patterson, Emma A1 Maidment, Ian YR 2023 UL http://qualitysafety.bmj.com/content/early/2023/12/05/bmjqs-2023-016615.abstract AB 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 antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised 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.PROSPERO registration number CRD42021280980.All data relevant to the study are included in the article or uploaded as supplementary information.