Shared decision-making (SDM) is widely seen as best practice in mental healthcare. It means clinicians and patients working together to decide on treatments, balancing clinical evidence with what matters most to the individual. Evidence shows SDM can improve quality of life, reduce hospital admissions, and strengthen patient rights. Yet a new study from the University of Nottingham highlights that culture plays a powerful role in shaping whether, and how, SDM actually happens.
Researchers surveyed 751 psychiatrists and trainees across 38 European countries and compared their attitudes to Hofstede’s model of national culture. The findings, published in European Psychiatry, show clear trends. Psychiatrists from cultures that value individual choice and personal freedom were more likely to favour SDM. Those from cultures where hierarchy is deeply entrenched were less likely to involve patients in shared decisions.
The implication is striking: something as intangible as cultural background influences how clinicians interpret their professional responsibilities. In more individualistic cultures, psychiatry is framed around autonomy and patient empowerment. In more hierarchical systems, the clinical voice tends to dominate. For patients, this can mean radically different experiences of care depending not just on the country, but on the cultural assumptions of the professionals they encounter.
Yet culture is not the whole story. Associate Professor Yasuhiro Kotera, who led the research, stresses that practical structures may outweigh cultural norms. Once factors such as healthcare system design, time with patients, and staff training are considered, cultural differences become less decisive. In other words, even in hierarchical cultures, well-designed systems and supportive policies can enable shared decision-making.
This nuance matters. It prevents us from treating culture as destiny and instead points to what can be changed. Training programmes that emphasise patient collaboration, policies that protect time for dialogue, and institutional expectations that value patient voice can all make SDM more consistent across borders.
The study raises important questions for mental health policy. If we accept that culture shapes clinician attitudes, then international initiatives to promote SDM must go beyond clinical evidence. They must be sensitive to local norms while also pushing for structural reforms that create space for genuine collaboration. A “one-size-fits-all” approach will not work.
At the same time, the research is a reminder that mental health care is never delivered in a vacuum. Decisions are always filtered through professional identities, national systems, and cultural frameworks. Patients, often at their most vulnerable, are navigating not just the complexity of illness but the assumptions of the professionals they turn to for help.
The lesson is clear: shared decision-making is not simply a clinical technique. It is a cultural and systemic practice that requires deliberate support. By recognising the role of culture while also strengthening training and system design, we can build mental healthcare that is both more collaborative and more respectful of the people it serves.
