¹Keele University, School of Medicine, Keele, United Kingdom, ²Midlands Partnership NHS Foundation Trust, Research, Stafford, United Kingdom, ³Aston University, College of Health and Life Science, Birmingham, United Kingdom, ⁴University of Birmingham, Department of Applied Health Sciences, Birmingham, United Kingdom, ⁵University of Sheffield, Department of Psychology, Sheffield, United Kingdom, ⁶University of Manchester, Division of Psychology and Mental Health, Manchester, United Kingdom

Background: People with severe mental illness (SMI) experience about two-three fold increased risk of premature mortality; with over 60% of deaths attributable to preventable cardiometabolic disease mostly due to metabolic side effects of antipsychotics. Despite the availability of lower-risk alternatives for almost a decade, switching APs to mitigate physical health harms remains uncommon due to clinician uncertainty, relapse concerns, and system-level barriers.

Aims & Objectives: We aimed to co-design and iteratively develop a clinical decision-support tool to facilitate switching from higher risk (olanzapine, risperidone, quetiapine) to lower risk antipsychotics (aripiprazole, lurasidone, cariprazine) APs while embedding shared decision-making (SDM) with patients and carers.

Method: iSWITCHED (implementing SWITCHing EDucational intervention) tool was co-designed using following an iterative process: two theory of change (ToC) workshops with 28 mental health clinicians to identify behavioral, clinical, and organizational barriers and enablers to AP switching; (ii) a systematic review of clinical practice guidelines (CPGs) of schizophrenia and related psychosis, (iii) qualitative interviews with SMI patients and caregivers exploring experiences, preferences, and perceived risks. Findings from these stages informed iSWITCHED tool development . The tool functionality was refined through: two consensus-building workshops (CBWs) with 26 participants, 8 think-aloud interviews with clinicians and 3 role-play activities with mental health clinicians and simulated patients and caregivers.

Results: Across two ToCs (28 psychiatrists, pharmacists, nurses), qualitative interviews (13 patients, 5 caregivers), and CBWs (26 participants), consistent themes highlighted the need for: clear communication of cardiometabolic risk; structured yet flexible switching guidance; clinician training to build confidence in switching decisions; and active patient and carer involvement through SDM. Key system-level challenges included limited consultation time, fragmented physical-mental healthcare integration, and lack of embedded decision support within routine clinical systems. The formative findings led to developing iSWITCHED that consisted of an intuitive electronic decision aid with integration capability within Rio (NHS electronic health care record system). It provides step by step guidance on switching antipsychotics to practicing clinician in real time and consists of following major components:

1. Electronic switching dose estimator
2. Linked guidance on switching antipsychotics based on synthesis of evidence from 33 CPGs
3. SDM guidance to structure discussions with patients and carers
4. Seven interactive training modules consisting for clinicians
5. Patient and clinician-facing informational leaflets to support switching and monitoring

Preliminary usability and acceptability feedback from think-aloud interviews (8 clinicians), focus group based on role-plays (7 participants) indicated that iSWITCHED was user-friendly, feasible for clinical use, and relevant to both clinicians and patients. Participants highlighted clear decision algorithms, instant access to estimated dose equivalences risk mitigation strategies when switching antipsychotics, graphical representation of dose titration process, and effective shared decision-making prompts as major advantages of the tool.

Discussion & Conclusions: iSWITCHED is the first electronic tool that can potentially be embedded in electronic health record system and provides dose estimation, shared decision making and a step by step guide on antipsychotic switching to reduce cardiometabolic risk in people with SMI. By integrating lived experience, clinical expertise, and implementation considerations, iSWITCHED has progressed from conceptualization to a functional, iteratively refined prototype which will be demonstrated in the presentation.