Samele et al ^{Reference Samele, Lawton-Smith, Warner and Mariathasan1} have highlighted the implications of patient choice in psychiatry and some of its main challenges. The importance of a patient-oriented approach in psychiatry has even been emphasised in the World Health Report. ² Patients seem to want more say in their treatment decisions, to receive appropriate information on their condition and make decisions concerning the management of their illness. ^{Reference Laugharne3} Psychiatry is a particularly challenging area with regard to this, because mental illness can affect both understanding and decision-making abilities. This topic has significance particularly to low- and middle-income countries such as Sri Lanka. The attitudes of patients and choice of therapy in low- and middle-income countries may differ from those in high-income countries as cultural norms and beliefs play a major role in decision-making. ^{Reference Soltani, Moayyeri and Raza4} Also, almost all the time, patients depend on the therapist to make decisions regarding their treatment either because they themselves are not knowledgeable enough or they think the therapist knows best. At present, suing by patients is found less frequently in low- and middle-income countries compared with the West, hence therapists are not under pressure when making decisions. This may contribute to the maintenance of the ‘therapist-centred’ approach in the management of patients in our part of the world. Another reason which makes patient choice less feasible in low- and middle-income countries is the limited number of therapeutic options, owing to lack of resources. This sometimes leads to medications being the only available option although other treatment modalities are indicated for the particular condition. Another factor which might impede patient choice is the lack of a proper mental health act. Some low- and middle-income countries either do not have a mental health act ² or the existing mental health acts are archaic, were developed during the pre-antipsychotic era and are not at all patient centred. Psychiatrists and policy makers, particularly in low- and middle-income countries, should be aware of these important issues when health plans are made and implemented.