The Psychosocial Risk Assessment (PRisMA) Guideline 2024, issued by the Department of Occupational Safety and Health (DOSH) Malaysia, marks a significant advancement in formalising mental health protections within the Malaysian workplace. However, the practical implementation of psychosocial risk assessment within small and medium enterprises (SMEs) — which constitute over 97% of Malaysian businesses — presents unique challenges that are not fully addressed by the current guideline documentation. This commentary draws on clinical occupational health practice to examine the implementation barriers faced by Malaysian SMEs, the limitations of the LEO26 instrument in culturally diverse workplaces, and opportunities for strengthening psychosocial risk governance in this underserved sector.