The effectiveness, implementation, and experiences of peer support approaches for mental health: a systematic umbrella review.

BACKGROUND: Peer support for mental health is recommended across international policy guidance and provision. Our systematic umbrella review summarises evidence on the effectiveness, implementation, and experiences of paid peer support approaches for mental health. METHODS: We searched MEDLINE, EMBASE, PsycINFO, The Campbell Collaboration, and The Cochrane Database of Systematic Reviews (2012-2022) for reviews of paid peer support interventions for mental health. The AMSTAR2 assessed quality. Results were synthesised narratively, with implementation reported using the CFIR (Consolidated Framework for Implementation Research). The protocol was registered with PROSPERO (registration number: CRD42022362099). RESULTS: We included 35 reviews (426 primary studies, n = 95-40,927 participants): systematic reviews with (n = 13) or without (n = 13) meta-analysis, or with qualitative synthesis (n = 3), scoping reviews (n = 6). Most reviews were low or critically low (97%) quality, one review was high quality. Effectiveness was investigated in 23 reviews. Results were mixed; there was some evidence from meta-analyses that peer support may improve depression symptoms (particularly perinatal depression), self-efficacy, and recovery. Factors promoting successful implementation, investigated in 9 reviews, included adequate training and supervision, a recovery-oriented workplace, strong leadership, and a supportive and trusting workplace culture with effective collaboration. Barriers included lack of time, resources and funding, and lack of recognised peer support worker (PSW) certification. Experiences of peer support were explored in 11 reviews, with 3 overarching themes: (i) what the PSW role can bring, including recovery and improved wellbeing for service users and PSWs; (ii) confusion over the PSW role, including role ambiguity and unclear boundaries; and (iii) organisational challenges and impact, including low pay, negative non-peer staff attitudes, and lack of support and training. CONCLUSIONS: Peer support may be effective at improving some clinical outcomes, self-efficacy, and recovery. Certain populations, e.g. perinatal populations, may especially benefit from peer support. Potential strategies to successfully implement PSWs include co-production, clearly defined PSW roles, a receptive hierarchical structure and staff, appropriate PSW and staff training with clinical and/or peer supervision alongside safeguarding. Services could benefit from clear, coproduced, setting specific implementation guidelines for PSW. PSW roles tend to be poorly defined and associations between PSW intervention content and impacts need further investigation. Future research should reflect the priorities of providers/service users involved in peer support.

Approaches to improving mental health care for autistic children and young people: a systematic review and meta-analysis.

Autistic children and young people (CYP) experience mental health difficulties but face many barriers to accessing and benefiting from mental health care. There is a need to explore strategies in mental health care for autistic CYP to guide clinical practice and future research and support their mental health needs. Our aim was to identify strategies used to improve mental health care for autistic CYP and examine evidence on their acceptability, feasibility, and effectiveness. A systematic review and meta-analysis were carried out. All study designs reporting acceptability/feasibility outcomes and empirical quantitative studies reporting effectiveness outcomes for strategies tested within mental health care were eligible. We conducted a narrative synthesis and separate meta-analyses by informant (self, parent, and clinician). Fifty-seven papers were included, with most investigating cognitive behavioral therapy (CBT)-based interventions for anxiety and several exploring service-level strategies, such as autism screening tools, clinician training, and adaptations regarding organization of services. Most papers described caregiver involvement in therapy and reported adaptations to communication and intervention content; a few reported environmental adjustments. In the meta-analyses, parent- and clinician-reported outcomes, but not self-reported outcomes, showed with moderate certainty that CBT for anxiety was an effective treatment compared to any comparison condition in reducing anxiety symptoms in autistic individuals. The certainty of evidence for effectiveness, synthesized narratively, ranged from low to moderate. Evidence for feasibility and acceptability tended to be positive. Many identified strategies are simple, reasonable adjustments that can be implemented in services to enhance mental health care for autistic individuals. Notable research gaps persist, however.

A qualitative meta-synthesis of service users' and carers' experiences of assessment and involuntary hospital admissions under mental health legislations: a five-year update.

BACKGROUND: Compulsory admissions occur in psychiatric hospitals around the world. They result in coercive and sometimes traumatic experiences for service users and carers. Legal and service reforms in various countries are intended to reduce rates of detention and improve service user experience. We aimed to inform policy and service delivery by providing an up-to-date synthesis of qualitative evidence on service users' and carers' experiences of assessment and detention under mental health legislation, updating previous reviews in which we searched for literature published up to 2018. METHODS: We searched five bibliographic databases for studies published between January 2018 and March 2023. We identified 24 additional studies reporting qualitative investigations of service users' or carers' experiences of assessment or detention under mental health legislation. A team including researchers with relevant personal experience analysed and synthesised data using a thematic synthesis approach. RESULTS: Findings suggest that views on compulsory admissions and assessment varied: many reports highlighted its often negative, traumatic impacts on emotional well-being and self-worth, with fewer accounts of it as an opportunity to access help and support, accompanied by feelings of relief. Experiences of racial discrimination, inequality of access, and dissatisfaction with support before and after hospital stay were more prominent than in our previous reviews. CONCLUSIONS: Increasing service user and carer involvement in treatment decisions, provision of timely information at key stages of the admission process, training of key personnel, addressing the issue of discrimination, and investing in community alternatives of inpatient care may contribute to and lead to better overall treatment experiences. PROTOCOL REGISTRATION: The study protocol has been registered in the PROSPERO database on 30th May 2023 (CRD42023423439).

A qualitative investigation of crisis cafés in England: their role, implementation, and accessibility.

BACKGROUND: Crisis cafés (also known as crisis sanctuaries or havens) are community-based services which support people in mental health crises, aiming to provide an informal, non-clinical and accessible setting. This model is increasingly popular in the UK; however, we are aware of no peer-reviewed literature focused on this model. We aimed to investigate the aims of crisis cafés, how they operate in practice and the factors that affect access to these services and implementation of the intended model. METHODS: A qualitative approach was used. Semi-structured interviews were conducted with 12 managers of crisis cafés across England. These interviews explored managers' views on the implementation of their services, and the factors that help and hinder successful implementation. Data were analysed using Braun and Clarke's reflexive thematic approach. RESULTS: We identified five main perceived aims for crisis cafés: providing an alternative to Emergency Departments; improving access to crisis care; providing people in acute distress with someone to talk to in a safe and comfortable space; triaging effectively; and improving crisis planning and people's coping skills. Factors seen as influencing the effectiveness of crisis cafés included accessibility, being able to deliver person-centred care, relationships with other services, and staffing. These factors could both help and hinder access to care and the implementation of the intended model. There were a number of trade-offs that services had to consider when designing and running a crisis café: (1) Balancing an open-door policy with managing demand for the service through referral routes, (2) Balancing risk management procedures with the remit of offering a non-clinical environment and (3) Increasing awareness of the service in the community whilst avoiding stigmatising perceptions of it. CONCLUSIONS: Findings illustrate the aims of the crisis café model of care and factors which are influential in its implementation in current practice. Future research is needed to evaluate the efficacy of these services in relation to their aims. Crisis café service users' views, and views of stakeholders from the wider crisis care system should also be ascertained.

Associations between constructs related to social relationships and mental health conditions and symptoms: an umbrella review.

BACKGROUND: Loneliness and social isolation are increasingly recognised as prevalent among people with mental health problems, and as potential targets for interventions to improve quality of life and outcomes, as well as for preventive strategies. Understanding the relationship between quality and quantity of social relationships and a range of mental health conditions is a helpful step towards development of such interventions. PURPOSE: Our aim was to give an overview of associations between constructs related to social relationships (including loneliness and social isolation) and diagnosed mental conditions and mental health symptoms, as reported in systematic reviews of observational studies. METHODS: For this umbrella review (systematic review of systematic reviews) we searched five databases (PsycINFO, MEDLINE, EMBASE, CINAHL, Web of Science) and relevant online resources (PROSPERO, Campbell Collaboration, Joanna Briggs Institute Evidence Synthesis Journal). We included systematic reviews of studies of associations between constructs related to social relationships and mental health diagnoses or psychiatric symptom severity, in clinical or general population samples. We also included reviews of general population studies investigating the relationship between loneliness and risk of onset of mental health problems. RESULTS: We identified 53 relevant systematic reviews, including them in a narrative synthesis. We found evidence regarding associations between (i) loneliness, social isolation, social support, social network size and composition, and individual-level social capital and (ii) diagnoses of mental health conditions and severity of various mental health symptoms. Depression (including post-natal) and psychosis were most often reported on, with few systematic reviews on eating disorders or post-traumatic stress disorder (PTSD), and only four related to anxiety. Social support was the most commonly included social construct. Our findings were limited by low quality of reviews and their inclusion of mainly cross-sectional evidence. CONCLUSION: Good quality evidence is needed on a wider range of social constructs, on conditions other than depression, and on longitudinal relationships between social constructs and mental health symptoms and conditions.

A realist interview study of a participatory public mental health project "#KindnessByPost".

BACKGROUND: #KindnessByPost (KbP) is a participatory public health initiative in which people anonymously send and receive cards containing messages of goodwill with others also taking part in the programme. Quantitative evaluations of KbP consistently find evidence of improvements to people's mental wellbeing and feelings of loneliness after participation and three months later. Our aim in the present study is to develop a programme theory of KbP, which describes for whom the KbP intervention improves mental wellbeing, other reported impacts, in which contexts it has these effects, and the mechanisms by which it works. METHODS: We use a realist interviewing methodology to develop the programme theory. We conducted a focus group with the KbP executive team, and 20 one-to-one interviews with KbP participants. During analysis, a co-production working group iteratively developed a Theory of Change model comprising context-mechanism-outcome statements [CMOs] to map out the mechanisms present in KbP. RESULTS: We developed 145 CMO statements, which we condensed and categorized into 32 overarching CMOs across nine thematic topics: access to scheme; pathways to involvement; resources; culture; giving post; receiving post; content of received post; community; long term impact. These CMOs set out pathways through which KbP benefited participants, including from doing something kind for someone else, of receiving post and appreciating the effort that went into it, and from the creative process of creating post and writing the messages inside them. Effects were sustained in part through people keeping the cards and through the social media communities that emerged around KbP. DISCUSSION: Both giving and receiving post and the sense of community benefited participants and improved their mood and feelings of connectedness with others. Connection with a stranger, rather than friends or family, was also an important feature of the initiative for participants. Our wide range of CMO pathways by which KbP produced positive outcomes may mean that the intervention is applicable or adaptable across many communities and settings. Taken together with evidence from the quantitative evaluations, KbP is potentially an effective, low-cost, and highly scalable public health intervention for reducing loneliness and improving wellbeing.

Implementation strategies for telemental health: a systematic review.

BACKGROUND: The COVID-19 pandemic resulted in a rapid shift from traditional face-to-face care provision towards delivering mental health care remotely through telecommunications, often referred to as telemental health care. However, the manner and extent of telemental health implementation have varied considerably across settings and areas, and substantial barriers are encountered. There is, therefore, a need to identify what works best for service users and staff and establish the key mechanisms for efficient integration into routine care. OBJECTIVE: We aimed to identify investigations of pre-planned strategies reported in the literature intended to achieve or improve effective and sustained implementation of telemental health approaches (including video calls, telephone calls, text messaging platforms or a combination of any of these approaches with face-to-face care), and to evaluate how different strategies influence implementation outcomes. METHODS: A systematic review was conducted, with five databases searched for any relevant literature published between January 2010 and July 2021. Studies were eligible if they took place in specialist mental health services and focused on pre-planned strategies to achieve or improve the delivery of mental health care through remote communication between mental health professionals or between mental health professionals and service users, family members, unpaid carers, or peer supporters. All included studies were quality-assessed. Data were synthesised using the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies and the taxonomy of implementation outcomes. RESULTS: A total of 14 studies were identified as meeting the inclusion criteria from a total of 14,294 records of which 338 were assessed at full text. All ERIC implementation strategies were used by at least one study, the most commonly reported being 'Train and educate stakeholders'. All studies reported using a combination of several implementation strategies, with the mean number of strategies used per study of 3.5 (range 2-6), many of which were reported to result in an improvement in implementation over time. Few studies specifically investigated a single implementation strategy and its associated outcomes, making conclusions regarding the most beneficial strategy difficult to draw. CONCLUSIONS: Using a combination of implementation strategies appears to be a helpful method of supporting the implementation of telemental health. Further research is needed to test the impact of specific implementation strategies on implementation outcomes.

'Beyond places of safety' - a qualitative study exploring the implementation of mental health crisis care innovations across England.

BACKGROUND: Mental health acute and crisis care consumes a large share of mental health budgets internationally but is often experienced as unsatisfactory and difficult to access. As a result, there is an increasing move towards developing innovative community crisis services, to improve patient experience and relieve pressure on inpatient and emergency services. This study aims to understand what helps and hinders the implementation of innovative mental health crisis care projects in England. METHODS: Using a qualitative approach, 18 interviews were conducted with crisis care service managers exploring their experiences and views of the development and implementation of their service developed with support from an English national capital funding programme. A framework analysis was conducted informed by implementation science. RESULTS: Key facilitators to implementation of innovative crisis services included bottom-up development, service user involvement, strong collaborative working, and leadership and management buy-in. Key barriers that affected the projects implementation included the complexities of crisis care, workforce challenges and resourcing issues. CONCLUSION: There is a recognised need to improve, update, and innovate current crisis care offers. Results from this study suggest that a range of models can help address the heterogenous needs of local populations and that new approaches can be implemented where they utilise a whole-systems approach, involving service users and relevant professional stakeholders beyond mental health services in planning and developing the service.

Stakeholder perspectives on intensive support teams for adults with intellectual disabilities who display behaviour that challenges in England.

BACKGROUND: Adults with intellectual disabilities often display behaviour that challenges that is a result of biological differences, psychological challenges, and lack of appropriate social support. Intensive Support Teams (IST) are recommended to support the care needs of this group and avoid hospitalisation. However, little attention has been paid to the perspectives of stakeholders who manage, work in, or use ISTs. METHOD: Interviews and focus groups were conducted with 50 stakeholders (IST service managers and professionals, adults with intellectual disabilities, and family and paid carers) of ISTs. Services operated according to one of two service models previously identified in ISTs in England (enhanced or independent). RESULTS: Thematic analysis identified accessible and flexible support, individualised care, and the involvement of carers and other relevant agencies in management plans and reviews as features of good IST care highlighted by all stakeholder groups. IST managers and professionals described the key challenges of current IST provision as unclear referral criteria, limited interfaces with other local services, and perceived threats associated with funding and staff retention. Findings were similar between the two IST models. CONCLUSIONS: ISTs are able to offer care and specialist support that is valued by families, service users and other care providers. However, they face several operational challenges that should be addressed if ISTs are to reach their potential along with community intellectual disability services in supporting adults with intellectual disabilities who display behaviour that challenges in the community.

Service user perspectives of community mental health services for people with complex emotional needs: a co-produced qualitative interview study.

BACKGROUND: There is consensus that services supporting people with complex emotional needs are part of a mental health care system in which change is needed. To date, service users' views and co-production initiatives have had little impact on the development of interventions and care. This needs to change, and our paper evidences the experiences and perspectives of a diverse range of people on how community services can best address the needs of people with complex emotional needs. METHODS: A co-produced qualitative research study. Lived experience researchers led data collection and analysis. Individual interviews were conducted with 30 people across England who had a diverse range of experiences and perspectives of using community services for complex emotional needs. Participants were asked about their experiences of using community services for their mental health, and views on how community services can best address their needs. Thematic analysis was used to analyse the data. RESULTS: Participants reported some experiences of good practice but also of experiences of severely stigmatising interventions, a lack of effective support and service fragmentation. Relational Practice was identified as the central overarching theme and describes how community services can best support people with complex emotional needs. This approach involves care delivered in a non-stigmatising, individualised and compassionate way and care that is trauma-informed. It involves care that is planned collaboratively with service users to ensure their multiple needs are addressed in a flexible, holistic and consistent way which accounts for the long-term and fluctuating nature of their needs. CONCLUSIONS: Relational practice approaches have potential to facilitate better community care for people with complex emotional needs. Research and service development are needed to examine how best to implement such approaches across the mental health service system. This work must be co-produced with people with relevant lived experience, their carers and the professionals who support them.

Interventions to improve social circumstances of people with mental health conditions: a rapid evidence synthesis.

BACKGROUND: Poor social circumstances can induce, exacerbate and prolong symptoms of mental health conditions, while having a mental health condition can also lead to worse social outcomes. Many people with mental health conditions prioritise improvement in social and functional outcomes over reduction in clinical symptoms. Interventions that improve social circumstances in this population should thus be considered a priority for research and policy. METHODS: This rapid evidence synthesis reports on randomised controlled trials of interventions to improve social circumstances across eight social domains (Housing and homelessness; money and basic needs; work and education; social isolation and connectedness; family, intimate and caring relationships; victimisation and exploitation; offending; and rights, inclusion and citizenship) in people with mental health conditions. Economic evaluations were also identified. A comprehensive, stepped search approach of the Cochrane library, MEDLINE, Embase, PsycINFO, Web of Science and Scopus was conducted. RESULTS: One systematic review and 102 randomised controlled trials were included. We did not find RCT evidence for interventions to improve family, intimate and caring relationships and only one or two trials for each of improving money and basic needs, victimisation and exploitation, and rights, inclusion and citizenship. Evidence from successful interventions in improving homelessness (Housing First) and employment (Individual Placement and Support) suggests that high-intensity interventions which focus on the desired social outcome and provide comprehensive multidisciplinary support could influence positive change in social circumstances of people with mental health conditions. Objective social isolation could be improved using a range of approaches such as supported socialisation and social skills training but interventions to reduce offending showed few benefits. Studies with cost and cost-effectiveness components were generally supportive of interventions to improve housing and vocational outcomes. More research is needed to ensure that social circumstances accompanied by high risks of further exacerbation of mental health conditions are adequately addressed. CONCLUSIONS: Although there is a large body of literature examining how to support some aspects of life for people with mental health conditions, more high-quality evidence is required in other social domains. Integration into mental health services of interventions targeting social circumstances could significantly improve a number of social outcomes.

Loneliness and the onset of new mental health problems in the general population.

PURPOSE: Loneliness is associated with poor health including premature mortality. There are cross-sectional associations with depression, anxiety, psychosis, and other mental health outcomes. However, it is not known whether loneliness is causally linked with the new onset of mental health problems in the general population. Longitudinal studies are key to understanding this relationship. We synthesized evidence from longitudinal studies investigating the relationship between loneliness and new onset of mental health problems, in the general population. METHOD: We systematically searched six electronic databases, unpublished sources, and hand-searched references, up to August 2021. We conducted a meta-analysis of eight independent cohorts and narrative synthesis of the remaining studies. RESULTS: We included 32 studies, of which the majority focused on depression. Our narrative synthesis found most studies show loneliness at baseline which is associated with the subsequent new onset of depression. The few studies on anxiety and self-harm also showed a positive association. Our meta-analysis found a pooled adjusted odds ratio of 2.33 (95% CI 1.62-3.34) for risk of new onset depression in adults who were often lonely compared with people who were not often lonely. This should be interpreted with caution given evidence of heterogeneity. CONCLUSION: Loneliness is a public mental health issue. There is growing evidence it is associated with the onset of depression and other common mental health problems. Future studies should explore its impact across the age range and in more diverse populations, look beyond depression, and explore the mechanisms involved with a view to better informing appropriate interventions.

What has changed in the experiences of people with mental health problems during the COVID-19 pandemic: a coproduced, qualitative interview study.

PURPOSE: We sought to understand how the experiences of people in the UK with pre-existing mental health conditions had developed during the course of the COVID-19 pandemic. METHODS: In September-October 2020, we interviewed adults with mental health conditions pre-dating the pandemic, whom we had previously interviewed 3 months earlier. Participants had been recruited through online advertising and voluntary sector community organisations. Semi-structured qualitative interviews were conducted by telephone or video-conference by researchers with lived experience of mental health difficulties, and, following principles of thematic analysis, were analysed to explore changes over time in people's experience of the pandemic. RESULTS: We interviewed 44 people, achieving diversity of demographic characteristics (73% female, 54% White British, aged 18-75) and a range of mental health conditions and service use among our sample. Three overarching themes were derived from interviews. The first theme "spectrum of adaptation" describes how participants reacted to reduced access to formal and informal support through personal coping responses or seeking new sources of help, with varying degrees of success. The second theme describes "accumulating pressures" from pandemic-related anxieties and sustained disruption to social contact and support, and to mental health treatment. The third theme "feeling overlooked" reflects participants' feeling of people with mental health conditions being ignored during the pandemic by policy-makers at all levels, which was compounded for people from ethnic minority communities or with physical health problems. CONCLUSION: In line with previous research, our study highlights the need to support marginalised groups who are at risk of increased inequalities, and to maintain crucial mental and physical healthcare and social care for people with existing mental health conditions, notwithstanding challenges of the pandemic.

A systematic review and meta-analysis of group peer support interventions for people experiencing mental health conditions.

BACKGROUND: Peer support is being integrated within mental health services to further the development of a recovery approach. However, the most effective models and formats of intervention delivery are unknown. We conducted this systematic review and meta-analysis to determine the effectiveness of peer support for improving outcomes for people with lived experience of mental health conditions, when delivered as group interventions. METHODS: Studies reporting randomised controlled trials of group peer support interventions for people experiencing mental health conditions were identified by searching MEDLINE, PsycINFO, Embase and Cochrane CENTRAL, from inception until July 12th 2019 and undertaking supplementary searches. Included studies were assessed for risk of bias and meta-analyses were conducted if three or more trials provided usable data. RESULTS: Eight trials met eligibility criteria, providing data from 2131 participants. Six trials had either high or unclear risk of bias. Interventions were categorised as mutual support groups, or peer support groups, sub-categorised as anti-stigma or self-management interventions. Meta-analyses were only possible for peer support groups and five outcomes. We found evidence that group peer support may make small improvements to overall recovery but not hope or empowerment individually, or to clinical symptoms. Evidence for effectiveness for outcomes which could not be meta-analysed was mixed. CONCLUSIONS: Findings from the few eligible trials suggest group peer support interventions may be specifically effective for supporting personal recovery and have a limited impact on other outcomes, though there were some risks of bias to study findings. Interventions were heterogeneous and most social outcomes were absent in the literature, highlighting further limitations to the current evidence-base. There is insufficient evidence available from trials of group peer support torecommend the routine implementation of these interventions across mainstream mental health services at present. More high-quality trials of peer-developed, group peer support interventions are needed in order tomake firm conclusions about intervention effectiveness.

Loneliness in early psychosis: a qualitative study exploring the views of mental health practitioners in early intervention services.

BACKGROUND: Loneliness is an important public health problem with established adverse effects on physical and mental health. Although people with psychosis often experience high levels of loneliness, relatively little is known about the relationship between loneliness and early psychosis. Potential interventions to address loneliness might be easier to implement early in the illness when social networks and social skills may be more intact than at a later stage. We investigated the views of mental health practitioners about the context and causes of loneliness in people with early psychosis, and about potential interventions. METHODS: Semi-structured face-to-face interviews were conducted with mental health practitioners (n = 20). Participants were purposively recruited from four early intervention services for first-episode psychosis in the UK. Interviews were transcribed verbatim and thematic analysis was conducted. RESULTS: Participants believed that the majority of service users with early psychosis experience feelings of loneliness. They often saw socially isolated and disconnected clients and believed them to be lonely, but rarely discussed loneliness explicitly in clinical interactions. A combination of symptoms, stigma and negative sense of self were believed to underpin loneliness. Participants could not identify any specific current interventions delivered by their services for tackling loneliness, but thought some routinely provided interventions, including social groups and psychological treatments, could be helpful. They favoured making a wider range of loneliness interventions available and believed that community agencies beyond mental health services should be involved to make these effective and feasible to deliver. They suggested social participation interventions without an explicit mental health focus as potentially promising and valued a co-produced approach to intervention development. CONCLUSIONS: This study suggests that loneliness is not routinely discussed in early intervention services, and a targeted strategy for tackling it is lacking. Co-produced, individualised community approaches, and interventions that target symptoms, stigma and negative self-schemas might be beneficial in alleviating loneliness for people with early psychosis. Empirical research is needed to develop and test such interventions.

Trajectories of loneliness and objective social isolation and associations between persistent loneliness and self-reported personal recovery in a cohort of secondary mental health service users in the UK.

BACKGROUND: Loneliness is a frequent and distressing experience among people with mental health problems. However, few longitudinal studies have so far investigated the trajectories of loneliness and objective social isolation, and the extent to which both issues may impact mental health outcomes among mental health service users. Therefore, this study aims to describe the trajectories of loneliness and objective social isolation and their associations with self-rated personal recovery among people leaving crisis resolution teams (CRTs). METHODS: A total of 224 participants receiving care from CRTs (recruited for a large multi-site randomised controlled trial) were included in this longitudinal cohort study. They completed the eight-item University of California at Los Angeles Loneliness Scale (ULS-8), Lubben-Social Network Scale (LNSN-6), and the Questionnaire about the Process of Recovery (QPR) (primary outcome) at baseline, 4- and 18-month follow-up, as well as baseline sociodemographic and clinical variables. RESULTS: We compared groups who were persistently lonely (at all time points), intermittently lonely (at one or two time points) and never lonely. After adjusting for all potential confounders and baseline predictive variables, persistent severe loneliness was associated with worse personal recovery at 18-month follow-up compared with the never lonely (reference group) (coef. = - 12.8, 95% CI -11.8, - 3.8, p < .001), as was being intermittently lonely (coef. = - 7.8, 95% CI -18.8, - 6.8, p < .001). The persistently objectively social isolated group (coef. = - 9.8, 95% CI -15.7, - 3.8, p = .001) also had poorer self-rated recovery at 18-month follow-up than those who were not socially isolated at any timepoint (i.e., reference category). CONCLUSION: Results suggest that both persistent loneliness and objective social isolation are associated with poorer self-rated recovery following a crisis, compatible with a causal relationship. These findings suggest a potential role for interventions aimed at alleviating loneliness and objective social isolation in improving recovery outcomes for people with mental health symptoms. Increased awareness of both issues among health practitioners is also warranted.

A systematic review of PTSD to the experience of psychosis: prevalence and associated factors.

BACKGROUND: Psychosis can be a sufficiently traumatic event to lead to post-traumatic stress disorder (PTSD). Previous research has focussed on the trauma of first episode psychosis (FEP) and the only review to date of PTSD beyond the first episode period was not systematic and is potentially outdated. METHODS: We searched electronic databases and reference lists using predetermined inclusion criteria to retrieve studies that reported prevalence rates and associated factors of psychosis-related PTSD across all stages of the course of psychosis. Studies were included if they measured PTSD specifically related to the experience of psychosis. Risk of bias was assessed using an adapted version of the Newcastle Ottawa Scale. Results were synthesised narratively. RESULTS: Six papers met inclusion criteria. Prevalence estimates of psychosis-related PTSD varied from 14 to 47%. Studies either assessed first-episode samples or did not specify the number of episodes experienced. Depression was consistently associated with psychosis-related PTSD. Other potential associations included treatment-related factors, psychosis severity, childhood trauma, and individual psychosocial reactions to trauma. CONCLUSIONS: Psychosis-related PTSD is a common problem in people with psychosis. There is a lack of published research on this beyond first episode psychosis. Further research is needed on larger, more generalizable samples. Our results tentatively suggest that prevalence rates of psychosis-related PTSD have not reduced over the past decade despite ambitions to provide trauma-informed care. Prospero registration number: CRD42019138750.

Acute day units for mental health crises: a qualitative study of service user and staff views and experiences.

BACKGROUND: Acute Day Units (ADUs) provide intensive, non-residential, short-term treatment for adults in mental health crisis. They currently exist in approximately 30% of health localities in England, but there is little research into their functioning or effectiveness, and how this form of crisis care is experienced by service users. This qualitative study explores the views and experiences of stakeholders who use and work in ADUs. METHODS: We conducted 36 semi-structured interviews with service users, staff and carers at four ADUs in England. Data were analysed using thematic analysis. Peer researchers collected data and contributed to analysis, and a Lived Experience Advisory Panel (LEAP) provided perspectives across the whole project. RESULTS: Both service users and staff provided generally positive accounts of using or working in ADUs. Valued features were structured programmes that provide routine, meaningful group activities, and opportunities for peer contact and emotional, practical and peer support, within an environment that felt safe. Aspects of ADU care were often described as enabling personal and social connections that contribute to shifting from crisis to recovery. ADUs were compared favourably to other forms of home- and hospital-based acute care, particularly in providing more therapeutic input and social contact. Some service users and staff thought ADU lengths of stay should be extended slightly, and staff described some ADUs being under-utilised or poorly-understood by referrers in local acute care systems. CONCLUSIONS: Multi-site qualitative data suggests that ADUs provide a distinctive and valued contribution to acute care systems, and can avoid known problems associated with other forms of acute care, such as low user satisfaction, stressful ward environments, and little therapeutic input or positive peer contact. Findings suggest there may be grounds for recommending further development and more widespread implementation of ADUs to increase choice and effective support within local acute care systems.

A qualitative study of stakeholder views on the use of a digital app for supported self-management in early intervention services for psychosis.

BACKGROUND: Digital tools such as Smartphones have the potential to increase access to mental health support including self-management interventions for individuals with psychosis, and ultimately to improve outcomes. Self-management strategies, including relapse prevention and crisis planning and setting personal recovery goals, are intended to assist people with long-term conditions to take an active role in their recovery, with evidence for a range of benefits. However, their implementation is inconsistent, and access and uptake need to be improved. The current study explores the acceptability of a Smartphone app (My Journey 3) that has been developed to facilitate supported self-management in Early Intervention in Psychosis (EIP) services. METHODS: Semi-structured one-to-one interviews were conducted with twenty-one EIP service users who had access to My Journey 3 as part of a feasibility trial, and with thirteen EIP service clinicians who were supporting service users with the app. Interviews focused on the acceptability and usability of My Journey 3. Data was coded to themes based on the Acceptability of Healthcare Interventions framework. RESULTS: Many service user participants found My Journey 3 to be acceptable. The symptom and medication trackers in particular were described as helpful. A smaller number of service users disliked the intervention. Individual-level factors that appeared to influence acceptability and engagement included recovery stage and symptom severity. Clinicians tended to report that My Journey 3 was a potentially positive addition to service users' care, but they often felt unable to provide support due to competing demands in their work, which in turn may have impacted acceptability and usage of the app. CONCLUSIONS: Our findings suggest that the app is perceived as having potential to improve users' capacity to self-manage and work towards recovery goals, but barriers prevented many clinicians providing consistent and effective support as intended. Further evaluation of supported self-management apps in psychosis is warranted but needs to address implementation challenges from the start.

Experiences of living with mental health problems during the COVID-19 pandemic in the UK: a coproduced, participatory qualitative interview study.

PURPOSE: Research is beginning to quantify the impact of COVID-19 on people with pre-existing mental health conditions. Our paper addresses a lack of in-depth qualitative research exploring their experiences and perceptions of how life has changed at this time. METHODS: We used qualitative interviews (N = 49) to explore experiences of the pandemic for people with pre-existing mental health conditions. In a participatory, coproduced approach, researchers with lived experiences of mental health conditions conducted interviews and analysed data as part of a multi-disciplinary research team. RESULTS: Existing mental health difficulties were exacerbated for many people. People experienced specific psychological impacts of the pandemic, struggles with social connectedness, and inadequate access to mental health services, while some found new ways to cope and connect to the community. New remote ways to access mental health care, including digital solutions, provided continuity of care for some but presented substantial barriers for others. People from black and ethnic minority (BAME) communities experienced heightened anxiety, stigma and racism associated with the pandemic, further impacting their mental health. CONCLUSION: There is a need for evidence-based solutions to achieve accessible and effective mental health care in response to the pandemic, especially remote approaches to care. Further research should explore the long-term impacts of COVID-19 on people with pre-existing mental health conditions. Particular attention should be paid to understanding inequalities of impact on mental health, especially for people from BAME communities.