Experiences of Mental Health Care Among Women Treated for Postpartum Psychosis in England: A Qualitative Study.

Postpartum psychosis has been found to affect 0.89-2.6 per 1000 women. Onset is typically rapid and severe. Early recognition and appropriate treatment are crucial for a good prognosis. Our aim in this study was to understand women's experiences of mental health care and services for psychosis in the postnatal period. Semi-structured interviews were conducted with 12 women who reported being treated for postpartum psychosis. Findings were analysed thematically. Women reported that healthcare professionals across maternity and mental health services often lacked awareness and knowledge of postpartum psychosis and did not always keep them or their partners/families informed, supported, and involved. Women wanted better collaboration between and within services, and more efficient, appropriate, and timely care. They valued inpatient services that could meet their needs, favouring Mother and Baby Units over general psychiatric wards. Early Intervention in Psychosis services and specialist perinatal community mental health teams were also well liked.

Experiences of parent-infant teams among mothers diagnosed with perinatal mental health difficulties.

BACKGROUND: Disrupted parent-infant bonds can have a negative impact on childhood development. In the United Kingdom, parent-infant teams can offer support to parents (most commonly mothers) to help strengthen parent-infant relationships. However, little is known about women's experiences of these teams. This study aimed to explore experiences of support from parent-infant teams among mothers diagnosed with perinatal mental health difficulties. METHOD: Qualitative semi-structured interviews were conducted with eleven mothers who had had been referred to and/or accessed a National Health Service parent-infant team. Interviews were analysed using thematic analysis. RESULTS: Women reported occasional difficulties accessing parent-infant services, particularly when they were left to contact services/follow up referrals themselves. However, once accessed mothers valued consistent, regular support with a therapist who was empathic and accepting of their difficult feelings. Some women saw therapists as resembling 'mother figures' and appreciated a feeling of being cared for. However, at times women felt there was an overemphasis on the role of the mother and mother-infant bond, and a disregard of fathers and other family members. CONCLUSION: Our study demonstrates that mothers value support from parent-infant teams. However, clinicians need to ensure they do not inadvertently reinforce problematic gender norms and narratives when offering support.

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.

Invisible experts: a systematic review & thematic synthesis of informal carer experiences of inpatient mental health care.

BACKGROUND: The negative impact of caregiving on carers' physical and psychological wellbeing is well documented. Carers of mental health inpatients have particularly negative experiences and largely report being dissatisfied with how they and their loved one are treated during inpatient care. It remains unclear why, despite policies intended to improve inpatient experiences. A comprehensive review of carers' inpatient experiences is needed to understand carer needs. As such, we aimed to conduct a systematic review and thematic synthesis of carer experiences of inpatient mental health care. METHODS: We searched MEDLINE, PsycINFO, Embase and CINAHL for qualitative studies examining carer experiences of mental health inpatient care. Searches were supplemented by reference list screening and forward citation tracking of included studies. Results were synthesised using thematic synthesis. Our protocol was registered on PROSPERO (CRD42020197904) and our review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. FINDINGS: Twelve studies were included from 6 countries. Four themes were identified: the emotional journey of inpatient care; invisible experts; carer concerns about quality of care for their loved one; and relationships and partnership between carers, service users and staff. INTERPRETATION: Greater attention should be paid to ensure carers are well-supported, well-informed, and included in care. More emphasis must be placed on fostering positive relationships between carers, service users and staff and in facilitating continuity of care across inpatient and community services to provide carers with a sense of security and predictability. Further research is needed to explore differences in experiences based on carer and service user characteristics and global context, alongside co-production with carers to develop and evaluate future guidelines and policies.

An analysis of views about supported reduction or discontinuation of antipsychotic treatment among people with schizophrenia and other psychotic disorders.

BACKGROUND: Antipsychotic medication can reduce psychotic symptoms and risk of relapse in people with schizophrenia and related disorders, but it is not always effective and adverse effects can be significant. We know little of patients' views about continuing or discontinuing antipsychotic treatment. AIMS: To explore the views of people with schizophrenia and other psychotic disorders about continuing their antipsychotic medication or attempting to reduce or discontinue this medication with clinical support. METHODS: We collected quantitative and qualitative data by conducting semi-structured interviews in London, UK. Factors predicting a desire to discontinue medication were explored. Content analysis of qualitative data was undertaken. RESULTS: We interviewed 269 participants. 33% (95% CI, 27 to 39%) were content with taking long-term antipsychotic medication. Others reported they took it reluctantly (19%), accepted it on a temporary basis (24%) or actively disliked it (18%). 31% (95% CI, 25 to 37%) said they would like to try to stop medication with professional support, and 45% (95% CI, 39 to 51%) wanted the opportunity to reduce medication. People who wanted to discontinue had more negative attitudes towards the medication but were otherwise similar to other participants. Wanting to stop or reduce medication was motivated mainly by adverse effects and health concerns. Professional support was identified as potentially helpful to achieve reduction. CONCLUSIONS: This large study reveals that patients are commonly unhappy about the idea of taking antipsychotics on a continuing or life-long basis. Professional support for people who want to try to reduce or stop medication is valued.

A qualitative exploration of family members' perspectives on reducing and discontinuing antipsychotic medication.

BACKGROUND: Antipsychotics are routinely prescribed to people diagnosed with schizophrenia or psychosis on a long-term basis. Considerable literature explores service users' opinions and experiences of antipsychotics, but studies investigating family members' views are lacking. AIMS: To explore family members' perspectives on antipsychotics, particularly their views on long-term use, reduction and discontinuation of antipsychotics. METHODS: Semi-structured interviews were conducted with 11 family members of people experiencing psychosis. Participants were recruited through community support groups and mental health teams. Interviews were analysed thematically. RESULTS: The majority of family members valued antipsychotic medication primarily in supporting what they saw as a fragile stability in the person they cared for. Their views of medication were ambivalent, combining concerns about adverse effects with a belief in the importance of medication due to fears of relapse. They described a need for constant vigilance in relation to medication to ensure it was taken consistently, and often found changes, particularly reduction in medication difficult to contemplate. CONCLUSIONS: Findings highlight that family members' attitudes to medication sometimes conflict with those of the people they care for, impacting on their health and the caring relationship. Family members may need more support and could be usefully involved in medication decision-making.

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.

Vocational rehabilitation via social firms: a qualitative investigation of the views and experiences of employees with mental health problems, social firm managers and clinicians.

BACKGROUND: Employment within social firms in the UK is under-developed and under-researched, but a potentially beneficial route to vocational rehabilitation for people with mental health problems. This study explores the views and experiences of employees with mental ill-health, managers of social firms and mental health clinicians, in order to understand the potential value of social firms for the vocational rehabilitation, employment and well-being of people with mental health problems. METHODS: Semi-structured interviews were conducted with 23 employees with mental health problems in 11 social firms in England. A focus group and individual interviews were conducted with 12 managers of social firms. Two focus groups were held with 16 mental health clinicians. Data were analysed using thematic analysis. RESULTS: Most employees expressed very positive views about working in a social firm. In responses from both employees and social firm managers, an overarching theme regarding the supportive ethos of social firms encompassed several related features: openness about mental health issues; peer, team and management support; flexibility; and support to progress and develop skills over time. Managers identified benefits of employing people with mental health problems who were sufficiently recovered. Knowledge of social firms within clinician focus groups was very limited, although clinicians thought they could be a welcome additional vocational resource. CONCLUSIONS: High levels of job satisfaction among social firm employees may be explained by the supportive ethos of these working environments. Social firms have potential to be a helpful addition to the range of vocational pathways available for people with mental ill-health. Further mixed methods investigations of experiences and outcomes in order to understand who engages with and benefits from this form of vocational rehabilitation would be valuable in informing decisions about scaling up the model.

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.

Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses.

PURPOSE: The COVID-19 pandemic has many potential impacts on people with mental health conditions and on mental health care, including direct consequences of infection, effects of infection control measures and subsequent societal changes. We aimed to map early impacts of the pandemic on people with pre-existing mental health conditions and services they use, and to identify individual and service-level strategies adopted to manage these. METHODS: We searched for relevant material in the public domain published before 30 April 2020, including papers in scientific and professional journals, published first person accounts, media articles, and publications by governments, charities and professional associations. Search languages were English, French, German, Italian, Spanish, and Mandarin Chinese. Relevant content was retrieved and summarised via a rapid qualitative framework synthesis approach. RESULTS: We found 872 eligible sources from 28 countries. Most documented observations and experiences rather than reporting research data. We found many reports of deteriorations in symptoms, and of impacts of loneliness and social isolation and of lack of access to services and resources, but sometimes also of resilience, effective self-management and peer support. Immediate service challenges related to controlling infection, especially in inpatient and residential settings, and establishing remote working, especially in the community. We summarise reports of swiftly implemented adaptations and innovations, but also of pressing ethical challenges and concerns for the future. CONCLUSION: Our analysis captures the range of stakeholder perspectives and experiences publicly reported in the early stages of the COVID-19 pandemic in several countries. We identify potential foci for service planning and research.

A qualitative investigation of models of community mental health care for women with perinatal mental health problems.

BACKGROUND: Specialist community perinatal mental health teams support women diagnosed with moderate to severe psychiatric difficulties in pregnancy or postnatally. These teams are being expanded across the UK, and there is considerable international interest in this model of care. However, not all women access these teams, and many are instead supported by community mental health services that do not specialise in the perinatal period. AIMS: To explore perinatal women's experiences of specialist perinatal versus generic non-perinatal community mental health support. METHODS: Semi-structured interviews were conducted with 36 women diagnosed with perinatal mental health difficulties who were supported in the community either by a specialist perinatal or general non-perinatal mental health service. Data were analysed thematically. RESULTS: Women felt that specialist perinatal and non-perinatal services alike were under-resourced and somewhat too narrow in their remit, but reported positive experiences across both settings. They particularly valued the specialist expertise offered by perinatal teams, but also valued greater continuity of care over a longer period, which some non-perinatal teams provided. CONCLUSIONS: The findings suggest that women who experience perinatal mental health difficulties value specialist perinatal expertise, but that general, non-perinatal teams may also have advantages for some. Further research into optimal care arrangements is merited.

The CORE service improvement programme for mental health crisis resolution teams: results from a cluster-randomised trial.

BACKGROUND: Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care. AIMS: To evaluate a 1-year programme to improve CRTs' model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233). METHOD: Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated. RESULTS: All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI -1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes. CONCLUSIONS: The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.

Experiences of taking neuroleptic medication and impacts on symptoms, sense of self and agency: a systematic review and thematic synthesis of qualitative data.

PURPOSE: Neuroleptic (antipsychotic) drugs reduce psychotic symptoms, but how they achieve these effects and how the drugs' effects are experienced by people who take them are less well understood. The present study describes a synthesis of qualitative data about mental and behavioural alterations associated with taking neuroleptics and how these interact with symptoms of psychosis and people's sense of self and agency. METHODS: Nine databases were searched to identify qualitative literature concerning experiences of taking neuroleptic medication. A thematic synthesis was conducted. RESULTS: Neuroleptics were commonly experienced as producing a distinctive state of lethargy, cognitive slowing, emotional blunting and reduced motivation, which impaired functioning but also had beneficial effects on symptoms of psychosis and some other symptoms (e.g. insomnia). For some people, symptom reduction helped restore a sense of normality and autonomy, but others experienced a loss of important aspects of their personality. Across studies, many people adopted a passive stance towards long-term medication, expressing a sense of resignation, endurance or loss of autonomy. CONCLUSIONS: Neuroleptic drugs modify cognition, emotions and motivation. These effects may be associated with reducing the intensity and impact of symptoms, but also affect people's sense of self and agency. Understanding how the effects of neuroleptics are experienced by those who take them is important in developing a more collaborative approach to drug treatment in psychosis and schizophrenia.

Peer-supported self-management for people discharged from a mental health crisis team: a randomised controlled trial.

BACKGROUND: High resource expenditure on acute care is a challenge for mental health services aiming to focus on supporting recovery, and relapse after an acute crisis episode is common. Some evidence supports self-management interventions to prevent such relapses, but their effect on readmissions to acute care following a crisis is untested. We tested whether a self-management intervention facilitated by peer support workers could reduce rates of readmission to acute care for people discharged from crisis resolution teams, which provide intensive home treatment following a crisis. METHODS: We did a randomised controlled superiority trial recruiting participants from six crisis resolution teams in England. Eligible participants had been on crisis resolution team caseloads for at least a week, and had capacity to give informed consent. Participants were randomly assigned to intervention and control groups by an unmasked data manager. Those collecting and analysing data were masked to allocation, but participants were not. Participants in the intervention group were offered up to ten sessions with a peer support worker who supported them in completing a personal recovery workbook, including formulation of personal recovery goals and crisis plans. The control group received the personal recovery workbook by post. The primary outcome was readmission to acute care within 1 year. This trial is registered with ISRCTN, number 01027104. FINDINGS: 221 participants were assigned to the intervention group versus 220 to the control group; primary outcome data were obtained for 218 versus 216. 64 (29%) of 218 participants in the intervention versus 83 (38%) of 216 in the control group were readmitted to acute care within 1 year (odds ratio 0·66, 95% CI 0·43-0·99; p=0·0438). 71 serious adverse events were identified in the trial (29 in the treatment group; 42 in the control group). INTERPRETATION: Our findings suggest that peer-delivered self-management reduces readmission to acute care, although admission rates were lower than anticipated and confidence intervals were relatively wide. The complexity of the study intervention limits interpretability, but assessment is warranted of whether implementing this intervention in routine settings reduces acute care readmission. FUNDING: National Institute for Health Research.

A qualitative comparison of experiences of specialist mother and baby units versus general psychiatric wards.

BACKGROUND: Mother and baby units (MBUs) are an inpatient mental health service where women experiencing acute severe postpartum psychiatric difficulties can be admitted with their babies. They are currently viewed as best practice in the UK and elsewhere. However, as service provision is fragmented, some women residing in areas without MBUs are admitted to acute general psychiatric wards without their infants. This study aimed to compare qualitatively experiences of these two service types from the perspectives of women and clinicians. METHODS: Semi-structured interviews were conducted with fifteen women who received treatment for perinatal mental health problems on a general psychiatric ward and/or MBU in England. Two focus groups were also conducted, one with MBU staff (n = 11) and one with acute ward staff (n = 6). Data were analysed thematically. RESULTS: Women generally preferred being co-admitted with their baby to an MBU over lone admission to a general psychiatric ward. Women and clinicians felt that MBUs provided more perinatally-focused, family-centred care, and were better-equipped to meet women's needs. General wards were reported by women and staff to lack the necessary facilities and expertise to support perinatal women adequately, while separation of mothers and babies was often experienced by women as traumatic and detrimental to recovery. However, some areas for improvement were also identified across both service types, particularly relating to difficulties transitioning home post-discharge, inadequate support for family members, staffing issues and access problems (with MBUs). CONCLUSIONS: Findings suggest that specialist perinatal inpatient care is considered preferable to generic care in the perinatal period from both service user and staff perspectives. Increased collaboration between perinatal and non-perinatal services could help improve perinatal expertise on general psychiatric wards, while further expansion of perinatal services (e.g. to cater for women currently considered too high risk for MBUs and for those discharged from inpatient settings) could tackle other shortfalls in care.

Adult mental health provision in England: a national survey of acute day units.

BACKGROUND: Acute Day Units (ADUs) exist in some English NHS Trusts as an alternative to psychiatric inpatient admission. However, there is a lack of information about the number, configuration, and functioning of such units, and about the extent to which additional units might reduce admissions. This cross-sectional survey and cluster analysis of ADUs aimed to identify, categorise, and describe Acute Day Units (ADUs) in England. METHODS: English NHS Mental Health Trusts with ADUs were identified in a mapping exercise, and a questionnaire was distributed to ADU managers. Cluster analysis was used to identify distinct models of service, and descriptive statistics are given to summarise the results of the survey questions. RESULTS: Two types of service were identified by the cluster analysis: NHS (n = 27; and voluntary sector services (n = 18). Under a third of NHS Trusts have access to ADUs. NHS services typically have multi-disciplinary staff teams, operate during office hours, offer a range of interventions (medication, physical checks, psychological interventions, group sessions, peer support), and had a median treatment period of 30 days. Voluntary sector services had mostly non-clinically qualified staff, and typically offered supportive listening on a one-off, drop-in basis. Nearly all services aim to prevent or reduce inpatient admissions. Voluntary sector services had more involvement by service users and carers in management and running of the service than NHS services. CONCLUSIONS: The majority of NHS Trusts do not provide ADUs, despite their potential to reduce inpatient admissions. Further research of ADUs is required to establish their effectiveness and acceptability to service users, carers, and staff.

How do women's partners view perinatal mental health services? A qualitative meta-synthesis.

OBJECTIVES: Perinatal mental health difficulties are prevalent among women and can adversely affect their partners too. There is also increasing recognition that a woman's partner can play a vital role in relation to her perinatal mental health and should be supported and involved in decisions about her care. Yet it is unclear how services are experienced by the partners of women with perinatal mental health difficulties. This study aimed to synthesize qualitative evidence of partners' views of perinatal mental health care. METHODS: A systematic search of 5 electronic databases identified 20 studies that met the inclusion criteria. The findings of these studies were synthesized using an approach based on meta-ethnography. RESULTS: Six themes were identified, namely, the marginalization and neglect of women's partners, an unmet need for information, partners' ambivalence about involvement and support, practical barriers to involvement, views about support for women's partners, and the impact on partners of the care women received. CONCLUSIONS: Given the importance of women's partners in relation to perinatal mental health as well as to women's engagement with support and treatment outcomes, greater consideration should be given to their needs to ensure they feel well informed and involved in perinatal mental health care, rather than marginalized. However, professionals also need to challenge the barriers to involvement and support that women's partners face and consider the ways in which services may reinforce these barriers.

The least worst option: user experiences of antipsychotic medication and lack of involvement in medication decisions in a UK community sample.

BACKGROUND: Treatment decision-making that fully involves service users is an aim across medicine, including mental health. AIM: To explore service users experiences of taking antipsychotic medication for psychotic disorders and their perceptions of decision-making about this. METHOD: Semi-structured interviews with 20 users of community mental health services, conducted by service user researchers and analysed using thematic analysis. RESULTS: Antipsychotic medication was perceived to have beneficial effects on symptoms and relapse risk, but adverse effects were prominent, including a global state of lethargy and demotivation. Weighing these up, the majority viewed antipsychotics as the least worst option. Participants were split between positions of "willing acceptance", "resigned acceptance" and "non-acceptance" of taking antipsychotics. Many felt their choices about medication were limited, due to the nature of their illness or pressure from other people. They commonly experienced their prescribing psychiatrist as not sufficiently acknowledging the negative impacts of medication on life quality and physical health concerns and described feeling powerless to influence decisions about their medication. CONCLUSION: The study highlights the complexity of agendas surrounding antipsychotic medication, including the pervasive influence of coercive processes and the challenges of implementing collaborative decision-making for people with serious mental health problems.

Exploring the feasibility and acceptability of a school-based self-referral intervention for emotional difficulties in older adolescents: qualitative perspectives from students and school staff.

BACKGROUND: Adolescents with emotional difficulties need accessible, acceptable and evidence-based mental health interventions. Self-referral workshops (DISCOVER workshops) were offered to stressed 16- to 19-year olds in 10 Inner London schools. METHOD: Semistructured interviews were conducted with three groups of participants: students who attended a 1-day workshop (n = 15); students who initially showed interest in the DISCOVER workshop programme, but decided not to take part (n = 9); and school staff who helped organise the programme in their schools (n = 10). Students were purposively sampled to ensure that those from Black and minority ethnic (BME) backgrounds were represented. Data were analysed using thematic analysis. RESULTS: The accounts generally indicate that the delivery and evaluation of this intervention is perceived as feasible and acceptable. Students, including those from BME backgrounds, described the setting as suitable and reported that the workshop helped them develop new understandings of stress and how to handle it. They expressed a preference for engaging and interactive activities, and valued a personalised approach to workshop provision. School staff felt that the workshop was in line with school values. They described some logistical barriers to providing the workshops in school settings, and expressed a desire for more information about the workshop in order to provide follow-up support. The main reason students gave for nonparticipation was limited time. CONCLUSIONS: Findings are discussed in relation to increasing the feasibility of implementing school-based psychological interventions and the value of providing access to mental health support in schools.

Attitudes to suicide following the suicide of a friend or relative: a qualitative study of the views of 429 young bereaved adults in the UK.

BACKGROUND: People bereaved by suicide are at increased risk of suicide attempt and suicide, but explanations for these associations remain theoretical. It is possible that the experience of suicide bereavement modifies personal attitudes towards suicide, but the nature of these changes remains unexplored. There is a need to understand personal attitudes to suicide following suicide bereavement, as this may inform the development of suicide prevention interventions. Our aim was to explore the attitudes of young adults bereaved by suicide towards their own likelihood of dying by suicide. METHODS: We conducted a cross-sectional study of staff and students aged 18-40 at 37 United Kingdom (UK) higher educational institutions in 2010. Ethical approval was granted by the UCL Research Ethics Committee. Qualitative responses to a question probing attitudes to own suicide were provided by 429 respondents who had experienced bereavement by the suicide of a close contact. We identified key themes in this dataset using thematic analysis. RESULTS: Analysis identified four main themes: suicide as a more tangible option (whether feared or not); identification with the deceased and awareness of shared vulnerabilities to suicide; personal determination to avoid suicide; and beliefs regarding safeguards against suicide. These themes reflected a broad split in participants' views regarding own likelihood of dying by suicide, influenced by the degree to which own suicide was feared and the extent to which they felt in control of determining a suicide death. Whilst the majority described an aversion to the idea of attempting suicide themselves, largely through an awareness of the impact on others, a minority described their experiences as having normalised suicide as a personal option. CONCLUSIONS: The views of a sample of UK-based adults bereaved by suicide suggest that exposure to the suicide of a close friend or relative can influence attitudes to suicide in ways that could influence own risk of suicide attempt. The normalising attitudes to suicide observed in a minority of respondents could contribute to the observed association between suicide bereavement and suicide attempt.