Understanding the inclusion and participation of adults from Black African Diaspora Communities (BAFDC) in health and care research in the UK: a realist review protocol.

INTRODUCTION: People from Black African Diaspora Communities (BAFDC) experience poorer health outcomes, have many long-term conditions and are persistently under-represented in health and care research. There is limited focus on programmes, or interventions that support inclusion and participation of people from BAFDC in research. Through coproduction, this realist review seeks to provide a programme theory explaining what context and mechanisms may be required, to produce outcomes that facilitate inclusion and participation for people from BAFDC in health and care research, in the UK. METHODS AND ANALYSIS: A group of people from BAFDC with lived and professional experience, representing all levels of the health and care research system, will coproduce a realist review with a team of African-Caribbean, white British and white British of Polish origin health and care researchers. They will follow Pawson's five steps: (1) shaping the scope of the review; (2) searching for evidence; (3) document selection and appraisal; (4) data extraction and (5) data synthesis. The coproduction group will help to map the current landscape, identifying key issues that may inhibit or facilitate inclusion. Data will be extracted, analysed and synthesised following realist logic analysis, identifying and explaining how context and mechanisms are conceptualised in the literature and the types of contextual factors that exist and impact on inclusion and participation. Findings will be reported in accordance with Realist and Meta-narrative Evidence Synthesis Evolving Standards . ETHICS AND DISSEMINATION: The coproduction group will agree an ethical approach considering accountability, responsibility and power dynamics, by establishing a terms of reference, taking a reflexive approach and coproducing an ethical framework. Findings will be disseminated to BAFDC and the research community through arts-based methods, peer-reviewed publications and conference presentations, agreeing a coproduced strategy for dissemination. Ethical review is not required. PROSPERO REGISTRATION NUMBER: CRD42024517124.

5-year mental health outcomes for children and adolescents presenting with psychiatric symptoms to general practitioners in England: a retrospective cohort study.

BACKGROUND: Little information is available on the clinical trajectories of children and adolescents who attend general practice (GP) with psychiatric symptoms. We aimed to examine 5-year service use in English primary care for children and adolescents with neurodevelopmental or mental health symptoms or diagnoses. METHODS: In this retrospective cohort study, we used anonymised primary care health records from the Clinical Practice Research Datalink Aurum database (CPRD-Aurum). We identified children and adolescents (aged 3-18 years) presenting to primary care in England between Jan 1, 2000, and May 9, 2016, with a symptom or diagnosis of a mental health, behavioural, or neurodevelopmental condition. Participants were excluded if they had less than 1 year of follow-up. We followed up participants from their index date until either death, transfer out of the practice, or the end of data collection on May 5, 2021, and for trajectory analysis we limited follow-up to 5 years. We used group-based multi-trajectory models to identify clusters with similar trajectories over 5 years of follow-up for three primary outcomes: mental health-related GP contacts, psychotropic medication prescriptions, and specialist mental health-care contact. We did survival analysis to examine the associations between trajectory-group membership and hospital admission for self-harm or death by suicide, as indicators of severe psychiatric distress. FINDINGS: We included 369 340 children and adolescents, of whom 180 863 (49·0%) were girls, 188 438 (51·0%) were boys, 39 (<0·1%) were of indeterminate gender, 290 125 (78·6%) were White, 9161 (2·5%) were South Asian, 10 418 (2·8%) were Black, 8115 (2·2%) were of mixed ethnicity, and 8587 (2·3%) were other ethnicities, and the median age at index presentation was 13·6 years (IQR 8·4-16·7). In the best-fitting, seven-group, group-based multi-trajectory model, over a 5-year period, the largest group (low contact; 207 985 [51·2%]) had low rates of additional service contact or psychotropic prescriptions. The other trajectory groups were moderate, non-pharmacological contact (43 836 [13·0%]); declining contact (25 469 [8·7%]); year-4 escalating contact (18 277 [6·9%]); year-5 escalating contact (18 139; 5·2%); prolonged GP contact (32 147 [8·6%]); and prolonged specialist contact (23 487 [6·5%]). Non-White ethnicity and presentation in earlier study years (eg, 2000-2004) were associated with low-contact group membership. The prolonged specialist-contact group had the highest risk of hospital admission for self-harm (hazard ratio vs low-contact group 2·19 [95% CI 2·03-2·36]) and suicide (2·67 [1·72-4·14]). INTERPRETATION: Most children and adolescents presenting to primary care with psychiatric symptoms or diagnoses have low or declining rates of ongoing contact. If these trajectories reflect symptomatic improvement, these findings provide reassurance for children and adolescents and their caregivers. However, these trajectories might reflect an unmet need for some children and adolescents. FUNDING: National Institute for Health and Care Research and the Wellcome Trust.

The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives.

BACKGROUND: Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these. AIMS: To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare. METHOD: A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts. RESULTS: Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities. CONCLUSIONS: During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Best practice recommendations for the integration of trauma-informed approaches in maternal mental health care within the context of perinatal trauma and loss: A systematic review of current guidance.

PURPOSE: The National Health Service (NHS) in England plans to increase accessibility to evidence-based, trauma-informed psychological care for women in the perinatal period. Therefore, this systematic review aimed to 1) synthesise current guidance from clinical guidelines, policy documents, and care standards on trauma-informed approaches to care in maternal mental health settings within the context of pregnancy-related trauma and 2) to offer recommendations informing the implementation and evaluation of this type of care. METHODS: Nine electronic databases were searched and screened. Data were extracted and analysed using narrative synthesis. Included records were quality-assessed. RESULTS: After screening 1095 identified records, 11 records were included. The findings were synthesised into eight recommendations: 1) screening for trauma, 2) access to care, 3) clear and sensitive communication, 4) consistency and continuity of care, 5) offering individualised care whilst recognising diversity, 6) collaboration between women, families, and services, 7) care provider training to enhance skills and knowledge, and 8) supervision and peer support for care providers. CONCLUSIONS: The findings of this review are highly relevant given the current development, delivery, and evaluation of specific maternal mental health services, particularly in the United Kingdom, but also with the increase in perinatal mental health provision more globally.

Working with suicidal mothers during the perinatal period: a reflexive thematic analysis study with mental health professionals.

BACKGROUND: Suicide is the leading cause of death in mothers postpartum and one of the most common causes of death during pregnancy. Mental health professionals who work in perinatal services can offer insights into the factors they perceive as being linked to mothers' suicidal ideation and behaviour, support offered to mothers and improvements to current practices. We aimed to explore the experiences and perceptions of perinatal mental health professionals who have worked with suicidal mothers during the perinatal period. METHOD: Semi-structured interviews were conducted face-to-face or via telephone with mental health professionals working in perinatal mental health inpatient or community services across England. Data were analysed using reflexive thematic analysis. RESULTS: From the professionals' (n = 15) accounts three main themes were developed from their interview data. The first, factors linked to suicidal ideation and behaviour, overarched two sub-themes: (1.1) the mother's context and (1.2) what the baby represents and what this means for the mother. These sub-themes described factors that professionals assessed or deemed contributory in relation to suicidal ideation and behaviour when a mother was under their care. The second main theme, communicating about and identifying suicidal ideation and behaviour, which outlined how professionals enquired about, and perceived, different suicidal experiences, encapsulated two sub-themes: (2.1) how to talk about suicide and (2.2) types of suicidal ideation and attempts. The third main theme, reducing suicidal ideation through changing how a mother views her baby and herself, focused on how professionals supported mothers to reframe the ways in which they viewed their babies and in turn themselves to reduce suicidal ideation. CONCLUSION: Professionals highlighted many factors that should be considered when responding to a mother's risk of suicide during the perinatal period, such as the support around her, whether the pregnancy was planned and what the baby represented for the mother. Professionals' narratives stressed the importance of adopting a tailored approach to discussing suicidal experiences with mothers to encourage disclosure. Our findings also identified psychological factors that professionals perceived as being linked to suicidal outcomes for mothers, such as self-efficacy; these factors should be investigated further.

Experience-based Investigation and Co-design of Psychosis Centred Integrated Care Services for Ethnically Diverse People with Multimorbidity (CoPICS): study protocol.

INTRODUCTION: Ethnic minorities (also called racialised groups) are more likely to experience severe mental illness (SMI). People with SMI are more likely to experience multimorbidity (MM), making psychosis among racialised groups more likely to lead to MM, poor outcomes, disability and premature mortality. METHODS AND ANALYSIS: This National Institute for Health and Care Research-funded study (151887) seeks to use innovative participatory methods including photovoice and biographical narrative interviews in urban and rural areas of England to assemble experience data. These data will be subjected to polytextual thematic analysis, and alongside pictures and captions, will inform an experienced-based co-design of interventions, the implementation of which will be evaluated. There will be an economic analysis and a process evaluation of the implementation. ETHICS AND DISSEMINATION: This programme of work has received ethical (IRAS 322421; Newcastle North Tyneside Research Ethics Committee 23/NE/0143) and sponsor approval. The findings will be disseminated in galleries showing the creative work, as lay and academic summaries and infographics; as practice briefings for practitioners, commissioners and policy makers; peer-reviewed publications. TRIAL REGISTRATION NUMBER: https://www.researchregistry.com/browse-the-registry%23home/registrationdetails/649c08111c037d0027b17d17/.

Prospective analysis of factors associated with perinatal depression.

BACKGROUND: Perinatal depression is a significant public health problem that has adverse effects on both mothers and infants. Little research has been conducted on how depressive symptoms change throughout the perinatal period, especially in the Middle East. This study examines changes in depressive symptoms from pregnancy to the postnatal period, and what explains these changes. METHODS: This prospective study recruited 306 Omani women in the third trimester of pregnancy and followed them up two to eight weeks after delivery. The Edinburgh Postnatal Depression Scale (EPDS), with a cut-off of ≥12, was used to assess depressive symptoms in both the antenatal and postnatal periods. Independent t-tests, one-way ANOVA, Tukey's honestly significant difference test and Chi-square tests were used to analyse the data. RESULTS: The prevalence of depressive symptoms was 27.12 % (n = 83) during late pregnancy and 29.30 % (n = 81) during the postnatal period. Four groups of women were identified based on the EPDS scores: 1) antenatal depression group (8.82 %; n = 27); 2) ante- and postnatal depression group (14.38 %; n = 44); 3) postnatal depression group (12.09 %; n = 37); and 4) non-depression group (54.90 %; n = 168). Depressive symptoms were associated with low birth weight babies (d = 0.50), which confirms the negative effects of depression on perinatal health outcomes. When compared to the non-depression group, the three depressed groups had higher antenatal Perceived Stress Scale (PSS) scores (ds > 0.52), while the non-depression group had higher antenatal and postnatal Maternity Social Support Scale (MSSS) scores (ds > 0.63), and better relationships with the mother-in-law antenatally (d= 0.57). CONCLUSION: The present study of this Middle Eastern cohort shows that there were distinct groups of women experiencing perinatal depressive symptoms, influenced by various psychosocial and obstetric factors, which were comparable to those identified in more regularly studied populations. However, this study also identified other novel factors, such as the quality of family relationships. There is a need for additional research into the factors associated with these groups in order to develop appropriate interventions.

User engagement in a randomised controlled trial for a digital health intervention for early psychosis (Actissist 2.0 trial).

Digital Health Interventions (DHIs) can help support people with mental health problems. Achieving satisfactory levels of patient engagement is a crucial, yet often underexplored, pre-requisite for health improvement. Actissist is a co-produced DHI delivered via a smartphone app for people with early psychosis, based on Cognitive Behaviour Therapy principles. This study describes and compares engagement patterns among participants in the two arms of the Actissist 2.0 randomised controlled trial. Engagement frequency and duration were measured among participants using the Actissist app in the intervention arm (n = 87) and the ClinTouch symptom monitoring only app used as the control condition (n = 81). Overall, 47.1 % of Actissist and 45.7 % of ClinTouch users completed at least a third of scheduled alerts while active in the study. The mean frequency (77.1 versus 60.2 total responses) and the median duration (80 versus 75 days until last response) of engagement were not significantly higher among Actissist users compared to ClinTouch users. Older age, White ethnicity, using their own smartphone device and, among Actissist users, an increased sense of therapeutic alliance were significantly associated with increased engagement. Through exploiting detailed usage data, this study identifies possible participant-level and DHI-level predictors of engagement to inform the practical implementation of future DHIs.

Improving mental healthcare access and experience for people from minority ethnic groups: an England-wide multisite experience-based codesign (EBCD) study.

BACKGROUND: Long-standing ethnic inequalities in access and mental healthcare were worsened by the COVID-19 pandemic. OBJECTIVES: Stakeholders coproduced local and national implementation plans to improve mental healthcare for people from minority ethnic groups. METHODS: Experience-based codesign conducted in four areas covered by National Health Service (NHS) mental health trusts: Coventry and Warwickshire, Greater Manchester, East London and Sheffield. Data were analysed using an interpretivist-constructivist approach, seeking validation from participants on their priority actions and implementation plans. Service users (n=29), carers (n=9) and health professionals (n=33) took part in interviews; focus groups (service users, n=15; carers, n=8; health professionals, n=24); and codesign workshops (service users, n=15; carers, n=5; health professionals, n=21) from July 2021 to July 2022. FINDINGS: Each study site identified 2-3 local priority actions. Three were consistent across areas: (1) reaching out to communities and collaborating with third sector organisations; (2) diversifying the mental healthcare offer to provide culturally appropriate therapeutic approaches and (3) enabling open discussions about ethnicity, culture and racism. National priority actions included: (1) co-ordination of a national hub to bring about system level change and (2) recognition of the centrality of service users and communities in the design and provision of services. CONCLUSIONS: Stakeholder-led implementation plans highlight that substantial change is needed to increase equity in mental healthcare in England. CLINICAL IMPLICATIONS: Working with people with lived experience in leadership roles, and collaborations between NHS and community organisations will be essential. Future research avenues include comparison of the benefits of culturally specific versus generic therapeutic interventions.

The Patient and Carer Race Equality Framework: a model to reduce mental health inequity in England and Wales.

The Patient and Carer Race Equality Framework (PCREF) is an Organisational Competence Framework (OCF), recommended by the Independent Review of the Mental Health Act as a means to improve mental health access, experience and outcomes for people from ethnic minority backgrounds, particularly Black people. This is a practical framework that should be co-produced with and tailored to the needs of service users, based on quality improvement and place-based approaches. We aim to use the PCREF to address the longstanding epistemic justices experienced by people with mental health problems, particularly those from minoritised ethnic groups. We will outline the work that led to the proposal, the research on racial inequalities in mental health in the UK, and how the PCREF will build on previous interventions to address these. By taking these into account, the PCREF should support a high minimum standard of mental health care for all.

Social network characteristics of Black African and Caribbean people with psychosis in the UK.

Poorer social networks predict more coercive pathways to care and other adverse outcomes in people with psychosis. People from Black African and Caribbean backgrounds have more negative experiences within UK mental health care systems and family relationships often breakdown. This study aimed to examine the social network characteristics of Black African and Caribbean people experiencing psychosis and associations between network characteristics and severity of psychosis, negative symptoms, and general psychopathology. Fifty-one participants completed social network mapping interviews (a gold standard approach to assessing social network composition) and the Positive and Negative Syndrome Scale. This is the first study to explicitly measure social network size amongst Black people with psychosis living within the UK and results showed that participants' social network size (mean = 12) was comparable to that of other psychosis samples. Networks were of moderate density and comprised disproportionately more relatives than other relationship types. Poor network quality was related to more severe psychosis symptoms suggesting that social network quality may be an important factor in influencing the severity of psychosis. Findings highlight the need for community-based interventions and family therapies to mobilise sources of social support for Black people with psychosis within the UK.

Prevalence and correlates of perinatal depression.

PURPOSE: This systematic review of systematic reviews aims to provide the first global picture of the prevalence and correlates of perinatal depression, and to explore the commonalities and discrepancies of the literature. METHODS: Seven databases were searched from inception until April 2022. Full-text screening and data extraction were performed independently by two researchers and the AMSTAR tool was used to assess the methodological quality. RESULTS: 128 systematic reviews were included in the analysis. Mean overall prevalence of perinatal depression, antenatal depression and postnatal depression was 26.3%, 28.5% and 27.6%, respectively. Mean prevalence was significantly higher (27.4%; SD = 12.6) in studies using self-reported measures compared with structured interviews (17.0%, SD = 4.5; d = 1.0) and among potentially vulnerable populations (32.5%; SD = 16.7, e.g. HIV-infected African women) compared to the general population (24.5%; SD = 8.1; d = 0.6). Personal history of mental illness, experiencing stressful life events, lack of social support, lifetime history of abuse, marital conflicts, maternity blues, child care stress, chronic physical health conditions, preeclampsia, gestational diabetes mellitus, being exposed to second-hand smoke and sleep disturbance were among the major correlates of perinatal depression. CONCLUSION: Although the included systematic reviews were all of medium-high quality, improvements in the quality of primary research in this area should be encouraged. The standardisation of perinatal depression assessment, diagnosis and measurement, the implementation of longitudinal designs in studies, inclusions of samples that better represent the population and better control of potentially confounding variables are encouraged.

A brief transdiagnostic group (the take control course) compared to individual low-intensity CBT for depression and anxiety: a randomized non-inferiority trial.

Few studies have examined brief transdiagnostic groups. The Take Control Course (TCC) was developed for patients with mild to moderate common mental health problems. We examined whether TCC is non-inferior to individual low-intensity cognitive behaviour therapy (CBT) in a single-blind individually randomised parallel non-inferiority trial. The primary outcomes were depression (PHQ9) and anxiety (GAD7) at 6-month follow-up (primary outcome point) and 12-month follow-up. The non-inferiority margin that we set, based on previous trials, corresponds to approximately 3 points on the PHQ9 and approximately 2.5 points on the GAD7. Intention-to-treat (ITT) and per-protocol (PP) analyses of 6-month data of 156 randomised patients indicated that TCC was non-inferior to individual low-intensity CBT on anxiety (ITT Coefficient = 0.24; 95% CI: -1.45 to 1.92; d = 0.04; p = .79), and depression (ITT Coefficient = 0.82; 95% CI: -1.06 to 2.69; d = 0.14; p = .39) outcomes, and functioning (ITT Coefficient = 0.69; 95% CI: -2.56 to 3.94; d = 0.08; p = .68). The findings at 12 months were inconclusive and require further testing. This randomised trial provides preliminary support that TCC is not less effective than short-term individual CBT within Improving Access to Psychological Therapies (IAPT) services.

Views of healthcare professionals and service users regarding anti-, peri- and post-natal depression in Oman.

WHAT IS KNOWN ON THE SUBJECT?: Anti-, peri- and post-natal depression negatively affect the relationship between mothers and their children. At least half of cases of anti-, peri- and post-natal depression were missed and underdiagnosed by healthcare professionals (HCPs) including doctors, nurses and midwives. Previous qualitative studies considered women's experiences relating to anti-, peri- and post-natal depression separately from studies looking at the views of HCPs. There is a lack of research in Middle Eastern countries, despite the high prevalence of anti-, peri- and post-natal depression. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This is the first qualitative study investigating the experiences of both HCPs and service users regarding anti-, peri- and post-natal depression from the Middle East perspective, particularly in Oman. This study revealed that anti-, peri- and post-natal depression has been neglected in primary healthcare systems in Oman. The study explored many barriers and facilitators which have been identified by both HCPs and patients in identifying and managing anti-, peri- and post-natal depression in the primary healthcare system. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses, midwives and doctors should develop an empathic screening procedure that allows for the discussion of mental health concerns and help-seeking behaviours with their patients. Training nurses and midwives in motivational interviewing, routinely screening mothers with any depressive symptoms, as well as providing public education programmes to increase mental health awareness, resources and access to a variety of mental healthcare alternatives, could be successful in recognizing and managing anti-, peri- and post-natal depression. ABSTRACT: INTRODUCTION: Anti-, peri- and post-natal depression is known to affect the relationship between infants and their mothers adversely. Previous studies have identified barriers and facilitators, reported by women and HCPs, related to the identification and management of anti-, peri- and post-natal depression. However, these studies considered the experiences of women separately from those of the healthcare professionals, even though their experiences of anti-, peri- and post-natal depression are interconnected. Additionally, there is a lack of research among people living in the Middle East, including Oman, which has one of the highest rates of anti-, peri- and post-natal depression globally. AIM: This study aimed to explore the views and experiences of HCPs and service users relating to anti-, peri- and post-natal depression from the Middle East perspective. METHOD: A qualitative descriptive study using semi-structured interviews was conducted. This study took place at the Family Medicine and Community Clinic at the University Hospital and three selected primary healthcare centres in Muscat, between May 2020 and February 2021. Purposive sampling was used: 15 HCPs with 2-20 years of clinical experience in anti-, peri- and post-natal primary care and 13 pregnant patients plus 2 post-birth patients were interviewed. Audio-recordings were transcribed verbatim, and the anonymized transcripts were then entered into the qualitative data management software, NVIVO 12. RESULTS: A thematic approach was used to analyse the data. Four themes were identified in the data, namely: (1) making sense of anti-, peri- and post-natal depression; (2) how to deal with anti-, peri- and post-natal depression; (3) barriers to addressing anti-, peri- and post-natal depression in primary anti-, peri- and post-natal care settings and (4) bridging the gap: facilitators in detecting and managing anti-, peri- and post-natal depression. CONCLUSIONS: Improving the identification and management of anti-, peri- and post-natal depression in primary healthcare systems will require a whole-system approach with interventions at the patient, practice and comprehensive primary care team levels. IMPLICATIONS FOR PRACTICE: The findings suggest implications for improving the identification and management of anti-, peri- and post-natal depression including an increased emphasis on mental health by enhancing the routine screening of mothers during the anti-, peri- and post-natal period, clearer referral systems, improving resources, providing training with regard to mental health and improving communication skills.

Central and Eastern European migrants' experiences of mental health services in the UK: A qualitative study post-Brexit.

OBJECTIVE: Central and Eastern European (CEE) migrants are a large minority group in the UK who are vulnerable to experiencing mental health problems. However, due to their shared 'whiteness' with the majority population, health service disparities may be overlooked. This is the first study exploring CEE-born people's experiences of mental health services post-Brexit. METHOD: Thirteen CEE migrants who had received mental health services in the UK were interviewed and data was thematically analysed. RESULTS: Barriers and facilitators to engagement reflected: 1) attitudes towards help-seeking; 2) cultural in/visibility; and 3) professional-service user communication. Some barriers were unique to the CEE community and not shared by other minority groups, such as the 'invisibility' of ethnic identity and this framed the way participants navigated interactions with services. CONCLUSIONS: Cultural differences and mental health stigma were reported to influence understanding of mental health, attitudes to help-seeking, and experiences of services. Flexible ethnic identity and majority group "passing" could conceal inequalities in healthcare. PRACTICE IMPLICATIONS: The need for culturally informed approaches, professional upskilling, strengthened inter-agency working, and collaboration with CEE communities. The need to build on pre-existing strengths, for self-directed and self-care activities, for appropriate pacing and confidentiality discussions, and the use of web-based resources.

Psychological intervention priorities according to perinatal women who experienced suicidal thoughts and perinatal mental health professionals: a Q-methodology study.

Introduction: Suicide is the leading direct cause of maternal death in the year following birth and the second leading cause during pregnancy, in the UK and Ireland. Currently no evidence-based psychological interventions exist specifically designed to reduce mothers' suicidal experiences during the perinatal period. Reducing suicidal ideation and behaviour in mothers is a priority to prevent deaths and lessen the distress felt by mothers and their families. As Q-methodology measures the consensus and disagreement between individuals on a given topic, the current study used Q-methodology to elicit the priorities for a future psychological intervention aimed at reducing suicidal ideation and behaviour during the perinatal period, from the collective perspectives of both mothers and professionals. Method: As part of this Q-methodology study, we developed a Q-set of 75 statements pertaining to possible elements of a psychological intervention that might help reduce a mother's suicidal ideation and behaviour during the perinatal period. Mothers and professionals were recruited via perinatal mental health services and social media advertisements. Results: Twenty-one mothers and 11 perinatal mental health professionals ranked each Q-set statement depending on its perceived importance in developing a new intervention. A centroid factor analysis was conducted and two factors, which accounted for 42% of the overall variance, were identified: Factor 1 "supporting the mother to create distance between herself and the appeal of suicide" and Factor 2 "establishing positive connections with the therapist, the baby and motherhood." All participants believed that developing plans to keep the mother safe from suicide was the most important aspect for inclusion in a future intervention. Participants who loaded onto Factor 1 also prioritised supporting mothers to learn more about triggers for their suicidal ideation and behaviour. Ensuring a robust therapeutic alliance was more important for those who loaded onto Factor 2. Conclusion: This is the first study using Q-methodology to explore the psychological intervention priorities of mothers and professionals. Findings indicate clear priorities in terms of planning and coping during a crisis, endorsed by all participants, and provide an initial step in the development of a new perinatal suicide prevention intervention.

Engagement with services in Black African and Caribbean people with psychosis: The role of social networks, illness perceptions, internalized stigma, and perceived discrimination.

OBJECTIVES: Research and policies in the United Kingdom have repeatedly highlighted the need to reduce ethnic disparities and improve engagement with mental health services among Black African and Caribbean people with psychosis. The aim of this study was to examine the role of social network characteristics and psychological factors in engagement with services in Black people with psychosis. METHODS: A cross-sectional study was conducted with 51 Black African and Caribbean adults with non-affective psychosis and currently receiving care from mental health services in England. Measures were completed to examine relationships between social networks, illness perceptions, perceived racial or ethnic discrimination in services, internalized stigma, and current engagement with services from service user and staff perspectives. RESULTS: Social network composition (ethnic homogeneity) moderately correlated with better service user and staff reported engagement. Greater perceived personal control over problems was associated with better staff reported engagement. Lower perceived ethnic or racial discrimination in services, and specific illness perceptions (higher perceived treatment control, greater self-identification with psychosis symptoms, more concern and greater emotional response related to problems) were associated with better service user reported engagement. Internalized stigma was not associated with service engagement. Multivariate regression analyses suggested that a more ethnically homogenous social network was the strongest predictor of better service user and staff reported engagement. CONCLUSIONS: Psychosocial interventions that target social networks, perceived ethnic and racial discrimination in services, and illness perceptions may facilitate better engagement and improve outcomes. Further longitudinal studies are required to examine causal mechanisms.

Exploring how to improve access to psychological therapies on acute mental health wards from the perspectives of patients, families and mental health staff: qualitative study.

BACKGROUND: Psychological therapy is core component of mental healthcare. However, many people with severe mental illnesses do not receive therapy, particularly in acute mental health settings. AIMS: This study identifies barriers to delivering and accessing psychological therapies in acute mental health settings, and is the first to recommend how services can increase access from the perspectives of different stakeholders (staff, patients and carers). METHOD: Sixty participants with experiences of acute mental health wards (26 staff, 22 patients and 12 carers) were interviewed about barriers to accessing therapy in in-patient settings and how therapies should be delivered to maximise access. RESULTS: Four themes were identified: (a) 'Models of care', including the function of in-patient wards, beliefs about the causes of mental health problems and the importance of strong leadership to support psychosocial interventions; (b) 'Integrated care', including the importance of psychologists being ward-based, as well as having strong links with community teams; (c) 'Acute levels of distress', including factors that aggravate or ameliorate the impact of this on engagement in therapy; and (d) 'Enhancing staff capability and motivation', which is influenced by contextual issues. CONCLUSIONS: It is possible to improve access to therapy through strong leadership (that is supportive of talking treatments), flexible delivery of therapy (that considers short admissions) and a whole-systems approach that promotes ward staff understanding of the psychosocial causes of mental illness and staff well-being. It is essential to ensure continuity between in-patient and community therapy services, and for wards to have physical space to carry out therapy.

What makes a perinatal woman suicidal? A grounded theory study.

BACKGROUND: Suicide is a leading cause of maternal death during pregnancy and up to a year after birth. Psychological and psychosocial risk factors for maternal suicide ideation and behaviour have been identified but do not account for why mothers begin to experience suicidal thoughts. Qualitative research offers a way of identifying what might drive mothers to initially consider suicide and then go on to act on such thoughts; crucial for the development of assessments to identify, and interventions to target, maternal suicide ideation and behaviour. We aimed to develop a grounded theory outlining what makes women think about suicide and/or engage in suicidal behaviour during pregnancy and the first 12 months following birth? METHOD: Semi-structured interviews were conducted with 12 mothers in the UK who had suicidal thoughts during pregnancy and/or the first year following birth. A constructivist approach to grounded theory was adopted which guided the data collection and analysis processes. RESULTS: We developed a model outlining the theorised process of psychological factors that culminates in mothers experiencing suicidal thoughts and then making a suicide attempt during the perinatal period. The process was initiated when mothers felt attacked by motherhood which led to feeling like a failure, self-identifying as a "bad mother" and subsequent appraisals of entrapment and/or defeat. When nothing resolved the distress and as mothers collated reasons for why they perceived they needed to die, suicidal behaviour became a viable and appealing option. We theorised that mothers might make a suicide attempt when they entered a state of intense "darkness" brought on by a trigger, followed by a temporary lapse in the conflict between the desire to live and desire to die and an opportunity to attempt. CONCLUSIONS: Participants stressed the rapid onset of suicidal thoughts. We suggest that healthcare professionals enquire about the mother's feelings towards the baby and of isolation, how she views herself as a mother, feelings of entrapment and defeat during routine contacts to aid identification and prevention of suicidal ideation/behaviour. Suggested interventions to prevent suicidal thoughts and behaviour include helping women manage their expectations for pregnancy and the postpartum period.