Safeguarding in adolescent mental health research: navigating dilemmas and developing procedures.

Mental disorders are prevalent during adolescence. Self-harm and suicide are more common in adolescents with a probable mental disorder, with one in four reporting to have attempted self-harm. Research involving adolescents is, therefore, likely to include participants experiencing mental ill health, even if mental health is not the primary focus. Researchers should adopt procedures and principles that safeguard adolescent mental health in their research practice. Yet there are gaps between theory and practice of research with adolescents in relation to their mental health, and limited guidance is available.We discuss emerging safeguarding dilemmas and procedures in adolescent mental health research. Our experiences of safeguarding adolescent mental health are grounded in the UK National Institute for Health and Care Research-funded SMART Schools Study. Drawing from this secondary school-based study, we focus on how our research team encountered and addressed a high prevalence of participants (aged 12-13 and 14-15 years) reporting thoughts and behaviours related to self-harm or suicide (24% of participants). This included reviewing our existing risk mitigation processes and consulting with several committees including young people with lived experiences of mental health.We present the SMART Schools study safeguarding approach for adolescent mental health. This encompasses key safeguarding principles, study procedures and relevant justifications. We address school and university roles and responsibilities, pupil understanding, and efficient, effective and secure communication pathways. We embed guidance throughout this article for researchers working with adolescents in the context of mental health. Lastly, we present five key recommendations to safeguard the mental health of adolescents participating in research, including (1) appointing a safeguarding lead within the research team; (2) codesigning a bespoke study safeguarding approach; (3) adopting a responsive approach to mental health safeguarding; (4) being transparent about the study mental health safeguarding approach and (5) report the implementation and outcomes of safeguarding approaches.Trial registration number ISRCTN77948572.

Youth partnership in suicide prevention research: moving beyond the safety discourse.

OBJECTIVE: In this communication article, we discuss coproduction in suicide prevention research, with an emphasis on involving young people. We critically reflect on the lessons we have learned by working alongside young people, and how these lessons may be useful to other research teams. SUMMARY: The meaningful involvement of young people in the design, implementation and translation of mental health research has received significant attention over the last decade. For most funding bodies, the involvement of patients and the public in the planning and delivery of research is advised and, in many cases, mandatory. When it comes to suicide prevention research, however, things are slightly different in practice. Involvement of young people in suicide prevention research has often been considered a controversial, unfeasible and even risky endeavour. In our experiences of working in this field, such concerns are expressed by funders, Higher Education Health and Safety committees and practitioners. By presenting an example from our research where the involvement of young people as experts by experience was integral, we highlight key lessons learnt that could maximise the potential of youth partnership in suicide prevention research. These lessons take on particular importance in mental health research against the background of long-entrenched power differences and the silencing of service user voices. Professional knowledge, obtained through education and vocational training, has historically taken priority over experiential knowledge obtained through lived experience, in psychiatric practice and research. Although this hierarchy has widely been challenged, any account of coproduction in mental health research is positioned against that background, and the remnants of those inequitable power relationships arguably take on greater resonance in suicide prevention research and require careful consideration to ensure meaningful involvement. CONCLUSION: We conclude that progress in suicide research cannot be fulfilled without the meaningful involvement of, and partnership with, young people with lived experience.

Which programmes and policies across health and community settings will generate the most significant impacts for youth suicide prevention in Australia and the UK? Protocol for a systems modelling and simulation study.

INTRODUCTION: Suicide is a leading cause of mortality among young people aged 15-24 globally. Despite the deployment of comprehensive suicide prevention strategies, we still do not know which interventions, for which groups of young people, for how long and with what intensity could generate the most significant reductions in suicide rates. System dynamics modelling has the potential to address these gaps. SEYMOUR (System Dynamics Modelling for Suicide Prevention) will develop and evaluate a system dynamics model that will indicate which suicide prevention interventions could generate the most significant reductions in rates of suicide and attempted suicide among young people aged 12-25 in Australia and the UK. METHODS AND ANALYSIS: A comparative case study design, applying participatory system dynamics modelling in North-West Melbourne (Australia) and Birmingham (UK). A computer simulation model of mental health service pathways and suicidal behaviour among young people in North-West Melbourne will be developed through three workshops with expert stakeholder groups (young people with lived experience, carers, clinicians, policy makers, commissioners). The model will be calibrated and validated using national, state and local datasets (inputs). The simulation model will test a series of interventions identified in the workshops for inclusion. Primary model outputs include suicide deaths, self-harm hospitalisations and self-harm presentations to emergency departments. An implementation strategy for the sustainable embedding of promising suicide prevention interventions will be developed. This will be followed by model customisation, re-parameterisation, and validation in Birmingham and adaptation of the implementation strategy. ETHICS AND DISSEMINATION: The project has received approval from the University of Melbourne Human Research Ethics Committee (2022-22885-25971-4), the University of Birmingham Science, Technology, Engineering and Mathematics Ethics Review Committee (ERN_21-02385) and the UK HRA (22/HRA/3826). SEYMOUR's dissemination strategy includes open-access academic publications, conference presentations, accessible findings coproduced with young people, e-briefs to policy makers, webinars for service providers and commissioners.

Smartphones, social Media and Adolescent mental well-being: the impact of school policies Restricting dayTime use-protocol for a natural experimental observational study using mixed methods at secondary schools in England (SMART Schools Study).

INTRODUCTION: Smartphone and social media use is prevalent during adolescence, with high levels of use associated with lower levels of mental well-being. Secondary schools in the UK have introduced policies that restrict daytime use of smartphones and social media, but there is no evaluation on the impact of these policies on adolescent mental well-being. The SMART Schools Study aims to determine the impact of daytime restrictions of smartphone and social media use on indicators of adolescent mental well-being, anxiety, depression, physical activity, sleep, classroom behaviour, attainment and addictive social media use. METHODS AND ANALYSIS: This is a natural experimental observational study using mixed methods. Secondary schools within a 100 mile radius of the recruiting centre in the West Midlands (UK) have been categorised into two groups: Schools that restrict (intervention) and permit (comparator) daytime use of smartphones. We aim to recruit 30 schools (20 restrictive, 10 permissive) and 1170 pupils aged 12-13 and 14-15 years. We will collect data on mental well-being, anxiety and depressive symptoms, phone and social media use, sleep and physical activity from pupil surveys, and accelerometers. Policy implementation measures and data on individual pupil factors will be collected through school staff surveys, and website/policy analysis. Six case study schools will explore individual, school and family/home factors that influence relationships between school smartphone policies, smartphone/social media use, and mental well-being. Economic evaluation will be completed through a cost-consequence analysis from an education sector perspective. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of Birmingham's Research Ethics Committee (ERN_22-0723). Parents/carers of pupil participants can complete a form to opt their child out of the study. Pupil, school staff and parent/carer participants are asked to complete online/written consent (or assent). Findings will be disseminated through policy briefings, resources for schools, social media, reports, and open access publications. TRIAL REGISTRATION NUMBER: ISRCTN77948572.

Understanding the processes underlying self-harm ideation and behaviors within LGBTQ+ young people: A qualitative study.

OBJECTIVE: This study aims to understand the processes underlying self-harmful thoughts and behaviors, with and without suicidal intent, among LGBTQ+ young people. METHOD: Nineteen semi-structured interviews took place between October 2019 and May 2020. Participants were aged between 16 and 25 years, had experiences of self-harm ideation and behaviors, and were part of the LGBTQ+ umbrella. A range of sexualities and gender identities were represented: eleven participants were cisgender, six were transgender and two were non-binary. Interviews were transcribed verbatim and anonymised. Thematic analysis and reflective member-checking were used to develop a thematic framework. RESULTS: Three themes were developed from the interviews and evaluated by four participants who engaged with reflective member-checking. Findings indicated that internal processes and external responses to being LGBTQ+ resulted in self-harmful thoughts and behaviors. Alongside these, additional stressors related to being a young person were led to difficulties with self-harm. CONCLUSIONS: Findings from this study indicate that young people often struggle with accepting their LGBTQ+ identity for a number of reasons, whether this is due to access to a resource or their own feelings about their identity. These negative self-perceptions can be enhanced by poor responses from others and additional life stressors which impact their self-esteem or self-perception.HIGHLIGHTSUnderstanding and accepting that one is LGBTQ+ is not always a simple process, struggling with these thoughts can influence self-harm.Lack of LGBTQ+ terminology hinders self-acceptance and caused young people to engage with self-harm.Peers and family members responses to a young people's LGBTQ+ identity is highly significant and can directly led to self-harmful thoughts and experiences.

Antibody and T-Cell Subsets Analysis Unveils an Immune Profile Heterogeneity Mediating Long-term Responses in Individuals Vaccinated Against SARS-CoV-2.

BACKGROUND: Based on the fact that coronavirus disease 2019 (COVID-19) is still spreading despite worldwide vaccine administration, there is an imperative need to understand the underlying mechanisms of vaccine-induced interindividual immune response variations. METHODS: We compared humoral and cellular immune responses in 127 individuals vaccinated with either BNT162b2, mRNA-1273, or ChAdOx1-nCoV-19 vaccine. RESULTS: Both mRNA vaccines induced faster and stronger humoral responses as assessed by high spike- and RBD-specific antibody titers and neutralizing efficacy in comparison to ChAdOx1-nCoV-19 vaccine. At 7 months postvaccination, a decreasing trend in humoral responses was observed, irrespective of the vaccine administered. Correlation analysis between anti-S1 IgG and interferon- (IFN-) production unveiled a heterogeneous immune profile among BNT162b2-vaccinated individuals. Specifically, vaccination in the high-responder group induced sizable populations of polyfunctional memory CD4 helper T cells (TH1), follicular helper T cells (TFH), and T cells with features of stemness (TSCM), along with high neutralizing antibody production that persisted up to 7 months. In contrast, low responders were characterized by significantly lower antibody titers and memory T cells and a considerably lower capacity for interleukin-2 and IFN- production. CONCLUSIONS: We identified that long-term humoral responses correlate with the individuals ability to produce antigen-specific persistent memory T-cell populations.

Assessing and Responding to Suicide Risk in Children and Young People: Understanding Views and Experiences of Helpline Staff.

INTRODUCTION: Suicide is a key issue impacting children and young people. Helplines offer unique benefits, such as anonymity, varied communication avenues and low cost, which help to promote help-seeking behaviour. The aim of this study was to explore the views and experiences of helpline organisations of identifying, assessing, and managing suicide risk among children and young people. METHODS: Thirteen professionals from three UK-based helplines and online counselling services took part in semi-structured interviews between November 2020 and January 2021 via Zoom. Interviews were transcribed verbatim and analysed using Thematic Analysis. RESULTS: Three superordinate themes were identified: (i) Starting conversations about suicide; (ii) Identifying and responding to "imminent" suicide risk; and (iii) Responses to suicide risk in relation to safeguarding. LIMITATIONS: Recruitment was limited by COVID-19 due to the demands needed from helplines at this time. CONCLUSIONS: Our findings highlight not only the different types and range of services helpline organisations offer to young people who might be at risk of suicide, but most importantly the distinct role they have in young people's help-seeking pathway.

Feasibility and acceptability of experience sampling among LGBTQ+ young people with self-harmful thoughts and behaviours.

This study was the first to determine whether it was feasible and acceptable to use experience sampling methods (ESM) among LGBTQ+ young people, who had current experiences of self-harm. Sixteen LGBTQ+ young people (16-25 years old) took part in the experience sampling study. This included a baseline assessment, a 7-day ESM assessment (participants were sampled six times a day using a phone app), and the option of an interview at the end of the 7-day ESM assessment. Feasibility data was descriptively analysed, with pilot ESM data presented. Qualitative data was thematically analysed to determine the acceptability (barriers and facilitators) of taking part in this study. Study feasibility was assessed by enrolment rate (55.2%), participant retention across assessment period (100%), ESM app feasibility (87.5%), and good adherence to total number of ESM surveys (67.6%). Individual study adherence ranged between 43 and 95.2%. Study acceptability was assessed by participant interviews. Thematic analysis indicated four superordinate themes; (i) Self-reflection and awareness; (ii) Practicalities of ESM surveys; (iii) Daily timeframes; and (iv) Suggestions for future studies. Pilot ESM data demonstrates that there was fluctuation of depressive and anxiety symptoms within- and between- participants over the course of the study, however, greater sample power is needed for full analysis. This study demonstrated that ESM designs are feasible and acceptable among LGBTQ+ young people with current experiences of self-harm. Pilot data indicated that specific experiences and moods are likely to be important to self-harm. These potentially have a temporal influence on self-harm behaviour or ideation, and therefore should be examined in a fully powered sample.

Characterization of the nicotinic acetylcholine receptor antibodies after an unexpected increase of antibody titer in thymoma associated myasthenia gravis patients.

Two thymoma-associated myasthenia gravis patients with chronic well-controlled disease but an unexpected increase in anti-nAChR autoantibodies titer are reported. The specificity of anti-nAChR autoantibodies directed against extracellular parts of the receptor was studied in order to investigate the discrepancy between clinical and immunological status. Analysis of the anti-nAChR autoantibodies recognizing the extracellular parts of the nAChR revealed that when the concentration of anti-nAChR autoantibodies titer increased both patients had non-anti-α1 autoantibodies. Since the clinical profile of both patients remained unchanged, the increase of non-anti-α1 autoantibodies did not affect the 2 patients' disease progression. Thus, immunotherapy modification due to an increase of anti-nAChR autoantibodies titer could be erroneous and potentially harmful.

Supporting general practitioners in the assessment and management of suicide risk in young people: an evaluation of an educational resource in primary care.

AIM: To conduct a local evaluation of the use of the educational resource: Suicide in Children and Young People: Tips for GPs, in practice and its impact on General Practitioners (GPs)' clinical decision making. BACKGROUND: This Royal College of General Practitioners (RCGP) resource was developed to support GPs in the assessment and management of suicide risk in young people. METHOD: The dissemination of the educational resource took place over a nine month period (February 2018-October 2018) across two Clinical Commissioning Groups in West Midlands. Subsequently, a survey questionnaire on GPs' experiences of using the resource was sent to GPs in both Clinical Commissioning Groups (CCGs). FINDINGS: Sixty-two GPs completed the survey: 21% reported that they had used the resource; most commonly for: (1) information; (2) assessing a young person; and (3) signposting themselves and young people to relevant resources. Five out of thirteen GPs (38.5%), who responded to the question about whether the resource had an impact on their clinical decision making, reported that it did; four (30.7%) responded that it did not; and four (30.7%) did not answer this question. Twenty out of thirty-two GPs (62.5%) agreed that suicide prevention training should be part of their NHS revalidation cycle. The generalizability of the findings is limited by the small sample size and possible response and social desirability bias. The survey questionnaire was not validated. Despite the limitations, this work can be useful in informing a future large-scale evaluation of the RCGP online resource to identify barriers and facilitators to its implementation.

Self-Harm in Eating Disorders (SHINE): a mixed-methods exploratory study.

INTRODUCTION: Self-harm is highly prevalent among young people with eating disorders. However, why a young person may develop and continue to experience both an eating disorder and self-harm is unclear. This study will investigate the frequency, intensity, duration, function, context and processes of self-harm among people aged 16-25 diagnosed with an eating disorder. It will explore participants' perspectives on the genesis and functions of both their self-harm and eating disorder, as well as their support needs. The study was designed with the input of members of a Young Persons' Advisory Group, who will be key to study delivery and dissemination. METHODS AND ANALYSIS: This exploratory study has a sequential mixed-methods explanatory design. Between 70 and 100 young people aged 16-25 with both an eating disorder diagnosis and self-harm thoughts and/or behaviours will be recruited from three NHS Eating Disorder outpatient services in England. Phase 1: a 14-day (six prompts per day) ecological momentary assessment (EMA) of participants' feelings, thoughts, motivations, behaviours and experiences of self-harm. Phase 2: 20-30 participants from phase 1 will be reapproached to take part in an in-depth qualitative interview on the psychological, emotional and social factors that underlie their self-harm and eating disorder as well as their support needs. EMA data from phase 1 will be analysed using descriptive and multilevel statistics. Qualitative interview data from phase 2 will be analysed using inductive and deductive thematic analysis. Results from both phases will be integrated using a mixed-methods matrix, with each participant's data from both phases compared alongside comparative analysis of the datasets as a whole. ETHICS AND DISSEMINATION: The study gained ethical approval from the NHS HRA West Midlands-Black Country Research Ethics Committee (number: 296032). We anticipate disseminating findings to clinical, academic and lived experience audiences, at academic conferences, through peer-reviewed articles, and through various public engagement activities (eg, infographics, podcasts).

Subjective experience and meaning of delusions in psychosis: a systematic review and qualitative evidence synthesis.

BACKGROUND: Delusions are a common transdiagnostic feature of psychotic disorders, and their treatment remains suboptimal. Despite the pressing need to better understand the nature, meaning, and course of these symptoms, research into the lived experience of delusional phenomena in psychosis is scarce. Thus, we aimed to explore the lived experience and subjective apprehension of delusions in help-seeking individuals with psychosis, regardless of diagnosis and thematic content of the delusion. METHODS: In our systematic review and qualitative evidence synthesis, we searched MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science for qualitative studies published in English from database inception, with the last search on Sept 9, 2021. Grey literature search and hand-searching of relevant journals were also done. Studies were eligible if they provided an analysis of lived experience of delusions or predelusional phenomena presented from the perspective of individuals (age 14-65 years) who had developed a clinical high-risk stage of psychosis, or a diagnosable affective or non-affective psychotic disorder (as clinically defined, self-reported, or assessed within the primary study). Studies with only a subset of relevant participants were eligible only if data for the population of interest were reported separately. Studies that did not discriminate between the experience of delusion and other positive symptoms (eg, hallucinations) were included only if data for delusions were reported separately or could be extracted. First-person accounts (and author interpretations) discussing changes in the sense of self, lived world, and meaning in relation to delusions were extracted and synthesised using a novel thematic synthesis approach informed by a critical realist stance and a phenomenological theoretical framework. Analytic themes were developed into a new overarching framework for understanding the emergence of delusional phenomena. The study was registered with PROSPERO, CRD42020222104. FINDINGS: Of the 3265 records screened, 2115 were identified after duplicate removal. Of these, 1982 were excluded after title and abstract screening and 106 after full-text eligibility assessment. Of the 27 studies entering quality assessment, 24 eligible studies were included in the qualitative evidence synthesis, representing the perspectives of 373 help-seeking individuals with lived experience of delusions in the context of psychosis. Gender was reported as male (n=210), female (n=110), transgender (n=1), or not reported (n=52). Only 13 studies reported ethnicity, with White being predominant. The age of most participants ranged from 15 to 65 years. We found no eligible studies investigating subclinical or predelusional experiences in at-risk mental state populations through qualitative methods. Most studies were undertaken in western, educated, industrialised, rich, and democratic (WEIRD) societies, and most included participants had received or self-reported a diagnosis within the schizophrenia spectrum. Studies differed in relation to whether they focused on one kind or theme of delusion or delusional phenomena more generally as a unified category. Three superordinate themes relating to experiential changes and meanings in delusion were identified: (1) a radical rearrangement of the lived world dominated by intense emotions; (2) doubting, losing, and finding oneself again within delusional realities; and (3) searching for meaning, belonging, and coherence beyond mere dysfunction. Based on the review findings and thematic synthesis, we propose the Emergence Model of Delusion to advance understanding of delusional phenomena in psychosis. INTERPRETATION: Delusions are best understood as strongly individualised and inherently complex phenomena emerging from a dynamic interplay between interdependent subpersonal, personal, interpersonal, and sociocultural processes. Integrative approaches to research on delusion, which consider their potential adaptiveness and favour explanatory pluralism, might be advantageous. Effective clinical care for individuals with psychosis might need adapting to match more closely, and take account of, the subjective experience and meaning of delusions as they are lived through, which might also help redress power imbalances and enduring epistemic injustices in mental health. FUNDING: Priestley Scholars, Wellcome Trust.

Analysis of nAChR Autoantibodies Against Extracellular Epitopes in MG Patients.

Myasthenia gravis (MG) is an autoimmune disorder caused by autoantibodies targeting components of the postsynaptic membrane of the neuromuscular junction (NMJ), leading to neuromuscular transmission deficiency. In the vast majority of patients, these autoantibodies target the nicotinic acetylcholine receptor (nAChR), a heteropentameric ion channel anchored to the postsynaptic membrane of the NMJ. Autoantibodies in patients with MG may target all the subunits of the receptor at both their extracellular and intracellular regions. Here, we combine immunoadsorption with a cell-based assay to examine the specificity of the patients' autoantibodies against the extracellular part of the nAChR. Our results reveal that these autoantibodies can be divided into distinct groups, based on their target, with probably different impacts on disease severity. Although our findings are based on a small sample group of patients, they strongly support that additional analysis of the specificity of the autoantibodies of patients with MG could serve as a valuable tool for the clinicians' decision on the treatment strategy to be followed.

The effectiveness of gaming interventions for depression and anxiety in young people: systematic review and meta-analysis.

BACKGROUND: Recent research has investigated the use of serious games as a form of therapeutic intervention for depression and anxiety in young people. AIMS: To conduct a systematic review and meta-analysis into the effectiveness of gaming interventions for treating either depression or anxiety in individuals aged 12-25 years. METHOD: An electronic search was conducted on the 30 March 2020, using PsycINFO, ISI Web of Science Core Collection, Medline and EMBASE databases. Standardised effect sizes (Hedge's g) were calculated for between-participant comparisons between experimental (therapeutic intervention) and control conditions, and within-participant comparisons between pre- and post-intervention time points for repeated measures designs. RESULTS: Twelve studies (seven randomised controlled trials (RCTs) and five non-randomised studies) were included. For RCTs, there was a statistically significant and robust effect (g = -0.54, 95% CI -1.00 to -0.08) favouring the therapeutic intervention when treating youth depression. For non-RCTs, using a repeated measures design, the overall effect was also strong (g = -0.75, 95% CI -1.64 to 0.14) favouring therapeutic intervention, but this was not statistically significant. Interestingly, we found no statistically significant effect for treating youth anxiety. CONCLUSIONS: There is preliminary evidence to suggest that gaming interventions are an effective treatment for youth depression, but not anxiety. Further research is warranted to establish the utility, acceptability and effectiveness of gaming interventions in treating mental health problems in young people.

Working with Young People at Risk of Suicidal Behaviour and Self-Harm: A Qualitative Study of Australian General Practitioners' Perspectives.

General Practitioners (GPs) play a crucial role in the identification and support of young people at risk of suicidal behaviour and self-harm; however, no studies have explored GPs' perspectives, approaches, challenges, and resource needs when working with this cohort in an Australian setting. This was a qualitative study where fifteen GPs (Mage = 45.25 years) from multiple clinics in Western Australia took part in semi-structured interviews, and data were analysed thematically. Seven main themes were identified: (1) working with young people has its unique challenges; (2) screening and assessment tools can help to manage uncertainty and discomfort; (3) going beyond tools-the dialogue and relationship are most important; (4) there are limits to what we can offer in the time available; (5) the service access and referral pathways lack clarity and coordination; (6) the provision of mental health support should not fall on GPs alone; and (7) more comprehensive training in suicide and self-harm is needed. The findings highlight a number of opportunities to enhance care and better assist GPs working with young people who present with suicidal behaviour and self-harm, including considerations for conducting assessments, targeted resources such as training, and system and service improvements.

A qualitative exploration of young people's experiences of attempted suicide in the context of alcohol and substance use.

The aim of this study was to explore young people's experiences of the role and the processes underpinning the use of alcohol and/or other substances in attempts to end their life. Seven young people, aged 16-25 years old, were interviewed using in-depth, semi-structured interviews. Interpretative Phenomenological Analysis was used to analyse these interviews and develop an understanding of how young people understand their attempted suicide in the context of alcohol and/or other substance use. The analysis identified four superordinate themes reflecting young people's experiences across the seven interviews. Superordinate themes included: i) The complexity of relationships; ii) The double-edged sword of alcohol and substance use; iii) The straw that broke the camel's back; and iv) Reflecting on the on-going processes of recovery. The results of this study highlight the complex and multifaceted functions of the consumption of alcohol, and other drugs, in the experiences of young people attempting suicide. Young people described a number of inter and intrapersonal factors which impact upon their suicidal experiences including suicidal ideation and attempts. Participants reported using alcohol and substances as methods of coping with distress, low mood, hearing voices, anxiety and mania. However they also reflected on the impact that this has on their own suicidal ideation and attempts.

Exploring the Processes Involved in Seeking Help from a General Practitioner for Young People Who Have Been at Risk of Suicide.

General practitioners (GPs) play a key role in the early identification and management of suicide risk in young people. However, little is known about the processes involved in how, when and why a young person decides to seek help from their GP. Eight young people, aged 17-23, took part in semi-structured interviews exploring their experiences of help seeking when feeling suicidal. Data were analysed using framework analysis. The analysis identified three main themes and seven subthemes. The main themes explored were: understanding when to seek help from a GP, barriers and facilitating factors at the GP consultation, and help seeking as a non-linear and dynamic process. The processes involved in how, when and why young people seek help from a GP when feeling suicidal were found to be dynamic and to fluctuate over time. Help seeking was initially related to how young people were able to understand and articulate their distress, the availability of informal support networks, and their perception of the GP as a source of help. During a GP consultation, help seeking was influenced by how safe and supported the young people felt. Perceived GP training, communication and validation of young people's concerns were important factors to help facilitate this process. Subsequent help seeking was influenced by prior experience of GP consultations and the availability of alternative support.