Mental health problems occur frequently in the perinatal period and timely identification is key for appropriate support to be offered. Women are routinely asked about their mental health and may undergo formal screening as part of healthcare services in the perinatal period. The aim of this review was to explore women’s views and experiences of being screened for mental health problems and to identify which aspects of this screening process they considered to be important. A systematic search was conducted across five electronic databases for potentially eligible studies published up to July 2025. A meta-ethnographic approach was used to synthesise the findings extracted from the thirty-eight papers included in the final analysis. Reciprocal translation resulted in a line of argument synthesis incorporating three over-arching themes. These were ‘Opportunities presented by screening’ ‘Difficulties with screening’ and ‘Context and constraints’. Identification of salient aspects of the screening process revealed that preferences for how screening is conducted were varied, but more important than the specific method/mode used was the value that women placed on the concept of screening. Nevertheless, several process related factors, such as women’s knowledge and expectations of screening, the screening method and environment, were found to be influential. An important implication for clinical care is that perinatal mental health screening can offer impactful and positive opportunities for women when they see value in the process and when this is facilitated by well validated, person-centred, and flexible screening approaches. Questions regarding suicide/self-harm specifically, presented difficulties, and there is an urgent need to examine how this can be made more acceptable to women.

Background Suicide is a leading cause of death worldwide, particularly in people with severe mental health problems, including schizophrenia. The development, and testing, of suicide-focused psychological interventions which can combat suicidal experiences is an unrealised necessity. However, it is vital that suicide-focused therapies are derived from robust, evidence-based mechanistic suicide theories. The Schematic Appraisals Model of Suicide is one such theory. Objective(s) The Cognitive AppRoaches to coMbatting Suicidality project had two objectives. First, based on the Schematic Appraisals Model of Suicide, to test psychological pathways underlying suicidal thoughts, plans and attempts. Second, to test the efficacy of Cognitive–Behavioural Suicide Prevention for psychosis, a suicide-focused intervention developed by our team. Design The randomised controlled trial had two groups: our suicide-focused therapy, Cognitive–Behavioural Suicide Prevention adapted Cognitive–Behavioural Suicide Prevention for psychosis, plus treatment as usual (treatment) versus treatment as usual only (control). There were three assessment time points of baseline, 6 and 12 months, with the 6-month time point being the critical point for the main primary outcome. Four qualitative methods workstreams were nested within the randomised controlled trial design. Settings Four National Health Service Trust sites in the North West of England, United Kingdom: Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust, and the former North West Boroughs Healthcare NHS Foundation Trust. Participants Main inclusion criteria: (1) non-affective psychosis (e.g. schizophrenia), (2) suicidal experiences in the 3 months prior to recruitment; (3) under the care of an National Health Service mental health services team and (iv) aged 18 or over. Main outcome measures The primary outcome measure was the Adult Suicidal Ideation Questionnaire, which measures suicidal ideation severity over the past month using 25 self-report items. The 6-month follow-up assessment point was the critical time point. There were two secondary suicide measures. Mechanism measures captured six appraisals of emotional difficulties, lack of social support, interpersonal problem-solving difficulties, defeat, entrapment and hopelessness. Results Recruitment ensued from on 21 June 2017 and lasted until 25 November 2020. The last 12-month follow-up assessment was completed on 10 January 2022. Two hundred and ninety-two participants were randomly allocated to the treatment (N = 149) and control (N = 143) groups. Reductions in suicidal ideation severity were not significantly greater in the treatment compared to the control group (p = 0.07; 95% confidence interval −15.41 to 0.68) at month 6. There were, similarly, no significant treatment effects for the secondary suicide outcomes. A therapy ‘dose–response’ showed that each therapy session reduced the suicidal ideation severity score by 0.46, but this effect was also not significant (p = 0.056; 95% confidence interval −0.94 to 0.01), nor was a compliance-adjusted analysis in which only participants who attended at least one session of therapy were included (p = 0.052; 95% confidence interval −0.39 to 0.00). However, a predicted mediation pathway was statistically significant for one of the six mechanism measures, in which the therapy group relative to the control group improved social support appraisals, which, in turn, reduced suicidal ideation severity at month 6 (effect = −2.85, 95% confidence interval −7.00 to −0.23). Qualitative and mixed-methods findings showed that (1) feelings of not mattering, disconnection and irrelevance were central to suicidal thoughts, (2) it is vital to develop better ways of communicating about suicide, (3) our suicide-focused therapy was acceptable and feasible and (4) that being part of suicide work in a trial was largely a positive experience. Limitations The sample was predominantly White/Caucasian and conducted in one geographical United Kingdom location, the primary outcome measure captured only suicidal thought severity, and there were only two follow-up time points. Conclusions This suicide-focused psychological intervention did not demonstrate a treatment effect in the primary suicide outcome measure at month 6 at the 5% significance threshold. There was also no significant treatment effect for secondary suicide outcomes. Future work Research programmes founded on convergent methods, and evidenced-based psychological suicide models are needed to examine how to bolster appraisals of poor social support, disconnection, and not mattering in the context of suicidal mind-sets, and in tandem with the development of creative and inclusive communication tools to relay suicidal experiences. In addition, exploration of the role of ‘dose’ of therapy is crucial for further treatment development. Trial registration This trial is registered as ClinicalTrials.gov NCT03114917 and ISRCTN17776666. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme (NIHR award ref: 13/161/25) and is published in full in Efficacy and Mechanism Evaluation; Vol. 13, No. 3. See the NIHR Funding and Awards website for further award information. Plain language summary Suicidal experiences are strikingly common. They are even more common in people with severe mental health problems, such as non-affective psychosis (e.g. schizophrenia). People with psychosis experience persistent and distressing hallucinations, delusions and paranoid feelings and beliefs. In order to take action against suicide, we have to better understand the psychological mind-sets of people who have suicidal experiences. Based on that understanding, we then have to develop psychological therapies which directly target these suicidal experiences. We have developed and started to test a type of psychological talking therapy which is specifically focused on suicide. In the next stage of our research, we wanted to further our understanding of the psychological mind-sets underpinning suicide, and in addition, to determine how much our suicide-focused therapy would actually reduce the severity of suicidal thoughts in people with non-affective psychosis across 6 months. We randomly split people into two groups – treatment and control. One hundred and forty-nine participants were offered our suicide-focused therapy, together with any ongoing treatment (treatment group), and 143 carried on with their usual treatment (control group). Those in the treatment group were offered up to 24 sessions of suicide-focused therapy, with each session lasting around 50 minutes and usually occurring weekly. We asked people to complete assessments at baseline, at 6 months and at 12 months. The main analyses showed that reductions in suicidal ideation severity were not significantly greater in the treatment compared to the control group across 6 months. Analyses designed to examine compliance with the therapy also did not result in a significant treatment effect. However, we did find that the suicide-focused therapy improved social support appraisals, which in turn improved suicidal ideation severity at 6 months. This indirect pathway was significant. Our qualitative interviews expanded on the impact of social support and social connectedness. Our participants also told us in qualitative work that the suicide-focused therapy was needed, acceptable and implementable in National Health Service services. Scientific summary Background The prevalence of suicidal thoughts, suicide plans, attempts and fatalities increase markedly in people with severe mental health problems, such as non-affective psychosis (e.g. schizophrenia). Suicidal experiences, including thoughts, plans, images, compulsions/urges, often derive from immense psychological pain and distress which, in the case of people with non-affective psychosis, can be compounded by seemingly relentless hallucinations, delusions and paranoid feelings and beliefs. Yet, such suicidal experiences can be countered with psychological ‘talking therapies’, such as forms of cognitive–behavioural therapy (CBT), but only if such therapies are developed specifically to be suicide-focused and to target the psychological mechanisms which underpin suicidal experiences. This means that it is vital to advance, and test, psychological models of suicidal experiences which can then act as a foundation for suicide-focused therapy development. The Schematic Appraisals Model of Suicide (SAMS) assimilates and expands evidence that negative appraisals of (1) emotional difficulties, (2) interpersonal social problem-solving difficulties and (3) lack of social support and perceptions of defeat, entrapment and hopelessness are central in pathways to suicidal experiences. Based on the SAMS, we have developed a transdiagnostic suicide-focused CBT called ‘Cognitive–Behavioural Suicide Prevention’, which we have further evolved for people with psychosis, termed ‘Cognitive–Behavioural Suicide Prevention for psychosis’ (CBSPp). Pilot work with people in the community with psychosis and male prisoners showed that this therapy was efficacious in reducing suicidal thoughts and behaviours, and was acceptable and feasible. The next stage in our suicide prevention work required us to (1) further investigate and advance the purported underlying psychological suicide mechanisms and (2) further test the efficacy of our suicide-focused psychological therapy, specifically in people experiencing psychosis. These were the overall goals of the Cognitive AppRoaches to coMbatting Suicidality (CARMS) project, which used convergent quantitative, qualitative and mixed methods to achieve four key objectives. Objectives To determine the extent to which a suicide-focused CBSPp in addition to usual care (i.e. the treatment group) would be more efficacious in reducing suicidal ideation severity compared to usual care alone (i.e. the control group) over 6 months. To test the extent to which appraisals of lack of social support, emotional difficulties and interpersonal problem-solving difficulties, defeat, entrapment and hopelessness would (1) be reduced in the treatment relative to the control group over 6 months and (2) mediate any positive treatment effect on suicidal ideation severity at 6 months. To determine to what extent the suicide-focused therapy was considered acceptable and implementable in NHS mental health services from the perspectives of both participants and mental health professionals. To investigate the positive and negative experiences of participating in a suicide-focused randomised controlled trial (RCT) as relayed by the participants themselves. Methods Design The design followed Consolidated Standards of Reporting Trials and Standard Protocol Items: Recommendations for Interventional Trials guidelines, and the Template for Intervention Description and Replication checklist and guide. It comprised a RCT with two groups of treatment [CBSPp therapy plus treatment as usual (TAU)] versus control (TAU alone), and stratification of NHS recruitment site and the use of antidepressant medication (yes/no). There were three assessment time points of baseline, month 6 and month 12, of which the 6-month time point was critical for assessing the effect of treatment on the primary outcome measure of suicidal ideation severity. Four qualitative and mixed-methods workstreams were nested within the RCT design, which examined psychological mechanisms, acceptability, implementation and participant’s experiences of taking part in a suicide-focused RCT. Sites Four NHS Trust sites in the North West (NW) of England, UK, namely Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust, and the former North West Boroughs Healthcare NHS Foundation Trust. Inclusion criteria There were six inclusion criteria, which were (1) adults, aged 18 or over; (2) able to give informed consent; (3) the presence of suicidal experiences (e.g. thoughts, plans, urges, compulsions, images, attempts) in the 3 months prior to recruitment; (4) experiences of a non-affective psychosis (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision classifications F20–F29); (5) being under the care of an NHS mental health services team with a care co-ordinator (the care co-ordinator could be the participant’s general practitioner or psychiatrist) and (6) having English as the participant’s primary language or having enough English-language fluency and abilities to take part without an interpreter. Exclusion criteria There were only two exclusion criteria of (1) dementia or organic brain disorder and (2) currently participating in a psychological intervention clinical trial. Randomised controlled trial sample sizes and attrition rate: the target sample size was 250 participants in total, with 125 in each of the treatment and control groups for the primary analyses based on a power of 80%, an alpha level of 0.05 and an effect size of 0.42. We account for clustering in the treatment group with an intraclass coefficient = 0.02, with 6 therapists seeing an average of 21 clients/participants and a variance of 21 participants. The number of clients/participants seen by each therapist is a count variable, meaning that we assume it follows a Poisson process so that the mean and variance are the same. There is no clustering in the TAU arm. An attrition rate of 25% was initially estimated across 6 months, meaning a target total of 333 was required. However, as retention levels consistently exceeded 75%, the desired target total was adjusted to 295. Therapy Our suicide-focused therapy (CBSPp) is highly collaborative, formulation-driven and based on general cognitive–behavioural principles but honed and advanced to explore evidence-based psychological mechanisms founded on the SAMS, which give rise to, and maintain, suicidal experiences. Participants allocated to the RCT treatment group were offered up to 24 sessions of therapy. Each session lasted approximately 50 minutes and usually took place weekly. Primary suicide outcome measure The Adult Suicidal Ideation Questionnaire, which is a self-report measure of suicidal ideation severity, over the past month. Secondary suicide outcome measures Two self-report questionnaires, namely the Suicide Probability Scale and the Beck Scale for Suicidal Ideation. In addition, where possible, a diary Timeline Followback method was used to document self-reported suicide attempts, serious self-harm incidents, suicide plans and suicidal thoughts. Mechanistic outcome measures Self-report questionnaires capturing six negative appraisals of emotional difficulties, interpersonal social problem-solving difficulties, lack of social support, defeat, entrapment and hopelessness. Clinical measures Structured clinical interviews were used to generate information about psychosis symptom severity, the cognitive–emotional impact of hallucinations and delusions, depression, sleep problems, general social and self-care functioning and general psychiatric symptoms. Participants in the treatment group and their therapists completed a measure of the Working Alliance Inventory at around session 4 of therapy and at therapy cessation. Statistical analysis plan Intention-to-treat principles were used across analyses. Data were presumed ‘missing at random’. Linear, mixed regression models were fitted to primary suicidal ideation severity scores at 6 and 12 months to assess efficacy, with the 6-month time point being critical. The treatment effect was the between-group adjusted mean difference between allocated groups, with 95% confidence intervals (CIs) and two-sided p-values. The same modelling procedure was applied to the secondary suicide outcomes, and mechanistic and clinical outcomes. Causal mediation analyses were based on parametric regression models, for which the primary suicidal ideation severity measure at 6 months was the outcome variable; allocated RCT group was the predictor variable; and mechanism outcomes at 6 months were mediators. Baseline scores were covariates. Indirect, direct and total effects were estimated. Two types of compliance analyses were planned, which were (1) systematic exclusion and (2) instrumental modelling of a therapy ‘dose–response’. Results Recruitment and retention Overall, CARMS recruited to target in that 252 participants completed the primary suicide outcome measure at 6 months. Attrition rates were less than expected, given that the target population had severe mental health problems of non-affective psychosis and recent suicidal experiences. Furthermore, excellent retention occurred despite the CARMS project needing to instantiate substantial procedural adjustments due to the COVID-19 pandemic. Efficacy findings There was no significant treatment effect in that across 6 months, suicidal ideation severity did not significantly decrease more in the treatment (suicide-focused therapy + TAU) group compared to the control (TAU) group {adjusted difference –7.36 [standard error (SE) 4.10]; 95% CI −15.41 to 0.68; p = 0.07}. After 12 months, suicidal ideation severity was statistically equivalent in both trial groups. This pattern of non-significance at both month 6 and month 12 extended to the secondary suicide outcome measures. Planned compliance analyses Participants had a median of 16 therapy sessions. When participants in the treatment group were excluded from the analysis if they had not attended any therapy sessions by 6 months, then the treatment effect was still not significant [adjusted difference −7.13 (SE 3.68), 95% CI −0.39 to 0.00; p = 0.052]. Using an instrumental modelling approach with randomisation as an instrument, at 6 months each additional session of therapy reduced the suicidal ideation severity score by 0.46 points, although this also failed to reach significance (95% CI −0.94 to 0.01; p = 0.056). Mediated (indirect) effects There was a significant mediated or indirect effect whereby appraisals of lack of social support (i.e. the mediator) were differentially improved in the treatment relative to the control group, which, in turn, gave rise to a reduction in suicidal ideation severity [effect = −2.85, SE 1.58 (95% CI −7.00 to −0.23)]. The direct effect was not significant. Although there were significant associations between the additional five appraisals of (1) emotional difficulties, (2) interpersonal problem-solving difficulties, (3) defeat, (4) entrapment and (5) hopelessness, and suicidal ideation severity at 6 months, the RCT allocation group did not differentially affect these five appraisals. Hence, the mediation effect was evident for only one out of six potential mediators. Qualitative thematic analyses of interview data provided an extended and expanded understanding of the significant mediated effect involving appraisals of poor social support, in that dynamics involving (1) mattering versus not mattering and (2) being connected versus becoming disconnected were fundamental to the inter-relationships between suicidal and psychotic experiences. Therapy endorsement and calls for implementation Qualitative work highlighted that while aspects of therapy could be perceived by participants as difficult and ‘hard work’, this was offset by (1) an expressed need for therapy, (2) a requirement for suicide to be a focus of therapy, (3) an increased and deepening understanding of suicide through therapy and (4) a growing confidence in using the gains of therapy outside in the ‘real world’. These sentiments were echoed when implementation of suicide-focused therapies in NHS services were discussed with both participants and mental healthcare professionals in that they emphasised that it was vital that suicide-focused therapies were readily available in NHS services, but also in a way that optimised and simplified access routes both to the therapy and also to staff training in suicide-focused therapies. Central to positive experiences of therapy and calls for implementation of suicide-focused therapies was an emphasis on the importance of creating genuine ‘safe spaces’ to talk and the need to be aware of, and open to, different ways of communicating about suicidal experiences. Experiences of being part of a randomised controlled trial about suicide Using a mixed, qualitative and quantitative methods approach, being part of CARMS was largely perceived in ways that were positive in both the shorter and longer terms. Data were collected using diverse methods of mini qualitative interviews, adjective checklists and a simple visual analogue scale mood rating at the end of every assessment/interview appointment. That the data converged provide confidence in the overall message that participation, while sometimes anxiety-provoking and/or distressing, was ‘worth it’ and of benefit. Serious adverse events Three participants died over the course of the CARMS project. However, the reports from the Coroner’s Office documented that these were not suicide-related deaths. The majority of serious adverse events (SAEs) were expected, and judged to be unrelated to the CARMS project. Furthermore, the number of participants involved in SAEs was similar across the two RCT groups. This lends reassurance to an increased impetus for the implementation of suicide-focused psychological therapies in mental health services. Conclusions and clinical implications This suicide-focused therapy intervention, CBSPp, did not demonstrate a significant treatment effect at the 5% significance threshold at month 6. Similarly, while an increasing ‘dose’ of therapy was associated with an increase in a reduction in suicidal ideation, this again did not meet statistical significance. However, there was a significant indirect (mediated) effect at 6 months, in which therapy improved participant’s appraisals of social support, which, in turn, reduced the severity of their suicidal thoughts over 6 months. Exploring appraisals of social support and social connectedness provides a pragmatic starting point for suicide-focused therapies. That said, social support appraisals were one of six different types of appraisals which were measured as part of the CARMS project, meaning that replication of the mediation effect is vital. Nevertheless, qualitative work did converge with the mediated pathway, and suggested that an important focus may be transitions from feeling disconnected to connected, and from a sense of not mattering to being of value. Although working with changing perceptions of social and interpersonal relationships might be expected to be a common aspect of therapeutic work, the CARMS qualitative work delineates how these perceptions are impacted by suicidal mind-sets. Qualitative workstreams from the CARMS project further illustrated how suicide-focused therapy was needed and desired by participants. The median number of therapy sessions attended was 16, demonstrating that people with some of the severest forms of mental health problems can engage with, and maintain, therapy attendance. Ratings of the therapeutic alliance by both participants/clients and therapists were robust, lending some reassurance to the ‘suitability’ of offering a formulation-driven, collaborative, suicide-focused therapy to people who live with both psychotic and suicidal experiences. Implications for future research The convergence between qualitative mechanism findings and the mediation analyses highlighted that we need to better understand how individuals with suicidal and psychotic experiences make transitions between (1) feeling irrelevant and inconsequential to feeling valued and appreciated, (2) feeling disconnected and an ‘outcast’ to feeling a sense of connection and belonging and (3) feeling ‘un-understandable’ to feeling ‘heard’ and worthy of being ‘heard’. Micro-longitudinal designs with both qualitative and quantitative components are needed to develop and maximise this understanding. Examining ways in which individuals fluctuate from having suicidal thoughts and urges to acting on those urges was beyond the scope of CARMS but is a research direction that is vital to advance. In the first instance, qualitative work using multimedia diary methods conjoint with experience sampling methodologies seem best suited to this research endeavour because these fluctuations seem non-linear, interactive, context-dependent and highly dynamic. CARMS investigated transdiagnostic psychological suicide mechanisms based on the SAMS. It is now essential to further develop these mechanisms so that they can explain ways in which specific mental health problems, for example, hallucinations, delusions and paranoid thoughts/beliefs, impact these mechanisms by investigating complex pathways using longitudinal and micro-longitudinal moderated mediation designs together with network analysis. A realist evaluation approach was beyond the scope of CARMS, but this approach offers the potential to better understand how multilayered contextual factors impact putative mechanisms and outcomes dependent on contextual factors. Qualitative findings revealed difficulties in navigating ‘suicide talk’. We need an improved understanding of how to communicate about suicide in ways that create genuine and trusted ‘safe spaces’, using diverse and creative channels that can be readily embraced by people with suicidal experiences, but also by health professionals, colleagues, friends, partners and family. Finally, that participants could attain high levels of formulation, experience high levels of therapeutic alliance, and that therapy ‘dose’ may confer therapy benefits suggest that these therapy process variables might be further explored. Trial registration This trial is registered as ClinicalTrials.gov NCT03114917 and ISRCTN17776666. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme (NIHR award ref: 13/161/25) and is published in full in Efficacy and Mechanism Evaluation; Vol. 13, No. 3. See the NIHR Funding and Awards website for further award information.

Objective The effects of anxiety on psychological pathways underpinning psychosis and suicidal thoughts are poorly understood. The overall goal of the present study was to rectify this by examining pathways linking emotional distress from psychotic symptoms, specifically, auditory hallucinations and delusions with suicide ideation severity, via anxiety, defeat, entrapment, and hopelessness. Methods Participants had psychosis and recent suicidal experiences and were under the care of mental health services. The design was cross-sectional. Two key mediated models were examined. In the first, the extent to which anxiety mediated the association between distress from psychosis and suicidal ideation severity was tested. In the second, the extent to which distress mediated the association between anxiety and ideation was tested. In both models, defeat, entrapment and hopelessness were parallel, proximal, mediators of suicidal ideation severity. General psychiatric symptoms were statistically controlled, as were severity levels of hallucinations and delusional symptoms. Results There was an indirect, mediated, association linking emotional distress from auditory hallucinations and delusions with ideation severity via anxiety and entrapment. There was also a second mediated effect in which anxiety was associated with suicidal ideation severity via emotional distress from auditory hallucinations and delusions and entrapment. These mediation effects were not significant when symptom severity, rather than distress arising from symptoms, was tested. Conclusion Our findings underscore the importance of incorporating into contemporary suicide theories the complex dynamics underpinning the emotional impact of auditory hallucinations and delusions on suicidal thoughts especially when linked with anxiety and entrapment, whilst simultaneously developing suicide-focused therapies.

Objectives:There is no research evidence about how healthcare professionals (HCPs) prioritise assessment and management of pain in different paediatric chronic musculoskeletal conditions (e.g. inflammatory or non-inflammatory). This study investigated and compared paediatric rheumatology HCPs' pain assessment/management priorities in inflammatory and non-inflammatory chronic musculoskeletal conditions and explored perceived barriers to implementation of prioritised pain assessment/management approaches. Methods:Participants were presented with online vignettes describing a young person with an inflammatory (JIA) or non-inflammatory (diffuse idiopathic pain) chronic musculoskeletal condition. Participants completed closed questions on pain assessment/management priorities and open questions on perceived barriers to implementation of these priorities in clinical practice. Data were analysed using within-subjects bivariate statistical analysis and content analysis. Results:Results from 56 HCPs (11 countries) found that broadly similar pain assessments were selected for both conditions. Biomedical management approaches were more frequently selected for the inflammatory condition, whereas psychosocial approaches were primarily selected for the non-inflammatory condition. Barriers to implementation of assessment/management approaches included limited time, resources, knowledge and skillset and HCPs' habits and beliefs about pain care (e.g. limiting access to components of biopsychosocial pain management due to preconceived beliefs about the musculoskeletal condition). Conclusion:Paediatric rheumatology HCPs generally prioritise similar pain assessments for inflammatory and non-inflammatory chronic musculoskeletal conditions. However, some HCPs perceive psychosocial pain management approaches as less important for managing pain in inflammatory conditions. Importantly, pain is always biopsychosocial in nature and clinical guidelines (that emphasise the biopsychosocial perspective) should ideally be followed regardless of condition type.

Abstract Introduction Health behaviours are important because they have been linked to pregnancy outcomes. During maternity care women are provided with health information, but little is known about how women experience these discussions. Therefore, a systematic review was conducted to investigate women’s experiences of discussing health behaviours within their maternity care interactions. Methods Bibliographic databases were searched to retrieve studies reporting qualitative data regarding women’s experiences. Included records were assessed for quality using the Critical Appraisal Skills Programme tool and then thematically synthesised. A professional and public stakeholder group was consulted for feedback at multiple stages. Findings Women’s experience from 81 records was captured within three themes. Theme 1 presents how women feel they do not know enough about health, theme 2 shows that women want to have a discussion about health, and theme 3 describes how healthcare provider communication style can impact how engaged women are in a discussion. Conclusion This suggests that healthcare providers should be engaging women in conversations where women can express motivation for change, and then together they can both contribute to shared discussions about the woman’s health. Future research should focus on providing support for healthcare providers to achieve this through training and intervention.

Suicidal experiences (e.g. suicidal thoughts, plans, urges, compulsions, images, acts, attempts) are common in the early stages of psychosis and represent a global healthcare concern. As well as hallucinations and delusions, psychosis is associated with difficulties in forming interpersonal relationships, causing isolation, disconnectedness, and significant psychological distress. This systematic literature review aimed to examine the effects of perceptions of offline and online social connectedness and disconnectedness on suicidal experiences in people with recent onset psychosis. We proposed a Social Connectedness and Disconnectedness (SoCaD) conceptual framework comprising six domains which guided the analytic process. A convergent, sequential explanatory approach to analysis was used. Fourteen studies were included from four electronic databases (i.e. PsycInfo, Embase, MEDLINE, Web of Science). The study screening and quality assessment procedures were checked by an independent researcher. Findings pertaining to five SoCaD domains were identified: 1. Supportive relationships with others; 2. Social identity and purpose; 3. A sense of belonging; 4. Perceived social value; and 5. A sense of mattering to others. No studies were identified that specifically examined experiences and perceptions of social connectedness or disconnectedness in the context of online social media activity and communication. This represents a substantial gap in the evidence. Overall, only a few studies made a useful contribution to better understanding the relationships between social connectedness and disconnectedness, recent onset psychosis, and suicidal experiences. Future research should methodically examine domains of social connectedness and disconnectedness across offline and online contexts and focus on context-specific understanding of these social dynamics to enhance suicide prevention strategies in this vulnerable population. Not applicable.

BACKGROUND:The perinatal period can be a challenging time for women with current or historical eating disorder (ED) experience. Maternal EDs are associated with risks to both the mother and the child. During pregnancy, women are more likely to disengage with ED behaviours for the good of their growing baby. However, the postpartum period is a particularly risky period for the re-emergence or worsening of ED behaviours, irrespective of women's pre-pregnancy ED status. Little is known about the factors which influence ED symptomology during the postpartum period. The aim of this study was to develop an understanding of the factors operating in the postpartum experience that influence ED symptomology. METHODS:Semi-structured interviews were conducted with 12 women who had experience of an ED before becoming pregnant. Interview took place during or after the postpartum period, with women reflecting specifically on the postpartum period. Interviews were analysed using Reflexive Thematic Analysis. RESULTS:Four themes were developed within the interview data; (1) Embracing the self, (2) Motherhood: an ED enabler or protector?, (3) ED as a 'plaster' for emotional distress, and (4) The influential voices of others. Theme 1 captures participants' reports of the primary ED recovery facilitator, with a focus on self-awareness, self-understanding, self-compassion, and self-identity. Themes 2-4 describe a 'triangle of powers' which interacted with one another to influence participants' ED symptomology both positively and negatively during the postpartum period. CONCLUSION:A new model is proposed which predicts that ED symptomology during the postpartum period is influenced by a complex interaction between various internal and external factors. Health care professionals encountering women with EDs during the perinatal period should be aware of these factors, to provide attuned and individualised care and improve outcomes for mothers and babies. Increased awareness how EDs may present during the postpartum period is needed.

ObjectiveTo identify healthcare professionals' perceptions of pulmonary rehabilitation as a management strategy for people with chronic obstructive pulmonary disease (COPD).DesignA qualitative interview study which adopted an interpretive phenomenological approach.MethodsTwenty-seven healthcare professionals were recruited from general practices in the North West of England and two hospital trusts, consisting of: general practitioners, practice nurses, and doctors and nurses working on general medical wards. Audio recorded semi-structured interviews investigated healthcare professionals' perceptions and knowledge of pulmonary rehabilitation; interpretive phenomenological analysis was conducted on the transcribed interviews.ResultsThree themes were identified: COPD Illness Perceptions, Pulmonary Rehabilitation Beliefs, and Organisational and Referral Pathway Perceptions. Commonalities and disparities were identified between primary and secondary care and amongst the different professional groups. Healthcare professionals held negative COPD illness perceptions including stigmatising beliefs in relation to the disease. These beliefs impacted their referral practice. Beliefs about pulmonary rehabilitation included views about patient suitability for the pulmonary rehabilitation programme. A lack of knowledge of pulmonary rehabilitation and the referral process was evident. Surprisingly, many working on general medical wards had not heard of pulmonary rehabilitation and none in their current role had referred to the programme. Organisational and referral pathway perceptions revealed barriers and facilitators to referral.ConclusionReferral to pulmonary rehabilitation programmes is influenced by healthcare professionals' perceptions and knowledge of pulmonary rehabilitation, referral pathways and how COPD affects patients. Together health professional perceptions could act as a predictor of referral practice and inform strategies for increasing referral rates.

BACKGROUND AND PURPOSE:In childhood brain tumors, minimizing long-term side effects of cancer therapy is a critical objective. Radiation-related imaging changes (ICs), indicative of potential radionecrosis, remain an area of active investigation in proton beam therapy (PBT). This study aimed to identify and correlate post-therapeutic ICs and radio-biological and dosimetric factors, including linear energy transfer (LET) and variable relative biological effectiveness (RBE), as well as clinical factors. MATERIALS AND METHODS:A 3:1 matched-pair cohort of 93 pediatric PBT patients from a register study was retrospectively analyzed. The cohort comprised various brain tumor entities, with follow-up MRI data available up to 14 months post-treatment. Potential clinical risk factors for therapy-induced ICs in pediatric brains were analyzed using logistic regression at both patient and voxel levels. Dosimetric parameters were evaluated for the entire brain, periventricular region (PVR), and brainstem. RESULTS:A total of 15 cases with post-therapeutic ICs from various childhood tumor entities were identified and localized in the brainstem, the PVR, and other brain regions. At the voxel level, the key predictor linked to increased IC probability was the product of dose D and proton dose-averaged LETd (D · LETdproton)σ=6 mm, excluding voxels below 5 Gy (RBE). The Gaussian filtering with a standard deviation σ of 6 mm served as a practical approach to account for spatial uncertainties. At the patient level, the median dose (D50%) within the volume of the healthy brain receiving more than 20 Gy (RBE) was most significant. CONCLUSION:The identified univariate voxel- and patient-level risk factors provide a foundation for predicting post-therapeutic ICs in pediatric CNS tumor patients treated with PBT. Our findings contribute to refining risk prediction models and optimizing treatment planning strategies, ultimately aiming to minimize long-term radiation-induced effects in pediatric brain tumor patients.

Suicidal experiences are highly prevalent in people with non-affective psychosis, as are anxiety problems. Understanding the interplay between suicidal and anxiety-related experiences in people with psychosis has been somewhat neglected. The over-arching aim of the current study was to redress this gap using a qualitative approach. A secondary Framework Analysis was applied to qualitative interviews with 18 people with recent suicidal and psychotic experiences. Qualitative analyses evidenced a complex dynamic between psychotic, anxiety-related, and suicidal experiences. An emotional and cognitive-emotional dynamic was central which reflected: (a) the prominence of fear; (b) the perceived relentlessness of mental health problems; (c) feeling overpowered, overwhelmed, thwarted, and defeated; (d) perceptions of no hope and no future; and (e) wanting an unlikely end to the trap of ‘mental illness’. Within the emotional and cognitive-emotional dynamic, two pathways were clearly discernible: i.a. direct influence of anxiety on suicidal experiences with psychosis exacerbating anxiety-related experiences; and ii. an explicit pathway between psychotic and suicidal experiences with anxiety worsening psychotic experiences. A third pathway captured a non-discernible ‘mixture’ of anxiety-related, psychotic, and suicidal experiences. A fourth pathway illustrated how depressed and low mood states could interact with psychosis and anxiety to trigger and/or worsen suicidal states of mind. It is vital to better understand the interplay between psychosis, anxiety-related, and suicidal experiences whilst conjointly developing suicide-focused psychological therapies so that they directly address ways in which different manifestations of anxiety interact with psychosis to lead to, and worsen, suicidal experiences. ClinicalTrials.gov (NCT03114917), first submitted 29th March 2017 (29/03/2017), first submitted that met QC Criteria 10th April 2017, first posted 14th April 2017 (14/04/2017). ISRCTN (reference ISRCTN17776666 https://doi.org/10.1186/ISRCTN17776666 ); 5th June 2017, (05/06/2017). Registration was recorded prior to participant recruitment commencing.

OBJECTIVE:To investigate parents' experiences and perspectives about pain communication with healthcare professionals in paediatric rheumatology. METHODS:Data were collected using semi-structured telephone interviews with parents of children/adolescents recruited from three UK tertiary paediatric rheumatology centres. A framework analysis was used to characterise parents' experiences and perspectives. RESULTS:Eighteen parents participated. Their children had a median age of 13 years (SD= 3.16 years, Range= 6-16 years, 55 % male), with diagnoses of chronic primary pain (e.g. Ehlers Danlos syndrome/Hypermobility) and chronic secondary pain (e.g. Juvenile Idiopathic Arthritis). Data were organised into four themes: 1) Parents' active role in pain communication, 2) Building blocks of effective pain communication, 3) Stark realities of pain communication and 4) Purpose for prioritising pain communication. Parents discussed their role in advocating for their child and encouraging their child to communicate about their pain. Parents reported experiences of unsatisfactory pain management advice being provided and frequent experiences of their child's pain being dismissed by healthcare professionals. CONCLUSION:Findings emphasise several advantages of involving parents in communication about their child's pain, as well as a range of challenges in pain communication with healthcare professionals from parent perspectives. PRACTICE IMPLICATIONS:These findings inform recommendations to facilitate more effective pain communication approaches which include parents in the future.

Recent changes to US research funding are having far-reaching consequences that imperil the integrity of science and the provision of care to vulnerable populations. Resisting these changes, the BJPsych Portfolio reaffirms its commitment to publishing mental science and advancing psychiatric knowledge that improves the mental health of one and all.

OBJECTIVES:Juvenile idiopathic arthritis (JIA) is a group of childhood-onset inflammatory rheumatic conditions characterized by pain as one of the most common and distressing symptoms. This cross-sectional study aimed to investigate whether relationships between reported pain and disease activity in JIA affected beliefs about pain, known as "personal models." METHODS:187 out of a possible 363 participants with JIA who completed questionnaires about function and pain perception were recruited through the Childhood Arthritis Prospective Study (CAPS). A pre-selected pain score threshold and validated disease activity score cut-offs were used to assign the participants into four groups: low pain/low disease, low pain/high disease, high pain/low disease, and high pain/high disease. Multivariable linear regressions examined associations between the groups and their "personal models." RESULTS:Compared to participants with low pain/low disease, those with high pain/high disease and those with high pain/low disease were more likely to sense greater threat, have more negative emotional representations, and perceive less control over their pain. Participants with low pain/high disease had similar pain beliefs compared to those with low pain/low disease. CONCLUSION:This is the first study to compare "personal models" of pain in JIA. Children and young people who experience high pain severity regardless of disease activity perceived high pain threat, low controllability, and negative emotional representations. This highlights the importance of considering and addressing personal models of pain at diagnosis, especially those who present high levels of pain.

Background There is a need for theoretically grounded and testable suicide-focused psychological therapies, especially in people with severe mental health problems, specifically non-affective psychosis. We aimed to test both the underlying mechanisms and efficacy of a suicide-focused therapy, cognitive behavioural suicide prevention for psychosis (CBSPp). Methods We did a multicentre, assessor-masked, randomised controlled trial conducted at four UK National Health Service (NHS) sites. Participants were eligible for enrolment if they were 18 years or older; met ICD-10 criteria for non-affective psychosis (F20-F29); had self-reported suicidal experiences in the 3 months before recruitment; were under the care of an NHS mental health services team; were not receiving a psychological therapy as part of a similar trial; had sufficient competency in the English language not to need an interpreter to participate; and were able to give informed consent. After screening for eligibility and completion of baseline assessments, participants were randomly allocated in a 1:1 ratio to either the treatment as usual group (control) or CBSPp therapy plus standard treatment group (treatment), with stratification by use of antidepressant medication and NHS site. Randomisation took place using an online Sealed Envelope randomisation procedure conducted and overseen by the Manchester Academic Health Sciences Centre Clinical Trials Unit (MCTU). This system was accessed only by specially allocated staff (eg, the CARMS Trial Manager or the MCTU Trial manager). When the system randomly allocated a participant, an unmasked email confirmation was sent to the unmasked coprincipal investigator and the CARMS Trial Manager (also unmasked). Assessors, the trial statistician, and one coprincipal investigator were masked to allocation group. Participants were informed of their randomised allocation group by an unmasked CARMS staff member. Experts-by- experience were involved in all stages of the research. For those in the treatment group, approximately 24 oneto-one therapy sessions were offered, usually weekly, for around 50 min per session. Assessments were conducted at baseline, month 6, and month 12. The primary outcome was suicide ideation severity measured by the 25-item Adult Suicide Ideation Questionnaire (ASIQ), assessed at month 6 relative to baseline. Outcome analyses used mixed models in the intention-to-treat population. Planned mediation indirect linear regression models examined appraisals of poor social support, emotional difficulties, interpersonal problem-solving difficulties, defeat, entrapment, and hopelessness as mediators at 6 months with allocation condition (treatment vs control) as the predictor variable and suicidal ideation severity (ASIQ) at 6 months as the outcome variable, whilst controlling for baseline levels of the mediator and outcome variables. The trial was registered before recruitment at ClinicalTrials.gov (NCT03114917) and ISRCTN (ISRCTN17776666) and is complete.

BACKGROUND:Communication between patients and staff is a crucial component of safe and effective healthcare. As people age, they have more consultations and these become more complex. As such, older people may be more likely to experience gaps and breakdowns in communication. OBJECTIVE:To develop a better understanding of older people's communication in interactions with primary care staff and the barriers to and enablers of this. SEARCH STRATEGY:Four databases were searched. Search terms covered the sample (older people), domain (verbal communication in healthcare interactions), context (primary care) and research type (qualitative research). DATA EXTRACTION AND SYNTHESIS:A meta-ethnographic approach was followed by one researcher, with input from the wider team. Twelve studies were included. Details of the designs, participants, methods and results were extracted. Data were synthesised through reciprocal translation, and a line of argument was developed. MAIN RESULTS:Barriers to communication were found in relation to raising and addressing concerns. Barriers arose from patient perceptions of their role, the nature of their relationship with staff, patient and staff perceptions of responsibility and reluctance to broach a topic, individual factors such as memory, how staff respond when concerns are raised and the degree of patient involvement in consultations. Potential enablers of communication were preparation and support from family or peers. CONCLUSIONS:Synthesising the existing qualitative literature on older people's communication in healthcare interactions enabled the identification of barriers and enablers that can be used to inform the development of an intervention to improve communication with primary care staff. PATIENT OR PUBLIC CONTRIBUTION:By identifying healthcare communication as the most important topic for the patient safety of older people with multiple long-term conditions in primary care and setting the scope of the review, patients and the public were involved in the design of the study. Four public contributors (older people with multiple long-term conditions and carers of older people with multiple long-term conditions) attended regular meetings, provided their reflections on the study findings and supported the interpretation of the data.

Research has demonstrated the ability to identify and treat individuals at high risk of developing psychosis. It is possible to use a similar strategy to identify people who have an emergent risk of bipolar disorder (BD). Interventions during the early phase may improve outcomes and reduce risk of transition. Criteria have been established to identify individuals considered to be at high risk for developing BD, also known as Bipolar At Risk (BAR). Offering a psychological intervention may provide the possibility of prevention. Evaluating efficacy and the mechanisms by which this treatment works is now required. A multicentre, rater-masked randomised controlled trial with two parallel arms will compare cognitive behaviour therapy (CBT) for young people meeting BAR criteria (CBTBAR) + Treatment as Usual (TAU) vs. TAU alone. Participants will be recruited from five National Health Service (NHS) sites in the UK. Outcome and mediational variables will be collected at baseline, 17-weeks (in treatment), 27-weeks (post-CBTBAR /TAU), and 52-weeks. Qualitative work will examine the perceived mechanisms of change and implementation of CBTBAR in the NHS. Our efficacy hypotheses are CBTBAR + TAU (compared to TAU alone) will lead to improvement in mood swings, a reduction in the likelihood of transition to BD, and improvements to functioning and quality of life. Our mechanistic hypothesis is CBTBAR + TAU causes improvement in mood swings due to the reduction of extreme positive and negative appraisals of internal states which in turn improves subsequent behaviours used to control mood and then internal states. Our trial will explore the perceived mechanism of change via this novel intervention (CBTBAR) and if the approach can be implemented within current services in the UK. The trial protocol is registered with (ISRCTN13363197, registered on 25th January 2023). Recruitment started in February 2023 and is ongoing.

ObjectiveTo understand healthcare professionals' experiences of developing therapeutic alliances (working relationships) with stroke survivors, and their views on how alliance relates to self-management in community settings.DesignQualitative study.SettingCommunity.ParticipantsHealthcare professionals recruited purposively from four National Health Service community stroke teams in England.Main measuresSemi-structured, one-to-one qualitative interviews, transcribed verbatim and analysed using Braun and Clarke's reflexive thematic analysis.ResultsNineteen clinicians (six physiotherapists, four occupational therapists, two speech and language therapists, two nurses, one psychologist and four people in assistant/trainee roles) were included in the study. Three main themes were developed from the data. (1) The team can't come forever: alliances were shaped by the time-limited nature of community rehabilitation and relied on trust, buy-in, and clearly defined roles and expectations. (2) Therapeutic alliances help and hinder: whilst alliances supported motivation and engagement, complicated power dynamics sometimes undermined self-management. (3) Confusion about what self-management is: participants often equated self-management with self-directed rehabilitation and described a lack of clarity, confidence and training in supporting emotional and long-term adjustment needs. Strong alliances were viewed as essential for self-management, but formal support strategies were rarely used.ConclusionsCommunity-based healthcare professionals consider therapeutic alliance to be the foundation for stroke self-management in the community. However, a limited understanding of self-management among clinicians, combined with unbalanced power dynamics, may restrict patient autonomy. Relationship-based training (e.g. Bridges) and the development of self-management champion roles within organisations may enhance clinicians' confidence and consistency in delivering self-management support in the community.