Thirty percent of the UK population live with a long-term physical health condition, and many also experience symptoms of low mood. Limited psychosocial support is currently available for people living with long-term physical health conditions and subthreshold depression, who are at risk of developing major depressive disorder. Online peer support offers a low-cost, scalable solution to intervene early and prevent the worsening of depressive symptoms. Partnering with lived experience experts, we co-designed CommonGround, an online peer support platform with embedded psychoeducation. This feasibility randomised controlled trial aimed to assess the usability and acceptability of CommonGround for people with long-term physical health conditions experiencing subthreshold depression and assess the feasibility of a larger confirmatory trial. We conducted a mixed-methods, two-arm, parallel-group, unblinded feasibility randomised controlled trial. We recruited adults living with at least one long-term physical health condition who had access to the internet and subthreshold depression (scoring 5–9 on the Patient Health Questionnaire-8). Participants were randomised to either the CommonGround platform or a control condition where fortnightly emails shared links to the National Health Service mental health webpages. Outcome assessments were administered at baseline (0 weeks), mid-intervention (6 weeks), and post-intervention (12 weeks) timepoints. The primary outcome was the number of participants recruited to the trial. A purposive sample was interviewed to evaluate participant experiences of the CommonGround platform, control condition, and trial procedures. Recruitment targets were met. It was feasible to obtain follow-up questionnaire responses. At screening, 25

In psychiatric inpatient care, coercive practices (e.g., physical restraint) are strategies employed to support assessment, treatment and safety plans. Their use, however, is associated with physical and psychological harms. Clinical guidelines recommend offering patients a post-incident review to mitigate these harms, yet evidence suggests these are not routine or consistently implemented. Understanding variation in their provision across coercive events and patient groups, is essential for developing effective and equitable post-coercive practice support interventions. This study aimed to identify distinct profiles of coercive practice exposure among mental health inpatients and examine how these profiles, alongside demographic factors, relate to use or omission of post-incident reviews. A cross-sectional, retrospective analysis of three years of anonymised patient incident data (>8,000 incidents, ~1,600 patients) from the centralised electronic incident reporting system of a mental health service provider in England was conducted. Latent class analysis and multinomial regression examined associations between class membership post-incident review occurrence and staff-reported reasons for omission. Latent class analysis identified four profiles: (1) removal/ separation, (2) threat-compliance coercion, (3) passive refusal, and (4) resistive refusal. Profiles were interpreted as differing in relative invasiveness and restrictiveness based on the types and combinations of coercive practices. Post-incident reviews were significantly less likely to occur following more invasive exposures. Black and racially minoritised groups were more frequently represented in profiles less likely to receive a post-incident review. Profile membership also predicted staff-reported reason for omission of post-incident review. Variation in implementation of post-incident reviews in inpatient mental healthcare is influenced by the coercive practice context and demographic factors. Findings suggest that broadening the scope of post-coercive practice support and tailoring it to the specific coercive practice context may enhance patient experience and help address inequities.

INTRODUCTION:Safety planning interventions are increasingly used in suicide prevention, yet their design and delivery often lack alignment with personal recovery principles. AIM:To explore with lived experience, empirical literature on safety planning for suicide prevention and examine the relationship between change mechanisms and personal recovery concepts. METHOD:An integrative literature review was conducted combined with critical meta-autoethnographic synthesis. Data were analysed using the Donabedian Model of Healthcare, the Conceptual Framework for Personal Recovery, lived experience and translated using reciprocal and refutational synthesis. RESULTS:Fifteen studies were included. An empirically based recovery-orientated framework was developed comprising three phases of personal development-Inspiring, Discovering and Embodying-and three mechanisms of change-Learning, Introspection and Self-reflection. The framework reconceptualises the clinicians' role as 'facilitator' highlighting the importance of relational, personalised approaches. DISCUSSION:The findings challenge dominant biomedical approaches, offering a more personalised, recovery-focused understanding of safety planning interventions. IMPLICATIONS FOR PRACTICE:The framework supports delivery of person-centred care, policy implementation, service redesign and workforce training aligned with NHS and WHO guidance. RECOMMENDATIONS:Future research should evaluate the framework's effectiveness and explore its application in diverse populations and settings.

Restrictive practices (RPs) encompass interventions that limit an individual's freedom, such as restraint, seclusion, and enforced treatment. While widely studied in acute mental health settings, their use within inpatient eating disorder services remains underexplored despite evidence of high prevalence. In addition to these formal restrictive interventions, eating disorder inpatient wards commonly employ structured behavioural rules as part of nutritional rehabilitation programs, including enforced rest periods, supervised meals, locked bathrooms, and limits on fluids or activity. A scoping review methodology following a five-step framework was implemented. Four databases (CINAHL, MEDLINE, Embase, and PsycInfo) were searched. The analysis involved both numerical and narrative synthesis in line with the framework. Thirty-six studies were included. Most originated from the UK, focused on anorexia nervosa, and used quantitative designs, with a substantial proportion conducted in child and adolescent inpatient settings. Common RPs included nasogastric tube feeding under restraint, involuntary admission, and physical restraint. Prevalence varied widely, with a small subset of patients accounting for most RP episodes. RPs were primarily applied in response to medical or nutritional risk rather than aggression, differentiating them from acute psychiatric contexts. Evidence regarding outcomes such as weight restoration, length of stay, and mortality was inconsistent, and RPs were frequently described by patients and staff as distressing, coercive, and potentially traumatic. Findings highlight the distinct nature of RP use in eating disorder settings and the need for context-specific policies, ethical guidance, and intervention strategies to minimize harm while ensuring patient safety.

BackgroundOnline peer support can help people living with long-term physical health conditions to manage their mental well-being. Although the potential negative events that can occur and risks associated with web-based peer communities are well recognized, our understanding of how best to moderate these spaces is relatively limited, particularly with regard to new communities. Previous work has focused on the experiences of either moderators or community members. ObjectiveThis study aims to explore the perspectives of both members and moderators of a new online peer support community to evaluate the moderation procedures and inform recommendations for best practice. MethodsCommunity members (n=39) who participated in a research trial of a new online peer community, CommonGround, were interviewed. The moderation team (n=5) was invited to a focus group. Community member interviews explored their opinions of moderation policies and the behavior of the moderation team. The moderator focus group explored their experiences of moderating the community, including perceived benefits, common challenges, and areas for improvement. All interviews and the focus group were conducted online, audio-recorded, and transcribed verbatim. An inductive thematic analysis was conducted to sort the data into overarching themes through an iterative process. ResultsEffective moderation was considered critical in creating a safe space that members wanted to engage with and for mitigating any risks, particularly around the spread of medical misinformation. Both moderators and community members felt that the moderation policies and practices were appropriate and applicable to the community. Moderators found navigating the moderation threshold, where they balanced safety against free speech, challenging when determining whether to intervene or not. Being part of a team with mixed clinical expertise helped moderators build confidence in navigating this threshold and also presented other benefits of easy access to support and improving the consistency of their moderation practices. It was suggested that in order for a community to flourish, community members would self-moderate. However, moderators and members felt that the strong community culture and high levels of member engagement that are needed to support self-moderation had not yet evolved. Proposed improvements to moderation included new features to support the efficiency of identifying new content for review and reviewing the rule of anonymity. ConclusionsModeration is critical in making online peer communities feel safe and engaging. Moderation practices should be co-produced with the target audience to ensure that they are aligned with the community’s unique moderation wants and needs, including clear escalation pathways, transparent communication patterns, and plans to review and update policies or procedures as the community evolves. There should be technological features that promote self-moderation, as the community may shift towards self-moderation as it matures. It is also critical to ensure that moderators feel supported so that they are best placed to support the broader community. Trial RegistrationClinicalTrials.gov NCT06222346; https://clinicaltrials.gov/study/NCT06222346 International Registered Report Identifier (IRRID)RR2-10.2196/71513

BackgroundThere is relatively limited psychological support dedicated to people living with long-term physical health conditions and subthreshold depressive disorder. Online peer support may be an appropriate intervention to help bolster patients’ mental well-being to prevent progression of their symptoms to major depressive disorder. For interventions to be successfully integrated into the self-management routines of people with long-term physical health conditions, they should be co-designed to ensure that they align with the wants and needs of the target audience. ObjectiveThis study aims to coproduce an online peer support intervention with people with lived experience, software experts, clinicians, and academics through an iterative process of co-design and subsequent co-validation through usability testing. MethodsWe followed a 4-stage coproduction process: co-assess, co-design, co-validate, and co-deliver. Our research advisory group was actively involved in all stages, consisting of 1 coinvestigator and 6 people with lived experience of long-term physical and/or mental health comorbidities. The co-assess and co-design stages involved our participatory design panel, which included 10 members living with various long-term conditions. The participatory design panel participated in online focus groups to assess their unmet psychosocial needs and then co-designed the intervention prototype through online workshops with software developers. The co-validation stage involved an additional group of participants (n=12) with long-term physical health conditions. During co-validation, the prototype underwent usability testing, including think-aloud exercises and semistructured interviews. Content analysis identified the priorities for the iterative development that formed the basis of further research advisory group co-design workshops. The next stage, co-delivery, involved coproducing the protocol of a feasibility and acceptability randomized controlled trial. ResultsParticipants highlighted that a platform must feel safe and trustworthy for the space to support the mental well-being of those living with long-term health conditions. The participatory design panel co-designed a platform prototype to meet this need. During the co-validation stage, the think-aloud exercises identified common issues related to navigation challenges and feature glitches. Content analysis of the semistructured interviews confirmed that the community forum, resources, and other platform pages were appropriate and acceptable, but revealed usability concerns. Participants stressed the need for intuitive navigation and suggested new features that would enhance user experience. Facilitators and barriers to engagement were also noted, including the importance of fostering trust in the platform’s ethos and branding to create a safe space. Through iterative development and subsequent usability testing, the final prototype was approved. ConclusionsWe have provided a worked example of a comprehensive, coproduction process where we worked alongside people with lived experience to successfully design an online peer support platform with embedded psychoeducation. The platform, called CommonGround, is ready to be evaluated in a feasibility randomized controlled trial.

Abstract Background: Mental health services are shifting towards person-centred care based on collaboration and shared decision making. Yet evidence indicates that these approaches may not be consistently embedded in the assessment and management of risk or safety. Methods: We conducted a cross-sectional online survey to examine perceived barriers and enablers to shared decision-making in risk assessment and management with people living with severe mental illness. Questionnaire development and data analysis were guided by the Theoretical Domains Framework, a psychological framework used to identify and understand factors influencing behaviour change. Items were rated on a 5 point Likert scale. In total, 243 service users and mental health professionals completed the survey. Results: Most service users reported that risk or safety had been discussed with them, but only half felt involved in the risk assessment or management process. Two thirds reported not receiving a copy of their risk assessment or management plan. Service users strongly agreed that communication with professionals about risk and safety requires improvement, and that risk is a difficult and emotive topic to discuss. Professionals reported high motivation to involve service users but identified time constraints and service user related factors as key barriers. Principal component analysis identified four components: (1) motivation; (2) social influences and memory/decision making; (3) beliefs about consequences; and (4) team, environment and training factors. More experienced professionals reported fewer negative beliefs about consequences, such as concerns about causing distress or disengagement. Conclusion: Findings highlight the need for clearer communication, organisational support and targeted training to enhance shared decision-making in risk assessment and management practices. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by the Wellcome Trust, and conducted as part of a PhD that was jointly funded by City, University of London, and East London NHS Foundation Trust (awarded to NA). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical committee of City, University of Londons School of Health Sciences gave ethical approval for this work I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript

Exposure to coercive practices in mental healthcare is associated with a range of patient harms. Clinical guidelines recommend that patients exposed to coercive practice in inpatient settings are offered support, however, existing post-coercive practice support models are often limited to debrief approaches, lack clear operationalisation, and have not integrated lived experience perspectives in their design. There remains a lack of clarity regarding the aims, optimal delivery approaches, core components and preferred personnel of such interventions. This consultation therefore aimed to determine areas of consensus and disagreement on the components and structure of a post-coercive practice support intervention for mental health inpatients. A consultation employing a three-round modified e-Delphi process was conducted with an expert panel of patients, family/carers, and mental health staff in the United Kingdom. Survey items comprised aims, delivery approaches, components and personnel for a patient post-coercive practice support intervention. In Round 1 experts rated importance of components; in Round 2 items were sequenced across three time points (immediate, intermediate and post-discharge); and in Round 3 the experts finalised a component checklist. Quantitative data were analysed descriptively, while qualitative data were analysed using reflexive thematic analysis. Consensus was defined a priori as agreement among ≥ 75

People living with long-term physical health conditions who are also experiencing subthreshold depression are at risk of developing major depression. In partnership with lived experience experts, clinicians, and software developers we co-designed CommonGround, an online peer support and psychoeducation platform. CommonGround’s Theory of Change (ToC) was also conceptualised that outlines the intermediate outcomes (and associated indicators of whether such outcome is achieved) needed to improve the mental health of the target population. This qualitative study, informed by the ToC, aimed to examine the acceptability, usability, and intervention mechanisms of CommonGround, ultimately aiming to refine the ToC and corresponding intervention design ahead of definitive evaluation. A nested qualitative study was conducted within a 12-week feasibility randomised controlled trial comparing CommonGround (intervention group) to signposting to NHS webpages (control group). Thirty-nine participants were interviewed about their experiences of CommonGround and trial participation. The interview schedule and thematic framework analysis were rooted in a pre-trial ToC whilst being responsive to emergent themes. Testing the assumptions and intermediate outcomes (via their indicators) refined our understanding of how CommonGround may support mental wellbeing. Overall, participants viewed CommonGround as an appropriate, safe space to access self-management information and support from others with unique shared understanding of chronic illness. However, many participants felt more time was needed for genuine social relations and community culture to evolve. Anonymity helped foster a sense of safety but, for some, limited the formation of genuine connections. Other factors contributing to low engagement included personal circumstances (e.g., limited time). Key suggestions for future development included creating a mobile application that would be easier and more intuitive to access and navigate. CommonGround was considered an acceptable and appropriate space to access peer support, with potential to positively impact psychological wellbeing by fostering shared understanding, support and knowledge exchange. Future evaluation should allow the community to operate for a longer period to enable genuine connections to form and to accommodate varying engagement needs. The refined ToC provides a foundation for the future evaluation of the clinical and cost-effectiveness of CommonGround within a definitive trial and accompanying process evaluation. ClinicalTrials.gov: NCT06222346 RR2-10.2196/71513

Abstract One-to-one peer support is widely used in mental health services, but the components associated with better outcomes remain unclear. We systematically reviewed randomised controlled trials and conducted additive component network meta-analyses to identify which components of one-to-one peer support worker interventions were associated with outcomes for adults using mental health services. CINAHL Ultimate, Embase, MEDLINE, PsycINFO, CENTRAL, ClinicalTrials.gov and ISRCTN were searched, supplemented by citation tracking, previous reviews and expert consultation. Interventions were coded for seven components: Training and development, Maintaining peer support worker wellbeing, Relationship-building, Social support, Emotional support, Practical support and Cultural adaptation. The review followed PRISMA-NMA reporting guidance and was registered with PROSPERO (CRD42022355291). Thirty-six trials randomised 6,645 participants across nine countries. Only quality of life and recovery yielded estimable component effects at one or more follow-up points. For quality of life, Practical support had a positive incremental estimate at 3 months (standardised mean difference 0.52, 95% confidence interval 0.17 to 0.87); no component showed clear evidence of benefit at 6 months; and at 12 months Social support had a positive estimate (1.57, 0.12 to 3.01), whereas Maintaining peer support worker wellbeing had a negative estimate (-1.66,-3.05 to-0.28). These estimates were not consistent across follow-up points. For recovery, Relationship-building had positive estimates at 6 months (0.90, 0.03 to 1.78) and 12 months (0.50, 0.29 to 0.72). Networks were sparse and often disconnected, and additivity could not be tested in disconnected networks. Current trials do not permit definitive prioritisation of peer-support components. Relationship-building was the most consistent candidate component, but all findings remain provisional. Future trials should prospectively specify, manipulate and measure component delivery.

Background Peer support roles in mental health services are significantly increasing in the United Kingdom and internationally. However, there is wide variation in these roles and limited research exploring the ways in which Peer Support Workers (PSWs) are currently working. We aimed to explore: 1) the values underpinning the PSW role; 2) the distinctive features of the work that PSWs' do; and 3) the perceived impact of the PSW role. Methods We conducted semi-structured qualitative interviews with paid mental health PSWs working across a range of settings. We took a co-produced, participatory approach: interviews were carried out by researchers with lived experience of mental health conditions and data were analysed using collaborative methods, guided by general principles of thematic analysis. Results We interviewed 35 PSWs. Overarching themes identified from iterative analysis included: 1) Underpinning values: (i) Recovery is possible: fostering hope, role-modelling and encouraging change, (ii) Mutuality: sharing lived experiences to bring empathy and build connection, (iii) Person-centred approach: adapting ways of working to the individual, (iv) Empowering instead of'fixing'service users. 2) Distinctive features:The centrality of an individualised approach, facilitating recovery through sharing lived experiences and building connection. PSWs advocated for service-user needs and most worked in non-clinical ways, offering holistic, recovery-orientated support. Tensions could arise with more clinical approaches. 3) Impacts: Participants thought that peer support helped service users feel understood, leading to greater openness and facilitating recovery, although some felt that it may not be right for everyone. The role had benefits for participants' own recovery, although its emotional demands could lead to burnout. Participants felt that PSWs could bring systemic improvements to services and use their lived experience to help teams meet service user needs. Conclusion PSWs work in a range of ways, but, a unifying feature is a flexible, person-centred approach, facilitating recovery through shared lived experience. A range of potential benefits of peer work were identified for PSWs and for service users, as well as reports of positive systemic change. These could be facilitated by recovery-orientated models in services, space for shared learning with PSWs, and flexibility to incorporate PSWs'unique ways of working. Clinical trial number Not applicable.

Patients with self-harm and suicidal ideation are increasingly presenting in emergency departments (ED) in the UK. Self-harm is the strongest risk factor for suicide. Currently, there are no evidence-based interventions for self-harm offered in the context of general hospitals in the UK. This trial, funded by the National Institute for Health and Care Excellence (NIHR), aims to assess the clinical and cost-effectiveness of the ASSURED intervention. The ASSURED intervention includes up to five rapid follow-up contacts, comprising a narrative interview and enhanced safety planning session and three solution-focused sessions. The trial is sponsored by Devon Partnership NHS Trust and City St George’s, University of London. ASSURED is a multicentre, two-arm, parallel-group, individually randomised, controlled trial comparing the ASSURED intervention with usual care. The primary outcome is whether study participants re-attend ED and are referred to liaison psychiatry within 18 months from the date of randomisation. Secondary outcomes include suicidality, self-reported self-harm, psychological wellbeing, social outcomes, experiences of attending the ED, and suicide. The study will also evaluate the cost-effectiveness of the intervention. The aim of this study was to recruit and randomise 620 patients across 14 acute hospital sites in London, Devon, Somerset, and the Midlands. Participants are invited to complete research assessments at baseline and 3, 9, and 18 months. The first participant was enrolled in the study in August 2022, and the recruitment target was met in December 2024. This will be the first UK trial to test the effectiveness and cost-effectiveness of a rapid intervention for patients presenting to EDs with self-harm and suicidal ideation and has the potential to improve outcomes for these patients. ISRCTN 13472559. Registered on 18 of November 2021.

BACKGROUND:Uniformed service personnel are routinely exposed to occupational trauma in their roles which contribute to elevated rates of mental health conditions. A wide range of mental health and wellbeing interventions may help uniformed service personnel manage their psychological responses to challenging incidents at work. Previous reviews of those interventions have focused on single groups of professionals or intervention types, limiting cross-sector insights. This review uses a mixed methods approach to synthesise evidence associated with mental health and wellbeing interventions across uniformed services. METHODS:The protocol was registered with PROSPERO (CRD42024605877). A mixed methods systematic review was conducted using the Joanna Briggs Institute (JBI) convergent segregated approach. Searches were conducted in Medline, CINAHL, Web of Science and PsycINFO (Dec 2024). Screening and quality appraisal (Mixed Methods Appraisal Tool) were performed independently by two reviewers. Due to heterogeneity, findings were narratively synthesised. Quantitative and qualitative results were integrated following the JBI approach. RESULTS:Eighty-six primary studies from 22 countries were included, covering a range of professions and intervention types. Synthesis of quantitative data from 82 studies showed that mindfulness-based training, resilience coaching, cognitive behavioural therapies and supported lifestyle activities demonstrated reduced symptoms of PTSD, anxiety and depression. However, interventions such as Critical Incident Stress Debriefing (CISD) and peer support yielded mixed results. Qualitative data from 9 studies were grouped into 5 categories: enhanced emotional insight, improved interpersonal relationships, perceived effectiveness, barriers to engagement and delivery challenges. Participants valued interventions that fostered self-awareness and support but cited stigma, guilt and logistical constraints as significant barriers. Integration of quantitative and qualitative findings revealed alignment in outcomes for several interventions, while highlighting evidence gaps, such as the lack of qualitative data for many interventions and limited exploration of cultural and organisational barriers. CONCLUSIONS:Mental health interventions for uniformed service personnel show promise but are influenced by delivery format, occupational culture and contextual factors. This review underscores the need for delivering interventions informed by ecological models, standardised outcome sets and deeper qualitative exploration into stigma and engagement barriers.

Emergency nurses are frequently the first point of contact for patients presenting to the emergency department (ED) with the symptoms of acute psychosis. Altered perception, fear and disorganised thinking can impair communication and precipitate distress, which may lead to agitation or aggressive behaviour, placing patients and staff at increased risk of harm. In these circumstances, verbal reasoning alone may be ineffective. Evidence indicates that non-verbal communication, such as body posture, eye-level alignment, proximity and tone of voice, can have a pivotal role in these situations by promoting calm and conveying safety, thereby preventing escalation to coercive or restrictive measures. Drawing on research and trauma-informed care principles, this article explores how emergency nurses can adapt Safewards interventions such as soft words, talk down and reassurance into effective non-verbal communication strategies in their practice. The authors provide guidance on embedding non-verbal de-escalation in routine ED nursing practice, highlighting approaches that are transferable to a wide range of mental health-related presentations and have the potential to improve safety, preserve dignity and strengthen therapeutic engagement in emergency care.

Background: Improving access to high-quality community-based crisis care and reducing inpatient admissions are key policy objectives in England, yet evidence on who uses crisis-related services and potential inequalities in access remains limited. Aims: To examine socio-demographic patterns in the use of six crisis-related services in England: 1) Crisis phonelines; 2) Crisis cafes; 3) Crisis Resolution and Home Treatment teams (CRHTs); 4) Voluntary inpatient admissions; 5) Compulsory inpatient admissions under the Mental Health Act 1983 (MHA); and 6) conveyance to a Place of Safety (PoS) by police under section 136 of the MHA. Method: We conducted a retrospective observational study using the Mental Health Services Data Set between 2021/22 and 2023/24. Adults (aged 18+) using any of the six services were included. A multinomial logit regression model was used to estimate the average marginal effects for age, sex, ethnicity, and area-level deprivation, with robust patient-level standard errors and year fixed-effects. Results: Within this population using any crisis-related services, adjusted analysis showed people from several ethnic minority backgrounds were more likely to be compulsorily detained or brought to a PoS by police, and less likely to use CRHTs than White individuals, with largest disparities in compulsory admissions for Black (+15.0 percentage points [pp]) and Asian (+7.3 pp) groups. Compulsory admissions were more common among older adults and men (+1.5 pp). Crisis phonelines were less commonly used by older adults, men (-4.8 pp), and people from Black (-15.6 pp) and Asian (-4.7 pp) backgrounds. Crisis cafes showed more even demographic distributions. Although adjusted differences by deprivation were small (all <1.0 pp), over half of all users lived in the two most deprived quintiles. Conclusions: Among crisis-related service users, demographic groups at greater risk of coercive care are less likely to access community crisis services. Addressing these disparities could improve access and reduce inequalities. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (grant no. NIHR206125). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in project design, data collection and analysis, or preparation of this paper. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Data Access Request Service (DARS) of NHS England waived the requirement for individual ethical approval for this work, as the analysis was conducted under a programme-level Data Sharing Agreement using pseudonymised data. The project uses pseudonymised secondary data, and results are reported at aggregated levels, with small numbers suppressed in line with NHS England guidance. The project does not involve direct contact with patients, and patients are not identifiable from the dataset. The data were subject to the NHS National Data Opt-Out, which was applied by the data provider. Analyses were conducted in secure environments in line with data sharing and confidentiality protocols. Individual service user consent was not required. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data supporting the findings of this study are available from NHS England. Restrictions apply to the availability of the following datasets that were used under licence for this study. This work uses data provided by patients and collected by the NHS as part of their care and support. The Mental Health Services Data Set is copyright 2021/22-2023/24, NHS England. Re-used with the permission of NHS England. All rights reserved.

People with mental health conditions frequently experience prolonged stays in the emergency department (ED) while awaiting specialist care or an inpatient bed. This article reports the findings of a service evaluation that explored the effectiveness of a daily 'huddle' between ED staff and the liaison psychiatric service (LPS) team in one ED in England in reducing length of stay for this patient population. The evaluation used a convergent mixed-methods design involving the collection and analysis of quantitative data on four key performance indicators (KPIs) (overall length of stay, time to psychiatric assessment, time to psychiatric referral and time to medical assessment) and qualitative data from a focus group discussion with staff. The findings suggest that ED staff should be provided with comprehensive training, including on de-escalation techniques and on recognising and understanding mental health issues, and that a cultural shift is required within EDs to achieve parity of esteem between mental health and physical health.

BackgroundOver 30% of people in the United Kingdom are living with a long-term physical health condition. Early preventative peer support interventions could improve the lives and psychosocial well-being of people with long-term physical health conditions and reduce progression of any symptoms of low mood to more significant depression. In partnership with people with long-term conditions and industry stakeholders, we have co-designed an online peer support platform, CommonGround, to help people with long-term health conditions connect, support others, share experiences, and receive evidence-based information and advice on self-management. ObjectiveThis feasibility randomized controlled trial will investigate whether the CommonGround platform is usable and acceptable for people with long-term physical health conditions experiencing mild depressive symptoms and whether conducting a future, larger confirmatory randomized controlled trial is feasible. MethodsA mixed methods, 2-arm, parallel-group, unblinded randomized controlled feasibility trial will be conducted nationally across the United Kingdom. Participants will include 150 adults (aged ≥18 years) who have access to the internet and are living with at least one long-term physical health condition and subthreshold depression (scoring 5-9 on the Patient Health Questionnaire–8). Following baseline assessments, eligible participants will be randomized to a coproduced online peer support and psychoeducation platform or a control condition where participants will receive fortnightly emails containing links to the National Health Service mental health web pages. Assessment measures will be collected at baseline and the midintervention (6 weeks) and postintervention (12 weeks) time points. A purposive sample of approximately 40 participants will be interviewed after the intervention to evaluate participant experiences and views on acceptability. The primary feasibility outcome is the number of participants recruited to the trial per week and in total via each recruitment route (as self-reported by participants). ResultsRecruitment for the feasibility trial began on February 12, 2024. Quantitative data collection was completed by October 23, 2024, and qualitative data collection was completed by December 3, 2024. ConclusionsThis trial will explore the acceptability and feasibility of our coproduced online peer support platform with embedded psychoeducational resources targeted for people living with long-term physical health conditions and subthreshold depression who are at risk of developing major depressive disorder. The findings will inform the future design of a larger randomized controlled trial exploring the platform’s clinical efficacy and cost-effectiveness. Trial RegistrationClinicalTrials.gov NCT06222346; https://clinicaltrials.gov/study/NCT06222346 International Registered Report Identifier (IRRID)DERR1-10.2196/71513

OBJECTIVES:Advance Choice Documents (ACDs) have been recommended for inclusion in new mental health legislation for England and Wales based on evidence they reduce compulsory psychiatric admission, with particular benefit for Black people. As Black people disproportionately experience compulsory psychiatric admission in the UK, our aim was to explore potential barriers and enablers to effective ACD implementation for Black people with previous experience of compulsory admission. METHODS:Six stakeholder workshops and one consensus workshop were held with: Black service users who had previously been involuntarily admitted, carers/supporters of Black service users, and mental health staff. Thematic analysis was conducted on workshop transcripts. RESULTS:Participants were service users (n = 13), carers/supporters (n = 7), service users and carers/supporters (n = 3), and staff (n = 18). Thematic analysis identified themes of 'training', 'completion', 'access', and 'use' concerning ACD implementation. Stakeholders highlighted the importance of understanding the racialised experience of Black service users for effective ACD implementation. Strong communication between and amongst stakeholders and helpful systems for access were also emphasised. Stakeholders also recommended joint training and independent facilitation of ACDs to address Black service user-staff power imbalances. CONCLUSIONS:Known enablers and barriers to ACD implementation are important when considering ACDs for Black people, as is explicitly engaging with their experiences holistically, including racialised historical and individual experiences that underline some treatment preferences. Independent facilitation and shifts in service user-staff power dynamics present as key to realising the potential of ACDs to empower Black service users in relation to their care, and in turn to potentially reduce coercive care.

Inpatient mental health care is an integral part of the continuum of mental health care in many countries, though it can be associated with challenges, such as reliance on coercive practices, negative patient experiences, and limited therapeutic options. Given these issues, there is a growing interest in exploring alternative approaches for individuals experiencing a mental health crisis. This research aimed to identify models which offer an alternative to standard inpatient mental health care across all age groups, both nationally and internationally, and to develop a typology for these alternative models. A dual literature search and expert consultation research methodology was adopted to identify relevant models. Three typologies of models were developed according to age group and acuity, including: alternatives to standard acute inpatient services for adults; alternatives to longer-stay inpatient services for adults, including rehabilitation and forensic inpatient services; and alternatives to standard inpatient services for children and young people. We identified an array of service models in each typology, some in community settings, some hospital-based and some working across settings. Models varied greatly in characteristics, extent of implementation and supporting evidence. Through this mapping exercise, we have developed three novel typologies of alternatives to standard inpatient care. A range of community-based, hospital-based and cross-setting approaches were identified. The identification of services providing inpatient care in a substantially different way to the standard suggests that some improvements could be provided within existing structures. Potential inequities in access to alternatives were identified for certain groups, such as people who are compulsorily detained, younger children, and young people transitioning between children’s and adults' services. These typologies can inform future description, evaluation and comparison of different service models. This research also yields some key considerations for the design, development and implementation of alternative mental health service models and service arrays.

Abstract Working in partnership with the service user is central to effective mental health nursing and a cornerstone to the recovery approach. This chapter outlines some of the skills and approaches that mental health nurses need to work in partnership and considers these across the various life stages. It also identifies some of the challenges that may be encountered when trying to implement these skills in the ‘real world’ of mental health services. It explores how collaborative working can help the service user draw on their knowledge and expertise and support them in making choices when working towards their recovery. The chapter highlights key policies and draws on research evidence and theories that support partnership working. Case studies and top tips are included to support learning.