BMC Psychiatry

ObjectivesCognitive behaviour therapy for psychosis (CBTp) should be delivered in psychiatric inpatient settings, yet little is known about therapists perspectives on delivering it. This study examined therapists perspectives on delivering a crisis-focused CBTp-informed (cCBTp) intervention. DesignThe study was part of the CRISIS (CRISis cbtp in Inpatient Settings) study, a feasibility randomised controlled trial of the cCBTp intervention for inpatients experiencing psychosis. A mixed methods approach combined therapy log data and qualitative interviews with therapists after the trial therapy was complete. MethodsSeven CRISIS study therapists completed a therapy log, which we analysed descriptively. Semi-structured interviews with six of these therapists explored their experiences with intervention training and delivery, which was analysed using thematic analysis. ResultsThe results from the therapy log demonstrated that therapists undertook a comprehensive assessment and prioritised engagement with all participants, and most developed a formulation, which informed change strategy delivery aligned with the patients goals. In the qualitative interviews, therapists emphasised the importance of delivering culturally competent flexible, person-centred therapy and supporting patients to work towards goals such as coping with the crisis and discharge planning. They described challenges of delivering therapy in the acute crisis context including interruptions to therapy sessions, patients experiencing acute symptoms, and environment restrictions. ConclusionsThe study demonstrated the importance of delivering cCBTp collaboratively and supporting patients in understanding and managing their own crisis. It also identified several challenges therapists had delivering the therapy. Further research is needed to explore therapists experiences of delivering psychological interventions in this setting. Practitioner Points1. Therapists must be flexible in their approach and remain adaptable with session timing, location and content to accommodate disruptions in inpatient settings, ensuring continuity of therapy despite high levels of distress and non-attendance. 2. A validating, therapeutic relationship is central to support patients with psychosis in crisis, enabling trust, safety and effective goal-directed work. 3. Therapists and patients collaboratively developing a crisis-focused formulation helps patients make sense of their current crisis, facilitates empowerment and enhances relapse prevention and discharge planning. 4. Therapist should actively explore and integrate patients cultural experiences including experiences of racism into therapy to help strengthen engagement and provide a holistic understanding of a patients experiences.

BackgroundRates of compulsory detention in psychiatric hospitals have risen over several decades in England and some other higher income countries. This study explores clinicians perspectives on how service users come to be compulsorily detained in psychiatric hospitals and their suggestions for reducing these detentions in the future. MethodsSemi-structured qualitative interviews were conducted with 23 clinicians working with individuals who have been compulsorily detained under the Mental Health Act in England. Interviews were carried out by telephone or videoconference. Data were analysed using template analysis. ResultsThree major themes were identified, with multiple sub-themes (a) service user factors that increase risk of compulsory detention, including high levels of risk, previous/underlying trauma, medication non-adherence, service user perceptions of their mental health state, disadvantage and discrimination, and lack of stability and involvement from family and social networks; (b) service-level reasons for being detained, including lack of communication and continuity of care, historical inability to obtain trust and confidence from parts of population, clinician biases and assumptions, lack of resources, lack of treatment and care variety, and systemic/institutional barriers to engagement; and (c) ways to improve services to reduce compulsory detainment, including increasing quality of care and patient/family level interventions, investing in services, offer choice regarding medication, offer alternatives to compulsory detention, and improve discharge planning. ConclusionsFindings suggested clinicians see that at least some compulsory hospital admissions as avoidable, particularly through better resourced and more accessible services and changes in staff attitudes to address unconscious biases and promote collaborative care. Our findings provide a range of potential means to reduce detentions, which warrant development and testing in research and practice.

BackgroundThe elimination of seclusion and restraint, that is, restrictive practices, is a major aim of mental health services globally. The role of art therapy, a predominantly non-verbal mode of creative expression, is under-explored in this context. AimsTo determine whether art therapy service provision was associated with a reduction in restrictive practices on an acute inpatient child and adolescent mental health services (CAMHS) unit. MethodsThe rate (events per 1,000 occupied bed days), frequency (percent of admitted care episodes with incident), duration, and total number of incidents of restrictive practices occurring between July 2015 - December 2021 were analysed in an ABAB design. The rate, frequency and number of incidents of intramuscular injected (IM) sedation, oral PRN (as-needed medication) use, and absconding incidents occurring in conjunction with an episode of seclusion or restraint were also analysed. ResultsThe rate, frequency, duration, and total number of incidents of seclusion, the frequency and total number of incidents of physical restraint, and the rate, frequency and total number of incidents of IM sedation showed a statistically significant decrease during phases of art therapy service provision. ConclusionsArt therapy service provision is associated with reduced use of restrictive practices in inpatient CAMHS.

BackgroundConsultation-Liaison Psychiatry (CLP) services are essential for addressing the psychiatric needs of patients with complex medical conditions in general hospitals. AimsThe study aims to characterize profiles of inpatient psychiatry referrals and assess trends and correlations between referrals, patient demographics, and psychiatric and somatic diagnoses. MethodData from January 2020 to December 2023 were collected from a CLP service during and after the pandemic, using psychiatric diagnoses from the International Classification of Diseases, Tenth Revision (ICD-10). Statistical analyses, including interrupted time series analysis with four periods, and including linear and segmented analyses, plus selective use of autocorrelation tests, were conducted to examine referral patterns and their associations with socio-demographic factors. Results6,105 patients were referred to the CLP Service during the study period, which was 6.73% of all hospital admissions. Medicine and Pneumology exhibited consistently high referrals, while services like Rheumatology and Endocrinology had lower rates. Common somatic diagnoses included neoplasms (20.7%) and respiratory diseases (9.4%), while neurotic, stress-related, and somatoform disorders were prevalent psychiatric diagnoses (42.5%). Interrupted time series analysis revealed fluctuations in monthly care visits, with notable decreases coinciding with the onset of the COVID-19 pandemic. ConclusionsOur study elucidated the characteristics of patients receiving CLP services at a major Peruvian general hospital, revealing depression as a prevalent reason for consultation, and highlighting the dynamic nature of psychiatric care delivery, especially amidst the COVID-19 pandemic.

Autistic adults are disproportionately affected by mental health conditions yet face significant barriers in accessing support and receiving suitable care. To understand this disparity better, using qualitative methods, we investigated the experiences of autistic adults in accessing and receiving mental health care and their priorities for improvement. Thirteen autistic adults with experience of mental health services in England were purposively selected to participate in semi-structured interviews. Reflexive thematic analysis principles guided the analysis of interview transcripts. Participants felt that an understanding of autism was key for professionals to provide effective support, and reported this was often lacking, resulting in insufficient recognition for their autism-specific needs, feelings of neglect and inadequate treatment. Inconsistent services, including varying appointments and unfamiliar professionals exacerbated anxiety and hindered treatment benefits. A recurring theme of validation emerged as participants expressed a shared sense of not being believed or taken seriously within the context of mental health support. In terms of priorities for improving services, adaptability was a central focus, while better understanding and addressing the specific needs of autistic people was considered crucial. Participants - females in particular - emphasised the need for professionals to adopt more effective communication strategies as they felt that poor communication and misunderstandings often delayed autism diagnoses. To enhance mental health support for autistic adults and mitigate negative outcomes, increasing mental health professionals understanding of autism is vital. Further research is needed to understand the manifestations and risk factors of mental health conditions in autistic adults. Participants stressed that autistic people need to be directly involved in driving these priorities and guiding the enhancement and adaptation of mental health care to meet their needs.

PurposeTo explore key stakeholders from rural communities perspectives of help-seeking for mental health difficulties. Methods/designSemi-structured interviews and a focus group were conducted with participants living in the East of England, UK. Thematic analysis was used to organise and analyse the data. ResultsNine participants were recruited. Participants described barriers and facilitators of help-seeking. Barriers included: lengthy waiting times, socioeconomic means, poor therapeutic relationships, insufficient treatment duration, poor transition between services, high staff turnover, and limited investment. Facilitators included: family involvement/support, school nurses, shorter delays in accessing specialist services such as eating disorder services, and the offer of family therapy. Suggestions for improving future help-seeking and pathways to care, included: peer-support for young people, enhanced support for carers, early intervention and raising awareness of mental health. OriginalityOur qualitative approach meant we were able to explore in detail the existence and mechanisms underlying varied barriers and facilitators of care pathways amongst our sample. This allowed us to report rich findings and recommendations for clinical practice and future research work. Practical implicationsTraining young people to support other young people, and identifying mental health champions in rural communities could reduce distress and ameliorate pressures on the health service.

First-hand experience with psychedelics may help clinicians develop skills and knowledge needed to work with the profound changes to conscious awareness occasioned by psychedelics. However, the topic remains contentious and underexplored. In this world-first study, we investigated the utility of psilocybin experiential therapist training in a sample of 14 mental healthcare professionals training to provide psilocybin-assisted therapy. Participants received one 25 mg dose of psilocybin in a clinical research context alongside psychological support before, during, and after dosing. Quantitative measures and semi-structured interviews were then undertaken by participants to explore their experiences and reflections. Through the intervention, participants reported developing a greater and embodied understanding of key therapeutic principles and processes. Moreover, they reported increases in therapeutic qualities (e.g., empathy, attunement, emotion regulation) that underpin therapeutic alliance and promote trust and safety. While participants did not report experiencing harms from participation, they speculated about two potential risks of psychedelic experiential therapist training: first, that it could elicit challenging material that feels destabilising for a period; and second, that therapists could project their experience onto clients in a manner that narrows interpretative range and reduces attunement. Recommendations were made for psychedelic experiential therapist training design and implementation, including strategies to mitigate such risks. Participants indicated that psychedelic experiential therapist training is necessary but not sufficient for providing the highest quality of care in psychedelic-assisted therapy. Findings support the inclusion of an optional psychedelic experiential component within psychedelic therapist training programs for clinicians with prior psychotherapeutic training and well-developed reflective capacity.

ObjectivesApproximately 10% of people with intellectual disability display aggressive challenging behaviour, usually due to unmet needs. There are a variety of interventions available, yet a scarcity of understanding about what mechanisms contribute to successful interventions. We explored how complex interventions for aggressive challenging behaviour work in practice and what works for whom by developing programme theories through contexts-mechanism-outcome (CMO) configurations. MethodsThis review followed modified rapid realist review methodology and RAMESES-II standards. Eligible papers reported on a range of population groups (intellectual disability, mental health, dementia, young people and adults) and settings (community and inpatient) to broaden the scope and available data for review. ResultsFive databases and grey literature were searched and a total of 59 studies were included. We developed three overarching domains comprising of 11 CMOs; 1. Working with the person displaying aggressive challenging behaviour, 2. Relationships and team focused approaches and 3. Sustaining and embedding facilitating factors at team and systems levels. Mechanisms underlying the successful application of interventions included improving understanding, addressing unmet need, developing positive skills, enhancing carer compassion and boosting staff self-efficacy and motivation. ConclusionThe review emphasises how interventions for aggressive challenging behaviour should be personalised and tailored to suit individual needs. Effective communication and trusting relationships between service users, carers, professionals, and within staff teams is essential to facilitate effective intervention delivery. Carer inclusion and service level buy-in supports the attainment of desired outcomes. Implications for policy, clinical practice and future directions are discussed. Prospero Registration NumberCRD42020203055.

Autistic psychiatrists occupy a paradoxical position: trained to recognise and assess autism in others, yet navigating a professional culture in which their own autistic identity remains largely concealed. Despite growing visibility of autistic clinicians, the barriers autistic psychiatrists face to formal diagnosis and professional disclosure remain unexplored. This study used interpretive phenomenological analysis to examine the experiences of seven autistic psychiatrists in relation to diagnosis and disclosure. Data were generated through in-depth interviews and Retzinger's framework for identifying shame in discourse was applied as an analytical tool within the interpretive process. Shame emerged as the overarching theme across the dataset, operating through four group experiential themes. Its origins lay in childhood experiences of difference and perceived defectiveness, transmitted through family, peers, and the broader social environment. In professional life, shame was sustained and amplified by colleagues' misconceptions about autism, anticipated loss of credibility, and the deficit-based diagnostic criteria - which rendered self-recognition difficult and made formal diagnosis a perceived professional liability. Critically, shame did not only create barriers: it functioned as an override mechanism, rendering the known benefits of disclosure - to participants themselves, to colleagues, and to patients - insufficient to translate into action. This override function was not explained by fear of discrimination or rational career protection alone; it reflected shame's operation as an internal prohibition, dissociated from its original social source and persisting even where stigma had been intellectually processed and rejected. These findings reposition shame not as one barrier among many but as the organising force through which all barriers operate. Interventions aimed at increasing disclosure by raising awareness of its benefits misread the operative mechanism. Creating conditions in which autistic psychiatrists can make decisions about their identities freely requires naming and addressing shame - in research, in clinical training, and in the culture of psychiatry.

Romantic/intimate relationships are an important part of most peoples lives, including people with mental health problems. However, people with mental health problems continue to have little access to support around romantic/intimate relationships. This study aimed to investigate social care staff perspectives on supporting people with romantic/intimate relationships. We conducted 15 qualitative interviews with mental health social care staff to explore their views on supporting people using services with desired romantic/intimate relationships, facilitators and barriers to these conversations, and strategies to offer support in this area. We purposively recruited staff working in a range of social care roles and with varied demographic characteristics. Interviews were analysed using reflexive thematic analysis. We identified three primary themes. These related to (i) whether romantic/intimate relationship support should be offered; (ii) how romantic/intimate relationship support should be offered; and (iii) whether social care staff are the right people to offer this support. Overall, participants felt that romantic/intimate relationship support is important for the quality of life of people accessing services. However, they noted a lack of resources and training relating to romantic/intimate relationship support, and discussed some safeguarding concerns. Findings highlight the need for clear organisational policy and training to address staff concerns, and research to understand the perspectives of people using services on romantic/intimate relationship support. Teaser TextMost people value romantic/intimate relationships in their lives, including people who use mental health services. While people with mental health issues often report that they want support with relationships, they often do not have access to it. This study sought to understand why, by interviewing 15 mental health social care staff about their views on providing support around romantic/intimate relationships to people who use social care services. Staff generally agreed that relationship support is important for helping those who use mental health services to feel empowered and improve their quality of life. However, they expressed concerns about a lack of resources and training available to help them offer romantic/intimate relationship support. They also discussed ethical worries, including wanting to protect vulnerable people and what to do when working with people who have an offending history. Accordingly, organisations should develop clear policies and practical training to help staff gain skills and confidence in providing this support. There is also a need for future research to find out more about what service users themselves want and need in this area.

BackgroundEarly access to services is essential for those suffering a psychotic illness or at risk for the condition. Lack of knowledge of services and public stigma are major barriers to care and are associated with increased duration of untreated psychosis and delays in those at clinical high-risk for psychosis (CHR-P) from accessing support. Education and contact programmes have shown promise in reducing stigmatizing views, however, few have been co-produced and delivered by service users and clinical staff. A three-hour co-produced educational workshop was developed and delivered by service users and Outreach and Support in South London (OASIS) staff. The aim was to assess the feasibility of delivering a co-produced workshop to youth community workers, to see if it improved knowledge of psychosis, attitudes to mental health services and reduced stigma towards people with psychosis as well as seeing if the workshop increased community referrals to OASIS. MethodEducational workshops were developed by community stakeholders and service users. Pre- and post-workshop questionnaires assessed knowledge of psychosis, attitudes towards mental health teams and stigma towards individuals with a psychotic disorder. Participants and service users views on the workshop were explored through two focus groups. Results9 workshops were delivered to 75 community participants. Following the workshop participants questionnaire scores showed improvements in knowledge of psychosis, improved attitudes towards mental health teams and a reduction in stigmatizing views towards people with psychosis. The workshop was overwhelmingly well received with 97% agreeing with the statement that they learnt something valuable from the workshop. Referrals to the OASIS service increased by 22% following the workshops. ConclusionThe co-produced educational workshop designed and delivered by service users and OASIS staff was successful in improving participants knowledge, attitudes and reducing stigma. We observed an increase in the rate of referrals to the OASIS service, although it is difficult to whether this was due to the workshops or to other outreach activities. Future research should examine whether these effects are long-lasting and explore online delivered workshops to reach more participants in the wider community.

Background Autistic people experience disproportionately high rates of co-occurring mental illness and suicide, yet mental healthcare services routinely fail to meet their needs. Patients unrecognised as autistic are at risk of ineffective or harmful treatment. Autistic psychiatrists occupy a unique position: as members of both medical and autistic communities, they offer dual insider perspectives that may directly shape patient outcomes. Despite being the second largest specialty group in Autistic Doctors International (ADI), this workforce remains largely unrecognised and underutilised. This study examines autistic psychiatrists' perspectives on mental healthcare for autistic people. Methods Loosely structured interviews were conducted with seven senior autistic psychiatrists across child and adolescent, adult, and liaison psychiatry, recruited from a psychiatry-specific subgroup of ADI. Data were analysed using reflexive thematic analysis: codes related to patient care and mental health services were extracted and analysed as a focused subset. Outcomes Nine themes were identified: autistic-to-autistic therapeutic rapport; benefit of recognition and diagnosis; early recognition and education as preventive factors; iatrogenic harm from non-recognition and systemic pathways to misdiagnosis; knowledge gaps and stereotypes; inaccessible services; resource constraints and diagnostic thresholds; autistic psychiatrists as an underutilised resource; and pathways to change. Interpretation Autistic psychiatrists' dual insider positionality affords a unique and under-acknowledged vantage point on what autistic patients experience and where mental healthcare fails them. The mental health burden autistic people carry is substantially shaped by systems not designed for them. Embedding neurodiversity-affirmative practice, closing training gaps, reforming diagnostic pathways, and recognising autistic psychiatrists as a clinical and epistemic resource offer a coherent pathway to improving mental health outcomes for autistic people.

BackgroundThe Offender Personality Disorder (OPD) Pathway, a joint health and criminal justice initiative across England and Wales, aims to support rehabilitation of individuals with a likely diagnosis of personality disorder. Pathways Enhanced Resettlement Services (PERS) is an OPD service currently operating in five open prisons in England, which aims to support people at high risk of being returned to closed conditions or reoffending in the community after release. We aimed to understand service user and staff experiences of PERS. MethodsWe conducted semi-structured interviews with ten staff and nine service users. We then conducted a reflexive thematic analysis generating three themes. ResultsThe three themes identified were: (1) "A shock to the system", describing the challenges for service users posed by the liminal space of open prison (between higher security conditions and the community); and how in this context PERS might be viewed with suspicion but was for interviewees ultimately a space where they felt valued. (2) "Weve got some understanding of their journey"; staff and service users described PERS staff developing more trusting relationships with service users than non-PERS staff, where service users felt understood and supported, practically and emotionally; and (3) "internal states can be real barriers to progression"; PERS staff supported service users to understand and overcome barriers, through enabling self-reflection, and tailoring support to times of greater stress, including key milestones such as parole boards or periods of trial leave. ConclusionsStaff and service users feel PERS provides support to progress through open prison, through development of positive trusting relationships and individualised support in a challenging context where such support was not otherwise available.

It is estimated that one in four people will experience poor mental health throughout their lifetime. However, ethnic minority groups, refugees and asylum seekers experience more barriers accessing mental health services and have poorer mental health outcomes than those from non-ethnic minority groups. Evidence suggests that interventions that improve access and engagement with mental health services may help reduce disparities affecting ethnic minority groups. This review aims to assess the effectiveness of interventions that enhance equitable or overall access to mental health services by ethnic minority groups. The review included evidence available up until 19th December 2023. Psycho-educational interventions that focused on providing culturally appropriate information, showed mixed results for help seeking behaviour, improvements in depressions stigma. Multi-component interventions within healthcare settings had mixed results. Some studies showed positive outcomes; such as increased help seeking intentions and improved attendance rates, while others did not show significant differences in outcomes. Interventions that included integrating specialist mental health services within primary care resulted in variable outcomes. The findings of interventions incorporating language support into mental health services were also variable. The effectiveness of interventions to enhance the cultural competency of mental health services varied across studies.

AimsEnsuring a successful transition to Adult Mental Health Services (AMHS) is fundamental for ADHD patients to prevent adverse scenarios in adults (e.g., psychiatric disorders, substance or alcohol abuse). Yet, most European nations do not have appropriate transition guidelines. This study aims to enquire about the current transition paths in Italy and the perceived experiences of the patients and their clinicians. MethodsThe present qualitative, observational study collected 36 interviews with young adults with ADHD who turned 18 between 2017 and 2021. Simultaneously, two questionnaires were filled in by the clinicians (both from pediatric and adult mental health services) who were involved in their transition paths. These tools collected information about the transition process, the services that cared for the young adults, and well-being indicators such as impairment in daily life, employment status, and the presence of sentinel events (e.g., critical stage accesses to the emergency room or hospitalizations). Successful and failed referrals were analyzed. ResultsA referral to an AMHS was attempted for sixteen young adults (8 before age 18 and 8 when turning 18), and 8 patients (22.2% overall) were successfully taken into the care of the AMHS. Twenty patients were not referred since it was deemed unnecessary (N=6) or because of the lack of specialized services or compliance (N=14). At the time of the interview, only nine participants were still under AMHS care. Of eleven individuals with a high need for care (identified by the level of impairment, support needs, or sentinel events), five were not followed by a mental health professional at the time of the interview. ConclusionsFor the majority of ADHD young adults, a transition path was never started or completed. While this is partly due to mild levels of impairment, in many cases it was difficult to find a service that could care for the adult patient. Only 1 out of 4 young adults are successfully transferred to AMHS care. Creating or improving evidence-based transition guidelines should be a priority of the public health system to ensure healthcare for as many patients as possible. The results of this study will converge towards the need for recommendations for the transition of services from adolescence to adulthood for young people with ADHD for Italian clinical practice.

Dialectical Behavioural Therapy for Adolescents (DBT-A) is an effective treatment for adolescents exhibiting features of borderline personality disorder (BPD). However, some do not benefit, potentially leading to major negative outcomes later in life. Previous quantitative studies have highlighted the importance of dynamic (changeable) factors in determining treatment success, including the therapeutic alliance, emotional dynamics between therapist and adolescent, and the motivation of those involved. Nevertheless, the specific contribution of these factors to the therapeutic process and perceived treatment success remains unclear. This study protocol outlines a multicenter, qualitative longitudinal study designed to explore how dynamic factors in DBT-A are experienced by adolescents, parents, and therapists at various stages of therapy. The study will track treatment journeys (trajectories) of fifteen youth during DBT-A therapy across four child and adolescent psychiatry institutions in the Netherlands. The triad of adolescent, parent(s), and therapist will be interviewed separately at four time points during treatment: at the start and after three, six, and nine months (resulting in 180 interviews in total). The semi-structured interviews, based on a theoretical framework, will be analyzed using reflexive thematic analysis, employing a combination of deductive framework analysis and inductive open coding methods. By bringing together the triad of perspectives, and monitoring how these perspectives evolve over time, this study will yield valuable, practice-based insights into how dynamic factors unfold during DBT-A. Insights from this study will offer therapists specific, actionable guidance for modifying dynamic factors to better address the unique needs of adolescents with BPD features.

British Columbias Mental Health Act permits the involuntarily detention and treatment of individuals who meet specific criteria. Over the past 15 years, British Columbia has seen an increasing trend in the number of involuntary psychiatric admissions. This qualitative study explores the lived experiences of people receiving and providing involuntary psychiatric treatment within two health organizations in British Columbia, Canada. Five focus groups were conducted with 23 individuals who had previously received involuntary psychiatric treatment at a facility operated by one of the two health organizations. All sessions were facilitated by individuals with lived experience of involuntary psychiatric treatment. Additionally, semi-structured interviews were conducted with 11 clinical staff and 10 non-clinical support personnel involved in delivering involuntary psychiatric treatment. Data were analyzed using a thematic approach. Seven key themes were generated, including the limited availability of voluntary care options, the compounding role of social determinants of health in mental health crises, the lack of conclusive evidence supporting involuntary psychiatric treatment, the negative impacts on both patients and providers, and the critical role of peer support. These findings underscore the need for systemic reform to reduce reliance on coercive practices and to expand access to voluntary, community-based mental health supports that address underlying social and structural factors contributing to mental health crises.

There is an urgent need for services to address the social and economic adversities which contribute to the aetiology and outcomes of mental health problems. However, the implementation of interventions to do so is inconsistent, and entrenched cycles of poor mental health and social exclusion persist. We conducted a service evaluation survey of 28 staff working across community and inpatient teams, enhanced by a series of in-depth case studies, in the largest NHS mental health trust in the UK to explore how social and economic needs are currently assessed and addressed. We found that assessment for social and economic needs varied across different domains; for example, family relationships were more consistently assessed than domains such as education and income. A range of support is available and provided by a patchwork of teams, including Community Mental Health Teams, other NHS teams, Local Authority staff, and many third sector organisations. However, what support is available is severely restricted and respondents highlighted a lack of adequate support in every domain we considered - employment, education and training, social participation and connectedness, family relationships, community support, social security, debt, income, housing, and trauma and victimisation, as well as additional domains including healthy eating, sex and relationships, and activities of daily living. Nevertheless, our case studies illustrate examples of approaches to addressing social and economic needs to improve outcomes for people with mental health problems.

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.

Background: While growing enthusiasm for the therapeutic potential of classic psychedelics has led to a rise in non-clinical use, attention to persisting adverse effects has emerged with delay. A subset of individuals reports persisting complications such as hallucinogen persisting perception disorder (HPPD), depersonalization/derealization disorder (DDD), anxiety and depression. Yet few medical services are equipped to address these complications. Aims: This qualitative study examines how societal, medical, and media discourses shape the experiences of individuals with persisting psychedelic-related complications, focusing on help-seeking trajectories. Methods: Thirteen semi-structured interviews with adults experiencing persisting psychedelic-related psychological symptoms (four women, nine men, age 19-49 years; HPPD (n = 10), DDD (n = 6), depression (n = 1), and anxiety (n = 1)) were conducted within a larger study on these complications. Data were analysed using reflexive thematic analysis. Reporting followed the COREQ guidelines. Results: Three interrelated themes emerged: (1) The dissonance between expectation and harm - idealised media and scientific portrayals of psychedelics shaped initial use and complicated recognition of adverse outcomes; (2) Stigma, silence, and self-blame - prohibitionist discourse and internalised shame significantly inhibited help-seeking; and (3) Between systemic absence and self-organised support - participants encountered clinical unpreparedness and epistemic dismissal, which often led them to rely on online peer communities and self-management strategies. Positive clinical encounters, characterised by professional expertise and nonjudgmental engagement, were experienced as helpful. Conclusions: Adequate clinical and conceptual frameworks for persisting psychedelic-related complications are lacking. An interdisciplinary, experience-informed approach integrating realistic risk communication, clinician training, and destigmatisation is required to support affected individuals.