Social Psychiatry and Psychiatric Epidemiology

The COVID-19 pandemic caused major disruptions to everyday life for children and young people. The aim of this study was to examine professionals views on the mental health problems and vulnerabilities of children and young people during the early phase of the COVID-19 pandemic. We conducted a secondary analysis of an online survey completed by mental health professionals in the UK between 22 April 2020 and 12 May 2020. The final sample was N = 601 professionals who at least partly worked with children and young people. Quantitative and qualitative survey data showed that professionals were concerned about young people experiencing economic disadvantage and young people from minority ethnic groups, as pre-existing social inequalities resulted in increased risk of infection and reduced access to physical and mental health care. Professionals were concerned about young people with little family support and young people at risk of relapse or deterioration in mental health, reporting the exacerbation of pre-existing mental health difficulties and challenging behaviours. Further research, involving young people as researchers, is needed to explore the continued impact for children and young people, and their families, including in comparison to their experiences before the pandemic.

BackgroundYouth is a period of elevated risk for mental ill health, yet young people often do not receive timely support. Barriers can include high clinical thresholds for treatment and long waiting lists, as overstretched statutory services can struggle to meet high demand. The Early Support Hubs available in some parts of England are a potentially promising model to increase access to support. These are community-based services offering open-access, holistic support for 11-25-year-olds without a referral. However, there is no standardised model and considerable variation in the support offered, highlighting the need for research to explore how Early Support Hubs operate, whether they are meeting the mental health and wellbeing needs of young people, and potential areas for improvement. AimsTo explore young peoples experiences of using Early Support Hubs for mental health or wellbeing support, and their views on best practice within these services. MethodsWe conducted semi-structured interviews with 20 young people aged 16-25 years, who had used Early Support Hub services across England. Data were analysed using codebook thematic analysis. ResultsAspects of hubs that were valued by young people included: easy accessibility; holistic approaches which go beyond clinical interventions; a sense of community, friendship and consistency; and youth-led philosophies. Limitations of the hub model included them being little known in local areas, lack of capacity to address more acute and complex mental health needs, and the limited scale of the services. ConclusionEarly Support Hubs appear to be valued by young people and have potential to be an adjunct to clinical services to help increase access to mental health support for young people. Evidence on populations served, what support they receive, and outcomes following support are needed to assess whether there is a policy case for wider roll out.

PurposePeople living with mental ill-health experience social and economic disadvantages, which contribute to poor outcomes and limit effectiveness of treatments. Interventions to improve social and economic circumstances have been developed, however, little is known about whether these interventions are effective for the most marginalised and disadvantaged groups, and those most in need of support. MethodWe conducted a systematic review in line with a pre-defined protocol to identify interventions to improve the social and economic circumstances of people experiencing mental ill-health. We included relevant records from two previous systematic reviews and updated their searches across four databases. We synthesised the intervention domains and locations of research, participant characteristics, and if effectiveness varied by participant gender, socioeconomic position, and race or ethnicity, and related indicators. ResultsWe identified 266 relevant studies across 34 countries. Certain intervention domains were better researched than others (e.g. housing and employment vs. debt and social security advice). Participant characteristics were poorly reported and so understanding related to inclusiveness and generalisability of research is limited. Only 8% of papers reported any stratified results and statistical reporting standards were poor, limiting our ability to determine what works for whom. There was some indication that interventions are less effective for those in lower socioeconomic groups. ConclusionImproved reporting and representation of marginalised groups, stratified analyses of intervention data, and replication of results is needed to confidently draw conclusions about what works for whom in this field.

BackgroundMost people seek to establish romantic or intimate relationships in life, including people with mental health problems. However, this has been a neglected topic in mental health practice and research. This study aimed to investigate views of mental health and social care staff about the appropriateness of helping service users with romantic relationships, barriers to doing this, and suggestions for useful ways to support this. MethodsAn online survey comprising both closed, multiple response and free-text questions was circulated to mental health organisations across the U.K. via social media, professional networks and use of snowballing sampling. A total of 63 responses were received. Quantitative data were analysed using descriptive statistics, and are reported as frequencies and percentages. Qualitative data were interpreted using thematic analysis, using an inductive approach. ResultsAlthough most participants reported that finding a relationship conversations were appropriate in their job role, many barriers to supporting service users were identified, including: a lack of training; concerns about professional boundaries; concerns about service user capacity and vulnerability; and concerns about being intrusive. Participant suggestions for future support included educating service users on safe dating behaviours, and practical interventions such as assisting service users to use dating sites and engage with social activities to develop social skills and meet others. ConclusionsStaff were willing to help service users seek an intimate relationship but may need specific training or guidance to facilitate this confidently and safely. This study elucidates the need for further research in this area, particularly in understanding service user perspectives, and in developing resources to support staff in this work.

BackgroundDepressive and anxiety disorders are the most common mental health conditions. In the United Kingdom (UK), NHS Talking Therapies for anxiety and depression (TTad) has provided evidence-based interventions for these conditions since 2008, although treatment outcomes are often suboptimal. Loneliness, consistently linked with poorer mental health outcomes, remains unexplored in this context. We investigated the views of NHS TTad therapists about the nature and origins of loneliness amongst their clients. MethodsWe conducted semi-structured qualitative interviews with 19 NHS TTad therapists, purposively sampled across job roles, experience levels, and service locations. Recruitment was via professional networks and online platforms. Interviews were conducted online, and data were analysed using thematic analysis with both inductive and deductive approaches. FindingsFour key themes emerged from analysis: (1) Life-transitions, (2) Mental health conditions, (3) Barriers to connection, (4) Stigma. NHS TTad therapists described loneliness experienced amongst their clients as arising from both external factors (e.g., relocation, financial difficulties) and internal psychological processes (e.g., low self-esteem, mental health conditions). Therapists believed that loneliness was experienced even when clients had social contacts, due to barriers like cultural differences and mental health symptoms. Therapists also observed some demographic variability in the experience of loneliness amongst clients (e.g., across age, gender, mental health diagnosis). Societal factors including stigma surrounding mental health and loneliness were viewed as further contributing to clients loneliness experiences and help-seeking behaviours. ConclusionsNHS TTad therapists perceived loneliness as a common experience amongst their clients, linked to life transitions, mental health symptoms, structural, cultural, and psychological barriers to connection. These findings highlighted the importance of recognising loneliness as a relevant factor in therapy and of developing strategies to identify and address it within, or outside of NHS TTad services. Future research should also examine the impact of social media, gender, and public stigma on loneliness. Addressing these factors at societal and policy levels is essential to reduce stigma and improve support for individuals experiencing loneliness.

BackgroundThe rates of compulsory admission and treatment (CAT) are rising in mental health systems in the UK. These disparities are reported among migrants and black and ethnic minorities in Europe and North America. Lived experience perspectives from marginalised and multiple disadvantaged people are neglected in research yet may offer vital and novel insights into preventive opportunities to reduce coercive care MethodsWe conducted a participatory photovoice research process to assemble the life- experiences of people within two years of receiving CAT. We purposively sampled to maximise diversity by age, ethnicity, and different sections of the Mental Health Act (England & Wales, 1983, 2007) from 8 health systems in England. The images, captions, and reflective narratives were deepened over 3 workshops before thematic analysis. OutcomesForty-eight ethnically diverse people with lived experience of CAT contributed over 500 images and 30 hours of transcribed narratives. Participants lives showed significant complexity in terms of multimorbidity, adverse childhood experiences, and carer roles. The findings suggest insufficient co-ordination to prevent CAT despite early help-seeking, not being taken seriously when seeking help, hostility and dismissive responses from professionals; unnecessary police involvement which was distressing, stigmatising, and risked criminalisation. Participants wanted more advocacy given their vulnerability and inability to process information in crisis, as well as therapeutic and creative activities in inpatient environments. Participants recommended more family and carer involvement, and more appropriate, frequent and personalised information about care options, appeals processes, levels of restriction, and seclusion. A major concern was the lack of highly skilled staff, trauma-informed care, and therapies into the community. InterpretationWe showed epistemic injustice in care processes and recommend better standards for essential skills, prevention, trauma informed care and therapies. Criminalising and coercive responses must also be reduced. FundingThis study/project is funded by the National Institute for Health Research (NIHR) Policy Research Programme [NIHR201704]. The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care

BackgroundThe COVID-19 pandemic increased psychiatric distress and impacts differed by family structure. We aimed to identify mechanisms contributing to these inequalities. MethodsSurvey data were from the UK Household Longitudinal Study. Psychiatric distress (GHQ-12) was measured in April 2020 (first UK lockdown; n=10,516), and January 2021 (lockdown re-introduced following eased restrictions; n=6,893). Pre-lockdown family structure comprised partner status and presence of children (<16 years). Mediating mechanisms included: active employment, financial strain, childcare/home-schooling, caring, and loneliness. Monte Carlo g-computation simulations were used to adjust for confounding and estimate total effects and decompositions into: controlled direct effects (effects if the mediator was absent), and portions eliminated (PE; representing differential exposure and vulnerability to the mediator). ResultsIn January 2021, after adjustment, we estimated increased risk of distress among couples with children compared to couples with no children (RR: 1.48; 95% CI: 1.15-1.82), largely because of childcare/home-schooling (PE RR: 1.32; 95% CI: 1.00-1.64). Single respondents without children also had increased risk of distress compared to couples with no children (RR: 1.55; 95% CI: 1.27-1.83), and the largest PE was for loneliness (RR: 1.16; 95% CI: 1.05-1.27), though financial strain contributed (RR: 1.05; 95% CI: 0.99-1.12). Single parents demonstrated the highest levels of distress, but confounder adjustment suggested uncertain effects with wide confidence intervals. Findings were similar in April 2020 and when stratified by sex. ConclusionsAccess to childcare/schooling, financial security and social connection are important mechanisms that need addressing to avoid widening mental health inequalities during public health crises. Key MessagesO_LICouples with young children compared to those without, had raised risk of psychiatric distress during UK lockdowns. Effect decompositions suggested this was largely due to a combination of differential exposure and vulnerability to childcare and home-schooling. C_LIO_LIAmong those without young children, being single compared to in a couple was associated with raised risk of psychiatric distress during UK lockdowns, with differential exposure to financial strain and loneliness both contributing to this inequality. C_LIO_LIThere was not sufficient evidence to indicate that being single with young children increased risk of psychiatric distress relative to couples with young children or singles without. C_LI

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.

BackgroundPeer support roles in mental health services are rapidly increasing in the UK 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 distinctive features of PSWs approaches in mental healthcare; 2) the values underpinning the role and 3) the perceived impact of the role. MethodsWe 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. ResultsWe interviewed 35 PSWs. Overarching themes identified from iterative analysis included: 1) The centrality of an individualised, flexible, 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. 2) Underpinning values included: i) Recovery is possible: bringing 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. 3) the role had benefits for participants own recovery, although its emotional demands could lead to burnout. 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. Participants felt that PSWs could bring systemic improvements to services and use their lived experience to help teams -meet service user needs. ConclusionPSWs 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.

BackgroundDespite improving legal protections in recent decades for sexual minorities in the UK, sexual minorities continue to experience significant mental health disparities relative to heterosexuals, and report negative experiences within mental health services that is related to their sexual identity. However, little attention has been paid to the impact of these negative experiences on outcomes within services, or to the experiences of sexual minority staff. To overcome these gaps, the aim of this review is to explore the experiences of sexual minority staff and service users in statutory mental health services in the UK, including a focus on outcomes for service users. MethodsFor the systematic search, we searched: Applied Social Sciences Index & Abstracts, EMBASE, MEDLINE(R), PsycINFO, CINAHL Plus, and Web of Science for relevant articles, and for the suppementaty search, we searched the websites of relevant organisations, in addition to searching Google, Google Scholar, and DuckDuckGo. We included all study designs, published from 2010 onwards, that included first-hand accounts of sexual minority staff or service users in statutory mental health services in the UK. We used a narrative synthesis to synthesise the findings. ResultsOf 7427 articles identified, 84 were assessed at full text screening, with 11 being included in the review. 9 of the included studies were with adults, with the majority being conducted in the context of Talking Therapies and primary care counselling services (n = 7). Across studies, sexual minorities reported anticipatory anxiety about experiencing prejudice and discrimination in services, microaggressions (e.g., heteronormative assumptions) and the pathologization of their sexual minority identities. There are mixed findings about whether certain sexual minority groups have worse outcomes in Talking Therapies services. We found no studies that explored the experiences of sexual minority staff. ConclusionsSexual minority service users are reporting negative experiences in some statutory mental health services in the UK that are related to their sexual identity. In line with service user recommendations, services should consider introducing sexual minority training for staff to improve the experiences of service users. An absence of research on sexual minority staff, and little research on the experiences of young people from sexual minorities, highlight the need for research in this area

IntroductionSocial and economic needs are greater in populations living with mental ill-health compared with the general population. However, services do not currently adequately assess these needs or offer appropriate interventions. A practical roadmap is required to work towards social and economic inclusion as a central component of mental health services. MethodsWe used the participatory Theory of Change method to conduct two qualitative workshops with health care professionals, third sector workers, academics and lived experience experts (Workshop 1, n=16; Workshop 2, n=14) in the area served by the South London and Maudsley NHS Trust. We co-developed a Theory of Change model which aimed to outline the key steps needed to put social inclusion at the centre of mental health care services in relation to the largest mental health trust in the United Kingdom (South London and Maudsley), yet with generalisable elements for mental health services in the United Kingdom more broadly. ResultsA shared goal for services was developed and agreed by participants of securing "a consistent mental health system that enables individuals to feel loved, valued, and capable of thriving beyond their basic needs". To progress from the current context to this shared goal, six objective pathways were co-produced to act as a roadmap: (1) Provision of person-centred culturally appropriate care; (2) Advocacy for funding for effective social inclusion services in line with need; (3) Advocacy for funding and support of social and peer programmes; (4) Co-located and localised community-based support hubs; (5) A shared feedback system with social inclusion Key Performance Indicators (KPIs) with an ability to include positive outcomes and drive accountability; and (6) A collaborative community service network. ConclusionsThis Theory of Change model offers a tangible framework to put social inclusion at the centre of mental health services. This model can be adapted and translated to other services and settings that are aiming to make social inclusion a core feature of their provision, beyond those in which it was developed.

ImportanceMental health disorders were among the leading global contributors to years lived with disability prior to the COVID-19 pandemic onset, and growing evidence suggests that population mental health outcomes have worsened since the pandemic started. The extent that these changes have altered common age-related trends in psychological distress, where distress typically rises until mid-life and then falls in both sexes, is unknown. ObjectiveTo analyse whether long-term pre-pandemic psychological distress trajectories have altered during the pandemic, and whether these changes have been different across generations and by sex. DesignCross-cohort study with prospective data collection over a 40-year period (earliest time point: 1981; latest time point: February/March 2021). SettingPopulation-based (adult general population), Great Britain. ParticipantsMembers of three nationally representative birth cohorts which comprised all people born in Great Britain in a single week of 1946, 1958, or 1970, and who participated in at least one of the data collection waves conducted after the start of the pandemic (40.6%, 42.8%, 39.4%, respectively). Exposure(s)Time, COVID-19 pandemic. Main Outcome(s) and Measure(s)Psychological distress factor scores, as measured by validated self-reported questionnaires. Results16,389 participants (2,175 from the 1946 birth cohort, 52.8% women; 7,446 from the 1958 birth cohort, 52.4% women; and 6,768 from the 1970 birth cohort, 56.2% women) participated in the study. By September/October 2020, psychological distress levels had reached or exceeded the levels of the peak in the pre-pandemic life-course trajectories, with larger increases in younger cohorts: Standardised Mean Differences (SMD) and 95% confidence intervals (CIs) of -0.02 [-0.07, 0.04], 0.05 [0.02, 0.07], and 0.09 [0.07, 0.12] for the 1946, 1958, and 1970 birth cohorts, respectively. Increases in distress were larger among women than men, widening the pre-existing inequalities observed in the pre-pandemic peak and in the most recent pre-pandemic assessment. Conclusions and RelevancePre-existing long-term psychological distress trajectories of adults born between 1946 and 1970 were disrupted during the COVID-19 pandemic, particularly among women, who reached the highest levels ever recorded in up to 40 years of follow-up data. This may impact future trends of morbidity, disability, and mortality due to common mental health problems.

BackgroundThe COVID-19 pandemic has disproportionately impacted womens mental health, although most evidence has focused on mental illbeing outcomes. Previous research suggests that gendered differences in time-use may explain this disparity, as women generally spend more time doing psychologically taxing activities than men. We investigated gender differences in the long-term trajectories of life satisfaction, how these were impacted during the pandemic, and the role of time-use differences in explaining gender inequalities. MethodsWe used data from 6766 (56.2% women) members of the 1970 British Cohort Study (BCS70), a nationally representative birth cohort of people born in Great Britain in 1970, who were alive and residing in the UK between May 2020 and March 2021. Life satisfaction was prospectively assessed between the ages of 26 (1996) and 51 (2021) using a single question with responses ranging from 0 (lowest) to 10 (highest). We analysed life satisfaction trajectories using piecewise latent growth curve models and investigated whether gender differences in the change in the life satisfaction trajectories with the pandemic were explained by self-reported time spent doing different paid and unpaid activities. FindingsWomen had consistently higher life satisfaction than men prior to the pandemic ({Delta}intercept,unadjusted=0.213 [95% CI: 0.087, 0.340], p=.001) and experienced a more accelerated decline with the pandemic onset ({Delta}quad2,unadjusted=-0.018 [-0.026, -0.011], p<.001). Time-use differences did not account for the more accelerated decrease in womens life satisfaction levels with the pandemic ({Delta}quad2,adjusted=-0.016 [-0.031, -0.001], p=.035). InterpretationOur study shows pronounced gender inequalities in the impact of the pandemic on the long-term life satisfaction trajectories of adults in their 50s, with women losing their historical advantage over men. Self-reported time-use differences did not account for these inequalities, suggesting that they could be linked to other factors including the mental load (invisible, unrecognised labour disproportionately undertook by women) or the menopausal transition.

Mental health services in the UK are increasingly pressured with long waiting times. Meanwhile, online forums for mental health, set up by charities, NHS services, and individual volunteers, have increased in popularity. Little is known, however, about who is using them and why. This study aimed to investigate this, using multiple methods to capture different types of users. A mixed-methods approach was used, with participants recruited from seven UK-based mental health forums. 791 forum users participated in a survey which was compared to the demographics of people accessing NHS Talking Therapies. 20 forum users took part in interviews, which were thematically analysed for reasons for use. Finally, the top keywords in the forum posts (a corpus of 28 million words) were calculated using the log likelihood test of statistical significance. One keyword was identified consistently across the forums, so its collocation profile was analysed. Surveys showed the forums were predominantly used by white, female, and younger people, though there was greater ethnic diversity and a higher proportion of non-binary people compared to NHS Talking Therapies. Thematic analysis of interviews indicated that people used forums because they are easily accessible, making it possible to overcome barriers to in-person support, such as the need to speak. Participants sought emotional support, advice, and connection with others experiencing similar challenges. The linguistic analysis showed "scared" was a common keyword across the forums, with common collocations being Im scared because and scared of. Reviewing the posts showed users tended to share fears over mental health symptoms and identity. Online forums serve as important alternative and complementary sources of mental health support, particularly for people who face discrimination or logistical barriers in accessing traditional services. These forums provide accessible, anonymous spaces for peer support, helping users to share fears and connect with others in similar situations.

BackgroundThe COVID-19 pandemic, coupled with concurrent social instabilities, has raised concerns about the long-term impact on the population mental health. While existing studies have primarily focused on the acute phase, less is known about how anxiety and depression symptoms have evolved throughout prolonged societal disruption. This study aimed to identify distinct anxiety and depression symptom trajectories and to determine the individual, relational, and societal protective and risk factors that influence anxiety and depression scores among Belgian adults from 2020 to 2024. MethodsWe used longitudinal data from five waves of the COVID-19 Health Surveys and the BELHEALTH study (n = 10,063) among Belgian adults, collected between April 2020 and June 2024. Anxiety and depression were assessed using the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9, respectively. Covariates were selected based on the social-ecological framework and included both time-invariant and time-dependent variables. Latent class linear mixed models identified subgroups with distinct trajectories. Multilevel linear mixed effects models examined associations between symptom severity and predictors across individual, relationship, and societal levels. The final model, selected based on the lowest AIC (Akaike Information Criterion), included the full set of covariates. ResultsFour depression and five anxiety trajectories were identified. While most participants maintained stable mild symptoms, 11.3% experienced increasing depression and 8.4% showed increasing anxiety over time. Financial difficulty, female gender, and younger age were overrepresented in moderate and severe symptom trajectories. Protective factors such as social support, satisfying social contact, and life satisfaction were associated with lower symptom severity. Over time, life satisfaction demonstrated an increasing protective effect, while the influence of social contact on reducing symptoms weakened progressively. Risk factors included financial and job-loss worry, loneliness, psychotropic medication use, and high mental health stigma. ConclusionsOur results demonstrate persistent heterogeneity in mental health responses, with a substantial share of the population experiencing worsening symptoms years after the pandemic began. Public mental health strategies must therefore go beyond short-term crisis response, address long-term risks such as financial insecurity, social isolation, and stigma, while fostering individual and collective resilience.

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.

BackgroundTrauma is increasingly linked to poor health outcomes. Adverse experiences in mental health inpatient settings can be traumatic and contribute to long-lasting negative effects like post-traumatic stress disorder. However, the full range of relevant experiences is often unaddressed in service design and delivery. AimTo describe the spectrum of negative experiences that people identify while they are inpatients in adult mental health services. MethodA systematic literature review was conducted to identify qualitative studies that included peoples subjective negative reports of their inpatient admissions. CINAHL, MEDLINE and PsycINFO were searched from 2000 onwards, alongside a search of Google Scholar. The quality of studies was assessed using the Critical Appraisal Skills Programme qualitative checklist. Data were synthesised using the best-fit framework synthesis approach. A patient and public involvement reference group contributed to the review. ResultsStudies (111) from 25 countries were included. Adverse mental health inpatient experiences can be conceptualised under three headings: the ecosystem (the physical environment and the resources available, and other people within or influential to that environment); systems (processes and transitions); and the individual (encroachments on autonomy and traumatisation). ConclusionsImproved patient experience is associated with improved patient outcomes, and addressing negative experiences could significantly impact patient care. Mental health professionals should strive to create inpatient environments that are supportive, respectful, and safe for patients, which consideration of the adversity framework developed from this review can facilitate.

BackgroundColombias PAPSIVI program is the worlds largest psychosocial support service for victims of armed conflict providing support for over half a million civilians. However, service delivery has only previously been examined in small studies, making it difficult to understand to what extent PAPSIVI delivers interventions that are adequately targeted to individuals with the most serious exposures to the armed conflict, and to what extent attendees remain engaged with interventions. MethodsWe investigated how different conflict exposures related to PAPSIVI intervention assignment and engagement. We linked anonymised national data from the register of victims of the Colombian armed conflict to data from N = 534,818 PAPSIVI attenders. Analysis used logistic and linear regression with cluster robust standard errors, adjusted for a range of potential confounders. ResultsIntervention types were broadly provided in line with PAPSIVI guidelines, with victims experiencing torture, sexual violence, and forced recruitment more likely to receive individual sessions, while community-level impacts received community interventions. Female sex, ethnic minority status, and receiving state-subsidised healthcare were associated with higher intervention engagement. Those with previous mental health diagnoses had increased odds of attending individual or family sessions but lower odds of group or community sessions, consistent with recommendations for more intensive intervention for those with higher mental health needs. 29% of individual session attendees only received a single session, potentially indicating early dropout or unsuitable service provision for a proportion of attendees. ConclusionsThis study provides insights into support provision for civilian victims of conflict indicating that psychosocial support provision can be managed effectively at very large scales.

BackgroundHealth service utilization is influenced by perceived and evaluated health status (need factors), sociodemographic characteristics and health beliefs (predisposing factors), and personal and community resources that facilitate or hinder access to care (enabling factors). No study has simultaneously quantified how these factors directly and indirectly influence psychotherapy and pharmacotherapy initiation for common mental disorders (CMD). The COVID-19 pandemic provides an opportunity to examine these dynamics due to heightened mental health needs and strained healthcare systems. MethodsWe conducted a cross-sectional study within the French Grippenet/Covidnet cohort (n=6,944) in April 2022. Data were collected through a voluntary online questionnaire. Participants not using CMD treatments before the pandemic (n=3,297) were included. Weighted structural equation modeling was used to analyze the direct and indirect pathways to psychotherapy and pharmacotherapy initiation. ResultsPsychotherapy initiation was directly associated with perceived need (poorer self-rated mental health, negative pandemic impact) and enabling factors (employed, mindfulness/relaxation activities, over-the-counter medication). Pharmacotherapy initiation was directly associated with evaluated need (CMD symptoms, non-psychiatric chronic disease), predisposing (female), and enabling factors (over-the-counter medication). Indirectly, predisposing factors influenced treatment initiation primarily through CMD symptoms (female, younger, lower education, living with adults, adverse life event and recent difficult event), while enabling and pandemic-related factors influenced it through poorer perceived need (loneliness, urban, employed, fewer financial difficulties, less deprived area, pandemic financial decline) and CMD symptoms (loneliness, less sport, most deprived area, symptomatic COVID-19). ConclusionsThis study highlights distinct pathways to psychotherapy and pharmacotherapy initiation and provides insights to improve access to each treatment.

BackgroundMental health problems are not distributed equally in society. Our understanding of when social inequalities in mental health emerge is limited. We sought to examine inequalities in trajectories of mental distress in diverse, representative cohorts of adolescents in inner-London. MethodsWe analysed longitudinal data from our cohort study of adolescent mental health, REACH (n=4663; 51% girls, 29% free school meals [FSM], 85% minoritised ethnic groups). We used latent growth curve models to estimate trajectories of mental distress (total, internalising, and externalising scores from the self-report Strengths and Difficulties Questionnaire) from age 11-16 years, overall and by gender, FSM, ethnic group, and their intersections. ResultsWe found strong evidence of differences in trajectories of mental distress by gender and FSM. Higher mean internalising scores in girls (vs. boys) were evident at age 11-12 and this inequality widened year-on-year (difference in mean intercepts: 0.74 [95% CI 0.52, 0.96]; slopes: 0.50 [0.39, 0.61]). Higher mean levels of distress among those receiving FSM (vs. not) were evident at age 11-12 years (e.g., difference in intercepts, general distress: 0.79 [0.19, 1.39]), and this difference, though modest, persisted through adolescence. By ethnic group and intersecting identities, the picture was more complex and mixed. Broadly, Black African youth generally reported better mental health trajectories vs. their peers; Black Caribbean and Mixed Black-and-White youth shared similar trajectories, differing somewhat from Black African; and by age 16, internalising distress was highest among lower-income White British girls. ConclusionsIn diverse inner-cities, adolescence is an important period in the emergence and persistence of some of the inequalities in mental health reported in adults; others are more nuanced.