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.

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.

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.

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.

Family and friends (family carers) provide substantial support to those with mental ill health, often affecting their own well-being. Subsequently, family carers have their own recovery journeys. Research highlights numerous benefits of attending Recovery Colleges, but whether these apply for family carers remains unexplored.

We aimed to explore family carers’ experiences of attending Recovery Colleges across England, to understand current provision and how this might better include and support family carers.

Together with lived experience researchers, this qualitative focus group study used collaborative thematic analysis of online focus groups and interviews with family carers and Recovery College staff from across England.

We generated six superordinate themes: ‘The “carer” identity is not clearcut’, ‘Recovery ethos applies to family carers too’, ‘Power of lived experience’, ‘Educational focus is appealing’, ‘Family carers deserve recognition and provision’ and ‘Reaching out and fitting around family carers’. Attending Recovery Colleges developed family carers understandings and gave them skills to navigate services and support themselves and others, which furthered their own recovery journeys. Shared learning spaces were helpful, but participants felt these were not always oriented to include family carers. Our findings revealed ways Recovery Colleges could increase their relevance and accessibility to family carers.

The unique characteristics of Recovery Colleges suited the recovery needs of family carers. However, more resources are needed to develop this potential and reach more family carers. Family carer co-researchers enriched our findings, and discussions with the Recovery College community furthered our recommendations for practice.

Relatively little is known about mental healthcare-related harm, with patient safety incidents (PSIs) in community-based services particularly poorly understood. We aimed to characterize PSIs, contributory factors, and reporter-identified solutions within community-based mental health services for working-age adults.

We obtained data on PSIs reported within English services from the National Reporting and Learning System. Of retrieved reports, we sampled all incidents reportedly involving ‘Death’, ‘Severe harm’, or ‘Moderate harm’, and random samples of a proportion of ‘Low harm’ or ‘No harm’ incidents. PSIs and contributory factors were classified through qualitative content analysis using existing frameworks. Frequencies and proportions of incident types were computed, and reporter-identified solutions were inductively categorized.

Of 1825 sampled reports, 1443 were eligible and classified into nine categories. Harmful outcomes, wherein service influence was unclear, were widely observed, with self-harm the modal concern amongst ‘No harm’ (15.0%), ‘Low harm’ (62.8%), and ‘Moderate harm’ (37.6%) categories. Attempted suicides (51.7%) and suicides (52.1%) were the most frequently reported events under ‘Severe harm’ or ‘Death’ outcomes, respectively. Incidents common to most healthcare settings were identified (e.g. medication errors), alongside specialty-specific incidents (e.g. Mental Health Act administration errors). Contributory factors were wide-ranging, with situational failures (e.g. team function failures) and local working conditions (e.g. unmanageable workload) widely reported. Solution categories included service user-directed actions and policy introduction or reinforcement.

Study findings provide novel insights into incidents, contributory factors, and reported solutions within community-based mental healthcare. Targets for safety improvement are outlined, aimed at strengthening system-based prevention of incidents.

Between 2008 and 2019, we reported positive change relating to mental health stigma and discrimination among the adult population of England, supporting the effectiveness of the Time to Change campaign.

Using data from the Attitudes to Mental Illness survey (2008/2009 to 2023), we investigated the extent to which positive changes in stigma were sustained by 2023, 2 years after the programme's end in 2021.

We used regression analyses to evaluate trends in outcomes. Measures were of stigma-related knowledge (Mental Health Knowledge Schedule (MAKS)), attitudes (Community Attitudes toward the Mentally Ill scale (CAMI)) and desire for social distance (Reported and Intended Behaviour Scale (RIBS)). We also examined willingness to interact with people based on vignettes of depression and schizophrenia, and attitudes toward workplace discrimination, using data from the British Social Attitudes Survey for comparison.

CAMI scores improved between 2008 and 2023 (s.d. 0.24, 95% CI 0.16–0.31), but decreased since 2019 (P = 0.015). After improvements between 2009 and 2019, 2023 MAKS and RIBS scores no longer differed from 2009 scores, indicating decreases in stigma-related knowledge (MAKS scores declined 7.8%; P < 0.001) and willingness to interact (RIBS scores declined by 10.2%; P < 0.001) since 2019. Conversely, comparison with British Social Attitudes Survey data indicated that willingness to interact with people with depression and schizophrenia increased gradually between 2007, 2015 and 2023, and attitudes to workplace discrimination also improved.

The lasting positive changes reflect support for non-discrimination and willingness to interact with someone after a sense of familiarity is evoked. Besides the end of Time to Change, interpretations for declines in other outcomes include the COVID-19 pandemic and economic stress.

During the COVID-19 pandemic, mental health problems increased as access to mental health services reduced. Recovery colleges are recovery-focused adult education initiatives delivered by people with professional and lived mental health expertise. Designed to be collaborative and inclusive, they were uniquely positioned to support people experiencing mental health problems during the pandemic. There is limited research exploring the lasting impacts of the pandemic on recovery college operation and delivery to students.

To ascertain how the COVID-19 pandemic changed recovery college operation in England.

We coproduced a qualitative interview study of recovery college managers across the UK. Academics and co-researchers with lived mental health experience collaborated on conducting interviews and analysing data, using a collaborative thematic framework analysis.

Thirty-one managers participated. Five themes were identified: complex organisational relationships, changed ways of working, navigating the rapid transition to digital delivery, responding to isolation and changes to accessibility. Two key pandemic-related changes to recovery college operation were highlighted: their use as accessible services that relieve pressure on mental health services through hybrid face-to-face and digital course delivery, and the development of digitally delivered courses for individuals with mental health needs.

The pandemic either led to or accelerated developments in recovery college operation, leading to a positioning of recovery colleges as a preventative service with wider accessibility to people with mental health problems, people under the care of forensic mental health services and mental healthcare staff. These benefits are strengthened by relationships with partner organisations and autonomy from statutory healthcare infrastructures.

The COVID-19 pandemic has disrupted lives and livelihoods, and people already experiencing mental ill health may have been especially vulnerable.

Quantify mental health inequalities in disruptions to healthcare, economic activity and housing.

We examined data from 59 482 participants in 12 UK longitudinal studies with data collected before and during the COVID-19 pandemic. Within each study, we estimated the association between psychological distress assessed pre-pandemic and disruptions since the start of the pandemic to healthcare (medication access, procedures or appointments), economic activity (employment, income or working hours) and housing (change of address or household composition). Estimates were pooled across studies.

Across the analysed data-sets, 28% to 77% of participants experienced at least one disruption, with 2.3–33.2% experiencing disruptions in two or more domains. We found 1 s.d. higher pre-pandemic psychological distress was associated with (a) increased odds of any healthcare disruptions (odds ratio (OR) 1.30, 95% CI 1.20–1.40), with fully adjusted odds ratios ranging from 1.24 (95% CI 1.09–1.41) for disruption to procedures to 1.33 (95% CI 1.20–1.49) for disruptions to prescriptions or medication access; (b) loss of employment (odds ratio 1.13, 95% CI 1.06–1.21) and income (OR 1.12, 95% CI 1.06 –1.19), and reductions in working hours/furlough (odds ratio 1.05, 95% CI 1.00–1.09) and (c) increased likelihood of experiencing a disruption in at least two domains (OR 1.25, 95% CI 1.18–1.32) or in one domain (OR 1.11, 95% CI 1.07–1.16), relative to no disruption. There were no associations with housing disruptions (OR 1.00, 95% CI 0.97–1.03).

People experiencing psychological distress pre-pandemic were more likely to experience healthcare and economic disruptions, and clusters of disruptions across multiple domains during the pandemic. Failing to address these disruptions risks further widening mental health inequalities.

Responses to anticipateddiscrimination are common among mental health service users and can have adetrimental impact on their recovery. Since 2009, the Time to Change (TTC)anti-stigma program in England has aimed to improve service users’ empowerment,reducing public stigma and discrimination. In this paper, we aim to evaluatewhether service users’ awareness of TTC is associated with fewer responses toanticipated discrimination.

We used data collected for the evaluation of TTC from samples of mental health service users interviewed by telephone in annual surveys 2009-2014.

Five thousand and nine hundredand twenty-three participants completed the survey, mainly suffering from mooddisorders (depression, 28.4%, n = 1,681) and schizophrenia related disorders(15.4%, n = 915).

In 23.2% of cases,participants were aware of any aspects of the TTC program, while participationin TTC was reported by 2.6%. Being aware of the TTC program was notsignificantly associated with responses to anticipated discrimination, exceptfor those participating in the TTC campaign in 2013. Stopping oneself fromapplying for work was significantly associated with experienced discriminationin both finding (p < 0.001) and keeping (p < 0.001) a job.Concealing mental health problems was associated with a general experience ofbeing shunned (p < 0.001).

Awareness of a nationalanti-stigma program may not be sufficient to encourage people to seek work/educationor to be open about their illness in situations in which they currentlyanticipate discrimination. There is the need to identify new multi-levelstrategies for challenging anticipated discrimination, even focusing ondifferent target groups.

Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.

To evaluate a 1-year programme to improve CRTs’ model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).

Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.

All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI −1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.

The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.

Our aim was to investigate patterns of change in public knowledge, attitudes, desire for social distance and reporting having contact with people with mental health problems in England during the Time to Change (TTC) programme to reduce stigma and discrimination 2009–2017.

Using data from an annual face-to-face survey of a nationally representative quota sample of adults, we evaluated longitudinal trends of the outcome measures with regression analyses and made assumptions on the basis of a simple random sample. We tested interactions between year and demographic subgroups.

There were improvements in all outcomes in 2017 compared with baseline measures (2008 or 2009). Reported in s.d. units [95% confidence interval (CI)], the improvement for knowledge was 0.17 (0.10–0.23); for attitudes 0.25 (0.18–0.31); and for social distance 0.29 (0.23–0.35). A higher likelihood of reporting contact was also associated with most recent survey year (odds ratio 1.47, 95% CI 1.27–1.71). Statistically significant interactions between year and region of England suggest greatest improvements in attitudes and intended behaviour in London, where both outcomes were significantly worse in the early years of the survey. However, for attitudes, this interaction was only significant among women. Other significant interactions suggest that attitudes improved most in the target age group (25–44).

The results provide support for the effectiveness of TTC across demographic groups. However, other societal changes may influence the results, such as the increasing prevalence of common mental disorder in young women.

Anti-stigma programmes should aim to increase disclosure to those who can support someone with a mental health problem and appropriate professional help-seeking.

We investigated associations among public awareness of England's Time to Change anti-stigma campaign and: (a) comfort envisaged in disclosing a mental health problem to family and friends; (b) comfort in disclosing to an employer; and (c) intended professional help-seeking from a general practitioner, i.e. a physician working in primary care.

Using data from a survey of a nationally representative sample of adults, we created separate logistic regression models to test for campaign awareness and other variables as predictors of comfort in disclosure and intended help-seeking.

We found positive relationships between campaign awareness and comfort in disclosing to family and friends (odds ratio (OR) = 1.27, 95% CI 1.14–1.43) and to a current or prospective employer (OR = 1.20, 95% CI 1.06–1.35); and likelihood of help-seeking (OR=1.18 95% CI 1.03–1.36).

Awareness of an anti-stigma campaign was associated with greater comfort in disclosing a mental health problem and intended help-seeking.