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Purpose: This study addresses a gap in evidence on small employer experiences of managing mental health problems in the workplace. The authors gathered first-hand experiences of small business managers to empirically investigate how the small business context affects the management and support of mental health problems in the workplace, and the practice implications that arise. Design/methodology/approach: Qualitative interviews, combining semi-structured and narrative approaches, with 21 small business managers with experience of managing employees with mental health difficulties. The 21 managers recounted a total of 45 employee cases, which were analysed thematically, using a case-based matrix. Study participants were drawn from small businesses within England and Scotland (UK). Interviews were conducted between November 2019 and February 2020. Findings: Support aligned with current understanding of effective practice, yet was often informal, instinctive and flexible. Accommodating employees with mental health problems impacted the workload of managers and co-workers, and business operation and growth. Challenges and tensions reflected the difficult balancing act faced by managers in organisations of all sizes. However, the intensity and immediacy of cross-pressures was enhanced for small businesses, due to their smaller workforce and lack of dedicated Human Resource Management and occupational health expertise. Practical implications: Guidance should address the navigation of day-to-day management and support for employees with mental health difficulties, including approaches to balancing the needs of the wider workforce and business operation. Access to HR and occupational health expertise is valuable. Financial subsidies may be of lesser concern to small businesses. Originality/value: This study offers originality in focusing exclusively on small business managers with first-hand experience of supporting employees with mental health problems. Findings challenge the perception that small firms have unique experiences, whilst highlighting contextual features that exacerbate intensity and immediacy of impacts. [ABSTRACT FROM AUTHOR]