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A Blakemore,1 C Dickens,2 CA Chew-Graham,3 CW Afzal,4 B Tomenson,5 PA Coventry,6 E Guthrie71Division of Nursing, Social Work and Midwifery, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; 2University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, UK; 3Research Institute, Primary Care and Health Sciences, West Midlands CLAHRC, Keele, University, Newcastle, UK; 4Health Innovation Manchester, Greater Manchester’s Academic Health Science Network, Manchester Academic Health Science Centre, Manchester, UK; 5Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK; 6Department of Health Sciences, University of York, York, UK; 7Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UKBackground: Depression is common in people with chronic obstructive pulmonary disease (COPD) and has been associated with a variety of poor outcomes. A large proportion of health care costs in the UK are spent on emergency care. This study examined the prospective relationship between depression and use of emergency care in patients with COPD managed in primary care.Methods: This was a twelve-month, prospective longitudinal study of 355 patients with COPD in six primary care practices in the UK. Baseline measures included demographic characteristics, depression and anxiety, severity of COPD, presence or absence of other chronic diseases, and prior use of emergency care. Outcome measures were (a) number of emergency department (ED) visits; or (b) an emergency hospital admission in the follow-up year.Results: Older age, number of comorbid physical health conditions, severity of COPD, prior use of emergency care, and depression were all independently associated with both ED attendance and an emergency hospital admission in the follow-up year. Subthreshold depression (HADS depression score 4–7) was associated with a 2.8 times increased odds of emergency hospital admission, and HADS depression >8 was associated with 4.8 times increased odds.Conclusion: Depression is a predictor of emergency care in COPD, independent of severity of disease or physical comorbidity. Even mild (subthreshold) symptoms of depression more than double the risk of using emergency care, suggesting there is a strong case to develop and deploy integrated preventive strategies in primary care that can promote mental health in people with COPD.Keywords: COPD, depression, anxiety, emergency care, United Kingdom, hospital admission, primary care

BACKGROUND: Depression is the most common mental health disorder in people aged over 65 years. Late-life depression is associated with chronic illness and disability. AIM: To investigate the feasibility of a collaborative care model for depression in older people in a primary care setting. DESIGN OF STUDY: Randomised controlled trial with 16-weeks follow up. SETTING: A primary care trust in Manchester. METHOD: Participants were 105 people aged 60 years or older who scored 5 or more on the Geriatric Depression Scale; 53 were randomly allocated to an intervention group and 52 to a usual care group. The intervention group received care managed by a community psychiatric nurse who delivered an intervention comprising a facilitated self-help programme with close liaison with primary care professionals and old-age psychiatry according to a defined protocol. The usual care group received usual GP care. A nested qualitative study explored the views of the health professionals and patients regarding the acceptability and effectiveness of the intervention. RESULTS: The main outcome measure was recovery from depression. Patients in the intervention group were less likely to suffer from major depressive disorder at follow up compared with usual care (0.32, 95% confidence = interval = 0.11 to 0.93, P = 0.036). The qualitative component of the study demonstrated the acceptability of the intervention to patients. CONCLUSION: A model of collaborative care for older people with depression, used in a primary care setting with a facilitated self-help intervention is more effective than usual GP care. This study demonstrates that the implementation of a collaborative care model is feasible in UK primary care and that the intervention is effective and acceptable to patients. [ABSTRACT FROM AUTHOR]

This paper reports an audit of Mental Health Trusts in North West England. The aim of the study was to investigate recruitment of community psychiatric nurses (CPNs), and to explore the experiences of the professionals trying to recruit nursing staff. A telephone survey was carried out in Autumn 2003 of five Mental Health (MH) Trusts in North West England. Telephone interviews with Human Resources staff and senior managers were set up although some conversations took place by E-mail. Content analysis of the notes of the telephone and e-mail conversations was carried out. It was hard to establish a true picture of nurse vacancies initially because it was difficult to find the appropriate person to speak to. It became apparent that recruitment and vacancies were recorded in terms of a person or post rather than hours. Managers admitted than posts were often filled with part-time staff. Using nursing hours as a measure of staffing levels rather than counting individuals gives a more accurate picture of staffing levels but such data was not available. In addition, it was reported that a post unfilled for more than three months stops being counted as a vacancy. It was reported that the amount being spent on temporary or 'bank' nurses has increased sharply in the past five years, which strongly suggests that there are not currently enough permanent nurses in post. In addition, an increase in international recruitment was reported and managers reported that recruitment to CPN posts was often at the expense of inpatient units. This study confirms the perception amongst Mental Health Trust Managers of a shortage of Psychiatric Nurses. The paper describes the difficulties in obtaining accurate vacancy data, and the perceived difficulties in recruitment of nursing staff. We suggest that current arrangements of care for people with mental health problems delivered by CPNs may not be sustainable. [ABSTRACT FROM AUTHOR]

BACKGROUND: Medical education is reported to be demanding and stressful and previous work with doctors suggests that there is a resistance within the profession to help-seeking and an ad hoc approach to dealing with stress and distress. AIM: To explore the attitudes of medical students at the University of Manchester, UK to the causes of stress and to examine their views on help-seeking. STUDY DESIGN: A qualitative study using semistructured interviews, with analysis of the data using the technique of constant comparison. METHODS: Medical students at the University of Manchester were invited to participate in the study. Sampling made the research representative of medical students in terms of gender, ethnicity and UK/overseas students. Semistructured interviews, with open questions, were conducted and audio-taped with consent. The tapes were transcribed verbatim. The schedule was revised in the light of the emerging themes. RESULTS: Medical students recognised that studying medicine contributes to stress, as experienced in their undergraduate careers. Students reported that perceptions of stigma associated with mental illness, including stress, were prevalent in the student body and were perceived to continue throughout the medical profession. Avoidance of appropriate help-seeking behaviour starts early and is linked to perceived norms which dictate that experiencing a mental health problem may be viewed as a form of weakness and has implications for subsequent successful career progression. CONCLUSION: The preparation of medical students for life as doctors involves more than facilitation of the acquisition of knowledge and skills, so that new doctors can conform to the principals of professional conduct. Support and mentoring are required so that stress can be identified early and dealt with appropriately. [ABSTRACT FROM AUTHOR]

Background: People with long-term physical conditions are more likely to experience distress, depression or anxiety. Physical-mental comorbidity is associated with lower quality of life, poorer clinical outcomes, and increased mortality than physical conditions alone. South Asians (SAs) are the largest minority group in the UK, and more likely to have long-term conditions (LTCs) such as diabetes and heart disease., Aim: To explore how men of SA origin with LTCs understand and experience emotional distress as well as the experiences of GPs supporting them., Design and Setting: UK qualitative study interviewing SA men with diabetes or coronary heart disease, and GPs working at practices with higher proportions of SAs., Method: Online semi-structured interviews with SA men and GPs. Data were analysed via reflexive thematic analysis. Topic guides were modified iteratively as data collection and analysis progressed. An ethnically appropriate patient advisory group of SA men was involved in all stages of the research., Results: Seventeen SA men with LTCs and 18 GPs were interviewed. Participants described contextualising distress including the interaction between having a LTC and distress, and the intersections of social determinants of distress including ethnicity, poverty and perceptions of prejudice. Participants understood distress as different to depression with the need to negotiate multiple identities as well as alternative paradigms of health., Conclusion: This study highlights the influence of social determinants of distress in SA men with LTCs. It provides an insight into how primary care has the potential to address health inequalities by considering the intersection of these factors., (Copyright © 2024, The Authors.)

Background: There has been significant investment in pharmacists working in UK general practice to improve the effective and safe use of medicines. However, evidence of how to optimise collaboration between GPs and pharmacists in the context of polypharmacy (multiple medication) is lacking., Aim: To explore GP and pharmacist views and experiences of in-person, interprofessional collaborative discussions (IPCDs) as part of a complex intervention to optimise medication use for patients with polypharmacy in general practice., Design and Setting: A mixed-method process evaluation embedded within the Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP) trial conducted in Bristol and the West Midlands, between February 2021 and September 2023., Method: Audio-recordings of IPCDs between GPs and pharmacists, along with individual semi-structured interviews to explore their reflections on these discussions, were used. All recordings were transcribed verbatim and analysed thematically., Results: A total of 14 practices took part in the process evaluation from February 2022 to September 2023; 17 IPCD meetings were audio-recorded, discussing 30 patients (range 1-6 patients per meeting). In all, six GPs and 13 pharmacists were interviewed. The IPCD was highly valued by GPs and pharmacists who described benefits, including: strengthening their working relationship; gaining in confidence to manage more complex patients; and learning from each other. It was often challenging, however, to find time for the IPCDs., Conclusion: The model of IPCD used in this study provided protected time for GPs and pharmacists to work together to deliver whole-patient care, with both professions finding this beneficial. Protected time for interprofessional liaison and collaboration, and structured interventions may facilitate improved patient care., (© The Authors.)

Background: Between 2003 and 2018, incident prescriptions of beta-blockers for anxiety increased substantially, particularly for young adults. National Institute for Health and Care Excellence guidance for anxiety does not recommend beta-blockers, probably due to a lack of evidence to support such use. Recent reports have highlighted the potential risks of beta-blockers., Aim: To understand when and why GPs prescribe beta-blockers for people with anxiety., Design and Setting: In-depth interviews with 17 GPs in Bristol and the surrounding areas., Method: Interviews were held by telephone or video call. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and analysed thematically., Results: Many GPs viewed beta-blockers as 'low risk', particularly for young adults. Some GPs viewed beta-blockers as an alternative to benzodiazepines, acting quickly and not leading to dependence. GPs reflected that some patients appeared to want an 'immediate fix' to their symptoms, which GPs thought beta-blockers could potentially offer. This is salient in light of substantial waiting lists for talking therapies and delays in antidepressants taking effect. GPs described how some patients seemed more willing to try beta-blockers than antidepressants, as patients did not perceive them as 'mental health drugs' and therefore viewed them as potentially more acceptable and less stigmatising. Further, GPs viewed beta-blockers as 'patient-led', with patients managing their own dose and frequency, without GP input., Conclusion: Many GPs believe that beta-blockers have a role to play in the management of anxiety. Given recent increases in the prescribing of these drugs in primary care, there is a need to assess their safety and effectiveness as a treatment for people with anxiety disorders., (© The Authors.)

Background: Incident benzodiazepine prescriptions in primary care for anxiety decreased between 2003 and 2018. However, from 2008, incident prescribing of benzodiazepines for anxiety increased among those aged 18-34 years. There are increasing concerns around prescribing of benzodiazepines. Further, although guidelines state benzodiazepines should only be prescribed short term, in 2017, 44% of incident prescriptions were prescribed for longer than the recommended duration of 2-4 weeks., Aim: To understand when and why GPs prescribe benzodiazepines for anxiety in young adults., Design and Setting: A qualitative study was undertaken using in-depth interviews with 17 GPs from 10 general practices in South West England., Method: Interviews were conducted by telephone or videocall. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and data analysed using reflexive thematic analysis., Results: GPs described caution in prescribing benzodiazepines for anxiety in young adults, but thought they had an important role in acute situations. GPs described caution in prescribing duration, but some thought longer-term prescriptions could be appropriate. In light of these views, some GPs questioned whether primary care needs to revisit how clinicians are using benzodiazepines. GPs perceived that some young adults requested benzodiazepines and suggested this might be because they wanted quick symptom relief. GPs noted that refusing to prescribe felt uncomfortable and that the number of young adults presenting to general practice, already dependent on benzodiazepines, had increased., Conclusion: Patient-driven factors for prescribing benzodiazepines suggest there are current unmet treatment needs among young adults with anxiety. Given increases in prescribing in this age group, it may be timely to revisit the role of benzodiazepines in the management of people with anxiety in primary care., (© The Authors.)

Background: People with inflammatory rheumatological conditions (IRCs) are at high risk of developing other conditions including cardiovascular disease (CVD) and mood disorders., Aim: To explore perspectives of people with IRCs and healthcare practitioners (HCPs) on the content and delivery of a review consultation aimed at identification and management of multiple long-term conditions (mLTCs)., Design & Setting: Semi-structured interviews and focus groups with people with IRCs and HCPs in primary and secondary care., Method: People with IRCs participated in individual semi-structured interviews by telephone or online platform. HCPs (including primary and secondary care clinicians) participated in online focus groups. Data were transcribed verbatim and analysed using inductive thematic analysis., Results: Fifteen people with IRCs were interviewed; three focus groups with HCPs were conducted. The following two main themes were identified: reflecting on the value of review consultations; and what would a new review look like? Overall, people with IRCs and HCPs reflected that access to reviews is inequitable, leading to duplication of reviews and fragmentation in care. People with IRCs, at times, had difficulty conceptualising reviews, especially when discussing their future risk of conditions. People suggested that preparation before the healthcare review could align patient and HCP agendas as part of a flexible and person-centred discussion., Conclusion: Any review introduced for people with IRCs must move beyond a 'tick-box' exercise. To gain maximum value from a review, preparation from both patient and HCP may be required alongside a person-centred approach while ensuring they are targeted at people most likely to benefit., (Copyright © 2024, The Authors.)

Background: Evidence is sparse regarding service usage and the clinical management of people recently discharged from inpatient psychiatric care who die by suicide., Aim: To improve understanding of how people discharged from inpatient mental health care are supported by primary care during this high-risk transition., Design & Setting: A nested case-control study, utilising interlinked primary and secondary care records in England for people who died within a year of discharge between 2001 and 2019, matched on age, sex, practice-level deprivation, and region with up to 20 living discharged people., Method: We described patterns of consultation, prescription of psychotropic medication, and continuity of care for people who died by suicide and those who survived. Mutually adjusted relative risk estimates were generated for a range of primary care and clinical variables., Results: More than 40% of patients who died within 2 weeks of discharge and >80% of patients who died within 1 year of discharge had at least one primary care consultation within the respective time periods. Evidence of discharge communication from hospital was infrequent. Within-practice continuity of care was relatively high. Those who died by suicide were less likely to consult within 2 weeks of discharge (adjusted odds ratio [AOR] 0.61 [95% confidence interval {CI} = 0.42 to 0.89]), more likely to consult in the week before death (AOR 1.71 [95% CI = 1.36 to 2.15]), be prescribed multiple types of psychotropic medication (AOR 1.73 [95% CI = 1.28 to 2.33]), experience readmission, and have a diagnosis outside of the 'severe mental illness' definition., Conclusion: Primary care clinicians have opportunities to intervene and should prioritise patients experiencing transition from inpatient care. Clear communication and liaison between services is essential to provide timely support., (Copyright © 2024, The Authors.)

Background: Relapse of depression is common and contributes to the overall associated morbidity and burden. We lack evidence-based tools to estimate an individual's risk of relapse after treatment in primary care, which may help us more effectively target relapse prevention., Objective: The objective was to develop and validate a prognostic model to predict risk of relapse of depression in primary care., Methods: Multilevel logistic regression models were developed, using individual participant data from seven primary care-based studies (n=1244), to predict relapse of depression. The model was internally validated using bootstrapping, and generalisability was explored using internal-external cross-validation., Findings: Residual depressive symptoms (OR: 1.13 (95% CI: 1.07 to 1.20), p<0.001) and baseline depression severity (OR: 1.07 (1.04 to 1.11), p<0.001) were associated with relapse. The validated model had low discrimination (C-statistic 0.60 (0.55-0.65)) and miscalibration concerns (calibration slope 0.81 (0.31-1.31)). On secondary analysis, being in a relationship was associated with reduced risk of relapse (OR: 0.43 (0.28-0.67), p<0.001); this remained statistically significant after correction for multiple significance testing., Conclusions: We could not predict risk of depression relapse with sufficient accuracy in primary care data, using routinely recorded measures. Relationship status warrants further research to explore its role as a prognostic factor for relapse., Clinical Implications: Until we can accurately stratify patients according to risk of relapse, a universal approach to relapse prevention may be most beneficial, either during acute-phase treatment or post remission. Where possible, this could be guided by the presence or absence of known prognostic factors (eg, residual depressive symptoms) and targeted towards these., Trial Registration Number: NCT04666662., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. Published by BMJ.)

Background: Self-harm is a growing problem in young people. GPs are usually the first point of healthcare contact for young people aged 16-25 years, after self-harm. GPs can experience barriers to supporting young people and behaviour change theory can help to understand these, and the influences on, GP behaviour., Aim: To explore the capabilities, opportunities, and motivations (COM-B model of behaviour) of GPs, and their perceived training needs, to help young people aged 16-25 years avoid future self-harm., Design and Setting: This was a qualitative study of GPs in England., Method: Semi-structured interviews were conducted with NHS GPs who were purposively sampled. Interviews occurred in 2021. Data were analysed using reflexive thematic analysis and mapped onto the COM-B model domains. The study's patient and public involvement group supported data analysis., Results: Fifteen interviews were completed. Four themes were generated. GPs described mixed capabilities, with many feeling they had the physical and psychological skills to support young people to avoid future self-harm, but some felt doing so was emotionally tiring. GPs identified opportunities to better support young people, such as use of electronic consultation tools, but cited lack of time as a concern. GPs reported motivation to help young people, but this can be influenced by their workload. Unmet training needs around communication, knowledge, and optimising safety were identified., Conclusion: GPs are supported by their practice teams to support young people after self-harm, but a lack of time hinders opportunities to do so. Future effective GP-led interventions may improve GP motivation to support young people after self-harm., (© The Authors.)

Background: Self-harm in young people is a growing concern and reducing rates a global priority. Rates of self-harm documented in general practice have been increasing for young people in the UK in the last two decades, especially in 13-16-year-olds. General practitioners (GPs) can intervene early after self-harm but there are no effective treatments presently available. We developed the GP-led COPING intervention, in partnership with young people with lived experience and GPs, to be delivered to young people 16-25 years across two consultations. This study aims to examine the feasibility and acceptability of conducting a fully powered effectiveness trial of the COPING intervention in NHS general practice., Methods: This will be a mixed-methods external non-randomised before-after single arm feasibility study in NHS general practices in the West Midlands, England. Patients aged 16-25 years who have self-harmed in the last 12 months will be eligible to receive COPING. Feasibility outcomes will be recruitment rates, intervention delivery, retention rates, and completion of follow-up outcome measures. All participants will receive COPING with a target sample of 31 with final follow-up data collection at six months from baseline. Clinical data such as self-harm repetition will be collected. A nested qualitative study and national survey of GPs will explore COPING acceptability, deliverability, implementation, and likelihood of contamination., Discussion: Brief GP-led interventions for young people after self-harm are needed to address national guideline and policy recommendations. This study of the COPING intervention will assess whether a main trial is feasible., Registration: ISRCTN (ISRCTN16572400; 28.11.2023)., Competing Interests: Competing interests: FM and NK were members of the 2022 self-harm NICE clinical guideline development committee. No other competing interests were disclosed., (Copyright: © 2024 Mughal F et al.)

Background: People from ethnic minority groups are disproportionately affected by COVID-19, less likely to access primary health care, and have reported dissatisfaction with health care. Although the prevalence of long COVID in ethnic minority groups is unclear, such populations are underrepresented in long-COVID specialist clinics and long-COVID lived-experience research, which informed the original long-COVID healthcare guidelines., Aim: To understand the lived experiences of long COVID in people from ethnic minority groups., Design and Setting: Qualitative study of people living with long COVID in the UK., Method: Semi-structured interviews with people who self-disclosed long COVID were conducted between June 2022 and June 2023 via telephone or video call. Thematic analysis of the data was conducted. People who were living with long COVID, or caring for someone with long COVID, advised on all stages of the research., Results: Interviews were conducted with 31 participants representing diverse socioeconomic demographics. Help-seeking barriers included little awareness of long COVID or available support, and not feeling worthy of receiving care. Negative healthcare encounters were reported in primary health care; however, these services were crucial for accessing secondary or specialist care. There were further access difficulties and dissatisfaction with specialist care. Experiences of stigma and discrimination contributed to delays in seeking care and unsatisfactory experiences, resulting in feelings of mistrust in health care., Conclusion: Empathy, validation of experiences, and fairness in recognition and support of healthcare needs are required to restore trust in health care and improve the experiences of people with long COVID., (© The Authors.)

Background: Postnatal depression necessitates timely and effective interventions to mitigate adverse maternal and child outcomes in the short term and over the life course. British south Asian women with depression are often underserved and undertreated due to stigma, language barriers, and cultural barriers. This trial aimed to test the clinical efficacy of a culturally adapted, group cognitive behavioural therapy (CBT)-based intervention, the Positive Health Programme (PHP), delivered by non-specialist health workers for postnatal depression in British south Asian women., Methods: This study was a randomised controlled trial, with culturally adapted recruitment and an internal pilot, comparing the PHP (intervention group) with treatment as usual (control group) in British south Asian women with postnatal depression. The study was conducted at five centres across the UK. Participants were aged 16 years or older, met the DSM-5 criteria for depression, and had infants aged 0-12 months. Randomisation (1:1) was stratified by centre, with a block size of 18, and was done through an independent remote telephone service. The PHP was delivered over 12 group sessions in 4 months. The primary outcome was recovery from depression (defined as a Hamilton Depression Rating Scale [HDRS] score ≤7) at 4 months after randomisation, and an assessment was also done at 12 months. Analysis was on an intention-to-treat basis including only participants with non-missing outcome data; we used a random-effects logistic regression model including fixed covariates for study site, baseline depression severity (HDRS score), parity, and years in education and a random coefficient for therapy group. This trial is registered with the ISRCTN (ISRCTN10697380)., Findings: Of the 9136 individuals approached for recruitment between Feb 8, 2017, and March 29, 2020, 4296 women were eligible for and consented to screening, among whom 732 screened positive and were randomly allocated: 368 (50%) to the PHP group and 364 (50%) to the control group. Participants were mostly of Pakistani (397 [55%] of 719 with available data), Indian (176 [24%]), or Bangladeshi ethnicity (127 [18%]), with an overall mean age of 31·4 years (SD 5·2), with their youngest infants having a mean age of 23·6 weeks (14·2). At 4 months from randomisation, the proportion of participants who showed recovery from depression on the HDRS was significantly higher in the PHP group (138 [49%] of 281) than in the control group (105 [37%] of 281; adjusted odds ratio 1·97 [95% CI 1·26-3·10]). At the 12-month follow-up, this difference was no longer significant (1·02 [95% CI 0·62-1·66])., Interpretation: In British south Asian women with postnatal depression, a culturally adapted group CBT-based intervention could aid in quicker recovery from depression compared with treatment as usual. Further research is needed to identify how to sustain the treatment effect and establish strategies for scale-up., Funding: UK National Institute for Health and Care Research., Competing Interests: Declaration of interests CW has written two CBT-based self-help resources for postnatal low mood and class-based and online postnatal low mood courses unrelated to the PHP; and is the Director of Five Areas, a limited company that commercialises these resources and of which he is a shareholder. NH has been a past Trustee of the Pakistan Institute of Living and Learning, Abaseen Foundation UK, Lancashire Mind UK, and Manchester Global Foundation; is an executive member of the Academic Faculty at the Royal College of Psychiatrists, London; and is an NIHR Senior Investigator. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Anxiety and depression in older adults (60+ years of age) are under-diagnosed and under-treated. Older adults are less likely to seek help for these problems due to a lack of awareness, difficulty accessing health care due to availability or disability and fear of loss of independence. Existing points of contact between older adults and non-traditional services, for example, the Fire and Rescue Service (FRS), could provide opportunities to support help-seeking for mental ill-health. The FRS conduct Home Fire Safety Visits (HFSVs) with older adults and are well positioned to provide health-related support. This study examines a range of perspectives on the potential role of the FRS in the identification of, and signposting for, anxiety and depression in older adults., Methods: This was a qualitative study carried out using mixed methods in West Midlands, UK. Semi-structured interviews were conducted with older adults and health and social care providers (practitioners, managers, commissioners) to explore the acceptability of the FRS expanding its role to detect and signpost for anxiety and depression in older adults. Observations examined delivery of existing HFSVs to older adults. Data were combined and analysed using a reflexive thematic approach., Results: Eighteen health and social care providers and 8 older adults were interviewed; 10 HFSVs were observed. Two overarching themes were identified: (1) Potential role for the FRS and (2) Operationalising identification of mental health problems by FRS. Interviews and observations demonstrated how HFSVs offer a suitable opportunity to start conversations about mental health. All interview participants felt that although the FRS would be well placed to deliver an intervention, they would require training, support and a referral pathway co-produced with and supported by health and social care partners., Conclusion: A whole-system approach is needed if the FRS are to expand HFSVs to identify mental health problems in older adults and provide signposting to appropriate services., Patient or Public Contribution: J.S. is a public co-investigator. A Patient Advisory Group contributed to the initial funding application, design and conduct of the study, including data analysis and advice on dissemination., (© 2024 The Author(s). Health Expectations published by John Wiley & Sons Ltd.)

Background: General practitioners (GPs) are key to the frontline assessment and treatment of young people after self-harm. Young people value GP-led self-harm care, but little is known about how GPs manage young people after self-harm., Aim: This study aimed to understand the approaches of GPs to self-harm in young people and explore their perspectives on ways they might help young people avoid repeat self-harm., Methods: We conducted semi-structured interviews with GPs from the National Health Service in England in 2021. GPs were recruited from four geographically spread clinical research networks and a professional special interest group. Data were analysed using reflexive thematic analysis. The study's patient and public involvement and community of practice groups supported participant recruitment and data analysis., Results: Fifteen interviews were undertaken with a mean age of participants being 41 years and a breadth of experience in practice ranging from 1 to 22 years. Four themes were generated: GPs' understanding of self-harm; approaches to managing self-harm; impact of COVID-19 on consultations about self-harm; and ways to avoid future self-harm., Conclusion: Negative attitudes towards self-harm within clinical settings are well documented, but GPs said they took self-harm seriously, listened to young people, sought specialist support when concerned and described appropriate ways to help young people avoid self-harm. GPs felt that relationship-based care is an important element of self-harm care but feared remote consultations for self-harm may impede on this. There is a need for brief GP-led interventions to reduce repeat self-harm in young people., Patient and Public Contribution: A study advisory group consisting of young people aged 16-25 years with personal experience of self-harm and parents and carers of young people who have self-harmed designed the recruitment poster of this study, informed its topic guide and contributed to its findings., (© 2024 The Author(s). Health Expectations published by John Wiley & Sons Ltd.)

Introduction: Bipolar disorder is a recurrent mental health disorder with a prevalence rate of 1.4%. On average, there can be a delay of 9.5 years from the initial presentation of symptoms to a confirmed diagnosis. Individuals living with bipolar disorder have a reduced life expectancy. There is limited evidence regarding the effectiveness of antidepressants in treating bipolar disorder. The ASCEnD clinical trial will test the clinical and cost-effectiveness of the aripiprazole/sertraline combination in comparison with quetiapine for the treatment of bipolar depression (individuals who suffer from depressive episodes in bipolar disorder) and will include a nested qualitative study., Methods: The qualitative study will use semi-structured interviews to explore pilot trial participants' and clinicians' perspectives on recruitment procedures, the acceptability of the intervention, the management of bipolar disorder and attitudes to medication combinations., Conclusion: Findings will inform recruitment strategies and optimise training for the participating sites in the ASCEnD full trial. They will also help to illuminate the lived experience of people with bipolar disorder and the clinicians who work with people with bipolar disorder. The discussion will explore perspectives on the delay in diagnosis, having a diagnosis, the impact of living with bipolar disorder and attitudes to treatment, including drug combinations., Patient or Public Contribution: A Lived Experience Advisory Panel (LEAP) has been convened with the support of the McPin Foundation, which will contribute to the ASCEnD trial and its nested qualitative study to provide input on the design and delivery of the trial and qualitative study, analysis of qualitative data and dissemination of findings., (© 2024 The Author(s). Health Expectations published by John Wiley & Sons Ltd.)