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The majority of research into the mental health benefits of blue space (outdoor places where water is a central feature) has focussed on the associations between neighbourhood exposure to these spaces and population‐level incidence of unipolar depression or anxiety disorder. There has been little exploration of the therapeutic use of blue space by those navigating bipolar, schizophrenia or other psychotic conditions. Knowledge arising from such an exploration could assist in the design and optimisation of nature‐based care for people with these conditions, as well as with self‐management. We conducted semi‐structured online and telephone interviews with 19 adults who self‐reported experience of these conditions. Interviews were conducted in the United Kingdom from August to December 2021. We describe four of the key interpretive themes identified via an in‐depth inductive thematic analysis of the interview transcripts to highlight how participants sought out moments of affective sanctuary through their blue encounters. Blue spaces were described as having the potential to reset the mind, emotions and body. This was in part due to their socially undemanding nature, and ability to provide respite from a socially stressful world. Participants described developing a blue identity, whereby a sense of attachment to and shared history with these places was articulated as well as incorporating blue spaces into self‐ and emotion‐regulation practices. Finally, participants described experiences of and recommendations for a therapeutic blue intervention. The role of biodiversity in contributing to the benefits of blue spaces was implied primarily in terms of perceived soundscapes, but also through visual observations. Synthesis and applications. Blue care for people with bipolar, schizophrenia or other psychotic conditions should consider the need that some individuals have for solitude and proximity to their home when they visit blue spaces, as well as individual differences

OBJECTIVE: Living Library events involve people being trained as living 'Books', who then discuss aspects of their personal experiences in direct conversation with attendees, referred to as 'Readers'. This study sought to generate a realist programme theory and a theory-informed implementation guide for a Library of Lived Experience for Mental Health (LoLEM). DESIGN: Integrated realist synthesis and experience-based co-design. SETTING: Ten online workshops with participants based in the North of England. PARTICIPANTS: Thirty-one participants with a combination of personal experience of using mental health services, caring for someone with mental health difficulties and/or working in mental health support roles. RESULTS: Database searches identified 30 published and grey literature evidence sources which were integrated with data from 10 online co-design workshops conducted over 12 months. The analysis generated a programme theory comprising five context-mechanism-outcome (CMO) configurations. Findings highlight how establishing psychological safety is foundational to productive Living Library events (CMO 1). For Readers, direct conversations humanise others' experiences (CMO 2) and provide the opportunity to flexibly explore new ways of living (CMO 3). Through participation in a Living Library, Books may experience personal empowerment (CMO 4), while the process of self-authoring and co-editing their story (CMO 5) can contribute to personal development. This programme theory informed the co-design of an implementation guide highlighting the importance of tailoring event design and participant support to the contexts in which LoLEM events are held. CONCLUSIONS: The LoLEM has appeal across stakeholder groups and can be applied flexibly in a range of mental health-related settings. Implementation and evaluation are required to better understand the positive and negative impacts on Books and Readers. TRIAL REGISTRATION NUMBER: PROSPERO CRD42022312789.

Objectives: The objective of this study is to explore what ageing well means to older adults with bipolar disorder. Methods: Older adults with bipolar disorder took photographs of aspects of their lives that they felt represented ageing well. They then completed audio-recorded photo elicitation interviews to explore what it meant to age well with bipolar disorder in detail. Data were analysed using reflexive thematic analysis. Results: Seventeen participants met the criteria for bipolar disorder I or II. The analysis resulted in four key themes to ageing well with bipolar disorder: (1) Lifelong learning – referring to how participants accumulated a wealth of knowledge about bipolar disorder and used this to maintain stability in later life; (2) Finding where you belong – relating to how participants prioritised finding new communities, utilised family support and refined their support networks over time to age well; (3) Recognising your value and worth – which involved participants using their strengths and experiences to support others; and (4) Continuity of support – older adults with bipolar disorder highlighted the benefits of continuous support that allowed them to be actively involved in their treatment. Conclusions: Participants ageing with bipolar disorder identified unique challenges indicating that services require adaptation to meet their needs and support them to age well. Findings suggested that services should provide continuous care that allows this group to actively engage with their treatment, build upon their strengths, and develop meaningful connections with professionals and peers. This approach may enhance support for older adults with bipolar disorder and reduce the inequalities they experience.

Mental health peer support forums have become widely used in recent years. The emerging mental health crisis and the COVID-19 pandemic have meant that finding a place online for support and advice when dealing with mental health issues is more critical than ever. The need to examine, understand and find ways to improve the support provided by mental health forums is vital in the current climate. As part of this, we present our initial explorations in using modern transformer models to detect four key concepts (connectedness, lived experience, empathy and gratitude), which we believe are essential to understanding how people use mental health forums and will serve as a basis for testing more expansive realise theories about mental health forums in the future. As part of this work, we also replicate previously published results on empathy utilising an existing annotated dataset and test the other concepts on our manually annotated mental health forum posts dataset. These results serve as a basis for future research examining peer support forums.

BACKGROUND: Online forums are widely used for mental health peer support. However, evidence of their safety and effectiveness is mixed. Further research focused on articulating the contexts in which positive and negative impacts emerge from forum use is required to inform innovations in implementation. OBJECTIVE: This study aimed to develop a realist program theory to explain the impacts of online mental health peer support forums on users. METHODS: We conducted a realist synthesis of literature published between 2019 and 2023 and 18 stakeholder interviews with forum staff. RESULTS: Synthesis of 102 evidence sources and 18 interviews produced an overarching program theory comprising 22 context-mechanism-outcome configurations. Findings indicate that users' perceptions of psychological safety and the personal relevance of forum content are foundational to ongoing engagement. Safe and active forums that provide convenient access to information and advice can lead to improvements in mental health self-efficacy. Within the context of welcoming and nonjudgmental communities, users may benefit from the opportunity to explore personal difficulties with peers, experience reduced isolation and normalization of mental health experiences, and engage in mutual encouragement. The program theory highlights the vital role of moderators in creating facilitative online spaces, stimulating community engagement, and limiting access to distressing content. A key challenge for organizations that host mental health forums lies in balancing forum openness and anonymity with the need to enforce rules, such as restrictions on what users can discuss, to promote community safety. CONCLUSIONS: This is the first realist synthesis of online mental health peer support forums. The novel program theory highlights how successful implementation depends on establishing protocols for enhancing safety and strategies for maintaining user engagement to promote forum sustainability. TRIAL REGISTRATION: PRO

Objectives: Suicide is a leading cause of death worldwide. People experiencing psychosis are at increased risk of death by suicide. Talking therapies can alleviate suicidal thoughts, plans, and attempts. Therapies need to also be acceptable to recipients. The aim of this study was to investigate the views on psychological therapy for people experiencing psychosis and suicidality using the Theoretical Framework of Acceptability. Design: Qualitative interview study. Methods: Participants were recruited from a randomised controlled trial comparing suicide prevention psychological therapy with treatment as usual. Individuals had a diagnosis of non‐affective psychosis and experience of suicidal thoughts, plans and/or attempts. To assess the acceptability of the therapy, semi‐structured interviews were conducted with 20 participants randomised to receive therapy. Data were deductively analysed using an adaptation of the Theoretical Framework of Acceptability. Results: Interviews (Mean = 45 min) were conducted and audio recorded with 21 participants. Data were organised into six themes: 1. Affective attitude, 2. Burden, 3. Alliance, 4. Intervention coherence, 5. Perceived effectiveness, and 6. Self‐efficacy. There was no evidence of issues relating to domains of ethicality and opportunity costs associated with receiving therapy. Conclusions: Talking about suicide was difficult and, at times, distressing, but it was perceived to be useful for understanding experiences. To be acceptable, it is important for therapists to ensure that clients' understanding of therapy aligns with expectations of effectiveness and to invest in building strong therapeutic alliances. Future research will benefit from examining therapists' experiences of delivering therapy through different modes (e.g. online, telephone).

To ascertain the prevalence and predictors of physical health comorbidities in older adults with bipolar disorder. The authors conducted a systematic review and narrative synthesis of peer-reviewed journal articles reporting on physical health comorbidities in older adults (aged ≥50) with a diagnosis of bipolar disorder. The Mixed Methods Appraisal Tool (MMAT) assessed study quality. 23 papers reporting on 19 studies met the inclusion criteria. The literature on diabetes, obesity and renal disease was inconclusive. There was some tentative evidence to higher rates of cardiovascular disease and some forms of cancer in older adults with bipolar disorder in comparison to the general population, but this requires further investigation. We identified no studies looking at oral health. The quality ratings of the identified research were generally low. Very few studies included a comparison sample from the general population or controlled for key covariates in their analysis. Existing literature provides tentative evidence that some physical health comorbidities are elevated in older adults with bipolar disorder. Clinicians should consider interventions that improve the physical health of this group, alongside the chronic mental health difficulties they experience. [Abstract copyright: Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.]

Purpose: Friends and family members can be important sources of support for people who are or have been suicidal. This review aimed to synthesise qualitative evidence regarding carers' perspectives of supporting someone who has experienced suicidal behaviour. Methods: Five electronic databases (Web of Science, CINAHL, PsychINFO, MEDLINE, and SocINDEX) were searched from inception to May 2022. Eligible qualitative studies were published in English and investigated the caring experiences of friends or family members of people who had experienced suicidal behaviour, defined as any form of suicidal ideation and/or attempts. Studies focused on non‐suicidal self‐injury or suicide bereavement were excluded. Data from 19 eligible studies were analysed using thematic synthesis. Results: Initial carer reactions to suicidal behaviour included profound anxiety and intensive monitoring for signs of increased suicide risk amongst those they supported. Carers also reported significant challenges with understanding how to provide effective interpersonal support following suicidal crises. Professional support was perceived to be most effective when provided in a timely, interpersonally sensitive and safety‐focused manner. However, several studies detailed carers' difficulties accessing appropriate support and challenges managing their own distress. Conclusions: Carers face significant challenges with knowing how to respond to suicidal behaviour, where to find appropriate help, and how to manage their own distress. Future research should seek to investigate the effectiveness of easily accessible methods of information provision and support tailored for carers of people who have experienced suicidal behaviour.