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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

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.

Background National policies and guidelines advocate that mental health practitioners employ positive risk management in clinical practice. However, there is currently a lack of clear guidance and definitions around this technique. Policy reviews can clarify complex issues by qualitatively synthesising common themes in the literature. Aims To review and thematically analyse national policy and guidelines on positive risk management to understand how it is conceptualised and defined. Method The authors completed a systematic review (PROSPERO: CRD42019122322) of grey literature databases (NICE, NHS England, UK Government) to identify policies and guidelines published between 1980 and April 2019. They analysed the results using thematic analysis. Results The authors screened 4999 documents, identifying 7 eligible policies and 19 guidelines. Qualitative synthesis resulted in three main themes: i) the conflicting aims of positive risk management; ii) conditional positive risk management; and iii) responsible positive risk management. Conclusions Analysis highlighted discrepancies and tensions in the conceptualisation of positive risk management both within and between policies. Documents described positive risk management in different and contradictory terms, making it challenging to identify what it is, when it should be employed, and by whom. Five policies offered only very limited definitions of positive risk management.

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.]

Background Individuals with psychosis have poor oral health compared with the general population. The interaction between oral health and psychosis is likely to be complex and have important ramifications for improving dental and mental health outcomes. However, this relationship is poorly understood and rarely studied using qualitative methods. Aims To explore patient perspectives on the relationship between oral health and psychosis. Method The authors recruited 19 people with experiences of psychosis from community mental health teams, early intervention in psychosis services, and rehabilitation units. Participants completed a qualitative interview. Transcripts were analysed with reflexive thematic analysis. Results The analysis resulted in three themes: theme 1, psychosis creates barriers to good oral health, including a detachment from reality, the threat of unusual experiences and increased use of substances; theme 2, the effects of poor oral health in psychosis, with ramifications for self-identify and social relationships; and theme 3, systems for psychosis influence oral health, with central roles for formal and informal support networks. Conclusions Psychosis was perceived to affect adherence to oral health self-care behaviours and overall oral health. Poor oral health negatively affected self-identity and social relationships. Clinical implications include a systemic approach to provide early intervention and prevention of the sequelae of dental disease, which lead to tooth loss and impaired oral function and aesthetics, which in turn affect mental health. Participants felt that mental health services play an important role in supporting people with oral health.

Background: Going to university is an important milestone in many people’s lives. It can also be a time of significant challenge and stress. There are growing concerns about mental health amongst student populations including suicide risk. Student mental health and counselling services have the potential to prevent suicide, but evidence-based therapies are required that fit these service contexts. The Broad-Minded Affective Coping intervention (BMAC) is a brief (6 sessions), positive imagery-based intervention that aims to enhance students access to past positive experiences and associated emotions and cognitions. Pilot data provides preliminary support for the BMAC for students struggling with suicidal thoughts and behaviours, but this intervention has not yet been evaluated in the context of a randomised controlled trial (RCT). The Mental Imagery for Suicidality in Students Trial (MISST) is a feasibility RCT that aims to determine the acceptability and feasibility of evaluating the BMAC as an intervention for university students at risk of suicide within a larger efficacy trial. Key feasibility uncertainties have been identified relating to recruitment, retention, and missing data. Intervention acceptability and safety will also be evaluated. Method: MISST is a feasibility randomised controlled trial design, with 1:1 allocation to risk assessment and signposting plus BMAC or risk assessment and signposting alone. Participants will be university students who self-report experiences of suicidal ideation or behaviour in the past 3 months. Assessments take place at baseline, 8, 16, and 24 weeks. The target sample size is 66 participants. A subset of up to 20 participants will be invited to take part in semi-structured qualitative interviews to obtain further data concerning the acceptability of the intervention. Discussion: The BMAC intervention may provide an effective, brief talking therapy to help university students struggling with suicidal thoughts that could be

Background: Bipolar disorder is characterised by episodes of mania and depression that cause significant impairment and disruptions to people’s lives. This diagnosis has been linked to increased rates of suicide, reduced lifespan, and increased mortality, although there is limited research exploring the challenges faced by people with bipolar disorder as they age. It is possible that there is an important interaction effect between ageing and bipolar disorder that exacerbates the difficulties faced by this group, meaning further attention and support is required. This thesis investigated the challenges faced by older adults with bipolar disorder and explored their preferences, priorities, and needs in later life. Knowledge gathered from four studies helped to identify potential adaptations to care that can be used to improve quality of life in this population and enable them to age well with bipolar disorder. Methods: A range of methods were used to complete this thesis. First, a systematic review and narrative synthesis of 23 papers reporting on 19 studies was completed to investigate the prevalence and predictors of physical health comorbidities in older adults with bipolar disorder. Second, a qualitative study consisting of photo elicitation interviews with 17 participants used reflexive thematic analysis to analyse data and explore what it means to age well for older adults with bipolar disorder. Third, 16 biographical narrative interviews were analysed using narrative analysis to understand the changing care and care needs of older adults with bipolar disorder. Finally, a multilevel analysis of seven waves from The English Longitudinal Study of Ageing data was completed to examine quality of life in older adults with bipolar mood states and assess the predictors of quality of life in this group. Results: Ageing with bipolar disorder was associated with an increased prevalence of certain physical health comorbidities such as cardiovascular disease and some forms

BACKGROUND: People with severe mental illness (e.g. psychosis, bipolar disorder) experience poor oral health compared to the general population as shown by more decayed, missing and filled teeth and a higher prevalence of periodontal disease. Attending dental services allows treatment of oral health problems and support for prevention. However, people with severe mental illness face multiple barriers to attending routine dental appointments and often struggle to access care. Link work interventions use non-clinical support staff to afford vulnerable populations the capacity, opportunity, and motivation to navigate use of services. The authors have co-developed with service users a link work intervention for supporting people with severe mental illness to access routine dental appointments. The Mouth Matters in Mental Health Study aims to explore the feasibility and acceptability of this intervention within the context of a feasibility randomised controlled trial (RCT) measuring outcomes related to the recruitment of participants, completion of assessments, and adherence to the intervention. The trial will closely monitor the safety of the intervention and trial procedures. METHODS: A feasibility RCT with 1:1 allocation to two arms: treatment as usual (control) or treatment as usual plus a link work intervention (treatment). The intervention consists of six sessions with a link worker over 9 months. Participants will be adults with severe mental illness receiving clinical input from secondary care mental health service and who have not attended a planned dental appointment in the past 3 years. Assessments will take place at baseline and after 9 months. The target recruitment total is 84 participants from across three NHS Trusts. A subset of participants and key stakeholders will complete qualitative interviews to explore the acceptability of the intervention and trial procedures. DISCUSSION: The link work intervention aims to improve dental access and reduce oral hea

Objectives: To test the hypotheses that: (1) Prevalence of periodontal disease would be higher in people with a history of psychosis when compared to the general population and (2) Demographic, life‐style related factors and co‐morbid medical conditions would predict periodontal disease in people experiencing psychosis. Methods: The authors performed cross‐sectional analysis of baseline data from the UK Biobank study (2007–2010), identifying cases with psychosis using clinical diagnosis, antipsychotic medication, and self‐report. Demographic (age, gender, ethnicity, socioeconomic status), lifestyle‐related(BMI, blood pressure, smoking and alcohol intake, physical activity) and physical co‐morbidities (cancer, cardiovascular, respiratory, inflammatory disease and metabolic conditions) were included as potential risk factors for periodontal disease among people with a history of psychosis using logistic regression analyses. The analysis sample included 502,505 participants. Results: Risk of periodontal disease was higher in people with psychosis, regardless of how cases were identified. Patients with a clinical diagnosis had the highest proportion of periodontal disease compared to the general population (21.3% vs. 14.8%, prevalence ratio 1.40, 95% CI: 1.26–1.56). Older and female cases were more likely to experience periodontal disease. Lifestyle factors (smoking) and comorbidities (cardiovascular, cancer or respiratory disease) were associated with periodontal disease among people with a history of psychosis. Conclusions: The findings suggest that periodontal disease is more common in people with a history of psychosis, compared to the general population. Prevention and early diagnosis of periodontal disease should be a priority for oral health promotion programmes, which should also address modifiable risk factors like smoking which also contribute to co‐morbid systemic disease.

Objectives: To test the hypotheses that: (1) Prevalence of periodontal disease would be higher in people with a history of psychosis when compared to the general population and (2) Demographic, life‐style related factors and co‐morbid medical conditions would predict periodontal disease in people experiencing psychosis. Methods: The authors performed cross‐sectional analysis of baseline data from the UK Biobank study (2007–2010), identifying cases with psychosis using clinical diagnosis, antipsychotic medication, and self‐report. Demographic (age, gender, ethnicity, socioeconomic status), lifestyle‐related(BMI, blood pressure, smoking and alcohol intake, physical activity) and physical co‐morbidities (cancer, cardiovascular, respiratory, inflammatory disease and metabolic conditions) were included as potential risk factors for periodontal disease among people with a history of psychosis using logistic regression analyses. The analysis sample included 502,505 participants. Results: Risk of periodontal disease was higher in people with psychosis, regardless of how cases were identified. Patients with a clinical diagnosis had the highest proportion of periodontal disease compared to the general population (21.3% vs. 14.8%, prevalence ratio 1.40, 95% CI: 1.26–1.56). Older and female cases were more likely to experience periodontal disease. Lifestyle factors (smoking) and comorbidities (cardiovascular, cancer or respiratory disease) were associated with periodontal disease among people with a history of psychosis. Conclusions: The findings suggest that periodontal disease is more common in people with a history of psychosis, compared to the general population. Prevention and early diagnosis of periodontal disease should be a priority for oral health promotion programmes, which should also address modifiable risk factors like smoking which also contribute to co‐morbid systemic disease.

Objectives: Suicide is a major public health concern and is now considered to be the leading cause of death in young people. Suicidal ideation within student populations has recently increased. The Broad‐Minded Affective Coping (BMAC) offers a brief psychological intervention targeting suicidal ideation by enabling access to competing positive emotions and thoughts using guided imagery. Its acceptability and feasibility in student populations are unclear. Design: A single arm pilot study investigated the feasibility and acceptability of a six‐session BMAC intervention for university students experiencing suicidal ideation. Method: Recruitment took place from university counselling services. Suicidal ideation and emotional states were assessed at baseline and after 6 and 12 weeks. Participants also completed corresponding sessional measures. Results: Twelve eligible participants consented to take part with 11 receiving the intervention. Ten participants completed post treatment and follow up assessments. Retention to treatment was high with participants attending an average of 5.2 (87%; SD = 1.54) out of six intervention sessions. There were also good completion rates of the BMAC technique between sessions. Participants reported high levels of satisfaction with the intervention. There was an associated reduction across a range of clinical outcomes, including suicidal ideation, with large effect sizes. Discussion: This pilot study showed promising results on the feasibility and acceptability of the BMAC intervention in students experiencing suicidal ideation. However, the study had a small sample size and no comparator control group. Further exploration of the BMAC intervention is warranted.

Childhood bullying has been associated with longstanding deleterious social, physical, and psychological outcomes, and is increasingly being recognised as a global public health concern. Section one reports a quantitative systematic literature review examining the characteristics and psychometric properties of childhood bullying instruments that measure co-occurring traditional and cyber bullying behaviours. Four databases were searched (PsychInfo, CINAHL, Embase and Ovid) and fifteen studies reporting on fourteen separate instruments met requirements for inclusion. The findings of the review highlighted differences between how each instrument measured childhood bullying. Differences centered around how the instruments scales were constructed, the use of a bullying definition and terminology, referent time frames, and response options. In addition, the instrument’s methodological quality and psychometric robustness were also widely inconsistent. The review concluded that no study evaluated all psychometric properties within the three measurement domains: reliability, validity, and responsiveness. Thus, further research is required to comprehensively evaluate the psychometric robustness of the identified instruments. Section two reports on an empirical study examining whether childhood peer victimisation can predict quality of life (QoL) in individuals with a diagnosis of bipolar disorder (BD), when controlling for sociodemographics and clinical covariates. Participants (n=109) completed an online survey. Multiple regression analysis found neither offline nor online peer victimisation to be significant predictors of QoL in individuals diagnosed with BD. Post-hoc mediation analysis indicated depression and anxiety to have a full mediating effect on the relationship between both offline and online peer victimisation and QoL. The findings suggest childhood peer victimisation may play an important role in QoL for individuals with a diagnosis of BD through anxiety and dep

Aims To explore inpatient staff's understanding and implementation of positive risk management. Background Risk management is an essential skill for staff working in acute mental health inpatient settings. National policies advocate the use of positive risk management as a form of collaborative, recovery-focused risk management. However, little is known about how staff understand, operationalize, and use positive risk management in practice. Design Qualitative reflexive thematic analysis study. Methods The authors recruited a purposive sample of healthcare professionals working in acute inpatient settings (N = 16) in 2019 across three National Health Service Trusts in the North-West of England. Participants completed semi-structured interviews which were analysed using reflexive thematic analysis. Results The analysis generated three themes: (a) within staff barriers; (b) within service user barriers; and (c) delivery in practice. Conclusion Understanding and implementation of positive risk management was dependant on multiple factors, including staffs’ beliefs about mental health, levels of worry and anxiety, and amount of experience and seniority. Staff were more likely to use positive risk management with service users that they perceived as being trustworthy and less risky. Use of positive risk management was reliant on the support practitioners received, how able they were to view situations from multiple perspectives, and the degree to which they felt able to prioritize positive risk management. Impact Although staff expressed the desire and intention to practice positive risk management, the current study highlights challenges around operationalization and implementation. The authors discuss the clinical implications of the findings.

Mood monitoring is widely used in the treatment and self‐management of bipolar mood swings. Typically, service‐users record their affective states in a paper or electronic diary over an extended period (e.g. weeks, months). The aim is to help people to achieve greater awareness and understanding of their affective states, which then enables them to better prepare and account for problematic changes in their mood, preventing escalation to mood episodes and relapse.

Aims To explore inpatient staff's understanding and implementation of positive risk management. Background Risk management is an essential skill for staff working in acute mental health inpatient settings. National policies advocate the use of positive risk management as a form of collaborative, recovery-focused risk management. However, little is known about how staff understand, operationalize, and use positive risk management in practice. Design Qualitative reflexive thematic analysis study. Methods The authors recruited a purposive sample of healthcare professionals working in acute inpatient settings (N = 16) in 2019 across three National Health Service Trusts in the North-West of England. Participants completed semi-structured interviews which were analysed using reflexive thematic analysis. Results The analysis generated three themes: (a) within staff barriers; (b) within service user barriers; and (c) delivery in practice. Conclusion Understanding and implementation of positive risk management was dependant on multiple factors, including staffs’ beliefs about mental health, levels of worry and anxiety, and amount of experience and seniority. Staff were more likely to use positive risk management with service users that they perceived as being trustworthy and less risky. Use of positive risk management was reliant on the support practitioners received, how able they were to view situations from multiple perspectives, and the degree to which they felt able to prioritize positive risk management. Impact Although staff expressed the desire and intention to practice positive risk management, the current study highlights challenges around operationalization and implementation. The authors discuss the clinical implications of the findings.

Mood monitoring is widely used in the treatment and self‐management of bipolar mood swings. Typically, service‐users record their affective states in a paper or electronic diary over an extended period (e.g. weeks, months). The aim is to help people to achieve greater awareness and understanding of their affective states, which then enables them to better prepare and account for problematic changes in their mood, preventing escalation to mood episodes and relapse.