Steven Jones

Background: Online health forums are used widely, yet evidence of their effectiveness is inconsistent. Evidence-based forum design guidance grounded in theory and lived experience could improve the efficacy and outcomes of these forums for the many people using them worldwide. Objective: This study aimed to draw on the experience of online forum users and staff, and insights from existing research on technology design and self-determination theory, to generate a set of theoretically grounded guidelines for safe and well-being–supportive online forums. Methods: We conducted 54 semistructured interviews (36 forum users and 18 forum staff) and 4 design workshops with forum staff, combined with input from a multidisciplinary research team. Principles of qualitative framework analysis were used to adapt a preexisting framework for well-being–supportive technology to the context of online health forums. Results: The resulting design guidelines are framed around 4 overarching principles relating to the psychological needs for autonomy, competence, and relatedness as defined by self-determination theory, and the additional need for safety in online forums. Each principle is presented alongside pragmatic design heuristics and specific implementation strategies. Conclusions: User experiences of online health forums are mixed. We have drawn on self-determination theory to propose evidence-informed guidelines for service development and refinement, adaptable to specific user groups across diverse settings.

The COVID-19 pandemic affected maternal mental health in the UK, increasing postpartum emotional distress. This scoping review identified forms of postpartum emotional distress (PPED) examined during the pandemic, the methodologies and assessment tools used, analytical approaches, reported limitations, future research directions, and overall findings. This review followed Arksey and O’Malley’s framework and the Joanna Briggs Institute scoping review guidelines. A comprehensive, keyword-based search strategy was applied across electronic databases, initially on 28 January 2023, and updated on 20 July 2023, and 3 September 2025. Strict inclusion criteria were used, and data from eligible studies were charted and synthesised. This review of 35 UK studies on postpartum emotional distress (PPED) during COVID-19 found a dominant focus on depression and anxiety, with other PPED forms largely neglected. Quantitative designs overwhelmingly outnumbered qualitative and mixed-method approaches. Common limitations included low sample diversity, reliance on online self-report surveys, cross-sectional designs, convenience sampling, and social-media-based recruitment. This review is the first to map research approaches used to explore postpartum emotional distress (PPED) during COVID-19 in the UK. The limitations and future research directions identified in this review highlight an urgent need for more diverse sampling, longitudinal study designs, qualitative research exploring women’s lived experience narratives of different forms of postpartum emotional distress, greater consideration of biopsychosocial factors, and evidence-based interventions.

Background: Suicide is a leading cause of death worldwide, particularly in people with severe mental health problems, including schizophrenia. The development, and testing, of suicide-focused psychological interventions which can combat suicidal experiences is an unrealised necessity. However, it is vital that suicide-focused therapies are derived from robust, evidence-based mechanistic suicide theories. The Schematic Appraisals Model of Suicide is one such theory. Objective(s): The Cognitive AppRoaches to coMbatting Suicidality project had two objectives. First, based on the Schematic Appraisals Model of Suicide, to test psychological pathways underlying suicidal thoughts, plans and attempts. Second, to test the efficacy of Cognitive–Behavioural Suicide Prevention for psychosis, a suicide-focused intervention developed by our team. Design: The randomised controlled trial had two groups: our suicide-focused therapy, Cognitive–Behavioural Suicide Prevention adapted Cognitive–Behavioural Suicide Prevention for psychosis, plus treatment as usual (treatment) versus treatment as usual only (control). There were three assessment time points of baseline, 6 and 12 months, with the 6-month time point being the critical point for the main primary outcome. Four qualitative methods workstreams were nested within the randomised controlled trial design. Settings: Four National Health Service Trust sites in the North West of England, United Kingdom: Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust, and the former North West Boroughs Healthcare NHS Foundation Trust. Participants: Main inclusion criteria: (1) non-affective psychosis (e.g. schizophrenia), (2) suicidal experiences in the 3 months prior to recruitment; (3) under the care of an National Health Service mental health services team and (iv) aged 18 or over. Main outcome measures: The primary outcome measure was the Adult Suicidal Ideation Questionnaire, which measures suicidal ideation severity over the past month using 25 self-report items. The 6-month follow-up assessment point was the critical time point. There were two secondary suicide measures. Mechanism measures captured six appraisals of emotional difficulties, lack of social support, interpersonal problem-solving difficulties, defeat, entrapment and hopelessness. Results: Recruitment ensued from on 21 June 2017 and lasted until 25 November 2020. The last 12-month follow-up assessment was completed on 10 January 2022. Two hundred and ninety-two participants were randomly allocated to the treatment ( N = 149) and control ( N = 143) groups. Reductions in suicidal ideation severity were not significantly greater in the treatment compared to the control group ( p = 0.07; 95% confidence interval −15.41 to 0.68) at month 6. There were, similarly, no significant treatment effects for the secondary suicide outcomes. A therapy ‘dose–response’ showed that each therapy session reduced the suicidal ideation severity score by 0.46, but this effect was also not significant ( p = 0.056; 95% confidence interval −0.94 to 0.01), nor was a compliance-adjusted analysis in which only participants who attended at least one session of therapy were included ( p = 0.052; 95% confidence interval −0.39 to 0.00). However, a predicted mediation pathway was statistically significant for one of the six mechanism measures, in which the therapy group relative to the control group improved social support appraisals, which, in turn, reduced suicidal ideation severity at month 6 (effect = −2.85, 95% confidence interval −7.00 to −0.23). Qualitative and mixed-methods findings showed that (1) feelings of not mattering, disconnection and irrelevance were central to suicidal thoughts, (2) it is vital to develop better ways of communicating about suicide, (3) our suicide-focused therapy was acceptable and feasible and (4) that being part of suicide work in a trial was largely a positive experience. Limitations: The sample was predominantly White/Caucasian and conducted in one geographical United Kingdom location, the primary outcome measure captured only suicidal thought severity, and there were only two follow-up time points. Conclusions: This suicide-focused psychological intervention did not demonstrate a treatment effect in the primary suicide outcome measure at month 6 at the 5% significance threshold. There was also no significant treatment effect for secondary suicide outcomes. Future work: Research programmes founded on convergent methods, and evidenced-based psychological suicide models are needed to examine how to bolster appraisals of poor social support, disconnection, and not mattering in the context of suicidal mind-sets, and in tandem with the development of creative and inclusive communication tools to relay suicidal experiences. In addition, exploration of the role of ‘dose’ of therapy is crucial for further treatment development. Trial registration: This trial is registered as ClinicalTrials.gov NCT03114917 and ISRCTN17776666. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme (NIHR award ref: 13/161/25) and is published in full in Efficacy and Mechanism Evaluation ; Vol. 13, No. 3. See the NIHR Funding and Awards website for further award information.

Many people use peer online forums to seek support for health-related problems. More research is needed to understand the impacts of forum use and how these are generated. However, there are significant ethical and practical challenges with the methods available to do the required research. We examine the key challenges associated with conducting each of the most commonly used online data collection methods: surveys, interviews, forum post analysis, and triangulation of these methods. Based on our learning from the Improving Peer Online Forums (iPOF) study, an interdisciplinary realist-informed mixed methods evaluation of peer online forums, we outline strategies that can be used to address key issues pertaining to assessing important outcomes, facilitating participation, validating participants (users who consent to take part in one or more parts of the study), protecting anonymity, gaining consent, managing risk, multistakeholder engagement, and triangulation. We share this learning to support researchers, reviewers, and ethics committees faced with deciding how best to address these challenges. We highlight the need for open, transparent discussion to ensure the research field keeps pace with evolving technology design and societal attitudes to online data use.

Background: Between major affective episodes some people with bipolar disorder experience persistent low mood or mood instability. Here we report an initial evaluation of the STABILISE programme (ISRCTN19416314; registration date 01.02.23), an adaptation of individual behavioural therapy that includes concepts and techniques addressing emotion regulation designed to support people experiencing these inter-episode symptoms. This study aimed to evaluate the safety, feasibility and acceptability of the intervention and to explore whether the pattern of clinical change had potential for the intervention to be of benefit. Twelve individuals with inter-episode bipolar symptoms received the STABILISE therapy in a randomised, multiple baseline case series. Participants were randomly assigned to wait 3, 4 or 5 weeks before commencing treatment, which comprised up to 22 sessions up to 7 months. Measures of symptoms, mood lability, recovery and quality of life were completed at intake, pre-therapy, and post therapy. Participants completed weekly measures of affective symptoms over the baseline and therapy periods, and for three weeks after. Results: All 12 participants completed the therapy programme and reported high levels of satisfaction overall. No adverse events were judged to be therapy related. There was one instance of reliable deterioration on one outcome measure. Across all parameters of clinical change 9 of the 12 participants showed an overall pattern of improvement and none showed a pattern of deterioration overall. Conclusions: This study provides preliminary support for the feasibility, acceptability, safety, and clinical potential of the STABILISE therapy. Further investigation of these aspects in a larger sample and within a randomised controlled trial design is required.

BACKGROUND The use of online forums to support health and wellbeing is widespread and growing, yet evidence of their safety and effectiveness is mixed. The absence of theory-informed guidance on how to design these forums, considering the expertise of forum users and moderators, is a barrier to improving outcomes. The development of evidence-based forum design guidance grounded in theory and lived experience could improve the efficacy and outcomes of these forums for the many people using them worldwide. OBJECTIVE To draw on the experience and expertise of online forum users and staff, together with insights from existing research on wellbeing-supportive design and self-determination theory, to generate a set of theoretically grounded and evidence-based design guidelines for safe, healthy and well-being supportive online forums. METHODS We conducted 52 semi-structured interviews with 36 forum users,18 with forum staff, and four design workshops with forum staff. We combined these with input from a multidisciplinary research team with expertise in forum delivery and evaluation. Principles of qualitative framework analysis were used to adapt a pre-existing framework for designing well-being supportive technology to the context of online health forums. RESULTS The resulting design guidelines for wellbeing supportive forum design are framed around four overarching principles relating to the psychological needs for autonomy, competence, and relatedness as defined by self-determination theory, and the additional need for safety in online forums. Each principle is provided with a series of pragmatic design heuristics and specific strategies that designers can use to promote the satisfaction of psychological needs in user experience and prevent harm. CONCLUSIONS User experience of online health forums shows that there is room for improvement with regard to how well these forums support basic psychological needs and safety. We have drawn on self-determination theory to respond to these findings by proposing a set of evidence-based guidelines for service development and refinement of online health forums. The guidance can be readily adapted to specific user groups across the diverse settings in which forums are hosted. INTERNATIONAL REGISTERED REPORT RR2-https://doi.org/10.1136/bmjopen-2023-075142

Background: Peer online forums offer people experiencing mental health challenges easily accessible and anonymous support. However, little is known about the impacts of using forums, how these impacts are generated, or who might benefit from which type of forum. Objective: We aimed to develop a program theory to understand how peer online mental health forums work to help potential users, health professionals, service providers, and commissioners to decide whether to use forums and which to choose. Methods: A realist evaluation using a mixed methods, case series design in collaboration with 7 peer online mental health forums was conducted. We triangulated analysis of a large web-based survey (n=791) with in-depth realist interviews (n=52) to test and refine previously developed program theories about the impacts of using online forums. We then analyzed forum posts to identify in situ evidence for our revised theories. We only used forum posts from individuals who had freely consented to posts being shared for research. Data collection and analysis involved extensive input from our patient and public involvement group, including forum users, moderators, and senior forum staff (n=22), which met monthly for 22 two-hour-long workshops throughout the study. Results: Impacts of using peer online mental health forums were largely positive. Forums that are easy to navigate, make users feel safe to post, and are supported by well-trained moderators offering timely and sensitive responses can help people find new ways to make sense of their mental health challenges, feel understood, and accepted in the forum. This can lead to an increase in self-efficacy, a reduction in self-stigma, and increased mental well-being. Writing about experiences in a forum can itself be cathartic, but when posts have evidently been helpful to other members, posters also benefit from a sense of greater purpose and value. Negative impacts can occur if forums are difficult to navigate or if moderation is unresponsive, insensitive, or inadequate, as users can be left feeling unheard, misunderstood, or overly responsible for the welfare of others. Conclusions: Forums offer accessible and inclusive ways to effectively support mental health for many people, some of whom may have limited access to other forms of help. The impacts on users are largely positive, but care is needed to ensure forums are well designed and moderators are well trained and supported. These findings are being used to inform the co-design of a web-based moderator toolkit and design guidelines, which will be made freely available. Trial Registration: ISRCTN 62469166; https://www.isrctn.com/ISRCTN62469166

Background: There has been an increase in the use of online mental health forums to support mental health. These forums are often moderated by trained moderators to ensure a safe, therapeutic environment. While the moderator role is rewarding, it can also be challenging. There is a need to understand the impact of the role on moderators and how they can best be supported to maintain psychological well-being. Objective: This study aimed to understand how, why, and in what contexts moderator well-being is affected by the moderator role and produce actionable recommendations for how moderators can best be supported to maintain workplace psychological well-being. Methods: We conducted realist synthesis of (1) published and gray literature from 2019 to 2023, (2) stakeholder interviews with forum moderators and hosts, and (3) moderator training manuals developed by organizations that host online mental health forums. Self-determination theory was used as the theoretical basis for this synthesis. Results: We developed 24 context-mechanism-outcome configurations from our realist analysis of 9 published papers, 18 interviews, and 5 training manuals. The findings highlight the specific ways in which moderator well-being can be supported through meeting the psychological needs for autonomy, competence, and relatedness. Forums that allow moderators to work in alignment with their personal motivations can increase moderator well-being. Forum organizations should support moderator competence through initial expectation setting, especially around moderator responsibility for user well-being, and ongoing support, such as meaningful supervision and peer support. Co-designed training, reflective practice, and experiential learning are all key to increasing moderator competence and satisfaction in the workplace. Working within a diverse team with access to innovative forum design can increase moderator psychological well-being. Organizational support for moderators’ well-being through monitoring and encouraging self-care is vital to ensure moderators can effectively carry out their role. Making and supporting meaningful relationships in the forum can boost psychological well-being and the therapeutic value of the moderator role. Key challenges for moderators were dealing with conflicts between supporting open discussion and ensuring a safe community environment, sharing lived experiences in positive ways for both moderator and user, and supporting people within the limitations of an anonymous forum. Conclusions: This realist synthesis is the first to examine the impacts on well-being of being a moderator of an online mental health forum. Recommendations to support moderator psychological well-being are proposed, targeted at specific stakeholder groups to aid implementation. Organizational-level endorsement and facilitation of support are particularly important for the realization of recommendations and interventions to support moderator well-being.

Background: Bipolar disorder (BD) is a severe mental health problem linked to substantial personal and social costs. Many individuals living with bipolar disorder are parents. Due to the nature of the condition, parents with BD often experience challenges in delivering consistent parenting. In addition, up to 60% of their children experience at least one mental health problem in childhood and are at increased risk of future severe mental health problems including bipolar disorder. This paper describes the rationale and protocol for a definitive randomised controlled trial of a new digital intervention (Integrated Bipolar Parenting Intervention; IBPI) to support effective parenting in the context of BD. Methods and design: The randomised controlled clinical and cost-effectiveness trial compares IBPI plus treatment as usual (TAU) with TAU alone. Parents with BD with a child aged 4–11 years old and living in the UK will be recruited through the NHS, mental health charities, and social media. Participants will be screened to confirm a clinical diagnosis of BD. They will then complete baseline assessments and be randomised to receive either IBPI + TAU or TAU with follow up assessments after 24- and 48- weeks. The primary clinical outcome is child emotional and behaviour problems measured by the Strengths and Difficulties Questionnaire at 24 weeks. The primary economic evaluation will be a cost-utility analysis at 24-weeks with quality-adjusted life years (QALYs) measured using the Child Health Utility 9 Dimensions measure of health-related quality of life. Secondary outcomes include parental mood and confidence and family functioning at 24- and 48- weeks, and child emotional and behavioural problems and health economic outcomes at 48 weeks. Discussion: Despite the challenges faced by children of parents with BD and the parents themselves, research on how to improve their lives is lacking. This will be the first definitive trial of a tailored intervention that aims to improve child and parent outcomes. Results will be reported in line with CONSORT guidance for clinical and health economic findings. Trial registration: ISRCTN Registry (ISRCTN15962574) registered on 03/05/2023.