Sonia Johnson

Background: Therapeutic relationships between service users and staff on inpatient mental health wards are central to the delivery of high-quality care and have been prioritised by policy makers. Yet these relationships are frequently found to be poor across inpatient settings, and more evidence is needed on how to foster good therapeutic relationships. In collaboration with lived experience researchers, we conducted a large systematic review, which was requested and carried out in partnership with NHS England, to identify facilitators and barriers to effective therapeutic relationships on inpatient wards. Methods: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC (between January 1999-September 2025) for quantitative, qualitative or mixed methods primary research studies. Study quality was assessed using the Mixed Method Appraisal Tool (MMAT). Data were synthesised using an iterative analytic process, informed by framework analysis and narrative synthesis, across five interconnected levels: 1) individual (service user and staff experiences), 2) microsystem (daily interactions), 3) mesosystem (ward environment), 4) macrosystem (the wider organisation), 5) chronosystem (time and change across levels). Results: 184 studies with 19,984 participants (n=16,138 service users, n=3,846 staff) were included. Across study designs, four main categories emerged: 1) reducing power imbalances helped facilitate positive relationships and, conversely, restrictive practices damaged them; 2) staff relational skills including empathy, non-judgemental approaches and treating service users as individuals, rather than simply ‘patients’, helped build positive relationships; 3) staff continuity and time for staff to connect with service users was critical to building positive relationships; ward contexts that prioritised task completion and/or were risk-focused weakened relationships; 4) ward environments that created opportunities to build interpersonal connections between staff and service users (e.g. shared spaces) strengthened relationships whereas those that provided limited opportunities for interaction weakened relationships. Conclusion: We identified four key factors that can help or hinder therapeutic relationships on mental health inpatient wards: power dynamics between staff and service users; restrictive practices; relational skills of staff; staff availability and consistency, and ward environments that facilitated interpersonal connections. We found evidence gaps particularly for minoritised ethnic communities and organisational influences. We suggest strategies which could help relationship building, including support with repairing relational ruptures, greater emphasis on relationship building in staff roles, and ward environments that support connection. Registration: The protocol was registered with PROSPERO (registration number: CRD420251047929).

Background: Autistic people experience substantially higher rates of mental health conditions and are overrepresented in mental health services. However, most interventions and service models have been developed for non-autistic people, and evidence is needed as to whether there are disparities in outcomes. This systematic review aimed to compare outcomes between autistic and non-autistic people receiving the same mental health interventions or services. Methods: We conducted a systematic review following PRISMA guidelines (PROSPERO: CRD420251021068). We searched academic databases (MEDLINE, Embase, PsycINFO, PubMed, CINAHL), a grey literature database (HMIC), a trial registry (ISRCTN), preprint servers (medRxiv and PsyArXiv), Google, and Google Scholar, to identify relevant papers published 01/01/1992-30/04/2026. We conducted backwards and forwards citation searching and contacted experts. Study quality was assessed using a modified Critical Appraisal Skills Programme Cohort Study Checklist and the Autism-Inclusive Research Assessment (AIRA). Data were synthesised narratively, with random effects meta-analyses where appropriate. Results: Thirty-nine studies were included, comprising 4787730 participants, assessing outcomes of psychological therapies (n = 17) and multi-component or service-level approaches (n = 22). Nearly half (46.2%) were UK-based, and under a quarter (23.1%) included people with intellectual disabilities. Ten studies (25.6%) were rated low quality, twenty-two (56.4%) medium quality, and seven (17.9%) high quality. AIRA ratings highlighted concerns about research inclusiveness for autistic people, including limited involvement of autistic people and lack of validated or adapted outcome measures. Findings varied by intervention: for some, multiple large, higher-quality studies showed less favourable outcomes for autistic people (e.g., less improvement in symptoms or functioning, or higher rates of restrictive practices or acute service use). For other interventions, comparable or mixed outcomes were found across studies, with interpretation often limited by small samples. Conclusions: Mental health treatment outcomes for autistic versus non-autistic people varied across interventions and outcome types. Where significant differences were observed, these usually showed poorer outcomes for autistic people, although they generally reflected smaller improvements rather than a lack of benefit. Action is needed to improve the accessibility and appropriateness of mental health care for autistic people, supported by more high-quality, co-produced research across a broader range of countries and service contexts.

Background: Loneliness has been increasingly associated with poor mental health outcomes, yet its prognostic role in people with Common Mental Disorders (CMDs) remains unclear. This systematic review aimed to examine whether loneliness is longitudinally associated with mental health outcomes in individuals with CMDs, regardless of treatment status. Methods: We searched PsycINFO, MEDLINE, Embase and CINAHL from inception to October 2025 for longitudinal studies examining associations between baseline loneliness and CMD outcomes at follow-up. Eligible studies included adults aged 16+ with CMDs. We conducted a narrative synthesis and where appropriate, random-effects meta-analyses for binary depression outcomes reflecting unfavourable course (recurrence, persistence, or non-remission). Study quality was assessed using the Newcastle-Ottawa Scale, and certainty of evidence was evaluated using GRADE. The protocol was registered with PROSPERO (registration number: CRD42023410401). Results: We included 22 studies, of which the majority focused on depression-related outcomes (operationalised as symptom severity, recurrence, persistence, remission, and service utilisation). Our narrative synthesis showed consistent associations between higher baseline loneliness and poorer depression-related outcomes at follow-up in people with CMDs across clinical, community, and treatment settings. Meta-analysis of four studies (all in older adults with depression) showed that individuals reporting loneliness at baseline had over three times the odds of poor depression outcomes at follow-up compared with those not lonely (pooled adjusted OR 3.26, 95% CI [2.26–4.70], p < 0.001). This finding should be interpreted with caution, as only one of the four studies adjusted for baseline depressive symptom severity. The few studies capturing suicidal ideation, anxiety, and mixed CMD outcomes found limited and inconsistent evidence. The GRADE certainty of evidence was high for depression outcomes, low for suicidal ideation and anxiety outcomes, and very low for mixed CMD outcomes. Conclusions: Loneliness is consistently associated with poorer subsequent depression outcomes in people with CMDs, particularly depressive disorders. These findings suggest loneliness may represent an important prognostic factor in depression and warrant further evaluation in intervention studies. Further high-quality longitudinal research is needed to clarify whether—and under what conditions—loneliness affects outcomes for other CMDs and treatment effectiveness.

Introduction: Early Intervention in Psychosis services were established throughout England over two decades ago, yet despite aiming to optimise care, less than 40% of patients achieve full clinical recovery and notable inequities persist in accessing NICE‐recommended treatments. Fragmented electronic health record systems and limited systematic data capture conceal how disparities in care delivery and effectiveness affect recovery and remission. The Early Psychosis Informatics into Care, EPICare, programme aims to develop a national, learning healthcare system incorporating a standardised core dataset and clinician dashboard to support equitable, data‐driven care. Methods: Our stakeholder co‐design approach comprised three interlinked work packages delivered between 2021 and 2022. Using participatory co‐design, we conducted four multi‐stakeholder workshops and preparatory lived experience sessions with people with lived experience, clinicians, informaticians, academics, and policymakers. We identified essential data elements using adapted “MoSCoW” card sort methodology, refined content, and developed dashboard requirements. Parallel informatics and implementation research assessed technical feasibility, data maturity, and harmonisation requirements and evaluated anticipated barriers and facilitators to future adoption. Results: Consensus was achieved on core EPICare dataset “must haves” including sociodemographic variables, routine treatment interventions, Patient‐ and Clinician‐Reported Outcome Measures, and longitudinal symptom data. Stakeholders defined key dashboard features, prioritising usability and alignment with clinical workflow. Substantial variation in Trust‐level data infrastructure informed flexible technical architecture to mitigate implementation risk. Conclusion: EPICare stakeholder engagement delivered the blueprint for a co‐designed, technically feasible and nationally scalable specification for a psychosis learning healthcare system, enabling progression to platform development and piloting across five Early Intervention in Psychosis services in the NHS.

Early Support Hubs are an emerging model of youth mental health provision, designed to offer holistic, open-access support for young people whose needs often fall below the threshold for specialist services. Despite increased expansion in many countries, little is known about how these Hubs are implemented in practice or the challenges faced by those responsible for delivering them. This paper presents a qualitative interview study with 19 managers of Early Support Hubs in England. A codebook thematic analysis was used to explore managers’ perceptions of the purpose of Early Support Hubs and factors that support or hinder effective implementation. Three overarching themes were identified. First , Hubs adopted a youth-centred, holistic ethos, characterised by open access and flexible support. Second , Hubs are balancing offers of early, brief interventions against the need for tailored/specialist support for some young people. Third , systemic factors key to effective delivery, include the need for strong inter-agency partnerships, a diverse and adaptable workforce, and sustainable funding. Early Support Hubs hold promise as an accessible, youth-led model that can plug gaps in traditional mental health systems and offer continuity across the transition into adulthood. However, these models are constrained by short-term funding cycles, workforce limitations, and rising demand from young people with more complex mental health needs. Establishing consistent service models, strengthening referral pathways, and securing long-term investment will be essential to realising the full potential of Early Support Hubs.

IntroductionEarly Intervention in Psychosis (EIP) services reduce the burden of psychotic disorders, yet significant inequities persist across England in access to NICE‑recommended treatments, provision of psychological therapies, and long‑term outcomes. These disparities are compounded by fragmented electronic health record (EHR) systems, inconsistent data capture, and limited interoperability, preventing routine real‑time evaluation of care quality and effectiveness. The Early Psychosis Informatics into Care (EPICare) programme aims to develop a national learning healthcare system incorporating a standardised core dataset and clinician dashboard to support equitable, data‑driven psychosis care. MethodsOur stakeholder co-design approach comprised three interlinked work packages delivered between 2021 and 2022. Using a participatory co‑design approach, four multi‑stakeholder workshops and preparatory lived‑experience sessions were conducted to identify essential data elements, refine content, and develop dashboard requirements. Stakeholders included people with lived experience, carers, clinicians, informaticians, academics, and policymakers. Parallel informatics work examined EHR systems across five NHS Mental Health Trusts to assess technical feasibility, data maturity, and harmonisation requirements. Implementation research—via interviews and workshop observations—evaluated anticipated barriers and facilitators to future adoption. ResultsConsensus was achieved on a core EPICare dataset including sociodemographic variables, NICE psychosis standard measures, PROMs (DIALOG, GBO, ReQOL), CROMs (HoNOS, symptoms), and longitudinal symptom data. Stakeholders defined key dashboard features such as outcome notifications, treatment reminders, and performance indicators, prioritising usability and alignment with clinical workflow. Substantial variation in Trust‑level data infrastructure informed a flexible technical architecture to mitigate implementation risk. DiscussionOur EPICare stakeholder engagement delivered a co‑designed, technically feasible and nationally scalable specification for a psychosis learning health system, enabling progression to platform development and piloting across five NHS demonstrator Trusts.

Introduction: Cumulative interpersonal traumatisation increases the risk of psychosis and is linked to psychotic symptom severity and reduced recovery rates. Psychosis and treatment themselves can also be traumatising, with a first episode of psychosis posing challenges to one’s identity. Despite a growing evidence base for the safety and effectiveness of trauma therapies for psychosis, implementation remains poor in early intervention for psychosis (EIP) services, partly due to resource constraints. Narrative exposure therapy (NET) is an effective intervention for post-traumatic stress disorder in ethnically diverse populations. Crucially it has potential to address barriers to implementation of trauma therapies in EIP as it has a brief duration with minimal training requirements. This feasibility study will evaluate the feasibility and acceptability of conducting a definite trial of NET in people with early psychosis. Methods and analysis: An individually randomised parallel groups feasibility randomised controlled trial with embedded qualitative evaluation will be conducted. 50 individuals with first episode psychosis and a history of multiple trauma under the care of an EIP service in two NHS trusts in England will be recruited. Participants will be randomised to receive either 15 sessions of NET in addition to treatment as usual or treatment as usual alone. Assessor blinded assessments will be conducted at baseline, 4 months (post-intervention) and 8 months (follow-up). Analyses will focus on feasibility outcomes (recruitment, retention and completion rates) and preliminary estimates of intervention effects to inform planning for a fully powered trial. Qualitative interviews will be carried out with participants allocated to NET and clinicians to investigate acceptability, barriers and facilitators, possible mechanisms of change, potential benefits or harms and recommendations. A sub-study in the NET group will investigate acceptability of completing Experience Sampling Data daily during therapy to monitor changes on candidate primary and secondary outcomes. Ethics and dissemination: This study received REC/HRA ethical approval from the London - City & East Research Ethics Committee (REC) (25/LO/0350). The results of the study will be reported and disseminated at international conferences and in open-access peer-reviewed scientific journals. Trial registration number: ISRCTN39471182 .

Background: Improving access to high-quality community-based crisis care and reducing inpatient admissions are key policy objectives in England, yet evidence on who uses crisis-related services and potential inequalities in access remains limited. Aims: To examine socio-demographic patterns in the use of six crisis-related services in England: 1) Crisis phonelines; 2) Crisis cafes; 3) Crisis Resolution and Home Treatment teams (CRHTs); 4) Voluntary inpatient admissions; 5) Compulsory inpatient admissions under the Mental Health Act 1983 (MHA); and 6) conveyance to a Place of Safety (PoS) by police under section 136 of the MHA. Method: We conducted a retrospective observational study using the Mental Health Services Data Set between 2021/22 and 2023/24. Adults (aged 18+) using any of the six services were included. A multinomial logit regression model was used to estimate the average marginal effects for age, sex, ethnicity, and area-level deprivation, with robust patient-level standard errors and year fixed-effects. Results: Within this population using any crisis-related services, adjusted analysis showed people from several ethnic minority backgrounds were more likely to be compulsorily detained or brought to a PoS by police, and less likely to use CRHTs than White individuals, with largest disparities in compulsory admissions for Black (+15.0 percentage points [pp]) and Asian (+7.3 pp) groups. Compulsory admissions were more common among older adults and men (+1.5 pp). Crisis phonelines were less commonly used by older adults, men (-4.8 pp), and people from Black (-15.6 pp) and Asian (-4.7 pp) backgrounds. Crisis cafes showed more even demographic distributions. Although adjusted differences by deprivation were small (all <1.0 pp), over half of all users lived in the two most deprived quintiles. Conclusions: Among crisis-related service users, demographic groups at greater risk of coercive care are less likely to access community crisis services. Addressing these disparities could improve access and reduce inequalities.

Compulsory admissions to psychiatric hospitals have been rising in England and some other higher-income countries. Patients and families often find such ad

Early Support Hubs have recently become widespread in the UK and aim to provide community-based, easy access mental health support to young people aged 11-25, integrating a variety of forms of support. Evidence is needed on the role such services aim to fulfil in addressing young people’s mental health needs, perceived good practice in their operations and challenges encountered in achieving this. In order to understand this, we conducted individual interviews with 24 staff members from eight Hubs across England. We analysed data using codebook thematic analysis, identifying five themes: providing varied and holistic support; supported signposting and referrals; visibility and accessibility of hubs; important values embedded in the model, and remaining unmet needs. All participants felt that receiving care from Early Support Hubs could improve young people’s mental health, wellbeing and social circumstances. Important values guiding the practice of Hubs included being youth-centred, providing easily accessible and comfortable safe spaces, and employing staff whose approach is in keeping with Hubs’ values and ethos. Barriers to implementing the intended model included inadequate staffing levels, limited opening hours, and high staff turnover. Where they could not meet young people’s mental health needs, an intended role of the Hubs was to support them to find appropriate help: however, young people with significant mental health difficulties referred on by the Hubs sometimes did not meet high thresholds for receiving treatment from local mental health services. Research is needed to further understand the Hubs’ role in the system as a whole, their overall impact on addressing the rising burden of young people’s mental ill health, and how well-functioning local service systems that do not result in significant gaps in provision can be established.