Claire Wicks

Background: Common mental health conditions are increasing in England, with growing severity and unmet need. Evidence shows that mental wellbeing is strongly shaped by wider social determinants such as income, housing, employment, and relationships. Conventional clinical approaches may not adequately address these underlying factors, highlighting the need for preventative, community-based solutions. Aim: This paper describes the community involvement and engagement (CEI) approach used to develop CoSign, a digital signposting tool designed to help individuals identify social determinants contributing to mental distress and access appropriate community support. Involvement and engagement approach: The development of CoSign incorporated CEI throughout the research process, guided by the INVOLVE research-cycle framework and the IAP2 Spectrum of Public Participation. A total of 29 stakeholders—including healthcare professionals, voluntary sector representatives, policymakers, and individuals with lived experience—contributed through workshops, consultations, and collaborative activities. Engagement focused on shaping the tool’s design, content, accessibility, and implementation considerations. Activities and impact: Stakeholder input informed key aspects of CoSign, including the identification of relevant domains of need, refinement of language to improve accessibility, and the structure of the user experience. Practical considerations, such as service capacity, inclusivity, and potential barriers to engagement, were highlighted and addressed. The resulting web-based tool enables users to self-identify areas of social need and receive tailored signposting to community resources. CEI enhanced the relevance, acceptability, and usability of the tool. Conclusion: Meaningful community involvement is essential in developing accessible, preventative mental health tools grounded in real-world needs. However, challenges such as limited resources, stakeholder fatigue, and equity in participation must be managed. The CoSign project demonstrates the value of CEI while underscoring the importance of flexible, context-sensitive approaches to engagement.

In 2022, the National Institute of Health and Care Excellence (NICE) introduced “patient choice” as a major new principle in the guideline “Depression in adults: treatment and management.” In 2024, NICE launched a “patient decision aid” to provide practical support for this principle. We explore data on the treatment of depression from the United Kingdom's National Health Service before and after the guideline was published to consider whether patient choice has been enabled by these developments. The types of treatment most commonly delivered prior to the new guideline (Guided Self-Help books, Counseling for Depression, Cognitive Behavior Therapy, and antidepressant prescriptions) are now more common than before. This suggests that the inclusion of patient choice in the guidelines has not yet translated into patients making a wider range of choices. We consider how patient choice came to be prioritized over patient experience in the guideline development process; whether the patient decision aid is likely to support patient choice and shared decision making; and whether there may be underlying ideological barriers which mean a more straightforward emphasis on patient experience would be a more logical route to enhancing patient choice.

This study investigates the association between protected characteristics and inequalities in mental health care in the UK. Multinomial regression was used to model the association between protected characteristics and self-reported distress. Data was extracted from waves 6–10 (2014–2019) of the UK Household Longitudinal Study. Two risk categories were constructed: “undiagnosed distress” referred to a General Health Questionnaire-12 (GHQ-12) score above “caseness” along with no history of mental health diagnosis; “diagnosis without self-report symptoms” referred to a GHQ-12 score consistently below “caseness” within the study time frame but having received a mental health diagnosis. Compared to people without a disability, people with a disability are at considerably greater risk of both undiagnosed distress (Relative risk ratios (RRR) 2.76; Confidence Interval (CI): 2.55, 2.99) and diagnosis without self-reported symptoms (RRR 3.61; CI: 2.80, 4.66). Likewise, women were more likely than men to report undiagnosed distress (RRR = 1.49; CI: 1.38,1.61) or a diagnosis without self-reported symptoms (RRR = 1.38; CI: 1.08, 1.76. Lesbian, gay, and bisexual people are at greater risk of undiagnosed distress compared with heterosexual people (RRR 1.42; CI: 1.19, 1.70). Adults aged 16–24 years were at greatest risk compared to all other age groups. People from a minority ethnic background had a reduced risk of diagnosis without self-report symptoms compared with people from a White ethnic background (RRR 0.34; CI: 0.20, 0.61). Education, employment and income variables moderated some of these associations. This is the first study to examine diagnosis without self-report symptoms alongside undiagnosed distress. Findings suggest that addressing inequality in mental health care requires increased understanding of the needs and strengths within different groups and to provide appropriate forms of social, medical or psychosocial intervention rather than a singular focus on increasing detection, diagnosis and treatment. People with a disability appear to be at greatest disadvantage, requiring greater attention in policy and practice.

Background: Exposure to green space and feeling connected to the natural environment have independently been associated with improved mental health outcomes. During the coronavirus pandemic, people experienced restrictions on access to the outdoors, and health data indicated a decline in mental health in the UK general population. Methods: Data available from two independent surveys conducted prior to and during the pandemic enabled a naturally occurring comparison of mental health and its correlates prior to and during the pandemic. Results: Survey responses from 877 UK residents were included in the analyses. Independent t-tests revealed significant declines in mental health scores during the pandemic. After controlling for age and gender, greater nature connection significantly predicted lower depression and stress and improved well-being. Percentage of green space did not significantly predict any mental health outcomes. Further, time point (pre- or during COVID) and the interaction of time point with green space and nature connection did not significantly predict any of the outcome measures. The findings indicate that nature connection may play an important role in promoting mental health. Strategies to improve mental health and reduce mental illness should consider the role of nature connection and the use of interventions that involve direct interaction with natural environments.

The UK government has invested £5.77 million in green social prescribing to prevent and tackle mental ill-health. Therapeutic community gardening, one type of green social prescription, provides a range of health outcomes. However, for increased accessibility, a greater understanding of how it impacts mental health and the facilitators and barriers to referral, uptake, and attendance by individuals with mental health problems is required. We conducted and thematically analysed interviews with thirteen stakeholders including social prescribing link workers and garden staff; and focus groups with twenty garden members. The mechanisms by which therapeutic community gardening were suggested to impact mental health were by engaging members with nature and the outdoors, providing hope for the future and facilitating social support and relationships. Factors facilitating referral, uptake, and attendance included a holistic and person-centred approach, which is flexible around health needs. Barriers included awareness of the full offering of therapeutic community gardens and accessibility, in terms of physical location and waiting lists. Given that nature-based interventions have the potential to protect and enhance population health and offer cost savings through reduced reliance on other health services; overcoming these barriers is key to ensuring that therapeutic community gardening is more widely available as an additional mental health treatment.

Background: literature on the mental health benefits of therapeutic community gardening is not specific to individuals with mental illness and reports short-term outcomes. The impact of the coronavirus pandemic on intervention effectiveness is also unknown. This study examined the impact of therapeutic community gardening prior to and across the pandemic on the wellbeing of individuals referred for support with their mental illness. Methods: garden members (n = 53; male = 36, female = 17) aged 47.38 ± 13.09 years reported their wellbeing at baseline and four follow-up points (FU1–FU4) across the pandemic. Results: there was significant quadratic growth in wellbeing (−1.248; p < 0.001) that varied between genders (p = 0.021). At baseline, male wellbeing scores were significantly lower (p = 0.020) than the UK population norm, but there were no significant differences at any other follow-up point. Female wellbeing was significantly lower than the UK population norm at baseline (p < 0.001), FU1 (p = 0.012) and FU2 (p < 0.001), but not FU3 and FU4. Conclusion: therapeutic community gardening can improve and maintain the wellbeing of individuals with mental illness, even when wellbeing is deteriorating nationally. Future research should further demonstrate the long-term and cost-effectiveness of interventions.

The impact of environmental context on the psychological benefits derived from physical activity has attracted research attention in recent years. Previous reviews have compared effects of indoor versus outdoor exercise. This review compares the effects of physical activity undertaken in outdoor green natural environments versus outdoor urban environments on psychological health outcomes in adult general populations. An electronic literature search identified 24 experimental studies meeting the inclusion criteria. Results were analysed via narrative synthesis (n = 24) and meta‐analysis (n = 9) of effect on six outcomes. Narrative synthesis found in favour of the natural environment for anxiety, anger/hostility, energy, affect and positive engagement. Post‐intervention effect sizes suggested duration and social context as potential moderators. The meta‐analyses revealed large or moderate effects in favour of the natural environment for anxiety, fatigue, positive affect and vigour, and a small effect for depression. Results were subject to high risk of bias and heterogeneity. Physical activity undertaken outdoors in natural environments is more beneficial for a range of psychological outcomes compared with urban environments. The various effect sizes evident in the meta‐analyses may be explained by differing mechanisms through which psychological gains are experienced during physical activity in nature.