Fear of childbirth during pregnancy: associations with observed mother-infant interactions and perceived bonding.

Fear of childbirth (FOC) is a common phenomenon that can impair functioning in pregnancy but potential longer term implications for the mother-infant relationship are little understood. This study was aimed at investigating postpartum implications of FOC on the mother-infant relationship. A UK sample of 341 women in a community setting provided data on anxiety, mood and FOC in mid-pregnancy and subsequently completed self-report measures of postnatal bonding in a longitudinal cohort study. Postnatal observations of mother-infant interactions were collected and rated for a subset of 141 women. FOC was associated with maternal perception of impaired bonding, even after controlling for sociodemographic factors, concurrent depression and the presence of anxiety disorders (Coef = 0.10, 95% CI 0.07-0.14, p < 0.001). Observed mother-infant interactions were not associated with FOC (Coef = -0.01-0.03 CI - 0.02 to 0.02, p = 0.46), weakly with concurrent depression (Coef = - 0.10, CI - 0.19 to 0.00, p = 0.06) and not associated with anxiety disorders. The self-efficacy component of FOC was most strongly associated with lower reported bonding (Coef 0.37, 95% CI 0.25-0.49, p < 0.001) FOC makes a distinct contribution to perceived postpartum bonding difficulties but observed mother-infant interaction quality was not affected. This may be due to low self-efficacy impacting psychological adjustment during pregnancy. Targeted interventions during pregnancy focusing both on treatment of key childbirth fears and bonding could help women adjust earlier

Factors Affecting Infant Feeding Practices Among Women With Severe Mental Illness

Background: The health benefits of breastfeeding are well-established but for mothers with severe mental illness (SMI), the decision to breastfeed can be complex. Very few prior studies have investigated the infant feeding choices of women with SMI, or the factors associated with this. Our aims were to examine antenatal infant feeding intentions and infant feeding outcomes in a cohort of women admitted for acute psychiatric care in the first postpartum year. We also aimed to examine whether demographic and clinical characteristics associated with breastfeeding were similar to those found in previous studies in the general population, including age, employment, education, BMI, mode of delivery, smoking status, and social support. Methods: This study was a mixed-methods secondary analysis of a national cohort study, ESMI-MBU (Examining the effectiveness and cost-effectiveness of perinatal mental health services). Participants had been admitted to acute care with SMI in the first postpartum year. Infant feeding outcomes were retrospectively self-reported by women during a 1-month post-discharge interview. Free-text responses to questions relating to infant feeding and experience of psychiatric services were also explored using thematic analysis. Results: 144 (66.1%) of 218 women reported breastfeeding (mix feeding and exclusive breastfeeding). Eighty five percentage of the cohort had intended to breastfeed and of these, 76.5% did so. Factors associated with breastfeeding included infant feeding intentions, employment and non-Caucasian ethnicity. Although very few women were taking psychotropic medication contraindicated for breastfeeding, over a quarter (n = 57, 26.15%) reported being advised against breastfeeding because of their medication. Women were given this advice by psychiatry practitioners (40% n = 22), maternity practitioners (32.73% n = 18) and postnatal primary care (27.27% n = 15). Most women stopped breastfeeding earlier than they had planned to as a result (81.1% n = 43). Twenty five women provided free text responses, most felt unsupported with infant feeding due to inconsistent information about medication when breastfeeding and that breastfeeding intentions were de-prioritized for mental health care. Conclusion: Women with SMI intend to breastfeed and for the majority, this intention is fulfilled. Contradictory and insufficient advice relating to breastfeeding and psychotropic medication indicates that further training is required for professionals caring for women at risk of perinatal SMI about how to manage infant feeding in this population. Further research is required to develop a more in-depth understanding of the unique infant feeding support needs of women with perinatal SMI

Psychometric properties of the five-level EuroQoL-5 dimension and Short Form-6 dimension measures of health-related quality of life in a population of pregnant women with depression

BACKGROUND: Although evidence suggests that the EuroQoL-5 dimension (EQ-5D) and Short Form-6 dimension (SF-6D) have equivalent psychometric properties in people with depression, there is some evidence that the EQ-5D may lack responsiveness in certain populations with depression. AIMS: To examine the psychometric properties of the five-level EQ-5D (EQ-5D-5L) and SF-6D measures of health-related quality of life in a representative sample of pregnant women with depression. METHOD: Data were taken from a cohort of pregnant women identified at or soon after the first antenatal care contact and followed-up at 3 months postpartum. Health-related quality of life was measured using both the EQ-5D-5L and the SF-6D at baseline and follow-up. We examined acceptability and conducted psychometric validation in the aspects of concurrent validity, convergent validity, known-group validity and responsiveness in 421 women with available data. RESULTS: The EQ-5D-5L and SF-6D have similarly high levels of acceptability. However, concurrent validation shows a lack of concordance between the EQ-5D-5L and SF-6D. The EQ-5D-5L tends to be higher than the SF-6D in individuals with better health states. The SF-6D tends to be higher than EQ-5D-5L in individuals with poorer health states. Convergent and known-group validity are comparable between the two utility measures. Longitudinally, women who recovered show larger increase in SF-6D utilities than those who did not recover at follow-up. With the EQ-5D-5L, this is not the case. Additionally, the ceiling effects were more apparent in the EQ-5D-5L. CONCLUSIONS: The effectiveness of perinatal mental health interventions may be better captured by the SF-6D than the EQ-5D-5L but this needs to be cross-validated in more studies. DECLARATION OF INTEREST: L.M.H. chaired the National Institute for Health and Care Excellence CG192 guidelines development group on antenatal and postnatal mental health in 2012-2014. L.M.H. reports grants from NIHR, MRC, Nuffield and the Stefanou Foundation, UK. K.T., M.H. and S.B. report funding by NIHR and the Stefanou Foundation, UK

Mental health professionals’ knowledge, skills and attitudes on domestic violence and abuse in the Netherlands:Cross-sectional study

Background Despite the high prevalence of domestic violence and abuse (DVA) among patients with psychiatric conditions, detection rates are low. Limited knowledge and skills on DVA in mental healthcare (MHC) professionals might contribute to poor identification.AimsTo assess the level of, and factors associated with, DVA knowledge and skills among MHC professionals. Method A total of 278 professionals in Dutch MHC institutions completed a survey assessing factual knowledge, perceived knowledge, perceived skills and attitudes about DVA. Results On average, low scores were reported for perceived skills and knowledge. MHC professionals in primary care scored higher than those working with individuals with severe mental illness (P<0.005). Levels of factual knowledge were higher; levels of attitudes moderate. Previous training was positively associated with skills (odds ratios (OR) = 3.0) and attitudes (OR = 2.7). Years of work was negatively associated with factual knowledge (OR = 0.97). Larger case-loads predicted higher scores on skills (OR = 2.1). Conclusions Training is needed, particularly for clinicians working with patients with severe mental illness

Young pregnant women and risk for mental disorders: findings from an early pregnancy cohort

BACKGROUND:Young women aged 16-24 are at high risk of common mental disorders (CMDs), but the risk during pregnancy is unclear.AimsTo compare the population prevalence of CMDs in pregnant women aged 16-24 with pregnant women ≥25 years in a representative cohort, hypothesising that younger women are at higher risk of CMDs (depression, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder), and that this is associated with low social support, higher rates of lifetime abuse and unemployment. METHOD:Analysis of cross-sectional baseline data from a cohort of 545 women (of whom 57 were aged 16-24 years), attending a South London maternity service, with recruitment stratified by endorsement of questions on low mood, interviewed with the Structured Clinical Interview DSM-IV-TR. RESULTS:Population prevalence estimates of CMDs were 45.1% (95% CI 23.5-68.7) in young women and 15.5% (95% CI 12.0-19.8) in women ≥25, and for 'any mental disorder' 67.2% (95% CI 41.7-85.4) and 21.2% (95% CI 17.0-26.1), respectively. Young women had greater odds of having a CMD (adjusted odds ratio (aOR) = 5.8, 95% CI 1.8-18.6) and CMDs were associated with living alone (aOR = 3.0, 95% CI 1.1-8.0) and abuse (aOR = 1.5, 95% CI 0.8-2.8). CONCLUSIONS:Pregnant women between 16 and 24 years are at very high risk of mental disorders; services need to target resources for pregnant women under 25, including those in their early 20s. Interventions enhancing social networks, addressing abuse and providing adequate mental health treatment may minimise adverse outcomes for young women and their children.Declaration of interestNone

The effectiveness of sexual assault referral centres with regard to mental health and substance use: a national mixed-methods study – the MiMoS Study

Background Sexual assault referral centres have been established to provide an integrated service that includes forensic examination, health interventions and emotional support. However, it is unclear how the mental health and substance use needs are being addressed. Aim To identify what works for whom under what circumstances for people with mental health or substance use issues who attend sexual assault referral centres. Setting and sample Staff and adult survivors in English sexual assault referral centres and partner agency staff. Design A mixed-method multistage study using realist methodology comprising five work packages. This consisted of a systematic review and realist synthesis (work package 1); a national audit of sexual assault referral centres (work package 2); a cross-sectional prevalence study of mental health and drug and alcohol needs (work package 3); case studies in six sexual assault referral centre settings (work package 4), partner agencies and survivors; and secondary data analysis of outcomes of therapy for sexual assault survivors (work package 5). Findings There is a paucity of evidence identified in the review to support specific ways of addressing mental health and substance use. There is limited mental health expertise in sexual assault referral centres and limited use of screening tools based on the audit. In the prevalence study, participants (n = 78) reported high levels of psychological distress one to six weeks after sexual assault referral centre attendance (94% of people had symptoms of post-traumatic stress disorder). From work package 4 qualitative analysis, survivors identified how trauma-informed care potentially reduced risk of re-traumatisation. Sexual assault referral centre staff found having someone with mental health expertise in the team helpful not only in helping plan onward referrals but also in supporting staff. Both sexual assault referral centre staff and survivors highlighted challenges in onward referral, particularly to NHS mental health care, including gaps in provision and long waiting times. Work package 5 analysis demonstrated that people with recorded sexual assault had higher levels of baseline psychological distress and received more therapy but their average change scores at end point were similar to those without sexual trauma. Limitations The study was adversely affected by the pandemic. The data were collected during successive lockdowns when services were not operating as usual, as well as the overlay of anxiety and isolation due to the pandemic. Conclusions People who attend sexual assault centres have significant mental health and substance use needs. However, sexual assault referral centres vary in how they address these issues. Access to follow-up support from mental health services needs to be improved (especially for those deemed to have ‘complex’ needs) and there is some indication that co-located psychological therapies provision improves the survivor experience. Routine data analysis demonstrated that those with sexual assault can benefit from therapy but require more intensity than those without sexual assault. Future work Further research is needed to evaluate the effectiveness and cost-effectiveness of providing co-located psychological therapy in the sexual assault referral centres, as well as evaluating the long-term needs and outcomes of people who attend these centres. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (16/117/03) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 21. Trial registration This trial is registered as PROSPERO 2018 CRD42018119706 and ISRCTN 18208347

For Baby's Sake: Final Evaluation Report

For Baby’s Sake is an intervention for expectant parents who want to break the cycle of domestic abuse and support their baby’s early emotional and social development. Both parents join For Baby’s Sake, whether together as a couple or not, and may be supported until their baby is aged two. The programme takes a whole-family approach that deals with the entire cycle and history of domestic violence and abuse, identifying and directly addressing the trauma or traumas that lie at the heart of the problem. The Stefanou Foundation, a UK charity, designed and created For Baby’s Sake and commissioned King’s College London to conduct an independent evaluation of the programme’s operation during the prototype phase in two sites in Hertfordshire and London from 2015-2019. For Baby’s Sake is the culmination of over ten years of investment, effort and continuous learning and the Stefanou Foundation is proud to publish its independent evaluation by a team of researchers from King’s College London, University of Warwick, University of Central Lancashire, University of Cambridge and McMaster University, Canada. The full report is available to download at www.forbabyssake.org.uk The report is being launched in the context of COVID-19 and the creation of new domestic abuse legislation, so this joint summary by the Stefanou Foundation and the academic evaluation team provides some current context before outlining the key findings from the independent evaluation. COVID-19 shines a spotlight on the challenges for those experiencing domestic violence and abuse (DVA) to come forward for support, as well as the physical, emotional and psychological risks and impact of the abuse. The pandemic is also raising questions about how best to support mental health and emotional regulation, especially for those with underlying needs caused by previous trauma. The welcome passage of the domestic abuse legislation through Parliament is drawing attention to the nature of domestic abuse and how best to address it. There are more calls to assist those who perpetrate abuse in changing their behaviour. There is growing recognition of the evidence that children are directly affected by domestic abuse and should be recognised as victims and not simply witnesses. For Baby’s Sake makes a distinctive contribution on all of these points. It creates a different opportunity for families to seek and receive support, through allocating practitioners to work individually and separately with both parents. It takes a trauma-informed approach to address the mental health needs of parents and babies. It underlines that the call to recognise and support child victims of domestic abuse must include babies, who are particularly affected from pregnancy until the age of two. This is because of how domestic abuse can affect the development of babies’ brains, bodies and relationships with their parents over that timescale. The academic evaluation report includes evidence from practitioners, stakeholders and a sample of parents who agreed to be interviewed up to three times during the course of the evaluation (2015 – 2019) and provides extensive data including validated research assessments. The four-year evaluation aimed to assess the feasibility, acceptability and impact of For Baby’s Sake as well as provide lessons for future research. Having stated the extent and profound risks and impact of the experience of DVA for parents and children during the perinatal period (conception to age two) and beyond, and having conducted a systematic evidence review, the report recognises that For Baby’s Sake is the first programme to address key limitations of existing interventions. The programme is at the vanguard of the move towards whole-family, trauma-informed approaches. For Baby’s Sake takes a unique approach, with practitioners working individually and separately with both parents, from pregnancy, combining evidence-based elements to break cycles of DVA, address the impact of parents’ own childhood trauma and improve adult mental health, alongside parenting interventions focused on infant mental health and parent-infant attachment. Results of the evaluation show the successful embedding of For Baby’s Sake in its first two diverse prototype sites (Stevenage, North Herts and Welwyn Hatfield districts of Hertfordshire and London Three Boroughs - Westminster, Kensington & Chelsea and Hammersmith & Fulham). Across both sites, the programme received referrals, particularly from children’s social care, and attracted both co-parents to engage, demonstrating the feasibility of this novel aspect of the model, and sustained this engagement, with only 18% and 11% of all those referred disengaging following sign-up in Hertfordshire and London Three Boroughs respectively. Those engaged in For Baby’s Sake, and recruited to the evaluation, had complex interpersonal abuse histories. There were challenges for service users in reporting on their experience and perpetration of domestic abuse, which included reports of bi-directional abuse in some relationships. The evaluation found that at their first, baseline interview, many service users did not acknowledge experiencing DVA or using DVA behaviours within the previous year, though they were much more likely to disclose that there had been domestic abuse at some time in the relationship. Almost all mothers also reported that they had experienced abuse at some stage from someone other than their co-parent. At the second interview, they were more likely to disclose experiencing abuse or using abusive behaviours. Evidence suggests that the initial low reports of abuse may be due to minimisation, to not recognising certain behaviours as abusive or to reluctance to disclose due to fear or shame. Qualitative data indicate how the therapeutic work could have affected disclosure of abuse, by enabling mothers to understand domestic abuse more clearly and link that knowledge to their experience. Service user interviews pointed to their multiple, complex needs, indicating the success of For Baby’s Sake in reaching its target population. A substantial proportion of men and women had symptoms of depression, anxiety and post-traumatic stress disorder (PTSD), as well as high numbers of disordered personality traits. As expected, the majority of parents reported adverse childhood experiences (ACEs), with many experiencing various forms of abuse and trauma and over half reporting that they experienced DVA as children. These childhood experiences link directly to one of the key reasons for expectant co-parents to engage in For Baby’s Sake. Many of the mothers and fathers explained how their motivation for change stemmed from their desire to provide a better life for their children and to be different kinds of parents in order to prevent their children having the same upbringing as they did. Similarly, practitioners reflected that the central emphasis on the baby is crucial in engaging service users and in facilitating healthy parenting behaviours, leading to secure attachments. The voluntary nature of For Baby’s Sake, and the contrast with service users’ previous experience of interventions, also acted as a motivating factor. Parents felt that the voluntary approach meant they did not feel coerced into participating and found interactions with the For Baby’s Sake teams to be non- judgemental, inviting and welcoming. Mothers and fathers engaging in For Baby’s Sake were positive about the programme, with many describing how ithad exceeded their expectations. They were able to identify the impacts for them, their relationships and their children, and to explore their successes, including gaining confidence and recognising and challenging abusive behaviours. These learnings were perceived to resonate particularly among some women from minority ethnic backgrounds who described how certain cultural expectations could create barriers to recognising domestic abuse and to speaking out against certain behaviours. The evaluation finds merit in the For Baby’s Sake approach ofsupporting parents whether together as a couple or not and making it clear that the programme has no goal in principle about parents staying together or separating. Each service user is supported and empowered to recognise and acton their own goals in this respect. The evaluation noted how these goals changed for some service users who expected to stay in the relationship but found personal growth instead. Over two thirds of women and all of the men interviewed for the evaluation were in a relationship with their co-parentatbaseline interviews. This reduced across time, with only a third of both men and women remaining in this relationship at the two-year follow-up. The researchers suggested that changes in the intimate relationship status with the co-parent can represent a useful assessment of the outcome of the programme. Mothers and fathers described how For Baby’s Sake had facilitated step- changes in their relationships with their babies and in their understanding of what parenting input babies need to develop. For the babies, birth and child developmentoutcomesatoneandtwoyears(includingbabies’ social, emotional and behavioural development) were largely in the normal range and only a third of families had any social care input at the two-year stage. This contrasted with 70% at baseline, of which 56% were either under a Child Protection Plan or Child in Need processes. Throughout the evaluation report, consistent messages about the mechanisms for change enabled by For Baby’s Sake were reflected by service users and practitioners alike. Parents talked about the value of the whole-family therapeutic approach, which provides support for the needs of the individual, within intimate and/or co-parenting relationships, and for the needs of the children. Parents are provided with tools and strategies to manage and improve their situations and feelings, including learning about visualisation and mindfulness, practising time-outs and using an anger scale. Many fathers, in particular, reflected on how the therapeutic model allowed them space to acknowledge their own emotions and to use tools and develop methods to instil healthy coping mechanisms. Another key mechanism for change was identified as the ability to develop a close therapeutic relationship with a highly skilled practitioner over a long period of time. Practitioners reflected that they were able to focus in a detailed way on a specific member of the family, while working with their colleagues to develop a holistic picture of the issues for all members of the family and understand much better any risks and safeguarding issues. Many parents specifically identified the Inner Child module, the therapeutic core of For Baby’s Sake, as particularly beneficial, building trust and working therapeutically with practitioners to examine their childhoods through a trauma-informed lens. For mothers, the Inner Child module was reported as giving them time and space to explore different aspects of their lives, process their childhood experiences and their experience of DVA as adults and build self-esteem and a sense of empowerment. For fathers, benefits were described in helping them to understand that what happened to them as a child was not their fault but that they were responsible for the behaviours and actions they engaged in as adults. This led to greater awareness among some fathers of the impact of their behaviour, a willingness to take responsibility for their actions, the commitment to no longer use violence and abuse and the desire to put the needs of their co-parents and children first. This shift ‘from being me-centred to child-centred’ describes practitioners’ and service users’ views thatplacing the baby atthe centre ofthe work and adopting a whole-family and co-parenting approach provide the best opportunity to affect change in parents’ lives and improve children’s outcomes and safety. Many families spoke of the value in receiving psychoeducation on how DVA impacts on children and in receiving general parenting support. Parents identified their learning about child brain development and how attachments form as contributing to them becoming more confident in their parenting and improving communication in their family. Building on this, mothers and fathers who took part in Video Interaction Guidance (VIG) within the programme perceived it had helped them to focus on attachment and sensitive, attuned parenting, allowing them to see the bonds they had developed with their child and providing reassurance about their parenting abilities. The researchers interviewed multi-agency professionals in Hertfordshire and London who reported on their views of For Baby’s Sake and their experience of working with the teams. They valued the holistic, whole family approach, endorsed the programme for being evidence-based and reported that the For Baby’s Sake teams were highly trained, skilled and responsive. Stakeholders described effective joint working practices and communication, with children’s social care and health in particular, citing how this would result in collaborative working around the safeguarding of children and families. The evaluation also described how dialogue between For Baby’s Sake and local stakeholders helped to build and strengthen understanding of the programme and encouraged this dialogue to continue at local and national levels. The evaluation report also provides valuable learning about the research process itself, concluding that it is feasible and acceptable to collect quantitative and qualitative data through a range of self-report, observational, staff and researcher-administered measures. These data can be collected from all family members among this cohort of families with multiple complex needs and intergenerational trauma histories, although data collection, from fathers in particular, across multiple time points can be challenging. Realist research methodologies that use qualitative and quantitative techniques to examine what works best for whom, when and in what context, are suggested for use in future evaluation, to suit the holistic and continuously developing nature of For Baby’s Sake. Undertaking longer-term follow-up of those engaged in prototype For Baby’s Sake sites and the introduction of a comparator group who receive standard support are encouraged for consideration in any future evaluation of the effectiveness of For Baby’s Sake. The evaluation team suggests further research is required with a larger sample in order to undertake a full economic evaluation of the programme. Finally, the report includes many insights and ideas to consider as the Stefanou Foundation and its partners continue to develop and roll-out For Baby’s Sake beyond its (now four) delivery sites. These include: • Development of an assessment of fidelity using key principles of For Baby’s Sake rather than adherence to specific elements of the programme manual, to reflect the flexibility now embedded within the programme that enables the match with service users’ needs and circumstances • Drawing on feedback about language and messaging to ensure the programme’s approach is well understood. For example, guarding against ‘victim’ and ‘perpetrator’ terminology which fathers found to be blaming, providing assurance to mothers about the programme’s approach to supporting one parent when the other parent disengages, and clarifying to stakeholders that the programme is not prescriptive about models of co- parenting • Developing a new outcome assessment to measure changes to the relationship status of co-parents throughout the programme, alongside indicators regarding not only practitioners’ assessment of risk but also parents’ perceptions of safety and risk of harm, both for themselves and for their children, to indicate the success of the programme • Providing training to local authorities and sharing learning from For Baby’s Sake more widely, including on adopting trauma-informed approaches to all of the factors (individual, family/personal relationships, communities and societal) that can contribute to domestic abuse and make it challenging to break the cycle • Finding new ways to examine the full range of outcomes achieved by families, reflecting the difficulty of applying quantitative measures to assess outcomes for families and longer-term outcomes for children. This would build on the Foundation’s move to incorporate more qualitative approaches that describe families’ journeys through For Baby’s Sake as a way to ‘show the true impact’ in addition to quantitative measures The evaluation has confirmed that For Baby’s Sake is the first programme to fill an important gap in provision through its unique approach. This early research evaluation into the prototype phase found that the majority of individuals who engaged in the evaluation and remained in the programme over time reported a positive experience, were able to identify specific ways that they had changed their behaviour and related these to aspects of the programme. These findings, alongside the recognition by the evaluation team of the importance of the innovation and the careful, evidence-based approach of the Foundation in creating and operating the programme, support the creation of two new sites in Cambridgeshire and Blackpool in 2019 and early 2020 respectively, and will contribute to the case for further expansion of For Baby’s Sake. The Stefanou Foundation is keen to work with partners to achieve this expansion, to reach more families, break the cycle of domestic abuse and give babies the best start in life

Assessing the Acceptability, Feasibility and Sustainability of an Intervention to Increase Detection of Domestic Violence and Abuse in Patients Suffering From Severe Mental Illness: A Qualitative Study

Rationale: Despite interventions to improve detection rates, domestic violence, and abuse (DVA) remains largely undetected by healthcare services. We therefore aimed to examine the acceptability, feasibility, and sustainability of an intervention aiming to improve DVA detection rates, which included a clear referral pathway (i.e., the BRAVE intervention) and to explore the acceptability and feasibility of DVA management and referrals in general, in the context of low detection rates. Methods: Qualitative study design with four focus groups of 16 community mental health (CMH) clinicians from both control and intervention arms. The focus groups discussed managing DVA in clinical practice and staff experiences with the BRAVE intervention in particular. Focus groups continued until saturation of the subject was reached. Interviews were analyzed using a thematic analysis approach. Results: DVA was seen to be highly relevant to mental healthcare but is also a very sensitive subject. Barriers in CMH professionals, institutions, and society meant CMH professionals often refrained from asking about DVA in patients. Barriers included communication difficulties between CMH professionals and DVA professionals, a fear of disrupting the therapeutic alliance with the patient, and a lack of appropriate services to help victims of DVA. Conclusion: The BRAVE intervention was acceptable but not feasible or sustainable. Personal, institutional, and public barriers make it not feasible for CMH professionals to detect DVA in mental healthcare. To increase the detection of DVA, professional standards should be combined with training, feedback sessions with peers and DVA counselors, and routine enquiry about DVA

A scoping review of trauma informed approaches in acute, crisis, emergency, and residential mental health care

Experiences of trauma in childhood and adulthood are highly prevalent among service users accessing acute, crisis, emergency, and residential mental health services. These settings, and restraint and seclusion practices used, can be extremely traumatic, leading to a growing awareness for the need for trauma informed care (TIC). The aim of TIC is to acknowledge the prevalence and impact of trauma and create a safe environment to prevent re-traumatisation. This scoping review maps the TIC approaches delivered in these settings and reports related service user and staff experiences and attitudes, staff wellbeing, and service use outcomes.We searched seven databases (EMBASE; PsycINFO; MEDLINE; Web of Science; Social Policy and Practice; Maternity and Infant Care Database; Cochrane Library Trials Register) between 24/02/2022-10/03/2022, used backwards and forwards citation tracking, and consulted academic and lived experience experts, identifying 4244 potentially relevant studies. Thirty-one studies were included.Most studies (n = 23) were conducted in the USA and were based in acute mental health services (n = 16). We identified few trials, limiting inferences that can be drawn from the findings. The Six Core Strategies (n = 7) and the Sanctuary Model (n = 6) were the most commonly reported approaches. Rates of restraint and seclusion reportedly decreased. Some service users reported feeling trusted and cared for, while staff reported feeling empathy for service users and having a greater understanding of trauma. Staff reported needing training to deliver TIC effectively.TIC principles should be at the core of all mental health service delivery. Implementing TIC approaches may integrate best practice into mental health care, although significant time and financial resources are required to implement organisational change at scale. Most evidence is preliminary in nature, and confined to acute and residential services, with little evidence on community crisis or emergency services. Clinical and research developments should prioritise lived experience expertise in addressing these gaps

Development of a conceptual framework to guide description and evaluation of social interventions for people with serious mental health conditions

People with serious mental health conditions face social exclusion and have poorer social outcomes compared to the general population in several areas of life. Social exclusion also negatively impacts mental health. Promising models of support to improve social outcomes for people with serious mental health conditions have been described in the literature and proliferate in practice, but typologies of support are not clearly established and a robust evidence base for effective approaches is lacking in many areas. We conducted a scoping review of relevant literature and consulted with experts in the field to identify models to improve social circumstances across eight life domains, with the aim of developing a conceptual framework to distinguish the main broad approaches to improving the social circumstances of people with serious mental health conditions. We also sought to explore which approaches have been used in models within each life domain. This work was conducted in collaboration with a group of expert stakeholders, including people with lived experience of accessing mental health services. We developed a conceptual framework which distinguishes sources and types of support, allowing description of complex interventions to improve the social circumstances of people with serious mental health problems, and providing a framework to guide future service development and evaluation