Background: Online forums are widely used for mental health peer support. However, evidence of their safety and effectiveness is mixed. Further research focused on articulating the contexts in which positive and negative impacts emerge from forum use is required to inform innovations in implementation. Objective: This study aimed to develop a realist program theory to explain the impacts of online mental health peer support forums on users. Methods: We conducted a realist synthesis of literature published between 2019 and 2023 and 18 stakeholder interviews with forum staff. Results: Synthesis of 102 evidence sources and 18 interviews produced an overarching program theory comprising 22 context-mechanism-outcome configurations. Findings indicate that users’ perceptions of psychological safety and the personal relevance of forum content are foundational to ongoing engagement. Safe and active forums that provide convenient access to information and advice can lead to improvements in mental health self-efficacy. Within the context of welcoming and nonjudgmental communities, users may benefit from the opportunity to explore personal difficulties with peers, experience reduced isolation and normalization of mental health experiences, and engage in mutual encouragement. The program theory highlights the vital role of moderators in creating facilitative online spaces, stimulating community engagement, and limiting access to distressing content. A key challenge for organizations that host mental health forums lies in balancing forum openness and anonymity with the need to enforce rules, such as restrictions on what users can discuss, to promote community safety. Conclusions: This is the first realist synthesis of online mental health peer support forums. The novel program theory highlights how successful implementation depends on establishing protocols for enhancing safety and strategies for maintaining user engagement to promote forum sustainability. Trial Registration: PROSPERO CRD42022352528; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=352528

Purpose: Friends and family members can be important sources of support for people who are or have been suicidal. This review aimed to synthesise qualitative evidence regarding carers' perspectives of supporting someone who has experienced suicidal behaviour. Methods: Five electronic databases (Web of Science, CINAHL, PsychINFO, MEDLINE, and SocINDEX) were searched from inception to May 2022. Eligible qualitative studies were published in English and investigated the caring experiences of friends or family members of people who had experienced suicidal behaviour, defined as any form of suicidal ideation and/or attempts. Studies focused on non‐suicidal self‐injury or suicide bereavement were excluded. Data from 19 eligible studies were analysed using thematic synthesis. Results: Initial carer reactions to suicidal behaviour included profound anxiety and intensive monitoring for signs of increased suicide risk amongst those they supported. Carers also reported significant challenges with understanding how to provide effective interpersonal support following suicidal crises. Professional support was perceived to be most effective when provided in a timely, interpersonally sensitive and safety‐focused manner. However, several studies detailed carers' difficulties accessing appropriate support and challenges managing their own distress. Conclusions: Carers face significant challenges with knowing how to respond to suicidal behaviour, where to find appropriate help, and how to manage their own distress. Future research should seek to investigate the effectiveness of easily accessible methods of information provision and support tailored for carers of people who have experienced suicidal behaviour.

Background. The likelihood of suicidal behaviour is elevated amongst people with psychosis or bipolar disorder. This study aimed to understand how carers experience supporting family members with psychosis or bipolar disorder who have also experienced suicidal behaviour. Methods. A qualitative thematic analysis of online peer forum posts was carried out on the Relatives Education and Coping Toolkit (REACT) website, an online intervention for carers of people with psychosis and bipolar disorder. Analysis was based on 178 posts by 29 forum users. Posts were selected based on their relevance to suicidal behaviour. Results. Three themes were generated. “Suicide as the ultimate threat” highlights fears emerging from carers’ difficulties with understanding and managing suicidal behaviour. “Bouncing from one crisis to another” reflects carers’ experiences of recurring crises and the challenges of relying on emergency healthcare support. “It definitely needs to be easier to get help” emphasises carers’ desires to be acknowledged by healthcare professionals and included in support offered to service users. Conclusions. Digital platforms, including online forums, brief interventions such as safety planning, and interagency crisis models, hold the potential to meet carers’ needs in this context. However, further research is required to investigate the effectiveness and implementation of these approaches.

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: Online forums are used widely to facilitate mental health peer support. However, concerns exist regarding potential harm associated with their use, and little is known about forum safety from the user’s perspective. Objective: This study sought to understand how users experience safety within online mental health peer support forums. Following previous research, safety was conceptualized with reference to both experiences of harm and feelings of interpersonal safety within the forum environment. Methods: Data were collected from 42 semistructured realist interviews and 504 cross-sectional survey responses from users of 3 UK-based online mental health forums. These included a forum hosted by a health service provider with subforums for anxiety, depression, and eating disorders; a corporate provider focused on young people’s mental health; and a voluntary sector provider with subforums for general mental health support, eating disorders, and postpartum psychosis. A bespoke survey was used to obtain descriptive quantitative data regarding user perceptions of forum safety. Qualitative data were used to refine an initial program theories framework comprising context-mechanism-outcome configurations related to forum safety developed in previously published realist synthesis. Results: Survey responses revealed that over half of the participants felt safe to post because of online anonymity (n=202, 40.1% agreed and n=97, 19.2% strongly agreed), while a minority reported encountering distressing forum posts (n=95, 18.8% agreed and n=18, 3.6% strongly agreed) and expressed concern that talking about mental health online could make them feel worse (n=113, 22.4% agreed and n=17, 3.4% strongly agreed). Refined program theories highlight: (1) the disclosure-promoting effect of anonymity, related to the mitigation of concerns that users’ mental health experiences could be linked to their offline identities; (2) the importance of proactive content moderation for addressing emerging safety issues; (3) a need for organizations to implement rule enforcement sensitively and balance between conversational openness and restricting topics likely to cause distress; (4) forum users’ experiences of self-moderating their exposure to potentially distressing online content; and (5) how the perceived nonjudgement, authenticity, and similarity of other forum users generates interpersonal safety. Conclusions: This is the first realist evaluation to directly assess processes underpinning safety in online mental health forums. A key novel finding of this study is that safety emerges not only from harm reduction procedures but also from a facilitative interpersonal atmosphere defined by sensitive moderation and the sharing of lived experiences. Hosts should therefore remain attentive to both potential risks and opportunities to foster connections between community members.

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