Informal carers’ experiences of mental health services regarding supporting those they care for and getting support for their own wellbeing: an umbrella review of qualitative evidence

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Their caregiving contributions are critical but often at the cost of considerable burdens. Despite growing qualitative evidence on carers’ experiences, an overarching synthesis of review-level insights is lacking. Objective This umbrella review aimed to synthesise qualitative review evidence on informal carers’ experiences of mental health services regarding supporting the individuals with mental health difficulties they care for and seeking support for their own wellbeing. Methods Following the Joanna Briggs Institute (JBI) methodology, a meta-aggregative umbrella review was conducted. Findings were extracted from eligible reviews and aggregated into categories, from which higher-order synthesised findings were developed. Results Twelve eligible qualitative reviews were identified through a systematic search across five databases. Six synthesised findings were identified: (1) emotional complexity in the caregiving journey; (2) recognition and coping with their loved ones’ mental health difficulties; (3) multiple barriers to accessing mental health support; (4) persistent responsibilities and roles in supporting service users; (5) complex experiences of engaging with services; and (6) relational strain during the caregiving process. The findings were rated as high confidence. Conclusion While some carers reported positive experiences, most described exclusion, emotional distress, and structural barriers to support. This review highlights the urgent need for mental health services to recognise, involve, and support informal carers. Psychiatry informal carers mental health services qualitative research umbrella review meta-aggregation Figures Figure 1 Introduction In the UK, around 13% of the approximately 1.5 million informal carers (e.g. family members, friends, or significant others) play a vital role in caring for individuals with mental health difficulties [ 1 , 2 ]. The carers often assist with the individuals’ daily living and functioning needs, provide emotional support, manage crises, facilitate medical engagement, and complement professional services [ 3 – 5 ]. A multinational survey estimated the monetary value of the care provided by each carer, which ranged from €34,960 to €125,412 per year, depending on living arrangements and valuation methods [ 6 ]. The benefits of carers’ involvement in caring for individuals with mental health difficulties are well-established. Increased carer involvement in treatment has been associated with service users’ reduced psychiatric symptoms, shorter durations of hospitalisation [ 7 ], and longer maintenance of remission [ 8 ]. While carers’ involvement is beneficial to service users, the caregiving role often places significant practical and psychological burdens on carers themselves, resulting in poorer mental health and higher psychiatric symptoms compared to non-caregivers [ 9 ]. The caring roles demand significant time, financial resources, and emotional energy. For instance, informal carers of individuals with mental health difficulties provided an average of 43.42 hours of care per week, rising to 65.41 hours for co-resident carers [ 6 ]. In addition to the practical burden, the emotional toll of caregiving is highlighted. Research has consistently shown that many informal carers experience reduced quality of life, with high levels of stress, anxiety, fear, and social isolation, although the degree and nature of experiences can vary depending on individual, cultural, and systemic contexts [ 9 – 13 ]. At the same time, carers are frequently marginalised within mental health systems [ 14 ]. The complexities of navigating mental health services and the lack of recognition of carers’ needs and corresponding support, combined with stigma, exacerbate carers’ difficulties [ 15 ]. Their involvement is often undervalued or even actively excluded by service providers due to concerns about confidentiality, risk, or professional boundaries [ 14 , 16 ]. These dynamics can create tension between carers and mental health professionals, further complicating their caregiving experience and amplifying psychological challenges [ 15 ]. Understanding carers’ experiences of accessing and engaging with mental health services regarding supporting the service users and getting support for their own wellbeing is essential for informing policy development and driving service adaptations to better support informal carers and promote their wellbeing, which is also recognised and encouraged by policy makers [ 17 ]. In response to this need, there has been a growing body of qualitative research exploring carers’ experiences of mental health services. Correspondingly, a number of qualitative systematic reviews and syntheses have been conducted to consolidate this evidence and provide broader insights into carers’ experiences across diverse contexts, such as inpatient services [ 15 ], respite care services [ 18 ], psychosis interventions [ 19 ], and others. However, to date, no comprehensive synthesis has integrated these diverse experiences into a single, high-level evidence base. Given the growing amount of qualitative systematic reviews in this area, an umbrella review that systematically identifies, evaluates, and synthesises evidence from existing review-level literature is warranted to collate and summarise existing evidence to inform the development of more inclusive, effective, and holistic caring systems. Thus, this study aims to conduct an umbrella review of review-level qualitative evidence on informal carers’ experiences of mental health services regarding supporting the individuals with mental health difficulties they care for and getting support for their own wellbeing. Methods The umbrella review was primarily guided by the JBI Manual for Evidence Synthesis, which provided comprehensive guidance on all stages of the umbrella review process, including protocol development, systematic literature selection, quality appraisal, data extraction, evidence synthesis, and certainty assessment [ 20 ]. Data synthesis used a meta-aggregative approach, based on JBI guidance on meta-aggregation and adapted for review-level analysis [ 20 ]. The protocol was pre-registered in the publicly accessible PROSPERO database on July 20, 2025 (PROSPERO 2025 CRD420251046003). Ethical approval was not required for this study as it was an umbrella review of existing literature. Eligibility criteria This umbrella review included published systematic reviews or qualitative meta-syntheses with distinguishable qualitative findings specific to the experiences of informal carers (e.g. family members, friends, or unpaid individuals) in accessing and engaging with mental health services in any setting (e.g., community, inpatient, outpatient) through their caring role for individuals with mental health difficulties. The reviews were eligible only if they searched at least two databases for qualitative or mixed-methods studies, and if the findings from the primary qualitative studies were distinguishable and explicitly identified in tables or text. There were no restrictions on language, geographic location, or date of the reviews. Reviews on informal carers’ experience of individuals with neurocognitive or neurodevelopmental disorders were excluded. Reviews focused on drug, alcohol, and smoking services, or specific, discrete interventions within mental health services were excluded. Reviews on the general experience of informal carers of individuals with mental health difficulties, that are not primarily and explicitly focused on carers’ experiences of mental health services, were also excluded to maintain a clear focus for the current review. Search strategy and study selection A literature search was conducted across five databases on 9th May 2025: CINAHL, MEDLINE, PsycInfo, the Cochrane Library, and Epistemonikos. The databases provided a comprehensive coverage of medical, psychological, nursing, and evidence-based review literature relevant to mental health and caregiving. The complete query strings can be found in S1 Appendix . The references were imported into Covidence, deduplicated, and screened [ 21 ]. Screening of titles and abstracts was undertaken by one independent reviewer. A second reviewer double-screened 10% of these results to ensure consistency, achieving strong agreement (κ = 0.88). Subsequently, two independent reviewers assessed potentially eligible reviews in full text. During the whole selection process, disagreements were resolved through discussion or consultation with a third independent reviewer. Data extraction Two independent reviewers manually extracted data from each eligible review using a structured, pre-defined table adapted from the JBI Data Extraction Form for Review for Systematic Reviews and Research Syntheses using Microsoft Excel [ 20 ]. The two reviewers first extracted data from three reviews, compared results to standardise procedures, and then completed the extraction from the rest reviews. Discrepancies were resolved through discussion or consultation with a third reviewer. Extracted information included: citation details, review type, analysis technique, sources searched, the search date range, details of original qualitative studies (number and types), context, review objectives, phenomena of interest, carer participant characteristics, and findings on informal carers’ experiences of mental health services, along with verbatim excerpts and selected quotes from the source reviews. Quality appraisal The methodological quality of the included reviews was appraised using the criteria adapted from SmithBattle et al.’s umbrella review [ 22 ], covering six domains: search criteria, review type, search process, findings extraction, identification of findings, and synthesis methods. The tool was selected for its appropriateness for qualitative umbrella reviews and its thorough coverage of key methodological domains. Two independent reviewers assessed each included review against the six criteria, rating them as either “yes” (criterion fulfilled) or “no” (criterion not fully met). Discrepancies between reviewers were resolved through discussion to reach a consensus. Unlike SmithBattle et al.’s original method, which reported only “yes” or “no” ratings, a three-level quality classification (high, moderate, low) was then applied to improve the interpretability of the ratings and to lay the foundation for certainty assessment. Reviews meeting five or more criteria were rated as high quality, those meeting three or four criteria as moderate quality, and those meeting fewer than three as low quality, whose thresholds were informed by logic and practice applied in dependability assessment in the JBI ConQual framework. Data synthesis Findings were synthesised using an adapted meta-aggregative approach, which forms credible synthesised findings through aggregation with deliberate efforts to minimise re-interpretation of original review-level synthesis [ 20 ]. Extracted findings were first grouped into categories based on similarity in meaning and representation of the carers’ experience. Each category was described in a clear, concise narrative that preserved the original intent of the primary review authors. Higher-order, synthesised findings were then developed by integrating two or more related categories. These findings were formulated as descriptive labels accompanied by summary statements. Narrative presentations supported by data excerpts or quotations were provided, allowing for a nuanced and meaningful representation of carers’ experiences. Certainty assessment The ConQual approach that the JBI Qualitative Methodology Group recommended in the guideline was adapted to assess the overall confidence in the synthesised findings [ 20 ]. The assessment considered the dependability (i.e. methodological quality) of the included reviews and the credibility (i.e. level of support from primary data) of individual findings rated alongside data extraction. Dependability was classified as high, moderate, or low. Credibility of individual, extracted findings was rated as unequivocal (i.e. clearly supported by direct and unambiguous evidence), equivocal (i.e. supported but open to some interpretation), or not supported. In line with the JBI guideline, unsupported findings were excluded from subsequent synthesis. Drawing on these assessments, the dependability and credibility ratings were assigned to each category, and the final ConQual ratings for each synthesised finding were then determined. Each synthesised finding was assigned a confidence rating (high, moderate, low, or very low). Results Search results and study characteristics A total of 12 eligible reviews were identified and included in the current review. The whole study selection process was demonstrated in the PRISMA flow diagram in Fig. 1 . The key characteristics of included reviews are reported in Table 1 . The included reviews were published between 2013 and 2024 and were all in English. Most included reviews were systematic reviews and qualitative meta-syntheses (n = 10), while there was one integrative literature review [18] and one narrative review [23]. Most qualitative syntheses were conducted thematically (n = 8), while others utilised meta-ethnography (n = 2) [24, 25], aggregation (n = 1) [19], and narrative synthesis (n = 1) [23]. The number of original qualitative studies on carers included in each review ranged from 5 [18, 26, 27] to 25 [28]. The types and context of the original qualitative studies were not included in the study characteristics table due to inconsistent reporting at the review level. Most reviews applied no geographical restrictions, except for one review focused exclusively on Australian studies [18]. Where the socio-economic context of primary studies was reported, the majority originated from high-income countries. The objectives of the reviews were generally to synthesise the qualitative evidence on informal carers’ experiences of mental health services. The mental health service settings and conditions explored across reviews were wide-ranging. Eleven included reviews focused on mental health services primarily aimed at service users, including services regarding compulsory admission [27, 29, 30], inpatient care [15, 26], psychosis [19, 23, 24], perinatal mental health [25], anorexia nervosa [28], and forensic mental health [31]. One review addressed respite care services, which explored carers’ experiences of using the services that were primarily for them, providing temporary relief by housing service users for short periods [18]. Carer participant characteristics were also not presented in a table in this umbrella review since only a few reviews synthesised and reported the information at a review level. Where participant descriptives were reported, carers were often family members and predominantly adult females [28, 30, 31]. While some reviews reported the total number of carers included, ranging from 100 [27] to 357 [28], others did not specify the total counts, reflecting variability in reporting standards. Detailed demographic breakdowns (e.g., age and ethnicity) were rarely available and inconsistently presented. Table 1. Study characteristics and quality appraisal. Citation details Type of review Analysis technique Sources searched Search date Number of studies a Phenomena of interest Quality appraisal (Y = Yes; N = No) 1 b 2 c 3 d 4 e 5 f 6 g Dependability AbouSeif et al., 2022 [ 15 ] Systematic review and thematic synthesis Thematic analysis MEDLINE, PsycINFO, Embase, and CINAHL Inception to February 2021 12 Informal carers’ expriences of adult (18+) mental health inpatient care Y Y Y Y Y Y High Almoaber et al., 2024 [ 18 ] Integrative literature review Thematic analysis CINAHL, MEDLINE, PsycINFO, and Scopus Between January 2005 and May 2023 5 The experiences of 18–65 years who were caring for a person aged 18 years or over with a primary diagnosis of mental illness regarding respite care services Y Y Y N N Y Moderate Bartl et al., 2024 [ 29 ] Systematic review and qualitative meta-synthesis A two stage process, informed by thematic synthesis MEDLINE, PsycINFO, HMIC and Embase, and the Social Sciences Citation Index Between January 2018 and March 2023 8 The experiences of compulsory admission or legally detained to a psychiatric hospital Y Y Y Y Y Y High Cairns V.A. et al., 2015 [ 24 ] Systematic review and qualitative meta-synthesis Noblit and Hare’s process of metaethnography PsycINFO,AMED, CINAHL, Web of Science, Medline, and PubMed From 1806 to 2013 13 Family members’ experience of seeking help for first-episode psychosis on behalf of a loved one Y Y Y N Y Y High Dawson et al., 2013 [ 19 ] Systematic review Aggregation and meta-synthesis CINAHL, PubMed, Scopus, PsycINFO, Embase, Mednar, ProQuest Dissertations and Theses, Trove From January 1990 to August 2012 22 Carers’ experience of a relative with first-episode psychosis, and in particular, their experience preceding and of seeking help from both informal (family and friends) and formal (services) sources. Y Y Y Y Y Y High Lever Taylor et al., 2018 [ 25 ] Systematic review and qualitative meta-synthesis An approach based on meta-ethnography PsycINFO, CINAHL, Embase, HMIC, and Medline Inseption up to June 2017 20 Women’s partners’ experiences and views of perinatal mental health care Y Y Y Y Y Y High (continued) Citation details Type of review Analysis technique Sources searched Search date Number of studies a Phenomena of interest Quality appraisal (Y = Yes; N = No) 1 b 2 c 3 d 4 e 5 f 6 g Dependability Oketah et al., 2023 [ 28 ] Systematic review and meta-synthesis Thematic analysis Medline, PsychINFO, CINHAL, Embase, Cochrane Library, and Web of Science Between January 1980 and August 1, 2023 25 Parents’ views on the treatment and recovery process of anorexia nervosa in their adolescent child. Y Y Y N Y Y High Reupert et al., 2023 [ 26 ] Systematic review Thematic synthesis CINAHL Plus, PsycINFO, ProQuest, MEDLINE, PubMed, and Scopus Between 2004 and 13th January 2022 5 The experiences of parents and other family members when a parent is hospitalised for their mental illness Y Y Y Y Y Y High Rodell & Parry, 2024 [ 23 ] Narrative review Narrative synthesis PsycINFO and PubMed. Reference lists were cross-checked. From November 2021 to February 2022 12 The experiences of supporting those under 18 years old reporting symptoms associated with the psychosis spectrum or unusual sensory experiences. Y Y Y N Y Y High Stuart et al., 2020 [ 30 ] Systematic review Thematic synthesis Medline, PsycINFO, HMIC, Embase, and Social Sciences Citation Index Search in January 2018, limited to papers published after 1983 23 Carers’ experiences of and views about assessment for involuntary admission and subsequent detention Y Y Y Y Y Y High Sugiura et al., 2020 [ 27 ] Systematic review and meta-synthesis Thematic analysis Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO, Ichushi, SveMed+, EBSCO, Enfispo, IBECS, LILACS, Psicodoc, and SciELO From 2008 to 2018 5 The experiences of involuntary psychiatric admission among adults Y Y Y N Y Y High Vestphal et al., 2023 [ 31 ] Systematic review and qualitative evidence synthesis Thematic synthesis CINAHL, Medline, PsycINFO, and Scopus From 2014 to 2022 13 Family caregivers’ experiences in forensic mental health care Y Y Y N Y Y High a The number of original qualitative studies on carers included in each primary review b Criterion 1: Are the search criteria clearly identified and appropriate for the aim? c Criterion 2: Is the type of review identified? d Criterion 3: Is the search process clearly described in a figure or text? e Criterion 4: Are procedures for data extraction, with what was extracted from primary studies, explicitly described? f Criterion 5: Are findings of primary qualitative studies clearly identified? g Criterion 6: Are findings from primary studies synthesised? The quality appraisal of included reviews is also reported in Table 1 . Eleven reviews were rated as high quality for satisfying at least five out of the six appraisal criteria. One review was rated as moderate quality for satisfying only four criteria [ 18 ]. All included reviews clearly reported their search criteria, review type, search process, and synthesised primary findings. However, one review did not clearly identify primary findings [ 18 ], and six lacked detailed information on data extraction processes [ 18 , 23 , 24 , 27 , 28 , 31 ]. These gaps suggest some limitations in the transparency and reproducibility of findings selection and interpretation in a minority of reviews. Meta-aggregative synthesis Six overarching synthesised findings were identified, derived from 102 individual findings that were subsequently aggregated into a set of 20 categories. 6 findings from the included reviews were not incorporated into categories due to uniqueness or lack of support from primary data. The structure of the synthesised findings is presented in Table 2 , indicating which categories contributed to each synthesis. Findings extracted from each included review are presented in S2 Appendix . Findings contributing to each category, including verbatim excerpts from the source reviews, are presented in S3 Appendix . Table 2 Organisation of the synthesised findings and supporting categories. Synthesised finding Category Certainty Assessment Dependability Credibility Emotional complexity in the caregiving journey High emotional distress during the build-up to help-seeking and accessing services High Unequivocal Mixed and complicated emotional responses to service involvement High Unequivocal Uncertainty and guarded hope about the future High Unequivocal (continued) Table 2 (Continued) Synthesised finding Category Certainty Assessment Dependability Credibility Recognition and coping with their loved ones’ mental health difficulties Early recognition, reactions, and management High Unequivocal Boosted help-seeking after reaching “crisis point” High Unequivocal Multiple barriers for carers in accessing mental health support Systematic barriers to accessing appropriate mental health support High Unequivocal The uneasy and continuous process of sourcing services High Unequivocal Lack of information and knowledge High Unequivocal Complex personal and relational barriers High Unequivocal Persistent responsibilities and multiple roles in supporting service users Experiential knowledge and potential to help High Unequivocal A strong sense of responsibility and persistent caring roles High Unequivocal Complex experiences of engaging with mental health services Dissatisfaction and distrust High Unequivocal Neglect of needs and lack of adequate support High Unequivocal Exclusion from care and decision-making High Unequivocal Unmet need for information and communication High Unequivocal Limitations of current mental health service models Moderate Equivocal Expectations of health professionals and services High Unequivocal Variations in views and experiences High Unequivocal Relational strain during the caregiving process Strained relationships between carers and service users High Unequivocal Unsatisfactory relationships between carers and health professionals High Unequivocal Synthesised finding 1: Emotional complexity in the caregiving journey Informal carers of people with mental health difficulties underwent a complex emotional journey marked by intense distress before accessing services, mixed and conflicting feelings during service involvement, and ongoing uncertainty and guarded hope about the future. These experiences reflected the psychological burden of caregiving shaped by uncertainty, fear, guilt, stigma, responsibility, and fluctuating hope across different stages of the care trajectory. Carers’ intense and difficult emotional experiences during the build-up to seeking and accessing mental health services were consistently described. Preceding formal engagement with services, carers were often the first to recognise early changes in their loved ones and manage escalating symptoms. The process was marked by overwhelming feelings of confusion, distress, and helplessness. Carers were often among the first to recognise changes in their loved ones, upon which they “experienced a sense of ‘not knowing’” [ 24 ]. Some carers felt “distressed, embarrassed and confused” when they confronted their loved ones’ symptoms and behaviour changes [ 19 ]. Anxiety, fear, sadness, and exhaustion were also reported [ 19 , 29 , 31 ]. Meanwhile, the deterioration of service users was often a gradual process, which typically progressed over an extended period before attracting clinical attention. The build-up to the service users’ crisis was described as distressing and overwhelming [ 15 ]. Before the service users were accepted by mental health services, carers struggled to face and manage the evolving situations on their own. The continued and uncertain process caused strong emotional impacts on carers, leading to difficult feelings such as “powerlessness and frustration” [ 15 ], “high stress and hypervigilance” [ 29 ], “fear, sadness, helplessness, hopelessness, and isolation” [ 19 ]. At the same time, many carers sought help on behalf of their loved ones, which also led to frustration when health professionals failed to recognise the severity of the service users’ conditions [ 29 ], high distress, and sometimes even a sense of trauma [ 24 ]. After the service users entered mental health services, carers reported experiencing mixed feelings in response to service engagement. While some findings reported positive emotions, such as relief and hope, when carers felt their loved ones were supported and protected, more described ongoing distress and complex emotional experiences. Carers expressed uncertainty and powerlessness regarding the treatment process, self-blame for delayed help-seeking or for contributing to their loved ones’ mental health difficulties, and feelings of loneliness and isolation arising from strained relationships and the stigma surrounding mental health difficulties. Many carers reported some relief when they felt the service users were safe and under appropriate treatments [ 15 , 18 , 25 , 29 , 30 ]. For instance, “one carer emphasised ‘feeling peace of mind that their loved one was safe’”, as cited in one review [ 18 ]. Positive feelings such as gratitude and hope were also reported in a few reviews [ 15 , 30 ]. However, difficult emotions still appear to be prominent. Some carers reported distress and even trauma related to initiating coercive measures, undergoing assessments, and witnessing admission [ 29 ]. Some expressed personal uncertainty [ 29 ] and reported feeling worried due to limited knowledge about the illness and the treatment process [ 28 ]. Some reported struggling with guilt and self-blame for not recognising the conditions earlier, delaying help-seeking, or even believing they were “causing the illness” [ 28 ]. The self-blame further led to a sense of helplessness or powerlessness, as illustrated by cited statements such as “we’d failed as parents” and “I kind of think that nothing I do helps, really” [ 28 ]. Relationship strain during service engagement also adversely affected carers’ well-being. Distress could arise from disagreements with other family members about the appropriate course of action and conflicts between the service users’ wishes and what was considered to be in their best interests [ 29 ]. Some carers reported feelings of loneliness and expressed a desire for connection [ 26 , 28 ]. Increased caregiving responsibilities led to social disconnection, while stigma surrounding mental illness contributed to reduced support and greater peer blame [ 28 ]. Collectively, these findings revealed that while formal service engagement could alleviate some burdens, it introduced new emotional and social challenges for carers. In terms of prospects, informal carers experienced enduring uncertainty and guarded hope regarding their loved ones’ recovery and future well-being, even after receiving professional treatment. Fear and frustration overshadowed optimism fostered by progress in the service user’s condition when setbacks occurred. For instance, carers expressed fear of relapse [ 28 ] and “experienced substantial anguish” when witnessing their children regress or relapse after making progress [ 23 ]. In addition, there was a tension between carers’ desire to be hopeful and the inclination to moderate it, as illustrated by the cited quotes: “I want to be optimistic but I feel maybe she can only be helped so much and then this will happen again. I fear she will backslide. My only hope is that she will be happy and enjoy life” [ 23 ]. The tension reflected an ongoing struggle to sustain hope amid the unpredictability of mental health recovery. Synthesised finding 2: Recognition and coping with their loved one’s mental health difficulties Whereas the first synthesised finding focused on carers’ emotional responses to their loved one’s situations, the second focused on their actions and coping strategies upon recognition of changes in their loved ones. Initial denial, attributions to non-mental health causes, and interpretations based on their own knowledge and belief system influence their perceptions and corresponding management. Help-seeking to external and professional sources was often prompted by a “crisis point,” where carers’ coping capacity was overwhelmed. Carers were often the first to notice changes in their loved ones, but their initial reactions varied. Some experienced denial or shock, while others struggled to make sense of the situation. Limited by their own knowledge and belief systems, carers’ misinterpretations were common, leading to delays in seeking help or turning to other sources rather than professional mental health services. Informal carers noticed issues with their loved ones through observing mood fluctuation, behavioural changes, and functional decline [ 19 ]. Upon recognition, some carers reacted with “denial and shock” [ 28 ]. Also, carers attempted to understand the changed presentations and make sense of the situation, mostly within their own knowledge and belief systems [ 24 ]. Their understanding and interpretations of the situations informed their subsequent type and timing of management. Some carers initially failed to recognise the seriousness of their loved ones’ conditions, as illustrated by the cited quote, “I thought it was a phase. I had no idea how serious,” which led to delayed help-seeking [ 28 ]. Others misattributed the early symptoms of mental health difficulties to other factors [ 19 ]. For instance, a mother misattributed her son’s mental health condition to supernatural causation, thus “forced her son to be exorcised in a Pentecostal church” [ 19 ]. After clarification of the presence of an illness, relatives sought to understand the possible causes or triggering factors of the condition [ 19 ]. These initial inactions in help-seeking were often resolved when carers reached what they perceived as a “crisis point,” where their personal coping resources became overwhelmed to manage the situation without professional mental health support [ 19 , 23 , 24 ]. This threshold triggered a sharp or urgent increase in seeking external support [ 19 , 23 , 24 ]. A review cited one carer’s reflection: “It took me quite a long time to understand that there was a mental issue there but it wasn’t until she started to become very ill. She actually had a crisis” [ 19 ]. Synthesised finding 3: Multiple barriers for carers in accessing mental health support After recognising their loved ones’ mental health difficulties and perceiving the necessity for professional support, carers played a crucial role in seeking help and accessing services on their behalf, often encountering numerous obstacles in the process. Carers faced multifaceted barriers when accessing mental health support, including systematic inadequacies, procedural difficulties, lack of information, and personal and relational challenges, often resulting in a prolonged, confusing, and emotionally consuming help-seeking process and delayed access to services. Carers frequently encountered systematic inadequacies when attempting to access mental health support for their relatives, including a lack of appropriate and continuous services, restrictive entry criteria, and inadequate community care and pathways. While mental health services were generally lacking, tailored and appropriate services for specific populations, such as young people, were even more scarce, highlighting a gap in current services [ 23 ]. Also, carers voiced a lack of continuity in services, which was especially prominent in transitions between services and following inpatient discharge [ 23 ]. Strict and restrictive entry criteria further limited service availability. Some professional services were only accessible when individuals with mental health difficulties were “convincingly unwell, in crisis, at risk of harming themselves or others, or at least willing to engage in treatment” [ 19 ]. Respite care also had restrictive entry criteria concerning “the patient’s health condition, diagnosis, geographical location, age, length of the caring role and ethnicity” [ 18 ]. Community services and pathways to care were also described as insufficient and inadequate [ 29 ]. These barriers underscored the need for improved availability of existing services, as well as more flexible, inclusive, and holistic service models that addressed diverse needs and offered continuous support throughout different stages of care. At the same time, sourcing mental health services was an uneasy and repeated process, which reflected procedural barriers to service access. Seeking help on behalf of the ill individuals often required multiple attempts and exhausting efforts [ 19 , 23 , 27 ]. For example, a review cited, “one parent described trying to convince health care professionals for over one year that her son needed help for his psychiatric illness” [ 19 ]. Difficulties in help-seeking led to delayed access to support and increased strain on carers. For instance, “families found it difficult to navigate the system to get support, they were frustrated with a delay in support, and they felt services were reactive rather than proactive” [ 27 ]. Carers’ lack of information and knowledge of mental health services further compounded the systematic and procedural barriers, creating confusion and hindered timely, informed decision-making. Many carers lacked clarity about available support [ 18 ], how and where to access it [ 23 ], and the procedures and legislation for interventions such as involuntary admission [ 18 , 23 , 27 ]. They expressed a need for more information and guidance from services to help them manage the situation, as illustrated by the cited quote: “There should be more support actually for me or actually tell me what I need to do to support him” [ 29 ]. Personal and relational barriers also hindered help-seeking and service access. Informal carers’ negative attitudes toward mental health services, often shaped by stigma or past negative experiences, and service users’ withdrawal or hostility toward carers’ help-seeking, both hindered access to services. Carers’ informal networks (e.g., family, friends, and community figures) and formal networks (e.g., healthcare professionals) may both obstruct help-seeking when dismissing difficulties or failing to provide appropriate support, though they facilitated service access with positive interactions. Informal carers’ own stigmatised attitudes toward mental health difficulties acted as initial barriers [ 23 ]. Carers’ negative past experiences of mental health services also led to “lasting distrust and reluctance to seek help from similar services” [ 23 ]. Service users may also play a role in impeding service access, being reluctant to engage in services when carers sought help [ 18 , 29 ]. They may withdraw from carers, mask their symptoms during assessments, or stay guarded [ 29 ]. Some may even be “hostile” to carers’ help-seeking efforts [ 23 ]. Carers’ informal networks, including family members, friends, and community figures such as religious leaders, can provide support to carers and may act as facilitators to service access [ 19 ]. The informal networks often contributed to “initial detection of problems, clarification of the seriousness of problems and encouragement to seek help” [ 19 ]. Meanwhile, another review highlighted that interactions within these networks could both facilitate help-seeking or hinder it when they normalised symptoms or dismissed difficulties [ 24 ]. The mediating effects of interactions were also evident when carers sought help from formal networks (e.g., mental health professionals, general practitioners, social workers, counsellors), as some interactions facilitated help-seeking and were regarded as helpful, while others acted as barriers [ 19 , 24 , 28 ]. Examples of barriers within formal networks included inappropriate treatment by professionals [ 24 ] and professional knowledge gaps, such as an inability to provide required treatment options [ 28 ]. Synthesised finding 4: Persistent responsibilities and multiple roles in supporting service users Even after navigating numerous challenges during the build-up to and accessing mental health services, carers did not disengage once service users were under care. While carers insisted on participating, they did have strong potential to facilitate treatment with their unique perspectives and in-depth knowledge of the service users. As carers felt a profound and persistent sense of duty in supporting the service users before, during, and after engaging in mental health services, they played important and multifaceted roles in supporting the service users. Carers possessed in-depth knowledge and expertise of the service users’ behaviour and history through long-term, close observation and interactions, which was valuable for care and treatment [ 29 , 31 ]. Carers perceived their experiential knowledge as a facilitator in their involvement in care and treatment [ 31 ], strengthening their belief in both their ability to contribute and the necessity of their participation in treatment decision-making. Their expertise, however, was often unrecognised or dismissed by health professionals, upon which carers reported feelings of anger, disempowerment, and mistrust [ 31 ]. Despite these challenges, carers remained committed to supporting their loved ones. Carers’ persistent efforts were driven by a strong sense of responsibility, which also led to significant burdens. They protected and supported their loved ones through various means, such as initiating admissions, mediating relationships between service users and professionals, and advocating for appropriate care when they perceived unfair treatment or neglect. Carers reported a strong sense of responsibility to the service users, persistently caring for them before, during, and after service engagement [ 29 , 31 ]. The responsibility led to prolonged, heavy burdens, some “to a point where they lived their lives with an almost constant focus on their ill family member” [ 31 ]. Carers remained vigilant to protect their loved ones and described themselves as “fighting from the outside inwards” [ 29 ]. They played multifaceted roles in protecting and supporting their loved ones. Some initiated admission, believing their actions provided protection [ 27 , 29 ]. Some mediated between service users and health professionals and advocated for the rights of the service users and appropriate care when they perceived unfair treatment or victimisation by healthcare systems or professionals [ 31 ]. For instance, a review cited that when perceiving a doctor’s dismissive response that downplayed the service user’s concerns, one carer challenged the doctor by stating, “I want you to repeat what you just said in front of a witness, because when she goes outa here and harms herself or somebody else, I’m taking you to court” [ 31 ]. Synthesised finding 5: Complex experiences of engaging with mental health services Regarding engagement with mental health services, carers expressed dissatisfaction with and distrust in the quality of care. They frequently reported experiencing neglect and inadequate support from services, exclusion from care and decision-making, and unmet needs for information and communication. Carers also raised concerns about inadequate staff competencies and service models that were inappropriate or culturally insensitive. Carers expected healthcare professionals to be empathetic, respectful, and compassionate. It was noticeable that carers expressed ambivalence about their involvement and support needs and reported mixed experiences with various treatment modalities. Carers’ general comments on their experiences with service engagement in the included reviews were predominantly negative. They expressed dissatisfaction with and distrust in current services, including service delays, safety concerns, unmet service user needs, clinicians and other staff’s lack of competence, lack of respect, heavy-handed treatment, and an overreliance on medication [ 15 , 27 – 30 ]. While acknowledging that interventions such as detention were sometimes necessary, carers expressed profound misgivings, as some were already disappointed for failing to get earlier, preventive help when they were desperate to [ 30 ]. Negative attitudes also emerged in response to poor communication, as well as perceived blame and judgment, from healthcare professionals [ 28 ]. The neglect of carers’ needs and the lack of corresponding support were key sources of negative experiences during service engagement. Carers were often overlooked, dismissed, or inadequately supported by the mental health system and professionals throughout the care process, despite their considerable needs and efforts to be recognised [ 15 , 25 , 27 , 29 , 30 ]. For instance, “the families clearly did not perceive staff as being supportive…they were seldom, if ever, acknowledged when they visited their child…”, as cited in one review [ 15 ]. They required proactive support before, during, and after formal service engagement to understand the situations, clarify their role in it, navigate the challenges, and adapt both emotionally and practically [ 29 , 30 ]. In addition to the neglect of carers’ needs, carers consistently reported active exclusion from the treatment process and decision-making for service users, leading to frustration and helplessness. Carers wanted to help and “be treated as a resource” [ 30 ], to inform clinical decision making with their experiential knowledge about the service users and to provide consistent support to them [ 29 , 30 ]. However, they consistently described being excluded from key aspects of their loved ones’ care, including communication with staff, treatment decisions, and discharge planning [ 15 , 23 , 29 – 31 ]. The experience was captured in the following quote: “I wasn’t involved, I was an afterthought. .. no one told us anything, no one rang to keep us up to date with the plan of care” [ 15 ]. The exclusion often led to feelings of frustration, helplessness, and marginalisation [ 23 , 30 ]. While an unmet need for communication and information may be considered a component of neglect and exclusion, it was especially and consistently highlighted in carers’ narratives as a distinct barrier that undermined their experiences. Carers consistently reported an unmet need for proactive, timely, and relevant information regarding their loved ones’ care, their own caregiving role, and the services available [ 25 , 26 , 29 ]. They were unsure about how to help and seek help [ 25 ]. “Being left in the dark” was described to be scary and disappointing [ 26 ]. In addition, confidentiality policies acted as barriers, preventing carers from receiving the information they needed [ 29 ]. Meanwhile, carers noticed limitations in current mental health service models. Carers were concerned that staff in services had insufficient skills to provide care [ 18 ]. Some services, such as respite care, supported diverse service user groups simultaneously but were not tailored to their specific needs [ 18 ]. There was also a general lack of cultural diversity in existing services, with limited attention given to this issue [ 18 ]. These limitations reduced the services’ ability to meet the needs of carers and service users. Although some carers expressed dissatisfaction with healthcare professionals during service engagement, others reported appreciation and emphasised some desired qualities. They expressed a desire for healthcare professionals to demonstrate affection, empathy, proactivity, and respect in their interactions [ 15 ]. They expressed appreciation for healthcare professionals’ “availability, competence, and positive attitudes like empathy, sensitivity, respectfulness, friendliness, and trustworthiness” [ 28 ]. Professionals with these helpful attributes were described as “some kind of saviour” [ 28 ]. Notably, carers were not a homogeneous group. Their views and experiences varied across individuals. While many carers desired inclusion, some expressed ambivalence about their involvement and support needs. For instance, some partners of women in perinatal mental health services depicted themselves as “struggling to identify their own needs, minimizing their own desires, prioritizing the woman, or expressing a reluctance to ask for or accept help or involvement” [ 25 ]. At the same time, carers reported divergent and inconsistent experiences with different treatment modalities [ 25 , 28 ]. Interventions that some carers viewed as appropriate and helpful were perceived by others as distressing, unhelpful, or even harmful [ 25 , 28 ]. These mixed experiences suggested that the suitability of treatment modalities may depend heavily on individual contexts, needs, and values. Synthesised finding 6: Relational strain during the caregiving process Relational dynamics were a core aspect of carers’ experiences throughout the process of seeking help for service users and engaging with mental health services, and thus presented as a separate synthesised finding. Emotional and relational distance between carers and the individuals they supported was frequently reported in the process. Simultaneously, carers reported unsatisfactory interactions with healthcare professionals. These dual tensions contributed to a sense of isolation and burdens in the caring role. Carers reported relational strain in their relationship with the service user. Distress arising from service users’ mental health difficulties, the power dynamics during the process, and social distancing, particularly in the context of service users’ detention, were key factors contributing to the strained relationships identified in the included reviews. Involuntary admission and hospitalisation could damage communication and relationships, leading to service users’ mistrust, rejection, and social distancing [ 15 , 23 , 29 , 30 ]. Some carers and service users blamed each other for the situation [ 15 ]. The power dynamic involved in the process contributed to the strained relationships. While many carers felt powerless, some experienced a sense of power in their roles through making decisions for service users and service users’ economic dependence [ 29 ]. The power unbalanced the relationship between carers and service users, causing emotional distance and distress [ 29 ]. Physical distancing caused by specialist services and practical difficulties to visit the service used also added to the weakened connection [ 15 , 23 ]. These relationship dynamics led to carers’ feelings of separation, loss, and distress [ 23 , 29 ]. Carers also experienced strain in their relationship with healthcare professionals, while they desired for partnership. They consistently expressed a desire for partnership with healthcare professionals and appreciated kind and respectful interactions [ 15 , 29 ]. However, their relationships with healthcare professionals were often unsatisfactory, marked by feelings of dismissal, invalidation, and a lack of compassion [ 29 , 30 ]. Tensions and divisions were reported in the relationship, as staff sometimes perceived carers as “threats, challenging, or nuisances” [ 15 ]. Findings not included in the final synthesis Six findings from the included reviews were not synthesised using the meta-aggregative approach due to their uniqueness or lack of supporting data across studies. These are presented separately to maintain transparency. Four findings were identified but not integrated into the synthesised findings due to their uniqueness or lack of recurrence across reviews. These included the protective factors for siblings in early adulthood during the prodromal phase [ 19 ], practical barriers to involvement in services [ 25 ], parental observations of gradual positive changes in recovery [ 28 ], and family group conferencing regarded as useful [ 27 ]. These findings were acknowledged for their potential relevance but were excluded to maintain the robustness and coherence of the synthesis. Nonetheless, they suggested potentially important areas for future investigation. Two findings were excluded from the synthesis due to limited supporting evidence. One mentioned carers’ personal growth from the caring experiences [ 23 ], and the other addressed carers’ feeling of isolation [ 23 ]. Excluding findings with insufficient credibility ensured the validity and focus of the current synthesis. Certainty assessment The dependability ratings of included reviews are presented in Table 1 , while the credibility ratings of individual findings are shown in S2 and S3 Appendices . Drawing on these assessments, the dependability and credibility ratings were assigned to each category and are presented in Table 2 . Overall, given the high methodological quality of most included reviews and the predominance of unequivocal findings, only one category was assigned moderate dependability and equivocal credibility ratings. All other categories were rated as having high dependability and unequivocal credibility. Consequently, all synthesised findings received a final ConQual rating of high confidence, demonstrating the robustness and reliability of the overall synthesis. Discussion Main findings This umbrella review synthesised qualitative evidence from 12 reviews to provide a comprehensive understanding of informal carers’ experiences of mental health services regarding supporting those they care for and getting support for their own wellbeing. Drawing on a meta-aggregative approach, six synthesised findings with strong confidence were developed, capturing carers’ emotional journey throughout the caregiving process, early recognition and management of their loved ones’ situations, barriers in accessing services, persistent caring for service users, experience and feedback regarding service engagement, and the relational strain in their caregiving roles. While carers’ emotional distress and difficult experiences were prominent themes consistent with previous literature [ 9 – 13 ], some positive emotions, such as relief, gratitude, and hope, were reported when carers felt that their loved ones had received appropriate and high-quality care [ 15 , 23 , 25 , 29 , 30 ]. A few reviews also reported positive experiences, such as carers observed service users’ recovery-related changes [ 28 ] and carers’ personal growth through the caregiving journey [ 23 ], though each of these was only included in one review and lacked sufficient recurrence for synthesis. The presence of these positive experiences, though limited, suggests the potential helpfulness and constructive roles of mental health services, dimensions that are often underrepresented in the caregiving literature [ 32 ]. However, emotional distress and negative experiences still predominated in the current synthesis. Carers’ persistent emotional distress and difficult experiences reflect the heavy burdens and the multifaceted challenges throughout caregiving, which echo with the wider literature and are increasingly acknowledged by policymakers [ 4 , 17 ]. The findings highlight the urgent need for more specific, comprehensive, and sustained support for informal carers. The challenges and barriers identified in this review suggest potential areas for improvement within current mental health services, including service accessibility, better guidance for carers, greater carer involvement, and enhanced competence among healthcare professionals. Implications for practice Enhancing services availability and accessibility The availability of mental health services for both carers and service users remain a significant concern and require improvement. While carers shouldered substantial burdens and stress in supporting the service users, their needs were often unaddressed by existing service structures [ 15 , 30 ]. More services tailored to carers’ needs are needed. For example, respite care services can provide temporary relief [ 18 ]. Smaller embedded interventions targeted particularly at carers, such as family psychoeducational programs, are often experienced as helpful and could be promoted more widely for empowering families and benefiting carers’ well-being [ 33 ]. Interventions that help mediate the relationship strain between carers and service users may also be helpful to reduce carers’ potential sense of conflicts and social isolation when their loved ones are receiving services [ 15 , 23 , 27 , 29 , 30 ]. Also, as reflected in the current review, the demand for appropriate and continued services for service users with fewer access barriers has been high [ 19 , 23 ]. Access barriers have contributed to carers’ dissatisfaction, frustration, and exhaustion, as well as service users’ poorer long-term outcomes, since they often resulted in delayed access to professional services when early interventions were critical for improving outcomes across both common and serious mental issues [ 34 , 35 ]. Preventive care, community-based support, and low-threshold, low-intensity services have been identified as a feasible strategy to cope with these challenges, which could expand access, promote service inclusion, mitigate service users’ symptoms, and enhance support to carers [ 36 – 38 ]. However, the limitations of community care and pathways was also identified in the current review. This gap underscores the need for increased attention and promotion of accessible, community -based approaches. Encouragingly, innovative services of this type have emerged with demonstrated strengths. For instance, non-diagnostic, network-based Open Dialogue has facilitated transparent, collaborative decision-making and emphasises relational continuity, which improved engagement and support for both carers and service users [ 39 ]. Community-based residential crisis houses provided flexible, short-term support without formal psychiatric admission, reducing coercion and promoting inclusivity [ 40 ]. These approaches enhanced access, reduced carers’ burden, and established strong practical potential to improve outcomes in non-acute settings [ 39 ]. Both example services have been praised for their flexibility and inclusion, enhancing access and improving outcomes in non-acute settings [ 40 ], which underline the importance of promoting community- and low-intensity mental health services as a response to the current gaps in service provision. Raising awareness and providing guidance While improved service availability and accessibility are essential, they are not sufficient on their own. Carers need awareness of these services and guidance on accessing and engaging with them effectively [ 18 , 23 , 25 – 27 , 29 ]. Upon recognising changes in their loved ones’ mental health, carers often attempted to interpret these shifts through their own knowledge and belief systems, which shaped subsequent coping strategies [ 19 ]. However, due to limited mental health knowledge, many delayed help-seeking until a ‘crisis point’, negatively impacting service users’ outcomes and carers’ own well-being [ 19 , 23 , 24 , 34 , 35 ]. This highlights the importance of public awareness campaigns to improve understanding of mental health difficulties, available supports, and pathways to care. Some initiatives have provided evidence of the positive impact of these campaigns, demonstrating how they can support both carers and service users. Example campaigns include Every Mind Matters , a UK public health campaign that enhanced mental health literacy, promoted self-care skills, and reduced stigma, with evidence showing it improved individuals’ help-seeking self-efficacy, empowering them to seek support more timely and confidently [ 41 ]. Similarly, RU OK? Day , an Australian initiative promoting peer support through structured conversations, has been associated with greater intentions, confidence, and actions to check in on others’ mental health, fostering broader social support and preventing severe mental health crisis [ 42 ]. The examples suggest the potential of establishing mental health public awareness initiatives to improve current services, which can benefit both carers’ and service users’ well-being by promoting coping strategies and fostering broader connectedness in their journey of accessing services and recovery. During and after engagement with mental health services, many carers continued to experience a lack of guidance on navigating the system and sustaining their caregiving roles, which often made them feel ill-equipped and powerless to manage both their own well-being and the needs of their loved ones [ 25 , 26 , 29 , 30 ]. Services should provide more guidance and communication to carers, enhancing their engagement and empowering them to contribute effectively. This can benefit carers’ self-efficacy and emotional well-being, while also strengthening service delivery and service users’ outcomes. The community-based, family-led education program, the Journey of Hope , that strengthened families’ knowledge and coping competencies with proactive communication, is a good example [ 43 ]. When carers feel more empowered and informed, they sustain their caregiving responsibilities more effectively with improved self-efficacy, emotional resilience, and caregiving competencies, leading to improved outcomes [ 43 ]. The beneficial effects of offering more proactive communication and guidance are highlighted, as collaborative, family-centred approaches not only improve carers’ experiences but also strengthen the overall service outcomes by fostering more engaged, informed, and supportive caregivers. In addition, carers observed that current service models often lack cultural sensitivity [ 18 ]. While mental health difficulties may involve biological components, they are largely experienced and interpreted through cultural frameworks [ 44 , 45 ]. The dominant knowledge of mental health, rooted primarily in Western ethnopsychiatry, has been critiqued for its limited cross-cultural validity [ 46 ]. Therefore, awareness initiatives should adopt culturally sensitive and inclusive approaches that consider diverse worldviews and lived experiences. Initiatives such as the Patient and Carer Race Equality Framework (PCREF) have been introduced to improve the inclusiveness and cultural competence of mental health services [ 47 ]. More specifically, the PCREF has guided healthcare providers in developing culturally competent care plans and advocated to train mental health professionals to interact with individuals from diverse backgrounds in a respectful and understanding way [ 47 ]. Such an approach may help to mitigate misunderstandings, reduce the risk of inappropriate treatment, and alleviate the additional social pressures that marginalised individuals potentially experience [ 47 ]. Culturally sensitive frameworks, such as the PCREF, could be more widely promoted and adopted to address the cultural insensitivity concerns raised by carers. These frameworks may help more effectively support both carers and service users from diverse backgrounds, fostering social inclusion and promoting equity in mental health services. Promoting carers’ involvement Within mental health services, improving the recognition of carers’ needs and enhancing their inclusion is crucial. Carers possessed profound experiential knowledge of the service users [ 29 , 31 ] and demonstrated sustained motivation, sense of responsibility, and willingness to persistently participate in care and support [ 27 , 29 , 31 ]. Excluding them not only led to marginalisation, mistrust, and a sense of powerlessness, but also wasted valuable resources that could support service users’ recovery [ 23 , 29 – 31 ]. Reconsidering and strengthening carers’ roles within services is therefore essential. The UK’s Triangle of Care model is a good example of frameworks that address these considerations [ 48 ]. It promotes collaboration between service users, professionals, and carers, encouraging routine information-sharing and carers’ meaningful involvement in care planning [ 48 ]. The model has shown promise in enhancing relational, emotional, and clinical outcomes in both carers and service users [ 48 , 49 ]. Interventions that facilitate carers’ involvement in treatment decisions, discharge planning, and aftercare are also highly valuable [ 50 ]. For instance, family group conferencing and a caregiver-involved discharge planning process have helped reduce caregiver burden and improved carers’ health status, demonstrating positive impacts of structured carer inclusion [ 27 , 51 ]. Embedding carers within the treatment process, cooperative and inclusive models, such as the examples discussed above, show significant potential in addressing the challenges of carer inclusion identified in this review. These models foster greater engagement, reduce isolation, and enhance the well-being of both carers and service users by ensuring a more holistic, integrated, and inclusive approach to care. Such frameworks should be actively promoted to strengthen support for carers and improve overall outcomes. Policies such as confidentiality, while essential for protecting service users’ rights, can sometimes hinder carer involvement [ 29 ]. Negotiation and flexibility are needed to navigate these tensions. Frameworks have emerged to address this issue. For example, when service users withhold consent, a best practice framework recommends a context-dependent distinction between general information (e.g. illness education) that can be shared without consent and service users’ personal information that cannot, allowing carers to receive support without breaching confidentiality [ 52 ]. Flexible, situation-dependent frameworks like this can help address policy limitations, balancing the need for carer involvement with the protection of service users’ privacy and ultimately enhancing the quality of care and support provided to both carers and service users. Improving healthcare professionals’ competence Last but not least, improving the professional competence of healthcare professionals is essential. Professionals need not only clinical knowledge and skills to make accurate diagnoses and suggest appropriate treatment options, but also the ability to recognise, engage, and collaborate with carers effectively [ 15 , 28 – 30 ]. Beyond clinical knowledge, healthcare professionals’ attitudes and interpersonal behaviours are a vital part of their clinical expertise and play a crucial role in shaping carers’ and service users’ experiences. Some staff displayed dismissive, stigmatising, or blaming attitudes, leading to carers’ distrust, distress, and reduced engagement [ 28 ]. Conversely, carers appreciated professionals who demonstrated kindness, respect, compassion, and a genuine concern for the needs of both service users and their families [ 15 , 28 ]. These attitudes should be actively fostered within healthcare professionals. Implications for research As mentioned earlier, emotional distress and negative experiences predominated in the current synthesis. Methodological and structural biases within the included reviews may have contributed to the skew. Many of the existing qualitative studies in the area were guided by a longstanding deficit-focused approach, where studies are primarily motivated by concerns related to distress, system inadequacies, or service failures [ 32 , 53 – 55 ]. For instance, 8 out of 12 included reviews focused on involuntary treatment, hospitalisation, and psychosis-related services, which are high-intensity settings with salient stress [ 29 ]. This reflects a broader pattern in the literature, where carers’ experiences in acute or coercive contexts are more frequently studied, entrenching problem-oriented perspectives. Potential overlaps in primary studies across the included reviews may also inflate the bias [ 56 ]. The absence of reviews that explicitly focus on community services or low-intensity care reflects a notable gap in perspective. Furthermore, potential underrepresentation of carers’ positive experiences may be amplified in umbrella reviews since such accounts may be deemed too infrequent or nuanced to warrant synthesis inclusion, leading to progressive downplaying at each stage of synthesis [ 56 , 57 ]. Future research that deliberately attends to carers’ strengths and positive experiences is needed to provide a more balanced and holistic understanding of their caregiving journey. At the same time, more studies on community-based or low-intensity mental health services are also increasingly called for. Such research would complement existing knowledge from acute service settings, informing the development of more comprehensive, cooperative, tailored, and accessible interventions that better include both carers and service users, effectively reduce access barriers, and improve outcomes. In addition, limited demographic and socio-cultural details were reported across reviews, revealing a gap in the current evidence base. When some demographic details were available, most primary studies were conducted in high-income countries with predominantly adult female participants, limiting the generalisability of findings. The gap underscores the need for research that diversifies participant demographics and concerns underrepresented groups, such as ethnic minority carers and young male carers. Such research would deepen understanding of how cultural values, gender norms, and social resources shape carers’ engagement with mental health services and their own wellbeing and provide insights into how services can be improved to best meet the needs of different groups [ 20 ]. In addition, only one included review on respite care explicitly examined interventions supporting carers’ own mental health [ 18 ]. Consequently, this synthesis provided limited evidence on services that directly promote carers’ wellbeing, highlighting the demand for research on carers’ broader needs and targeted interventions. Given the need to enhance current services, future research should also prioritise the development and evaluation of service models designed to support carers. Limitations This review has several limitations. First, although focusing on carers’ experiences of mental health services, many primary reviews also included carers’ broader experiences of supporting their loved ones. These findings were included. However, wider literature on carers’ general experiences was not comprehensively captured, potentially omitting valuable insights. Second, while providing a high-level, overarching synthesis, the umbrella review and meta-aggregative approach has some inherent methodological constraints. Both the cumulative synthesis process of an umbrella review and the meta-aggregative method, which prioritises summarising findings over comparative or interpretive analysis, may oversimplify complex experiences, reduce contextual richness, and omit nuanced or minority perspectives, thereby biasing results toward dominant themes [ 57 , 58 ]. The prevailing deficit focus across the included studies, combined with the umbrella review’s inclination to highlight dominant narratives, may have inadvertently obscured positive experiences or developments occurring within mental health services. In addition, as umbrella reviews are built upon systematic reviews, which in turn synthesise primary studies, there is an inevitable temporal lag that may obscure recent developments in service provision [ 57 ]. The meta-aggregative approach may also lack interpretive depth and flexibility, as it relies on the synthesis of existing reviews [ 58 , 59 ]. Overlapping primary studies across included reviews may result in overrepresentation of certain findings [ 56 ]. Together, these factors should be considered when understanding and interpreting the synthesised findings. Third, demographic and contextual information were limited in the included reviews, making it difficult to understand how factors, such as carers’ age, gender, ethnicity, or socio-cultural backgrounds, may have influenced their experiences of accessing and engaging with professional mental health services. Also, as for context, the included reviews disproportionately focused on acute and hospital-based contexts, with few findings reflecting carers’ experiences in community or low-intensity services and did not differentiate findings by context. As a result, the synthesis mainly reflects high-intensity or coercive settings, limiting generalisability. Conclusion This umbrella review synthesised qualitative review-level evidence on informal carers’ experiences of accessing and engaging with mental health services. Drawing on twelve qualitative reviews and using a meta-aggregative approach, the synthesis identified six key findings that reflected carers’ emotional complexity, efforts to cope and engage with services, systematic challenges and limitations of services they experienced, and relational tensions embedded in the caregiving experience. The findings highlight an urgent need to reform mental health services in ways that actively involve, inform, and support informal carers before, during, and after service users’ formal service engagement. Improving service accessibility, raising public awareness and providing guidance, facilitating carer involvement, and enhancing professionals’ competencies are critical priorities. This review provides a foundation for future research, service innovation, and policy development that centres carers as essential partners in mental health systems. 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World Psychiatry 21(1):96–123 Seikkula J, Alakare B, Aaltonen J (2011) The comprehensive open-dialogue approach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis 3(3):192–204 Lloyd-Evans B, Johnson S (2019) Community alternatives to inpatient admissions in psychiatry. World psychiatry 18(1):31 Hahn JS, Chua K-C, Jones R, Henderson C (2023) The Every Mind Matters campaign: changes in mental health literacy and its associations with campaign awareness. Eur J Pub Health 33(6):1008–1013 Ross AM, Bassilios B (2019) Australian RU OK? Day campaign: improving helping beliefs, intentions and behaviours. Int J mental health Syst 13(1):61 Pickett-Schenk SA, Lippincott RC, Bennett C, Steigman PJ (2008) Improving knowledge about mental illness through family-led education: the journey of hope. Psychiatric Serv 59(1):49–56 Rose N, Abi-Rached JM, Neuro (2013) The new brain sciences and the management of the mind. Princeton University Press, Neuro Kleinman A (1987) Anthropology and psychiatry: The role of culture in cross-cultural research on illness. Br J Psychiatry 151(4):447–454 Summerfield D (2012) Afterword: Against global mental health. Transcult Psychiatry 49(3–4):519–530 Smith SM, Kheri A, Ariyo K, Gilbert S, Salla A, Lingiah T et al (2023) The Patient and Carer Race Equality Framework: a model to reduce mental health inequity in England and Wales. Front Psychiatry 14:1053502 Hannan R (2013) The Triangle of Care: carers included. J Public Mental Health 12(3):171–172 Misra A, Malik O, Sheridan ML, Tracy D (2025) Triangle of Care Standards Incorporation and Audit Implementation to Optimise Carer Involvement and Support Services Across Psychiatric Rehabilitation and Acute Wards at Cygnet Churchill Hospital London. BJPsych Open 11(Suppl 1):S258 Petkari E, Kaselionyte J, Altun S, Giacco D (2021) Involvement of informal carers in discharge planning and transition between hospital and community mental health care: a systematic review. J Psychiatr Ment Health Nurs 28(4):521–530 Lin L-E, Lo S-C, Liu C-Y, Chen S-C, Wu W-C, Liu W-I (2018) Effectiveness of needs-oriented hospital discharge planning for caregivers of patients with schizophrenia. Arch Psychiatr Nurs 32(2):180–187 Slade M, Pinfold V, Rapaport J, Bellringer S, Banerjee S, Kuipers E et al (2007) Best practice when service users do not consent to sharing information with carers: national multimethod study. Br J Psychiatry 190(2):148–155 Dellagiacoma M (2017) Public policy and services: rethinking the approach to carers and their dependants. Macquarie University INQUIRY OCIQ Problematising the research landscape Cunningham NA, Cunningham TR, Roberston JM (2019) Understanding and measuring the wellbeing of carers of people with dementia. Gerontologist 59(5):e552–e64 Fernandez R, Sharifnia AM, Khalil H (2025) Umbrella reviews: a methodological guide. Eur J Cardiovasc Nurs. :zvaf012 Ortega A, Lopez-Briz E, Fraga-Fuentes MD (2016) From qualitative reviews to umbrella reviews. Springer, Umbrella reviews, pp 21–41 Bergdahl E (2019) Is meta-synthesis turning rich descriptions into thin reductions? A criticism of meta‐aggregation as a form of qualitative synthesis. Nurs Inq 26(1):e12273 Sim J, Mengshoel AM (2023) Metasynthesis: issues of empirical and theoretical context. Qual Quant 57(4):3339–3361 Additional Declarations The authors declare no competing interests. Supplementary Files S1S3Appendices.docx S1 Appendix. Complete query strings. S2 Appendix. Findings extracted from each included review. S3 Appendix. Findings contributing to each category. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8995678","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":598545991,"identity":"7a6c831c-72b9-4c72-93e6-eb1d0f2c5be9","order_by":0,"name":"Xiaoye Liu","email":"","orcid":"","institution":"Division of Psychiatry, Faculty of Brain Sciences, University College London","correspondingAuthor":false,"prefix":"","firstName":"Xiaoye","middleName":"","lastName":"Liu","suffix":""},{"id":598546342,"identity":"0dd958f3-3778-40dc-a1f2-286da5b20cc9","order_by":1,"name":"Phoebe Barnett","email":"","orcid":"","institution":"Division of Psychiatry, Faculty of Brain Sciences, University College London","correspondingAuthor":false,"prefix":"","firstName":"Phoebe","middleName":"","lastName":"Barnett","suffix":""},{"id":598546343,"identity":"5e16e881-bde6-484f-aea4-7115c00aa3ab","order_by":2,"name":"Patrick Nyikavaranda","email":"","orcid":"","institution":"Division of Psychiatry, Faculty of Brain Sciences, University College London","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"","lastName":"Nyikavaranda","suffix":""},{"id":598546344,"identity":"570eebe5-b7fd-4acd-b036-80764d1de676","order_by":3,"name":"Brynmor Lloyd-Evans","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYBACAwbmxgMMDMxQbgUDAx+ElYBHC2MDkpYzDAxspGlhbCNCizlIy8c2awZ+ieRnD3/OOyzPxsD88ANjWxpOLZYNjA0HZ7alM0jOSDM35t122LCNgc1YgrEtB7fDDjA2HOZtO1y/4cwBM2nGbYcTgA4zA7qwgqAWBvszx79J/pwD0sL+jTgtBuw9ZhK8DSAtPCBbcDvMshnolxnn0hkkjveUSfMcSzdsY+Yplkg4h9v75uzNBx98KAOGWDP7NskfNdby/OztGz98KEvGqQUcI4xs6CIJuDVAwR+CKkbBKBgFo2AkAwBfV02Hk0T5PAAAAABJRU5ErkJggg==","orcid":"","institution":"Division of Psychiatry, Faculty of Brain Sciences, University College London","correspondingAuthor":true,"prefix":"","firstName":"Brynmor","middleName":"","lastName":"Lloyd-Evans","suffix":""}],"badges":[],"createdAt":"2026-02-28 13:29:16","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8995678/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8995678/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104302679,"identity":"e7087b20-4726-45e1-b965-373d7e2a27d9","added_by":"auto","created_at":"2026-03-10 09:22:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":395153,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA flow diagram.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-8995678/v1/df21edb4159d576a424fc282.png"},{"id":104405566,"identity":"b24a5d05-396f-4c3f-a3d6-3b590da65f37","added_by":"auto","created_at":"2026-03-11 12:23:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1763361,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8995678/v1/e369f356-0aae-433d-a19f-768e0cd89cc9.pdf"},{"id":104302680,"identity":"687e41aa-13ca-4f1e-a96b-05795195628a","added_by":"auto","created_at":"2026-03-10 09:22:50","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":119181,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eS1 Appendix. Complete query strings.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eS2 Appendix. Findings extracted from each included review.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eS3 Appendix. Findings contributing to each category.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"S1S3Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-8995678/v1/c465aec171455ecf0f146613.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eInformal carers’ experiences of mental health services regarding supporting those they care for and getting support for their own wellbeing: an umbrella review of qualitative evidence\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the UK, around 13% of the approximately 1.5\u0026nbsp;million informal carers (e.g. family members, friends, or significant others) play a vital role in caring for individuals with mental health difficulties [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The carers often assist with the individuals\u0026rsquo; daily living and functioning needs, provide emotional support, manage crises, facilitate medical engagement, and complement professional services [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A multinational survey estimated the monetary value of the care provided by each carer, which ranged from \u0026euro;34,960 to \u0026euro;125,412 per year, depending on living arrangements and valuation methods [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The benefits of carers\u0026rsquo; involvement in caring for individuals with mental health difficulties are well-established. Increased carer involvement in treatment has been associated with service users\u0026rsquo; reduced psychiatric symptoms, shorter durations of hospitalisation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and longer maintenance of remission [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile carers\u0026rsquo; involvement is beneficial to service users, the caregiving role often places significant practical and psychological burdens on carers themselves, resulting in poorer mental health and higher psychiatric symptoms compared to non-caregivers [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The caring roles demand significant time, financial resources, and emotional energy. For instance, informal carers of individuals with mental health difficulties provided an average of 43.42 hours of care per week, rising to 65.41 hours for co-resident carers [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In addition to the practical burden, the emotional toll of caregiving is highlighted. Research has consistently shown that many informal carers experience reduced quality of life, with high levels of stress, anxiety, fear, and social isolation, although the degree and nature of experiences can vary depending on individual, cultural, and systemic contexts [\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. At the same time, carers are frequently marginalised within mental health systems [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The complexities of navigating mental health services and the lack of recognition of carers\u0026rsquo; needs and corresponding support, combined with stigma, exacerbate carers\u0026rsquo; difficulties [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Their involvement is often undervalued or even actively excluded by service providers due to concerns about confidentiality, risk, or professional boundaries [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These dynamics can create tension between carers and mental health professionals, further complicating their caregiving experience and amplifying psychological challenges [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnderstanding carers\u0026rsquo; experiences of accessing and engaging with mental health services regarding supporting the service users and getting support for their own wellbeing is essential for informing policy development and driving service adaptations to better support informal carers and promote their wellbeing, which is also recognised and encouraged by policy makers [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In response to this need, there has been a growing body of qualitative research exploring carers\u0026rsquo; experiences of mental health services. Correspondingly, a number of qualitative systematic reviews and syntheses have been conducted to consolidate this evidence and provide broader insights into carers\u0026rsquo; experiences across diverse contexts, such as inpatient services [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], respite care services [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], psychosis interventions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and others. However, to date, no comprehensive synthesis has integrated these diverse experiences into a single, high-level evidence base. Given the growing amount of qualitative systematic reviews in this area, an umbrella review that systematically identifies, evaluates, and synthesises evidence from existing review-level literature is warranted to collate and summarise existing evidence to inform the development of more inclusive, effective, and holistic caring systems. Thus, this study aims to conduct an umbrella review of review-level qualitative evidence on informal carers\u0026rsquo; experiences of mental health services regarding supporting the individuals with mental health difficulties they care for and getting support for their own wellbeing.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe umbrella review was primarily guided by the JBI Manual for Evidence Synthesis, which provided comprehensive guidance on all stages of the umbrella review process, including protocol development, systematic literature selection, quality appraisal, data extraction, evidence synthesis, and certainty assessment [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Data synthesis used a meta-aggregative approach, based on JBI guidance on meta-aggregation and adapted for review-level analysis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The protocol was pre-registered in the publicly accessible PROSPERO database on July 20, 2025 (PROSPERO 2025 CRD420251046003). Ethical approval was not required for this study as it was an umbrella review of existing literature.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEligibility criteria\u003c/h2\u003e \u003cp\u003eThis umbrella review included published systematic reviews or qualitative meta-syntheses with distinguishable qualitative findings specific to the experiences of informal carers (e.g. family members, friends, or unpaid individuals) in accessing and engaging with mental health services in any setting (e.g., community, inpatient, outpatient) through their caring role for individuals with mental health difficulties. The reviews were eligible only if they searched at least two databases for qualitative or mixed-methods studies, and if the findings from the primary qualitative studies were distinguishable and explicitly identified in tables or text. There were no restrictions on language, geographic location, or date of the reviews.\u003c/p\u003e \u003cp\u003eReviews on informal carers\u0026rsquo; experience of individuals with neurocognitive or neurodevelopmental disorders were excluded. Reviews focused on drug, alcohol, and smoking services, or specific, discrete interventions within mental health services were excluded. Reviews on the general experience of informal carers of individuals with mental health difficulties, that are not primarily and explicitly focused on carers\u0026rsquo; experiences of mental health services, were also excluded to maintain a clear focus for the current review.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch strategy and study selection\u003c/h3\u003e\n\u003cp\u003eA literature search was conducted across five databases on 9th May 2025: CINAHL, MEDLINE, PsycInfo, the Cochrane Library, and Epistemonikos. The databases provided a comprehensive coverage of medical, psychological, nursing, and evidence-based review literature relevant to mental health and caregiving. The complete query strings can be found in \u003cb\u003eS1 Appendix\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eThe references were imported into Covidence, deduplicated, and screened [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Screening of titles and abstracts was undertaken by one independent reviewer. A second reviewer double-screened 10% of these results to ensure consistency, achieving strong agreement (κ\u0026thinsp;=\u0026thinsp;0.88). Subsequently, two independent reviewers assessed potentially eligible reviews in full text. During the whole selection process, disagreements were resolved through discussion or consultation with a third independent reviewer.\u003c/p\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003eTwo independent reviewers manually extracted data from each eligible review using a structured, pre-defined table adapted from the JBI Data Extraction Form for Review for Systematic Reviews and Research Syntheses using Microsoft Excel [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The two reviewers first extracted data from three reviews, compared results to standardise procedures, and then completed the extraction from the rest reviews. Discrepancies were resolved through discussion or consultation with a third reviewer.\u003c/p\u003e \u003cp\u003eExtracted information included: citation details, review type, analysis technique, sources searched, the search date range, details of original qualitative studies (number and types), context, review objectives, phenomena of interest, carer participant characteristics, and findings on informal carers\u0026rsquo; experiences of mental health services, along with verbatim excerpts and selected quotes from the source reviews.\u003c/p\u003e\n\u003ch3\u003eQuality appraisal\u003c/h3\u003e\n\u003cp\u003eThe methodological quality of the included reviews was appraised using the criteria adapted from SmithBattle et al.\u0026rsquo;s umbrella review [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], covering six domains: search criteria, review type, search process, findings extraction, identification of findings, and synthesis methods. The tool was selected for its appropriateness for qualitative umbrella reviews and its thorough coverage of key methodological domains. Two independent reviewers assessed each included review against the six criteria, rating them as either \u0026ldquo;yes\u0026rdquo; (criterion fulfilled) or \u0026ldquo;no\u0026rdquo; (criterion not fully met). Discrepancies between reviewers were resolved through discussion to reach a consensus.\u003c/p\u003e \u003cp\u003eUnlike SmithBattle et al.\u0026rsquo;s original method, which reported only \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo; ratings, a three-level quality classification (high, moderate, low) was then applied to improve the interpretability of the ratings and to lay the foundation for certainty assessment. Reviews meeting five or more criteria were rated as high quality, those meeting three or four criteria as moderate quality, and those meeting fewer than three as low quality, whose thresholds were informed by logic and practice applied in dependability assessment in the JBI ConQual framework.\u003c/p\u003e\n\u003ch3\u003eData synthesis\u003c/h3\u003e\n\u003cp\u003eFindings were synthesised using an adapted meta-aggregative approach, which forms credible synthesised findings through aggregation with deliberate efforts to minimise re-interpretation of original review-level synthesis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Extracted findings were first grouped into categories based on similarity in meaning and representation of the carers\u0026rsquo; experience. Each category was described in a clear, concise narrative that preserved the original intent of the primary review authors. Higher-order, synthesised findings were then developed by integrating two or more related categories. These findings were formulated as descriptive labels accompanied by summary statements. Narrative presentations supported by data excerpts or quotations were provided, allowing for a nuanced and meaningful representation of carers\u0026rsquo; experiences.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCertainty assessment\u003c/h2\u003e \u003cp\u003eThe ConQual approach that the JBI Qualitative Methodology Group recommended in the guideline was adapted to assess the overall confidence in the synthesised findings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The assessment considered the dependability (i.e. methodological quality) of the included reviews and the credibility (i.e. level of support from primary data) of individual findings rated alongside data extraction. Dependability was classified as high, moderate, or low. Credibility of individual, extracted findings was rated as unequivocal (i.e. clearly supported by direct and unambiguous evidence), equivocal (i.e. supported but open to some interpretation), or not supported. In line with the JBI guideline, unsupported findings were excluded from subsequent synthesis. Drawing on these assessments, the dependability and credibility ratings were assigned to each category, and the final ConQual ratings for each synthesised finding were then determined. Each synthesised finding was assigned a confidence rating (high, moderate, low, or very low).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSearch results and study characteristics\u003c/h2\u003e \u003cp\u003e A total of 12 eligible reviews were identified and included in the current review. The whole study selection process was demonstrated in the PRISMA flow diagram in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eThe key characteristics of included reviews are reported in \u003cstrong\u003eTable 1\u003c/strong\u003e. The included reviews were published between 2013 and 2024 and were all in English. Most included reviews were systematic reviews and qualitative meta-syntheses (n = 10), while there was one integrative literature review [18] and one narrative review [23]. Most qualitative syntheses were conducted thematically (n = 8), while others utilised meta-ethnography (n = 2) [24, 25], aggregation (n = 1) [19], and narrative synthesis (n = 1) [23]. The number of original qualitative studies on carers included in each review ranged from 5 [18, 26, 27] to 25 [28]. The types and context of the original qualitative studies were not included in the study characteristics table due to inconsistent reporting at the review level. Most reviews applied no geographical restrictions, except for one review focused exclusively on Australian studies [18]. Where the socio-economic context of primary studies was reported, the majority originated from high-income countries. The objectives of the reviews were generally to synthesise the qualitative evidence on informal carers\u0026rsquo; experiences of mental health services. The mental health service settings and conditions explored across reviews were wide-ranging. Eleven included reviews focused on mental health services primarily aimed at service users, including services regarding compulsory admission [27, 29, 30], inpatient care [15, 26], psychosis [19, 23, 24], perinatal mental health [25], anorexia nervosa [28], and forensic mental health [31]. One review addressed respite care services, which explored carers\u0026rsquo; experiences of using the services that were primarily for them, providing temporary relief by housing service users for short periods [18]. Carer participant characteristics were also not presented in a table in this umbrella review since only a few reviews synthesised and reported the information at a review level. Where participant descriptives were reported, carers were often family members and predominantly adult females [28, 30, 31]. While some reviews reported the total number of carers included, ranging from 100 [27] to 357 [28], others did not specify the total counts, reflecting variability in reporting standards. Detailed demographic breakdowns (e.g., age and ethnicity) were rarely available and inconsistently presented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Study characteristics and quality appraisal.\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"14\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCitation details\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of review\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnalysis technique\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSources searched\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSearch date\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of studies\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePhenomena of interest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c14\" namest=\"c8\"\u003e \u003cp\u003eQuality appraisal\u003c/p\u003e \u003cp\u003e(Y\u0026thinsp;=\u0026thinsp;Yes; N\u0026thinsp;=\u0026thinsp;No)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e5\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e6\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eDependability\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbouSeif et al., 2022 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review and thematic synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThematic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMEDLINE, PsycINFO, Embase, and CINAHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInception to February 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInformal carers\u0026rsquo; expriences of adult (18+) mental health inpatient care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlmoaber et al., 2024 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntegrative literature review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThematic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCINAHL, MEDLINE, PsycINFO, and Scopus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBetween January 2005 and May 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe experiences of 18\u0026ndash;65 years who were caring for a person aged 18 years or over with a primary diagnosis of mental illness regarding respite care services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBartl et al., 2024 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review and qualitative meta-synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA two stage process, informed by thematic synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMEDLINE, PsycINFO, HMIC and Embase, and\u003c/p\u003e \u003cp\u003ethe Social Sciences Citation Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBetween January 2018 and March 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe experiences of compulsory admission or legally detained to a psychiatric hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCairns V.A. et al., 2015 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review and qualitative meta-synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNoblit and Hare\u0026rsquo;s process of metaethnography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePsycINFO,AMED, CINAHL, Web of Science, Medline,\u003c/p\u003e \u003cp\u003eand PubMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFrom 1806 to 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFamily members\u0026rsquo; experience of seeking help for first-episode psychosis on behalf of a loved one\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDawson et al., 2013 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAggregation and meta-synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCINAHL, PubMed, Scopus, PsycINFO, Embase, Mednar, ProQuest Dissertations and Theses, Trove\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFrom January 1990 to August 2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCarers\u0026rsquo; experience of a relative with first-episode psychosis, and in particular, their experience preceding and of seeking help from both informal (family and friends) and formal (services) sources.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLever Taylor et al., 2018 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review and qualitative meta-synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAn approach based on meta-ethnography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePsycINFO, CINAHL, Embase, HMIC, and Medline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInseption up to June 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWomen\u0026rsquo;s partners\u0026rsquo; experiences and views of perinatal mental health care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e(continued)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"14\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCitation details\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of review\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnalysis technique\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSources searched\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSearch date\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of studies\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePhenomena of interest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c14\" namest=\"c8\"\u003e \u003cp\u003eQuality appraisal\u003c/p\u003e \u003cp\u003e(Y\u0026thinsp;=\u0026thinsp;Yes; N\u0026thinsp;=\u0026thinsp;No)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e5\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e6\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eDependability\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOketah et al., 2023 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review and meta-synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThematic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedline, PsychINFO, CINHAL, Embase, Cochrane Library, and Web of Science\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBetween January 1980 and August 1, 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eParents\u0026rsquo; views on the treatment and recovery process of anorexia nervosa in their adolescent child.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReupert et al., 2023 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThematic synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCINAHL Plus, PsycINFO, ProQuest, MEDLINE, PubMed, and Scopus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBetween 2004 and 13th January 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe experiences of parents and other family members when a parent is hospitalised for their mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRodell \u0026amp; Parry, 2024 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNarrative review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNarrative synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePsycINFO and PubMed. Reference lists were cross-checked.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFrom November 2021 to February 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe experiences of supporting those under 18 years old reporting symptoms associated with the psychosis spectrum or unusual sensory experiences.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStuart et al., 2020 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThematic synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedline, PsycINFO, HMIC, Embase, and Social Sciences Citation Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSearch in January 2018, limited to papers published after 1983\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCarers\u0026rsquo; experiences of and views about assessment for involuntary admission and subsequent detention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSugiura et al., 2020 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review and meta-synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThematic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAcademic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO, Ichushi, SveMed+, EBSCO, Enfispo, IBECS, LILACS, Psicodoc, and SciELO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFrom 2008 to 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe experiences of involuntary psychiatric admission among adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVestphal et al., 2023 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review and qualitative evidence synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThematic synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCINAHL, Medline, PsycINFO, and Scopus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFrom 2014 to 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFamily caregivers\u0026rsquo; experiences in forensic mental health care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003eThe number of original qualitative studies on carers included in each primary review\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Criterion 1: Are the search criteria clearly identified and appropriate for the aim?\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u003c/sup\u003e Criterion 2: Is the type of review identified?\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ed\u003c/sup\u003e Criterion 3: Is the search process clearly described in a figure or text?\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ee\u003c/sup\u003e Criterion 4: Are procedures for data extraction, with what was extracted from primary studies, explicitly described?\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ef\u003c/sup\u003e Criterion 5: Are findings of primary qualitative studies clearly identified?\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eg\u003c/sup\u003e Criterion 6: Are findings from primary studies synthesised?\u003c/p\u003e\u003cp\u003eThe quality appraisal of included reviews is also reported in \u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e. Eleven reviews were rated as high quality for satisfying at least five out of the six appraisal criteria. One review was rated as moderate quality for satisfying only four criteria [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. All included reviews clearly reported their search criteria, review type, search process, and synthesised primary findings. However, one review did not clearly identify primary findings [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and six lacked detailed information on data extraction processes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These gaps suggest some limitations in the transparency and reproducibility of findings selection and interpretation in a minority of reviews.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMeta-aggregative synthesis\u003c/h2\u003e \u003cp\u003eSix overarching synthesised findings were identified, derived from 102 individual findings that were subsequently aggregated into a set of 20 categories. 6 findings from the included reviews were not incorporated into categories due to uniqueness or lack of support from primary data. The structure of the synthesised findings is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, indicating which categories contributed to each synthesis. Findings extracted from each included review are presented in \u003cb\u003eS2 Appendix\u003c/b\u003e. Findings contributing to each category, including verbatim excerpts from the source reviews, are presented in \u003cb\u003eS3 Appendix\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eOrganisation of the synthesised findings and supporting categories.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSynthesised finding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCertainty Assessment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDependability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCredibility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEmotional complexity in the caregiving journey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh emotional distress during the build-up to help-seeking and accessing services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed and complicated emotional responses to service involvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUncertainty and guarded hope about the future\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e(continued)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e(Continued)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSynthesised finding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCertainty Assessment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDependability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCredibility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRecognition and coping with their loved ones\u0026rsquo; mental health difficulties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly recognition, reactions, and management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoosted help-seeking after reaching \u0026ldquo;crisis point\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMultiple barriers for carers in accessing mental health support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic barriers to accessing appropriate mental health support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe uneasy and continuous process of sourcing services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of information and knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplex personal and relational barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePersistent responsibilities and multiple roles in supporting service users\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiential knowledge and potential to help\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA strong sense of responsibility and persistent caring roles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eComplex experiences of engaging with mental health services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDissatisfaction and distrust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeglect of needs and lack of adequate support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExclusion from care and decision-making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnmet need for information and communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimitations of current mental health service models\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEquivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpectations of health professionals and services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariations in views and experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRelational strain during the caregiving process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrained relationships between carers and service users\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnsatisfactory relationships between carers and health professionals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnequivocal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSynthesised finding 1: Emotional complexity in the caregiving journey\u003c/h2\u003e \u003cp\u003eInformal carers of people with mental health difficulties underwent a complex emotional journey marked by intense distress before accessing services, mixed and conflicting feelings during service involvement, and ongoing uncertainty and guarded hope about the future. These experiences reflected the psychological burden of caregiving shaped by uncertainty, fear, guilt, stigma, responsibility, and fluctuating hope across different stages of the care trajectory.\u003c/p\u003e \u003cp\u003eCarers\u0026rsquo; intense and difficult emotional experiences during the build-up to seeking and accessing mental health services were consistently described. Preceding formal engagement with services, carers were often the first to recognise early changes in their loved ones and manage escalating symptoms. The process was marked by overwhelming feelings of confusion, distress, and helplessness. Carers were often among the first to recognise changes in their loved ones, upon which they \u0026ldquo;experienced a sense of \u0026lsquo;not knowing\u0026rsquo;\u0026rdquo; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Some carers felt \u0026ldquo;distressed, embarrassed and confused\u0026rdquo; when they confronted their loved ones\u0026rsquo; symptoms and behaviour changes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Anxiety, fear, sadness, and exhaustion were also reported [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Meanwhile, the deterioration of service users was often a gradual process, which typically progressed over an extended period before attracting clinical attention. The build-up to the service users\u0026rsquo; crisis was described as distressing and overwhelming [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Before the service users were accepted by mental health services, carers struggled to face and manage the evolving situations on their own. The continued and uncertain process caused strong emotional impacts on carers, leading to difficult feelings such as \u0026ldquo;powerlessness and frustration\u0026rdquo; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], \u0026ldquo;high stress and hypervigilance\u0026rdquo; [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], \u0026ldquo;fear, sadness, helplessness, hopelessness, and isolation\u0026rdquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. At the same time, many carers sought help on behalf of their loved ones, which also led to frustration when health professionals failed to recognise the severity of the service users\u0026rsquo; conditions [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], high distress, and sometimes even a sense of trauma [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAfter the service users entered mental health services, carers reported experiencing mixed feelings in response to service engagement. While some findings reported positive emotions, such as relief and hope, when carers felt their loved ones were supported and protected, more described ongoing distress and complex emotional experiences. Carers expressed uncertainty and powerlessness regarding the treatment process, self-blame for delayed help-seeking or for contributing to their loved ones\u0026rsquo; mental health difficulties, and feelings of loneliness and isolation arising from strained relationships and the stigma surrounding mental health difficulties. Many carers reported some relief when they felt the service users were safe and under appropriate treatments [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. For instance, \u0026ldquo;one carer emphasised \u0026lsquo;feeling peace of mind that their loved one was safe\u0026rsquo;\u0026rdquo;, as cited in one review [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Positive feelings such as gratitude and hope were also reported in a few reviews [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, difficult emotions still appear to be prominent. Some carers reported distress and even trauma related to initiating coercive measures, undergoing assessments, and witnessing admission [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Some expressed personal uncertainty [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and reported feeling worried due to limited knowledge about the illness and the treatment process [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Some reported struggling with guilt and self-blame for not recognising the conditions earlier, delaying help-seeking, or even believing they were \u0026ldquo;causing the illness\u0026rdquo; [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The self-blame further led to a sense of helplessness or powerlessness, as illustrated by cited statements such as \u0026ldquo;we\u0026rsquo;d failed as parents\u0026rdquo; and \u0026ldquo;I kind of think that nothing I do helps, really\u0026rdquo; [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Relationship strain during service engagement also adversely affected carers\u0026rsquo; well-being. Distress could arise from disagreements with other family members about the appropriate course of action and conflicts between the service users\u0026rsquo; wishes and what was considered to be in their best interests [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Some carers reported feelings of loneliness and expressed a desire for connection [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Increased caregiving responsibilities led to social disconnection, while stigma surrounding mental illness contributed to reduced support and greater peer blame [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Collectively, these findings revealed that while formal service engagement could alleviate some burdens, it introduced new emotional and social challenges for carers.\u003c/p\u003e \u003cp\u003eIn terms of prospects, informal carers experienced enduring uncertainty and guarded hope regarding their loved ones\u0026rsquo; recovery and future well-being, even after receiving professional treatment. Fear and frustration overshadowed optimism fostered by progress in the service user\u0026rsquo;s condition when setbacks occurred. For instance, carers expressed fear of relapse [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and \u0026ldquo;experienced substantial anguish\u0026rdquo; when witnessing their children regress or relapse after making progress [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In addition, there was a tension between carers\u0026rsquo; desire to be hopeful and the inclination to moderate it, as illustrated by the cited quotes: \u0026ldquo;I want to be optimistic but I feel maybe she can only be helped so much and then this will happen again. I fear she will backslide. My only hope is that she will be happy and enjoy life\u0026rdquo; [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The tension reflected an ongoing struggle to sustain hope amid the unpredictability of mental health recovery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSynthesised finding 2: Recognition and coping with their loved one\u0026rsquo;s mental health difficulties\u003c/h2\u003e \u003cp\u003e Whereas the first synthesised finding focused on carers\u0026rsquo; emotional responses to their loved one\u0026rsquo;s situations, the second focused on their actions and coping strategies upon recognition of changes in their loved ones. Initial denial, attributions to non-mental health causes, and interpretations based on their own knowledge and belief system influence their perceptions and corresponding management. Help-seeking to external and professional sources was often prompted by a \u0026ldquo;crisis point,\u0026rdquo; where carers\u0026rsquo; coping capacity was overwhelmed.\u003c/p\u003e \u003cp\u003eCarers were often the first to notice changes in their loved ones, but their initial reactions varied. Some experienced denial or shock, while others struggled to make sense of the situation. Limited by their own knowledge and belief systems, carers\u0026rsquo; misinterpretations were common, leading to delays in seeking help or turning to other sources rather than professional mental health services. Informal carers noticed issues with their loved ones through observing mood fluctuation, behavioural changes, and functional decline [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Upon recognition, some carers reacted with \u0026ldquo;denial and shock\u0026rdquo; [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Also, carers attempted to understand the changed presentations and make sense of the situation, mostly within their own knowledge and belief systems [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Their understanding and interpretations of the situations informed their subsequent type and timing of management. Some carers initially failed to recognise the seriousness of their loved ones\u0026rsquo; conditions, as illustrated by the cited quote, \u0026ldquo;I thought it was a phase. I had no idea how serious,\u0026rdquo; which led to delayed help-seeking [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Others misattributed the early symptoms of mental health difficulties to other factors [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. For instance, a mother misattributed her son\u0026rsquo;s mental health condition to supernatural causation, thus \u0026ldquo;forced her son to be exorcised in a Pentecostal church\u0026rdquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. After clarification of the presence of an illness, relatives sought to understand the possible causes or triggering factors of the condition [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese initial inactions in help-seeking were often resolved when carers reached what they perceived as a \u0026ldquo;crisis point,\u0026rdquo; where their personal coping resources became overwhelmed to manage the situation without professional mental health support [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This threshold triggered a sharp or urgent increase in seeking external support [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A review cited one carer\u0026rsquo;s reflection: \u0026ldquo;It took me quite a long time to understand that there was a mental issue there but it wasn\u0026rsquo;t until she started to become very ill. She actually had a crisis\u0026rdquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSynthesised finding 3: Multiple barriers for carers in accessing mental health support\u003c/h2\u003e \u003cp\u003eAfter recognising their loved ones\u0026rsquo; mental health difficulties and perceiving the necessity for professional support, carers played a crucial role in seeking help and accessing services on their behalf, often encountering numerous obstacles in the process. Carers faced multifaceted barriers when accessing mental health support, including systematic inadequacies, procedural difficulties, lack of information, and personal and relational challenges, often resulting in a prolonged, confusing, and emotionally consuming help-seeking process and delayed access to services.\u003c/p\u003e \u003cp\u003eCarers frequently encountered systematic inadequacies when attempting to access mental health support for their relatives, including a lack of appropriate and continuous services, restrictive entry criteria, and inadequate community care and pathways. While mental health services were generally lacking, tailored and appropriate services for specific populations, such as young people, were even more scarce, highlighting a gap in current services [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Also, carers voiced a lack of continuity in services, which was especially prominent in transitions between services and following inpatient discharge [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Strict and restrictive entry criteria further limited service availability. Some professional services were only accessible when individuals with mental health difficulties were \u0026ldquo;convincingly unwell, in crisis, at risk of harming themselves or others, or at least willing to engage in treatment\u0026rdquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Respite care also had restrictive entry criteria concerning \u0026ldquo;the patient\u0026rsquo;s health condition, diagnosis, geographical location, age, length of the caring role and ethnicity\u0026rdquo; [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Community services and pathways to care were also described as insufficient and inadequate [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These barriers underscored the need for improved availability of existing services, as well as more flexible, inclusive, and holistic service models that addressed diverse needs and offered continuous support throughout different stages of care.\u003c/p\u003e \u003cp\u003eAt the same time, sourcing mental health services was an uneasy and repeated process, which reflected procedural barriers to service access. Seeking help on behalf of the ill individuals often required multiple attempts and exhausting efforts [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. For example, a review cited, \u0026ldquo;one parent described trying to convince health care professionals for over one year that her son needed help for his psychiatric illness\u0026rdquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Difficulties in help-seeking led to delayed access to support and increased strain on carers. For instance, \u0026ldquo;families found it difficult to navigate the system to get support, they were frustrated with a delay in support, and they felt services were reactive rather than proactive\u0026rdquo; [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCarers\u0026rsquo; lack of information and knowledge of mental health services further compounded the systematic and procedural barriers, creating confusion and hindered timely, informed decision-making. Many carers lacked clarity about available support [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], how and where to access it [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and the procedures and legislation for interventions such as involuntary admission [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. They expressed a need for more information and guidance from services to help them manage the situation, as illustrated by the cited quote: \u0026ldquo;There should be more support actually for me or actually tell me what I need to do to support him\u0026rdquo; [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePersonal and relational barriers also hindered help-seeking and service access. Informal carers\u0026rsquo; negative attitudes toward mental health services, often shaped by stigma or past negative experiences, and service users\u0026rsquo; withdrawal or hostility toward carers\u0026rsquo; help-seeking, both hindered access to services. Carers\u0026rsquo; informal networks (e.g., family, friends, and community figures) and formal networks (e.g., healthcare professionals) may both obstruct help-seeking when dismissing difficulties or failing to provide appropriate support, though they facilitated service access with positive interactions. Informal carers\u0026rsquo; own stigmatised attitudes toward mental health difficulties acted as initial barriers [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Carers\u0026rsquo; negative past experiences of mental health services also led to \u0026ldquo;lasting distrust and reluctance to seek help from similar services\u0026rdquo; [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Service users may also play a role in impeding service access, being reluctant to engage in services when carers sought help [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. They may withdraw from carers, mask their symptoms during assessments, or stay guarded [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Some may even be \u0026ldquo;hostile\u0026rdquo; to carers\u0026rsquo; help-seeking efforts [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Carers\u0026rsquo; informal networks, including family members, friends, and community figures such as religious leaders, can provide support to carers and may act as facilitators to service access [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The informal networks often contributed to \u0026ldquo;initial detection of problems, clarification of the seriousness of problems and encouragement to seek help\u0026rdquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Meanwhile, another review highlighted that interactions within these networks could both facilitate help-seeking or hinder it when they normalised symptoms or dismissed difficulties [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The mediating effects of interactions were also evident when carers sought help from formal networks (e.g., mental health professionals, general practitioners, social workers, counsellors), as some interactions facilitated help-seeking and were regarded as helpful, while others acted as barriers [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Examples of barriers within formal networks included inappropriate treatment by professionals [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and professional knowledge gaps, such as an inability to provide required treatment options [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSynthesised finding 4: Persistent responsibilities and multiple roles in supporting service users\u003c/h2\u003e \u003cp\u003eEven after navigating numerous challenges during the build-up to and accessing mental health services, carers did not disengage once service users were under care. While carers insisted on participating, they did have strong potential to facilitate treatment with their unique perspectives and in-depth knowledge of the service users. As carers felt a profound and persistent sense of duty in supporting the service users before, during, and after engaging in mental health services, they played important and multifaceted roles in supporting the service users.\u003c/p\u003e \u003cp\u003eCarers possessed in-depth knowledge and expertise of the service users\u0026rsquo; behaviour and history through long-term, close observation and interactions, which was valuable for care and treatment [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Carers perceived their experiential knowledge as a facilitator in their involvement in care and treatment [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], strengthening their belief in both their ability to contribute and the necessity of their participation in treatment decision-making. Their expertise, however, was often unrecognised or dismissed by health professionals, upon which carers reported feelings of anger, disempowerment, and mistrust [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Despite these challenges, carers remained committed to supporting their loved ones.\u003c/p\u003e \u003cp\u003eCarers\u0026rsquo; persistent efforts were driven by a strong sense of responsibility, which also led to significant burdens. They protected and supported their loved ones through various means, such as initiating admissions, mediating relationships between service users and professionals, and advocating for appropriate care when they perceived unfair treatment or neglect. Carers reported a strong sense of responsibility to the service users, persistently caring for them before, during, and after service engagement [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The responsibility led to prolonged, heavy burdens, some \u0026ldquo;to a point where they lived their lives with an almost constant focus on their ill family member\u0026rdquo; [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Carers remained vigilant to protect their loved ones and described themselves as \u0026ldquo;fighting from the outside inwards\u0026rdquo; [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. They played multifaceted roles in protecting and supporting their loved ones. Some initiated admission, believing their actions provided protection [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Some mediated between service users and health professionals and advocated for the rights of the service users and appropriate care when they perceived unfair treatment or victimisation by healthcare systems or professionals [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. For instance, a review cited that when perceiving a doctor\u0026rsquo;s dismissive response that downplayed the service user\u0026rsquo;s concerns, one carer challenged the doctor by stating, \u0026ldquo;I want you to repeat what you just said in front of a witness, because when she goes outa here and harms herself or somebody else, I\u0026rsquo;m taking you to court\u0026rdquo; [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSynthesised finding 5: Complex experiences of engaging with mental health services\u003c/h2\u003e \u003cp\u003eRegarding engagement with mental health services, carers expressed dissatisfaction with and distrust in the quality of care. They frequently reported experiencing neglect and inadequate support from services, exclusion from care and decision-making, and unmet needs for information and communication. Carers also raised concerns about inadequate staff competencies and service models that were inappropriate or culturally insensitive. Carers expected healthcare professionals to be empathetic, respectful, and compassionate. It was noticeable that carers expressed ambivalence about their involvement and support needs and reported mixed experiences with various treatment modalities.\u003c/p\u003e \u003cp\u003eCarers\u0026rsquo; general comments on their experiences with service engagement in the included reviews were predominantly negative. They expressed dissatisfaction with and distrust in current services, including service delays, safety concerns, unmet service user needs, clinicians and other staff\u0026rsquo;s lack of competence, lack of respect, heavy-handed treatment, and an overreliance on medication [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. While acknowledging that interventions such as detention were sometimes necessary, carers expressed profound misgivings, as some were already disappointed for failing to get earlier, preventive help when they were desperate to [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Negative attitudes also emerged in response to poor communication, as well as perceived blame and judgment, from healthcare professionals [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe neglect of carers\u0026rsquo; needs and the lack of corresponding support were key sources of negative experiences during service engagement. Carers were often overlooked, dismissed, or inadequately supported by the mental health system and professionals throughout the care process, despite their considerable needs and efforts to be recognised [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. For instance, \u0026ldquo;the families clearly did not perceive staff as being supportive\u0026hellip;they were seldom, if ever, acknowledged when they visited their child\u0026hellip;\u0026rdquo;, as cited in one review [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. They required proactive support before, during, and after formal service engagement to understand the situations, clarify their role in it, navigate the challenges, and adapt both emotionally and practically [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to the neglect of carers\u0026rsquo; needs, carers consistently reported active exclusion from the treatment process and decision-making for service users, leading to frustration and helplessness. Carers wanted to help and \u0026ldquo;be treated as a resource\u0026rdquo; [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], to inform clinical decision making with their experiential knowledge about the service users and to provide consistent support to them [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, they consistently described being excluded from key aspects of their loved ones\u0026rsquo; care, including communication with staff, treatment decisions, and discharge planning [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The experience was captured in the following quote: \u0026ldquo;I wasn\u0026rsquo;t involved, I was an afterthought. .. no one told us anything, no one rang to keep us up to date with the plan of care\u0026rdquo; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The exclusion often led to feelings of frustration, helplessness, and marginalisation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile an unmet need for communication and information may be considered a component of neglect and exclusion, it was especially and consistently highlighted in carers\u0026rsquo; narratives as a distinct barrier that undermined their experiences. Carers consistently reported an unmet need for proactive, timely, and relevant information regarding their loved ones\u0026rsquo; care, their own caregiving role, and the services available [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. They were unsure about how to help and seek help [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. \u0026ldquo;Being left in the dark\u0026rdquo; was described to be scary and disappointing [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In addition, confidentiality policies acted as barriers, preventing carers from receiving the information they needed [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMeanwhile, carers noticed limitations in current mental health service models. Carers were concerned that staff in services had insufficient skills to provide care [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Some services, such as respite care, supported diverse service user groups simultaneously but were not tailored to their specific needs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. There was also a general lack of cultural diversity in existing services, with limited attention given to this issue [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These limitations reduced the services\u0026rsquo; ability to meet the needs of carers and service users.\u003c/p\u003e \u003cp\u003eAlthough some carers expressed dissatisfaction with healthcare professionals during service engagement, others reported appreciation and emphasised some desired qualities. They expressed a desire for healthcare professionals to demonstrate affection, empathy, proactivity, and respect in their interactions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. They expressed appreciation for healthcare professionals\u0026rsquo; \u0026ldquo;availability, competence, and positive attitudes like empathy, sensitivity, respectfulness, friendliness, and trustworthiness\u0026rdquo; [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Professionals with these helpful attributes were described as \u0026ldquo;some kind of saviour\u0026rdquo; [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNotably, carers were not a homogeneous group. Their views and experiences varied across individuals. While many carers desired inclusion, some expressed ambivalence about their involvement and support needs. For instance, some partners of women in perinatal mental health services depicted themselves as \u0026ldquo;struggling to identify their own needs, minimizing their own desires, prioritizing the woman, or expressing a reluctance to ask for or accept help or involvement\u0026rdquo; [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. At the same time, carers reported divergent and inconsistent experiences with different treatment modalities [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Interventions that some carers viewed as appropriate and helpful were perceived by others as distressing, unhelpful, or even harmful [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These mixed experiences suggested that the suitability of treatment modalities may depend heavily on individual contexts, needs, and values.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSynthesised finding 6: Relational strain during the caregiving process\u003c/h2\u003e \u003cp\u003e Relational dynamics were a core aspect of carers\u0026rsquo; experiences throughout the process of seeking help for service users and engaging with mental health services, and thus presented as a separate synthesised finding. Emotional and relational distance between carers and the individuals they supported was frequently reported in the process. Simultaneously, carers reported unsatisfactory interactions with healthcare professionals. These dual tensions contributed to a sense of isolation and burdens in the caring role.\u003c/p\u003e \u003cp\u003eCarers reported relational strain in their relationship with the service user. Distress arising from service users\u0026rsquo; mental health difficulties, the power dynamics during the process, and social distancing, particularly in the context of service users\u0026rsquo; detention, were key factors contributing to the strained relationships identified in the included reviews. Involuntary admission and hospitalisation could damage communication and relationships, leading to service users\u0026rsquo; mistrust, rejection, and social distancing [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Some carers and service users blamed each other for the situation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The power dynamic involved in the process contributed to the strained relationships. While many carers felt powerless, some experienced a sense of power in their roles through making decisions for service users and service users\u0026rsquo; economic dependence [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The power unbalanced the relationship between carers and service users, causing emotional distance and distress [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Physical distancing caused by specialist services and practical difficulties to visit the service used also added to the weakened connection [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These relationship dynamics led to carers\u0026rsquo; feelings of separation, loss, and distress [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCarers also experienced strain in their relationship with healthcare professionals, while they desired for partnership. They consistently expressed a desire for partnership with healthcare professionals and appreciated kind and respectful interactions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, their relationships with healthcare professionals were often unsatisfactory, marked by feelings of dismissal, invalidation, and a lack of compassion [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Tensions and divisions were reported in the relationship, as staff sometimes perceived carers as \u0026ldquo;threats, challenging, or nuisances\u0026rdquo; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eFindings not included in the final synthesis\u003c/h2\u003e \u003cp\u003eSix findings from the included reviews were not synthesised using the meta-aggregative approach due to their uniqueness or lack of supporting data across studies. These are presented separately to maintain transparency.\u003c/p\u003e \u003cp\u003eFour findings were identified but not integrated into the synthesised findings due to their uniqueness or lack of recurrence across reviews. These included the protective factors for siblings in early adulthood during the prodromal phase [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], practical barriers to involvement in services [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], parental observations of gradual positive changes in recovery [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and family group conferencing regarded as useful [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These findings were acknowledged for their potential relevance but were excluded to maintain the robustness and coherence of the synthesis. Nonetheless, they suggested potentially important areas for future investigation. Two findings were excluded from the synthesis due to limited supporting evidence. One mentioned carers\u0026rsquo; personal growth from the caring experiences [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and the other addressed carers\u0026rsquo; feeling of isolation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Excluding findings with insufficient credibility ensured the validity and focus of the current synthesis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eCertainty assessment\u003c/h2\u003e \u003cp\u003eThe dependability ratings of included reviews are presented in \u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e, while the credibility ratings of individual findings are shown in \u003cb\u003eS2 and S3 Appendices\u003c/b\u003e. Drawing on these assessments, the dependability and credibility ratings were assigned to each category and are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Overall, given the high methodological quality of most included reviews and the predominance of unequivocal findings, only one category was assigned moderate dependability and equivocal credibility ratings. All other categories were rated as having high dependability and unequivocal credibility. Consequently, all synthesised findings received a final ConQual rating of high confidence, demonstrating the robustness and reliability of the overall synthesis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eMain findings\u003c/h2\u003e \u003cp\u003eThis umbrella review synthesised qualitative evidence from 12 reviews to provide a comprehensive understanding of informal carers\u0026rsquo; experiences of mental health services regarding supporting those they care for and getting support for their own wellbeing. Drawing on a meta-aggregative approach, six synthesised findings with strong confidence were developed, capturing carers\u0026rsquo; emotional journey throughout the caregiving process, early recognition and management of their loved ones\u0026rsquo; situations, barriers in accessing services, persistent caring for service users, experience and feedback regarding service engagement, and the relational strain in their caregiving roles.\u003c/p\u003e \u003cp\u003eWhile carers\u0026rsquo; emotional distress and difficult experiences were prominent themes consistent with previous literature [\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], some positive emotions, such as relief, gratitude, and hope, were reported when carers felt that their loved ones had received appropriate and high-quality care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A few reviews also reported positive experiences, such as carers observed service users\u0026rsquo; recovery-related changes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and carers\u0026rsquo; personal growth through the caregiving journey [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], though each of these was only included in one review and lacked sufficient recurrence for synthesis. The presence of these positive experiences, though limited, suggests the potential helpfulness and constructive roles of mental health services, dimensions that are often underrepresented in the caregiving literature [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, emotional distress and negative experiences still predominated in the current synthesis. Carers\u0026rsquo; persistent emotional distress and difficult experiences reflect the heavy burdens and the multifaceted challenges throughout caregiving, which echo with the wider literature and are increasingly acknowledged by policymakers [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The findings highlight the urgent need for more specific, comprehensive, and sustained support for informal carers. The challenges and barriers identified in this review suggest potential areas for improvement within current mental health services, including service accessibility, better guidance for carers, greater carer involvement, and enhanced competence among healthcare professionals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eImplications for practice\u003c/h2\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eEnhancing services availability and accessibility\u003c/h2\u003e \u003cp\u003eThe availability of mental health services for both carers and service users remain a significant concern and require improvement. While carers shouldered substantial burdens and stress in supporting the service users, their needs were often unaddressed by existing service structures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. More services tailored to carers\u0026rsquo; needs are needed. For example, respite care services can provide temporary relief [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Smaller embedded interventions targeted particularly at carers, such as family psychoeducational programs, are often experienced as helpful and could be promoted more widely for empowering families and benefiting carers\u0026rsquo; well-being [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Interventions that help mediate the relationship strain between carers and service users may also be helpful to reduce carers\u0026rsquo; potential sense of conflicts and social isolation when their loved ones are receiving services [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlso, as reflected in the current review, the demand for appropriate and continued services for service users with fewer access barriers has been high [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Access barriers have contributed to carers\u0026rsquo; dissatisfaction, frustration, and exhaustion, as well as service users\u0026rsquo; poorer long-term outcomes, since they often resulted in delayed access to professional services when early interventions were critical for improving outcomes across both common and serious mental issues [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Preventive care, community-based support, and low-threshold, low-intensity services have been identified as a feasible strategy to cope with these challenges, which could expand access, promote service inclusion, mitigate service users\u0026rsquo; symptoms, and enhance support to carers [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, the limitations of community care and pathways was also identified in the current review. This gap underscores the need for increased attention and promotion of accessible, community -based approaches. Encouragingly, innovative services of this type have emerged with demonstrated strengths. For instance, non-diagnostic, network-based \u003cem\u003eOpen Dialogue\u003c/em\u003e has facilitated transparent, collaborative decision-making and emphasises relational continuity, which improved engagement and support for both carers and service users [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Community-based residential crisis houses provided flexible, short-term support without formal psychiatric admission, reducing coercion and promoting inclusivity [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. These approaches enhanced access, reduced carers\u0026rsquo; burden, and established strong practical potential to improve outcomes in non-acute settings [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Both example services have been praised for their flexibility and inclusion, enhancing access and improving outcomes in non-acute settings [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], which underline the importance of promoting community- and low-intensity mental health services as a response to the current gaps in service provision.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eRaising awareness and providing guidance\u003c/h2\u003e \u003cp\u003eWhile improved service availability and accessibility are essential, they are not sufficient on their own. Carers need awareness of these services and guidance on accessing and engaging with them effectively [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Upon recognising changes in their loved ones\u0026rsquo; mental health, carers often attempted to interpret these shifts through their own knowledge and belief systems, which shaped subsequent coping strategies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, due to limited mental health knowledge, many delayed help-seeking until a \u0026lsquo;crisis point\u0026rsquo;, negatively impacting service users\u0026rsquo; outcomes and carers\u0026rsquo; own well-being [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This highlights the importance of public awareness campaigns to improve understanding of mental health difficulties, available supports, and pathways to care. Some initiatives have provided evidence of the positive impact of these campaigns, demonstrating how they can support both carers and service users. Example campaigns include \u003cem\u003eEvery Mind Matters\u003c/em\u003e, a UK public health campaign that enhanced mental health literacy, promoted self-care skills, and reduced stigma, with evidence showing it improved individuals\u0026rsquo; help-seeking self-efficacy, empowering them to seek support more timely and confidently [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Similarly, \u003cem\u003eRU OK? Day\u003c/em\u003e, an Australian initiative promoting peer support through structured conversations, has been associated with greater intentions, confidence, and actions to check in on others\u0026rsquo; mental health, fostering broader social support and preventing severe mental health crisis [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The examples suggest the potential of establishing mental health public awareness initiatives to improve current services, which can benefit both carers\u0026rsquo; and service users\u0026rsquo; well-being by promoting coping strategies and fostering broader connectedness in their journey of accessing services and recovery.\u003c/p\u003e \u003cp\u003eDuring and after engagement with mental health services, many carers continued to experience a lack of guidance on navigating the system and sustaining their caregiving roles, which often made them feel ill-equipped and powerless to manage both their own well-being and the needs of their loved ones [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Services should provide more guidance and communication to carers, enhancing their engagement and empowering them to contribute effectively. This can benefit carers\u0026rsquo; self-efficacy and emotional well-being, while also strengthening service delivery and service users\u0026rsquo; outcomes. The community-based, family-led education program, \u003cem\u003ethe Journey of Hope\u003c/em\u003e, that strengthened families\u0026rsquo; knowledge and coping competencies with proactive communication, is a good example [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. When carers feel more empowered and informed, they sustain their caregiving responsibilities more effectively with improved self-efficacy, emotional resilience, and caregiving competencies, leading to improved outcomes [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The beneficial effects of offering more proactive communication and guidance are highlighted, as collaborative, family-centred approaches not only improve carers\u0026rsquo; experiences but also strengthen the overall service outcomes by fostering more engaged, informed, and supportive caregivers.\u003c/p\u003e \u003cp\u003eIn addition, carers observed that current service models often lack cultural sensitivity [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While mental health difficulties may involve biological components, they are largely experienced and interpreted through cultural frameworks [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The dominant knowledge of mental health, rooted primarily in Western ethnopsychiatry, has been critiqued for its limited cross-cultural validity [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Therefore, awareness initiatives should adopt culturally sensitive and inclusive approaches that consider diverse worldviews and lived experiences. Initiatives such as the Patient and Carer Race Equality Framework (PCREF) have been introduced to improve the inclusiveness and cultural competence of mental health services [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. More specifically, the PCREF has guided healthcare providers in developing culturally competent care plans and advocated to train mental health professionals to interact with individuals from diverse backgrounds in a respectful and understanding way [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Such an approach may help to mitigate misunderstandings, reduce the risk of inappropriate treatment, and alleviate the additional social pressures that marginalised individuals potentially experience [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Culturally sensitive frameworks, such as the PCREF, could be more widely promoted and adopted to address the cultural insensitivity concerns raised by carers. These frameworks may help more effectively support both carers and service users from diverse backgrounds, fostering social inclusion and promoting equity in mental health services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003ePromoting carers\u0026rsquo; involvement\u003c/h2\u003e \u003cp\u003eWithin mental health services, improving the recognition of carers\u0026rsquo; needs and enhancing their inclusion is crucial. Carers possessed profound experiential knowledge of the service users [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and demonstrated sustained motivation, sense of responsibility, and willingness to persistently participate in care and support [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Excluding them not only led to marginalisation, mistrust, and a sense of powerlessness, but also wasted valuable resources that could support service users\u0026rsquo; recovery [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eReconsidering and strengthening carers\u0026rsquo; roles within services is therefore essential. The UK\u0026rsquo;s \u003cem\u003eTriangle of Care\u003c/em\u003e model is a good example of frameworks that address these considerations [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. It promotes collaboration between service users, professionals, and carers, encouraging routine information-sharing and carers\u0026rsquo; meaningful involvement in care planning [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The model has shown promise in enhancing relational, emotional, and clinical outcomes in both carers and service users [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Interventions that facilitate carers\u0026rsquo; involvement in treatment decisions, discharge planning, and aftercare are also highly valuable [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. For instance, family group conferencing and a caregiver-involved discharge planning process have helped reduce caregiver burden and improved carers\u0026rsquo; health status, demonstrating positive impacts of structured carer inclusion [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Embedding carers within the treatment process, cooperative and inclusive models, such as the examples discussed above, show significant potential in addressing the challenges of carer inclusion identified in this review. These models foster greater engagement, reduce isolation, and enhance the well-being of both carers and service users by ensuring a more holistic, integrated, and inclusive approach to care. Such frameworks should be actively promoted to strengthen support for carers and improve overall outcomes.\u003c/p\u003e \u003cp\u003ePolicies such as confidentiality, while essential for protecting service users\u0026rsquo; rights, can sometimes hinder carer involvement [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Negotiation and flexibility are needed to navigate these tensions. Frameworks have emerged to address this issue. For example, when service users withhold consent, a best practice framework recommends a context-dependent distinction between general information (e.g. illness education) that can be shared without consent and service users\u0026rsquo; personal information that cannot, allowing carers to receive support without breaching confidentiality [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Flexible, situation-dependent frameworks like this can help address policy limitations, balancing the need for carer involvement with the protection of service users\u0026rsquo; privacy and ultimately enhancing the quality of care and support provided to both carers and service users.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eImproving healthcare professionals\u0026rsquo; competence\u003c/h2\u003e \u003cp\u003eLast but not least, improving the professional competence of healthcare professionals is essential. Professionals need not only clinical knowledge and skills to make accurate diagnoses and suggest appropriate treatment options, but also the ability to recognise, engage, and collaborate with carers effectively [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Beyond clinical knowledge, healthcare professionals\u0026rsquo; attitudes and interpersonal behaviours are a vital part of their clinical expertise and play a crucial role in shaping carers\u0026rsquo; and service users\u0026rsquo; experiences. Some staff displayed dismissive, stigmatising, or blaming attitudes, leading to carers\u0026rsquo; distrust, distress, and reduced engagement [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Conversely, carers appreciated professionals who demonstrated kindness, respect, compassion, and a genuine concern for the needs of both service users and their families [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These attitudes should be actively fostered within healthcare professionals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eImplications for research\u003c/h2\u003e \u003cp\u003eAs mentioned earlier, emotional distress and negative experiences predominated in the current synthesis. Methodological and structural biases within the included reviews may have contributed to the skew. Many of the existing qualitative studies in the area were guided by a longstanding deficit-focused approach, where studies are primarily motivated by concerns related to distress, system inadequacies, or service failures [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. For instance, 8 out of 12 included reviews focused on involuntary treatment, hospitalisation, and psychosis-related services, which are high-intensity settings with salient stress [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This reflects a broader pattern in the literature, where carers\u0026rsquo; experiences in acute or coercive contexts are more frequently studied, entrenching problem-oriented perspectives. Potential overlaps in primary studies across the included reviews may also inflate the bias [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. The absence of reviews that explicitly focus on community services or low-intensity care reflects a notable gap in perspective. Furthermore, potential underrepresentation of carers\u0026rsquo; positive experiences may be amplified in umbrella reviews since such accounts may be deemed too infrequent or nuanced to warrant synthesis inclusion, leading to progressive downplaying at each stage of synthesis [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Future research that deliberately attends to carers\u0026rsquo; strengths and positive experiences is needed to provide a more balanced and holistic understanding of their caregiving journey. At the same time, more studies on community-based or low-intensity mental health services are also increasingly called for. Such research would complement existing knowledge from acute service settings, informing the development of more comprehensive, cooperative, tailored, and accessible interventions that better include both carers and service users, effectively reduce access barriers, and improve outcomes.\u003c/p\u003e \u003cp\u003eIn addition, limited demographic and socio-cultural details were reported across reviews, revealing a gap in the current evidence base. When some demographic details were available, most primary studies were conducted in high-income countries with predominantly adult female participants, limiting the generalisability of findings. The gap underscores the need for research that diversifies participant demographics and concerns underrepresented groups, such as ethnic minority carers and young male carers. Such research would deepen understanding of how cultural values, gender norms, and social resources shape carers\u0026rsquo; engagement with mental health services and their own wellbeing and provide insights into how services can be improved to best meet the needs of different groups [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, only one included review on respite care explicitly examined interventions supporting carers\u0026rsquo; own mental health [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Consequently, this synthesis provided limited evidence on services that directly promote carers\u0026rsquo; wellbeing, highlighting the demand for research on carers\u0026rsquo; broader needs and targeted interventions. Given the need to enhance current services, future research should also prioritise the development and evaluation of service models designed to support carers.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis review has several limitations. First, although focusing on carers\u0026rsquo; experiences of mental health services, many primary reviews also included carers\u0026rsquo; broader experiences of supporting their loved ones. These findings were included. However, wider literature on carers\u0026rsquo; general experiences was not comprehensively captured, potentially omitting valuable insights. Second, while providing a high-level, overarching synthesis, the umbrella review and meta-aggregative approach has some inherent methodological constraints. Both the cumulative synthesis process of an umbrella review and the meta-aggregative method, which prioritises summarising findings over comparative or interpretive analysis, may oversimplify complex experiences, reduce contextual richness, and omit nuanced or minority perspectives, thereby biasing results toward dominant themes [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. The prevailing deficit focus across the included studies, combined with the umbrella review\u0026rsquo;s inclination to highlight dominant narratives, may have inadvertently obscured positive experiences or developments occurring within mental health services. In addition, as umbrella reviews are built upon systematic reviews, which in turn synthesise primary studies, there is an inevitable temporal lag that may obscure recent developments in service provision [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. The meta-aggregative approach may also lack interpretive depth and flexibility, as it relies on the synthesis of existing reviews [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Overlapping primary studies across included reviews may result in overrepresentation of certain findings [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Together, these factors should be considered when understanding and interpreting the synthesised findings. Third, demographic and contextual information were limited in the included reviews, making it difficult to understand how factors, such as carers\u0026rsquo; age, gender, ethnicity, or socio-cultural backgrounds, may have influenced their experiences of accessing and engaging with professional mental health services. Also, as for context, the included reviews disproportionately focused on acute and hospital-based contexts, with few findings reflecting carers\u0026rsquo; experiences in community or low-intensity services and did not differentiate findings by context. As a result, the synthesis mainly reflects high-intensity or coercive settings, limiting generalisability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis umbrella review synthesised qualitative review-level evidence on informal carers\u0026rsquo; experiences of accessing and engaging with mental health services. Drawing on twelve qualitative reviews and using a meta-aggregative approach, the synthesis identified six key findings that reflected carers\u0026rsquo; emotional complexity, efforts to cope and engage with services, systematic challenges and limitations of services they experienced, and relational tensions embedded in the caregiving experience. The findings highlight an urgent need to reform mental health services in ways that actively involve, inform, and support informal carers before, during, and after service users\u0026rsquo; formal service engagement. Improving service accessibility, raising public awareness and providing guidance, facilitating carer involvement, and enhancing professionals\u0026rsquo; competencies are critical priorities. This review provides a foundation for future research, service innovation, and policy development that centres carers as essential partners in mental health systems.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdult Social Care Statistics Team, Digital NHS Personal Social Services Survey of Adult Carers in England 2021\u0026ndash;22 [Internet]. 2022 NHS Digital; Published 23 June 2022. [cited 2025 Aug 28]. 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Macquarie University\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eINQUIRY OCIQ Problematising the research landscape\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCunningham NA, Cunningham TR, Roberston JM (2019) Understanding and measuring the wellbeing of carers of people with dementia. Gerontologist 59(5):e552\u0026ndash;e64\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandez R, Sharifnia AM, Khalil H (2025) Umbrella reviews: a methodological guide. Eur J Cardiovasc Nurs. :zvaf012\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrtega A, Lopez-Briz E, Fraga-Fuentes MD (2016) From qualitative reviews to umbrella reviews. Springer, Umbrella reviews, pp 21\u0026ndash;41\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBergdahl E (2019) Is meta-synthesis turning rich descriptions into thin reductions? A criticism of meta‐aggregation as a form of qualitative synthesis. Nurs Inq 26(1):e12273\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSim J, Mengshoel AM (2023) Metasynthesis: issues of empirical and theoretical context. Qual Quant 57(4):3339\u0026ndash;3361\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University College London","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"informal carers, mental health services, qualitative research, umbrella review, meta-aggregation","lastPublishedDoi":"10.21203/rs.3.rs-8995678/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8995678/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eInformal carers play a vital role in supporting individuals with mental health difficulties. Their caregiving contributions are critical but often at the cost of considerable burdens. Despite growing qualitative evidence on carers\u0026rsquo; experiences, an overarching synthesis of review-level insights is lacking.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis umbrella review aimed to synthesise qualitative review evidence on informal carers\u0026rsquo; experiences of mental health services regarding supporting the individuals with mental health difficulties they care for and seeking support for their own wellbeing.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFollowing the Joanna Briggs Institute (JBI) methodology, a meta-aggregative umbrella review was conducted. Findings were extracted from eligible reviews and aggregated into categories, from which higher-order synthesised findings were developed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTwelve eligible qualitative reviews were identified through a systematic search across five databases. Six synthesised findings were identified: (1) emotional complexity in the caregiving journey; (2) recognition and coping with their loved ones\u0026rsquo; mental health difficulties; (3) multiple barriers to accessing mental health support; (4) persistent responsibilities and roles in supporting service users; (5) complex experiences of engaging with services; and (6) relational strain during the caregiving process. The findings were rated as high confidence.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWhile some carers reported positive experiences, most described exclusion, emotional distress, and structural barriers to support. This review highlights the urgent need for mental health services to recognise, involve, and support informal carers.\u003c/p\u003e","manuscriptTitle":"Informal carers’ experiences of mental health services regarding supporting those they care for and getting support for their own wellbeing: an umbrella review of qualitative evidence","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 09:22:46","doi":"10.21203/rs.3.rs-8995678/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0a04bebb-833b-4b06-895d-4764304993c6","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":63699590,"name":"Psychiatry"}],"tags":[],"updatedAt":"2026-03-10T09:22:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 09:22:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8995678","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8995678","identity":"rs-8995678","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}