Table 3 Illustrative participant quotations by theme

Theme 1: Perceived lack of mental ill health recognition

[P1] “The only thing that came up about mental health was because of the bowel obstruction, … ..and they thought the medication I’m on, the antipsychotics, could be a potential cause, … .so they brought that up. But other than that he didn’t talk about me having a mental illness at any point. He never asked or questioned it”.

[P7] – “I didn’t talk about it. See I think not to, well you’re damned if you do and damned if you don’t. And no, he didn’t ask, no.”

[P5] “I mean, how would they even know that I’m going through something already? So it becomes two struggles. One is the internal mental health struggle, and the external surgery struggle. I think when people are more attentive, more thoughtful and more caring. I felt if somebody is crying, definitely the person needs somebody to have a word with them, or at least ask them are you all right? That would make a difference to me”.

[P2] – “Like, if the doctor said, you know, “If you make progress in the next two weeks, then the week after we’ll decide that you can go home”. Rather than, kind of, leaving it in the air, sort of thing … just indicators that might give you an idea of the timeline”.

Theme 2: Highly variable patient and clinician interactions

[P8] - “I really was very pleased that they brought it up and that they gave it such credence in their practice and diagnosis, and has always asked me how it’s going with my psychiatrist and how things are … .. yeah, but it’s not widely acknowledged just as yet, I think, so I was really pleased that they had that attitude, so it helped me as well”.

[P5] – “Fortunately my surgeon was a very jolly person. He was always joking around and because I felt so comfortable with him, I was also joking and so I think that made a lot of difference because he took everything so lightly and he was very talkative and friendly. It calmed my anxiety and took my mind away from my mental health”.

[P7] – “I trusted them, they’re the professionals. I’ve got no role here. They’re the professionals. I think it broke my trust in the system, my trust in the hospital system. I feel like I’m powerless in that situation”.

[P3] – “No I just told my friends. I just kept everything to myself … .nobody really asked about how I’m feeling …. I always had people to talk to but I don’t think anybody came up from the mental health side of it and spoke to me how I’m feeling and how am I coping and stuff like that”.

[P5] – “I tell you, the opinions of the people, the judgmental attitude of the people, that creates a lot of stress. I want to tell them about my mental health problems, but there’s nobody to listen to me”.

[P4] – “I remember crying the day before surgery, which was a sign I wasn’t well as I don’t normally cry. I was also crying afterwards, which wasn’t a normal reaction for me. … with retrospect the crying was a big red flag for me but no one asked me about it. I didn’t see anyone like a social worker or psychologist.”

Theme 3: Impact of healthcare services

[P7] – “As I said I felt like I was just a number – just in and out sort of thing”.

[P5] – “I think I was the only one crying, because I think it gets too much when you have a mental illness, plus you have this horrible pain and nobody is taking you in because everybody in ED is in their particular emergency”.

[P6] – “It doesn’t take much to be able to read a man’s medical history … .and determine that. I believe, they ought to go one further in investing in keyword search. And these keywords, this man suffers from a primary health diagnosis, mental health … they should be highlighted on the screen ….” .

[P2] – “The system. It does feel at times that I have to advocate for myself. Maybe that’s a good thing. Maybe its like a double-edge sword.”

Theme 4: Strategies for improvement

[P6] – “They’re all referring to the same database, but its perhaps not adapted to a person who is upset, and is going to respond differently to the next person in the queue, behind me. This issue, that’s what I’d like to see changed”.

[P4] – “It would have been good for a simple message about if your mood changes just to watch out for it. There was nothing about mental health. I wasn’t given any numbers to call or what to do if I had any drastic changes in my mood.”

[P8] – “And if they know that there’s someone they could ring in the hospital or after they’ve visited they might even do that, rather than do it right at the time. It’s a sort of a process for everyone really, it can be different for everyone.”

[P4] – “It would help if someone helped coordinate what is going to happen, especially when you go home”.

[P8] – “Because, I mean, I’m very aware that people can present like nothing’s going on and that things are going really badly inside, so I think always bringing it up and giving people the option, even if they don’t say there’s anything wrong at that time, if you give them the option to contact someone if things do start to go wrong, that would be a good thing. I think it’s always good to have a safety net there”.