Mental health services for parents affected by mental illness

The cost-utility of an intervention for children and adolescents with a parent having a mental illness in the framework of the German health and social care system: a health economic evaluation of a randomized controlled trial

BACKGROUND

Children of families with a parent with a mental illness have an increased risk of developing social and mental health problems resulting in decreased quality of life. Therefore, children and adolescents living in families with a parent with mental illness are regarded as a target group for preventive interventions. To date, only a few economic evaluation studies for interventions directed at preventing the intergenerational transmission of mental health problems exist. In this investigation we estimated the cost utility of an intervention for the support of children and adolescents with a parent having a mental illness from the perspective of the German health and social care system.

METHODS

We randomly assigned a total of 214 families with 337 children and adolescents to the intervention (INT) group (108/170) or the control (TAU) group (106/167). Families in the intervention group received on average eight intervention sessions (50-90 min) over 6 months. We estimated total cost of illness by means of the Children and Adolescent Mental Health Service Receipt Inventory (CAMHSRI) over 24 months. For the estimation of Quality-Adjusted Live Years (QALYs) we applied the KIDSCREEN-10. For estimating the incremental cost-utility of the intervention compared to treatment as usual we used the net-benefit approach.

RESULTS

We estimated the annual cost of illness amounting to € 3784.59 (SD € 8581.11) in the TAU group and € 3264.44 (SD € 9431.89) in the INT group. The annual cost difference between INT and TAU was € - 516.14 (SE 1124.95) which was not significant (p ≤ 0.05). We estimated the average QALY to be 0.759 (SD 0.073) in the TAU group and 0.763 (SD 0.072). The QALY difference between INT and TAU was 0.0037 (SE 0.0092) which was not significant (p ≤ 0.05). The incremental cost utility ratio (ICUR) indicated that the gain of one additional year in full health by means of the intervention was associated with the saving of € 139.49. However, the stochastic insecurity of the ICUR did not allow a unique decision about the cost-utility of the intervention.

CONCLUSIONS

More information on the economic value of the intervention for families with a parent with mental illness in comparison to treatment as usual in Germany is needed.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT02308462; German Clinical Trials Register: DRKS00006806.

A randomized controlled study of an e-learning program (YURAIKU-PRO) for public health nurses to support parents with severe and persistent mental illness and their family members

BACKGROUND

Supporting parents with severe and persistent mental illness (SPMI) requires knowledge, skills, and a positive attitude toward parenthood. We developed a Japanese e-learning program for public health nurses (PHNs) to enable them to support parents with SPMI and their family members. This study aimed to evaluate the effectiveness of the program in improving the knowledge, skills, attitudes, and self-efficacy of PHNs in supporting them.

METHODS

A three-hour video-based e-learning program was developed. A randomized controlled trial was conducted with 176 PHNs responsible for maternal and child health in Japan. The outcome measures included the Sense of Coping Difficulty/Possibility Scale, skills to support people with SPMI, and achievement of program goals. Outcome data were collected at three time points during the study: baseline (T1), post-intervention (T2), and one month after T2 (T3) using self-administered electronic questionnaires. Outcome measures were assessed by comparing the two groups at the endpoint (T3) using t-tests and ANOVA. Effectiveness over time was assessed using a mixed model for repeated measures, with group and time interactions as fixed effects.

RESULTS

The study participants were randomly allocated to two groups:89 in the intervention group, and 87 in the control group. The total score and the scores in the two subscales of the Sense of Coping Difficulty/Possibility Scale in the intervention group at T3 were significantly higher than those in the control group, as shown by the t-test and ANOVA (all p<0.001). The Sense of Coping Difficulty subscale had a large effect size (Cohen's d=1.27). The analysis of the results of a mixed model for repeated measures showed that the group and time interactions on all outcome measures were not significantly different at T1 but were significantly different at T2 and T3.

CONCLUSIONS

The program was effective one month after its completion, particularly in reducing PHNs' difficulties in supporting parents with SPMI.

TRIAL REGISTRATION

UMIN000045765, November 1, 2021.

Mental health professionals' awareness of the parental functioning of persons with severe mental disorders: a retrospective chart study

Background:

The proportion of persons with severe mental illness (SMI) who are parents has increased in recent decades. Children of parents with SMI are at increased risk for medical, behavioral, emotional, developmental, academic, and social problems. They also have an increased risk for injuries, accidents, and mortality, addictions, and various psychiatric disorders compared to children of parents with no such diagnoses. We aimed to examine the extent to which mental health professionals (MHPs) who treat adult patients with SMI in ambulatory settings are aware of these individuals’ functioning in three parenting domains: parental functioning, familial support system and children’s conditions. We also compared psychiatrists’ awareness with that of psychologists and social workers.

Methods:

In this retrospective practice-oriented study, we reviewed 80 clinical files of individuals diagnosed with schizophrenia, affective disorder or personality disorder treated in a mental health outpatient clinic, using the Awareness of Family’s Mental Health Checklist (AFMHC) developed for this study. Thus, awareness was determined on the basis of what was recorded in the patient file.

Results:

Almost half of the MHPs were unaware to their patients’ parental functioning as only 44% of files contained records relating to this issue. Awareness to other domains was even lower: 24% of files contained information on patient’s support system and 12% had information about their children’s mental and/or physical health. No statistically significant differences between psychiatrists and other MHPs were found with regards to awareness to the various domains. Positive correlations were found among MHP’s for awareness in the three domains.

Conclusion:

Lack of awareness among MHPs to their patients’ parental functioning is not specific to a certain profession and may be attributed to patients (e.g., reluctance to disclose relevant information) or to MHPs (e.g., lack of training). Awareness of family and parental functioning by MHPs working with persons with SMI should be part of a standard procedure, integrated into policy and training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-022-00547-4.

Parental Mental Illness, Borderline Personality Disorder, and Parenting Behavior: The Moderating Role of Social Support

PURPOSE OF REVIEW

Parental mental disorders, particularly borderline personality disorder (BPD), impair parenting behavior. Consequently, the children exhibit an elevated risk for psychopathology across their lifespan. Social support for parents is thought to moderate the relationship between parental mental illness and parenting behavior. It may dampen negative effects and serve as starting point for preventive interventions. This paper provides a literature overview regarding the impact of social support on the sequelae of parental mental illness and BPD for parenting behavior.

RECENT FINDINGS

Current literature highlights the increased burden of families with a mentally ill parent and associated changes in parenting behavior like increased hostility and affective dysregulation, especially in the context of parental BPD. Literature further demonstrates the powerful impact of social support in buffering such negative outcomes. The effect of social support seems to be moderated itself by further factors like socioeconomic status, gender, or characteristics of the social network. Social support facilitates positive parenting in mentally ill parents and may be particularly important in parents with BPD. However, social support is embedded within a framework of influencing factors, which need consideration when interpreting scientific results.

Associations of Family Functioning and Social Support With Psychopathology in Children of Mentally Ill Parents: Multilevel Analyses From Different Rating Perspectives

Offspring of mentally ill parents is at heightened risk for psychological symptoms. The identification of environmental factors that predict their mental health is crucial for the development of preventive and therapeutic measures. In the current study, we addressed the combined role of family functioning and social support by taking mentally ill patients’, their partners’, and children’s perspectives into account. The cross-sectional sample included n=195 families (195 patients, 127 partners, and 295 children). Family members completed questionnaires related to family functioning, social support as well as parental and child psychopathology. We conducted multilevel analyses to investigate the associations with internalizing and externalizing problems in children. Family functioning and social support were significantly associated with child internalizing and externalizing problems. However, results varied depending on the rating perspective. We found significant interaction effects of family functioning and social support on child psychopathology. The findings point to the importance of family functioning and social support as potential targets for interventions. Findings should be replicated in future longitudinal studies.

Attachment anxiety as mediator of the relationship between childhood trauma and personality dysfunction in borderline personality disorder

Insecure attachment has been described as mediating the relationship between childhood trauma and dysfunctional personality traits in different mental disorders. Despite the role insecure attachment and childhood trauma have independently demonstrated to play as determinants of borderline personality disorder, less is known about the mediating mechanisms explaining these associations. For the first time, we assessed adult attachment, childhood trauma and dimensional personality pathology in a sample of outpatients with borderline personality disorder and tested whether the association between childhood trauma and personality dysfunction was at least partially attributable to insecure attachment. The results showed that attachment anxiety fully mediated the relationship between specific types of trauma (emotional abuse and physical neglect) and emotional dysregulation. Further, emotional abuse was both directly associated with dissocial behaviour and indirectly via attachment anxiety (partial mediation). Emotional abuse has been described as an essential environmental factor for the development of borderline personality disorder and emotional dysregulation, on its part, as the core feature of the condition. Our results indicate that attachment anxiety explains the link between these central aspects of borderline personality disorder. Our findings are consistent with previous research and current etiological understanding of the condition and provide support for recommending a careful assessment of childhood traumatic experiences and adult attachment style to gain a more comprehensive insight into the symptoms and its heterogeneity. As a secondary aim, we assessed the effect parental mental illness may have in these mediation models, but no significant influence on childhood trauma, attachment or personality was found.

Evaluation of a Family-Based Intervention Program for Children of Mentally Ill Parents: Study Protocol for a Randomized Controlled Multicenter Trial

Background: Children of mentally ill parents have a three to seven times higher risk of developing mental disorders compared to the general population. For this high-risk group, specialized prevention and intervention programs have already been developed. However, there has been insufficient sytematic evaluation to date. Moreover, effectiveness and the cost-effectiveness data of the respective programs until today is very scarce and at the same time constitutes the pre-condition for the program's implementation into regular health care. Methods: The study consists of a two-group randomized controlled multicenter trial conducted at seven study sites throughout Germany and Switzerland. Participants are families with mentally ill parents and their children aged from 3 to 19 years. The intervention comprises 6 to 8 semi-structured sessions over a period of about 6 months. Topics discussed in the intervention include parental mental illness, coping, family relations and social support. Families in the control condition will receive treatment as usual. The children's mental health, assessed using the K-SADS-PL by blinded external raters will constitute the primary efficacy outcome. Further outcomes will be assessed from the parents' as well as from the children's perspectives. Participants are investigated at baseline, 6, 12, and 18 months after baseline assessment. In addition to the assessment of various psychosocial outcomes, a comprehensive health-economic evaluation will be performed. Discussion: This paper describes the evaluation of a family-based intervention program for children of mentally ill parents (CHIMPs) in the regular health care system in Germany and Switzerland. A methodically sophisticated study design has been developed to reflect the complexity of the actual health care situation. This trial will contribute to the regular health care for the high-risk group of children of mentally ill parents. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02308462; German Clinical Trials Register: DRKS00006806.

A Scoping Review of Interventions Designed to Support Parents With Mental Illness That Would Be Appropriate for Parents With Psychosis

The experience of psychosis can present additional difficulties for parents, over and above the normal challenges of parenting. Although there is evidence about parenting interventions specifically targeted at parents with affective disorders, anxiety, and borderline personality disorder, there is currently limited evidence for parents with psychotic disorders. It is not yet known what, if any, interventions exist for this population, or what kinds of evaluations have been conducted. To address this, we conducted a scoping review to determine (1) what parenting interventions have been developed for parents with psychosis (either specifically for, or accessible by, this client group), (2) what components these interventions contain, and (3) what kinds of evaluations have been conducted. The eligibility criteria were broad; we included any report of an intervention for parents with a mental health diagnosis, in which parents with psychosis were eligible to take part, that had been published within the last 20 years. Two reviewers screened reports and extracted the data from the included reports. Thirty-eight studies of 34 interventions were included. The findings show that most interventions have been designed either for parents with any mental illness or parents with severe mental illness, and only two interventions were trialed with a group of parents with psychosis. After noting clusters of intervention components, five groups were formed focused on: (1) talking about parental mental illness, (2) improving parenting skills, (3) long-term tailored support for the whole family, (4) groups for parents with mental illness, and (5) family therapy. Twenty-three quantitative evaluations and 13 qualitative evaluations had been conducted but only eight interventions have or are being evaluated using a randomized controlled trial (RCT). More RCTs of these interventions are needed, in addition to further analysis of the components that are the most effective in changing outcomes for both the parent and their children, in order to support parents with psychosis and their families.

[Preventive and therapeutic interventions for children of mentally ill parents]

Preventive and therapeutic interventions for children of mentally ill parents Abstract. The risk of developing mental disorders increases markedly in children of mentally ill parents. Several risk factors have been identified and become possible targets of preventive and therapeutic interventions. Numerous studies investigated the efficacy of these interventions, which are very heterogeneous regarding content and methodology. One part of these studies focuses on infants of depressed and substance-addicted mothers; the other part focuses on children and adolescents of parents suffering from various mental disorders. Today, we have several meta-analyses at our disposal which yielded small effect sizes concerning the development of psychological symptoms or disorders in these affected children. The current review reveals a lack of high-quality studies, and analyses on cost-effectiveness are also needed. The preventive and therapeutic interventions now available show inadequate efficacy to effectively improve the situation of these children and adolescents. Future research is needed to develop and implement cost-effective interventions as well as high-quality studies to investigate the efficacy of these interventions.

Psychopathology and impairment of quality of life in offspring of psychiatric inpatients in southern Brazil: a preliminary study

OBJECTIVE

To evaluate the quality of life and risk of psychopathology in the infant and adolescent offspring of psychiatric inpatients from a general hospital unit.

METHODS

Offspring (4-17 years old) of psychiatric inpatients were interviewed face-to-face and assessed with the Strengths and Difficulties Questionnaire (SDQ). Interviews with caregivers and the hospitalized parents were also performed. The quality of life of the offspring, psychopathology of their hospitalized parents, and their current caregivers were investigated in order to evaluate any associations between these aspects and psychopathology in the offspring.

RESULTS

Thirty-four children of 25 patients were evaluated, 38.2% of which presented high risk for some type of psychopathology including hyperactivity or attention deficit disorder (38.2%), behavioral disorders (20.6%), and emotional disorders (17.6%). While only the minority of these children (17.6%) were already receiving mental health treatment, another 41.2% of them exhibited some degree of symptoms and were only referred for specialized assessment. Additionally, 61.8% of the children were reported to be suffering from some impairment in their quality of life.

CONCLUSION

This preliminary study found a high rate of psychopathology in children of psychiatric inpatients. These results corroborate previous evidence that children and adolescents with parents with severe psychopathology are at high risk for developing mental disorders. Public policies and standard protocols of action directed to this population are urgently needed, especially for offspring of parents that are hospitalized in psychiatric in-patient units of general hospitals.

Profitieren psychisch erkrankte Eltern und psychisch belastete Kinder von einer gemeinsamen Eltern-Kind-Behandlung?

Zusammenfassung. Es wird überprüft, ob die Teilnahme am Gruppenprogramm SEEK (Seelische Erkrankungen, Eltern und Kinder) für psychisch erkrankte Eltern im Rahmen einer stationären Eltern-Kind-Behandlung kurz- und längerfristige additive Behandlungseffekte erbringt hinsichtlich psychischer Symptome der Eltern (erfasst mit der Hopkins-Symptom-Checkliste-25; HSCL-25), der elterlichen Stressbelastung (erfasst mit dem Eltern-Belastungs-Inventar; EBI) sowie psychischer und körperlicher Symptome des Kindes (erfasst mit der Child Behavior Checklist; CBCL). Die Vergleichsgruppe (n = 11), die das übliche Behandlungsprogramm durchlief, und die Interventionsgruppe (n = 15), die zusätzlich an SEEK teilnahm, werden zu drei Messzeitpunkten (t1 bei Aufnahme, t2 bei Entlassung und t3 sechs Monate nach Entlassung) miteinander verglichen. Additive Effekte des Gruppenprogramms können bei dieser Untersuchung im umfangreichen stationären Behandlungssetting nicht belegt werden. Beide Gruppen erscheinen (mit Ausnahme zweier CBCL-Skalen im t1-t2-Vergleich) vergleichbar bezüglich ihres Behandlungserfolgs. Es zeigen sich sowohl kurzfristige Effekte als auch längerfristig stabile Effekte der stationären Eltern-Kind-Behandlung im 6-Monats-Follow-Up.

Child-rearing Support Provided by Public Health Nurses to People with Mental Illness: Qualitative Descriptive Study

Background:

The growing rates of deinstitutionalization in Japan have resulted in an increase in the number of children being raised by parents with mental illness. Given this situation, public health nurses working for local governments play an important role.

Objective:

The purpose of this qualitative descriptive study was to describe the child-rearing support provided by public health nurses to parents with mental illness.

Methods:

Seven nurses identified 28 cases of parents with mental illness. Descriptions of the goals and details of the appropriate nursing support were extracted from transcripts, coded, and categorized.

Results:

Parents with mental illness diagnosed with addiction and personality disorders were more difficult to support than those diagnosed with mood disorders or schizophrenia. Public health nurses supported parents with mental illness with the aim of achieving goals such as “building continuous consultative relationships,” “ensuring living conditions had a minimum level of safety and comfort,” “parents playing their roles,” “parents and children living together in the community,” and “fostering children’s growth.” While they provided support by “assessing their relationships with parents,” “building consultative relationships with parents,” “assessing parents’ illnesses/disorders and supporting,” “assessing child-rearing abilities and supporting,” and “cooperating with related agencies,” they tended to focus on the growth of the children rather than the recovery of parents.

Conclusion:

Consultative relationships were the beginning of support, as well as the most important and difficult skill. Public health nurses need to provide support for the recovery of parents with mental illness and learn about personality disorders and addiction.

Incidence of child and adolescent mental disorders in children aged 0-17 with familial high risk for severe mental illness - A Danish register study

BACKGROUND

Offspring of parents with severe mental illness (SMI: schizophrenia, bipolar disorder or major depressive disorder) have an increased risk of developing mental disorder themselves. In childhood they may have neurodevelopmental delays, cognitive deficits and social adversities. We aimed to investigate if these individuals are more at risk of being diagnosed with a mental disorder during childhood/adolescence in a national sample.

METHODS

By linking Danish registers we established a cohort consisting of all persons born to parents with SMI with those born to parents without SMI serving as a reference group. Incidence rate ratios (IRRs) for offspring diagnosed with a mental disorder by parental mental disorder were calculated.

RESULTS

Offspring of parents with SMI showed increased IRR for all diagnoses of child and adolescent mental disorders compared to the reference group. Offspring of mothers with schizophrenia had IRR of 2.60 (CI: 2.50-2.70, N=2550) of having any diagnoses, for children of fathers with schizophrenia IRR was 2.06 (CI: 1.97-2.16, N=1901) and for offspring of two parents with schizophrenia IRR was 4.57 (CI: 3.94-5.31, N=175). For individuals with a mother with bipolar disorder the IRR was 2.29 (CI: 2.09-2.50, N=502), with a father 1.77 (CI: 1.74-1.87, N=320), whereas the IRR was 2.96 (CI: 2.63-3.34, N=264) if both parents had unipolar depression.

DISCUSSION

Offspring of parents with a SMI have a higher risk of being diagnosed with any child and adolescent mental disorder. The IRRs for all diagnoses during childhood were increased by a factor 2-4. Having two ill parents increased the IRR.

Young adults' childhood experiences of support when living with a parent with a mental illness

There are several concerns in relation to children living with a parent suffering from a mental illness. In such circumstances, the health-care professionals need to involve the whole family, offering help to the parents on parenting as well as support for their children. These children are often helped by participating in meetings that provide them with contact with others with similar experiences. The aim of this study was to investigate young adults' childhood experiences of support groups when living with a mentally ill parent. Seven young women were chosen to participate in this study. A qualitative descriptive method was chosen. The main category emerged as 'the influence of life outside the home because of a parent's mental illness' from the two generic categories: 'a different world' and 'an emotion-filled life'. The participants' friends did not know that their parent was ill and they 'always had to…take responsibility for what happened at home'. These young adults appreciated the support group activities they participated in during their childhood, stating that the meetings had influenced their everyday life as young adults. Despite this, they associated their everyday life with feelings of being different. This study highlights the need for support groups for children whose parents suffer from mental illness.

How to support patients with severe mental illness in their parenting role with children aged over 1 year? A systematic review of interventions

PURPOSE

There are well-established risks for parents with severe mental illness (i.e. psychotic and bipolar disorders), both for their children and themselves. Interventions to help parents fulfil their role should therefore be a public health objective, but their implementation needs to be underpinned by research evidence. This systematic review determines what is known about the nature and effectiveness of interventions for parents with severe mental illness.

METHODS

We conducted a narrative synthesis of controlled and uncontrolled studies reporting interventions for this patient group after the post-natal period (i.e. after the child has turned 1 year old).

RESULTS

Eighteen publications reported data from 15 studies. All but two studies were rated as low quality studies. Interventions included home visiting programmes, complex community programmes, residential treatments, and online interventions. Interventions targeted diverse areas, with parenting skills and understanding the impact of mental illness on parenting most frequently addressed. Both parent and child-related outcomes improved, but children were only assessed via observers and follow-up times were short.

CONCLUSIONS

Interventions were diverse with respect to their nature and effectiveness. Future interventions should combine different intervention strategies to target multiple areas in a flexible manner. The addition of positively focussed and resource-oriented components should be investigated. Trials should include direct assessments of both parents and children, outcomes that are relevant from a public health perspective, and establish the long-term effects ideally until children have reached 18 years of age.

Standards of practice for the adult mental health workforce: meeting the needs of families where a parent has a mental illness

This article outlines the development of practice standards for the adult mental health workforce for addressing the needs of families where a parent has a mental illness (FaPMI). The practice standards recommended here were formulated using a modified cooperative inquiry process with a group of senior clinical leaders in adult mental health services in Australia, following consultation with the available literature and policy documents. The aim of the project was to generate, align, and operationalize family-inclusive practice standards within the core activities of the adult mental health workforce and integrate into the continuum of care and recovery for service users who are parents of dependent children. As part of a modified Delphi method, the standards were also ranked by the senior clinical leaders to determine what they believe to be essential and recommended practices for the adult mental health workforce they manage. We argue that developing practice standards that provide practical and realistic expectations of the adult mental health service workforce enable services and workers to better adapt practice to respond to FaPMI.

Familienstatus, mütterliche Belastung, dysfunktionales Erziehungsverhalten und kindliche Auffälligkeiten

In der Bundesrepublik Deutschland wächst fast jedes fünfte Kind in einer 1-Elternfamilie auf. Alleinerziehende Mütter und deren Kinder sind dabei häufig von erhöhten psychischen Belastungen bzw. Auffälligkeiten betroffen. Für eine gezielte Unterstützung ist die Kenntnis des Wirkzusammenhangs zwischen dem Familienstatus und der kindliche Belastung von großer Bedeutung. In der vorliegenden Untersuchung soll der Einfluss der mütterlichen Belastung und des dysfunktionalen Erziehungsverhalten im Rahmen einer multiplen Mediationsanalyse überprüft werden. Hierfür wurden die Angaben von n = 60 alleinerziehenden Müttern und n = 219 Müttern aus 2-Elternfamilien analysiert. Es zeigte sich, dass der Einfluss des Familienstatus auf die kindlichen Auffälligkeiten vollständig durch die psychische Belastung der Mütter mediiert wurde; das dysfunktionale Erziehungsverhalten mediierte seinerseits partiell den Zusammenhang der mütterlichen Belastung und der kindlichen Auffälligkeiten. Schlussfolgernd konnten Ansatzpunkte für zielgruppenorientierte Interventionsmaßnahmen identifiziert werden. Diese sollten sich dabei stärker an der elterlichen Belastung und weniger am Familienstatus selbst orientieren.