Whole-family programmes for families living with parental mental illness: a systematic review and meta-analysis.

Several interventions have been developed to support families living with parental mental illness (PMI). Recent evidence suggests that programmes with whole-family components may have greater positive effects for families, thereby also reducing costs to health and social care systems. This review aimed to identify whole-family interventions, their common characteristics, effectiveness and acceptability. A systematic review was conducted according to PRISMA 2020 guidelines. A literature search was conducted in ASSIA, CINAHL, Embase, Medline, and PsycINFO in January 2021 and updated in August 2022. We double screened 3914 abstracts and 212 papers according to pre-set inclusion and exclusion criteria. The Mixed Methods Appraisal Tool was used for quality assessment. Quantitative and qualitative data were extracted and synthesised. Randomised-control trial data on child and parent mental health outcomes were analysed separately in random-effects meta-analyses. The protocol, extracted data, and meta-data are accessible via the Open Science Framework ( https://osf.io/9uxgp/ ). Data from 66 reports-based on 41 independent studies and referring to 30 different interventions-were included. Findings indicated small intervention effects for all outcomes including children's and parents' mental health (dc = -0.017, -027; dp = -0.14, -0.16) and family outcomes. Qualitative evidence suggested that most families experienced whole-family interventions as positive, highlighting specific components as helpful, including whole-family components, speaking about mental illness, and the benefits of group settings. Our findings highlight the lack of high-quality studies. The present review fills an important gap in the literature by summarising the evidence for whole-family interventions. There is a lack of robust evidence coupled with a great need in families affected by PMI which could be addressed by whole-family interventions. We recommend the involvement of families in the further development of these interventions and their evaluation.

Validating two survey methods for identifying cases of autism spectrum disorder among adults in the community.

BACKGROUND: There are no tested methods for conducting epidemiological studies of autism spectrum disorders (ASDs) in adult general population samples. We tested the validity of the Autism Diagnostic Observation Schedule module-4 (ADOS-4) and the 20-item Autism-Spectrum Quotient (AQ-20). METHOD: Randomly sampled adults aged ≥16 years were interviewed throughout England in a general population multi-phase survey. The AQ-20 was self-completed by 7353 adults in phase 1. A random subset completed phase 2, ADOS-4 assessments (n=618); the probability of selection increased with AQ-20 score. In phase 3, informant-based Diagnostic Interview Schedule for Social and Communication Disorders (DISCO) and Autism Diagnostic Interview-Revised (ADI-R) developmental assessments were completed (n=56). Phase 1 and 2 data were presented as vignettes to six experienced clinicians (working in pairs). The probability of respondents having an ASD was compared across the three survey phases. RESULTS: There was moderate agreement between clinical consensus diagnoses and ADOS-4. A range of ADOS-4 caseness thresholds was identified by clinicians: 5+ to 13+ with greatest area under the curve (AUC) at 5+ (0.88). Modelling of the presence of ASD using 56 DISCO assessments suggested an ADOS-4 threshold in the range of 10+ to 13+ with the highest AUC at ADOS 10+ to 11+ (0.93-0.94). At ADOS 10+, the sensitivity was 1 [95% confidence interval (CI) 0.59-1.0] and the specificity 0.86 (95% CI 0.72-0.94). The AQ-20 was only a weak predictor of ADOS-4 cases. CONCLUSIONS: Clinically recommended ADOS-4 thresholds are also recommended for community cases: 7+ for subthreshold and 10+ for definite cases. Further work on adult population screening methods is needed.

Chronic behavioral stress induces apical dendritic reorganization in pyramidal neurons of the medial prefrontal cortex.

Both the hippocampus and the medial prefrontal cortex (mPFC) play an important role in the negative feedback regulation of hypothalamic-pituitary-adrenal (HPA) activity during physiologic and behavioral stress. Moreover, chronic behavioral stress is known to affect the morphology of CA3c pyramidal neurons in the rat, by reducing total branch number and length of apical dendrites. In the present study, we investigated the effects of behavioral stress on the mPFC, using the repeated restraint stress paradigm. Animals were perfused after 21 days of daily restraint, and intracellular iontophoretic injections of Lucifer Yellow were carried out in pyramidal neurons of layer II/III of the anterior cingulate cortex and prelimbic area. Cellular reconstructions were performed on apical and basal dendrites of pyramidal neurons in layer II/III of the anterior cingulate and prelimbic cortices. We observed a significant reduction on the total length (20%) and branch numbers (17%) of apical dendrites, and no significant reduction in basal dendrites. These cellular changes may impair the capacity of the mPFC to suppress the response of the HPA axis to stress, and offer an experimental model of stress-induced neocortical reorganization that may provide a structural basis for the cognitive impairments observed in post-traumatic stress disorder.

Ultrastructure of primitive hematopoietic stem cells isolated using probes of functional status.

The most primitive hematopoietic stem cells capable of longterm reconstitution of the entire hematopoietic system following transplantation are characterized by their ability to exclude both Rhodamine 123 and Hoechst 33342 dyes (Rh/Ho(dull)), and are an appropriate target population for the determination of stem cell ultrastructure. We have used a fluorescence-activated cell sorter to enrich to near purity these rare, highly quiescent cells. Analysis of the in vitro growth characteristics of Rh/Ho(dull) cells demonstrated an obligatory requirement for multiple growth factors, with 62% of the sorted population having the capacity to form colonies in the presence of CSF-1 + IL-1alpha + IL-3 + SCF. The Rh/Ho(dull) cells were small, with profiles having a mean diameter of 4.6 microm. Ultrastructural examination showed numerous ribosomes and several mitochondria in the thin rim of cytoplasm surrounding the nucleus, with other cytoplasmic organelles revealed in serial sections. The cells were generally homogeneous in appearance apart from the nucleus, which had an irregular shape with a single deep indentation. The heterochromatin around the margin was distinctly more pronounced in about 50% of nuclei. The findings provide a basis for studying the structural changes that occur with progressive differentiation of early hematopoietic cells.

Pretreatment with cytosine arabinoside does not protect against the delayed effects of irradiation on thrombopoiesis and erythropoiesis.

We have examined the capacity of the thrombopoietic and erythropoietic systems to respond to challenge with the cytotoxic drug 5-fluorouracil (5-FU) following sublethal doses of irradiation. Normal adult mice respond to 5-FU with a mild thrombocytopenia followed by a marked rebound thrombocytosis. One month after 2 Gy whole-body radiation, platelet counts took longer than normal to reach a nadir after 5-FU, and the rebound thrombocytosis was reduced. A normal response was seen when the interval after radiation was extended to 4 months. Increasing the radiation dose to 6.5 Gy resulted in a much smaller rebound thrombocytosis when 5-FU was given 1 month later. Extending the interval before the drug was given resulted in a normal response being regained between 4 and 7 months. Erythrocyte levels were temporarily depressed after 5-FU in all mice, and it took longer for recovery to occur if they had been irradiated. In another series of experiments, we investigated the effect of priming the mice before irradiation to see if this resulted in radioprotection. An injection of cytosine arabinoside (Ara-C) 2 days before a dose of 6.5 Gy resulted in the expected earlier recovery in platelet counts. To see if cells of the megakaryocyte lineage were protected from the delayed effects of irradiation by this treatment, mice were given 5-FU 1 month after Ara-C plus irradiation. The period of thrombocytopenia was followed by only a small rebound thrombocytosis, and platelet counts were indistinguishable from those found for mice not primed with Ara-C before irradiation. These experiments revealed a delayed effect of irradiation on the thrombopoietic and erythropoietic systems, which was long-lasting but not permanent at the doses used. The effects were not eliminated by priming mice with Ara-C before irradiation.

Radiation response of mouse lymphoid and myeloid cell lines. Part II. Apoptotic death is shown by all lines examined.

The mode of death induced by gamma-irradiation in a panel of 10 mouse lymphoid or myeloid cell lines was examined. Four of these lines were known to lose viability (membrane integrity) rapidly after irradiation, whilst the others were known to lose viability considerably more slowly. However, based on the criteria of morphology and DNA degradation pattern, all 10 lines showed apoptotic death. The occurrence of apoptosis after irradiation in rapid-dying lymphoid cell lines was consistent with published results, whilst the demonstration of apoptosis in slow-dying lines was unexpected. Cells of the slow-dying lymphoid lines underwent one or more mitoses prior to death, a feature also reported for fibroblastoid cell lines. However, the occurrence of radiation-induced necrosis in fibroblasts suggests that the pathways leading to 'mitotic death' differ between fibroblastoid and lymphoid cell lines.

Compensatory mechanisms in platelet production: lack of a paracrine response in W/Wv mice treated with 5-fluorouracil.

W/Wv mice maintain normal platelet levels despite having a reduced functional stem cell pool, indicating that platelet production in these mice is compensated by altered megakaryocytopoiesis. In this study the effect of 5-fluorouracil (5-FU) treatment on platelet production in W/Wv mice and their congenic normal littermates was assessed. Recovery of circulating platelet levels occurred 11 days after 5-FU administration in W/Wv mice and subsequently did not increase above control values. In contrast, normal littermates showed an increased platelet count by day 8 and significant thrombocytosis between days 11 and 14. Investigation of bone marrow megakaryocytopoiesis in W/Wv mice showed there was no recovery in the number of megakaryocyte progenitors (CFU-Meg) per femur between days 3 and 5, but control values were reached by day 10. In addition, by day 8 the number of mature megakaryocytes per unit volume of bone marrow in these mice had not returned to control values, although the megakaryocytes were of an increased size. In comparison, the number of CFU-Meg per femur in normal mice treated with 5-FU began to recover after day 3, returned to control values by day 8 and increased to supranormal levels by day 14. Bone marrow megakaryocyte concentration was increased 2-fold over the control by day 8 and an increase in mean megakaryocyte size was also observed. The data suggest that platelet production in mice is dependent on the rate of establishment of both the progenitor cell and megakaryocyte pools. The inability of W/Wv mice to enhance and accelerate progenitor cell levels led to a reduced bone marrow response and failure to produce a marked thrombocytosis.

Delayed hematopoietic development in osteopetrotic (op/op) mice.

Changes in structure, cellularity, hematopoietic progenitor cell and macrophage content, and osteoclast activity were investigated in the hematopoietic organs of the colony-stimulating factor 1(CSF-1)-less osteopetrotic (op/op) mouse. The data indicated that op/op mice undergo an age-related hematopoietic recovery and resolution of osteopetrosis, suggesting that the hematopoietic system has the capacity to use alternative mechanisms to compensate for the absence of an important multifunctional growth factor, CSF-1. In young animals, op/op femurs were heavily infiltrated with bone, and marrow cellularity was significantly reduced. After 6 wk of age, there was an increase in the marrow space available for hematopoiesis. The femoral cavity of op/op mice progressively enlarged, and by 22 wk of age its appearance and marrow cellularity was comparable to that of controls. The percentage of op/op mononuclear phagocytes, defined by F4/80 antigen expression, progressively increased to normal levels by 35 wk of age. There was no difference in the incidence of both primitive and mononuclear phagocyte-committed, CSF-1-responsive progenitor cells in op/op marrow, but their femoral content was significantly reduced in young mice. During the period of reduced hematopoiesis in the marrow of young op/op mice, splenic hematopoietic activity was elevated. This mutant mouse represents a system for the study of the CSF-1-independent regulatory mechanisms involved in hematopoietic regulation.

Characterization of endothelial cells in murine long-term marrow culture. Implication for hemopoietic regulation.

Establishing the presence of various cell types in long-term marrow culture (LTMC) has an important bearing on understanding the regulation of stromal cell-related hemopoiesis. Controversy has surrounded the identity of the very large cells in murine LTMC; they have been given a variety of designations, including blanket cells. Using dual immunogold labeling with a recently derived monoclonal antibody, H513E3, and anti-human factor VIII antibodies, we have conclusively located endothelial cells in LTMC. Endothelial cells are relatively large, with thinly spread cytoplasm, and they overlie macrophages, granulocytes, and other less differentiated developing hemopoietic cells. Previously, demonstration of endothelial cells in LTMC had been difficult due to lack of specific markers in the mouse. We have demonstrated that LTMC endothelial cells have the exact location and ultrastructural characteristics as the previously described blanket cells. We propose that previous designations should not be continued and that these cells should be referred to as endothelial cells. The known functions of endothelial cells now become relevant to the understanding of stromal regulation of hemopoiesis.

Cytotoxicity of 5-aza-2'-deoxycytidine in a mammalian cell system.

After the addition of 5-aza-2'-deoxycytidine, a potent inhibitor of DNA methylation and S-phase-specific cytotoxic agent, metaphase chromosomes of Chinese hamster ovary (CHO) cells exhibited a highly decondensed and extended morphology (numerous "fragile sites") at the first mitotic division. However, when a lethal dose of this drug was added in early G1 phase to cells synchronised by mitotic selection, the majority subsequently divided at the same time as an untreated control cell population with few division abnormalities and with few of the more usual types of chromosome aberrations such as gaps, breaks and exchanges. The drug-treated cells also entered and completed the second S-phase without significant delay and it was only at the second mitosis after addition of 5-azadeoxycytidine that cells showed delays in entering mitosis and significant increases in abnormal divisions concomitant with a modest increase in chromosome aberrations. If cells in a tumour behave similarly, the tumour mass would be expected to double before any reduction in tumour burden could be expected to occur.

Megakaryocyte maturation in long-term marrow culture.

Evidence has been sought for megakaryocyte maturation in long-term cultures of mouse bone marrow. Cultures up to 14 weeks of age were examined for the presence of megakaryocytes with processes, that is, resembling the morphological appearance seen in vivo prior to platelet liberation. Such cells were found floating just above the adherent stromal layer using low magnification phase contrast microscopy. It was rare to observe as many as 20 of these cells per 25-cm2 flask. At higher magnification, processes were seen to be attenuated with constrictions at intervals along their length. Time-lapse photography was used to follow the development and behavior of the processes. Direct evidence of rupture was very rare; generally the megakaryocytes retracted their processes within 48 h. Careful searching of cultures occasionally revealed the presence of several process fragments, and sometimes individual platelets were found. Ultrastructurally, the processes were seen to contain organelles that are usually associated with platelets. The observations applied to both Dexter and Whitlock-Witte cultures. It is concluded that maturation of megakaryocytes occurs in long-term marrow culture to the point where platelet release appears imminent. Final rupture is rare and may require shearing forces, which in vivo would be provided by blood flow.

A mouse endothelial cell-specific monoclonal antibody: its reactivity with LTMC endothelium.

The binding of a marrow cell-related monoclonal antibody (H513E3 MAb) has been investigated in long-term marrow cultures (LTMC) and in vivo. Immunogold labeling and electron microscopy revealed that this antibody labeled an endothelial-like cell. Cross-reaction of anti-human Factor VIII confirmed endothelial specificity of the H513E3 MAb. In addition, vessel endothelium (vena cava, aorta, and marrow) exhibited binding of the antibody. This antibody provides a unique tool to study the cellular architecture of LTMC and implicates endothelium as an important component of LTMC. The function of the endothelial cell-specific surface antigen is unknown, although preferential labeling of the upper surface of endothelial cells suggests that it may play a role in cell communication, particularly with the floating population. The H513E3 MAb reacts with an external membrane antigen, a property that makes this antibody particularly useful for fluorescences-activated sorting of endothelial cells.

Compensatory mechanisms in platelet production: the response of Sl/Sld mice to 5-fluorouracil.

Sl/Sld mice are a unique animal model for studying platelet production in that they sustain normal platelet mass despite reduced marrow activity. The aim of this study was to determine if the compensatory mechanisms operating in these mice could be augmented by further reducing bone marrow activity with the drug 5-fluorouracil (5-FU), known to induce a strong stimulatory effect on platelet production. The platelet recovery in Sl/Sld mice after 5-FU administration contrasted that found in their normal littermates. Sl/Sld mice did not display the sustained thrombocytosis that was observed in +/+ mice between days 10 and 14. Platelet number was elevated in Sl/Sld mice at day 20, when the marrow megakaryocyte compartment had normalized. A significant increase in marrow megakaryocyte number and size was observed at days 8 and 11 in both +/+ and Sl/Sld mice after 5-FU administration. The data suggest that the increase in megakaryocyte size and number following 5-FU treatment was not able to significantly contribute to a sustained rebound thrombocytosis at the time of increased marrow megakaryocytopoiesis. It is concluded that the already compromised marrow of Sl/Sld mice is able to respond to the damage invoked by 5-FU to produce larger than normal megakaryocytes. In contrast to normal mice (+/+ littermates), the increase in marrow megakaryocytopoiesis observed does not lead to a thrombocytosis, indicating that platelet production and release in Sl/Sld mice cannot be further amplified by a strong marrow stimulation.

Use of bone marrow somatic cell hybrid lines to generate monoclonal antibodies specifically reactive with rare marrow cells.

The technique of somatic cell hybridization has been applied to obtain new sources of immunogen for monoclonal antibody production. A marrow population enriched for rare and undifferentiated cells was hybridized with A9 cells. Mature cells were depleted by using mice at 8 days following 5-fluorouracil treatment and by using a sorting procedure. Selection of hybrids was in medium containing hypoxanthine, aminopterin, and thymidine (HAT). Chromosome analysis was used to verify that clones contained hybrid cells. An example of an antibody (H513E3) obtained by immunizing with a hybrid cell line (H5Scl1.4.4) is presented. The H513E3 antibody showed low reactivity with normal marrow (0%-3%), and hemopoietic cell lines of various types exhibited no cross-reaction. However, about 10% of cells from the adherent stromal layer of long-term marrow cultures reacted with the H513E3 antibody. A specific cell type was labeled that appeared to have endothelial-like morphology when observed with immunogold labeling and electron microscopy. The hybridization technique allows a cell of a particular differentiation lineage to be conserved, wholly or partially, in a cloned form, thus overcoming the heterogeneity of a normal marrow population.

The response of megakaryocytes with processes to thrombin.

The response of megakaryocytes to thrombin (1-10 U/ml) has been examined by time-lapse cinemicrography and electron microscopy. The study was confined to mature megakaryocytes which had developed processes following incubation in vitro. The initial response of all cells was to undergo retraction of processes, behaviour thought to be linked with the depolymerization of microtubules which extend longitudinally through the processes. The majority of cells completely withdrew their processes, but about 30% responded differently and underwent only limited retraction, followed by secretion. Analysis of time-lapse film showed that processes from the latter group of cells had formed attachments with the coverslip prior to exposure to thrombin. Within the partially retracted processes of these cells, secretory granules were found to be clustered centripetally and enveloped by a microfilamentous structure in the form of a cylinder. Vacuoles appeared, some of which were located outside the microfilamentous structure. Microtubules were present, but many appeared disorientated. The shape of the microfilamentous structure suggests that the cytoplasm is not organized into putative platelets at the time of process formation.

Megakaryocyte fragments and the microtubule coil.

We have examined megakaryocyte process fragments that migrate out of bone marrow explants after a short period of incubation and assume a beaded form, consisting of 2 or more putative platelets. The fragmentation appears to occur in vivo and supports the proposal that platelet liberation does not always occur in a sequential manner from the distal ends of megakaryocyte processes. Transmission electron microscopy revealed that microtubules were generally oriented longitudinally in the process fragments. Rarely, a microtubule coil was found in a terminally located putative platelet. The observations favour the view that the marginal coil of microtubules, which is a characteristic of circulating platelets, does not usually form until after platelets have been liberated.

Characterization of megakaryocyte spleen colony-forming units by response to 5-fluorouracil and by unit gravity sedimentation.

Properties of megakaryocyte progenitor cells in mouse bone marrow have been examined using an in vivo assay system. Perturbation with 5-fluorouracil (5-FU) and separation by unit gravity sedimentation was used to characterize the cells. Bone marrow was assayed for the presence of megakaryocyte colony-forming cells (MK CFU-S) by transplantation into lethally irradiated mice and examining spleen sections 10 days later. Donor mice were untreated or injected intravenously with 5-FU (150 mg/kg), 1 (FU-1) or 7 (FU-7) days beforehand. There was a lack of correlation between the numbers of MK CFU-S and cells giving rise to macroscopic spleen surface colonies (CFU-S10). The sedimentation profile of MK CFU-S in normal marrow was similar (modal velocity 4.16 +/- 0.05 mm/hr) to that of CFU-S10. In FU-1 marrow, MK CFU-S exhibited a bimodal sedimentation profile, with peaks at 3.26 +/- 0.06 mm/hr and 4.53 +/- 0.07 mm/hr. The marrow content of CFU-S10 was reduced to 5% of normal, while MK CFU-S numbers were only reduced to 60%. In FU-7 marrow, the sedimentation profile of MK CFU-S (modal velocity 4.86 +/- 0.16 mm/hr) differed from that of CFU-S10 (5.5 +/- 0.16 mm/hr). It was concluded MK CFU-S and CFU-S10 are different entities. The MK colonies formed from FU-1 marrow contained on average 3.8-fold more cells than those formed from normal marrow. The enhanced megakaryocyte production may be accounted for on the basis of the generation-age model for cell proliferation. It is proposed that MK CFU-S are a heterogeneous population with regard to proliferation potential and that the FU-1 marrow contains cells that survive 5-FU and have a high proliferative potential. These cells may be equivalent among megakaryocytic progenitors to the high proliferative potential colony-forming cells of the granulocyte/macrophage series. They may be responsible for the enhanced megakaryocytopoiesis seen in the marrow of mice 7 days after the injection of 5-FU.

In vitro production of CFU-S and cells with erythropoiesis repopulating ability by 5-fluorouracil treated mouse bone marrow.

Mouse bone marrow, obtained from donors three days after treatment with 5-fluorouracil, had a very low ability to form macroscopic spleen colonies in irradiated mice at 10 days after transplantation of the cells (CFU-S10); such marrow also had no detectable erythropoiesis repopulating ability but did have near normal marrow repopulating ability and spleen megakaryocyte repopulating ability. Incubation of this marrow in vitro for 7 days with medium containing growth factor preparations (a) pregnant mouse uterus extract plus human spleen conditioned medium or (b) mouse spleen conditioned medium, resulted in marked increases in CFU-S10 and in cells with erythropoietic repopulating ability together with maintenance of cells with marrow repopulating ability. These responses were not observed in cultures with control medium alone. Spleen megakaryocyte repopulating ability was also maintained in the presence of the factor preparations.

Fate of senescent megakaryocytes in the bone marrow.

Degenerating senescent megakaryocytes have been identified in mouse bone marrow by light and electron microscopy. The ultrastructural changes which occur as degeneration proceeds are characteristic of death by apoptosis, although most cells appear to round up rather than undergo fragmentation. A hitherto unreported finding in degenerating cells was the presence of bundles of approximately 7 nm diameter parallel filaments in nuclei and membrane-bound nuclear fragments. Structurally, they resembled bundles of filaments induced in nuclei with dimethyl sulphoxide and identified as actin. Often a bundle appeared to terminate at the inner membrane. In the cytoplasm the presence of microtubules and centrioles indicates that not all the latter organelles are lost by the megakaryocyte during platelet release. Degenerating senescent megakaryocytes are rare in the marrow of normal mice but increase in frequency during 5-fluorouracil stimulated thrombocytosis. The dying cells are eventually phagocytosed by macrophages, a process that can occur extravascularly, showing that entry of senescent megakaryocytes into the circulation is not necessary for their disposal.