Economic Evaluation of Family-Focused Programs When Parents Have a Mental Health Problem: Methodological Considerations.

OBJECTIVES: The nature of adverse effects of parental mental health problems and of the interventions to address them may require specific designs of economic evaluation studies. Nevertheless, methodological guidance is lacking. We aim to understand the broad spectrum of adverse effects from parental mental health problems in children and the economic consequences on an individual and societal level to navigate the design of economic evaluations in this field. METHODS: We conducted a systematic literature search of empirical studies on children's adverse effects from parental mental illness. We clustered types of impact, identified individual and public cost consequences, and illustrated the results in an impact inventory. RESULTS: We found a wide variety of short- and long-term (mental) health impacts, impacts on social functioning and socioeconomic implications for the children individually, and adverse effects on the societal level. Consequently, public costs can occur in various public sectors (eg, healthcare, education), and individuals may have to pay costs privately. CONCLUSIONS: Existing evaluations in this field mostly follow standard methodological approaches (eg, cost-utility analysis using quality-adjusted life-years) and apply a short-time horizon. Our findings suggest applying a long-term time horizon (at least up to early adulthood), considering cost-consequence analysis and alternatives to health-related quality of life and quality-adjusted life-years as outcome measures, and capturing the full range of possible public and private costs.

Editorial Perspective: Prato Research Collaborative for change in parent and child mental health - principles and recommendations for working with children and parents living with parental mental illness.

Children whose parents have mental illnesses are among the most vulnerable in our communities. There is however, much that can be done to prevent or mitigate the impact of a parent's illness on children. Notwithstanding the availability of several evidence-based interventions, efforts to support these children have been limited by a lack of adequate support structures. Major service reorientation is required to better meet the needs of these children and their families. This editorial provides recommendations for practice, organisational, and systems change.

Promoting Self-Determination in Parents With Mental Illness in Adult Mental Health Settings.

This article reports a strengths-based intervention to support parents with mental illness and their children in adult mental health settings: "Let's Talk About Children" (LTC) intervention. A qualitative methodology was adopted with parent participants receiving LTC in adult mental health and family services. The benefits for parents receiving LTC were described through in-depth interviews with 25 parents following the delivery of the program. Interview data identified an impact on parental self-regulation-mainly through a change in a sense of agency as a parent-and skill building, once a clearer picture of their child's everyday life was understood. This study outlines the benefits of talking with parents about the strengths and vulnerabilities of their children during routine mental health treatment. The role for self-determination of parents in preventive interventions for children is an important consideration for mental health recovery, and it also helps to break the cycle of transgenerational mental illness within families.

Intergenerational Trauma and Its Relationship to Mental Health Care: A Qualitative Inquiry.

Intergenerational trauma is a discrete form of trauma which occurs when traumatic effects are passed across generations without exposure to the original event. This qualitative study aimed to explore how psychiatrists understand intergenerational trauma in respect to their practice, for the purposes of identifying interventions for addressing intergenerational trauma in public mental health services. Findings revealed that psychiatrists observe intergenerational trauma frequently in their roles and try to opportunistically promote awareness of trauma with adults, and refer families to external services for supportive interventions. They feel powerless when faced with directly intervening with intergenerational trauma and required restructuring of their roles to adequately address it in public settings. Findings have implications for training, advocacy and research on the relationship between trauma and mental illness. Alongside this, there is an indicated need for examination of how systems can ensure access to appropriate services once organisations become trauma-informed.

A qualitative inquiry into psychiatrists' perspectives on the relationship of psychological trauma to mental illness and treatment: implications for trauma-informed care.

BACKGROUND: Trauma is a factor impacting the lives of many people experiencing psychiatric disorders. Trauma affects people's responses to illness as well as their interactions with services. AIM: This study aimed to explore the understandings and experiences of psychiatrists of working with trauma and emerging models of Trauma-Informed Care. METHODS: An interpretive qualitative inquiry was undertaken using semi-structured in-depth interviews with psychiatrists. RESULTS: Four themes were identified: Making sense of trauma; A contentious relationship between trauma and mental illness; Treatment made more challenging by trauma; Trauma-Informed Care highlights tensions. Psychiatrists are familiar with the concept of trauma but there are differences in beliefs about its relationship to mental illness that are consequential for practice. Trauma-Informed Care is seen as an effort to humanise mental health services, but with perceived limited impact on psychiatrists' roles. CONCLUSION: Findings indicate need for further consultation and collaboration with psychiatrists around trauma-informed care implementation; as well as consideration of what is required to develop professional consensus on trauma and its relationship to illness.

Supporting children who have a parent with a mental illness in Tyrol: a situational analysis for informing co-development and implementation of practice changes.

BACKGROUND: A research project, which aims to improve the situation of children of parents with a mental illness (COPMI) is currently underway in the Austrian region of Tyrol. The project aims to strengthen formal and informal support structures around the child, through enhancing their village of collaborative support. Understanding the current situation in the region is vital for implementing practice change. This paper aims to gain knowledge regarding the Tyrolean societal and service provision context. METHODS: We collected qualitative (17 interviews among stakeholder and people with lived experience) and quantitative data (e.g. health insurance data) regarding overall societal characteristics, epidemiology of mental illness, currently existing services, uptake of services, and current practices and challenges of identifying and supporting COPMIs. We analysed data along eight external context dimensions: 1) professional influences, 2) political support, 3) social climate, 4) local infrastructure, 5) policy and legal climate, 6) relational climate, 7) target population, and 8) funding and economic climate. RESULTS: We identified that there is awareness of potential challenges related to COPMIs at both a professional and planning level. Additionally, there is a lack of installed support processes and standards to meet these children's needs across Tyrol. A variety of services are available both for unwell parents, as well as for families and individual family members. Yet, only one small service addresses COPMIs directly. Services fall into different sectors (education, health, social affairs) and are funded from different sources, making coordination difficult. Access varies from universal to rather restricted (i.e. through referral). The potential number of parents which could be reached in order to identify their children via adult mental health, differs considerably by setting. Societal structures indicate that the informal and voluntary sector may be a realistic source for supporting COPMIs. CONCLUSIONS: The societal structures and the current services provide a rich resource for improving identification and support of COPMIs, however considerable coordination and behaviour change efforts will be required due to the fragmentation of the system and professional cultures. The insights into the context of supporting COPMIs have been of high value for developing and implementing practice changes in the local organizations.

An exploration of whether mental health nurses practice in accordance with The Family Model.

BACKGROUND: The Family Model is increasingly used as a framework to promote a whole family approaches in mental health services. The purpose of this qualitative study was to (i) explore whether nurses practice in accordance with the Model when providing services for parents who have mental illness, (ii) determine whether components of the model are employed more in some workplaces (i.e. acute in-patient units versus community settings) and (iii) ascertain reasons as to why this may be the case. METHOD: A purposive sample of 14 nurses from eight mental health services in Ireland, completed semi-structured interviews. RESULTS: Findings indicated that nurses' practice incorporated most key components of The Family Model, including supporting service users' dependent children. However, some practices were not explicit in the Model, such as supporting other adult family members (i.e. grandparents). While nurses' practice in community settings was more aligned with The Family Model than in acute in-patient units, there was a notable absence of reference to domain six (cultural considerations) in both settings. A holistic and family-centered philosophy, coupled with collegial and managerial support and a focus on prevention were the main features that enabled family focused practice in community settings. CONCLUSION: As only a subgroup of nurses practice in accordance with The Family Model, efforts are required by nurses, their organisations and the broader system to promote family focused practice. The Family Model may be a useful framework, with further refinement, for guiding nurses' practice.

Preventing intergenerational trauma transmission: A critical interpretive synthesis.

AIM AND OBJECTIVE: To synthesise and critically interpret literature of relevance to intervening in intergenerational transmission of relational trauma within parent-infant relationships. BACKGROUND: Intergenerational trauma is a discrete process and form of psychological trauma transmitted within families and communities. Intergenerational trauma can be transmitted through attachment relationships where the parent has experienced relational trauma and have significant impacts upon individuals across the lifespan, including predisposition to further trauma. DESIGN: Critical interpretive synthesis (CIS) was used. CIS is an inductive qualitative process that generates new theory grounded within reviewed literature. METHODS: The review commenced by systematically searching for literature on interventions for intergenerational trauma. As the core theoretical construct emerged, elements that may contribute to preventing intergenerational trauma were identified iteratively and influenced further searching. In the final synthesis, 77 articles were included from the fields of intergenerational trauma, trauma interventions and attachment interventions. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. RESULTS: The key construct is that prevention of intergenerational trauma transmission is the key intervention. The two contributing constructs were identified as "resolving parental trauma" and "actively supporting parent-infant attachment." CONCLUSIONS: Prevention is the most effective intervention approach for intergenerational transmission of trauma. Prevention requires trauma-specific interventions with adults and attachment-focused interventions within families. Preventative strategies need to target individual, relationship, familial, community and societal levels, as addressing and preventing trauma requires a multipronged, multisystemic approach. RELEVANCE TO CLINICAL PRACTICE: Systematic trauma-informed attachment-focused interventions in health and social service settings are recommended. There are opportunities to provide multifocal individual and relational interventions within existing services that work with parents to help prevent the likelihood and impact of transmission of intergenerational relational trauma within families. Nurses are well placed to provide preventative interventions in mental health, early childhood and primary health settings.

Developing an Australian-first recovery model for parents in Victorian mental health and family services: a study protocol for a randomised controlled trial.

BACKGROUND: A considerable number of people with a mental illness are parents caring for dependent children. For those with a mental illness, parenting can provide a sense of competence, belonging, identity and hope and hence is well aligned to the concept of personal recovery. However, little research has focused on the recovery journey of those who are parents and have a mental illness. This randomised controlled trial aims to (i) evaluate the effectiveness of an intervention model of recovery for parents (Let's Talk about Children) in three different mental health service sectors and (ii) examine the economic value of a larger roll out (longer term) of the parent recovery model. METHODS: A two arm parallel randomised controlled trial will be used with participants, who are being treated for their mental illness in adult mental health, non-government community mental health or family welfare services. The study will involve 192 parents, who are considered by their treating practitioner to be sufficiently well to provide informed consent and participate in an intervention (Let's Talk about Children) or control group (treatment as usual). Participant randomisation will occur at the level of the treating practitioner and will be based on whether the randomised practitioner is trained in the intervention. Outcomes are compared at pre, post intervention and six-month follow-up. Recovery, parenting and family functioning, and quality of life questionnaires will be used to measure parent wellbeing and the economic benefits of the intervention. DISCUSSION: This is the first randomised controlled trial to investigate the efficacy of a parenting intervention on recovery outcomes and the first to provide an economic evaluation of an intervention for parents with a mental illness. An implementation model is required to embed the intervention in different sectors. TRIAL REGISTRATION: The trial was retrospectively registered: ACTRN12616000460404 on the 8/4/2016.

Differences Between Irish and Australian Psychiatric Nurses' Family-Focused Practice in Adult Mental Health Services.

Psychiatric nurses' practice with parents who have mental illness, their children and families is an important issue internationally. This study provides a comparison of Irish and Australian psychiatric nurses' family-focused practices in adult mental health services. Three hundred and forty three nurses across Ireland and 155 from Australia completed the Family Focused Mental Health Practice Questionnaire. Cross-country comparisons revealed significant differences, in terms of family-focused skill, knowledge, confidence and practice. Australian psychiatric nurses engaged in higher family-focused practice compared to Irish nurses. The comparative differences between countries may be attributable to differences in training, workplace support and policy.

Profession differences in family focused practice in the adult mental health system.

There is a large gulf between what psychiatric services should (or could) provide and what they do in practice. This article sought to determine practice differences between the differing professions working in adult mental health services in terms of their family focused work. Three hundred and seven adult mental health professionals completed a cross-sectional survey of family focused practices in adult mental health services. Findings highlight that social workers engaged in more family focused practice compared to psychiatric nurses, who performed consistently the lowest on direct family care, compared to both social workers and psychologists. Clear skill, knowledge, and confidence differences are indicated between the professions. The article concludes by offering direction for future profession education and training in family focused practices.

Acceptability, engagement and exploratory outcomes and costs of a co-designed intervention to support children of parents with a mental illness: Mixed-methods evaluation and descriptive analysis.

Children whose parents have a mental illness are much more likely to experience mental health problems and other adverse long-term impacts. Child-centred psychosocial interventions can be effective, but not much is known about how to design and implement them in different settings. A pre-post, mixed methods, single-arm evaluation of a co-designed social support intervention with parents and children (4-18 years) measured parents' mental health (PHQ-9), perceived social support (ENRICHD), parental self-efficacy (PSAM) and children's mental health (SDQ), quality of life (Kidscreen-27), and child service use (CAMHSRI-EU) at baseline and 6 months. Qualitative data were gathered at 6 months to explore parents' and children's experience with the intervention. Twenty-nine parents and 21 children completed baseline and follow-up questionnaires; 22 parents and 17 children participated in interviews. Parents' depression (MD -1.36, SD 8.08), perceived social support (MD 1, SD 5.91), and children's mental health potentially improved, and children's service use and costs potentially reduced (€224.6 vs. €122.2, MD 112.4). Parental self-efficacy was potentially reduced (MD -0.11, SD 3.33). The sample was too small to perform statistical analysis. Favourable themes emerged describing the high satisfaction with the intervention, parents' improved understanding of the impact of their mental health problems on children, and improvements in parent-child relationships. This study contributes to an emerging evidence base for co-designed child-centred interventions to prevent the transgenerational transmission of poor mental health.

Goal setting within family care planning: families with complex needs.

OBJECTIVE: To identify the key goals that are established by children and parents from families in which parents have substance use and/or mental health problems, and the level of progress achieved towards goals over 1 year of case management. DESIGN, SETTING AND PARTICIPANTS: Participants from three rural sites of a New South Wales non-government agency completed family care plans between 2008 and 2010. They included 44 parents and 41 children from 37 families where at least one parent had a dual diagnosis or mental illness. Family care plans were analysed to identify the frequency and progress of child and parent goals across 11 domains. MAIN OUTCOME MEASURES: Goals identified by parents and children, and change scores over a 12-month period. RESULTS: Children most frequently set goals to enhance their knowledge of mental illness, schooling, family connectedness and interpersonal skills. Parents most frequently set goals to improve their knowledge of mental health. Children recorded greatest goal achievement: in enhancing their mental health knowledge, community/social connectedness and accommodation needs. Parents recorded most goal progress in understanding developmental milestones of their children. CONCLUSIONS: Goal setting appears to be an important mechanism for assisting families with complex needs. Clinicians need to address the mental health literacy of families where a parent has a substance use problem and/or mental illness.

Medullary pyramid thickness: The optimal cut-off value associated with the need for pyeloplasty in infants.

INTRODUCTION: The medullary pyramid compresses during the early phases of severe hydronephrosis and represents a promising ultrasound metric for the diagnosis and surveillance of PUJ obstruction. The aim of this study was to define the optimal cut-off value and utility of medullary pyramid thickness (MPT) associated with the need for pyeloplasty in infants being followed up for hydronephrosis. METHODS: A retrospective review was performed over a five-year period to identify patients that were under surveillance for hydronephrosis during infancy and underwent a MAG3 to monitor the possible need for pyeloplasty. Ultrasound images were retrospectively reviewed to measure the MPT of the affected kidney in a blinded fashion. The primary outcome measure was subsequent requirement for pyeloplasty before three years of age. The Mann-Whitney U Test was used to determine statistically significant differences in the minimum MPT between the infant group requiring pyeloplasty and the non-operative group. Receiver operating characteristic analysis was performed to determine the optimal cut-off value associated with the requirement for pyeloplasty. RESULTS: A total of 63 patient cases were included, of which 45 underwent pyeloplasty (70%). A significant difference was found in the median MPT measurement between the pyeloplasty and non-operative groups (1.7 mm vs. 3.8 mm, p < 0.001). The optimal cut-off value of MPT associated with pyeloplasty was 3.4 mm. An MPT threshold of ≤3.4 mm conferred a sensitivity of 98%, specificity of 63%, positive predictive value of 86%, and negative predictive value of 92%. CONCLUSION: Thinning of the medullary pyramid is an important ultrasound sign of parenchymal deterioration in high-grade hydronephrosis. An optimal MPT cut-off value of ≤3.4 mm is associated with subsequent pyeloplasty in infants. MPT should be considered in future studies addressing the diagnosis and surveillance of PUJ obstruction.

Practices to support co-design processes: A case-study of co-designing a program for children with parents with a mental health problem in the Austrian region of Tyrol.

Forms of collaborative knowledge production, such as community-academic partnerships (CAP), have been increasingly used in health care. However, instructions on how to deliver such processes are lacking. We aim to identify practice ingredients for one element within a CAP, a 6-month co-design process, during which 26 community- and 13 research-partners collaboratively designed an intervention programme for children whose parent have a mental illness. Using 22 published facilitating and hindering factors for CAP as the analytical framework, eight community-partners reflected on the activities which took place during the co-design process. From a qualitative content analysis of the data, we distilled essential practices for each CAP factor. Ten community- and eight research-partners revised the results and co-authored this article. We identified 36 practices across the 22 CAP facilitating or hindering factors. Most practices address more than one factor. Many practices relate to workshop design, facilitation methods, and relationship building. Most practices were identified for facilitating 'trust among partners', 'shared visions, goals and/or missions', 'effective/frequent communication', and 'well-structured meetings'. Fewer practices were observed for 'effective conflict resolution', 'positive community impact' and for avoiding 'excessive funding pressure/control struggles' and 'high burden of activities'. Co-designing a programme for mental healthcare is a challenging process that requires skills in process management and communication. We provide practice steps for delivering co-design activities. However, practitioners may have to adapt them to different cultural contexts. Further research is needed to analyse whether co-writing with community-partners results in a better research output and benefits for participants.

Sequential quantitative X-ray elemental imaging of frozen-hydrated and freeze-dried biological bulk samples in the SEM.

Planed frozen-hydrated (FH) bulk biological samples of chicken retina were analysed by X-ray elemental imaging in a scanning electron microscope and reanalysed after freeze-drying in the microscope column. Sequential elemental imaging of the same bulk sample in this way provides improved information on element distributions. There was no evidence of element redistribution during the freeze-drying process. Quantitative elemental images were obtained and interpreted to deduce relative and absolute element concentrations in different regions of the retina. Water concentrations were determined from the difference in oxygen concentrations at 15 kV and 5 kV in FH and freeze-dried (FD) samples, respectively. Two accelerating voltages were used to maintain similar X-ray excitation volumes. Water concentrations were also estimated by relating measured oxygen concentration in FH samples to the concentration of oxygen in solutions of a generalized protein in water and by comparing concentrations of phosphorous or sulphur in the FH and FD states.

The family-focused mental health practice questionnaire.

It is estimated that 1 in 5 children have a parent with a mental illness, and studies have shown that such children are more likely to develop mental health problems when compared with their peers. Research has demonstrated the benefits of mental health clinician family-sensitive practice to both parents and their children; however, a measure of clinician practice is not available. The psychometric properties of a questionnaire measuring family-focused practice in the psychiatric setting are reported here. There were 307 public adult mental health worker participants, predominantly from the nursing profession and working full time. Principal component analysis highlighted 14 subscales that summarize 49 items reflecting organizational and worker factors, such as skill/knowledge about the impact of parental mental illness on children and worker confidence. Subscales are discussed in relation to the literature and psychiatric policy. The measure appears a useful tool for evaluation, benchmarking for training and organizational improvement, and ultimately, for increasing quality services to parents, families, and particularly children associated with psychiatric services.

Engaging with, and understanding children whose parents have a dual diagnosis.

BACKGROUND: The perspective of children whose parents have a mental health and a substance use disorder (dual diagnosis) are rarely considered in either research or clinical practice. This study sought to (i) identify the issues when engaging children whose parents have a dual diagnosis into research, and (ii) present their needs and preferred supports. METHOD: Semi-structured, qualitative interviews were conducted with 12 children whose parent had a dual diagnosis. Analyses involved thematic analysis, inter-rater reliability and respondent validation. RESULTS: Building trust with parents was crucial to gain access to children. Children described the importance of family, the secrecy around their parent's substance abuse, and various maladaptive coping strategies. Children requested more positive times in their families and specific support for their parent's substance abuse. CONCLUSION: The primacy of family in the child's life is highlighted. The need to acknowledge and work with the individual needs of children and parents, as well as family dynamics, is indicated.

Integrating home treatment into the Austrian child and adolescent mental health care system: an implementation science perspective.

BACKGROUND: In Austria, similar to other countries, health care planners have considered implementing home treatment (HT) programs for children and adolescents with mental health problems. However, introducing any new service innovation into the complex environment of the child and adolescent mental health care system requires context and implementation issues to be taken into account in advance. METHODS: We identified implementation themes from international HT models and developed a questionnaire with open-ended implementation-related questions for Austrian professionals. We analysed the qualitative results alongside the domains in the Context and Implementation of Complex Interventions (CICI) framework to detect key implementation challenges for HT in Austria. RESULTS: We found six implementation themes in international HT models, which formed the basis for development of the questionnaire. Within the qualitative data from ten Austrian professionals who responded to the questionnaire, we identified implementation challenges in all eight context and all four implementation domains of the CICI framework. CONCLUSIONS: Key implementation challenges detected highlight the need to address the fit of HT within existing sociocultural norms and limited available human resources. Regional context-specific solutions need to be found on how to embed this new element best into the existing provider and financing structures. This calls for monitoring and evaluation alongside implementation to support decision-making.

A Sustainability Model for Family-Focused Practice in Adult Mental Health Services.

BACKGROUND: Translating evidence-based practice to routine care is known to take significant time and effort. While many evidenced-based family-focused practices have been developed and piloted in the last 30 years, there is little evidence of sustained practice in Adult Mental Health Services. Moreover, many barriers have been identified at both the practitioner and organizational level, however sustainability of practice change is little understood. What is clear, is that sustained use of a new practice is dependent on more than individual practitioners' practice. DESIGN AND METHOD: Drawing on research on sustaining Let's Talk about Children in adult mental health services and in the field of implementation science, this article proposes a model for sustaining family focused practice in adult mental health services. SUSTAINABILITY MODEL FOR FAMILY-FOCUSED PRACTICE: An operational model developed from key elements for sustaining Let's Talk about Children identifies six action points for Adult Mental Health Services and their contexts to support the sustainability of family-focused practices. The model aims to support Services to take action in the complexity of real-world sustainability, providing action points for engaging with service users and practitioners, aligning intra-organizational activities, and the wider context. CONCLUSION: The model for sustaining family-focused practice draws attention to the importance of sustainability in this field. It provides a practical framework for program developers, implementers, adult mental health services and policy-makers to consider both the components that support the sustainability and their interconnection. The model could be built on to develop implementation guides and measures to support its application.