Periodic Reporting for period 5 - CAPRI (Children and Adolescents with PaRental mental Illness: Understanding the ‘who’ and ‘how’ of targeting interventions)
Période du rapport: 2022-10-01 au 2023-09-30
The number of children and adolescents living with parental mental illness (CAPRI) relied on evidence from small clinical samples or population samples. Beyond the need for reliable prevalence estimates, little information was available about who those children are, or the families in which they live. Early literature focussed exclusively on risk of CAPRI developing schizophrenia or other mental disorders, rather than other aspects of their lives. Given that most CAPRI will NOT develop mental illness, we needed to pick out which CAPRI needed help most, and when. We combined innovative epidemiology in extant high quality data sources across three different countries; by triangulating data from primary and secondary care, and from high-quality population-based surveys; by linking epidemiology with clinician-dependent measures of infant development and novel, infant neuroimaging measuring neural responses to vocal and non-vocal stimuli. CAPRI are identifiable at conception, or childhood. A key goal was to develop a method that could be used in routine clinical assessment to inform care pathways of at-risk children.
We wanted to provide an enriched narrative about these children’s lives: risks, unmet needs, identify sources of resilience and which children, parents and families needed what types of intervention, and when. We wanted to inform future clinical practice and seek a way to assess children identified at birth as at-risk, monitoring them for likelihood of expressing risk in future. We chose educational attainment as a risk marker to explore ways in which this was affected in CAPRI. We aimed to develop a clinical risk algorithm which combined work on CAPRI life outcomes with clinical development and imaging data. With more precise prevalence estimates over time, this was designed to inform policymakers about the extent of likely unmet need; to assist in allocation of resources for services in the UK; and, importantly, help clinicians and families make decisions about what they might do to mitigate future risks.
We wanted to provide an enriched narrative about these children’s lives: risks, unmet needs, identify sources of resilience and which children, parents and families needed what types of intervention, and when. We wanted to inform future clinical practice and seek a way to assess children identified at birth as at-risk, monitoring them for likelihood of expressing risk in future. We chose educational attainment as a risk marker to explore ways in which this was affected in CAPRI. We aimed to develop a clinical risk algorithm which combined work on CAPRI life outcomes with clinical development and imaging data. With more precise prevalence estimates over time, this was designed to inform policymakers about the extent of likely unmet need; to assist in allocation of resources for services in the UK; and, importantly, help clinicians and families make decisions about what they might do to mitigate future risks.
WP 1- PREVALENCE, FERTILITY, INCOME INEQUALITY
•1 in 4 children in the UK lives with a mother with any mental illness; and in Sweden,1 in 7 live with a parent with a severe mental illness.
•In both datasets, we show that the proportion of CAPRI is higher in adolescence, providing evidence that the proportion is increasing over time.
•Children with a parent with a mental illness are almost three times more likely to be in a household where both parents are unemployed; 21% live in families in the lowest quintile of income; they are more likely to live in deprivation and have teenage parents.
•The effect becoming a mother has on mental illness is much stronger for teenagers than older women and they are the highest risk group for developing postnatal depression.
•Teenage mothers should be targeted for preventive interventions for postnatal mental illness.
•There is a need to understand how multiple adversities influence CAPRI outcomes independently of parental mental illness and to disentangle genetic from other risks that are modifiable.
•People with mental disorders continue to demonstrate reduced fertility
•In the UK, the switch in prescribing from 1st to 2nd gen antipsychotics did not appear to improve fertility in women with psychosis, contrary to popular understanding of the benefits of using 2nd gen drugs.
• Mental illness is associated with lower fertility. In teenage women, mental illness is associated with significantly higher fertility. The well-recognised reduction in fertility has not changed with introduction of so-called prolactin-sparing agents, important in treatment planning given the significant effects of these medications.
• Higher rates of maternal mental illness observed in the UK compared to Sweden may result from greater income inequality in the UK and also by the type of healthcare data accessed in the UK (primary care) compared to Sweden (secondary care). CAPRI living in Sweden were more likely to live in families in the lowest income quintile receiving benefits and separated from one/both parents. Swedish CAPRI where there was parental psychosis or addiction were living in the most adverse circumstances.
WP 2: RISKS AND RESILIENCE FOR CAPRI
• A systematic review of the association between parental mental illness and physical health in offspring showed CAPRI have more physical conditions than children of healthy parents. Specifically: atopic disorders, infections, injuries; and, in lower/middle income countries, diarrhoea and vomiting. Little information was available about risks associated with paternal mental health or other mental illnesses beyond the perinatal period or apart from mood disorder.
• Detailed Swedish analyses of childhood injuries associated with parental mental illness showed significantly increased risk particularly in the first year of a child’s life and in offspring with parental common (depression) rather than severe (schizophrenia) mental illness. Risks were significantly higher where there was maternal vs paternal mental illness.
• In the UK, the association between CAPRI and atopy varied. We found a specific association between maternal depression and atopic disease, that was not evident among other maternal disorders. A reduced risk of allergy among CAPRI exposed to maternal addiction suggesting early life mechanisms that might increase resilience to allergy among some CAPRI associated with microbiome exposures.
•Childhood cancer among CAPRI increased in those exposed to maternal depression only, and CAPRI exposed to maternal schizophrenia had a reduced risk. We discovered an increased risk of cancer among children exposed to antibiotics in pregnancy.
• UK and WA data demonstrated that healthcare use in CAPRI was greater; particularly in CAPRI with maternal mental illness. CAPRI are seen more in all care settings compared with children of well mothers.
• In the UK, every healthcare contact has been costed indicating £0.5bn annual excess to the NHS from additional use of services by CAPRI.
•The C-19 pandemic began and we included examination of vaccination uptake for CAPRI. Maternal mental illness contributes significantly to missed childhood vaccinations in the UK and given there are more vaccine programmes e.g. HPV, these findings are concerning.
• Poorer uptake of preventive interventions are consistent with our previous work. There is an imperative to develop tailored, targeted prevention strategies for families with mental illness and for CAPRI.
•In all cohorts, we report a gradient of poverty, with the poorest children at highest risk of being CAPRI.
•In the UK, we reviewed the prevalence of self-harm in the perinatal period as self-harm is elevated among women with mental illness and is associated with a 50-fold increase in suicide, conferring additional adversity to CAPRI. Overall, pregnancy halved self-harm risk, with largest reductions in risk observed among women with a history of mental illness. This was not observed among young mothers identifying a specific at-risk group of CAPRI aged 0 -1 years.
WP3:CAPRI-VOC
•Successful submissions to the relevant UK regulatory authorities and establishment of an Ethics Board.
•16 NHS sites recruited 54 SMI and 29 controls. We were on target to reach 150 CAPRI, however the study was paused /closed due to the pandemic.
•1 in 4 children in the UK lives with a mother with any mental illness; and in Sweden,1 in 7 live with a parent with a severe mental illness.
•In both datasets, we show that the proportion of CAPRI is higher in adolescence, providing evidence that the proportion is increasing over time.
•Children with a parent with a mental illness are almost three times more likely to be in a household where both parents are unemployed; 21% live in families in the lowest quintile of income; they are more likely to live in deprivation and have teenage parents.
•The effect becoming a mother has on mental illness is much stronger for teenagers than older women and they are the highest risk group for developing postnatal depression.
•Teenage mothers should be targeted for preventive interventions for postnatal mental illness.
•There is a need to understand how multiple adversities influence CAPRI outcomes independently of parental mental illness and to disentangle genetic from other risks that are modifiable.
•People with mental disorders continue to demonstrate reduced fertility
•In the UK, the switch in prescribing from 1st to 2nd gen antipsychotics did not appear to improve fertility in women with psychosis, contrary to popular understanding of the benefits of using 2nd gen drugs.
• Mental illness is associated with lower fertility. In teenage women, mental illness is associated with significantly higher fertility. The well-recognised reduction in fertility has not changed with introduction of so-called prolactin-sparing agents, important in treatment planning given the significant effects of these medications.
• Higher rates of maternal mental illness observed in the UK compared to Sweden may result from greater income inequality in the UK and also by the type of healthcare data accessed in the UK (primary care) compared to Sweden (secondary care). CAPRI living in Sweden were more likely to live in families in the lowest income quintile receiving benefits and separated from one/both parents. Swedish CAPRI where there was parental psychosis or addiction were living in the most adverse circumstances.
WP 2: RISKS AND RESILIENCE FOR CAPRI
• A systematic review of the association between parental mental illness and physical health in offspring showed CAPRI have more physical conditions than children of healthy parents. Specifically: atopic disorders, infections, injuries; and, in lower/middle income countries, diarrhoea and vomiting. Little information was available about risks associated with paternal mental health or other mental illnesses beyond the perinatal period or apart from mood disorder.
• Detailed Swedish analyses of childhood injuries associated with parental mental illness showed significantly increased risk particularly in the first year of a child’s life and in offspring with parental common (depression) rather than severe (schizophrenia) mental illness. Risks were significantly higher where there was maternal vs paternal mental illness.
• In the UK, the association between CAPRI and atopy varied. We found a specific association between maternal depression and atopic disease, that was not evident among other maternal disorders. A reduced risk of allergy among CAPRI exposed to maternal addiction suggesting early life mechanisms that might increase resilience to allergy among some CAPRI associated with microbiome exposures.
•Childhood cancer among CAPRI increased in those exposed to maternal depression only, and CAPRI exposed to maternal schizophrenia had a reduced risk. We discovered an increased risk of cancer among children exposed to antibiotics in pregnancy.
• UK and WA data demonstrated that healthcare use in CAPRI was greater; particularly in CAPRI with maternal mental illness. CAPRI are seen more in all care settings compared with children of well mothers.
• In the UK, every healthcare contact has been costed indicating £0.5bn annual excess to the NHS from additional use of services by CAPRI.
•The C-19 pandemic began and we included examination of vaccination uptake for CAPRI. Maternal mental illness contributes significantly to missed childhood vaccinations in the UK and given there are more vaccine programmes e.g. HPV, these findings are concerning.
• Poorer uptake of preventive interventions are consistent with our previous work. There is an imperative to develop tailored, targeted prevention strategies for families with mental illness and for CAPRI.
•In all cohorts, we report a gradient of poverty, with the poorest children at highest risk of being CAPRI.
•In the UK, we reviewed the prevalence of self-harm in the perinatal period as self-harm is elevated among women with mental illness and is associated with a 50-fold increase in suicide, conferring additional adversity to CAPRI. Overall, pregnancy halved self-harm risk, with largest reductions in risk observed among women with a history of mental illness. This was not observed among young mothers identifying a specific at-risk group of CAPRI aged 0 -1 years.
WP3:CAPRI-VOC
•Successful submissions to the relevant UK regulatory authorities and establishment of an Ethics Board.
•16 NHS sites recruited 54 SMI and 29 controls. We were on target to reach 150 CAPRI, however the study was paused /closed due to the pandemic.
The project is now at its conclusion and further research in this important area will continue.