Family Talk versus usual services in improving child and family psychosocial functioning in families with parental mental illness: a randomised controlled trial and cost analysis.

Background: Parental mental illness (PMI) is common and places children at high risk of developing psychological disorders. Family Talk (FT) is a well-known, whole-family, 7-session intervention designed to reduce the risk of transgenerational psychopathology. However, very few larger-scale evaluations of FT (across only a limited number of settings) have been conducted to date while there have been no cost analyses. This study aimed to assess the effectiveness and costs of delivering FT in improving child and family psychosocial functioning in families with PMI within routine mental health settings. Methods: A total of 83 families with PMI, with children aged 5-18 years, were randomly assigned on a 2:1 ratio to receive either the FT intervention (n=55 families) or usual services (n=28 families) across 10 adult, child and primary care mental health sites in Ireland. Parental disorders included anxiety/depression (57%), Bipolar Disorder (20%), Borderline Personality Disorder (12%), Post-Traumatic Stress Disorder (8%) and psychosis (2%). Detailed assessments with parents were conducted at baseline and 6-month follow up. Results: FT led to significant improvements in family functioning and child behaviour at 6-month follow up when compared to usual services, with medium effect sizes indicated. Parent participants with lower mental health literacy at baseline also showed significant post-intervention improvements. Those parents with less severe mental illness at baseline, and families with more partner and economic supports, reported additional significant post-intervention improvements in child depression/anxiety and parental mental health symptoms. The cost of FT amounted to €761.50 per family, although this decreased to €415.31 when recurring costs only were included. Conclusion: The findings from this study, which was conducted within the context of a national programme to introduce family-focused practice in Ireland, demonstrate that FT is a low-cost intervention that improved child and family psychosocial functioning across different mental health disorders within routine adult, child and primary care mental health services. The findings contribute to the growing evidence base for FT, and provide a robust basis to inform practice and policy development for families with parental mental illness both in Ireland and elsewhere. Clinical trial registration: https://www.isrctn.com/ISRCTN13365858, identifier ISRCTN13365858.

The Family Talk Programme in Ireland: A Qualitative Analysis of the Experiences of Families With Parental Mental Illness.

Background: Parental mental illness is common, costly, can lead to children developing mental disorders and impaired lifetime outcomes, and places a substantial burden on caregiving partners. Family Talk (FT) is a widely implemented, 7-session, whole-family programme, with promising evidence of effectiveness in targeting the intergenerational transmission of mental illness. However, to date, very little qualitative research of family experiences of FT has been undertaken. The objectives of this study were to: (1) investigate the experiences of families attending FT; and (2) explore the key facilitators and barriers to engagement in mainstream mental health settings. Methods: This study was nested within a randomised controlled trial (RCT) of Family Talk [N = 86 families (139 parents, 221 children)] implemented in 15 adult, child and primary care mental health sites in Ireland. Semi-structured interviews were conducted with a purposive sample of 45 participants, including 23 parents with mental illness (PMI), 7 partners and 15 children/young people aged 9 to 18 years. Interview data were transcribed verbatim and analysed using constructivist grounded theory. Results: Over two thirds of families across sites reported substantial benefits from participation in FT, including reduced stigma, giving children and partners a voice, increased service-user confidence, and improved family communication/relationships. Key facilitators identified by families included: programme delivery by a competent, non-judgmental clinician; the whole-family approach; and family readiness to engage. Barriers to engagement included stigma, family crises/relapse, service constraints, impact of COVID-19, and a need for further child, family and follow-up sessions/supports. Conclusion: This study is the first qualitative analysis of family experiences of FT to be conducted within the context of an RCT and national programme to introduce family-focused practise for families with PMI. The findings illustrate that FT is beneficial across cultural/policy contexts, different mental disorders and can be implemented across adult and child mental health settings, including children with existing mental health challenges. Key barriers and facilitators to implementation were identified by families, all of which should help to inform the future implementation of FT, and other similar interventions, both in Ireland and elsewhere.

A Family-Focused Intervention for Parental Mental Illness: A Practitioner Perspective.

Background: Parental mental illness (PMI) is common and can lead to children developing mental disorders. Family Talk (FT) is a well-known and widely implemented intervention designed to reduce the risk of transgenerational psychopathology. However, given the research to practise "gap," very little qualitative research, to date, has investigated practitioner experiences in implementing FT. This study aimed to explore the practitioner-perceived barriers and facilitators to the implementation and sustainability of FT within mainstream mental health settings. Methods: This qualitative study was nested within a randomised controlled trial (RCT) of Family Talk [N = 86 families (139 parents, 221 children)] within 15 adult (AMHS), child (CAMHS), primary care mental health, and child protection sites in Ireland. Semi-structured interviews and focus groups were undertaken with a purposive sample of clinicians (n = 31) and managers (n = 10), based on their experiences of implementing FT. Interview data were transcribed verbatim, analysed using constructivist grounded theory, and informed by Fixsen's implementation science framework. Results: Service providers highlighted a number of benefits for approximately two thirds of families across different diagnoses and mental health settings (AMHS/CAMHS/primary care). Sites varied in their capacity to embed FT, with key enablers identified as acquiring managerial and organisational support, building clinician skill, and establishing interagency collaboration. Implementation challenges included: recruitment difficulties, stresses in working with multiply-disadvantaged families, disruption in delivery due to the COVID-19 global pandemic, and sustainability concerns (e.g., perceived fit of FT with organisational remit/capacity, systemic and cultural barriers to change). Conclusion: This study is only the second qualitative study ever conducted to explore practitioner experiences in implementing FT, and the first conducted within the context of an RCT and national research programme to introduce family-focused practise (FFP) for families living with PMI. The findings illuminate the successes and complexities of implementing FFP in a country without a "think family" infrastructure, whilst highlighting a number of important generalisable lessons for the implementation of FT, and other similar interventions, elsewhere.

Covid-19 and Families With Parental Mental Illness: Crisis and Opportunity.

The COVID-19 emergency has affected us all, but not equally. Families where parents have mental illness (PMI) are potentially at increased risk, but little is known about how they or their support services managed under lockdown/restrictions. We harnessed our existing partnerships with adult and child mental health services in the Republic of Ireland (RoI) and Northern Ireland (NI) to investigate the qualitative experiences of service users and families in coping during the first COVID-19 lockdown (March-May 2020), and how services were supporting them. Semi-structured phone/online interviews were conducted with 22 clinicians/managers (12 from RoI; 10 from NI) who provided information from their caseloads (~155 families with PMI). Sixteen family members (10 from RoI, 6 from NI) were also interviewed. Data were analysed using standard thematic analysis. Sixty percent of families reported improved mental health, primarily due to respite from daily stresses and the "normalisation" of mental distress in the general population. Approximately 30%, typically with more severe/enduring mental illness, reported additional challenges, and mental distress including: unmanageable child behaviours; fear of relapse/hospitalisation; financial difficulties; absence of child care; and a lack of routines. Service provision varied considerably across regions. The experiences within this case study highlight unique opportunities to address the multiple stresses of pre-emergency daily living. We also highlight how mental health services and governments might become more "pandemic ready" to more effectively support vulnerable families, including addressing service overload issues, optimising the use of digital technologies, and providing in-person contact and social supports where required.