The mental health of The mental health of parents and their parents and their

children children – a GP perspective– a GP perspective

Professor Colin BradleyProfessor Colin Bradley

Professor of General PracticeProfessor of General Practice

University College CorkUniversity College Cork

for the Patients. Parents. People. conference, Barnardos, Croke Park, 19th June 2014

Talk OutlineTalk Outline

• Psychological and social problems Psychological and social problems faced by parentsfaced by parents

• Medical responses to theseMedical responses to these• PharmacologicalPharmacological• Non pharmacologicalNon pharmacological

• Mental ill health in childrenMental ill health in children• DiagnosisDiagnosis• ManagementManagement

• Community based family supports Community based family supports • Inter agency workingInter agency working

• Confidentiality issuesConfidentiality issues

Psychological and social Psychological and social problems problems

faced by parentsfaced by parents• PovertyPoverty• Educational disadvantageEducational disadvantage• Lack of opportunityLack of opportunity• UnemploymentUnemployment• Unhealthy life-stylesUnhealthy life-styles• AnxietyAnxiety• DepressionDepression• Substance misuseSubstance misuse• Intra-familial violence and abuseIntra-familial violence and abuse

Impact on children of Impact on children of parental mental ill healthparental mental ill health

• Michael Rutter 1966 – Children of sick Michael Rutter 1966 – Children of sick parentsparents

• Paul Ramchandani & Alan Stein 2003 Paul Ramchandani & Alan Stein 2003 – Impact of parental psychiatric – Impact of parental psychiatric disorder on children (BMJ)disorder on children (BMJ)

• SCIE (UK, 2009) Think child, think SCIE (UK, 2009) Think child, think parent, think familyparent, think family

• Justine Horgan for NCAD (Ireland, Justine Horgan for NCAD (Ireland, 2011) Parental Substance Misuse: 2011) Parental Substance Misuse: Addressing its Impact on ChildrenAddressing its Impact on Children

““Man hands on misery to man, Man hands on misery to man,

It deepens like a coastal shelfIt deepens like a coastal shelf

Get out as early as you can and Get out as early as you can and

Don’t have any kids yourself”Don’t have any kids yourself”

This Be The Verse, LarkinThis Be The Verse, Larkin

The Medical ResponseThe Medical Response

• The medical modelThe medical model• History, examination, History, examination, investigationinvestigation DiagnosisDiagnosis

• Diagnosis Diagnosis TreatmentTreatment• TreatmentTreatment

• PharmacologicalPharmacological• Non- pharmacologicalNon- pharmacological

• Very individually focussedVery individually focussed• have you any children? – not usually have you any children? – not usually

askedasked

Pharmacological Pharmacological Treatments for mental ill Treatments for mental ill

healthhealth• BenzodiazepinesBenzodiazepines• Non-benzodiazpine hypnotics (e.g. Non-benzodiazpine hypnotics (e.g.

Stilnoct®)Stilnoct®)• Anti-depressantsAnti-depressants

• Selective serotonin reuptake inhibitors (e.g. Selective serotonin reuptake inhibitors (e.g. Prozac®)Prozac®)

• Others e.g. TCAs, SNRI, MAOIs etc.Others e.g. TCAs, SNRI, MAOIs etc.

• Anti-convulsants e.g. Lyrica®Anti-convulsants e.g. Lyrica®• Anti-psychotics e.g Seroquel®Anti-psychotics e.g Seroquel®

Non-pharmacological Non-pharmacological treatmentstreatments

• Cognitive behaviour therapyCognitive behaviour therapy• Skills based trainingSkills based training• CounsellingCounselling• Supportive psychotherapySupportive psychotherapy• PsychoanalysisPsychoanalysis• Stimulus controlStimulus control• Sleep hygieneSleep hygiene• ExerciseExercise• Complementary treatments Complementary treatments

• relaxation techniquesrelaxation techniques• physical manipulation techniquesphysical manipulation techniques

Problems with Problems with non-pharmacological non-pharmacological

treatmentstreatments

• Require skilled personnel (who are Require skilled personnel (who are in relatively short supply)in relatively short supply)

• Require patient commitmentRequire patient commitment• Time consumingTime consuming• Slow to workSlow to work• Expensive (seemingly)Expensive (seemingly)• Not much good for social problemsNot much good for social problems

Problems with Problems with pharmacological pharmacological

treatmentstreatments

• Require skilled personnel (i.e. doctors Require skilled personnel (i.e. doctors but they are relatively available)but they are relatively available)

• Require patient commitment (but Require patient commitment (but only to take the pills)only to take the pills)

• Safer ones are slower to work & Safer ones are slower to work & possibly less effectivepossibly less effective

• Safer ones are more expensive (but Safer ones are more expensive (but are still sometimes deemed are still sometimes deemed affordable)affordable)

• Not much good for social problemsNot much good for social problems

More problems with More problems with pharmacological treatments pharmacological treatments

(esp benzo’s)(esp benzo’s)• DependenceDependence• ToleranceTolerance• Withdrawal Withdrawal

syndromesyndrome• Drug-drug Drug-drug

interactionsinteractions• esp. other esp. other

psychotropicspsychotropics• Cross dependence Cross dependence

esp with alcoholesp with alcohol• Street use Street use

• criminalitycriminality• Paradoxical effectsParadoxical effects

• DrowsinessDrowsiness• Cognitive impairmentCognitive impairment• AtaxiaAtaxia• DizzinessDizziness• Psychomotor Psychomotor

retardationretardation• Increased accidents/ Increased accidents/

fallsfalls• ApathyApathy• ConstipationConstipation

Mental ill health in Mental ill health in childrenchildren

- diagnosis- diagnosis• AnxietyAnxiety

• PhobiasPhobias• Separation anxietySeparation anxiety

• ADHDADHD• Developmental disordersDevelopmental disorders

• Autism spectrum disorderAutism spectrum disorder• DepressionDepression• Substance misuseSubstance misuse• PsychosesPsychoses• Behavioural problems – conduct Behavioural problems – conduct

disordersdisorders• Eating disordersEating disorders

Mental ill health in Mental ill health in childrenchildren

- management- management• Non pharmacological treatmentsNon pharmacological treatments• Pharmacological treatmentsPharmacological treatments• Treatment in the child’s contextTreatment in the child’s context

• Home (“the child is a barometer of the Home (“the child is a barometer of the home”)home”)

• SchoolSchool

• Management of co-existing/ Management of co-existing/ underpinning parental mental ill healthunderpinning parental mental ill health• very, very tricky!!very, very tricky!!

Community based Community based family supportfamily support

• Tusla – Child and Family AgencyTusla – Child and Family Agency• Family and Community SupportFamily and Community Support

•Family resource centres (107)Family resource centres (107)•Psychology servicesPsychology services•Early years servicesEarly years services

• Voluntary sectorVoluntary sector• BarnardosBarnardos• ISPCCISPCC• Specific focus groups – COPE, Autism Specific focus groups – COPE, Autism

Action, Down’s Syndrome IrelandAction, Down’s Syndrome Ireland

Inter-agency workingInter-agency working• We all believe in it BUT we don’t always We all believe in it BUT we don’t always

do itdo it• Barriers for GPsBarriers for GPs

• Concerns re CONFIDENTIALITY – lack of trustConcerns re CONFIDENTIALITY – lack of trust• Too many patients, too little timeToo many patients, too little time• Too many agenciesToo many agencies• Too many different people (who change all the Too many different people (who change all the

time)time)• Meetings are difficult to attend (time, venue Meetings are difficult to attend (time, venue

etc.)etc.)• Meetings are not always fruitful (from our Meetings are not always fruitful (from our

viewpoint)viewpoint)

Happy and unhappy Happy and unhappy familiesfamilies

Happy families Happy families are all alike; are all alike; each unhappy each unhappy family is family is unhappy in its unhappy in its own way. own way.

Anna Karenina,Anna Karenina, Tolstoy