BMJ 2020;369:m1317 doi: 10.1136/bmj.
m1317 (Published 8 April 2020)
Editorials
Injuries in the children of parents living with mental
illness
Excess risk is greatest in the first year of life
Antonis A Kousoulis director for England and Wales
Mental Health Foundation, London SE1 2SX, UK
If health and social care systems are to rise to the challenge of
reducing the prevalence of mental health problems they need
to follow holistic and preventative measures, an approach
promised in the national health service long term plan in the
United Kingdom.1 Holistic measures mean that attention should
fall not only on the individual with a diagnosis of mental illness,
but also on the family environment and the wider social contexts
in which people are born, grow, live, and age.
In a linked study, Nevriana and colleagues (doi:10.1136/bmj.
m853) report a large analysis of preventable injuries in children
whose parents were living with mental illness.2 This
retrospective cohort study used national Swedish longitudinal
health and administrative registers to examine associations
between all types of maternal and paternal mental illness and
risk of injuries from birth to adolescence. The study population
was more than 1.5 million offspring born between 1996 and
2011. The analysis shows the value and limitations of studies
that use big datasets.
On the one hand such analyses help to strengthen our
understanding of healthcare delivery and patient outcomes,
provide datasets that prompt many further research questions,
and support the development of evidence based personalised
medicine.3 This real world evidence is now increasingly being
used to inform clinical practice and guidelines.4
The authors report that children of parents who experienced
mental health problems (especially depression and substance
misuse) were at a higher risk of injury throughout their
childhood and adolescence than those of parents with no
diagnosis of mental illness. The greatest risk recorded was
during the first year of life (adjusted rate ratio at age 0-1 for the
overall association between any parental mental illness that has
been recorded in the registers and injuries 1.30, 95% confidence
interval 1.26 to 1.33), linked in particular to violence, poisoning,
and burns. These findings are in line with previous studies
conducted elsewhere, address some of the previous limitations
in the evidence base, and should bring extra weight to inform
preventative practice.
On the other hand, observational studies like this have no easy
way of capturing the wider context of people’s lives, which
akousoulis@mentalhealth.org.uk
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EDITORIALS
affects their behaviours and outcomes. Although the authors
have adjusted for a range of individual level socioeconomic
factors in their analyses, they acknowledge that these are
unlikely to be an entirely accurate reflection of those families’
environments. For example, it is well recorded that there are
structural risk factors for violence at community and societal
levels (such as experiencing toxic stress, living in impoverished
neighbourhoods, or experiencing racism) that are more
fundamental than a diagnosis of mental illness.5 Indeed the
prevalence of both mental illness and violence is distributed
according to a social gradient, which means that these problems
are already more common further down the social ladder.6
Families where parental mental illness exists are more likely to
live in less affluent, more violent, and potentially more
dangerous areas with poor housing conditions, which could
contribute to the excess risk of injuries seen in these children.7
Thus we are led yet again to the million dollar question on
violence and mental health. How can we use data and evidence
that are uncomfortable, and have in the past been misunderstood,
to inform policy and practice that protects those who are most
vulnerable? It is a difficult balance to strike. If we are to
implement measures and care that are more likely to be
successful in these families, we need greater understanding and
action at many levels. Doctors and practitioners should
understand that a one size fits all approach does not work in
public health. For people who are at high risk or live very
challenging lives, simply increasing access to universal
programmes is often not effective. Targeted solutions should
be designed in coproduction with patients.8
Patients should be ready, with support, to offer their voice in
any safeguarding conversations. Discussing the strategies that
people living with mental illness feel might assist them in their
parenting role, and understanding which support networks are
helpful will add nuance to the data and could improve
outcomes.9 Additionally, societies everywhere must continue
the journey to reduce mental health stigma. The structural drivers
of mental illness are fundamental and shared across communities
globally.10
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BMJ 2020;369:m1317 doi: 10.1136/bmj.m1317 (Published 8 April 2020)
This study adds timely weight to what we already know about
the need for person centred and early interventions in mental
health. To achieve sustainable change we need to place the lived
experience of citizens at the core of research, decisions, and
interventions in mental health across sectors, disciplines, and
countries.
Competing interests: The BMJ has judged that there are no disqualifying financial
ties to commercial companies. The author declares no related conflicts of interest.
The BMJ policy on financial interests is here: https://www.bmj.com/sites/default/
files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf."
Provenance and peer review: Commissioned; not peer reviewed.
1 Kousoulis A, Goldie I. The window of opportunity to improve mental health is now open.
BMJ Opinion November 5, 2018; Available at: https://blogs.bmj.com/bmj/2018/11/05/the-
window-of-opportunity-in-public-mental-health-is-now-open/ (Accessed: March 25, 2020).
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 2 of 2
EDITORIALS
2 Nevriana A, Pierce M, Dalman C, etal . Association between maternal and paternal mental
illness and risk of injuries in children and adolescents: nationwide register based cohort
study in Sweden. BMJ 2020;369:m853.
3 Murdoch TB, Detsky AS. The inevitable application of big data to health care. JAMA
2013;309:1351-2. 10.1001/jama.2013.393 23549579
BMJ: first published as 10.1136/bmj.m1317 on 8 April 2020. Downloaded from http://www.bmj.com/ on 10 April 2020 by guest. Protected by copyright.
4 Oyinlola JO, Campbell J, Kousoulis AA. Is real world evidence influencing practice? A
systematic review of CPRD research in NICE guidances. BMC Health Serv Res
2016;16:299. 10.1186/s12913-016-1562-8 27456701
5 Farrington DP, Loeber R, Ttofi MM. Risk and protective factors for offending. In: Welsh
BC, Farrington DP, eds. The Oxford handbook of crime prevention. Oxford University
Press, 2012: 46-6910.1093/oxfordhb/9780195398823.001.0001.
6 Wilkinson RG, Pickett K. The inner level: how more equal societies reduce stress, restore
sanity and improve everybody’s wellbeing. Penguin Books, 2018.
7 McDaid S, Kousoulis A. Tackling social inequalities to reduce mental health problems:
how everyone can flourish equally. Mental Health Foundation, 2020.
8 Kousoulis A. Prevention and mental health. Mental Health Foundation, 2019.
9 Faulkner A, Carr S, Gould D, etal . ‘Dignity and respect’: An example of service user
leadership and co-production in mental health research. Health Expect 2019.31556244
10 Schomerus G, Schwahn C, Holzinger A, etal . Evolution of public attitudes about mental
illness: a systematic review and meta-analysis. Acta Psychiatr Scand 2012;125:440-52.
10.1111/j.1600-0447.2012.01826.x 22242976
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