In this podcast, Dr. Praveetha Patalay, Associate Professor for Institute of Education (IOE) at University College London, discusses data sets, the difference between mental health and mental health well-being and school-based interventions.
Praveetha also talks about her recent JCPP paper on ‘Prescribing measures: unintended negative consequences of mandating standardized mental health measurement’.
Do follow Dr. Praveetha Patalay on twitter @pravpatalay
Dr Praveetha Patalay is an Associate Professor based across the Centre for Longitudinal Studies at the IOE and at the MRC Unit for Lifelong Health and Ageing in the Faculty of Population Health Sciences, UCL. Her research focuses on the development, risk/protective factors and the consequences of mental ill-health and the ways in which we can reduce the stigma around mental illness and promote well-being. She uses large national studies, including the British birth cohorts, to investigate mental health through the life course and works on evaluations of school-based intervention programmes to support and promote young people’s mental health. Bio taken from UCL.
Interviewer: Hello, welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in Psychology. Today I’m interviewing Dr Praveetha Patalay, Associate Professor based across the Centre for Longitudinal Studies at the Institute of Social Research and the MRC Unit for Lifelong Health and Ageing at the Faculty of Population Health Sciences at UCL. Praveetha uses large population based datasets to investigate mental health through the life course and also works on evaluations of school based intervention programmes.
If you’re a fan of our In Conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Praveetha, thank you for joining me. Can you start with an introduction?
Dr. Praveetha Patalay: Well, my research interests primarily fall in the areas of developmental science and epidemiology with a focus on mental health. So my research focuses on mental health through the life course, health inequalities, and increasingly or more recently, the intersection between physical and mental health, or more broadly, as I like to just think of it as health. I am interested in how we can achieve better health and wellbeing through our lives and the universal interventions and structural changes that we might need. Or in other words, how do we better design our societies to achieve better health and well-being?
Interviewer: And what’s your background? What brought you into this field of work?
Dr. Praveetha Patalay: This is a tough one and I think lots of things come together here. So my first degree was a triple major that included psychology and political science, which I know is probably unusual but I studied in India and I studied after that developmental and social psychology for my master’s. So I’ve always thought studying developmental psychology is really important in the context of social psychology. So I wanted a master’s programme that did both.
If I did not become a researcher, I think I’d have been a schoolteacher. I’m inherently interested in children’s development and in schools as a context that is important for children. And I think all of these things come together in my research. And now I am based across two faculties in two very multidisciplinary departments at UCL. So I have a cross faculty post. So I work with economists, sociologists, anthropologists, demographers, but also on the other hand with psychiatrists, medics and clinical scientists. And I think this really multidisciplinary perspective is really valuable and informs a lot of the way I do research.
Interviewer: Praveetha, you use large national studies, including the British Birth Cohort, to investigate mental health through the life course. What key areas have arisen from this work, particularly in relation to mental health and younger people in the UK?
Dr. Praveetha Patalay: Yes. So as you said, I use lots of British Birth Cohort studies, but primarily I’ve used the youngest of the British Birth Cohorts, which is called the Millennium Cohort Study, which is a cohort of over 19,000 babies born at the turn of the century. I think lots of interesting findings related to mental health have come from investigating this cohort because it’s a really valuable, large population based study with mental health data right from childhood onwards. Some work that we did looked at, for example, mental ill health and mental wellbeing and how these are not necessarily the same thing and that they often have different correlates.
And because it’s such a rich multidisciplinary study, we were able to look at a wide range of things that are associated with mental ill health and wellbeing. So from individual characteristics, but family environment parental factors, but also the school environment, friends and even wider, so neighbourhood and environment, perceived neighbourhood safety and urban rural context and so on. So this really rich data set that is so multidisciplinary allows us to look at the varying factors that influence children’s mental health. And I think this particular research highlighted how important children’s well-being is as well and how often wellbeing is forgotten in the research on mental health when most mental health research isn’t really research about mental health disorders, and I think we often forget that children’s wellbeing is a part of their mental health.
Interviewer: You said that sometimes people fail to see the difference between mental ill health and mental wellbeing. Can you define the difference, specify it?
Dr. Praveetha Patalay: I know we don’t like drawing analogies with physical health, but one way to think about it is that you could have a chronic physical health condition like Type 1 diabetes or asthma, but still be very, very physically healthy and even be a competitive athlete, for example. I think… and I don’t see why mental health shouldn’t be at least considered in the same way. We recognise that at severe levels of difficulties wellbeing is very difficult, but wellbeing is about finding meaning in life, purpose, feeling like you’re doing the things you want to be doing and not being held back by your mental health difficulties. So I think it is genuinely possible for children to occasionally sometimes experience anxiety, sometimes serious mental health difficulties, but still live a life where they find meaning and purpose and achieve the things they would like to achieve, or are able to try the things they want to try and so on. So I think that’s where the distinction between wellbeing and good mental health.
Interviewer: You talked about the rich area, rich data that you’re using, are there any particular key aspects of it that you want to highlight?
Dr. Praveetha Patalay: Yes, that’s a really nice point. So I think the key thing to highlight really is that these data sets are available for all researchers to use. We share them through the UK data service. And all you really have to do if you’re a researcher is agree to obviously all the data protection and all of these aspects of it, but then you can use the data set. It costs no money; it doesn’t… there’s no barriers to access. So not only are there data that no individual researcher could ever collect on their own, the scale of them and the expense, but importantly they’re available to the entire research community to use. And we did some work looking at who uses Millennium Core Study data, and psychologists don’t use the data set very much at all…
Dr. Praveetha Patalay: … compared to lots of other disciplines. I think just want to flag that these data they’re amazing.
Interviewer: Your recent research has highlighted the increasing levels of mental health difficulties faced by the current generation of young people in the UK. Can you quantify this for us? What does this increase look like?
Dr. Praveetha Patalay: Yes. So in our research, we have mainly compared quite recent generations of young people, young people in the Millennium Cohort Study. So they will be around 19 years old now. But at the last data that we analysed closely was when they were 14, 15, around 2015, and we compared this to adolescents born ten years previously, so around 1990, 1991. And what we see is that there’s lots of changes in mental health and health related behaviours. And this is something that lots of other data sets corroborate. So we know from evidence, not just in the UK, but across other mainly rich industrialised nations that mental health difficulties are increasing in young people. But at the same time, we also see that other things are also changing, but not necessarily for the worse.
So, for example, a key thing for us has been understanding changes, but understanding changes across different health outcomes for young people. So where prevalence of internalising mental health is increasing and prevalence of things like self harming behaviour, other things are not increasing or decreasing even, like antisocial behaviours and substance use. So less young people smoke and drink alcohol and also start at older ages than was the case in prior generations. This leads to really interesting questions around how changing social norms around smoking and drinking, for example, affect the associations between these things because we know substance use and mental health are related, for example, but as their prevalence has changed in opposite directions, that leads to the question of are their associations also changing over time, and what we find in more recent work that we’ve done is that although smoking is decreasing, it seems to be decreasing at a faster rate in young people without mental health problems. In other words, mental health difficulties and smoking are more likely to co-occur now than they used to co-occur.
Find similar associations with BMI, so although higher BMIs are becoming more common in this cohort, so that’s another parallel trend over the last few decades, is that BMI is increasing in every generation compared to the generation before. But we find that higher BMIs and more mental health problems are now more likely to co-occur than it used to be the case. So although higher BMIs are becoming more widespread, and you might argue that you might find the opposite, so as more young people have higher BMIs the association with mental health might not be as strong, but actually we find the opposite, which is as… So, yes, I think there’s some really interesting implications from these generational differences in not only how any one thing changes affect whether it’s substance abuse or mental health difficulties, but also how these changes reflect their changing association.
And I think there’s really important implications of this also for public health interventions and how they’re planned because lots of the data we use in terms of what we think is important to how we approach public health interventions or public health messaging is based on evidence from prior decades because that’s how evidence works in science; we build evidence base and then eventually influence policy, but then by the time they influence policy, sometimes it might be the case that actually the associations we see or what the policy is based on may no longer be the case.
Interviewer: But there has been a large increase in certain types of mental health difficulties, those internalised mood disorders such as depression and also an increase in self-harming behaviour, and I wonder what you think it is that’s going on in contemporary society that accounts for this.
Dr. Praveetha Patalay: This is the million dollar question to be honest with you. I suspect it’s many things coming together. So I really, really doubt it will be one thing that explains the increases we see in mental health difficulties. It’s important to flag that it’s not something we only see in young people. So the increase in psychological distress, broadly speaking, is something we observe across all age groups, which makes sense because today’s young people are tomorrow’s parents, so I think we can expect to see the repercussions of the increases we’re seeing now in future years as well.
I guess the other thing to flag is that these increases in mental health come at a time when we live longer than ever before and are better off than ever as a society. So I think there’s some interesting things to unpack there about what it is about the way we design society that is leading to increased levels of distress. And so I am increasingly interested in thinking about the questions around how we structure our societies and what we value as a society and the role of this in our mental health. And I think there’s lots of interesting writing and reading out there just to highlight one thing. So the focus on GDP is something we have used to guide policy for many decades and how this does not seem to improve our wellbeing or mental health and doesn’t seem to improve the wellbeing of earth either as in the sense of lots of implications of constant focus on GDP growth or climate change and other things as well. So I think a future where we put human wellbeing at the heart of decision making and policy seems like it needs to be an inevitable next step if we are to avoid the increasing levels of distress we’re seeing now.
Important to flag again, that although I completely agree with the notion that our biology and our genes are very important at determining risk, and susceptibility to greater mental difficulties, that the rapid increases we’re seeing, generation on generation, are unlikely to be due to fundamental ways in which our genes or biology have changed because we don’t evolve that quickly if that makes sense. Really important to think about wider societal, structural, environmental things that might be at play and how they might be at play together. All of these things also don’t happen in isolation. So lots of things are probably coming together, but also interacting in interesting ways with each other.
Interviewer: I want to turn now to how you translate some of this research into clinical practice and into community based interventions. Can you tell me about your work evaluating school based intervention?
Dr. Praveetha Patalay: Yes, so most of the school based intervention programmes I’m involved in I support this work rather than lead it but most of it is related to thinking about earlier intervention and prevention. So, again, most of the way we deal with mental ill health is reactive. So we wait for children and young people, adults, to really struggle. And then when people meet a certain threshold for really struggling, they receive mental health services and it’s very hard in a system that has very little capacity at the moment to support everybody with difficulties. So it has become the case that you have to really be struggling and there’s often long waiting lists and so on.
So I think it’s really important to think about earlier intervention and prevention because mental health difficulties have such a large cost both to individuals, but also to society at large. And when we wait for difficulties to get really serious before we try to help individuals, we’ve lost the opportunity to have possibly helped when things were less dire and prevented them from getting so bad. So I think in this context, especially for young people, schools are really important because most young people go to school and in that sense they simultaneously have this universal aspect of being able to access most young people there, but also this destigmatising aspect as well because if you do universal stuff in schools, it is for everyone, so it removes the stigma that can be sometimes associated with mental health difficulties.
And thinking of a paper that got published a couple of weeks ago, we looked at data from over 600 primary schools and so this is survey data from around 25,000 young people in primary schools that is linked to school administrative data, so schools survey data and also to the national pupil database, and then to look at how mental health varies across schools. So we know, for example, for educational attainment, a substantial proportion of attainment is explained by the school level. So, 20 percent of children’s educational attainment, that variance is explained by clustering within schools. And similarly, we wanted to look at this for mental health and we find a substantial between school variation and mental health, so around five percent. And what we found really interesting is we looked… From the school census data we looked at characteristics of the school. So things like the school size but also the proportion of children in the school that come from a more socio-economically disadvantaged families, the proportion of girls and boys, proportion of ethnic minorities, and we also looked at school climate.
So school climate be more around things like children feeling like they have an adult they can trust in their school, children feeling like their school is a safe space. And what we find is the school composition factors don’t really explain much of the school variation in mental health, but the school climate explains around a third to a half of the between school differences we see in mental health, so it has enormous effect. It’s just that I know lots of the school based interventions tend to be very manualised approaches. So you have a manualised intervention with a name often involving payment to the developers and so on, and this is what we normally evaluate. And this might be the way, but equally I have the sense that what our findings show is that schools that make children feel safe and can trust an adult in their school are better environments for children’s mental health than schools where this is not the case and this is not a surprise. Intuitively it makes sense, but equally, it’s really interesting how much it matters. And not only are schools with better environments better for children’s mental health, but we know from lots of other research that they are better environments for learning and attainment and other educational outcomes that the government and Ofsted and things tend to care about more than mental health as well. These findings made us think about the importance of structured named interventions. I think there is scope for this and we have to carry on doing the research we do to evaluate them robustly. But equally, I think there is scope for valuing schools being good at what they do and encouraging and nurturing and safe climate for children. And I think it’s really important also to flag here that schools have a lot going on and… So there’s an increased government focus on schools as a context for children’s mental health, I think that is important, but equally it comes at a time where schools are not getting more funding or more resources to be able to do this.
We did a study across ten European countries to try and work out what schools do, what provision the schools have, what support do they have, what they think about providing mental health support to the children in their schools, and also asked around the barriers and facilitators so what they find are the biggest barriers to be able to providing the supports they want to. By and large, it’s not things that people think it will be. So people think, oh, yes, it’s around stigma and things but no, schools care about their child’s mental health, and the biggest barriers are teacher capacity, resources, funding. So it’s not that schools don’t want to do more, it’s just they also need resources and support to be able to do more.
Interviewer: Praveetha, I’m going to turn to something else now. You recently co-authored a paper in the Journal of Child Psychology and Psychiatry, the JCPP, giving your perspective on the standardised mental health measurement. Under these plans, obtaining funding for research related to depression and anxiety will be conditional on using specific scales. Can you summarise your concerns about this move?
Dr. Praveetha Patalay: Yes. So for listeners who might not be aware of the background, essentially a few months ago, the Wellcome Trust in the UK and the National Institutes of Mental Health in the US and NIMH, which together are probably some of the biggest funders of mental health research worldwide, announced that mental health research related to depression and anxiety will be conditional on using four specific scales that they laid out, one that measures depression, one that measures anxiety, one that measures depression and anxiety in children, and one wellbeing measure.
I think there are several issues with this, and we outlined thieses really well in the paper. I think the implications are for both the quality and robustness of mental health science but also for the scope of what we consider when we study mental ill health. So, for example, if you limit research on depression to these nine symptoms of depression, you potentially lose out on lots of insights that are important to various aspects related to depression. So I think that alongside questions around is it a good idea for funding to be conditional on how you measure depression, I think there’s also real concerns around how this might narrow what we learn about mental health in the next few decades if this actually comes into force.
With young people’s mental health, for me there’s also this frustration that while the forest burns around us, we seem to be discussing imperfect ways of measuring the flames. And this is a terrible analogy I realise, and I totally believe measurement is really important. But whichever way you measure it, the evidence clearly indicates that difficulties are worsening for young people. And I do not see how only measuring things in one very specific way will help us fix it because when we narrow the scope of inquiry, we massively risk also narrowing the scope of the solutions we come up with. More recently and more broadly thinking about the role of funders, and this is not in the paper, but this is just something that I’ve been thinking of for the last couple of weeks, I understand the need or the role of funders in improving scientific conduct, and ethics, and research, and bias, and inequality in how research funding is allocated, but you know how in journal articles, sometimes you see the statement, where you declare that the funders had no role in the conducting or reporting of this research and this disconnect between funders’ role as funders and their role in how the science is actually conducted, I think has been important for science. And with this move, we essentially won’t be able to declare this anymore. So we won’t be able to honestly say on a paper that the funders had no role in the conducting and reporting of this research because they pre-decided for us exactly the nine items we have to use to measure depression at the exclusion of things that might have actually been more valuable or relevant or useful for that particular study. So I am also uncertain about whether this is a good development in terms of funders’ roles in the scientific process.
Interviewer: With this mandate what action, if any, would you like to see to mitigate the consequences of this?
Dr. Praveetha Patalay: We outlined some recommendations in the paper around slowing down the rollout, considering how it’s going, and maybe also reconsidering the implications of this mandate and how it might affect the quality of mental health science in future. I think there’s probably important considerations around also how mental health is measured in different cultures and different societies. For example, we recently did a project looking at adolescent mental health in India with young people, and we spoke to stakeholders and experts locally, and things that they felt were important to capture and the words that were used to capture in the questionnaire was different from the measures we might use here in the UK with young people in schools. So I think if you say you have to use X, Y, Z items from X measure, you also risk forcing one certain conceptualisation, which is fairly western, on the rest of the world. And I don’t think we’ve done enough research across contexts and cultures with these measures yet to know whether that’s a valid or appropriate thing to do.
Interviewer: What other research areas are coming up for you and is there anything else in the pipeline that you’d like to mention?
Dr. Praveetha Patalay: So we spoke about the research that we’re doing increasingly around how things are changing around time. And I think with, similar to time, there’s also this question around place. So I think most mental health research, as I just alluded to, tends to come from a small group of mainly rich industrialised countries and this has implications for how we understand mental health but how we also treat and think about supporting young people, and some interventions might be universally suitable, but some might be very context specific.
So I am increasingly interested in understanding things in multiple contextual settings. And so most recently, we’ve done something really simple. We said let’s take something we think is very simple, so the gender gap in adolescent mental health. So with colleagues, we looked at data from over 70 countries. So this is nationally representative data from over 70 countries of more than half a million adolescents who completed simple measures of psychological distress and wellbeing. And when you look at the gender gap across these 70 countries, you see enormous heterogeneity.
So we think we know there’s a gender gap and that teenage girls are likely to have worse mental health than boys. And this is true in most countries, but that the extent of that gap really varies. It’s enormously heterogeneous and it’s not… and varies differently for different outcomes. So you look at psychological distress and there’s some heterogeneity in the gap, but then you look at wellbeing and it’s different. There’s some countries in which boys have less wellbeing as teenagers than girls. So I think even with something really, really simple, you might argue, like the gender gap, you see so much difference when you look at it across different countries properly.
The other thing coming up on a more upsetting front, and probably will be out by the time this podcast is released, is the most recent data from the UK national Millennium Cohort Study when cohort members were aged 17, that data was just made available in the start of October. And we published in the first report around the prevalences of mental health difficulties and very high levels of difficulties, of quite serious mental health difficulties. So not only serious psychological distress, but also self-harm and attempted suicide. And I think the findings really remind us that we’re very far away from not only understanding but also being able to do and prevent mental health difficulties in adolescence. And I think this is leading to research where I think we need to think of solutions at a larger scale.
So we tend to focus in mental health research on adjusting small things, adjusting individual habits, or providing coping mechanisms, or adjusting the direct environment, and all of these things are probably helpful, but I think the scale at which mental difficulties are getting worse, we need to think about big picture solutions and think about what a good childhood might look like and whether we’re doing the things that help us get there.
Interviewer: I notice from your website that you are both a scientist and an artist, so I’m curious about whether these two sides intersect?
Dr. Praveetha Patalay: Yes. So, yes, I am a scientist and an artist. So I paint; that’s my original art form, I’ve been painting since I was a child, but more recently when I was a PhD student, I trained to be a silversmith or a goldsmith, so I’m a jeweller, I also make things, so I make things with metal, but I also do pottery, I upcycle clothes, so I stitch. And sometimes my science and art intersect, sometimes in very small ways. So, for example, I sometimes make jewellery inspired from my statistical models. More recently I think they also intersect in trying to think about communicating complex scientific findings. Often we do really good research and it stays in scientific journals. Part of this is because there’s a little bit of translation work we would need to do to make it more accessible to a wider audience, whether this is policymakers, wider public, or other stakeholders. And I think I’m trying to now more recently use my creative side to also think about visually appealing but still accurate and good ways of communicating complex scientific findings.
Interviewer: Finally, Praveetha, what is your takeaway message for those listening to our conversation?
Dr. Praveetha Patalay: I probably don’t have to highlight to this audience that young people’s mental health is a public health challenge we need to take more seriously. I’d probably end on saying think about context, whether it is cultural or social in which the young person is situated and use evidence from the relevant context to inform whether it’s policy interventions or support. And mental health is health. And mental health is not just mental illness, but also good mental health. So although we need to focus on reducing serious mental health difficulties, let’s also think about wellbeing and flourishing, and how we also have a society in which we can have better wellbeing.
Interviewer: Praveetha, thank you ever so much. For more details on Doctor Praveetha Patalay please visit the ACAMH website www.acam.org and Twitter at ACAMH. ACAMH is spelled A C A M H, and don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.
Patalay, P., et al. (2020). “School characteristics and children’s mental health: A linked survey-administrative data study.” Preventive Medicine 141: 106292.
Campbell, O., et al. (2020). “The gender gap in adolescent mental health: a cross-national investigation of 566,827 adolescents across 73 countries.” medRxiv.
Gage, S. H. and P. Patalay (2020). “Have associations between mental health and health related behaviours changed between 2005 and 2015? A population based cross-cohort study.” medRxiv.
Patalay, P. and E. Fitzsimons (2016). “Correlates of mental illness and wellbeing in children: are they the same? Results from the UK Millennium Cohort Study.” Journal of the American Academy of Child & Adolescent Psychiatry 55(9): 771-783.
Patalay, P. and E. I. Fried (2020). Editorial Perspective: Prescribing measures: unintended negative consequences of mandating standardized mental health measurement. JCPP
Patalay, P. and S. H. Gage (2019). “Changes in millennial adolescent mental health and health-related behaviours over 10 years: a population cohort comparison study.” International journal of epidemiology 48(5): 1650-1664.
Patalay, P., Giese, L., Stanković, M., Curtin, C., Moltrecht, B., & Gondek, D. (2016). Mental health provision in schools: priority, facilitators and barriers in 10 European countries. Child and Adolescent Mental Health, 21(3), 139-147. doi:10.1111/camh.12160