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Methods for testing trends in mental health – is it really possible to compare ‘like with like’?. Dr Stephan Collishaw Cardiff University [email protected] NCRM Research Methods Festival, Oxford, July 2014. Outline. Prevalence and burden

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methods for testing trends in mental health is it really possible to compare like with like
Methods for testing trends in mental health – is it really possible to compare ‘like with like’?

Dr Stephan Collishaw

Cardiff University

[email protected]

NCRM Research Methods Festival, Oxford, July 2014

  • Prevalence and burden
  • Trends in diagnosis – need for epidemiological data
  • Cross-cohort comparisons using symptom screens
    • Issues to think about in comparing ‘like with like’
    • Results – adolescent mental health 1970s-2000s
  • Replication and validation
  • Trends in child mental health 1999-2008
Child psychiatric disorders:

Burden and prognosis

  • 1 in 10 has a clinically significant psychiatric disorder
  • Impact on family life, friendships, learning
  • Suicide and self harm (3rd leading cause of death)
  • Long-term prognosis
    • Most child/adolescent disorders persist to adulthood
    • >50% of adult mental disorders have onset <18 years
    • Parenting, employment, social exclusion, illness, mortality
    • Economic burden

Green et al., 2005; Kim-Cohen et al, 2003; Thapar et al., 2012; Windfuhr et al., 2008; Maughan et al., 2014

diagnosis and treatment autism adhd depression anxiety
Diagnosis and treatment: autism, ADHD, depression, anxiety
  • Increased help seeking, diagnosis and treatment
  • Substantial increases in psychotropic medication
  • Rates increased 3-5 fold per decade 1990s and 2000s
  • Similar trends in many countries

Getahun et al., 2013; Kosidou et al, 2010; Olfson et al., 2014; Stephenson et al, 2013

trends in diagnosis and treatment
Trends in diagnosis and treatment

Important for planning service provision


Increases in referrals and diagnoses may be due to

Increased public awareness & clinical recognition

Changing diagnostic criteria and practice

Treatment availability and perceived efficacy

‘Medicalisation’ of normal behaviour?


Majority still don’t access services

Ford et al., 2007; Potter et al., 2012

epidemiological evidence
Epidemiological evidence
  • Two major meta-analyses of depression and ADHD
  • Epidemiological studies using structured diagnostic interviews
  • Meta-analyses: no evidence of increase in depression or ADHD


  • Variability in methods (samples, measures, diagnostic system)
  • Rates of depression range from <1%to >25%
  • ‘Noise’ and variability likely to make trends difficult to detect

Costello et al., 2006; Polanczyk et al., 2014

like for like cross cohort comparisons
‘Like-for-like’ cross-cohort comparisons
  • Comparable representative cohorts with equivalent measures
    • e.g. UK cohorts since 1960s have included Rutter/SDQ
  • Threats to comparability
    • Selective attrition
    • Minor changes to questionnaire make a big difference
      • Disobedience: “applies somewhat” (33%) vs “sometimes” (75%)
      • Calibration can be effective for aligning non-identical instruments
    • Change in reporting

Goodman et al., 2007

uk cross cohort comparisons 1974 1999
UK cross-cohort comparisons: 1974-1999
  • Large nationally representative surveys (NCDS, BCS70, BCAMHS) assessed in 1974, 1986, 1999
  • Age 15-16
  • Parent rated Rutter or SDQ
    • Emotional problems
    • Conduct problems
    • Hyperactivity/inattention
  • Calibration data used to align SDQ and Rutter questionnaires
  • Study-specific weights using prior predictors of non-response

Collishaw et al, 2004

emotional problems high scores
Emotional problems: high scores

Cohort 3 vs. cohort 2

OR = 1.72

N = 10,499

N = 7,293

N = 868

Collishaw et al, 2004

conduct problems high scores
Conduct problems: high scores

Total OR = 1.56 per cohort

Collishaw et al, 2004

hyperactivity mean scores
Hyperactivity: mean scores

Collishaw et al, 2004

  • Only parent reports
  • Imperfection of Rutter/SDQ calibration?
  • Crude measures
  • Are population shifts also occurring at extremes?
  • What about ‘change in reporting’?
  • Need for replication and validation
replication the youth trends study 1986 2006
Replication: The Youth Trends study (1986 & 2006)

Two nationally representative surveys of English youth

1986: BCS70 age 16 (N = 9,766)

2006: HSE follow-up ages 16-17 (N = 747)

Identical self rated symptom screens (GHQ/Malaise)


Increase in youth-reported symptoms

Variation in trends by severity?

Collishaw et al, 2010

adolescent emotional symptoms youth reports
Adolescent emotional symptoms (youth reports)

ES = 0.36; p < .001

ES = 0.13; p = .06

Collishaw et al., 2010

trends by severity
Trends by severity

cohort differences significant at all thresholds, p<.01; Interaction p < .05

Collishaw et al, 2010

do trends reflect a change in reporting
Do trends reflect a change in reporting?
  • Shift in informant ‘thresholds’?

(e.g. different expectations about normal behaviour)

  • Greater willingness to report problems than in the past?


  • Specificity of findings (no increase in hyperactivity)
  • Validation using external criteria desirable…
adolescent conduct problems and risk of pervasive adult dysfunction 4 adverse outcomes age 30
Adolescent conduct problems and risk of pervasive adult dysfunction: 4+ adverse outcomes age 30

Collishaw et al, 2004

Child mental health trends: 1999-2008
  • 1999: BCAMHS 7-year olds (n = 1034)
  • 2004: BCAMHS 7-year olds (n = 648)
  • 2008: MCS 7-year collection (n = 13,489)
  • Parent & teacher SDQ symptoms & impact
  • Weights used to adjust for attrition and stratified design

Sellers et al, in press

Child mental health trends: 1999-2008

SDQ total and subscale mean scores all declined

  • Boys: total score effect size = -0.27
  • Girls: total score effect size = -0.12
  • Bigger drop in problem scores for boys than girls (p = 0.027)
  • Similar conclusions based on parent and teacher reports
  • Drop in children scoring in abnormal range (11%, 10%, 8%)
  • But: increase in impact of problems, e.g. classroom learning

Sellers et al, in press

  • Comparing ‘like-with-like’ essential for testing trends
  • Replication and validation important
  • Long-term change in adolescent mental health
  • Recent data: improvements in child mental health
  • Latest data 2008, what has happened since?

Barbara Maughan (KCL)

Andrew Pickles (KCL)

Robert Goodman (KCL)

Anita Thapar (Cardiff)

Ruth Sellers (Cardiff)

Frances Gardner (Oxford)

Jacqueline Scott (Cambridge)

Ginny Russell (Exeter)

National Centre for Social Research; Department of Health

Medical Research Council; Nuffield Foundation; Waterloo Foundation


Collishaw et al (2004). Time trends in adolescent mental health. J Child Psychol Psych, 45, 1350-1362.

Collishaw et al (2010). Trends in adolescent emotional problems in England. J Child Psychol Psych, 51, 885-94.

Costello et al (2006). Is there an epidemic of child and adolescent depression? J Child Psychol Psych, 47, 1263-71

Ford et al (2007). Child mental health is everybody’s business. Child Adolescent Mental Health, 12, 13-20.

Getahun et al (2013). Recent trends in childhood ADHD. JAMA Pediatrics, 167, 282-8.

Goodman et al (2007). Seemingly minor changes to a questionnaire. Soc Psych PsychEpi, 42, 322-327.

Green et al (2005). Mental health of children and young people in GB, 2004. Palgrave Macmillan

Kim-Cohen et al (2003). Prior juvenile diagnoses in adults with mental disorders. Archives General Psychiatry, 60. 709-17

Kosidouet al (2010). Recent trends. ActaPsychiatricaScandinavica, 22, 47-55.

Maughan et al (2014). Adolescent conduct problems and premature mortality. Psych Med, 44, 1077-86.

Olfsonet al (2014). National trends in the mental health care of children, adolescents and adults. JAMA Psych, 71, 81-90

Polanczyket al (2014). ADHD prevalence estimates across three decades. Int J Epidemiology, online first

Potter et al (2012). Missed opportunities mental disorder in children of parents with depression. BJGP, 62, e487

Sellers et al (in press). Trends in parent- and teacher-rated emotional, conduct. J Child PsycholPsych, in press.

Stephenson et al (2013). Trends in the utilisation of psychotropic medication. Austr New Zealand J Psychiatry, 47, 74-87.

Thapar et al (2012). Depression in adolescence. Lancet, 379, 1056-67.

Windfuhret al (2008). Suicide in juveniles and adolescents in the United Kingdom. J Child Psychol Psych, 49, 1155-65