Centre for Youth Mental Health - Theses
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ItemCharacteristics and Predictors of Suicidality in Young People with Depressive Disorders( 2023)Depression is one of the most prevalent and disabling mental health conditions among young people worldwide. Suicidality and depression are closely intertwined, yet the specific factors that contribute to the nature and severity of suicidality, or changes in suicidality over time, are not perfectly understood. Factors other than depressive symptom severity, such as comorbid psychopathology and personality traits, might be important contributors. In order to reduce the burden of suicidality in young people with depression, we need to improve our understanding of its underlying constructs and contributory elements. This has the potential to contribute to improved prevention and early intervention efforts across multiple stages of suicidality, in addition to informing more targeted clinical treatment approaches. Aims and Objectives The broad aim of this research program was to contribute towards an improved understanding of suicidal thoughts and behaviours in young people with clinically diagnosed depressive disorders. More specifically, the aim was to identify modifiable intervention targets, which could inform clinical treatment approaches, and suicide prevention and early intervention efforts more broadly. Methods This research program comprises four studies each addressing different research questions. Study 1 is a comprehensive systematic review of contributors to suicidality in young people with unipolar and bipolar depression. Study 2 is an analysis of the dimensionality of a widely used measure of suicidal ideation, including associations between this measure’s latent factors and actual suicidal behaviour in young people with major depressive disorder (MDD). Study 3 is an investigation of how different dimensions of social support are associated with suicidal ideation in a treatment seeking cohort of young people with MDD; and Study 4 is a longitudinal analysis of associations between a range of psychosocial correlates and suicidal ideation severity in this same cohort of young people MDD, assessed over a 12-week period. Main Results Several key themes can be drawn from the findings of this research program. First, there is a lack of consensus regarding how the construct of suicidality should be defined, highlighting the need for international collaboration in the development of a standardised, validated classification system for suicidal ideation and suicidal behaviours. The second key finding is that suicidality in young people with depressive disorders is multidimensional in nature. That is, the way in which suicidality manifests in an individual is multifaceted. Suicidality is comprised of multiple constructs encompassing both active and passive ideation, intrapersonal cognitions such as hopelessness and lack of self-worth, and interpersonal factors such as perceived burdensomeness. The third key finding is that there are multiple determinants of suicidality in young people with depressive disorders; in addition to depressive symptoms, there are numerous other predictors of the nature and severity of suicidality. Notably, familial support is an important protective factor, while psychopathological features such as state and trait anxiety contribute to suicidality severity. Discussion Outcomes of this research program reinforce the notion that suicidality is complex and multideterminant in nature. Depression symptomatology is an important contributor, suggesting that regular monitoring of depression symptom severity should be a core aspect of the clinical management of suicidality in young people with depressive disorders. Suicidality is not driven by depression symptomatology alone and it is clear that suicide prevention and intervention efforts need to go beyond simply reducing depression severity. Psychiatric comorbidity with depression, particularly comorbid anxiety, is an important determinant of suicidality. Anxiety and depression, in particular, share many clinical features and risk factors. Interventions targeting transdiagnostic features could have clinical utility in reducing the burden of suicide in young people. In addition, methodological assessment of personality features and carefully targeted intervention approaches such as dialectal behaviour therapy, or mentalization-based therapy, could be a beneficial component of the clinical management of depression and suicidality in young people. An important clinical implication of this research program is that there is likely substantial variability underlying the mechanisms for suicidality from one depressed young person to the next. This suggests that there is perhaps a similarly high degree of variability with respect to potentially effective treatment targets for suicidality. It raises the question of how useful it is to consider a diagnosis of depression as a specific risk factor for suicidality in young people. Alternative approaches to identifying aetiological mechanisms of suicidality, such as a specific symptom approach, could be warranted. It is crucial to develop and employ early intervention approaches for suicidality in young people which focus on the earliest stage of suicidality. Potential targets for early intervention, such as increasing adaptive social support to reduce severity of suicidal ideation, are likely to be beneficial in preventing transition to suicidal behaviour. This highlights the need to assess and monitor suicidality early in young people presenting with mental health symptoms, irrespective of the specific diagnosis. This requires the use of age-appropriate suicidality assessment tools designed for use in young people. Given the fluctuating nature of suicidality, real-time symptom monitoring could perhaps be implemented as part of routine clinical care. The use of transdiagnostic interventions aimed at modifying common cognitive processes underlying depression, anxiety, and suicidality could be an effective treatment approach. Although suicidality is a complex phenomenon and no single approach to prevention or intervention is likely to be universally effective, the findings of this research program do have the potential to help reduce the suicidality-related health burden in this particularly vulnerable population.