In this Papers Podcast, Dr. Kenny Chiu discusses his JCPP Advances paper ‘Social anxiety symptoms and their relationship with suicidal ideation and depressive symptoms in adolescents: A prospective study’ (https://doi.org/10.1002/jcv2.12249). Kenny is the lead author of the paper.
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- Insight into the dataset used, which originated from the Wellcome Trust NSPN (Neuroscience in Psychiatry Network) study.
- The questionnaire measures used for social anxiety symptoms, generalised anxiety symptoms, depressive symptoms, and suicidal ideation.
- How the researchers dealt with missing data – a common feature of longitudinal cohort studies due to various reasons – and how they tried to account for this to test their hypothesis.
- The researcher’s experience of pre-registering the analysis on the Open Science Framework.
- Insight into the analytic models used to analyse the data.
- Implications of the findings for clinicians and other researchers.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Dr. Kenny Chiu is a Clinical Lecturer and Research Tutor at the University of East Anglia’s Clinical Psychology Doctorate Programme. Kenny’s research aims to improve understanding and treatment of adolescent anxiety and trauma-related disorders, particularly social anxiety. His work employs various methods, including prospective and experiential studies, meta-analyses, and clinical trials.
Transcript
[00:00:10.000] Dr. Umar Toseeb: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Umar Toseeb, a Professor at the University of York. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.
Today, I’m talking to Dr. Kenny Chiu, Clinical Lecturer and Research Tutor at the University of East Anglia. Kenny is the Lead Author of a paper entitled “Social Anxiety Symptoms and their Relationship with Suicidal Ideation and Depressive Symptoms in Adolescents: A Prospective Study” in JCPP Advances. This paper will be the focus of today’s podcast. If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with your friends and colleagues.
Kenny, thank you so much for joining us. Can you start by just giving us a quick introduction about who you are and what you do?
[00:01:07.029] Dr. Kenny Chiu: Sure, and my name is Dr. Kenny Chiu and I’m a Clinical Psychologist and I currently work as a Clinical Lecturer and a Research Tutor at the ClinPsyD programme, based at the University of East Anglia. And I’d – enjoy conducting research to advance on knowledge of improving mental health of children and adolescents and, over the years, I’ve developed specific focus on understanding social anxiety in adolescents and developing effective treatments for them.
[00:01:44.423] Dr. Umar Toseeb: Thank you, and let’s turn to the paper. Can you give us a brief overview of your paper?
[00:01:49.232] Dr. Kenny Chiu: Certainly. This paper represent a collaboration with Dr. Eleanor Leigh, a social anxiety expert based at the Oxford University, and Professor Argyris Stringaris, an expert in the area of depression, who is currently based at UCL. Among the three of us, we began to develop an interest in understanding more about the adverse effects of social anxiety on young people. So, in our previous research, we’ve looked into quite a couple – range of outcomes, including academic functioning, social functioning, concentration in class, and this time, we’d like to understand a bit more about the relationship between children and anxiety symptoms and suicidal ideation, as well as other depressive symptoms in adolescents.
And as we know that depression is a condition that encompasses of multiple features, with low mood, lack of interest and for some, that might involve suicidal ideation, in this project, we try to look into the relationship by endor – adopting a multidimensional approach by breaking them a bit down, and to look at the differential relationship with social anxiety. So, in this project, we used data from a large community sample, with the data collected by – from the NeuroScience in Psychiatry Network, to investigate whether social anxiety measured at the start was associated with later suicidal thoughts and other depressive symptoms two years later and whether these relationships were mediated by depressive symptoms at one year.
[00:03:32.826] Dr. Umar Toseeb: Excellent, thank you. I mean, you’ve touched a bit upon the next question I was going to ask you, but do you just want to expand on the methodology? So, you use secondary analysis of existing data. Do you want to tell us a bit more about the dataset?
[00:03:43.449] Dr. Kenny Chiu: Regarding the methodology used in the study, we used our secondary data analysis of data collected from the NeuroScience in Psychiatry Network, also known as NSPN. So, in this NSPN initiative, the Researchers collected lots of data from young people aged 14 to 24, from different parts of UK and they followed them over two years. And they’ve collected quite a lot of diff – data, including your experience of internalising symptoms, as well as externalising behaviours, as well as brain imaging data.
So, in the study we published, we’ve used some of the questionnaires that tap into social anxiety, depression and suicidal ideation and more importantly, there are also follow-up studies looking into cognitive functioning and some neuroscience research. So, it’s a really rich, massive, well thought out dataset.
[00:04:42.665] Dr. Umar Toseeb: Did you access the data remotely, or were you working in Cambridge? How did this come about?
[00:04:47.824] Dr. Kenny Chiu: When I first started to grow as a Research Tutor in the programme, I start thinking about research projects that are available to trainees. One of my amazing colleagues, Professor Richard Meiser-Stedman, who came across this dataset and put me in touch with the group there. So, through discussion with the group, I was really fortunate to get access to their dataset to start answering some questions using this amazing resource.
[00:05:19.019] Dr. Umar Toseeb: Ah, excellent. Well…I’m not sure if I mentioned, but I worked on the NSPN project. So, I was there as a postdoc in, like, 2012, 2014, that – during that period. I led on the data collection for this, as a weird coincidence. So, I recruited the schools, colleges, universities and, like, it was really – a really fun time.
I got to drive around lots of Cambridge and then, like, we’d get, like, bags full of, like, questionnaires coming in through the post and then, there’d be – so, it’s really nice that people are using the data.
[00:05:47.544] Dr. Kenny Chiu: I’m so glad to be talking to you today, Umar, because I feel very blessed to have access to such amazing resources and through that, to be able to do something meaningful. And you also remind me of, again, maybe five to ten years ago, it’s not too long ago, it was actually pre-pandemic, that even in my Doctor of Clinical Psychology training, I was printing out 600 questionnaires, using a suitcase, going to schools to get data, going back to in front of a computer and type that in. But things have changed drastically.
[00:06:19.560] Dr. Umar Toseeb: And you describe in your paper that you had measures of anxiety/depressive symptoms and suicide ideation. Can you tell us a bit more about those measures? I’m assuming they’re questionnaire-based measures.
[00:06:30.798] Dr. Kenny Chiu: Indeed, they are questionnaires measures. It was an interesting process to figure out to what extent we could use an existing dataset like this to answer a question that might not be quite immediately obvious. Because, for example, we were able to identified – approximately measure social anxiety from the Revised Children’s Anxiety and Depression Scale and we were able to not only looking into depressive symptoms captured by the Mood and Feelings Questionnaire. We also found that, in the same questionnaire, there are actually items tapping into suicidal ideation and there is research suggesting that these items can form a subscale that has some good, you know, psychometric properties as a standalone measurement. And that’s how we start becoming excited about the possibility of, ooh, actually asking the questions that had never been thought about.
[00:07:28.431] Dr. Umar Toseeb: Thank you, and so, my understanding of it is that you have a timepoint zero, which is the baseline assessment, and that young people did a series of questionnaires, and then you have a follow-up a year later and then, a follow-up a further year later. And as with all longitudinal studies, you had sample attrition. So, you had people who took part at the first timepoint who didn’t take part at the second or third timepoint, and those, kinds of, issues around missing data. How did you deal with that missing data?
[00:07:54.478] Dr. Kenny Chiu: Thanks for this question. Yes, in longitudinal cohort studies like this, missing data is very common and due to various reason. It could be because people decided not to take part, or there could be a logistical reason why sometimes data can be – data cannot be collected. And I have experience of conducting this sort of longitudinal cohort research and from there, I learned that in order to conduct analysis to find findings that are valid and reliable, we need to figure out solutions, such as looking into the pattern of missing data to see, how were they missed? Were there a pattern in it? And based on that observation and also, consideration of the reason for why things go missing, I learned that it’s been possible to apply methodology, such as multiple data imputation, to try to account for those missing data and improve statistical power to test our hypothesis.
And while imputation is not perfect when there is a high percentage of missing data, from experience, I’ve learned that it’s good practice to look at both complete data analysis, as well as data analysis using some form of data imputation methods, to see if we arrive at a similar conclusion.
[00:09:18.523] Dr. Umar Toseeb: Yeah, and I think that’s important, and did you test both with and without imputed data and did you arrive at a similar conclusion?
[00:09:25.999] Dr. Kenny Chiu: Yes, I did look into using two analytic approaches and the results are largely consistent, and that’s also not surprising, given this is such a big dataset and the data collection qualities, in my opinion, is great. Again, it’s – if they are pointing drastically at different conclusion, then that would then – obviously, there will be more challenges of how to interpret the discrepancy.
[00:09:52.223] Dr. Umar Toseeb: And one of the things that I really liked about this paper was that you pre-registered your analysis. So – and that’s particularly interesting because it’s secondary analysis of existing data. So, when we access those datasets, I think there’s a risk that people might end up on a fishing expedition, where you have lots of data and then, you try and find patterns and effects and the more you look, the more you’re likely to find. So, the fact that you pre-registered this data analysis is fantastic. Can you talk us through your experience of pre-registering this analysis?
[00:10:21.478] Dr. Kenny Chiu: Yes. Pre-registering the analysis on the Open Science Framework was a new experience to me, and by working with Eleanor and Argyris, both of whom are experts in their – in the field and have lots of experience, I’ve learned about the importance of developing our hypothesis and analytic plan in advance, and to tolerate the temptation to conduct exploratory analysis. And the experience to me, it was initially challenging, because I wasn’t involved in collecting the data and I have no idea why data were missed. I do not know why certain a questionnaire were used and how validated they are. So, there are lots of background work needed that need to be done for a literature search to be sure that this is a viable direction. So, I would describe it as short-term pain period.
But as soon as we publish the plan and start running analysis, I did have a very different and more positive experience down the line because I know exactly what we were looking for and there were no excuse for me to branch out to explore other alternatives, so I can keep focus and be faithful to what I’ve planned to do. Overall, I would definitely recommend doing pre-registration for secondary data analysis and in fact, this has become a culture in my UEA anxiety programme that, for example, all of the trainees I supervise who are working on using a similar approach, all of them pre-register their proposal before actually looking through data.
[00:12:04.104] Dr. Umar Toseeb: As you say, it’s a fantastic way forward because a lot of the thinking around what the analysis will look like, what the models that you will fit will be and which variables you want to use, you do that upfront. So, then, when you actually have the data in front of you in going to do the analysis, you’ve done a lot of the hard work already and then, it’s just the technical aspects of doing the analysis. So, yeah, I think it’s a fantastic way forward and I’m so glad you did it for this paper.
[00:12:29.160] Dr. Kenny Chiu: Yeah, thank you.
[00:12:29.918] Dr. Umar Toseeb: Just to move onto the analytic models themselves. So, I can see that you did regression models and mediation models and those were fantastic, and we’ll talk about the – what you’ve found in a few moments’ time. But I did wonder, when I was reading this, that the dataset, because there’s three timepoints, and given your research questions, I did wonder whether it would lend itself to a random intercept cross-lagged panel model, where you can look at the within and between person variation over time. Is that something you considered?
[00:12:59.970] Dr. Kenny Chiu: I did consider this way of analysing the data and particularly because it could account for – distinguish between – within person and between person effects. However, admittedly, this is not something I thought of when I pre-register study and it was something that came up after I submit the first – I submit the manuscript, that I become more a time of critical appraisal to understand to what extent I need to look into these more complex way of analysing data. So, we did, within the research group, we did have a – have discussion on, “Do we need to make a drastic change on our pre-registration to use the different analytic methods?” But since the paper has been submitted and has been reviewed once, and it wasn’t our initial intention, we didn’t report that finding, but I do acknowledge that it would be helpful and perhaps more rigorous, to conduct an analysis of that.
[00:13:56.222] Dr. Umar Toseeb: I suppose not even more rigorous. I mean, also, I think that it’s just a different way of doing it and I think that it’s important to point out that the – a random intercept cross-lagged panel model isn’t the answer to all of the problems and, you know, it – there are a number of assumptions that have to be met, as you know. And so, I suppose, like, it’s just a different way of doing it, and let’s talk about your findings. So, we’ve gone through some of the rationale and then, we’ve talked about the cohort itself and the analysis methods. What did you find and what findings would you particularly like to highlight?
[00:14:25.460] Dr. Kenny Chiu: Oh, key findings are that the young people’s self-reported baseline social anxiety symptoms were associated with their self-reported suicidal ideation and other depressive symptoms measured two years later, even after we control for baseline level of the predicted outcomes. So, that’s one of the findings, and in addition, when we conduct mediation analysis, we’ve noticed that those had been suggesting that the relationship between these variables were partially explained or mediated by depressive symptoms at one year. And there are many ways to interpret the data because they are correlational data and observational data.
I would be cautious of, you know, making bold causal inference here, but one interpretation could be that maybe this is showing that social anxiety could play a role in the maintenance of suicidal ideation as far as the persistence of depressive symptoms. And I think that it would be fair to at least say that as a possible explanation, given that there will be ethical challenges to using other ways, such as incremental study, to see if social anxiety indeed create increased – cause depression and suicidal ideation. So, that would be the key findings we reported in the paper, yeah.
[00:15:44.878] Dr. Umar Toseeb: And what might the implications of those findings for Clinicians, for example, or other Researchers?
[00:15:52.264] Dr. Kenny Chiu: One major implication is that it would be helpful to consider that for young people who experience an elevated level of social anxiety, in a community, not even a clinical population, the fact that, well, this high-level social anxiety could be a sign of the risk factor for experiencing later suicidal thoughts and other depressive symptoms. So, that might point to the importance of providing assessment that could accurately, sensitively, look into all these aspects and highlight the importance of supporting young people to overcome their social anxiety if they feel distressed by it. And viewing on this research may be – the results also suggest that there might be a need to further understand the mechanism linking social anxiety to suicidal ideation, particularly because there are many theories about – around why people develop suicidal thoughts or commit to report suicidal behaviours.
One aspect is about the interpersonal aspects that people might be more vulnerable to experience these thoughts when they experience negative social experience and feel defeated by that. And this is something quite special about and quite specific to social anxiety in adolescent periods. So, that might be something more to look into to understand the underling mechanism of it, and when I say ‘mechanism’, that should be the social anxious thoughts and suicidal thoughts. Maybe there are also other beliefs or other – or imageries or other common process in play.
[00:17:27.503] Dr. Umar Toseeb: Thank you, and I suppose you’ve already touched on this, so we’ll just expand on that, so where next? Are you planning any follow-up research, or is there anything else in the pipeline that you’d like to share with us?
[00:17:37.159] Dr. Kenny Chiu: We do have a discussion on follow-up research ideas, and I mean, especially, we seem to have received quite overwhelming interest from different Researchers about this project, particular in relation to the link between social anxiety and suicidal ideation. And, of course, because as we are – we do have experience of gratification crisis, so it’s always advisable to replicate the study using more comprehensive multi-item measures or – of social anxiety and suicidal ideation, maybe more than through self-report, but using other reports. So, to build up the evidence, this is indeed, something that it can be replicated, because there are not many studies that look into this relationship.
And in addition, perhaps there is a value to investigate other outcomes, such as suicidal behaviours, or attempts, or non-suicidal self-injuries. So, there are lots of thoughts and behaviours or other processes that might be in play when a person feels so vulnerable to a point that they become distressed with these thoughts, and it is worth understanding more.
[00:18:42.865] Dr. Umar Toseeb: And I think one of the things that I think I might suggest is that I am quite sure ALSPAC, the Avon Longitudinal Study of Parents and Children, has, like, interview data on, like, mental health. So, they might have stuff on social anxiety and then, subsequent suicide ideation. So, I mean, I suppose that’s a different informant than self-report, but anyway, that might be useful to look at, if that’s something you’re interested in.
[00:19:06.232] Dr. Kenny Chiu: I’ve looked into it, and I think so, and it’s certainly – that’s the go-to place to get the UK data.
[00:19:12.909] Dr. Umar Toseeb: Yeah.
[00:19:13.692] Dr. Kenny Chiu: Yeah, and…
[00:19:14.715] Dr. Umar Toseeb: So, you’re one step ahead.
[00:19:17.057] Dr. Kenny Chiu: …that – no, and yeah, it’s – I’m glad you mentioned it. So, it’s actually quite feasible nowadays, because you’ve got these data available and that means that that challenge us, as Researcher, to develop different skills, such as being aware of where – what data we could look into or what are the, kind of, data – just skills in our toolbox we could use? And when we combine them together, are we going to get an answer that has – that could bring a potential impact? Another place could be looking outside UK at maybe other datasets, such as the APCD data, that might also provide some other insights.
And in addition, we – it might be good to look into other dataset that collect from more specific cohorts, such as people with neurodiversity, to see if we understand a similar association or are they actually stronger than in the community population? So, the – there are plenty of opportunities out there and which really – is a really exciting time that we can now be able to do this without dragging our suitcase and collecting data. You know, we’re building on the giant’s shoulder and working together as a scientific community.
[00:20:29.911] Dr. Umar Toseeb: And finally, what’s your take home message for our listeners?
[00:20:33.522] Dr. Kenny Chiu: So, the first take home message is that there’s always something more to learn about mental distress and the relationship and in this project, even just by looking into the relationship between a different form of mental health symptoms, kind of, producing quite variable insights. So, that’s something, potentially, we could look into further. And the second take home message, which is more generic, it’s that it is completely feasible to conduct studies like this nowadays and everybody could do that, as long as we know where to look for data. We’ve done a literature review carefully online, with a blessing of the data holders. It’s so feasible nowadays to discover new insights and I do really encourage everyone to do that more.
[00:21:23.034] Dr. Umar Toseeb: Thank you ever so much. For more details on the paper and Dr. Kenny Chiu, please visit the ACAMH website, that’s www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with your friends and colleagues.
