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?

Dr. Kenny Chiu: Sure, and my name is Dr. Kenny Chiu and I’m a Clinical Psychologist and Icurrently 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.

Dr. Umar Toseeb: Thank you, and let’s turn to the paper. Can you

give us a brief overview of your paper?

Dr. Kenny Chiu: Certainly. This paper represent a collaboration with Dr Eleanor Leigh, a socialanxiety 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.

Dr. Umar Toseeb: Excellent, thank you. I mean, you’ve touched a bit upon the next questionI 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?

Dr. Kenny Chiu: Regarding the methodology used in the study, we used our secondary data analysis ofdata 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.

Dr. Umar Toseeb: Did you access the data remotely, or were you working inCambridge? How did this come about?

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.

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.

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.

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.

Dr. Kenny Chiu: Indeed, they are questionnaires measures. It was an interesting process to figureout 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.

Dr. Umar Toseeb: Thank you, and so, my understanding of it is that you havea 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?

Dr. Kenny Chiu: Thanks for this question. Yes, in longitudinal cohort studies like this, missingdata 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.

Dr. Umar Toseeb: Yeah, and I think that’s important, and did you testboth with and without imputed data

and did you arrive at a similar conclusion?

Dr. Kenny Chiu: Yes, I did look into using two analytic approaches and the results are largelyconsistent, 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.

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?

Dr. Kenny Chiu: Yes. Pre-registering the analysis on the Open Science Framework was a new experienceto 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.

Dr. Umar Toseeb: As you say, it’s a fantastic way forward because a lot of the thinking aroundwhat 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.

Dr. Kenny Chiu: Yeah, thank you.

Dr. Umar Toseeb: Just to move onto the analytic models themselves. So, I can see that you didregression 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?

Dr. Kenny Chiu: I did consider this way of analysing the data and particularly because itcould 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.

Dr. Umar Toseeb: I suppose not even more rigorous. I mean, also, I think that it’s just a differentway 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?

Dr. Kenny Chiu: Oh, key findings are that the young people’s self-reported baselinesocial 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.

Dr. Umar Toseeb: And what might the implications of those findings for Clinicians,for example, or other Researchers?

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.

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?

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.

Dr. Umar Toseeb: And I think one of the things that I think I might suggest is thatI 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.

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.

Dr. Umar Toseeb: Yeah.

Dr. Kenny Chiu: Yeah, and…

Dr. Umar Toseeb: So, you’re one step ahead.

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 dataavailable 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 cannow 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.

Dr. Umar Toseeb: And finally, what’s your take home message for our listeners?

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 thesecond take

home message, which is more generic, it’s that it is completely feasible to conductstudies like this nowadays and everybody

could do that, as long as we know where to look fordata. We’ve done a literature review carefully online, with a blessing

of the data holders. It’s sofeasible nowadays to discover new insights and I do really encourage everyone to do that more.

Dr. Umar Toseeb: Thank you ever so much. For more details on the paper and Dr. KennyChiu, 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

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