Predictors of suicidal ideation severity among treatment-seeking young people with major depressive disorder: The role of state and trait anxiety.

OBJECTIVE: Depression and suicidal ideation are closely intertwined. Yet, among young people with depression, the specific factors that contribute to changes in suicidal ideation over time are uncertain. Factors other than depressive symptom severity, such as comorbid psychopathology and personality traits, might be important contributors. Our aim was to identify contributors to fluctuations in suicidal ideation severity over a 12-week period in young people with major depressive disorder receiving cognitive behavioural therapy. METHODS: Data were drawn from two 12-week randomised, placebo-controlled treatment trials. Participants (N = 283) were 15-25 years old, with moderate to severe major depressive disorder. The primary outcome measure was the Suicidal Ideation Questionnaire, administered at baseline and weeks 4, 8 and 12. A series of linear mixed models was conducted to examine the relationship between Suicidal Ideation Questionnaire score and demographic characteristics, comorbid psychopathology, personality traits and alcohol use. RESULTS: Depression and anxiety symptom severity, and trait anxiety, independently predicted higher suicidal ideation, after adjusting for the effects of time, demographics, affective instability, non-suicidal self-injury and alcohol use. CONCLUSIONS: Both state and trait anxiety are important longitudinal correlates of suicidal ideation in depressed young people receiving cognitive behavioural therapy, independent of depression severity. Reducing acute psychological distress, through reducing depression and anxiety symptom severity, is important, but interventions aimed at treating trait anxiety could also potentially be an effective intervention approach for suicidal ideation in young people with depression.

Assessing Suicidal Ideation in Young People With Depression: Factor Structure of the Suicidal Ideation Questionnaire.

Evaluating suicidal ideation in young people seeking mental health treatment is an important component of clinical assessment and treatment planning. To reduce the burden of youth suicide, we need to improve our understanding of suicidal ideation, its underlying constructs, and how ideation translates into suicidal behaviour. Using exploratory factor analysis, we investigated the dimensionality of the Suicidal Ideation Questionnaire (SIQ) among 273 participants aged 15-25 with Major Depressive Disorder. Area under the receiver operating characteristic curve (AUROC) analysis was used to explore associations between latent factors and actual suicidal behaviour. Findings suggested that the SIQ assesses multiple factors underlying suicidal ideation. AUROC analyses demonstrated that latent factors relating to both active and passive suicidal ideation predicted past-month suicidal behaviour and suicide attempt. These findings contribute to an improved understanding of the complexities of suicidal ideation and relationships with suicidal behaviour in young people with depression.

Applying the Free Energy Principle to Complex Adaptive Systems.

The free energy principle (FEP) is a formulation of the adaptive, belief-driven behaviour of self-organizing systems that gained prominence in the early 2000s as a unified model of the brain [...].

Correlates of suicidality in young people with depressive disorders: A systematic review.

OBJECTIVE: Depression is one of the most prevalent and disabling mental health conditions among young people worldwide. The health and economic burdens associated with depressive illness are substantial. Suicide and depression are closely intertwined, yet a diagnosis of depression itself lacks predictive specificity for suicidal behaviour. To better inform suicide prevention and early intervention strategies for young people, improved identification of modifiable intervention targets is needed. The objective of this review was to identify clinical, psychosocial and biological correlates of suicidality in young people diagnosed with a broad range of unipolar and bipolar depressive disorders. METHOD: Systematic searches were conducted across MEDLINE, Embase and PsycINFO to identify studies of young people aged 15-25 years diagnosed with unipolar or bipolar depressive disorders. An assessment of suicidality was required for inclusion. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 and Synthesis Without Meta-analysis guidelines. RESULTS: We integrated findings from 71 studies including approximately 24,670 young people with clinically diagnosed depression. We identified 26 clinical, psychosocial and biological correlates of suicidality. Depression characteristics (type and severity), psychiatric comorbidity (particularly anxiety and substance use disorders) and neurological characteristics emerged as having the most evidence for being associated with suicidal outcomes. Our ability to pool data and conduct meaningful quantitative synthesis was hampered by substantial heterogeneity across studies and incomplete reporting; thus, meta-analysis was not possible. CONCLUSION: Findings of this review reinforce the notion that suicidality is a complex phenomenon arising from the interplay of multiple contributing factors. Our findings question the utility of considering a diagnosis of depression as a specific risk factor for suicidality in young people. Suicidality itself is transdiagnostic; adoption of a transdiagnostic approach to investigating its aetiology and treatment is perhaps warranted. Future research investigating specific symptoms, or symptom networks, might help to further our understanding of suicidality among young people experiencing mental illness.

Why Depressed Mood is Adaptive: A Numerical Proof of Principle for an Evolutionary Systems Theory of Depression.

We provide a proof of principle for an evolutionary systems theory (EST) of depression. This theory suggests that normative depressive symptoms counter socioenvironmental volatility by increasing interpersonal support via social signalling and that this response depends upon the encoding of uncertainty about social contingencies, which can be targeted by neuromodulatory antidepressants. We simulated agents that committed to a series of decisions in a social two-arm bandit task before and after social adversity, which precipitated depressive symptoms. Responses to social adversity were modelled under various combinations of social support and pharmacotherapy. The normative depressive phenotype responded positively to social support and simulated treatments with antidepressants. Attracting social support and administering antidepressants also alleviated anhedonia and social withdrawal, speaking to improvements in interpersonal relationships. These results support the EST of depression by demonstrating that following adversity, normative depressed mood preserved social inclusion with appropriate interpersonal support or pharmacotherapy.

New generation antidepressants for depression in children and adolescents: a network meta-analysis.

BACKGROUND: Major depressive disorders have a significant impact on children and adolescents, including on educational and vocational outcomes, interpersonal relationships, and physical and mental health and well-being. There is an association between major depressive disorder and suicidal ideation, suicide attempts, and suicide. Antidepressant medication is used in moderate to severe depression; there is now a range of newer generations of these medications. OBJECTIVES: To investigate, via network meta-analysis (NMA), the comparative effectiveness and safety of different newer generation antidepressants in children and adolescents with a diagnosed major depressive disorder (MDD) in terms of depression, functioning, suicide-related outcomes and other adverse outcomes. The impact of age, treatment duration, baseline severity, and pharmaceutical industry funding was investigated on clinician-rated depression (CDRS-R) and suicide-related outcomes. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR)), together with Ovid Embase, MEDLINE and PsycINFO till March 2020. SELECTION CRITERIA: Randomised trials of six to 18 year olds of either sex and any ethnicity with clinically diagnosed major depressive disorder were included. Trials that compared the effectiveness of newer generation antidepressants with each other or with a placebo were included. Newer generation antidepressants included: selective serotonin reuptake inhibitors; selective norepinephrine reuptake inhibitors (SNRIs); norepinephrine reuptake inhibitors; norepinephrine dopamine reuptake inhibitors; norepinephrine dopamine disinhibitors (NDDIs); and tetracyclic antidepressants (TeCAs). DATA COLLECTION AND ANALYSIS: Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed risk of bias. We analysed dichotomous data as Odds Ratios (ORs), and continuous data as Mean Difference (MD) for the following outcomes: depression symptom severity (clinician rated), response or remission of depression symptoms, depression symptom severity (self-rated), functioning, suicide related outcomes and overall adverse outcomes. Random-effects network meta-analyses were conducted in a frequentist framework using multivariate meta-analysis. Certainty of evidence was assessed using Confidence in Network Meta-analysis (CINeMA). We used "informative statements" to standardise the interpretation and description of the results. MAIN RESULTS: Twenty-six studies were included. There were no data for the two primary outcomes (depressive disorder established via clinical diagnostic interview and suicide), therefore, the results comprise only secondary outcomes. Most antidepressants may be associated with a "small and unimportant" reduction in depression symptoms on the CDRS-R scale (range 17 to 113) compared with placebo (high certainty evidence: paroxetine: MD -1.43, 95% CI -3.90, 1.04; vilazodone: MD -0.84, 95% CI -3.03, 1.35; desvenlafaxine MD -0.07, 95% CI -3.51, 3.36; moderate certainty evidence: sertraline: MD -3.51, 95% CI -6.99, -0.04; fluoxetine: MD -2.84, 95% CI -4.12, -1.56; escitalopram: MD -2.62, 95% CI -5.29, 0.04; low certainty evidence: duloxetine: MD -2.70, 95% CI -5.03, -0.37; vortioxetine: MD 0.60, 95% CI -2.52, 3.72; very low certainty evidence for comparisons between other antidepressants and placebo). There were "small and unimportant" differences between most antidepressants in reduction of depression symptoms (high- or moderate-certainty evidence). Results were similar across other outcomes of benefit. In most studies risk of self-harm or suicide was an exclusion criterion for the study. Proportions of suicide-related outcomes were low for most included studies and 95% confidence intervals were wide for all comparisons. The evidence is very uncertain about the effects of mirtazapine (OR 0.50, 95% CI 0.03, 8.04), duloxetine (OR 1.15, 95% CI 0.72, 1.82), vilazodone (OR 1.01, 95% CI 0.68, 1.48), desvenlafaxine (OR 0.94, 95% CI 0.59, 1.52), citalopram (OR 1.72, 95% CI 0.76, 3.87) or vortioxetine (OR 1.58, 95% CI 0.29, 8.60) on suicide-related outcomes compared with placebo. There is low certainty evidence that escitalopram may "at least slightly" reduce odds of suicide-related outcomes compared with placebo (OR 0.89, 95% CI 0.43, 1.84). There is low certainty evidence that fluoxetine (OR 1.27, 95% CI 0.87, 1.86), paroxetine (OR 1.81, 95% CI 0.85, 3.86), sertraline (OR 3.03, 95% CI 0.60, 15.22), and venlafaxine (OR 13.84, 95% CI 1.79, 106.90) may "at least slightly" increase odds of suicide-related outcomes compared with placebo. There is moderate certainty evidence that venlafaxine probably results in an "at least slightly" increased odds of suicide-related outcomes compared with desvenlafaxine (OR 0.07, 95% CI 0.01, 0.56) and escitalopram (OR 0.06, 95% CI 0.01, 0.56). There was very low certainty evidence regarding other comparisons between antidepressants. AUTHORS' CONCLUSIONS: Overall, methodological shortcomings of the randomised trials make it difficult to interpret the findings with regard to the efficacy and safety of newer antidepressant medications. Findings suggest that most newer antidepressants may reduce depression symptoms in a small and unimportant way compared with placebo. Furthermore, there are likely to be small and unimportant differences in the reduction of depression symptoms between the majority of antidepressants. However, our findings reflect the average effects of the antidepressants, and given depression is a heterogeneous condition, some individuals may experience a greater response. Guideline developers and others making recommendations might therefore consider whether a recommendation for the use of newer generation antidepressants is warranted for some individuals in some circumstances. Our findings suggest sertraline, escitalopram, duloxetine, as well as fluoxetine (which is currently the only treatment recommended for first-line prescribing) could be considered as a first option. Children and adolescents considered at risk of suicide were frequently excluded from trials, so that we cannot be confident about the effects of these medications for these individuals. If an antidepressant is being considered for an individual, this should be done in consultation with the child/adolescent and their family/caregivers and it remains critical to ensure close monitoring of treatment effects and suicide-related outcomes (combined suicidal ideation and suicide attempt) in those treated with newer generation antidepressants, given findings that some of these medications may be associated with greater odds of these events. Consideration of psychotherapy, particularly cognitive behavioural therapy, as per guideline recommendations, remains important.

Characteristics and predictors of suicidality in young people with clinical depression: a systematic review protocol.

OBJECTIVE: The objective of this review is to examine clinical, psychosocial, and biological factors associated with suicidality in young people diagnosed with depression. This review will describe risk and protective factors, focusing on modifiable attributes, in order to inform suicide prevention and early intervention strategies. INTRODUCTION: Suicide is the world's second-leading cause of death among young people. Depression is closely associated with suicide; however, it lacks specificity as a predictor of suicidal behavior. There is a clear need to improve our understanding of both risk and protective factors associated with the full spectrum of suicidality in young people, across a range of depressive disorders. INCLUSION CRITERIA: Studies that include young people 15 to 25 years of age with a diagnosis of depression made in accordance with a diagnostic classification standard will be considered. Diagnosis must be made using a structured clinical interview or be received through standard clinical practice. Analytical cross-sectional studies, prospective and retrospective cohort studies, and case-control studies will be included. Studies must include an assessment of suicidality made using standardized or non-standardized tools. A broad range of inpatient and outpatient settings will be considered. METHODS: MEDLINE, Embase, and PsycINFO will be searched for studies published in English, with no date limitation. Two independent reviewers will conduct study screening, assess methodological quality, and extract data using standardized tools. If there is sufficient homogeneity across studies, meta-analyses using a random-effects model will be conducted. If quantitative meta-analysis is not possible, a narrative synthesis will be undertaken. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020151612.

Relationships Between Different Dimensions of Social Support and Suicidal Ideation in Young People with Major Depressive Disorder.

BACKGROUND: Suicidal ideation (SI) is a common feature of depression and is closely associated with suicidal behaviour. Social support is implicated as an important determinant of suicide, but it is unclear how different social support dimensions influence SI in young people with depression. This study examines relationships between social support dimensions and SI in young people with major depressive disorder (MDD). METHODS: 283 Australians aged 15-25, diagnosed with MDD, were recruited from two clinical trials conducted in youth-specific outpatient mental health services. The Multidimensional Scale of Perceived Social Support (MSPSS) was used to evaluate perceived support from Family, Friends, and a Significant Other. Suicidal ideation was assessed using the Suicidal Ideation Questionnaire (SIQ). Hierarchical regression was used to explore associations between social support and SI, controlling for demographics and depression severity. RESULTS: A hierarchical regression model predicted 9% of the variability in SI, with depression severity being the most significant predictor. Family Support was inversely related to SI and uniquely contributed 2% of the variance; ß = -0.15 (95% CI -0.27 - -0.02) p < .05. Demographics and support from Friends or a Significant Other were not significantly associated with SI. LIMITATIONS: Findings are correlational; it cannot be determined that increasing family support would decrease SI severity. CONCLUSION: Perceived Family Support was negatively associated with SI in young people with MDD. This suggests that family members might play important roles in suicide prevention efforts. More work is needed exploring ways to empower families to develop adaptive family functioning and support.

A World Unto Itself: Human Communication as Active Inference.

Recent theoretical work in developmental psychology suggests that humans are predisposed to align their mental states with those of other individuals. One way this manifests is in cooperative communication; that is, intentional communication aimed at aligning individuals' mental states with respect to events in their shared environment. This idea has received strong empirical support. The purpose of this paper is to extend this account by proposing an integrative model of the biobehavioral dynamics of cooperative communication. Our formulation is based on active inference. Active inference suggests that action-perception cycles operate to minimize uncertainty and optimize an individual's internal model of the world. We propose that humans are characterized by an evolved adaptive prior belief that their mental states are aligned with, or similar to, those of conspecifics (i.e., that 'we are the same sort of creature, inhabiting the same sort of niche'). The use of cooperative communication emerges as the principal means to gather evidence for this belief, allowing for the development of a shared narrative that is used to disambiguate interactants' (hidden and inferred) mental states. Thus, by using cooperative communication, individuals effectively attune to a hermeneutic niche composed, in part, of others' mental states; and, reciprocally, attune the niche to their own ends via epistemic niche construction. This means that niche construction enables features of the niche to encode precise, reliable cues about the deontic or shared value of certain action policies (e.g., the utility of using communicative constructions to disambiguate mental states, given expectations about shared prior beliefs). In turn, the alignment of mental states (prior beliefs) enables the emergence of a novel, contextualizing scale of cultural dynamics that encompasses the actions and mental states of the ensemble of interactants and their shared environment. The dynamics of this contextualizing layer of cultural organization feedback, across scales, to constrain the variability of the prior expectations of the individuals who constitute it. Our theory additionally builds upon the active inference literature by introducing a new set of neurobiologically plausible computational hypotheses for cooperative communication. We conclude with directions for future research.

The hierarchically mechanistic mind: an evolutionary systems theory of the human brain, cognition, and behavior.

The purpose of this review was to integrate leading paradigms in psychology and neuroscience with a theory of the embodied, situated human brain, called the Hierarchically Mechanistic Mind (HMM). The HMM describes the brain as a complex adaptive system that functions to minimize the entropy of our sensory and physical states via action-perception cycles generated by hierarchical neural dynamics. First, we review the extant literature on the hierarchical structure of the brain. Next, we derive the HMM from a broader evolutionary systems theory that explains neural structure and function in terms of dynamic interactions across four nested levels of biological causation (i.e., adaptation, phylogeny, ontogeny, and mechanism). We then describe how the HMM aligns with a global brain theory in neuroscience called the free-energy principle, leveraging this theory to mathematically formulate neural dynamics across hierarchical spatiotemporal scales. We conclude by exploring the implications of the HMM for psychological inquiry.

The hierarchically mechanistic mind: A free-energy formulation of the human psyche.

This article presents a unifying theory of the embodied, situated human brain called the Hierarchically Mechanistic Mind (HMM). The HMM describes the brain as a complex adaptive system that actively minimises the decay of our sensory and physical states by producing self-fulfilling action-perception cycles via dynamical interactions between hierarchically organised neurocognitive mechanisms. This theory synthesises the free-energy principle (FEP) in neuroscience with an evolutionary systems theory of psychology that explains our brains, minds, and behaviour by appealing to Tinbergen's four questions: adaptation, phylogeny, ontogeny, and mechanism. After leveraging the FEP to formally define the HMM across different spatiotemporal scales, we conclude by exploring its implications for theorising and research in the sciences of the mind and behaviour.

Variational ecology and the physics of sentient systems.

This paper addresses the challenges faced by multiscale formulations of the variational (free energy) approach to dynamics that obtain for large-scale ensembles. We review a framework for modelling complex adaptive control systems for multiscale free energy bounding organism-niche dynamics, thereby integrating the modelling strategies and heuristics of variational neuroethology with a broader perspective on the ecological nestedness of biotic systems. We extend the multiscale variational formulation beyond the action-perception loops of individual organisms by appealing to the variational approach to niche construction to explain the dynamics of coupled systems constituted by organisms and their ecological niche. We suggest that the statistical robustness of living systems is inherited, in part, from their eco-niches, as niches help coordinate dynamical patterns across larger spatiotemporal scales. We call this approach variational ecology. We argue that, when applied to cultural animals such as humans, variational ecology enables us to formulate not just a physics of individual minds, but also a physics of interacting minds across spatial and temporal scales - a physics of sentient systems that range from cells to societies.

The Depressed Brain: An Evolutionary Systems Theory.

Major depression is a debilitating condition characterised by diverse neurocognitive and behavioural deficits. Nevertheless, our species-typical capacity for depressed mood implies that it serves an adaptive function. Here we apply an interdisciplinary theory of brain function to explain depressed mood and its clinical manifestations. Combining insights from the free-energy principle (FEP) with evolutionary theorising in psychology, we argue that depression reflects an adaptive response to perceived threats of aversive social outcomes (e.g., exclusion) that minimises the likelihood of surprising interpersonal exchanges (i.e., those with unpredictable outcomes). We suggest that psychopathology typically arises from ineffectual attempts to alleviate interpersonal difficulties and/or hyper-reactive neurobiological responses to social stress (i.e., uncertainty), which often stems from early experience that social uncertainty is difficult to resolve.

Differences Between Landline and Mobile Phone Users in Sexual Behavior Research.

This study investigated differences between the demographic characteristics, participation rates (i.e., agreeing to respond to questions about sexual behavior), and sexual behaviors of landline and mobile phone samples in Australia. A nationally representative sample of Australians aged 18 years and over was recruited via random digit dialing in December 2011 to collect data via computer-assisted telephone interviews. A total of 1012 people (370 men, 642 women) completed a landline interview and 1002 (524 men, 478 women) completed a mobile phone interview. Results revealed that telephone user status was significantly related to all demographic variables: gender, age, educational attainment, area of residence, country of birth, household composition, and current ongoing relationship status. In unadjusted analyses, telephone status was also associated with women's participation rates, participants' number of other-sex sexual partners in the previous year, and women's lifetime sexual experience. However, after controlling for significant demographic factors, telephone status was only independently related to women's participation rates. Post hoc analyses showed that significant, between-group differences for all other sexual behavior outcomes could be explained by demographic covariates. Results also suggested that telephone status may be associated with participation bias in research on sexual behavior. Taken together, these findings highlight the importance of sampling both landline and mobile phone users to improve the representativeness of sexual behavior data collected via telephone interviews.

Self-reported parenting style is associated with children's inflammation and immune activation.

Family environments and parenting have been associated with inflammation and immune activation in children and adolescents; however, it remains unclear which specific aspects of parenting drive this association. In this study, we cross-sectionally examined the association between 5 discrete parenting styles and inflammation and immune activation in late childhood. Data were drawn from 102 families (55 with female children, mean age 9.50 years, SD = 0.34) participating in the Imaging Brain Development in the Childhood to Adolescence Transition Study. Children provided saliva samples from which inflammation (C-reactive protein) and immune competence/activation (secretory immunoglobulin A) were measured. Parents completed the Alabama Parenting Questionnaire, which measures 5 aspects of parenting style-positive parental involvement, positive disciplinary techniques, consistency in disciplinary techniques, corporal punishment, and monitoring and supervision. Results showed that higher scores on the poor parental monitoring scale were associated with higher levels of both inflammation and immune activation in children. This study highlights parental monitoring and supervision as a specific aspect of parenting behavior that may be important for children's physical and mental health. (PsycINFO Database Record

The lifetime experience of traumatic events is associated with hair cortisol concentrations in community-based children.

Adversity early in life can disrupt the functioning of the hypothalamic-pituitary-adrenal axis (HPAA) and increase risk for negative health outcomes. Recent research suggests that cortisol in scalp hair represents a promising measure of HPAA function. However, little is known about the relationship between early exposure to traumatic events and hair cortisol concentrations (HCC) in childhood, a critical period of HPAA development. The current study measured HCC in scalp hair samples collected from 70 community-based children (14 males, mean age=9.50) participating in the Imaging Brain Development in the Childhood to Adolescence Transition Study (iCATS). Data were also collected on lifetime exposure to traumatic events and current depressive symptoms. Lifetime exposure to trauma was associated with elevated HCC; however, HCC was not associated with current depressive symptoms. Consistent with some prior work, males were found to have higher HCC than females, although results should be treated with caution due to the small number of males who took part. Our findings suggest that hair cortisol may represent a biomarker of exposure to trauma in this age group; however, further study is necessary with a particular focus on the characterization of trauma and other forms of adversity.

Design and methods of the Second Australian Study of Health and Relationships.

UNLABELLED: Background This paper describes the methods and process of the Second Australian Study of Health and Relationships. METHODS: A representative sample of the Australian population was contacted by landline and mobile phone modified random-digit dialling in 2012-13. Computer-assisted telephone interviews elicited sociodemographic and health details as well as sexual behaviour and attitudes. For analysis, the sample was weighted to reflect the study design and further weighted to reflect the location, age and sex distribution of the population at the 2011 Census. RESULTS: Interviews were completed with 9963 men and 10131 women aged 16-69 years from all states and territories. The overall participation rate among eligible people was 66.2% (63.9% for landline men, 67.9% for landline women and 66.5% for mobile respondents). Accounting for the survey design and adjusting to match the 2011 Census resulted in a weighted sample of 20094 people (10056 men and 10038 women). The sample was broadly representative of the Australian population, although as in most surveys, people with higher education and higher status occupations were over-represented. Data quality was high, with the great majority saying they were not at all or only slightly embarrassed by the questionnaire and almost all saying they were 90-100% honest in their answers. CONCLUSIONS: The combination of methods and design in the Second Australian Study of Health and Relationships, together with the high participation rate, strongly suggests that the results of the study are robust and broadly representative of the Australian population.