Critical Appraisal: Depression and Suicide Risk in Young Adults

This report presents a critical appraisal of two research papers focusing on depression and suicide risk in young adults. The first paper, a qualitative study by Orri et al. (2014), explores the perspectives of adolescents with suicidal attempts, utilizing the CASP tool for qualitative studies. The report evaluates the study's methodology, including clarity of research questions, sample recruitment, data collection, and rigor in analysis, highlighting the use of IPA methodology and triangulation. The second paper, a systematic review by Grimmond et al. (2019), examines experiences and perceptions of youth suicide, also appraised using the CASP tool. The appraisal assesses the systematic review's methodology, search strategy, and limitations, emphasizing the selection of relevant papers and the focus on qualitative research. The report concludes with an assessment of the trustworthiness, relevance, and clinical utility of both studies, providing insights for clinicians and researchers in the field of adolescent mental health and suicide prevention. The report also discusses the ethical considerations and validity checking methods employed in both research papers.

Running head: CRITICAL APPRAISAL
Critical appraisal
Name of the student:
Name of the University:
Author’s note

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Part 1: INTRODUCTION
The assignment 1 and 2 focused on identifying the cause behind depression and suicide
risk in young adults and evaluate whether their perceptions or experiences related to depression
influenced suicide and depression outcome in youths or not. Research in this area was done
because of high rate of depression in youths and the need to find out the contextual factors that
increase risk of depression and suicide in this population. One primary research article by Orri et
al. (2014) and one systematic review by Grimmond et al. (2019) was identified as the best article
to answer the research question. The main purpose of this paper is conduct critical appraisal of
the two papers to find out how well they meet the research objective and give answer to the
research questions. The intention is to critically appraise the methodology used in each paper and
evaluate whether the information is trustworthy and applicable too meet the above information
need.
The first primary article that will be appraised is the study by Orri et al. (2014) that used
qualitative approach to evaluate the perspective of adolescents who are directly involved in
suicidal acts. The CASP (Critical Appraisals Skills Programme) tool for qualitative study has
been chosen as the critical appraisal tool for the paper and the main rationale for selecting the
CAPS tool is that it has separate checklist for assessment of journal articles based on the research
design and it has questions to evaluate not just the research methodology, but also presence of
any bias or validity issues in the paper. The CASP tool can help to determine the rigor of
qualitative study and evaluate the internal consistency between study aims and findings (Kim,
Sefcik & Bradway, 2017). Hence, by using CASP for qualitative study, it will be possible to
appraise the paper according to the main features and quality requirement in a qualitative

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research paper. According to Galdas (2017), CASP is a popular tool that is widely used in
clinical research as it focuses on establishing reliability and validity in qualitative research.
The second article that will be appraised is the systematic review titled ‘A qualitative
systematic review of experiences and perceptions of youth suicide’ by Grimmond et al. (2019).
The CASP tool for systematic review has been chosen as the critical appraisal tool for this study
as this study uses 10 questions to make sense of the research design. This checklist enables
exploring rigour in the area of quality assessment of the included studies, combining the findings
and consideration of all important outcomes (CASP, 2020). Hence, the checklist is likely to
guide in determining whether the above article fulfils the information needs or research goals or
not.
PART 2: CRITICAL APPRAISAL OF THE PRIMARY RESEARCH
a. Methodology:
i. Clarity of research question: In the qualitative study done by Orri et al. (2014), clarity of
focus as it had a clear statement of aim or research question. The aim of the study was to
evaluate the perspective of those adolescents who have engaged in suicidal attempts. The
intention was to provide clinicians with necessary information that they can use while
caring for youths with suicidal behaviour. The use of qualitative methodology was
appropriate for the study because the researcher wanted to interpret experiences of
research participants related to suicidal attempts and qualitative research uses interpretive
method to explore opinions or views of participants related to the phenomenon of
interest. Qualitative research design has significant value in assessing the lived

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experience and it is suitable when information of beliefs, attitude or preferences is needed
(Hammarberg, Kirkman & de Lacey, 2016).
ii. Setting and sample recruitment strategy: The study was conducted in two local hospitals and
one psychiatric hospital. All the physicians or psychologists at these hospitals were contacted
and inquired if they had adolescent patients with suicide attempts. The subjects were chosen only
if they had attempted at least one suicide during adolescence or post adolescent period. Another
inclusion criterion was that all participants must be within 15-25 years. The eligible participants
were recruited only when they received complete information about research and gave informed
consent for research. The study included adolescents with single and multiple suicide attempts.
Orri et al. (2014) explained the reason for selecting the above sample group. The rationale was
that this would enable inclusion of heterogeneous and diverse sample group. This would favour
analysis of various situation and experiences. According to Gentles et al. (2015), selection of
diverse and heterogeneous sample is likely to enhance the credibility and generalizability of the
findings as such samples will be example of most representative sample. The authors gave
overview of two individuals who refused taking part in the research. Overall, the recruitment
strategy was appropriate as purposive sampling favoured taking sample characteristics as per the
research objective (Etikan, Musa & Alkassim, 2016).
iii. Data collection/analysis: The research was conducted in two local general hospitals which
had inpatient and outpatient adolescent psychiatric department and one psychiatric hospital in
north-eastern Italy. The use of these settings is justified as more number of youths with mental
illness and suicide attempts is likely to come in these settings. Moreover, data was collected
through 16 individual semi-structure face-to-face interviews. Completeness in reporting of data
collection method was found as the researchers justified why semi-structured interview method

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was chosen. The main purpose of taking this method was to explored lived experience of each
participant. Semi-structured interviewing is appropriate as it allows collecting open-ended data to
deeply explore feelings and beliefs on a particular research topic (DeJonckheere & Vaughn,
2019). The strength of the paper was the author gave explicit details about how interview was
conducted and how valid questions were prepared. For instance, the authors gave explicit details
about audio recording the transcript and developing 8 open-ended questions in advanced using
interview guide. In addition to this, data analysis was done using IPA (Interpretative
phenomenological analysis) methodology. The benefit of using this method is that this
qualitative approach facilitates providing detailed information on personal lived experiences.
This approach is very suitable to the research aim and objectives (Smith & Osborn, 2015).
iv. Rigour in data collection/data analysis: In addition, rigor in data collection method was seen
as the researcher acknowledged that as the topic was sensitive, giving more attention to the
review of participant’s opinion was important. The researchers were vigilant of the impact of
their opinion on contributing to bias. This is evidenced by the fact that they practiced reflexivity
during data collection by discussing about the impact of their own feelings on data collection and
data analysis process. This type of consideration is reflective of trustworthiness of the paper.
Such form of discussion on relationship between participants and themselves adds to creditability
of the findings and promotes proper interpretation of the findings too (Dodgson, 2019).
Furthermore, rigor during data analysis was seen as the authors gave in-depth description related
to why IPA method was chosen and how the analytic process was completed. In accordance with
qualitative research method, the method of developing themes was clearly described. Each
interview transcripts were read and reread and notes from the transcript were mapped to develop
emergent themes. Validity during the process was maintained by using triangulation method. It is

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an excellent method to facilitate validation or verification of data by two or more sources (Carter
et al., 2014).
v. Congruency of decision making: Congruency of decision making was seen at each stage.
During data collection method, researcher arranged meeting to discussion about the possibility of
bias because of the influence of their own opinion. In addition, during data analysis, congruency
was maintained by verifying transcripts after discussion with three researchers.
vi. Ethics: All ethical responsibilities were fulfilled as informed consent and details of the
research process was given and approval for research was taken from institutional review boards
of three hospitals. The impact of confidentiality issues on research process was considered too as
confidentiality was considered during the process of informed consent process too (Silverman,
2016).
b. Results:
i. Depth and detail: In congruence with the features of qualitative research, the findings
were reported in great details and depth. Five themes related to experience of attempted
suicide were identified. Participant’s narratives as well as in-depth discussion gave clear
insight about experience of youths who committed suicide.
ii. Grounded in data: Key outcomes were grounded in data as the study revealed that suicide
attempts were influenced by negative emotions toward the self, need to have control over lives,
perceived problem in family relationship, inability to communicate about poor coping abilities
and the feelings of revenge. Participants justified that they found committing suicide better for
taking revenge as this would make the other individual feel guilty.

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iii. Representativeness: The findings are representative of sample diversity too as youths with
single and multiple suicide attempts were taken.
iv. Interpretation with respect to other studies: One of the strength of the paper by () is that it
compared the findings with other studies and found it consistent with previous studies. For
example, the subjective experience of loneliness and isolation has been reported in other research
literatures too. The result also suggested the importance of interpersonal relations on predicting
suicidal behaviour. For example, Hill et al. (2019) explained how poor interpersonal trust
increased the risk of suicide ideation among adolescents.
v. Validity checking: Validity checking of the findings has been maintained by using
triangulation approach and comparing findings with other research literatures. Moreover, multi-
dimensional analysis and well-documented processes ensured credibility of the findings (Leung,
2015).
c. Relevance:
Based on critical review of research methodology, consideration of biases and review of
rigor in research, it can be concluded that the study by Ori et al. (2014) is a very trustworthy and
high quality of evidence to understand the factors that leads youth to commit suicide. The author
used rigour in data collection method by considering data saturation limits, taking heterogeneous
samples and fulfilling all ethical requirements to avoid conflict. Moreover, the reliability of the
findings was maintained by triangulation approach, elimination impact of personal opinion on
data collection or analysis and using IPA method that ensured in-depth and valid findings could
be achieved. The findings are relevant to the research question as it gave idea about experiences

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related to suicide. The clinical utility of the findings is that it gives lessons to the clinicians to
consider revenge and relational aspects of youths who have committed suicides.
Part 3: CRITICAL APPRAISAL OF SYSTEMATIC REVIEW
3a. Methodology:
The systematic review by Grimmond et al. (2019) had a clear focus as the objective of
the research was to explore experiences and perceptions of suicide in people aged 25 years and
below. As per the research aim, the authors looked for only qualitative research papers which
used qualitative interviews to discuss about youth suicide and suicidal ideation. From the review
of inclusion criteria, it can be said that the most relevant papers were chosen to address the
review question. As the objective was to explore experiences and perception, choosing to review
only qualitative papers were justified as these papers can give in-depth knowledge about
opinions and feelings related to a phenomenon (Tracy, 2019). The search for article was done in
four electronic databases like PuBMed, PsychINFO, Scopus and CINAHL. The search strategy
was modified as per differences in syntax and MeSH terms for each database. In addition,
reference list of the studies were also checked to identify more studies in accordance with the
exclusion criteria. Thus, the search process was suitable to the research objective and focus of
the research.
One limitation of the methodology was that publication biases were not considered.
Grimmond et al. (2019) used all papers without any restriction in dates. Moreover, no discussion
was given regarding the ways to address publication. This is a limitation that may affect reaching
any conclusion. This is evidence in the inclusion criteria too. Three specific inclusion criteria for
the review included qualitative studies published in English language with no data restriction,

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young adults aged 25 years or below who had attempted suicide or professionals who have
worked with these group of people and qualitative interviews. Moreover, sources like editorials,
theses, quantitative studies and secondary sources were excluded. Not choosing any specific
publication date was not appropriate as this would affect the generalizability of the findings
(Dalton, Bolen & Mascha, 2016).
Quality assessment or method of appraisal is an important component of the systematic
review as it is reflective of validity of the included studies and presence of rigour during the
search process. The quality appraisal was done by three members of the research team and the
CASP tool for qualitative studies was used as the checklist for quality appraisal. The choice of
the appraisal tool is appropriate as the systematic review selected only qualitative research
papers. The advantage of the CASP criteria is that they are generic and very relevant to analysis
of trustworthiness aspects in qualitative studies. It is an effective tool to analyse the internal
consistency between study aim and findings (Kim, Sefcik & Bradway, 2017). The full CASP
rating for each study was clearly rated down.
Another important aspect of any systematic review method is that the search process and
methodology should be written in such a way that the method is easily reproducible by anyone.
Rigour in the area of reproducibility was maintained by giving full details of the search strategy
in a table and giving a brief overview of the study selection process using the PRISMA flow
diagram. In addition, the method of representation of CASP rating was very clear too as it
enabled easy interpretation of quality of each of the selected papers.
During the data abstraction and data analysis method, the results of the review were
combined. This was done using data analysis method. Grimmond et al. (2019) compiled key

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themes for each articles and then grouped them based on common traits. Rigor during data
analysis method was seen as line-to-line colour coding was done and each sub-themes weas re-
examined for similarities and differences. The validity during data analysis method was further
maintained by review of findings by multiple team members. According to Mittal, Goyal and
Mittal (2017), meticulous methodology of systematic review ensures eliminating biases and valid
translations of findings to clinical practice.
The ethical considerations in all the selected papers were considered by the use of ethics
elements in the CASP tool. Other than that no other ethical considerations were needed as
systematic reviews use accessible peer reviewed documents and there is no need to seek any
institutional ethics approval before commencing this type of study. However, other ethical
considerations that is important for a systematic review includes informing the research process
using right based theories and ethics of care. The guiding principles for quality research may
include informed reflexivity, purposeful selective inclusivity and transparency. This form of
rigour was seen by comprehensive review of findings. However, one ethical issue that was
identified was that the fund was taken from a single agency, which may have a vested interest in
the findings (Suri, 2020). Thus, conflict of interest may arise in such situation leading to ethical
dilemmas.
3b. Results:
The authors took the decision to combine studies by similarities and differences in
findings. By using line-to-line coding and theme generation, 27 studies were finally included in
the review. Based on common findings and differences, four themes were identifies. These
themes were triggers and risk leading to suicidality, factors involved in recovery, need for

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institutional treatment and beliefs regarding suicide at a community level. The findings were
represented in the form of the above themes and each theme had several sub-categories. For
example, sub-categories for the first theme included behaviours, emotions, family influence and
peer influence. This theme highlighted that difficulty with communication, feelings of
worthlessness, death of close family members and experience of bullying and poor academic
performance increased risk of suicide ideation. In case of the second theme, other subcategories
like interpersonal, cultural and individual factors were identified. The significance of this theme
is that it reported about the factors that are helpful in the recovery of children with suicide
ideation such as strengthening cultural values, promoting spirituality and changing personal
mindsets. Similar approach was used to discuss about other themes. The use of categories and
sub-categories enhanced interpretation of the findings (Compernolle et al., 2019).
As this systematic review was done using qualitative research papers, no analysis of
outcome was done using statistical calculations. Thus, to arrive at precision of findings, the
findings were compared with past research literatures. Moreover, reflexivity and transparency in
reporting about the findings were reviewed (Mann et al., 2016). For each theme, Grimmond et al.
(2019) cited several studies which were consistent with the findings reported in each themes. For
example, for the fourth theme, it was found that the participants wanted more accessible
information on youth suicides and the need for education related to warning signs. The study by
Schwartz et al. (2010) and Everall, Bostik and Paulson (2005) were found consistent with the
above results. Moreover, transparency in reporting was found as the author considered
investigating relationship between themes and discussed how inter-relationship between each
categories were complex. Rigor in reporting about research findings was found as the researchers
compared relationship of the findings with theoretical models too. For instance, the findings

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were linked to current theoretical models of suicide such as Interpersonal Theory of Suicide and
the 3 Step Theory. However, the issue that moderately affect the validity of findings is that no
comment was made regarding the quality of each papers. This was done only in CASP ratings
table. This could have been avoided if more time was allowed.
3c. Relevance:
Based on the critical appraisal of the systematic review article, it can be concluded that
the article was trustworthy and gave useful findings related to the experience of suicide ideation
in youths. This paper answers the research questions as explored opinions of those youths who
have engaged in at least on suicidal acts. The paper is a high quality research paper as extensive
method was used for data analysis and quality appraisal and reporting of findings was done in an
accurate manner. Great rigour was seen in data presentation too as findings were presented
thematically and compared with both research literature as well as theoretical models of suicide.
The clinical utility of the study by Grimmond et al. (2019) is that it gives the implication to
inform future clinical practice and identify the types of support and education to be provided to
youths with history of suicide attempts.

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