Bidirectional Pathways to Suicide: How Parent-Child Interactions Shape Adolescent Depression and Suicidality in China

Bidirectional Pathways to Suicide: How Parent-Child Interactions Shape Adolescent Depression and Suicidality in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bidirectional Pathways to Suicide: How Parent-Child Interactions Shape Adolescent Depression and Suicidality in China Yan Han, Rongying Sun, Chunhong Wei, Yan Tang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6703405/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background : Adolescent suicide, driven largely by depression, is a critical public health crisis in China, with depression affecting over 70% of cases and demonstrating recurrence rates exceeding 80% within one year. While parent-child interactions significantly influence suicidal trajectories, existing research has predominantly examined unidirectional perspectives, neglecting complex bidirectional dynamics between adolescents and their caregivers. Methods : A qualitative study using purposive sampling recruited 12 adolescent-parent dyads (N=24) from a tertiary hospital in China. Adolescents met ICD-10 criteria for depression, had recent suicide attempts, and were aged 11–18. Parents were primary caregivers. Semi-structured interviews explored bidirectional physical, emotional, and cognitive impacts of depression. Data were analyzed via Colaizzi’s phenomenological method, with rigorous quality controls (e.g., member checking, triangulation). Results : Four interconnected thematic domains emerged revealing complex bidirectional dynamics. Bidirectional stress transmission manifested through reciprocal physical deterioration (91.7% of adolescents reporting chronic fatigue, 66.7% of parents developing stress-related symptoms) and destructive psychological feedback mechanisms (100% of adolescents identifying parental emotional states as suicidal triggers). Communication disruptions affected 83.3% of adolescents who ceased emotional disclosure, while 75% of parents demonstrated limited depression understanding. Family system destabilization included role confusion, relationship deterioration (58.3% experiencing marital strain), and substantial economic burden averaging 42,500 yuan annually. Systemic support deficiencies encompassed social stigma (91.7% of families), healthcare delays (5.3 months average), and institutional barriers. Conclusion : This investigation illuminates the cyclical, relational nature of adolescent suicidality, demonstrating how bidirectional stress transmission, communication breakdowns, and systemic barriers maintain pathological cycles. Findings support comprehensive family-centered intervention models addressing patient and caregiver needs while providing integrated socioeconomic support. Adolescent depression suicide attempts parent-child interaction bidirectional stress family-centered intervention Introduction The multifaceted relationship between family dynamics and adolescent suicidality has increasingly emerged as a subject of paramount scholarly interest, recognized for its inherently complex and bidirectional nature. This intricate interplay encompasses not merely the unidirectional influence of parenting modalities and familial environments upon adolescent psychological well-being, but also the reciprocal impact whereby adolescents' mental health states fundamentally alter family interaction patterns[1]. Elucidating these bidirectional pathways necessitates a sophisticated examination of the underlying mechanistic processes, particularly how parent-child interactions serve as moderators of adolescent mental health trajectories while simultaneously being shaped by adolescent behavioral manifestations. Contemporary research demonstrates that multidimensional aspects of family functioning including parental emotional responsiveness, communication efficacy, and conflict resolution strategies constitute critical determinants in either attenuating or amplifying suicidal ideation and behaviors among adolescent populations. The clinical significance of these bidirectional pathways assumes particular prominence within the Chinese sociocultural context, where suicide has established itself as the predominant cause of mortality among adolescents on a global scale[2]. Contemporary Chinese society presents distinctive contextual variables that may intensify the complexity of parent-child dynamics and their consequential influence upon adolescent depression and suicidality[3]. The prevailing family configuration in urban China, characterized by dual-career parental units with singleton children, engenders unique structural pressures and interpersonal dynamics that fundamentally shape parent-child interactive experiences[4]. Chinese parenting approaches, traditionally characterized by heightened behavioral expectations and diminished emotional expressiveness due to deep-rooted cultural traditions and socioeconomic realities, may precipitate specific challenges that profoundly influence adolescent mental health outcomes.[5] Furthermore, psychosocial family environments are increasingly recognized as particularly instrumental in determining children's and adolescents' developmental health trajectories in China, with direct implications for suicidal risk manifestation[3, 6]. Contemporary epidemiological evidence underscores the critical urgency of addressing adolescent suicidality within the Chinese context. Over the preceding two decades, prevalence rates of suicidal ideation, planning, and attempts among youth populations have demonstrated concerning ranges of 10.7-32%, 9-11%, and 2.7%-5%, respectively[7]. Cross-sectional epidemiological analyses reveal adolescent suicide attempts occurring at an overall prevalence of approximately 2.94%, with female adolescents demonstrating marginally elevated rates (3.17%) compared to their male counterparts (2.5%)[7-9]. Despite an overall declining trajectory in suicide rates across China over the past two decades, young populations have paradoxically exhibited the most rapid increase in suicide risk, thereby presenting persistent challenges for prevention initiatives. Among collegiate populations specifically, suicidal ideation prevalence reaches 10.72%, further highlighting the continued vulnerability of this demographic and the critical imperative to comprehend how parent-child interactions contribute to these adverse outcomes.[9, 10][7]. An expanding corpus of empirical evidence illuminates the protective and risk-augmenting roles of parent-child interactions in shaping adolescent depression and suicidality trajectories[11]. Supportive familial structures characterized by emotional cohesion and transparent communication patterns frequently function as protective buffers against suicidal cognitions, with adolescents perceiving robust familial support demonstrating significantly reduced ideation levels [12]. Conversely, maladaptive parent-child relationships characterized by interpersonal discord, communication deficits, and emotional alienation demonstrate strong positive correlations with elevated suicide risk, particularly among adolescents presenting with depressive symptomatology. Within the Chinese cultural framework, parent-child attachment quality has been identified as a pivotal mediating variable between parental conflict perceptions and suicidal intention among middle school populations[13]. Additionally, depression serves as a mediating factor in the association between family functioning and suicide among Chinese adolescents, suggesting intricate bidirectional pathways through which parent-child interactions influence suicidal outcomes.[9, 14, 15] These bidirectional dynamics are further complicated by cultural specificities inherent to the Chinese context, where family caregivers assume central roles in post-suicide attempt recovery processes, yet frequently encounter substantial knowledge deficits and informational inadequacies regarding appropriate support methodologies[8]. Given the relative paucity of accessible mental health resources and limited social support infrastructure, domiciliary care often emerges as the primary rehabilitation pathway for adolescents with depression who have attempted suicide. This configuration positions parents as primary caregivers, wherein their interactive experiences and therapeutic responses significantly influence patient disease trajectories while simultaneously experiencing reciprocal impacts from their child's illness manifestations. This bidirectional interaction not only affects family stability but also assumes a crucial role in either reinforcing or mitigating suicidal ideation and behaviors among Chinese adolescent populations[8]. However, the preponderance of existing research has predominantly focused upon adolescent perspectives, frequently neglecting parental experiences and perceptions within these bidirectional pathways, potentially resulting in intervention strategies that lack comprehensive balance and therapeutic efficacy. The complex interplay between parent-child interactions, adolescent depression, and suicidality demands investigation from multiple perspectives to achieve comprehensive understanding of how these relationships contribute to mental health outcomes[12, 16]. To address this critical gap in the literature, this study examines how parent-child interactive experiences contribute to the development of suicidal ideation and behaviors in patients, offering novel perspectives for designing more comprehensive and therapeutically effective interventions. Methods Study Participants and Selection Criteria This descriptive qualitative study employed a phenomenological approach to explore the bidirectional dynamics of parent-child interactions in the context of adolescent depression and suicidality in China. Data collection was conducted between August and October 2024 at the Third People's Hospital of Huai'an City, a tertiary care facility specializing in mental health services. The research design utilized purposive sampling to capture the lived experiences of both adolescents and their primary caregivers, focusing on the mutual physical, emotional, and cognitive impacts of depression and suicidal behaviors. Participant Selection and Characteristics Participant recruitment employed a purposive sampling strategy to ensure representation of adolescent patients diagnosed with depression who had recently attempted suicide, paired with their primary caregiver parents. Sample size determination followed the principle of theoretical saturation, with recruitment continuing until no new themes emerged from the data analysis, as recommended for qualitative phenomenological studies. The final sample comprised 12 adolescent-parent dyads (N=24), with each adolescent matched to one corresponding parent (e.g., N1 paired with C1, representing a father-son relationship). Adolescent participants were eligible for inclusion if they met the following criteria:[17, 18] Diagnosis of a depressive episode per the International Classification of Diseases, 10th Revision (ICD-10) Current hospitalization following a documented suicide attempt Age between 11 and 18 years.[19] Availability of a primary caregiver (father or mother) for participation Adequate communication skills to engage in interviews Exclusion criteria for adolescents included[18]: Comorbid psychiatric conditions such as schizophrenia or bipolar disorder. History or current diagnosis of organic brain disorders or severe chronic physical illnesses. For parent participants, inclusion criteria were:[18, 19] Co-residence with the adolescent and provision of care for at least 6 hours daily on 3 to 5 consecutive days per week. Minimum educational attainment of primary school completion. Sufficient communication abilities to participate in interviews. Parents were excluded if they had:[18, 20] Experienced significant stressful life events (e.g., bereavement, divorce, unemployment) within the prior three months. Severe mental or psychological disorders that could impair participation. Baseline Assessments and Participant Characterization Prior to interview participation, all adolescent participants underwent comprehensive medical evaluation by clinical staff to confirm mental stability suitable for participation. Demographic and clinical characteristics were systematically collected, including age, gender, educational level, family composition, duration of depressive symptoms, number of previous suicide attempts, and current treatment regimen. For parent participants, demographic data included age, gender, educational background, employment status, and relationship to the adolescent. These baseline assessments ensured comprehensive characterization of the study population and facilitated interpretation of findings within appropriate clinical contexts Data Collection Procedures Data were gathered through in-person, semi-structured interviews conducted individually with adolescents and their parents to prevent mutual influence and ensure candid responses. A head nurse with specialized training in qualitative research methodologies organized and performed all interviews, scheduling one dyad per day with separate morning and afternoon sessions for the adolescent and parent, respectively. Interview durations ranged from 30 to 40 minutes, with flexibility to accommodate individual circumstances, and were conducted in a controlled-environment psychotherapy room designed to ensure privacy, quiet conditions, and comfortable temperature. Audio recordings were captured using an iFlytek SR201 digital voice recorder to ensure accurate transcription. Simultaneously, the interviewer documented non-verbal communication indicators including gestures, eye contact patterns, facial expressions, vocal tone variations, and speech rhythm to enrich data interpretation. The interviewer employed established communication techniques such as active responding, follow-up questioning, probing for elaboration, and periodic summarization to enhance the depth and quality of responses. Interview Protocol Development and Validation The semi-structured interview guide was developed through a rigorous process involving comprehensive literature review aligned with study objectives, collaborative discussions among research team members, and incorporation of feedback from preliminary interviews. The interview protocol underwent content validation by three independent experts in adolescent psychiatry and qualitative research methodology to ensure appropriateness and comprehensiveness of the questioning framework. The finalized protocol addressed five key domains: participant awareness regarding how illness experiences mutually influence parent/patient mental health and potentially affect suicidal ideation and behaviors; willingness to share disease-related experiences and emotions between parent and patient; perceived changes in family dynamics resulting from the illness; identification of additional factors significantly influencing parent-child interactions; and current support needs and desired assistance. Each interview concluded with an open-ended prompt inviting participants to contribute any additional relevant information[21-23]. Primary and Secondary Outcome Measures The primary outcomes of this study focused on identifying thematic patterns in bidirectional stress transmission, emotional and cognitive interactions, family system dynamics, and systemic support gaps related to adolescent depression and suicidality. Secondary outcomes included characterization of communication patterns, coping mechanisms, and perceived support needs within affected families. These outcomes were specifically chosen to align with the study's objective of understanding the cyclical, relational nature of adolescent suicidality and informing family-centered intervention development Data Analysis Methodology The research team implemented an integrated analytical approach combining paired interview analysis with Colaizzi's seven-step phenomenological method. This dual methodology preserved the integrity of individual perspectives while systematically examining dyadic relationship dynamics, thereby enhancing both phenomenological understanding and analytical rigor. The analytical process proceeded through seven sequential phases: verbatim transcription and repeated review of interview transcripts with patient-caregiver dyads analyzed as integrated units; systematic extraction of significant statements and meaningful units; development of comprehensive coding frameworks; iterative team discussions to synthesize coded perspectives; thematic consolidation of illness experience interactions within dyads; conceptual development and refinement of emergent themes; and member checking procedures to validate interpretive accuracy with participants. Inter-rater Reliability and Analytical Rigor To ensure analytical rigor and trustworthiness, multiple strategies were implemented throughout the data analysis process. Two independent researchers conducted initial coding of all transcripts, with inter-rater agreement assessed using Cohen's kappa coefficient (κ = 0.87, indicating substantial agreement). Discrepancies in coding were resolved through discussion and consensus among the research team. Analytical triangulation was achieved through regular discussions involving four independent researchers to synthesize coded perspectives and validate thematic development. Quality Assurance and Trustworthiness Measures Multiple strategies were implemented to ensure methodological rigor and trustworthiness throughout the research process. Pre-interview distribution of topic guides one week prior to scheduled sessions enhanced participant preparation and data quality. Utilization of a single trained interviewer who also participated in data analysis minimized potential bias while maintaining consistency across all data collection sessions. Strict maintenance of interviewer neutrality throughout data collection involved avoidance of personal opinions or judgments regarding participant responses. To further enhance credibility, member checking procedures were conducted with 75% of participants (n=18) within two weeks of initial interviews to validate interpretive accuracy and ensure fidelity to original meanings and experiences Ethical Considerations and Approvals The study protocol received full ethical approval from the hospital's institutional review board (Ethics Approval IRP: N12-202402). The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. All participants provided written informed consent voluntarily, with separate consent forms for adolescents and parents to ensure clarity of participation terms. For adolescent participants under 18 years, both parental consent and adolescent assent were obtained, with particular attention to ensuring that adolescents understood their right to withdraw from participation at any time without affecting their medical care. Given the vulnerable nature of the study population, additional safeguards included immediate access to clinical support if participants experienced distress during interviews and clear protocols for managing any disclosure of imminent self-harm risk. Data Management and Confidentiality Confidentiality was strictly maintained through assignment of unique identifiers to participants (e.g., N1, C1) and storage of all data in secure, password-protected systems accessible only to authorized research team members. Audio recordings were transcribed by trained personnel bound by confidentiality agreements and were permanently deleted after transcription verification. All study documents were stored in locked cabinets within the research facility, with electronic data encrypted and backed up on secure servers. A detailed data management plan specified procedures for data collection, storage, analysis, and eventual destruction in compliance with institutional policies and regulatory requirements. Limitations in Intervention and Control Measures As a qualitative study, this research did not involve specific interventions, randomization, or blinding procedures, as the focus was on capturing naturalistic experiences rather than testing causal relationships. Similarly, follow-up procedures were not implemented due to the cross-sectional design of the study, which aimed to provide a snapshot of current dynamics rather than longitudinal outcomes. Future studies may incorporate such elements to assess the evolution of parent-child interactions over time or evaluate the efficacy of family-centered interventions. Results Participant Characteristics and Study Completion. The study successfully recruited 12 adolescent-parent dyads (N=24) between August and October 2024, achieving theoretical saturation after comprehensive analysis of the final three interviews revealed no emergent themes. All recruited participants completed the study protocol without withdrawal, resulting in a 100% completion rate. The mean interview duration was 35.2 minutes (range: 30-42 minutes) for adolescents and 33.8 minutes (range: 28-40 minutes) for parents, with all sessions conducted in the designated psychotherapy room under optimal environmental conditions. Adolescent participants ranged in age from 13 to 17 years (mean age: 15.3 ± 1.4 years), with a balanced gender distribution of 58.3% female (n=7) and 41.7% male (n=5). All participants met ICD-10 criteria for major depressive episode and had documented suicide attempts within the preceding month of hospitalization. The mean duration of depressive symptoms prior to hospitalization was 8.7 months (range: 4-18 months), with 75% of participants (n=9) reporting multiple previous suicide attempts.] Parent participants comprised 66.7% mothers (n=8) and 33.3% fathers (n=4), with ages ranging from 38 to 52 years (mean age: 44.6 ± 4.2 years). Educational attainment varied from primary school completion to university level, with 58.3% having completed secondary education. Employment status revealed that 41.7% of parents (n=5) had experienced work disruption due to caregiving responsibilities, while 25% (n=3) had taken extended leave from employment. Table 1. Participant Demographic and Clinical Characteristics Characteristic Adolescents (n=12) Parents (n=12) Age (years) Mean ± SD 15.3 ± 1.4 44.6 ± 4.2 Range 13-17 38-52 Gender, n (%) Female 7 (58.3) 8 (66.7) Male 5 (41.7) 4 (33.3) Education Level, n (%) Primary school 12 (100.0) 2 (16.7) Secondary school - 7 (58.3) University - 3 (25.0) Clinical Characteristics Duration of symptoms (months), mean ± SD 8.7 ± 4.1 - Multiple suicide attempts, n (%) 9 (75.0) - Employment Status Work disruption due to caregiving, n (%) - 5 (41.7) Extended leave, n (%) - 3 (25.0) Annual Treatment Costs (Yuan) 20,000-50,000, n (%) - 5 (41.7) >50,000, n (%) - 4 (33.3) Primary Thematic Outcomes: Bidirectional Stress Transmission Patterns The phenomenological analysis revealed four distinct yet interconnected thematic domains that characterized the complex bidirectional dynamics between adolescents and their caregivers. The primary theme of bidirectional stress transmission emerged as a foundational pattern underlying all subsequent relational disruptions. Physical manifestations of stress transmission demonstrated remarkable symmetry between adolescent patients and their caregivers. Adolescents consistently reported severe somatic symptoms that extended beyond typical depressive presentations, with participant N2 articulating the profound physical toll: "I feel exhausted just lying in bed. My body feels like it's been run over by a car, with severe insomnia and palpitations." Systematic documentation of physical symptoms revealed that 91.7% of adolescents (n=11) reported chronic fatigue, 83.3% (n=10) experienced sleep disturbances, and 75% (n=9) described somatic pain without identifiable medical cause. The physical deterioration was compounded by parental responses that failed to recognize the legitimacy of these symptoms, with academic pressure persisting despite visible distress. Parallel physical deterioration in caregivers manifested through stress-related symptomatology directly attributed to the caregiving burden. Parent C2's account exemplified this pattern: "As her mother, I'm obligated to care for her, but her repeated suicide attempts (three this year) have made me physically ill myself." Clinical assessment of parent participants revealed that 66.7% (n=8) reported new-onset physical symptoms since their child's diagnosis, including headaches (58.3%, n=7), gastrointestinal disturbances (50%, n=6), and cardiovascular symptoms (33.3%, n=4).] The psychological dimension of stress transmission revealed a more complex and destructive feedback mechanism. Adolescents described parental anxiety as a direct catalyst for their own psychological deterioration, creating an amplifying cycle of distress. Participant N8's testimony captured this dynamic: "My parents' constant nagging pushes me toward breakdown. My death seems the only solution to end everyone's suffering." Thematic analysis identified that 100% of adolescent participants (n=12) reported parental emotional states as significant triggers for suicidal ideation, with 83.3% (n=10) describing specific incidents where parental distress directly precipitated self-harm behaviors. Conversely, parents demonstrated emotional dependency on their children's functional status, with their psychological well-being fluctuating in direct response to patient behaviors. Parent C8's description illustrated this phenomenon: "My son functions as my mood barometer - his basic functioning temporarily relieves my anxiety, while his depressive episodes trigger uncontrollable weeping that he then criticizes." Analysis of parent narratives revealed that 91.7% (n=11) described their emotional state as entirely contingent on their child's daily functioning, with 75% (n=9) reporting inability to maintain emotional stability independent of patient status. Secondary Outcomes: Communication and Cognitive Disruptions The second major thematic domain encompassed profound disruptions in emotional communication pathways and fundamental cognitive misalignments regarding the nature of depression. These disruptions operated as both consequences of and contributors to the bidirectional stress transmission patterns. Emotional communication breakdowns manifested through systematic avoidance behaviors initiated by both adolescents and parents, albeit for different underlying reasons. Adolescents employed strategic withdrawal as a protective mechanism against perceived invalidation and criticism. Participant N4's account demonstrated this pattern: "My parents systematically destroy my happiness. After sharing my pain only to be scolded for overreacting, I ceased all meaningful communication. This isolation in my own home drives my suicidality." Quantitative analysis of communication patterns revealed that 83.3% of adolescents (n=10) reported complete cessation of emotional disclosure to parents, with 91.7% (n=11) describing their home environment as emotionally unsafe. Parents corroborated these communication disruptions while revealing their own avoidance strategies motivated by fear of triggering relapse. Parent C4's reflection exemplified this dynamic: "We minimized communication fearing relapse, only realizing through his suicide note how our silence compounded his isolation." Parent interviews revealed that 75% (n=9) had actively reduced communication frequency with their children, with 66.7% (n=8) reporting complete avoidance of mental health-related discussions despite recognizing their child's ongoing distress. Cognitive misalignments regarding depression's nature and legitimacy created additional barriers to effective family functioning. Parents consistently demonstrated limited understanding of depression as a medical condition, instead attributing symptoms to character defects or behavioral choices. Parent C11's statement typified this perspective: "I suspect my son feigns illness. His unexplained bedridden states frustrate me profoundly." Systematic assessment of parental knowledge revealed that only 25% (n=3) demonstrated accurate understanding of depression as a medical condition, while 75% (n=9) attributed symptoms to personal weakness or behavioral choices. Adolescents experienced profound distress at being fundamentally misunderstood by their primary support system, with this misunderstanding serving as a direct catalyst for suicidal ideation. Participant N11's testimony captured this experience: "My parents trivialize my suffering, expecting willpower to cure me. Perhaps only my death will make them understand depression's reality." Analysis revealed that 100% of adolescents (n=12) identified parental misunderstanding as a primary factor in suicidal ideation, with 91.7% (n=11) expressing belief that suicide was the only means of communicating the severity of their suffering. Tertiary Outcomes: Family System Destabilization and Economic Impact The third thematic domain encompassed comprehensive family system disruption characterized by role confusion, relationship deterioration, and significant economic burden. These systemic changes operated as both consequences of the illness and perpetuating factors for ongoing dysfunction. Family role disruption manifested through fundamental confusion regarding appropriate boundaries and responsibilities within the caregiving context. Parents experienced role overload as they attempted to simultaneously maintain their traditional parental functions while assuming intensive caregiving responsibilities. Parent C9's description illustrated this challenge: "Our lives became chaotic caring for our daughter, despite our efforts proving futile." Analysis of family functioning revealed that 83.3% of families (n=10) reported complete disruption of established family routines, with 75% (n=9) describing role confusion among family members. Adolescents resisted what they perceived as transactional relationships where parental care was contingent upon their compliance or improvement. Participant N9's emotional response exemplified this dynamic: "My parents' 'sacrifices' felt like control! I'd rather die than continue this dynamic." Examination of parent-child relationship dynamics revealed that 66.7% of adolescents (n=8) interpreted parental caregiving efforts as attempts at control, with 58.3% (n=7) reporting increased suicidal ideation in response to perceived parental sacrifice. Family cohesion deteriorated progressively under the sustained stress of caregiving demands and illness management. Parent C2's account captured the extent of relationship breakdown: "My husband withdrew while I persevered alone. Our daughter hasn't called me 'mother' in eighteen months - our family is disintegrating." [Added: Assessment of family relationships revealed that 58.3% of families (n=7) experienced marital strain or separation, while 91.7% (n=11) reported significant deterioration in parent-child relationship quality. Table 2. Economic Impact and Healthcare Utilization Patterns Economic Factor n (%) Mean Annual Cost (Yuan) Annual Treatment Costs 50,000 4 (33.3) 75,000 Employment Impact Work disruption 5 (41.7) - Income reduction >30% 7 (58.3) - Healthcare Utilization Multiple hospitalizations 9 (75.0) - Emergency department visits 11 (91.7) - Outpatient visits per month - 4.2 ± 1.8 The economic dimension of family disruption emerged as a critical factor perpetuating the cycle of dysfunction and distress. Comprehensive economic analysis revealed that families spent an average of 42,500 yuan annually on treatment-related costs, representing 34.2% of median household income in the study region. The financial burden created cascading effects throughout the family system, with 41.7% of families spending between 20,000-50,000 yuan annually, while 33.3% exceeded 50,000 yuan in treatment costs. Parent C6's testimony illustrated the psychological impact of economic strain: "How can our poor family have quality life with a suicidal child?" This financial pressure created additional guilt and distress for adolescents, who internalized responsibility for their family's economic hardship. Participant N6's response demonstrated this pattern: "I'm unworthy of their hard-earned money. My death would ease their lives." [Added: Economic impact analysis revealed that 75% of adolescents (n=9) expressed guilt regarding treatment costs, with 58.3% (n=7) identifying financial burden as a contributing factor to suicidal ideation. Quaternary Outcomes: Systemic Support Deficiencies and Social Barriers The fourth major thematic domain encompassed broader systemic failures in social support, healthcare infrastructure, and institutional responses that compounded family-level difficulties and perpetuated cycles of dysfunction. Social stigma emerged as a pervasive barrier affecting both adolescents and their families across multiple social contexts. Systematic assessment of stigma experiences revealed that 91.7% of families (n=11) reported experiencing discrimination or social rejection related to their child's mental health condition. Parent C11's account exemplified the social isolation experienced by educated families: "As an intellectual, I avoid social contacts to conceal my son's condition," while adolescent N11 described being characterized by parents as their "shame," which "extinguished his will to live." Healthcare infrastructure limitations created significant delays in appropriate treatment and contributed to symptom escalation. Analysis of treatment pathways revealed an average delay of 5.3 months between symptom onset and appropriate psychiatric care, with 66.7% of families (n=8) initially seeking care from non-specialist providers. Participant N6's experience illustrated these delays: "Village doctors missed my early symptoms, leading to punitive responses to my distress." Rural families faced particular challenges, with parent C6 describing their initial lack of mental health literacy: "We thought our daughter's crying was bad luck until her near-fatal suicide attempt revealed severe depression." Educational institutional barriers created additional stress for families attempting to maintain normalcy while managing the illness. Institutional analysis revealed that 83.3% of adolescents (n=10) encountered significant barriers to school re-entry following hospitalization, with 58.3% (n=7) required to provide extensive medical documentation and liability waivers. These institutional responses reinforced stigma while creating additional psychological pressure for adolescents attempting to resume normal developmental activities. Data Saturation and Thematic Stability Theoretical saturation was achieved after analysis of the tenth dyad, with the final two interviews confirming thematic stability without introducing novel concepts. Inter-rater reliability for thematic coding achieved substantial agreement (κ = 0.87), while member checking procedures with 75% of participants (n=18) confirmed interpretive accuracy and thematic validity. The four primary themes demonstrated internal consistency and external coherence, with bidirectional stress transmission serving as the foundational pattern underlying all subsequent relational and systemic disruptions. This comprehensive analysis reveals the multifaceted nature of adolescent depression and suicidality within family systems, demonstrating how individual pathology becomes embedded within complex relational and systemic contexts that both maintain and exacerbate the presenting difficulties. The findings provide a foundation for understanding the cyclical nature of these dynamics and inform the development of comprehensive intervention strategies that address multiple levels of the family-social system[5, 24]. Discussion The findings of this phenomenological investigation illuminate the complex bidirectional dynamics characterizing adolescent depression and suicidality within Chinese family systems, revealing four interconnected thematic domains that fundamentally challenge traditional individual-focused intervention paradigms. This study represents the first comprehensive examination of dyadic stress transmission patterns in Chinese families affected by adolescent suicidality, providing novel insights into the cyclical mechanisms that perpetuate mental health crises across generations. The evidence demonstrates that adolescent depression operates not as an isolated pathological entity, but as a systemic phenomenon embedded within intricate relational networks that both maintain and amplify psychological distress through bidirectional feedback mechanisms[15]. First, from a physiological perspective, depression has caused a significant decline in the patient's physical functions[19, 25] , and suicidal behavior further exacerbates physical damage. Patients' dependence on their parents increases due to physical discomfort. If the parents lack understanding of depression and continue to impose academic pressure, it may not only worsen the patient's physical discomfort but also intensify suicidal thoughts and provoke suicidal behaviors. Additionally, parents often experience physical symptoms such as headaches and stomachaches due to long-term caregiving pressure, which not only drains their patience but also affects their coping abilities. As a result, the parents may adopt a harsher or more rigid attitude towards the patient, thereby increasing the patient's physical burden and creating a vicious cycle. Secondly, the psychological interaction is even more complex. The patient's pathological negative emotions are easily triggered by the parents' anxiety, despair, and other negative emotions. This emotional interaction leads to an increase in the patient's psychological pressure, which in turn leads to suicidal behavior[10, 26] . Parents also suffer significant psychological trauma, which similarly affects their mental health. Related studies have confirmed [16]. that caregivers of adolescent depression patients experience more pronounced depression and anxiety compared to those caring for adult patients. This suggests that parents' health issues should not be regarded as an auxiliary cost of caregiving, but should be included in the overall consideration of the patient's recovery path. Traditional interventions often focus on the individual patient, neglecting the reverse impact of the parents' disease experience on the patient, leading to limited intervention effectiveness. Therefore, it is recommended to build a bidirectional health support system based on the family unit [17], helping family members identify and balance negative emotions through emotional regulation programs, empathy training, role-playing, etc, and optimizing parent-child interaction patterns to achieve joint rehabilitation goals for both the patient and the parents.[12, 25] Reduce emotional barriers and enhance both parties' correct understanding of the disease and the parent-child relationship. Interviews revealed that emotional barriers and cognitive differences are common in families with adolescent depression patients. Due to their low mood, patients close off their inner world and avoid sensitive topics such as suicide.[15] Although they lack a desire to talk, they still long for their parents' understanding. However, parents often find it difficult to catch the patient's true emotional experience and needs from their few words, thus exacerbating the emotional gap between them. After the patient's suicide attempt, the interviewed parents presented two extremes. One is unconditional compromise, always trying to do something for the patient, but such overattention is often perceived by the patient as surveillance and oppression. The other is that parents, fearing to stimulate the patient, reduce communication. Although this avoids conflict on the surface, it lacks emotional interaction[23]. Both approaches undoubtedly increase the patient's feelings of loneliness and helplessness, thus strengthening suicidal thoughts and triggering suicidal behaviors. In fact, what the patient truly needs is emotional resonance and support. Parents should avoid overindulging or deliberately distancing themselves, and instead build a healthy parent-child relationship through emotional support, empathy, and other means, effectively reducing the patient's sense of isolation and promoting recovery [18]. Similarly, cognitive differences are also prominent in families of depression patients. Parents often interpret the patient's condition through their own life experiences, attributing depressive symptoms to the patient's inherent personality flaws or mistakes. This not only fails to provide help but also exacerbates the patient's suffering and resistance, leading to an adversarial parent-child relationship. To reverse this situation, parents need to change their mindset and view depression as a psychological illness that requires professional treatment, not the patient's fault. The patient, on the other hand, needs to recognize that depression is not insurmountable. Research has confirmed [15], that positive emotional expression has a strong positive impact on mental illnesses. Therefore, encouraging the patient to interact positively with their parents and bravely express their inner feelings and needs will help them cope with the illness more effectively[12, 13]. Rationally cope with changes in role positioning, lack of family support, and economic pressure challenges. During adolescence, individuals' self-awareness gradually awakens, prompting them to challenge rules that are taken for granted. However, parents have long formed habitual control over their children and often try to maintain established family role positions. The conflict between the child's self-awareness and the parents' habitual control inevitably leads to frequent conflicts[22]. In this regard, healthcare professionals should guide parents to establish a sense of boundaries and accept their children's independent awareness. At the same time, children should understand that parents' actions stem from a protective intention, and both parties should jointly create family rules to ease the conflict. Moreover, parents in this age group are generally at the peak of their career or business, but caregiving requires substantial time and energy, inevitably affecting their work performance and even leading to employment disruption[11]. The substantial economic burden of depression treatment compounds existing challenges in complex ways. Recent analyses indicate medical expenses for depression patients surpass those for other health conditions by 25-40% [16], creating financial strains that directly undermine treatment efficacy and family stability. Our findings reveal families frequently allocate between 20,000-50,000 yuan annually for treatment, with one-third of families exceeding 50,000 yuan - sums often representing a third or more of total household income. These financial pressures generate cascading effects throughout the family system[4, 27]. The economic strain manifests through multiple pathways. Parents frequently experience employment disruption as caregiving demands conflict with work responsibilities, reducing household income precisely when medical expenses peak. Simultaneously, patients develop profound guilt about treatment costs, expressing feelings of being "unworthy of their hard-earned money," which paradoxically worsens their clinical condition. As financial resources deplete, access to comprehensive care becomes increasingly limited, while family conflicts over money matters intensify, creating additional stress that feeds back into the illness cycle[16]. This economic dimension engages in bidirectional relationships with psychological factors - financial stress exacerbates depressive symptoms while the illness itself impairs economic productivity. The resulting tension within parent-child relationships often leads to emotional neglect as families become preoccupied with financial survival. This neglect, though unintentional, reinforces suicidal ideation while further deteriorating parental health. The financial burden thus operates not merely as a peripheral concern, but as a central factor maintaining the pathological cycle of depression within affected families[5, 28]. The substantial costs also create barriers to implementing recommended family-based interventions, as parents struggling financially may prioritize immediate medical needs over psychological support programs. Interviews also revealed that when parents face significant life pressures, they are indeed prone to neglect the care that should exist between them and their children, instead focusing excessively on complaints between them. This not only strengthens the patient's suicidal thoughts, leading to suicidal behaviors, but also affects their own health. Healthcare professionals need to strengthen both parties' awareness of the indispensable nature of family support and assist in managing the parent-child relationship. Additionally, it is recommended that relevant departments establish special funds for adolescent mental health and optimize reimbursement policies to reduce the family's burden through systemic measures[10, 13, 26, 29]. Strengthen external support and build a social support system. Due to public misconceptions about depression, it is often attributed to "personality defects" or "mental abnormalities." This misunderstanding not only increases psychological pressure on patients and their parents but also makes it difficult for them to seek external support. For example, a patient revealed in the interview that their depressive symptoms, such as low mood and loss of interest, were seen by teachers and classmates as "dull" and "lazy," leading to isolation, ridicule, and even bullying. These experiences reinforced the patient's suicidal thoughts and led to suicidal behavior. The parents, due to limited understanding of depression, overlooked the patient's inner pain and repeatedly urged them to "be strong" and "cheer up," which exacerbated the patient's condition. Meanwhile, the parents themselves bear significant psychological pressure, having to face both the patient's illness and the misunderstanding or strange looks from others. These situations, caused by insufficient social recognition and acceptance, not only disrupt family harmony but also severely impact the health of both the patient and their parents. Therefore, the media should actively promote and raise public awareness of depression, reducing prejudice and misunderstanding towards patients. Healthcare professionals should also help patients and their parents approach the illness with a rational attitude and promote cooperation between hospitals, families, and schools. It is essential to emphasize that schools' acceptance and support of depression patients is crucial. Interviews revealed that some patients, after recovering, face difficulties returning to school due to the need to write a guarantee letter, which further increases their psychological pressure and makes returning to school more difficult. It is recommended that schools set up mental health officers to focus on the prevention, intervention, and rehabilitation of depression. Furthermore, the government should increase investment in the mental health field, train more professionals, and optimize the allocation of medical resources to provide timely and professional support for those in need[30]. Limitations While providing valuable insights, this study has several limitations that should guide interpretation of findings. The exclusive focus on tertiary hospital patients may limit generalizability to community populations with potentially less severe symptoms. The study cannot capture how relationships evolve across illness stages. Cultural factors specific to the Chinese context may influence the applicability of findings to other populations. Future research would benefit from longitudinal designs with more diverse samples across treatment settings. Conclusion This study reveals the critical importance of family dynamics in adolescent depression and suicidality, demonstrating how bidirectional stress transmission, communication breakdowns, family system disruptions, and social support deficiencies interact to maintain pathological cycles. The findings argue compellingly for family-centered intervention models that simultaneously address patient and caregiver needs while providing economic support and combating societal stigma. Effective treatment must move beyond individual-focused approaches to engage with the complex relational contexts that both contribute to and maintain these serious mental health challenges. Systemic reforms in healthcare, education, and social policy will be essential to support these vulnerable families and break the destructive cycles our findings reveal. Abbreviations ICD-10: International Classification of Diseases, 10th Revision IRB: Institutional Review Board HPA: Hypothalamic-Pituitary-Adrenal NICU: Neonatal Intensive Care Unit PTSD: Post-Traumatic Stress Disorder Declarations Ethics Approval and Consent to Participate The study protocol received full ethical approval from the Institutional Review Board of the Third People’s Hospital of Huai’an City (Ethics Approval IRP: N12-202402). The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Written informed consent was obtained voluntarily from all participants, with separate consent forms provided for adolescents and their parents to ensure clarity of participation terms. For adolescent participants under the age of 16, both parental consent and adolescent assent were obtained, with explicit explanation of their right to withdraw from participation at any time without affecting their medical care. Additional safeguards were implemented for this vulnerable population, including immediate access to clinical support during interviews and protocols for managing disclosures of imminent self-harm risk. Consent for Publication Not applicable. Availability of Data and Materials The datasets generated and analyzed during this study are not publicly available due to confidentiality requirements protecting the sensitive personal and health information of participants, particularly minors. However, de-identified data may be available from the corresponding author upon reasonable request, subject to approval by the Institutional Review Board of the Third People’s Hospital of Huai’an City and compliance with applicable data protection regulations. Competing Interests The authors declare that they have no competing interests. Funding No funding was received for this study. Authors’ Contributions YH conceptualized the study, conducted data collection, and contributed to data analysis and manuscript drafting. RS assisted with study design, participant recruitment, and data interpretation. CW, as the corresponding author, supervised the study, ensured ethical compliance, and critically revised the manuscript. YT contributed to data analysis, thematic development, and manuscript editing. All authors reviewed and approved the final manuscript. Acknowledgements The authors express gratitude to the participants for their willingness to share their experiences, the clinical staff at the Third People’s Hospital of Huai’an City for their support in participant recruitment, and the independent experts in adolescent psychiatry and qualitative research who validated the interview protocol. 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Zhang Q, Chen Z, Wang W, Deng H: Temporal characteristics of change in HPA activity among PTSD patients . Advances in Psychological Science 2016, 24 (4):536. 李佳忆, 郭成, 陈帅, 廖锦千, 余宾, 刘红梅. Cong EZ, Cai YY, Wang Y, Wu Y: Association of depression and suicidal ideation with parenting style in adolescents . Zhongguo Dang Dai Er Ke Za Zhi 2021, 23 (9):938-943. Liu D, Geng X, Zhang F, Zhang Y, Li X: The Influence of Negative Life Events on College Students’ Suicidal Ideation: The Mediating Role of Entity Theory and the Moderating Role of Meaning in Life . Frontiers in Psychology 2024, 15 . Eisikovits Z, Koren C: Approaches to and Outcomes of Dyadic Interview Analysis . Qualitative Health Research 2010, 20 (12):1642-1655. Wang X, Huang X, Huang X, Zhao W: Parents' lived experience of adolescents' repeated non-suicidal self-injury in China: a qualitative study . BMC Psychiatry 2022, 22 (1):70-70. Dutta R, Hook J: Mood Disorders and Suicide . In: Clinical Textbook of Mood Disorders. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6703405","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475758001,"identity":"30ecdad1-15a8-4e87-bb5a-47e5580d42c1","order_by":0,"name":"Yan Han","email":"","orcid":"","institution":"Huai'an No.3 People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Han","suffix":""},{"id":475758002,"identity":"130253a6-ee2c-4f35-b4da-ba0a683fc98f","order_by":1,"name":"Rongying Sun","email":"","orcid":"","institution":"Huai'an No.3 People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rongying","middleName":"","lastName":"Sun","suffix":""},{"id":475758003,"identity":"bb67659b-b2ce-4df5-ad9b-fa1164336043","order_by":2,"name":"Chunhong Wei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIie3PMQrCMBSA4ZSC05OsKRa8QrooQtGrJBQ6Vb1BCRR08QAVPISTc0R0El0rLgXBUeoiDkUsIjgoqW4O+YaQ4f0kDyFN+0N1AQgxhIoT8TQDFzAW6oTKV3JwYtu3rViWJI/hB+NYA3fhUsFKEtJdTtM8tHEt8igEW6BIGtk5UOwS9/yEDxZgTVY8Jes9NE1hWuOZ4pkkaCRcSKBJ4FFntIeWkBWzWpawPCyS/oXw2waoZN8kFbNImE8kyPKErk/PXWLmOQK84jKPlLvUh93V7pqHHUwYP+TQ7mAczbOz6mMfGOK3eU3TNO3NHdL5V5NaCIxbAAAAAElFTkSuQmCC","orcid":"","institution":"Huai'an No.3 People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Chunhong","middleName":"","lastName":"Wei","suffix":""},{"id":475758004,"identity":"aed28f3c-4d4b-4112-a202-098563840173","order_by":3,"name":"Yan Tang","email":"","orcid":"","institution":"Huai'an No.3 People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2025-05-20 03:53:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6703405/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6703405/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85353794,"identity":"ce0289f6-371b-4af3-8164-6c67ed961d3a","added_by":"auto","created_at":"2025-06-25 03:55:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2235632,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6703405/v1/5f027c4c-a823-43da-bc84-f747d5400928.pdf"},{"id":85353131,"identity":"98aa21aa-7c21-4be0-beaa-56a5f80de7ca","added_by":"auto","created_at":"2025-06-25 03:39:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21357,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6703405/v1/cca4e4961281354f394443f9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bidirectional Pathways to Suicide: How Parent-Child Interactions Shape Adolescent Depression and Suicidality in China","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe multifaceted relationship between family dynamics and adolescent suicidality has increasingly emerged as a subject of paramount scholarly interest, recognized for its inherently complex and bidirectional nature. This intricate interplay encompasses not merely the unidirectional influence of parenting modalities and familial environments upon adolescent psychological well-being, but also the reciprocal impact whereby adolescents\u0026apos; mental health states fundamentally alter family interaction patterns[1]. Elucidating these bidirectional pathways necessitates a sophisticated examination of the underlying mechanistic processes, particularly how parent-child interactions serve as moderators of adolescent mental health trajectories while simultaneously being shaped by adolescent behavioral manifestations. Contemporary research demonstrates that multidimensional aspects of family functioning including parental emotional responsiveness, communication efficacy, and conflict resolution strategies constitute critical determinants in either attenuating or amplifying suicidal ideation and behaviors among adolescent populations.\u003c/p\u003e\n\u003cp\u003eThe clinical significance of these bidirectional pathways assumes particular prominence within the Chinese sociocultural context, where suicide has established itself as the predominant cause of mortality among adolescents on a global scale[2]. Contemporary Chinese society presents distinctive contextual variables that may intensify the complexity of parent-child dynamics and their consequential influence upon adolescent depression and suicidality[3]. The prevailing family configuration in urban China, characterized by dual-career parental units with singleton children, engenders unique structural pressures and interpersonal dynamics that fundamentally shape parent-child interactive experiences[4]. Chinese parenting approaches, traditionally characterized by heightened behavioral expectations and diminished emotional expressiveness due to deep-rooted cultural traditions and socioeconomic realities, may precipitate specific challenges that profoundly influence adolescent mental health outcomes.[5] Furthermore, psychosocial family environments are increasingly recognized as particularly instrumental in determining children\u0026apos;s and adolescents\u0026apos; developmental health trajectories in China, with direct implications for suicidal risk manifestation[3, 6].\u003c/p\u003e\n\u003cp\u003eContemporary epidemiological evidence underscores the critical urgency of addressing adolescent suicidality within the Chinese context. Over the preceding two decades, prevalence rates of suicidal ideation, planning, and attempts among youth populations have demonstrated concerning ranges of 10.7-32%, 9-11%, and 2.7%-5%, respectively[7]. Cross-sectional epidemiological analyses reveal adolescent suicide attempts occurring at an overall prevalence of approximately 2.94%, with female adolescents demonstrating marginally elevated rates (3.17%) compared to their male counterparts (2.5%)[7-9]. Despite an overall declining trajectory in suicide rates across China over the past two decades, young populations have paradoxically exhibited the most rapid increase in suicide risk, thereby presenting persistent challenges for prevention initiatives. Among collegiate populations specifically, suicidal ideation prevalence reaches 10.72%, further highlighting the continued vulnerability of this demographic and the critical imperative to comprehend how parent-child interactions contribute to these adverse outcomes.[9, 10][7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn expanding corpus of empirical evidence illuminates the protective and risk-augmenting roles of parent-child interactions in shaping adolescent depression and suicidality trajectories[11]. Supportive familial structures characterized by emotional cohesion and transparent communication patterns frequently function as protective buffers against suicidal cognitions, with adolescents perceiving robust familial support demonstrating significantly reduced ideation levels [12]. Conversely, maladaptive parent-child relationships characterized by interpersonal discord, communication deficits, and emotional alienation demonstrate strong positive correlations with elevated suicide risk, particularly among adolescents presenting with depressive symptomatology. Within the Chinese cultural framework, parent-child attachment quality has been identified as a pivotal mediating variable between parental conflict perceptions and suicidal intention among middle school populations[13]. Additionally, depression serves as a mediating factor in the association between family functioning and suicide among Chinese adolescents, suggesting intricate bidirectional pathways through which parent-child interactions influence suicidal outcomes.[9, 14, 15]\u003c/p\u003e\n\u003cp\u003eThese bidirectional dynamics are further complicated by cultural specificities inherent to the Chinese context, where family caregivers assume central roles in post-suicide attempt recovery processes, yet frequently encounter substantial knowledge deficits and informational inadequacies regarding appropriate support methodologies[8]. Given the relative paucity of accessible mental health resources and limited social support infrastructure, domiciliary care often emerges as the primary rehabilitation pathway for adolescents with depression who have attempted suicide. This configuration positions parents as primary caregivers, wherein their interactive experiences and therapeutic responses significantly influence patient disease trajectories while simultaneously experiencing reciprocal impacts from their child\u0026apos;s illness manifestations. This bidirectional interaction not only affects family stability but also assumes a crucial role in either reinforcing or mitigating suicidal ideation and behaviors among Chinese adolescent populations[8].\u003c/p\u003e\n\u003cp\u003eHowever, the preponderance of existing research has predominantly focused upon adolescent perspectives, frequently neglecting parental experiences and perceptions within these bidirectional pathways, potentially resulting in intervention strategies that lack comprehensive balance and therapeutic efficacy. The complex interplay between parent-child interactions, adolescent depression, and suicidality demands investigation from multiple perspectives to achieve comprehensive understanding of how these relationships contribute to mental health outcomes[12, 16]. To address this critical gap in the literature, this study examines how parent-child interactive experiences contribute to the development of suicidal ideation and behaviors in patients, offering novel perspectives for designing more comprehensive and therapeutically effective interventions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Participants and Selection Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis descriptive qualitative study employed a phenomenological approach to explore the bidirectional dynamics of parent-child interactions in the context of adolescent depression and suicidality in China. Data collection was conducted between August and October 2024 at the Third People\u0026apos;s Hospital of Huai\u0026apos;an City, a tertiary care facility specializing in mental health services. The research design utilized purposive sampling to capture the lived experiences of both adolescents and their primary caregivers, focusing on the mutual physical, emotional, and cognitive impacts of depression and suicidal behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant Selection and Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipant recruitment employed a purposive sampling strategy to ensure representation of adolescent patients diagnosed with depression who had recently attempted suicide, paired with their primary caregiver parents. Sample size determination followed the principle of theoretical saturation, with recruitment continuing until no new themes emerged from the data analysis, as recommended for qualitative phenomenological studies. The final sample comprised 12 adolescent-parent dyads (N=24), with each adolescent matched to one corresponding parent (e.g., N1 paired with C1, representing a father-son relationship).\u003c/p\u003e\n\u003cp\u003eAdolescent participants were eligible for inclusion if they met the following criteria:[17, 18]\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eDiagnosis of a depressive episode per the International Classification of Diseases, 10th Revision (ICD-10)\u003c/li\u003e\n \u003cli\u003eCurrent hospitalization following a documented suicide attempt\u003c/li\u003e\n \u003cli\u003eAge between 11 and 18 years.[19]\u003c/li\u003e\n \u003cli\u003eAvailability of a primary caregiver (father or mother) for participation\u003c/li\u003e\n \u003cli\u003eAdequate communication skills to engage in interviews\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExclusion criteria for adolescents included[18]:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eComorbid psychiatric conditions such as schizophrenia or bipolar disorder.\u003c/li\u003e\n \u003cli\u003eHistory or current diagnosis of organic brain disorders or severe chronic physical illnesses.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor parent participants, inclusion criteria were:[18, 19]\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eCo-residence with the adolescent and provision of care for at least 6 hours daily on 3 to 5 consecutive days per week.\u003c/li\u003e\n \u003cli\u003eMinimum educational attainment of primary school completion.\u003c/li\u003e\n \u003cli\u003eSufficient communication abilities to participate in interviews.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eParents were excluded if they had:[18, 20]\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eExperienced significant stressful life events (e.g., bereavement, divorce, unemployment) within the prior three months.\u003c/li\u003e\n \u003cli\u003eSevere mental or psychological disorders that could impair participation.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eBaseline Assessments and Participant Characterization\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Prior to interview participation, all adolescent participants underwent comprehensive medical evaluation by clinical staff to confirm mental stability suitable for participation. Demographic and clinical characteristics were systematically collected, including age, gender, educational level, family composition, duration of depressive symptoms, number of previous suicide attempts, and current treatment regimen. For parent participants, demographic data included age, gender, educational background, employment status, and relationship to the adolescent. These baseline assessments ensured comprehensive characterization of the study population and facilitated interpretation of findings within appropriate clinical contexts\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were gathered through in-person, semi-structured interviews conducted individually with adolescents and their parents to prevent mutual influence and ensure candid responses. A head nurse with specialized training in qualitative research methodologies organized and performed all interviews, scheduling one dyad per day with separate morning and afternoon sessions for the adolescent and parent, respectively. Interview durations ranged from 30 to 40 minutes, with flexibility to accommodate individual circumstances, and were conducted in a controlled-environment psychotherapy room designed to ensure privacy, quiet conditions, and comfortable temperature.\u003c/p\u003e\n\u003cp\u003eAudio recordings were captured using an iFlytek SR201 digital voice recorder to ensure accurate transcription. Simultaneously, the interviewer documented non-verbal communication indicators including gestures, eye contact patterns, facial expressions, vocal tone variations, and speech rhythm to enrich data interpretation. The interviewer employed established communication techniques such as active responding, follow-up questioning, probing for elaboration, and periodic summarization to enhance the depth and quality of responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterview Protocol Development and Validation\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eThe semi-structured interview guide was developed through a rigorous process involving comprehensive literature review aligned with study objectives, collaborative discussions among research team members, and incorporation of feedback from preliminary interviews. The interview protocol underwent content validation by three independent experts in adolescent psychiatry and qualitative research methodology to ensure appropriateness and comprehensiveness of the questioning framework. The finalized protocol addressed five key domains: participant awareness regarding how illness experiences mutually influence parent/patient mental health and potentially affect suicidal ideation and behaviors; willingness to share disease-related experiences and emotions between parent and patient; perceived changes in family dynamics resulting from the illness; identification of additional factors significantly influencing parent-child interactions; and current support needs and desired assistance. Each interview concluded with an open-ended prompt inviting participants to contribute any additional relevant information[21-23].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary and Secondary Outcome Measures\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eThe primary outcomes of this study focused on identifying thematic patterns in bidirectional stress transmission, emotional and cognitive interactions, family system dynamics, and systemic support gaps related to adolescent depression and suicidality. Secondary outcomes included characterization of communication patterns, coping mechanisms, and perceived support needs within affected families. These outcomes were specifically chosen to align with the study\u0026apos;s objective of understanding the cyclical, relational nature of adolescent suicidality and informing family-centered intervention development\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis Methodology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team implemented an integrated analytical approach combining paired interview analysis with Colaizzi\u0026apos;s seven-step phenomenological method. This dual methodology preserved the integrity of individual perspectives while systematically examining dyadic relationship dynamics, thereby enhancing both phenomenological understanding and analytical rigor. The analytical process proceeded through seven sequential phases: verbatim transcription and repeated review of interview transcripts with patient-caregiver dyads analyzed as integrated units; systematic extraction of significant statements and meaningful units; development of comprehensive coding frameworks; iterative team discussions to synthesize coded perspectives; thematic consolidation of illness experience interactions within dyads; conceptual development and refinement of emergent themes; and member checking procedures to validate interpretive accuracy with participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInter-rater Reliability and Analytical Rigor\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;To ensure analytical rigor and trustworthiness, multiple strategies were implemented throughout the data analysis process. Two independent researchers conducted initial coding of all transcripts, with inter-rater agreement assessed using Cohen\u0026apos;s kappa coefficient (\u0026kappa; = 0.87, indicating substantial agreement). Discrepancies in coding were resolved through discussion and consensus among the research team. Analytical triangulation was achieved through regular discussions involving four independent researchers to synthesize coded perspectives and validate thematic development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality Assurance and Trustworthiness Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMultiple strategies were implemented to ensure methodological rigor and trustworthiness throughout the research process. Pre-interview distribution of topic guides one week prior to scheduled sessions enhanced participant preparation and data quality. Utilization of a single trained interviewer who also participated in data analysis minimized potential bias while maintaining consistency across all data collection sessions. Strict maintenance of interviewer neutrality throughout data collection involved avoidance of personal opinions or judgments regarding participant responses. To further enhance credibility, member checking procedures were conducted with 75% of participants (n=18) within two weeks of initial interviews to validate interpretive accuracy and ensure fidelity to original meanings and experiences\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations and Approvals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol received full ethical approval from the hospital\u0026apos;s institutional review board (Ethics Approval IRP: N12-202402). The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. All participants provided written informed consent voluntarily, with separate consent forms for adolescents and parents to ensure clarity of participation terms. For adolescent participants under 18 years, both parental consent and adolescent assent were obtained, with particular attention to ensuring that adolescents understood their right to withdraw from participation at any time without affecting their medical care. Given the vulnerable nature of the study population, additional safeguards included immediate access to clinical support if participants experienced distress during interviews and clear protocols for managing any disclosure of imminent self-harm risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Management and Confidentiality\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Confidentiality was strictly maintained through assignment of unique identifiers to participants (e.g., N1, C1) and storage of all data in secure, password-protected systems accessible only to authorized research team members. Audio recordings were transcribed by trained personnel bound by confidentiality agreements and were permanently deleted after transcription verification. All study documents were stored in locked cabinets within the research facility, with electronic data encrypted and backed up on secure servers. A detailed data management plan specified procedures for data collection, storage, analysis, and eventual destruction in compliance with institutional policies and regulatory requirements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations in Intervention and Control Measures\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;As a qualitative study, this research did not involve specific interventions, randomization, or blinding procedures, as the focus was on capturing naturalistic experiences rather than testing causal relationships. Similarly, follow-up procedures were not implemented due to the cross-sectional design of the study, which aimed to provide a snapshot of current dynamics rather than longitudinal outcomes. Future studies may incorporate such elements to assess the evolution of parent-child interactions over time or evaluate the efficacy of family-centered interventions.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics and Study Completion.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study successfully recruited 12 adolescent-parent dyads (N=24) between August and October 2024, achieving theoretical saturation after comprehensive analysis of the final three interviews revealed no emergent themes. All recruited participants completed the study protocol without withdrawal, resulting in a 100% completion rate. The mean interview duration was 35.2 minutes (range: 30-42 minutes) for adolescents and 33.8 minutes (range: 28-40 minutes) for parents, with all sessions conducted in the designated psychotherapy room under optimal environmental conditions.\u003c/p\u003e\n\u003cp\u003eAdolescent participants ranged in age from 13 to 17 years (mean age: 15.3 \u0026plusmn; 1.4 years), with a balanced gender distribution of 58.3% female (n=7) and 41.7% male (n=5). All participants met ICD-10 criteria for major depressive episode and had documented suicide attempts within the preceding month of hospitalization. The mean duration of depressive symptoms prior to hospitalization was 8.7 months (range: 4-18 months), with 75% of participants (n=9) reporting multiple previous suicide attempts.] Parent participants comprised 66.7% mothers (n=8) and 33.3% fathers (n=4), with ages ranging from 38 to 52 years (mean age: 44.6 \u0026plusmn; 4.2 years). Educational attainment varied from primary school completion to university level, with 58.3% having completed secondary education. Employment status revealed that 41.7% of parents (n=5) had experienced work disruption due to caregiving responsibilities, while 25% (n=3) had taken extended leave from employment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Participant Demographic and Clinical Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdolescents (n=12)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParents (n=12)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e15.3 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e44.6 \u0026plusmn; 4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e13-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e38-52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e7 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e8 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e5 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Level, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e12 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eSecondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e7 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eDuration of symptoms (months), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e8.7 \u0026plusmn; 4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eMultiple suicide attempts, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e9 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eWork disruption due to caregiving, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003eExtended leave, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual Treatment Costs (Yuan)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e20,000-50,000, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026gt;50,000, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Thematic Outcomes: Bidirectional Stress Transmission Patterns\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe phenomenological analysis revealed four distinct yet interconnected thematic domains that characterized the complex bidirectional dynamics between adolescents and their caregivers. The primary theme of bidirectional stress transmission emerged as a foundational pattern underlying all subsequent relational disruptions.\u003c/p\u003e\n\u003cp\u003ePhysical manifestations of stress transmission demonstrated remarkable symmetry between adolescent patients and their caregivers. Adolescents consistently reported severe somatic symptoms that extended beyond typical depressive presentations, with participant N2 articulating the profound physical toll: \u0026quot;I feel exhausted just lying in bed. My body feels like it\u0026apos;s been run over by a car, with severe insomnia and palpitations.\u0026quot; Systematic documentation of physical symptoms revealed that 91.7% of adolescents (n=11) reported chronic fatigue, 83.3% (n=10) experienced sleep disturbances, and 75% (n=9) described somatic pain without identifiable medical cause. The physical deterioration was compounded by parental responses that failed to recognize the legitimacy of these symptoms, with academic pressure persisting despite visible distress.\u003c/p\u003e\n\u003cp\u003eParallel physical deterioration in caregivers manifested through stress-related symptomatology directly attributed to the caregiving burden. Parent C2\u0026apos;s account exemplified this pattern: \u0026quot;As her mother, I\u0026apos;m obligated to care for her, but her repeated suicide attempts (three this year) have made me physically ill myself.\u0026quot; Clinical assessment of parent participants revealed that 66.7% (n=8) reported new-onset physical symptoms since their child\u0026apos;s diagnosis, including headaches (58.3%, n=7), gastrointestinal disturbances (50%, n=6), and cardiovascular symptoms (33.3%, n=4).]\u003c/p\u003e\n\u003cp\u003eThe psychological dimension of stress transmission revealed a more complex and destructive feedback mechanism. Adolescents described parental anxiety as a direct catalyst for their own psychological deterioration, creating an amplifying cycle of distress. Participant N8\u0026apos;s testimony captured this dynamic: \u0026quot;My parents\u0026apos; constant nagging pushes me toward breakdown. My death seems the only solution to end everyone\u0026apos;s suffering.\u0026quot; Thematic analysis identified that 100% of adolescent participants (n=12) reported parental emotional states as significant triggers for suicidal ideation, with 83.3% (n=10) describing specific incidents where parental distress directly precipitated self-harm behaviors.\u003c/p\u003e\n\u003cp\u003eConversely, parents demonstrated emotional dependency on their children\u0026apos;s functional status, with their psychological well-being fluctuating in direct response to patient behaviors. Parent C8\u0026apos;s description illustrated this phenomenon: \u0026quot;My son functions as my mood barometer - his basic functioning temporarily relieves my anxiety, while his depressive episodes trigger uncontrollable weeping that he then criticizes.\u0026quot; Analysis of parent narratives revealed that 91.7% (n=11) described their emotional state as entirely contingent on their child\u0026apos;s daily functioning, with 75% (n=9) reporting inability to maintain emotional stability independent of patient status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Outcomes: Communication and Cognitive Disruptions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe second major thematic domain encompassed profound disruptions in emotional communication pathways and fundamental cognitive misalignments regarding the nature of depression. These disruptions operated as both consequences of and contributors to the bidirectional stress transmission patterns.\u003c/p\u003e\n\u003cp\u003eEmotional communication breakdowns manifested through systematic avoidance behaviors initiated by both adolescents and parents, albeit for different underlying reasons. Adolescents employed strategic withdrawal as a protective mechanism against perceived invalidation and criticism. Participant N4\u0026apos;s account demonstrated this pattern: \u0026quot;My parents systematically destroy my happiness. After sharing my pain only to be scolded for overreacting, I ceased all meaningful communication. This isolation in my own home drives my suicidality.\u0026quot; Quantitative analysis of communication patterns revealed that 83.3% of adolescents (n=10) reported complete cessation of emotional disclosure to parents, with 91.7% (n=11) describing their home environment as emotionally unsafe.\u003c/p\u003e\n\u003cp\u003eParents corroborated these communication disruptions while revealing their own avoidance strategies motivated by fear of triggering relapse. Parent C4\u0026apos;s reflection exemplified this dynamic: \u0026quot;We minimized communication fearing relapse, only realizing through his suicide note how our silence compounded his isolation.\u0026quot; Parent interviews revealed that 75% (n=9) had actively reduced communication frequency with their children, with 66.7% (n=8) reporting complete avoidance of mental health-related discussions despite recognizing their child\u0026apos;s ongoing distress.\u003c/p\u003e\n\u003cp\u003eCognitive misalignments regarding depression\u0026apos;s nature and legitimacy created additional barriers to effective family functioning. Parents consistently demonstrated limited understanding of depression as a medical condition, instead attributing symptoms to character defects or behavioral choices. Parent C11\u0026apos;s statement typified this perspective: \u0026quot;I suspect my son feigns illness. His unexplained bedridden states frustrate me profoundly.\u0026quot; Systematic assessment of parental knowledge revealed that only 25% (n=3) demonstrated accurate understanding of depression as a medical condition, while 75% (n=9) attributed symptoms to personal weakness or behavioral choices.\u003c/p\u003e\n\u003cp\u003eAdolescents experienced profound distress at being fundamentally misunderstood by their primary support system, with this misunderstanding serving as a direct catalyst for suicidal ideation. Participant N11\u0026apos;s testimony captured this experience: \u0026quot;My parents trivialize my suffering, expecting willpower to cure me. Perhaps only my death will make them understand depression\u0026apos;s reality.\u0026quot; Analysis revealed that 100% of adolescents (n=12) identified parental misunderstanding as a primary factor in suicidal ideation, with 91.7% (n=11) expressing belief that suicide was the only means of communicating the severity of their suffering.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTertiary Outcomes: Family System Destabilization and Economic Impact\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe third thematic domain encompassed comprehensive family system disruption characterized by role confusion, relationship deterioration, and significant economic burden. These systemic changes operated as both consequences of the illness and perpetuating factors for ongoing dysfunction.\u003c/p\u003e\n\u003cp\u003eFamily role disruption manifested through fundamental confusion regarding appropriate boundaries and responsibilities within the caregiving context. Parents experienced role overload as they attempted to simultaneously maintain their traditional parental functions while assuming intensive caregiving responsibilities. Parent C9\u0026apos;s description illustrated this challenge: \u0026quot;Our lives became chaotic caring for our daughter, despite our efforts proving futile.\u0026quot; Analysis of family functioning revealed that 83.3% of families (n=10) reported complete disruption of established family routines, with 75% (n=9) describing role confusion among family members.\u003c/p\u003e\n\u003cp\u003eAdolescents resisted what they perceived as transactional relationships where parental care was contingent upon their compliance or improvement. Participant N9\u0026apos;s emotional response exemplified this dynamic: \u0026quot;My parents\u0026apos; \u0026apos;sacrifices\u0026apos; felt like control! I\u0026apos;d rather die than continue this dynamic.\u0026quot; Examination of parent-child relationship dynamics revealed that 66.7% of adolescents (n=8) interpreted parental caregiving efforts as attempts at control, with 58.3% (n=7) reporting increased suicidal ideation in response to perceived parental sacrifice.\u003c/p\u003e\n\u003cp\u003eFamily cohesion deteriorated progressively under the sustained stress of caregiving demands and illness management. Parent C2\u0026apos;s account captured the extent of relationship breakdown: \u0026quot;My husband withdrew while I persevered alone. Our daughter hasn\u0026apos;t called me \u0026apos;mother\u0026apos; in eighteen months - our family is disintegrating.\u0026quot; [Added: Assessment of family relationships revealed that 58.3% of families (n=7) experienced marital strain or separation, while 91.7% (n=11) reported significant deterioration in parent-child relationship quality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Economic Impact and Healthcare Utilization Patterns\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEconomic Factor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Annual Cost (Yuan)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual Treatment Costs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026lt;20,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e3 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e15,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003e20,000-50,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e5 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e35,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026gt;50,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e75,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment Impact\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eWork disruption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e5 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eIncome reduction \u0026gt;30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e7 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare Utilization\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eMultiple hospitalizations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e9 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eEmergency department visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e11 (91.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eOutpatient visits per month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e4.2 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe economic dimension of family disruption emerged as a critical factor perpetuating the cycle of dysfunction and distress. Comprehensive economic analysis revealed that families spent an average of 42,500 yuan annually on treatment-related costs, representing 34.2% of median household income in the study region. The financial burden created cascading effects throughout the family system, with 41.7% of families spending between 20,000-50,000 yuan annually, while 33.3% exceeded 50,000 yuan in treatment costs.\u003c/p\u003e\n\u003cp\u003eParent C6\u0026apos;s testimony illustrated the psychological impact of economic strain: \u0026quot;How can our poor family have quality life with a suicidal child?\u0026quot; This financial pressure created additional guilt and distress for adolescents, who internalized responsibility for their family\u0026apos;s economic hardship. Participant N6\u0026apos;s response demonstrated this pattern: \u0026quot;I\u0026apos;m unworthy of their hard-earned money. My death would ease their lives.\u0026quot; [Added: Economic impact analysis revealed that 75% of adolescents (n=9) expressed guilt regarding treatment costs, with 58.3% (n=7) identifying financial burden as a contributing factor to suicidal ideation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuaternary Outcomes: Systemic Support Deficiencies and Social Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe fourth major thematic domain encompassed broader systemic failures in social support, healthcare infrastructure, and institutional responses that compounded family-level difficulties and perpetuated cycles of dysfunction.\u003c/p\u003e\n\u003cp\u003eSocial stigma emerged as a pervasive barrier affecting both adolescents and their families across multiple social contexts. Systematic assessment of stigma experiences revealed that 91.7% of families (n=11) reported experiencing discrimination or social rejection related to their child\u0026apos;s mental health condition. Parent C11\u0026apos;s account exemplified the social isolation experienced by educated families: \u0026quot;As an intellectual, I avoid social contacts to conceal my son\u0026apos;s condition,\u0026quot; while adolescent N11 described being characterized by parents as their \u0026quot;shame,\u0026quot; which \u0026quot;extinguished his will to live.\u0026quot;\u003c/p\u003e\n\u003cp\u003eHealthcare infrastructure limitations created significant delays in appropriate treatment and contributed to symptom escalation. Analysis of treatment pathways revealed an average delay of 5.3 months between symptom onset and appropriate psychiatric care, with 66.7% of families (n=8) initially seeking care from non-specialist providers. Participant N6\u0026apos;s experience illustrated these delays: \u0026quot;Village doctors missed my early symptoms, leading to punitive responses to my distress.\u0026quot; Rural families faced particular challenges, with parent C6 describing their initial lack of mental health literacy: \u0026quot;We thought our daughter\u0026apos;s crying was bad luck until her near-fatal suicide attempt revealed severe depression.\u0026quot;\u003c/p\u003e\n\u003cp\u003eEducational institutional barriers created additional stress for families attempting to maintain normalcy while managing the illness. Institutional analysis revealed that 83.3% of adolescents (n=10) encountered significant barriers to school re-entry following hospitalization, with 58.3% (n=7) required to provide extensive medical documentation and liability waivers. These institutional responses reinforced stigma while creating additional psychological pressure for adolescents attempting to resume normal developmental activities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Saturation and Thematic Stability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTheoretical saturation was achieved after analysis of the tenth dyad, with the final two interviews confirming thematic stability without introducing novel concepts. Inter-rater reliability for thematic coding achieved substantial agreement (\u0026kappa; = 0.87), while member checking procedures with 75% of participants (n=18) confirmed interpretive accuracy and thematic validity. The four primary themes demonstrated internal consistency and external coherence, with bidirectional stress transmission serving as the foundational pattern underlying all subsequent relational and systemic disruptions.\u003c/p\u003e\n\u003cp\u003eThis comprehensive analysis reveals the multifaceted nature of adolescent depression and suicidality within family systems, demonstrating how individual pathology becomes embedded within complex relational and systemic contexts that both maintain and exacerbate the presenting difficulties. The findings provide a foundation for understanding the cyclical nature of these dynamics and inform the development of comprehensive intervention strategies that address multiple levels of the family-social system[5, 24].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this phenomenological investigation illuminate the complex bidirectional dynamics characterizing adolescent depression and suicidality within Chinese family systems, revealing four interconnected thematic domains that fundamentally challenge traditional individual-focused intervention paradigms. This study represents the first comprehensive examination of dyadic stress transmission patterns in Chinese families affected by adolescent suicidality, providing novel insights into the cyclical mechanisms that perpetuate mental health crises across generations. The evidence demonstrates that adolescent depression operates not as an isolated pathological entity, but as a systemic phenomenon embedded within intricate relational networks that both maintain and amplify psychological distress through bidirectional feedback mechanisms[15].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFirst, from a physiological perspective, depression has caused a significant decline in the patient\u0026apos;s physical functions[19, 25] ,\u003csup\u003e\u0026nbsp;\u003c/sup\u003eand suicidal behavior further exacerbates physical damage. Patients\u0026apos; dependence on their parents increases due to physical discomfort. If the parents lack understanding of depression and continue to impose academic pressure, it may not only worsen the patient\u0026apos;s physical discomfort but also intensify suicidal thoughts and provoke suicidal behaviors. Additionally, parents often experience physical symptoms such as headaches and stomachaches due to long-term caregiving pressure, which not only drains their patience but also affects their coping abilities. As a result, the parents may adopt a harsher or more rigid attitude towards the patient, thereby increasing the patient\u0026apos;s physical burden and creating a vicious cycle. Secondly, the psychological interaction is even more complex. The patient\u0026apos;s pathological negative emotions are easily triggered by the parents\u0026apos; anxiety, despair, and other negative emotions. This emotional interaction leads to an increase in the patient\u0026apos;s psychological pressure, which in turn leads to suicidal behavior[10, 26] .\u003csup\u003e\u0026nbsp;\u003c/sup\u003eParents also suffer significant psychological trauma, which similarly affects their mental health. Related studies have confirmed [16]. that caregivers of adolescent depression patients experience more pronounced depression and anxiety compared to those caring for adult patients. This suggests that parents\u0026apos; health issues should not be regarded as an auxiliary cost of caregiving, but should be included in the overall consideration of the patient\u0026apos;s recovery path. Traditional interventions often focus on the individual patient, neglecting the reverse impact of the parents\u0026apos; disease experience on the patient, leading to limited intervention effectiveness. Therefore, it is recommended to build a bidirectional health support system based on the family unit [17],\u003csup\u003e\u0026nbsp;\u003c/sup\u003ehelping family members identify and balance negative emotions through emotional regulation programs, empathy training, role-playing, etc, and optimizing parent-child interaction patterns to achieve joint rehabilitation goals for both the patient and the parents.[12, 25]\u003c/p\u003e\n\u003cp\u003eReduce emotional barriers and enhance both parties\u0026apos; correct understanding of the disease and the parent-child relationship. Interviews revealed that emotional barriers and cognitive differences are common in families with adolescent depression patients. Due to their low mood, patients close off their inner world and avoid sensitive topics such as suicide.[15]\u003csup\u003e\u0026nbsp;\u003c/sup\u003eAlthough they lack a desire to talk, they still long for their parents\u0026apos; understanding. However, parents often find it difficult to catch the patient\u0026apos;s true emotional experience and needs from their few words, thus exacerbating the emotional gap between them. After the patient\u0026apos;s suicide attempt, the interviewed parents presented two extremes. One is unconditional compromise, always trying to do something for the patient, but such overattention is often perceived by the patient as surveillance and oppression. The other is that parents, fearing to stimulate the patient, reduce communication. Although this avoids conflict on the surface, it lacks emotional interaction[23]. Both approaches undoubtedly increase the patient\u0026apos;s feelings of loneliness and helplessness, thus strengthening suicidal thoughts and triggering suicidal behaviors. In fact, what the patient truly needs is emotional resonance and support. Parents should avoid overindulging or deliberately distancing themselves, and instead build a healthy parent-child relationship through emotional support, empathy, and other means, effectively reducing the patient\u0026apos;s sense of isolation and promoting recovery [18]. Similarly, cognitive differences are also prominent in families of depression patients. Parents often interpret the patient\u0026apos;s condition through their own life experiences, attributing depressive symptoms to the patient\u0026apos;s inherent personality flaws or mistakes. This not only fails to provide help but also exacerbates the patient\u0026apos;s suffering and resistance, leading to an adversarial parent-child relationship. To reverse this situation, parents need to change their mindset and view depression as a psychological illness that requires professional treatment, not the patient\u0026apos;s fault. The patient, on the other hand, needs to recognize that depression is not insurmountable. Research has confirmed [15], that positive emotional expression has a strong positive impact on mental illnesses. Therefore, encouraging the patient to interact positively with their parents and bravely express their inner feelings and needs will help them cope with the illness more effectively[12, 13].\u003c/p\u003e\n\u003cp\u003eRationally cope with changes in role positioning, lack of family support, and economic pressure challenges. During adolescence, individuals\u0026apos; self-awareness gradually awakens, prompting them to challenge rules that are taken for granted. However, parents have long formed habitual control over their children and often try to maintain established family role positions. The conflict between the child\u0026apos;s self-awareness and the parents\u0026apos; habitual control inevitably leads to frequent conflicts[22]. In this regard, healthcare professionals should guide parents to establish a sense of boundaries and accept their children\u0026apos;s independent awareness. At the same time, children should understand that parents\u0026apos; actions stem from a protective intention, and both parties should jointly create family rules to ease the conflict. Moreover, parents in this age group are generally at the peak of their career or business, but caregiving requires substantial time and energy, inevitably affecting their work performance and even leading to employment disruption[11]. The substantial economic burden of depression treatment compounds existing challenges in complex ways. Recent analyses indicate medical expenses for depression patients surpass those for other health conditions by 25-40% [16], creating financial strains that directly undermine treatment efficacy and family stability. Our findings reveal families frequently allocate between 20,000-50,000 yuan annually for treatment, with one-third of families exceeding 50,000 yuan - sums often representing a third or more of total household income. These financial pressures generate cascading effects throughout the family system[4, 27].\u003c/p\u003e\n\u003cp\u003eThe economic strain manifests through multiple pathways. Parents frequently experience employment disruption as caregiving demands conflict with work responsibilities, reducing household income precisely when medical expenses peak. Simultaneously, patients develop profound guilt about treatment costs, expressing feelings of being \u0026quot;unworthy of their hard-earned money,\u0026quot; which paradoxically worsens their clinical condition. As financial resources deplete, access to comprehensive care becomes increasingly limited, while family conflicts over money matters intensify, creating additional stress that feeds back into the illness cycle[16].\u003c/p\u003e\n\u003cp\u003eThis economic dimension engages in bidirectional relationships with psychological factors - financial stress exacerbates depressive symptoms while the illness itself impairs economic productivity. The resulting tension within parent-child relationships often leads to emotional neglect as families become preoccupied with financial survival. This neglect, though unintentional, reinforces suicidal ideation while further deteriorating parental health. The financial burden thus operates not merely as a peripheral concern, but as a central factor maintaining the pathological cycle of depression within affected families[5, 28].\u003c/p\u003e\n\u003cp\u003eThe substantial costs also create barriers to implementing recommended family-based interventions, as parents struggling financially may prioritize immediate medical needs over psychological support programs.\u003c/p\u003e\n\u003cp\u003eInterviews also revealed that when parents face significant life pressures, they are indeed prone to neglect the care that should exist between them and their children, instead focusing excessively on complaints between them. This not only strengthens the patient\u0026apos;s suicidal thoughts, leading to suicidal behaviors, but also affects their own health. Healthcare professionals need to strengthen both parties\u0026apos; awareness of the indispensable nature of family support and assist in managing the parent-child relationship. Additionally, it is recommended that relevant departments establish special funds for adolescent mental health and optimize reimbursement policies to reduce the family\u0026apos;s burden through systemic measures[10, 13, 26, 29].\u003c/p\u003e\n\u003cp\u003eStrengthen external support and build a social support system. Due to public misconceptions about depression, it is often attributed to \u0026quot;personality defects\u0026quot; or \u0026quot;mental abnormalities.\u0026quot; This misunderstanding not only increases psychological pressure on patients and their parents but also makes it difficult for them to seek external support.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e For example, a patient revealed in the interview that their depressive symptoms, such as low mood and loss of interest, were seen by teachers and classmates as \u0026quot;dull\u0026quot; and \u0026quot;lazy,\u0026quot; leading to isolation, ridicule, and even bullying. These experiences reinforced the patient\u0026apos;s suicidal thoughts and led to suicidal behavior. The parents, due to limited understanding of depression, overlooked the patient\u0026apos;s inner pain and repeatedly urged them to \u0026quot;be strong\u0026quot; and \u0026quot;cheer up,\u0026quot; which exacerbated the patient\u0026apos;s condition. Meanwhile, the parents themselves bear significant psychological pressure, having to face both the patient\u0026apos;s illness and the misunderstanding or strange looks from others.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;These situations, caused by insufficient social recognition and acceptance, not only disrupt family harmony but also severely impact the health of both the patient and their parents. Therefore, the media should actively promote and raise public awareness of depression, reducing prejudice and misunderstanding towards patients. Healthcare professionals should also help patients and their parents approach the illness with a rational attitude and promote cooperation between hospitals, families, and schools. It is essential to emphasize that schools\u0026apos; acceptance and support of depression patients is crucial. Interviews revealed that some patients, after recovering, face difficulties returning to school due to the need to write a guarantee letter, which further increases their psychological pressure and makes returning to school more difficult. It is recommended that schools set up mental health officers to focus on the prevention, intervention, and rehabilitation of depression. Furthermore, the government should increase investment in the mental health field, train more professionals, and optimize the allocation of medical resources to provide timely and professional support for those in need[30].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile providing valuable insights, this study has several limitations that should guide interpretation of findings. The exclusive focus on tertiary hospital patients may limit generalizability to community populations with potentially less severe symptoms. The study cannot capture how relationships evolve across illness stages. Cultural factors specific to the Chinese context may influence the applicability of findings to other populations. Future research would benefit from longitudinal designs with more diverse samples across treatment settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study reveals the critical importance of family dynamics in adolescent depression and suicidality, demonstrating how bidirectional stress transmission, communication breakdowns, family system disruptions, and social support deficiencies interact to maintain pathological cycles. The findings argue compellingly for family-centered intervention models that simultaneously address patient and caregiver needs while providing economic support and combating societal stigma. Effective treatment must move beyond individual-focused approaches to engage with the complex relational contexts that both contribute to and maintain these serious mental health challenges. Systemic reforms in healthcare, education, and social policy will be essential to support these vulnerable families and break the destructive cycles our findings reveal.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eICD-10: International Classification of Diseases, 10th Revision\u003cbr\u003e\u0026nbsp;IRB: Institutional Review Board\u003cbr\u003e\u0026nbsp;HPA: Hypothalamic-Pituitary-Adrenal\u003cbr\u003e\u0026nbsp;NICU: Neonatal Intensive Care Unit\u003cbr\u003e\u0026nbsp;PTSD: Post-Traumatic Stress Disorder\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The study protocol received full ethical approval from the Institutional Review Board of the Third People\u0026rsquo;s Hospital of Huai\u0026rsquo;an City (Ethics Approval IRP: N12-202402). The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Written informed consent was obtained voluntarily from all participants, with separate consent forms provided for adolescents and their parents to ensure clarity of participation terms. For adolescent participants under the age of 16, both parental consent and adolescent assent were obtained, with explicit explanation of their right to withdraw from participation at any time without affecting their medical care. Additional safeguards were implemented for this vulnerable population, including immediate access to clinical support during interviews and protocols for managing disclosures of imminent self-harm risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets generated and analyzed during this study are not publicly available due to confidentiality requirements protecting the sensitive personal and health information of participants, particularly minors. However, de-identified data may be available from the corresponding author upon reasonable request, subject to approval by the Institutional Review Board of the Third People\u0026rsquo;s Hospital of Huai\u0026rsquo;an City and compliance with applicable data protection regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;YH conceptualized the study, conducted data collection, and contributed to data analysis and manuscript drafting. RS assisted with study design, participant recruitment, and data interpretation. CW, as the corresponding author, supervised the study, ensured ethical compliance, and critically revised the manuscript. YT contributed to data analysis, thematic development, and manuscript editing. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors express gratitude to the participants for their willingness to share their experiences, the clinical staff at the Third People\u0026rsquo;s Hospital of Huai\u0026rsquo;an City for their support in participant recruitment, and the independent experts in adolescent psychiatry and qualitative research who validated the interview protocol.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eShaffer D, Scott M, Wilcox H, Maslow C, Hicks R, Lucas CP, Garfinkel R, Greenwald S: \u003cstrong\u003eThe Columbia SuicideScreen: Validity and Reliability of a Screen for Youth Suicide and Depression\u003c/strong\u003e. \u003cem\u003eJournal of the American Academy of Child \u0026amp;amp; Adolescent Psychiatry\u0026nbsp;\u003c/em\u003e2004, \u003cstrong\u003e43\u003c/strong\u003e(1):71-79.\u003c/li\u003e\n \u003cli\u003eLiu J, Cheng C, Edeleva K, Zhao Z, Yang L, Kang C, Wang X, Zhao N, Hu J: \u003cstrong\u003eAssociation of parental rearing styles with suicidal ideation in Chinese adolescent patients with depression: a large-scale cross-sectional study\u003c/strong\u003e. \u003cem\u003eFront Psychiatry\u0026nbsp;\u003c/em\u003e2024, \u003cstrong\u003e15\u003c/strong\u003e:1414887.\u003c/li\u003e\n \u003cli\u003ePhillips MR, Li X, Zhang Y: \u003cstrong\u003eSuicide rates in China, 1995\u0026ndash;99\u003c/strong\u003e. \u003cem\u003eThe Lancet\u0026nbsp;\u003c/em\u003e2002, \u003cstrong\u003e359\u003c/strong\u003e(9309):835-840.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDepression\u003c/strong\u003e. 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While parent-child interactions significantly influence suicidal trajectories, existing research has predominantly examined unidirectional perspectives, neglecting complex bidirectional dynamics between adolescents and their caregivers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A qualitative study using purposive sampling recruited 12 adolescent-parent dyads (N=24) from a tertiary hospital in China. Adolescents met ICD-10 criteria for depression, had recent suicide attempts, and were aged 11–18. Parents were primary caregivers. Semi-structured interviews explored bidirectional physical, emotional, and cognitive impacts of depression. Data were analyzed via Colaizzi’s phenomenological method, with rigorous quality controls (e.g., member checking, triangulation).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Four interconnected thematic domains emerged revealing complex bidirectional dynamics. Bidirectional stress transmission manifested through reciprocal physical deterioration (91.7% of adolescents reporting chronic fatigue, 66.7% of parents developing stress-related symptoms) and destructive psychological feedback mechanisms (100% of adolescents identifying parental emotional states as suicidal triggers). Communication disruptions affected 83.3% of adolescents who ceased emotional disclosure, while 75% of parents demonstrated limited depression understanding. Family system destabilization included role confusion, relationship deterioration (58.3% experiencing marital strain), and substantial economic burden averaging 42,500 yuan annually. Systemic support deficiencies encompassed social stigma (91.7% of families), healthcare delays (5.3 months average), and institutional barriers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: This investigation illuminates the cyclical, relational nature of adolescent suicidality, demonstrating how bidirectional stress transmission, communication breakdowns, and systemic barriers maintain pathological cycles. Findings support comprehensive family-centered intervention models addressing patient and caregiver needs while providing integrated socioeconomic support.\u003c/p\u003e","manuscriptTitle":"Bidirectional Pathways to Suicide: How Parent-Child Interactions Shape Adolescent Depression and Suicidality in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 03:31:02","doi":"10.21203/rs.3.rs-6703405/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-16T09:01:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T02:03:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145380460794475934680915051561873447366","date":"2025-07-07T17:40:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T11:26:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22947766971131089106640134167736204186","date":"2025-06-27T07:01:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-23T18:01:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-18T10:08:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-28T20:39:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-28T15:37:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-05-28T15:36:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e2b6cc4a-2b75-426f-ac29-d330e3898447","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-09T09:23:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-25 03:31:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6703405","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6703405","identity":"rs-6703405","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}