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The impact of mindfulness on suicidal behavior: a systematic review

Kyara Rodrigues de Aguiar Júlia Bierhals Bilhalva Mariana Dias Cabelleira Giovanna Oliveira Guimarães Thiago Madureira Arela Agako Marília Silva de Souza Luciano Dias de Mattos Souza About the authors

Abstract

Introduction

Mindfulness-based interventions (MBI) have been growing progressively as treatment options in the field of mental health. Aim: To assess the impact of mindfulness-based interventions for reducing suicidal thoughts and behaviors.

Methods

A systematic review was performed in December 2020 using PubMed, PsycINFO, EMBASE, SciELO, Pepsic, and LILACS databases with no year restrictions. The search strategy included the terms (‘mindfulness’ OR ‘mindfulness-based’) AND (‘suicide’ OR ‘suicidal’ OR ‘suicide risk’ OR ‘suicide attempt’ OR ‘suicide ideation’ OR ‘suicide behavior’). The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO), CRD42020219514.

Results

A total of 14 studies met all inclusion criteria and were included in this review. Most of the studies presented Mindfulness-Based Cognitive Therapy as the MBI assessed (n=10). An emerging and rapidly growing literature on MBI presents promising results in reduction of suicide risk, particularly in patients with MDD. Four studies assessing other MBI treatment protocols (Mindfulness-Based Stress Reduction; Daily Mindfulness Meditation Practice; Mind Body Awareness and Mindfulness-Based Cognitive Behavior Therapy) all demonstrated that MBI reduces factors associated with suicide risk.

Conclusion

MBI might target specific processes and contribute to suicide risk reduction.

Suicide; suicide ideation; suicide behavior; mindfulness; systematic review

Introduction

Mindfulness is conceptualized as a particular way of paying attention to the present moment in an intentional, non-judgmental, and non-reactive manner.11. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008;300:1350-2.

Mindfulness-based interventions (MBI) have been growing progressively as treatment options in the field of mental health.22. Dawson AF, Brown WW, Anderson J, Datta B, Donald JN, Hong K, et al. Mindfulness-based interventions for university students: a systematic review and meta-analysis of randomised controlled trials. Appl Psychol Heal Well Being. 2020;12:384-410. Mindfulness-based Cognitive Therapy (MBCT),33. Teasdale JD, Segal Z, Williams JM. How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behav Res Ther. 1995;33:25-39. Mindfulness-Based Stress Reduction (MBSR),44. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books; 2013. and Mindfulness-Based Relapse Prevention (MBPR) are of particular note among the most well-known MBI.55. Bowen S, Chawla N, Collins SE, Witkiewitz K, Hsu S, Grow J, et al. Mindfulness-based relapse prevention for substance use disorders: a pilot efficacy trial. Subst Abus. 2009;30:295-305. Different MBI approaches have proven effective in the treatment of psychiatric disorders66. Sanada K, Montero-Marin J, Barceló-Soler A, Ikuse D, Ota M, Hirata A, et al. Effects of mindfulness-based interventions on biomarkers and low-grade inflammation in patients with psychiatric disorders: a meta-analytic review. Int J Mol Sci. 2020;21:2484. (e.g., anxiety, depressive, personality disorders)77. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010;78:169-183.,88. Wupperman P, Neumann CS, Whitman JB, Axelrod SR. The role of mindfulness in borderline personality disorder features. J Nerv Ment Dis. 2009;197:766-71. and are associated with improved outcomes of other clinical conditions (e.g., cancer, rheumatoid arthritis).99. Xunlin N, Lau Y, Klainin-Yobas P. The effectiveness of mindfulness-based interventions among cancer patients and survivors: a systematic review and meta-analysis. Support Care Cancer. 2020;28:1563-78.,1010. Zhou B, Wang G, Hong Y, Xu S, Wang J, Yu H, et al. Mindfulness interventions for rheumatoid arthritis: a systematic review and meta-analysis. Complement Ther Clin Pract. 2020;39:101088.

MBSR was introduced to the field of medicine by John Kabat Zinn and was initially developed to help people manage pain and chronic conditions for which clinicians could no longer offer help.44. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books; 2013. The 8-week protocol guides participants through specific meditation and movement practices to cultivate mindfulness.44. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books; 2013. Since its inception, in addition to chronic pain, it has been shown to be effective in a wide variety of medical and psychological conditions and, as a result, multiple adaptations to the protocol have been developed. Teasdale et al. adapted MBSR specifically for clinical depression by incorporating components of cognitive therapy and depression psychoeducation into the curriculum (MBCT).33. Teasdale JD, Segal Z, Williams JM. How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behav Res Ther. 1995;33:25-39. Both protocols train participants in secular mindfulness meditation practices and metacognitive coping skills that help them manage physical feelings of anxiety (MBSR) or triggers that can precipitate a relapse into depression (MBCT). Based on the MBSR and MBCT framework, Marllat et al. developed a program for addictive behavior (MBRP).55. Bowen S, Chawla N, Collins SE, Witkiewitz K, Hsu S, Grow J, et al. Mindfulness-based relapse prevention for substance use disorders: a pilot efficacy trial. Subst Abus. 2009;30:295-305. Their protocol also consists of 8 weekly sessions that integrate cognitive-behavioral relapse prevention skills with mindfulness practices.

Suicidal thoughts and behaviors are important public health concerns around the world,1111. Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, et al. Risk factors for suicidal thoughts and behaviors : a meta-analysis of 50 years of research. Psychol Bull. 2016;143:187-232. although the prevalence appears to be higher in lower-middle-income countries such as Brazil.1212. Turecki G, Brent DA, Gunnell D, O’Connor RC, Oquendo MA, Pirkis J, et al. Suicide and suicide risk. Nat Rev Dis Primers. 2019;5:74. In this context, it is imperative to identify feasible preventive treatments. MBI can promote changes in neuroplasticity1313. Fox KC, Nijeboer S, Dixon ML, Floman JL, Ellamil M, Rumak SP, et al. Is meditation associated with altered brain structure? A systematic review and meta-analysis of morphometric neuroimaging in meditation practitioners. Neurosci Biobehav Rev. 2014;43:48-73. and can facilitate the process of emotional regulation1414. Cooper D, Yap K, Batalha L. Mindfulness-based interventions and their effects on emotional clarity: a systematic review and meta-analysis. J Affect Disord. 2018;235:265-76. which is a key component of suicidal risk in some disorders.1515. Harris L, Chelminski I, Dalrymple K, Morgan T, Zimmerman M. Suicide attempts and emotion regulation in psychiatric outpatients. J Affect Disord. 2018;232:300-4. There is evidence that MBI have a positive effect on mediating and precipitating factors of suicidal behavior1616. Xue J, Zhang Y, Huang Y, Tusconi M. A meta-analytic investigation of the impact of mindfulness-based interventions on ADHD symptoms. Medicine (Baltimore). 2019;98:e15957.,1717. González-Valero G, Zurita-Ortega F, Ubago-Jiménez JL, Puertas-Molero P. Use of meditation and cognitive behavioral therapies for the treatment of stress, depression and anxiety in students. A systematic review and meta-analysis. Int J Environ Res Public Health. 2019;16:4394. which could potentially make them a preventive intervention for suicide risk.

However, the literature on MBI and suicide risk is mixed. Although there is possibly a relationship between MBI and a lower incidence of suicidal thoughts and behavior, a recent review has identified suicidal behavior as a possible adverse effect of mindfulness.1818. Farias M, Maraldi E, Wallenkampf KC, Lucchetti G. Adverse events in meditation practices and meditation-based therapies: a systematic review. Acta Psychiatr Scand. 2020;142:374-93. In contrast, three other reviews suggest MBI is effective in reducing suicide risk.1919. Schmelefske E, Per M, Khoury B, Heath N. The effects of mindfulness-based interventions on suicide outcomes: a meta-analysis. Arch Suicide Res. 2020 Oct 30;1-18. doi: 10.1080/13811118.2020.1833796. Online ahead of print.

20. Chesin MS, Benjamin-Phillips CA, Keilp J, Fertuck EA, Brodsky BS, Stanley B. Improvements in executive attention, rumination, cognitive reactivity, and mindfulness among high-suicide risk patients participating in adjunct mindfulness-based cognitive therapy: preliminary findings. J Altern Complement Med. 2016;22:642-9.
-2121. Raj S, Ghosh D, Verma SK, Singh T. The mindfulness trajectories of addressing suicidal behaviour: a systematic review. Int J Soc Psychiatry. 2021;67:507-19. However, one of these reviews did not follow a systematic approach for the literature review process2020. Chesin MS, Benjamin-Phillips CA, Keilp J, Fertuck EA, Brodsky BS, Stanley B. Improvements in executive attention, rumination, cognitive reactivity, and mindfulness among high-suicide risk patients participating in adjunct mindfulness-based cognitive therapy: preliminary findings. J Altern Complement Med. 2016;22:642-9. and only half of the articles included in each of the two most recent systematic reviews were in common between them because of use of different selection criteria,1919. Schmelefske E, Per M, Khoury B, Heath N. The effects of mindfulness-based interventions on suicide outcomes: a meta-analysis. Arch Suicide Res. 2020 Oct 30;1-18. doi: 10.1080/13811118.2020.1833796. Online ahead of print.,2121. Raj S, Ghosh D, Verma SK, Singh T. The mindfulness trajectories of addressing suicidal behaviour: a systematic review. Int J Soc Psychiatry. 2021;67:507-19. making it difficult to draw conclusions. Thus, the aim of the current systematic review is to assess the impact of MBI for reducing suicidal thoughts and behaviors using a more comprehensive search strategy.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed for the present review.2222. Moher D, Liberati A, Tetzlaff J, Douglas G Altman; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097. The protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) under ID CRD42020219514, on December 14, 2020.

Eligibility criteria

  1. Population: Any study that reported measures of suicidal ideation or suicide attempts in participants from clinical or non-clinical samples at any stage of development, without excluding any physical or psychiatric conditions.

  2. Intervention: Studies using psychosocial or psychotherapeutic interventions based on mindfulness were included.

  3. Comparators: Any study that reported other forms of psychotherapy, psychopharmacological, or psychosocial interventions, treatment as usual (TAU), or without treatment (waiting list) as control was included. Pre-post intervention studies without control groups were also included.

  4. Outcome: Studies that assessed suicide risk (suicidal thoughts or behavior) as an independent variable through either a question/item or scale for interview both before and after the proposed MBI were included.

  5. Design of the study: Studies characterized as randomized controlled trials (RCT), including cluster RCTs, non-randomized controlled trials (non-RCT), studies using a historically controlled design or uncontrolled longitudinal design, and pre-post intervention (quasi-experimental) studies were included.

  6. Language: Studies published in English, Spanish or Portuguese were included.

Information sources

We searched PubMed, PsycINFO, EMBASE, SciELO, Pepsic, and LILACS with no year restrictions for articles up to December 2020.

Search strategy

Our search strategy was designed to be broadly sensitive to ensure a comprehensive search. The following search terms were used: ‘suicide’ OR ‘suicidal’ OR ‘suicide risk’ OR ‘suicide attempt’ OR ‘suicide ideation’ OR ‘suicide behavior’ to capture outcomes. For the intervention, we used the terms ‘mindfulness’ OR ‘mindfulness-based’. The search: (‘mindfulness’ OR ‘mindfulness-based’) AND (‘suicide’ OR ‘suicidal’ OR ‘suicide risk’ OR ‘suicide attempt’ OR ‘suicide ideation’ OR ‘suicide behavior’) was conducted on all of the electronic research databases mentioned above.

Selection process

All abstracts of articles selected in the searches of each electronic database mentioned above were double screened by two reviewers who evaluated each of the studies against specific criteria, depending on study design. In cases of disagreement, a third author read the full text and discussed each article with the reviewers until a consensus was reached. Additionally, the references from other reviews on the subject1919. Schmelefske E, Per M, Khoury B, Heath N. The effects of mindfulness-based interventions on suicide outcomes: a meta-analysis. Arch Suicide Res. 2020 Oct 30;1-18. doi: 10.1080/13811118.2020.1833796. Online ahead of print.

20. Chesin MS, Benjamin-Phillips CA, Keilp J, Fertuck EA, Brodsky BS, Stanley B. Improvements in executive attention, rumination, cognitive reactivity, and mindfulness among high-suicide risk patients participating in adjunct mindfulness-based cognitive therapy: preliminary findings. J Altern Complement Med. 2016;22:642-9.
-2121. Raj S, Ghosh D, Verma SK, Singh T. The mindfulness trajectories of addressing suicidal behaviour: a systematic review. Int J Soc Psychiatry. 2021;67:507-19. were scanned in order to identify potential additional articles (Figure 1).

Figure 1
PRISMA flowchart illustrating the systematic review process.

Data collection process

The Rayyan QCRI platform was used to remove all duplicated documents and run the first screening based on title and abstracts, done by two independent reviewers.2323. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5:1-10.

The platform automatically identifies duplicates and following this process, one of the researchers (KRA) reviewed the articles that were flagged and manually deleted duplicates. Subsequently, using the “blinding on” option, two independent researchers (KRA, LDMS) accessed the platform and carried out screening of articles by reading the title and abstract. Lastly, the full texts of articles were reviewed (KRA, MS, JBB, GOG, MDC).

Data extraction

The primary outcome assessed was suicidal ideation. We also included secondary outcome measures of suicidal behavior, defined as suicide attempts and suicide deaths.

As we were interested in the effects of the interventions, we reported effects at post intervention as well as all possible follow-up periods (when available) for each outcome. For each article we collected information about the first author, year of publication, study aim, design, number of participants, sample selection process, specific sample characteristics, description of mindfulness intervention, comparison group, instruments used to measure suicide risk, main results, and results regarding suicide ideation or behavior.

Study risk of bias and quality assessment

For each paper included in this study, two authors (LDMS, AA) used the Cochrane risk of bias tool to assess the quality and risk of bias for the clinical trials initially selected2424. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. or used the NHLBI tool to assess the quality of pre-post intervention studies without control groups.2525. Pavletic SZ, Vogelsang GB, Lee SJ. 2014 National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: preface to the series. Biol Blood Marrow Transplant. 2015;21:387-8. In cases of disagreement between evaluators, a third author was called in to break the impasse.

Results

The literature search yielded 630 studies. Of these, 213 were duplicates and 396 studies were excluded because the titles and abstracts were not relevant to the research topic, leaving 21 potentially eligible studies for which the full text was reviewed. In addition, we hand-searched the references of the studies included and found 2 additional studies to include. At this stage, 9 studies did not meet the inclusion criteria. A total of 14 studies met all inclusion criteria and were included in the systematic review (Figure 1). Of these, 7 were randomized clinical trials (2 of which were pilots) and 7 were pre and post-intervention studies with no control group (quasi-experimental studies). All studies employed a convenience sampling strategy.

Most of the studies presented MBCT as the MBI (n = 10). For this reason, we split the results description into two sections according to the MBI used to better interpret its impact on suicide risk. Table 1 shows an overview of the studies included. Publication dates ranged from 2007 to 2019, and 6 studies were conducted in the United States of America. Total sample size ranged from 10 to 194. Regarding the assessment of suicide, four of the studies used the Beck Scale for Suicide Ideation (BSSI) and another one used a modified version of this instrument. Suicidal thoughts, ideation, or cognitions were part of the outcome of all papers included. None of the studies presented suicide death as outcome. Suicide attempts or suicidal behaviors were part of the outcome of at least 6 studies (Table 1).

Table 1
Main features of studies included in the systematic review

The impact of mindfulness on suicide risk: evidence from MBCT

The systematic review included 10 studies assessing whether MBCT reduces suicide-related outcomes. Nine of them showed that MBCT reduces factors associated with suicide risk.2020. Chesin MS, Benjamin-Phillips CA, Keilp J, Fertuck EA, Brodsky BS, Stanley B. Improvements in executive attention, rumination, cognitive reactivity, and mindfulness among high-suicide risk patients participating in adjunct mindfulness-based cognitive therapy: preliminary findings. J Altern Complement Med. 2016;22:642-9.,2626. Nabipour S, Rafiepour A, Haji Alizadeh K. The effectiveness of mindfulness based cognitive therapy training on anxiety of death and thoughts of suicide of patients with cancer. Zahedan J Res Med Sci. 2018;20:1-7.,2929. Forkmann T, Wichers M, Geschwind N, et al. Effects of mindfulness-based cognitive therapy on self-reported suicidal ideation: results from a randomised controlled trial in patients with residual depressive symptoms. Compr Psychiatry. 2014;55:1883-90.,3030. Forkmann T, Brakemeier EL, Teismann T, Schramm E, Michalak J. The effects of mindfulness-based cognitive therapy and cognitive behavioral analysis system of psychotherapy added to treatment as usual on suicidal ideation in chronic depression: results of a randomized-clinical trial. J Affect Disord. 2016;200:51-7.,3232. Lu R, Zhou Y, Wu Q, Peng X, Dong J, Zhu Z, et al. The effects of mindfulness training on suicide ideation among left-behind children in China: a randomized controlled trial. Child Care Health Dev. 2019;45:371-9.

33. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, Williams JM. Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study. Behav Res Ther. 2009;47:366-73.
-3434. Barnhofer T, Crane C, Brennan K, et al. Mindfulness-based cognitive therapy (MBCT) reduces the association between depressive symptoms and suicidal cognitions in patients with a history of suicidal depression. J Consult Clin Psychol. 2015;83:1013-20.,3636. Kenny MA, Williams JM. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behav Res Ther. 2007;45:617-25.,3737. Chesin MS, Sonmez CC, Benjamin-Phillips CA, Beeler B, Brodsky BS, Stanley B. Preliminary effectiveness of adjunct mindfulness-based cognitive therapy to prevent suicidal behavior in outpatients who are at elevated suicide risk. Mindfulness (N Y). 2015;6:1345-55.,3939. Miklowitz DJ, Alatiq Y, Goodwin GM, et al. A pilot study of mindfulness-based cognitive therapy for bipolar disorder. Int J Cogn Ther. 2009;2:373-82. Two studies employed Mindfulness-Based Cognitive Therapy for Suicide (MBCT-S) including specific contents about suicide ideation and behaviour.2020. Chesin MS, Benjamin-Phillips CA, Keilp J, Fertuck EA, Brodsky BS, Stanley B. Improvements in executive attention, rumination, cognitive reactivity, and mindfulness among high-suicide risk patients participating in adjunct mindfulness-based cognitive therapy: preliminary findings. J Altern Complement Med. 2016;22:642-9.,3737. Chesin MS, Sonmez CC, Benjamin-Phillips CA, Beeler B, Brodsky BS, Stanley B. Preliminary effectiveness of adjunct mindfulness-based cognitive therapy to prevent suicidal behavior in outpatients who are at elevated suicide risk. Mindfulness (N Y). 2015;6:1345-55.

In a study by Barnhofer et al. investigating the effects of MBCT in patients currently symptomatic with chronic Major Depressive Disorder (MDD) and with history of suicide risk, participants were randomly allocated to receive MBCT plus treatment-as-usual (TAU) or TAU alone.2626. Nabipour S, Rafiepour A, Haji Alizadeh K. The effectiveness of mindfulness based cognitive therapy training on anxiety of death and thoughts of suicide of patients with cancer. Zahedan J Res Med Sci. 2018;20:1-7. Suicidal ideation was measured using the BSSI. Neither analyses by intention to treat (p = 0.50) or of the completers subset (p = 0.47) showed significant effects on BSSI scores. In this pilot study, the MBCT was not able to reduce suicidal ideation.

Another study included veterans recruited from outpatient mental health care with MDD in partial remission after at least one episode of MDD.2929. Forkmann T, Wichers M, Geschwind N, et al. Effects of mindfulness-based cognitive therapy on self-reported suicidal ideation: results from a randomised controlled trial in patients with residual depressive symptoms. Compr Psychiatry. 2014;55:1883-90. Suicidal ideation was measured using the respective item from the self-rating form of the Inventory of Depressive Symptoms. The focus was on stable residual symptoms in the context of a previous depressive episode. In this study, participants were also randomized to a treatment arm TAU plus MBCT or a TAU plus waiting list arm. Post-hoc tests showed a significant reduction in suicidal ideation in the MBCT-group (p = 0.008), but not in the waiting list control-group (p = 0.41). These results suggest that MBCT may reduce suicidal ideation in patients with residual depressive symptoms. However, the impact of MBCT on suicidal ideation may be partly mediated by reduction in worry and not by change in depression, rumination, or mindfulness skills. Further, another study included an outpatient sample, although participants in the sample had Persistent Depressive Disorder.3434. Barnhofer T, Crane C, Brennan K, et al. Mindfulness-based cognitive therapy (MBCT) reduces the association between depressive symptoms and suicidal cognitions in patients with a history of suicidal depression. J Consult Clin Psychol. 2015;83:1013-20. In this study, patients were randomly assigned to either TAU or to receive – in addition to TAU – either MBCT or Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Suicide risk was measured with item 3 of the Hamilton Depression Rating Scale (HAMD) and item 9 of the Beck Depressive Inventory (BDI). The aim of the present investigation was to examine the effects of group MBCT and CBASP, compared to a TAU condition, on suicide ideation in chronic depressed patients, while controlling for changes in other depressive symptoms. Baseline scores on the HAMD suicide item did not differ between treatment groups. However, significant differences between treatment groups at baseline were found for the BDI suicide item (p = 0.02), with significantly lower scores on the BDI suicide item in the CBASP group than in the MBCT group. Paired sample tests revealed that both MBCT (p = 0.04) and CBASP (p = 0.00) reduced suicidal symptoms if measured with HAMD. However, suicide measured with the BDI suicide item was reduced by MBCT (p = 0.03), but not by CBASP. TAU did not show any effect on suicide in the pre-post evaluation, either according to HAMD or BDI scores. On the other hand, neither the MBCT (p = 0.72) nor the CBASP (p = 0.32) showed any incremental effect in reducing suicide ideation as assessed with the BDI suicide item, when compared to TAU. According to the HAMD, treatment condition (MBCT p = 0.02; CBASP p = 0.001) had a significantly larger effect on suicide ideation than TAU. Additionally, when compared to each other with the BDI, with MBCT as a reference condition, CBASP showed a significantly smaller effect on suicide (p = 0.03) compared to MBCT. These results showed that both MBCT added to TAU and CBASP added to TAU have an additional effect on suicidality, specifically when measured with the HAMD suicide item.

Chesin et al.2020. Chesin MS, Benjamin-Phillips CA, Keilp J, Fertuck EA, Brodsky BS, Stanley B. Improvements in executive attention, rumination, cognitive reactivity, and mindfulness among high-suicide risk patients participating in adjunct mindfulness-based cognitive therapy: preliminary findings. J Altern Complement Med. 2016;22:642-9. conducted a pre-post quasi-experimental project seeking to test changes in cognitive functioning after an MBCT-S intervention in outpatients who had a 6-month history of attempted suicide or active suicidal ideation plus suicidal ideation at the beginning of the study. Data on history of suicide attempts were collected using the Columbia University Suicide History Form and the hopelessness/suicidality subscale of the Leiden Depression Sensitivity Index - Revised (LEIDS-R) was used to measure cognitive reactivity to hopelessness/suicidality. Their findings showed significant reductions in rumination and cognitive reactivity to hopelessness/suicidality post MBCT-S treatment (p < 0.01). However, changes in cognitive functioning were not related to changes in suicidal ideation during treatment. This study suggests that the improvements observed in cognitive functioning of hopelessness/suicidality were not simply the result of improved mood with treatment, since these improvements were also not correlated with improvements in depression during MBCT-S. Another study3232. Lu R, Zhou Y, Wu Q, Peng X, Dong J, Zhu Z, et al. The effects of mindfulness training on suicide ideation among left-behind children in China: a randomized controlled trial. Child Care Health Dev. 2019;45:371-9. assessed suicidal cognitions investigating the impact of MBCT, Cognitive Psychoeducation (CPE), and TAU in 194 patients with a history of suicidal depression in a randomized controlled trial. They reported a significant difference between levels of improvement of suicidal cognitions in the group who had received MBCT (p < 0.001) and groups who had received treatments that did not include training in mindfulness. Furthermore, despite the fact that levels of depressive symptoms remained relatively unchanged, participants in the MBCT group showed a general reduction in suicidal cognitions.

Another study, conducted with patients who had endorsed current suicidal ideation and had a history of serious suicidal ideation or a suicide attempt within the past 6 months, showed significant post-treatment reductions in suicidal ideation, which was measured with the BSSI before and after the MBCT-S (p = 0.02). However, considering the data from dropout patients, the intent-to-treat analysis presented a trend towards significance for suicidal thoughts (p = 0.07).3838. Le TN, Gobert JM. Translating and implementing a mindfulness-based youth suicide prevention intervention in a native american community. J Child Fam Stud. 2015;24:12-23.

A study conducted with the objective of testing the effectiveness of MBCT in depressive patients analyzed a sample of currently actively depressed participants who had not responded fully to standard treatments.2727. Britton WB, Lepp NE, Niles HF, Rocha T, Fisher NE, Gold JS. A randomized controlled pilot trial of classroom-based mindfulness meditation compared to an active control condition in sixth-grade children. J Sch Psychol. 2014;52:263-78. This study assessed participants who met DSM IV criteria for MDD, Bipolar Disorder in the mood depressive episode (MDE) phase or Persistent Depressive Disorder with/without suicidal ideation as part of their symptoms. They compared the pre-treatment BDI scores of patients who reported thoughts of death and suicide and those who did not report such thoughts. The average BDI for suicidal patients in pre-treatment was significantly higher than the scores for patients without suicidal thoughts (p = 0.003). Both groups’ BDI scores had decreased after treatment. The results illustrate that although individuals experiencing suicidal ideation started MBCT with a greater severity of depression, there were no differences in their pattern of response to MBCT. Although the authors did not present any absolute data about suicidal ideation at the post intervention assessment, they described in the results section that there was a significant reduction in the suicide item post-treatment in addition to four other items (sadness; lack of pleasure; guilt; and loss of interest).

Another study including patients with bipolar disorder examined the feasibility of and benefits associated with an 8-week MBCT intervention and found a reduction in symptom scores from pre to post treatment in BSSI scores (Pretreatment M [SD] 4.05 [5.69] - Posttreatment M[SD] 1.87 [2.02] (d = 0.51, SE = 0.31). However, only 22 cases were involved in this study and no statistical methods were used. In this study, MBCT seemed to be a promising treatment option for bipolar disorder, particularly for managing subthreshold depressive symptoms.4040. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4:33-47.

Two studies investigated the impact of MBCT in specific samples.3030. Forkmann T, Brakemeier EL, Teismann T, Schramm E, Michalak J. The effects of mindfulness-based cognitive therapy and cognitive behavioral analysis system of psychotherapy added to treatment as usual on suicidal ideation in chronic depression: results of a randomized-clinical trial. J Affect Disord. 2016;200:51-7.,3636. Kenny MA, Williams JM. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behav Res Ther. 2007;45:617-25. One study selected cancer patients (women) who were randomly and equally divided into a control group and an experimental group.3636. Kenny MA, Williams JM. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behav Res Ther. 2007;45:617-25. Suicidal ideation was measured using BSSI. The goal of this study was to evaluate the effectiveness of MBCT for reducing suicidal thoughts and death anxiety of patients with cancer. The MBCT significantly reduced suicidal thoughts and death anxiety in the experimental group (p < 0.01).

Another study examined Chinese children left-behind by one or both parents to examine the effectiveness of MBI on suicide ideation and other mental health outcomes.3030. Forkmann T, Brakemeier EL, Teismann T, Schramm E, Michalak J. The effects of mindfulness-based cognitive therapy and cognitive behavioral analysis system of psychotherapy added to treatment as usual on suicidal ideation in chronic depression: results of a randomized-clinical trial. J Affect Disord. 2016;200:51-7. The Positive and Negative Suicide Ideation (PANSI) inventory was used to measure suicide ideation. In this study, participants were randomized to a MBI training group or a waiting list control group. The MBI training group was based on an MBCT protocol. As some of the protocol was designed for working with adults and depression, it was adapted for the present sample, replacing such sessions with MBSR protocol practices and creating MBCT-based game sets. When compared with the waiting list control group, the mindfulness training group showed a significant reduction in suicide ideation following the intervention (p = 0.049). These findings indicate that MBCT can reduce suicidal ideation in the aforementioned groups.

The impact of mindfulness on suicide risk: evidence from heterogeneous MBI

The systematic review included four studies assessing different MBI treatment protocols.2727. Britton WB, Lepp NE, Niles HF, Rocha T, Fisher NE, Gold JS. A randomized controlled pilot trial of classroom-based mindfulness meditation compared to an active control condition in sixth-grade children. J Sch Psychol. 2014;52:263-78.,2828. Serpa JG, Taylor SL, Tillisch K. Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Med Care. 2014;52:S19-24.,3535. Raj S, Sachdeva SA, Jha R, Sharad S, Singh T, Arya YK, et al. Effectiveness of mindfulness based cognitive behavior therapy on life satisfaction, and life orientation of adolescents with depression and suicidal ideation. Asian J Psychiatr. 2019;39:58-62.,3838. Le TN, Gobert JM. Translating and implementing a mindfulness-based youth suicide prevention intervention in a native american community. J Child Fam Stud. 2015;24:12-23. All of them showed that MBI reduces factors associated with suicide risk. The interventions ranged from MBSR3939. Miklowitz DJ, Alatiq Y, Goodwin GM, et al. A pilot study of mindfulness-based cognitive therapy for bipolar disorder. Int J Cogn Ther. 2009;2:373-82. through Daily mindfulness meditation practice,3333. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, Williams JM. Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study. Behav Res Ther. 2009;47:366-73. Mind Body Awareness,3838. Le TN, Gobert JM. Translating and implementing a mindfulness-based youth suicide prevention intervention in a native american community. J Child Fam Stud. 2015;24:12-23. and Mindfulness Based Cognitive Behavior Therapy.2828. Serpa JG, Taylor SL, Tillisch K. Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Med Care. 2014;52:S19-24.

One study including veterans at a large urban Veteran Health Administration (VA) with the aim of presenting results on the quality of the effects of an MBSR4141. Hargus E, Crane C, Barnhofer T, Williams JM. Effects of mindfulness on meta-awareness and specificity of describing prodromal symptoms in suicidal depression. Emotion. 2010;10:34-42. course on several health outcomes showed that the frequency of suicidal ideation decreased by almost half after the intervention (p = 0.049).3939. Miklowitz DJ, Alatiq Y, Goodwin GM, et al. A pilot study of mindfulness-based cognitive therapy for bipolar disorder. Int J Cogn Ther. 2009;2:373-82. The study used item 9 from the 9-Item Patient Health Questionnaire (PHQ-9) to measure suicidal ideation. Le et al.3232. Lu R, Zhou Y, Wu Q, Peng X, Dong J, Zhu Z, et al. The effects of mindfulness training on suicide ideation among left-behind children in China: a randomized controlled trial. Child Care Health Dev. 2019;45:371-9. aimed to verify whether a mindfulness-based prevention intervention, Mind Body Awareness,44. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books; 2013. could be translated and implemented in a Native American youth population.3535. Raj S, Sachdeva SA, Jha R, Sharad S, Singh T, Arya YK, et al. Effectiveness of mindfulness based cognitive behavior therapy on life satisfaction, and life orientation of adolescents with depression and suicidal ideation. Asian J Psychiatr. 2019;39:58-62. One group of eight youths participated in a 9-week pilot of the intervention. Suicidality was also assessed through the PHQ-9. At pre-treatment, 44% of participants reported they were better off dead or had thoughts of hurting themselves in some way “several days” to “more than half the days.” At post-treatment, 100% of participants responded “not at all” to the item. No statistical method was employed to verify significant differences between the assessment times. These finds suggest that MBI for indigenous communities can be culturally appropriate and sustainable in real world settings.

Concerning adolescents with Depression and Suicidal Ideation, a pre-post study with the objective of analyzing the effectiveness of the Mindfulness Based Cognitive Behavior Therapy intervention and exploring the potential usefulness of mindfulness techniques showed that suicidal ideation scores decreased post-treatment.2828. Serpa JG, Taylor SL, Tillisch K. Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Med Care. 2014;52:S19-24. Suicidal ideation was measured using the Modified Scale for Suicidal Ideation (MSSI). The Mindfulness Based Cognitive Behavior Therapy sessions included cognitive behavior therapy techniques (psychoeducation, emotional regulation skills) and techniques of mindfulness (exercises and application of its understanding in the patient’s life). This study was excluded from the MBCT report because it emphasizes psychoeducation as a CBT technique and did not present inquiry as a mindfulness technique.

Finally, another study examined effects of mindfulness when applied to a group of children.3333. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, Williams JM. Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study. Behav Res Ther. 2009;47:366-73. Sixth-grade students were divided into four classrooms that were matched in aptitude, learning style, maturity, social characteristics, and gender. Each fall, two classrooms were randomly assigned to the meditation intervention, while the remaining two classrooms were assigned to an active control condition. This study sought to examine the effects of a mindfulness meditation intervention on standard clinical measures of mental health and affect in high school children. The meditation condition integrates traditional “third person” didactic, knowledge-based learning, with critical first person experiential learning: (1) breath; (2) awareness; and (3) body sweeps. The third person (didactic) portion of the active control condition was a 6-week curriculum on the history of ancient Africa (including Egypt). To coincide with the first person component of the meditation condition, the control condition included a non-didactic, experiential and new activity that matched the didactic content of the class: building a life-size three-dimensional model of a Pharaoh’s tomb. The Youth Self Report (YSR) was used to evaluate ideation or self-harm. The study showed that in the post-intervention, 10.4% of controls reported suicidal ideation or self-mutilation, while no meditators reported such behavior or ideation (p = 0.005).

Quality assessment

Ratings on quality of evidence of the studies included indicated a fair/good quality for reduction of suicide risk post intervention in most of the pre-post intervention studies, with the exception of items relating to blind assessment of the participants and multiple times outcome measures (Table 2). Cochrane risk of bias tool assessment of the 7 clinical trials included showed low risk of bias for most of the items with exception of blinding of participants and personnel item (Table 3).

Table 2
NHLBI Tool Quality Assessments of Pre and Post-Intervention Studies

Table 3
Cochrane risk of bias tool for assessment of study quality

Discussion

There is an emerging and rapidly growing body of literature on MBI that demonstrates promising results for reduction of suicide risk. For MBCT, specifically, there are multiple good quality studies supporting its impact, reducing suicide risk, especially in populations with MDD. Other studies of MBI in general also support its use for reducing suicide risk.

Only one study presented no effect of MBI on suicide risk.3333. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, Williams JM. Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study. Behav Res Ther. 2009;47:366-73. Another study found conflicting results depending on how suicide ideation was measured.3030. Forkmann T, Brakemeier EL, Teismann T, Schramm E, Michalak J. The effects of mindfulness-based cognitive therapy and cognitive behavioral analysis system of psychotherapy added to treatment as usual on suicidal ideation in chronic depression: results of a randomized-clinical trial. J Affect Disord. 2016;200:51-7. Both studies pointed out that only a small subset of participants had presented with suicidal ideation at the baseline assessment. These results suggest that a possible floor effect could be present that may have influenced the results of the statistical analysis. Furthermore, the way that suicidal ideation was assessed in these two studies was also highlighted as a potential explanation for the results observed.3434. Barnhofer T, Crane C, Brennan K, et al. Mindfulness-based cognitive therapy (MBCT) reduces the association between depressive symptoms and suicidal cognitions in patients with a history of suicidal depression. J Consult Clin Psychol. 2015;83:1013-20. The larger variance in responses and use of more sensitive terminology in item 3 of the HAMD may have facilitated observation of a statistically significant difference. This is particularly important when compared with item 9 of the BDI,3434. Barnhofer T, Crane C, Brennan K, et al. Mindfulness-based cognitive therapy (MBCT) reduces the association between depressive symptoms and suicidal cognitions in patients with a history of suicidal depression. J Consult Clin Psychol. 2015;83:1013-20. which was used as an outcome measure in some of the studies above, but which doesn’t allow for as much variance in responses and uses different terminology.

MBI is associated with several positive benefits that might mediate this effect on suicide risk. MBI reduces factors such as impulsivity and depressive symptoms,1212. Turecki G, Brent DA, Gunnell D, O’Connor RC, Oquendo MA, Pirkis J, et al. Suicide and suicide risk. Nat Rev Dis Primers. 2019;5:74.,1818. Farias M, Maraldi E, Wallenkampf KC, Lucchetti G. Adverse events in meditation practices and meditation-based therapies: a systematic review. Acta Psychiatr Scand. 2020;142:374-93. which are associated with a higher risk of suicide. Furthermore, it also improves various cognitive processes like executive functioning2020. Chesin MS, Benjamin-Phillips CA, Keilp J, Fertuck EA, Brodsky BS, Stanley B. Improvements in executive attention, rumination, cognitive reactivity, and mindfulness among high-suicide risk patients participating in adjunct mindfulness-based cognitive therapy: preliminary findings. J Altern Complement Med. 2016;22:642-9. and attention2020. Chesin MS, Benjamin-Phillips CA, Keilp J, Fertuck EA, Brodsky BS, Stanley B. Improvements in executive attention, rumination, cognitive reactivity, and mindfulness among high-suicide risk patients participating in adjunct mindfulness-based cognitive therapy: preliminary findings. J Altern Complement Med. 2016;22:642-9.,2727. Britton WB, Lepp NE, Niles HF, Rocha T, Fisher NE, Gold JS. A randomized controlled pilot trial of classroom-based mindfulness meditation compared to an active control condition in sixth-grade children. J Sch Psychol. 2014;52:263-78. and increases meta-awareness4242. Pintado S. Changes in body awareness and self-compassion in clinical psychology trainees through a mindfulness program. Complement Ther Clin Pract. 2019;34:229-34. and self-consciousness.4242. Pintado S. Changes in body awareness and self-compassion in clinical psychology trainees through a mindfulness program. Complement Ther Clin Pract. 2019;34:229-34. The hypothesis that MBI training increases formal practice of better cognitive processes and a less symptomatic lifestyle and, consequently, leads to lower suicide risk seems very plausible. Learning mindfulness skills is an important mediator in reduction of depressive symptoms.3939. Miklowitz DJ, Alatiq Y, Goodwin GM, et al. A pilot study of mindfulness-based cognitive therapy for bipolar disorder. Int J Cogn Ther. 2009;2:373-82. However, the mechanisms of change involved in this process are as yet unknown. Changes in specific processes, like worry, appear to mediate the effect of MBI intervention on suicidal ideation and depressive symptoms.2929. Forkmann T, Wichers M, Geschwind N, et al. Effects of mindfulness-based cognitive therapy on self-reported suicidal ideation: results from a randomised controlled trial in patients with residual depressive symptoms. Compr Psychiatry. 2014;55:1883-90.,4343. Batink T, Peeters F, Geschwind N, van Os J, Wichers M. How does MBCT for depression work? Studying cognitive and affective mediation pathways. PLoS One. 2013;8:1-13.,4444. Lau MA, Segal ZV, Williams JM. Teasdale’s differential activation hypothesis: Implications for mechanisms of depressive relapse and suicidal behaviour. Behav Res Ther. 2004;42:1001-17. The repetitive thinking worry process is considered a proximal risk factor for suicide behavior and is frequently associated with suicide ideation.4444. Lau MA, Segal ZV, Williams JM. Teasdale’s differential activation hypothesis: Implications for mechanisms of depressive relapse and suicidal behaviour. Behav Res Ther. 2004;42:1001-17.

45. O’Connor RC, Platt S, Gordon J. International handbook of suicide prevention: research, policy and practice. New Jersey: John Wiley & Sons; 2011.
-4646. Watkins ER. Constructive and unconstructive repetitive thought. Psychol Bull. 2008;134:163-206. It was surprising that MBI did not improve rumination,3636. Kenny MA, Williams JM. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behav Res Ther. 2007;45:617-25. as formal mindfulness meditation has been associated with improvements in this construct.4747. Hawley LL, Schwartz D, Bieling PJ, Irving J, Corcoran K, Farb NA, et al. Mindfulness practice, rumination and clinical outcome in mindfulness-based treatment. Cognit Ther Res. 2014;38:1-9. Furthermore, worry and rumination are highly correlated processes which may suggests that there might be something specific to rumination in the context of suicidal ideation that may need further exploration.4848. Fresco DM, Frankel AN, Mennin DS, Turk CL, Heimberg RG. Distinct and overlapping features of rumination and worry: the relationship of cognitive production to negative affective states. Cognit Ther Res. 2002;26:179-88. Moreover, MBI improves an individual’s ability to delineate the prodromal signs and symptoms related to a past suicidal crisis possibly due to memory process and meta-awareness improvements.4242. Pintado S. Changes in body awareness and self-compassion in clinical psychology trainees through a mindfulness program. Complement Ther Clin Pract. 2019;34:229-34. MBI might target specific processes and collaborate with suicide risk reduction. However, more clinical studies of potential mediators are necessary.

We believe that the most important point that should be highlighted in our work is our research strategy. This is designed to be broadly sensitive in order to ensure a comprehensive search. However, there are limitations to this review that should be acknowledged. First, there might be a possible publication bias, considering that most of the studies in the literature provided positive results which demonstrate the effectiveness of MBI in reducing the risk of suicide. It is possible that studies with null results might not have been published and therefore not included in this article.

The second limitation is the variability among studies regarding the definition of suicide risk as well as the instruments used and the criteria evaluated with them. Most studies made exclusive use of self-report measures of suicide ideation, excluding variables such as suicidal behaviors, non-suicidal self-injury, and suicidal attempts. Future research might benefit from including suicide attempts as a potential outcome in larger samples as well as observed suicidal behavior over the long term.

Lastly, the heterogeneity in the format of mindfulness protocols makes it difficult to synthesize findings. Although, it is important to adapt psychosocial interventions to their audiences, the cultural aspect of patient samples might produce different results.3232. Lu R, Zhou Y, Wu Q, Peng X, Dong J, Zhu Z, et al. The effects of mindfulness training on suicide ideation among left-behind children in China: a randomized controlled trial. Child Care Health Dev. 2019;45:371-9. Furthermore, the mindfulness protocols were different in terms of duration (number of sessions, time of each session), practices and exercises used, and intervention models (group x individual), and protocols had different targets. All this variability between studies makes it difficult to synthesize results and draw formal conclusions regarding efficacy and effectiveness. Further research is needed in terms of which aspects of the current MBI protocols are most effective for reducing suicidal risk.

It is thus worth highlighting that this research may be important for development of a more robust MBI protocol which could then be employed and researched as a possible preventative measure of suicide risk. To contribute to this topic, we conducted a rigorous search including recent data (December 2020) in a large number of databases, following the PRISMA guidelines, registered the protocol on PROSPERO, and assessed the quality of the studies included.

Overall, it has been demonstrated that MBI is a feasible and effective treatment for reducing suicide risk, and MBCT in particular, when used with individuals with mood related disorders. Although more research is necessary into MBI as a preventative tool for suicide risk, the current results are promising.

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Publication Dates

  • Publication in this collection
    06 May 2022
  • Date of issue
    2022

History

  • Received
    19 May 2021
  • Accepted
    28 July 2021
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