Reviewing Mindfulness-Based Behaviors For Suicidal Ideation

Archives of Suicide Research
ISSN: 1381-1118 (Print) 1543-6136 (Online) Journal homepage: http://www.tandfonline.com/loi/usui20
Reviewing Mindfulness-Based Interventions for

Suicidal Behavior
Megan Chesin Ph.D., Alejandro Interian Ph.D., Anna Kline Ph.D., Christopher
Benjamin-Phillips, Miriam Latorre Psy.D. & Barbara Stanley Ph.D.
To cite this article: Megan Chesin Ph.D., Alejandro Interian Ph.D., Anna Kline Ph.D.,
Christopher Benjamin-Phillips, Miriam Latorre Psy.D. & Barbara Stanley Ph.D. (2016): Reviewing
Mindfulness-Based Interventions for Suicidal Behavior, Archives of Suicide Research, DOI:
10.1080/13811118.2016.1162244
To link to this article: http://dx.doi.org/10.1080/13811118.2016.1162244
Accepted author version posted online: 16

Mar 2016.
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Download by: [Orta Dogu Teknik Universitesi] Date: 18 March 2016, At: 05:55
MINDFULNESS-BASED INTERVENTIONS WITH SUICIDAL INDIVIDUALS 16
Reviewing Mindfulness-Based Interventions for Suicidal
Behavior
Megan Chesin, Ph.D.
Department of Psychology, William Paterson University, Wayne, NJ
Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, New
Downloaded by [Orta Dogu Teknik Universitesi] at 05:55 18 March 2016
York, NY
Alejandro Interian, Ph.D.
Mental Health & Behavioral Sciences, VA New Jersey Healthcare System, Lyons, NJ
Anna Kline, Ph.D.
Christopher Benjamin-Phillips
York, NY
Miriam Latorre, Psy.D.
Barbara Stanley, Ph.D.
York, NY
1
Address correspondence to Megan S. Chesin, Ph.D., William Paterson University, Department of
Psychology, 300 Pompton Road, Wayne, NJ 07470. Tel. 973.720.3393. E-mail:
cheisnm@wpunj.edu
Abstract
Objective: This paper describes the rationale for using mindfulness-based interventions (MBIs) to
prevent suicidal behavior in high suicide-risk individuals.

Methods: A narrative review of studies testing the feasibility of MBIs with individuals at risk for
suicidal behavior and the effectiveness of MBIs for reducing suicidality was conducted. Studies
testing the effectiveness of MBIs for reducing deficits specific to suicide attempters among
depressed individuals were also reviewed as were studies examining moderators of MBI treatment
adherence and effectiveness to the extent that these might suggest possible limitations to using
MBIs with high suicide-risk individuals.
Results: Findings from the handful of available studies support targeting suicidal ideation with
MBI. Additional studies show deficits associated with suicide attempt, namely attentional
dyscontrol, problem solving deficits, and abnormal stress response, are improved by MBI and thus
strengthen the rationale for using MBIs with high suicide-risk individuals.
Conclusion: This work extends the work of Williams, Duggan, Crane, & Fennell (2006, Williams,
Fennell, Barnhofer, Silverton, & Crane, 2015) who described using Mindfulness-Based Cognitive
Therapy to prevent relapse to depression among individuals remitted from depression that included
suicidal thinking and/or attempt.
Keywords: attention, mindfulness-based intervention, problem solving, safety planning, stress
response, suicidal outpatients
2
Suicide is the 10th leading cause of death in the U.S., resulting in over 40,600 suicide
deaths annually (Center for Disease Control and Prevention [CDC] National Center for Injury
Prevention and Control, 2014). Suicide attempts occur up to 25-times more often than completed
suicides (Crosby, Han, Ortega, Parks, & Gfoerer, 2011). Three to five percent of adults in the U.S.
attempt suicide in their lifetime (Nock & Kessler, 2006). Many more individuals in the U.S.
seriously consider suicide. Over 8 million U.S. adults report serious thoughts of suicide annually
(Crosby et al., 2011).

Psychiatric disorder greatly increases the risk of suicidal thoughts and attempt (Borges et
al., 2010). On psychological autopsy, ninety percent of suicide victims are found to have a
psychiatric disorder (Cavanagh, Carson, Sharpe, & Lawrie, 2003). A major depressive episode is
among the psychiatric conditions associated with the greatest risk for suicidal thoughts and
behavior. Forty to sixty percent of depressed individuals report suicidal thoughts (Bottlender,
Jger, Strau, & Mller, 2000; Chartrand, Robinson, & Bolton, 2012), between 15% and 20%
attempt suicide (Bottlender et al., 2000; Chen & Dilsaver, 1996), and between 6% and 15% die by
suicide (Mller, 2003). Suicidal thoughts and behavior are not only associated with severe
depression. In up to 25% of cases, mild and moderate depressive episodes include suicidal thoughts
(Gao et al., 2015).
Given the prevalence and incidence of suicidal thoughts and behavior in the U.S. and in
depression, there is a pressing public health need to develop and test treatments to prevent suicidal
behavior among individuals at high risk for suicidal behavior, including depressed individuals.
Despite this need, surprisingly few psychotherapies targeting suicidal behavior have been
developed (U.S. Department of Health and Human Services (HHS) Office of the Surgeon General
and National Action Alliance for Suicide Prevention, 2012). The psychotherapy with the best
3
evidence for reducing suicidal behavior is Dialectical Behavior Therapy (DBT), a cognitive-
behavioral treatment that incorporates Eastern principles and practices, including mindfulness
training (Panos, Jackson, Hasan, & Panos, 2013). With respect to suicide-related outcomes, DBT
has been primarily tested on patients with borderline personality disorder.
Almost one decade ago, Williams et al. (2006) proposed Mindfulness-Based Cognitive
Therapy (MBCT) (Segal, Williams, & Teasdale, 2002; Segal, Williams, & Teasdale, 2013), which
also combines mindfulness training with cognitive therapy, as another potentially promising
therapy to mitigate suicide behavior risk. MBCT involves a shorter, less intensive treatment
program than DBT and is delivered in a group format. Moreover, where DBT teaches mindfulness
as a micro skill, MBCT focuses on training mindfulness through long experiential exercises, e.g.,
sitting mindfulness meditation practices. When first proposed as a potential intervention for suicide
risk, there was evidence that MBCT was effective in reducing the risk of the recurrence of
depression among remitted individuals (Ma & Teasdale, 2004; Teasdale et al., 2000), but the
intervention had not yet been tested as a treatment to prevent the recurrence of depression including
suicidal thoughts and/or behavior, i.e., suicidal depression. Williams et al. (2006, 2015), however,
argued that MBCT would be feasible and effective for mitigating suicide risk among those who
had a history of suicidal depression due to the effectiveness of MBCT for reducing cognitive
reactivity, i.e., the rapid onset of biased thinking and information processing subsequent to non-
pathological mood deterioration (Teasdale, 1987). Greater cognitive reactivity, and particularly
the tendency towards less effective interpersonal problem solving when emotionally distressed,
had been found to be a distinctive characteristic in patients remitted from suicidal depression
compared to remitted depressed individuals with no history of suicidal thinking (Williams,
Barnhofer, Crane, & Beck, 2005).
4
Although Williams et al. (2006) presented a strong theoretical argument for the potential
effectiveness of MBCT for addressing suicidal behavior, there was little empirical evidence
supporting the use of MBCT for this purpose. Since 2006, however, evidence has accumulated
supporting a role for MBCT and similar mindfulness-based interventions (MBIs) (i.e.,
interventions that focus on the practice of secular derivatives of traditional meditation practices
and that are time-limited and target mental health symptoms and distress) in reducing suicide risk.
Williams et al. (2006) also suggested adaptations to MBCT that would increase its safety,
acceptability, and likely effectiveness for individuals at risk of suicide, such as crisis planning and
identification of individual warning signs for suicidal behavior. In this manuscript, we: 1. review
the accumulating empirical evidence supporting the application of MBIs to patients at risk of
suicidal behavior, 2. review moderators of MBI treatment adherence and effectiveness to
understand potential limits to the utility, safety and effectiveness of MBIs for suicidal behavior,
and 3. propose, based on our review of studies showing MBIs reduce deficits specific to suicide
attempters, possible mechanisms of action by which MBIs may lower suicide risk. Future
directions for research to develop and test MBIs to prevent suicidal behavior are also provided.
METHODS
To thoroughly capture published data on changes to suicidal behavior and psychological,
physiological and neurocognitive factors associated with suicidal behavior with MBIs, we
conducted a literature search using PsychInfo, PubMED, and Google Scholar electronic databases.
Search criteria employed included mindfulness-based AND suicid* OR mechanism OR
attention OR stress response OR problem solving. We also searched bibliographies of articles
identified during the review and reviewed all of the tables of contents of Mindfulness Research
Monthly, a digest that was begun in 2010 and lists all of the research published on mindfulness
5
each month. Our review was limited to studies published on or before June 2015. Studies testing
suicidal ideation or behavior outcomes where mindfulness training was more circumscribed (e.g.,
where long, sitting meditations are not part of the intervention as in Acceptance and Commitment
Therapy or Dialectical Behavior Therapy) were excluded. When reviewing mechanism studies or
tests of the effects of MBIs on risk factors for suicidal behavior, we excluded studies where
outcomes did not include factors specific to suicide attempters. That is, the review focused only
on trials examining suicide behavior, suicidal ideation, or factors strongly associated with these
phenomena. We included studies of varying levels of methodological sophistication, including, for
example, uncontrolled quasi-experimental tests of MBIs for suicidal behavior, given the limited
state of the research on MBIs for suicidal behavior. The study selection process is illustrated in
Figure 1. Details of MBI treatment studies that were included in the review are provided in Table
1.
MBCT Overview
Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2002, 2013) is an 8-session,
once weekly, group-training program that was designed to prevent depressive relapse. MBCT
combines mindfulness meditation training and practice, i.e., training and practice relating to
present experience without judgment and with an attitude of acceptance (Bishop et al., 2004;
Kabat-Zinn, 1994), with some cognitive therapy (CT) techniques (Segal et al., 2002). The main
focus of the intervention, which differentiates it from traditional CT approaches, is on changing
cognitive processing as opposed to content through mindfulness meditation practice. During
mindfulness meditations, participants sit quietly and are instructed to attend to specific stimuli,
e.g., sensations associated with breathing and in the body, and to return their attention to these
sensations whenever they notice that their attention has drifted. In later meditation sessions,
6
attentional stability is leveraged when participants practice acknowledging and attending to
difficult emotions and thoughts. Psychoeducation about depression and the cognitive model of
depression (i.e., how thoughts, feelings, and behaviors are interrelated and contribute to mood),
and relapse prevention planning are the main CT techniques included in MBCT. Mindfulness
meditation practices, and guided discussion of them, constitute the bulk of most sessions and daily
mindfulness meditation practices, as well as some CT exercises (e.g., activity monitoring), are
assigned for homework.

As both an adjunct to TAU and a stand-alone treatment, MBCT has been found to prevent
relapse to depression among individuals remitted from depression (Galante, Iribarren, & Pearce,
2013; Kuyken et al., 2008; Segal et al., 2010). Over the longer-term, MBCT is as effective at
preventing relapse to depression as maintenance medication (Kuyken, 2008; Segal et al., 2010).
MBCT also works to treat current depression (Barnhofer et al., 2009; Eisendrath et al., 2008;
Hofmann, Sawyer, Witt, & Oh, 2010; Kenny & Williams, 2007; Manicavasagar, Perich, & Parker,
2012; van Aalderen et al., 2012), with preliminary data from uncontrolled studies showing
maintenance of post-MBCT treatment reductions in acute depression for 34 years (Mathew,
Whitford, Kenny, & Denson, 2010; Munshi, Eisendrath, & Delucchi, 2012).
Existing Evidence Supporting the Use of an MBI With Suicidal Patients
Findings from two studies show adjunct MBCT is acceptable to, i.e. well attended and
adhered to by, depressed patients who have current suicidal ideation and individuals with a history
of suicidal thoughts or behavior during depression (Barnhofer et al., 2009; Kenny & Williams,
2007). Moreover, MBCT is effective in reducing depression among these patients (Barnhofer et
al., 2009; Kenny & Williams, 2007). Further, findings from a few trials, including our own pilot
7
study of a modified version of MBCT for patients at risk of suicide (MBCT-S), show preliminary
effectiveness for MBIs for reducing suicidal ideation. In a community sample of 6 th graders,
students in classrooms randomized to receive an MBI were less likely to have developed suicidal
thoughts or self-harm behavior at post-study assessment than students in classrooms assigned to
an active control condition (Britton et al., 2014). In an RCT, participants with a history of MDD
and residual depression who received MBCT reported more improvement in passive suicidal
ideation, than those in TAU who were wait-listed for MBCT (Forkmann et al., 2014). In a small,
uncontrolled pilot study, Mindfulness-Based Stress Reduction (MBSR), the MBI on which MBCT
is based, was adapted to align with Native American cultural beliefs and practices and found to
reduce suicidal ideation among Native American high school students who self-selected to receive
it (Le & Gobert, 2013). In a small (n = 16), uncontrolled pilot study of MBCT-S, we found MBCT-
S was acceptable, feasible, safe, and effective for reducing suicidal ideation and depresion among
outpatients with a 6-month history of active suicidal ideation with method or plan or suicide
attempt and suicidal ideation at study entry (Chesin et al., 2015). In contrast, in one study, the
addition of MBCT to TAU did not result in reductions in suicidal ideation among chronically
depressed patients (Barnhofer et al., 2009). Minimal baseline levels of ideation and a small sample
size may account for the negative finding in this study.
A few conclusions can be drawn from these preliminary tests of MBIs for addressing
suicidal thoughts. First, MBIs seem acceptable to suicidal individuals. Second, MBIs show some
promise for improving suicidal ideation. However, although MBIs show some benefit for reducing
suicidal ideation among community members and patients, in no MBI studies have the benefits of
MBI for preventing suicide attempt been tested. The scarcity of data on suicide-related outcomes
with MBCT likely stems from two sources: initial conceptualization and testing of MBCT as a
8
protocol to prevent relapse to depression and exclusion of participants with current suicidal
thoughts from most trials of MBCT. MBCT was designed for use with individuals who were
remitted from depression (Segal et al., 2002, 2013). Thus, as is typical in the course of depression
(e.g., ten Have et al., 2009), suicidal thoughts and behavior were not present, or when present,
were not persistent, among MBCT trial participants who were between mood episodes. More
recently, MBCT has been tested among individuals with chronic depression who were both within
and between depressive episodes at trial entry. Most trials, regardless of the target sample, have,
however, excluded patients who report suicidal ideation or behavior at study intake. Thus, testing
of changes to suicidal thoughts and behavior with MBCT has been precluded by sample selection
procedures and the resultant (purposefully) low base rates of suicidal thoughts and behavior in
study samples.
POTENTIAL LIMITATIONS TO USING MBIS WITH SUICIDAL
PATIENTS
Conclusions about the limitations to MBIs for suicidal patients await additional empirical
study of moderators of treatment adherence and effectiveness. Few studies have tested moderators
of MBI adherence or effectiveness among community or patient participants. Studies of
demographic or clinical characteristics that change adherence or outcomes among MBI
participants who have past or current suicidal ideation or behavior are almost nonexistent.
Nonetheless, a review of the preliminary empirical information about moderators of MBI treatment
adherence and effectiveness can suggest for whom an MBI may be contraindicated or at least for
whom among the target population expected outcomes or processes of an MBI targeting suicidal
behavior should be modified to increase acceptability, engagement and response.
9
Two studies have examined clinical factors affecting MBI adherence and effectiveness to
mixed result. Crane and Williams (2010) found baseline rumination and cognitive reactivity were
positively related to MBCT dropout among individuals with a history of suicidal depression.
Meanwhile, Kuyken et al. (2010) found baseline clinical factors, including depressive symptom
severity and psychiatric comorbidity, did not predict response to MBCT treatment among
depressed patients. Thus, there is preliminary evidence pointing to fixed and rigid cognitive styles
among suicidal patients as special considerations for MBI treatment. If confirmed in future studies,
adaptations that provide greater support to patients with these cognitive styles may be indicated as
rumination and cognitive reactivity can be successfully targeted with MBI (e.g., Raes, Dewulf,
Van Heeringen, & Williams, 2009; van Aalderen et al., 2012).
Other diagnostic considerations have emerged mainly from case report and small pilot
studies. Specifically, concerns about using MBCT with patients with psychosis, Post-Traumatic
Stress Disorder (PTSD), and Bipolar Disorder have surfaced and are noteworthy given the high
rates of PTSD, Bipolar Disorder, and psychotic disorders in suicidal populations (e.g., Beautrais
et al., 1996; Isomets, 2001; Nock, Hwang, Sampson, & Kessler, 2010). Such concerns stem from
reports in case studies that mindfulness-meditation practitioners, including those who are and are
not predisposed to mental health problems and those who are and are not practicing in the context
of an integrated Western treatment, sometimes experience meditation-induced de-realization, de-
personalization, other psychotic, mood or anxiety symptoms (Chadwick, 2014; Dobkin et al.,
2011; Shonin, Van Gordon, & Griffiths, 2014). Yet, in meta-analysis, MBIs are shown to be
feasible with and moderately effective for reducing negative symptoms among patients with
psychotic disorders (Khoury, Lecomte, Gaudiano, & Paquin, 2013). Further, there is now
emerging evidence that MBIs work to improve psychiatric symptoms, including anxiety, avoidant
10
and depressive symptoms, among Veterans with PTSD (Steinberg & Eisner, 2015, for a review).
Data from pilot studies further show adjunct MBCT is feasible, acceptable, and effective for
reducing subclinical mood and anxiety symptoms among bipolar patients who are between
episodes (Weber et al., 2010; Miklowitz et al., 2009; Williams et al., 2008). In a larger-scale RCT,
improvements in anxiety specific to MBCT among Bipolar patients were confirmed (Perich et al.,
2013). Meanwhile, among community members practicing meditation or participating in MBIs, it
appears meditation can sometimes, albeit not often, heighten loneliness, emotional dysregulation,
and self-judgment (Dobkin et al., 2011, for a review; Lomas, Ridge, Cartwright, & Edginton,
2014). To the extent that these factors trigger suicide risk (e.g., Anestis, Bagge, Tull, & Joiner,
2011; Stravynski & Boyer, 2001), such outcomes, no matter how transient, cause concern about
using an MBI to treat individuals at suicide risk. Suggestions for mitigating adverse effects
associated with meditation practice include having MBI sessions led by a professional who is
experienced in mindfulness meditation and managing and treating psychiatric patients as well as
ensuring participants in MBIs with mental health difficulties are concurrently receiving mental
health treatment (Chadwick, 2014; Dobkin et al., 2011; Lustyk, 2009; Shonin et al., 2014).
There are dire costs to providing ineffective or intolerable treatment to individuals at risk
of suicidal behavior. Unfortunately, empirical study of moderators of treatment adherence and
gains among patients and community members receiving MBIs is very limited and findings are
mixed. Better-controlled, predictor studies are needed to understand clinical characteristics that
may signal the need for adaptation of MBCT-S or another MBI for suicidal thoughts and behavior
or indicate that the treatment is contraindicated.
11
POSSIBLE MECHANISMS OF ACTION IN MBIS FOR
SUICIDAL BEHAVIOR
Individuals who have attempted suicide demonstrate attentional dyscontrol, problem-
solving difficulties, and altered stress response. These factors are also found to improve with MBIs.
Thus, we propose three potential mechanisms of action in MBIs for suicidal behavior, improved
attentional control, problem solving and stress response.

Attentional Control
Attentional control is the ability to detect subjectively salient or adaptive stimuli while
facing simultaneous distraction. Individuals who have attempted suicide perform more poorly on
attentional control tasks than psychiatric controls (Keilp, Gorlyn, Oquendo, Burke, & Mann, 2008,
2013). Attentional dyscontrol, and specifically attentional biases toward suicide-relevant stimuli
and attentional fixation or preoccupation with suicide as the only solution are found among suicide
attempters (Wenzel & Beck, 2008, for a review), and thus, attentional dyscontrol is posited as a
risk factor in Wenzels and Becks (2008) empirically-based cognitive model of suicidal behavior.
Findings from structural and task-based functional neuroimaging studies of suicide attempters and
completers align with these data and ideas. Specifically, suicide attempters and completers show
structural brain abnormalities and dysfunction in regions associated with attentional control,
namely the anterior cingulate cortex (ACC) and the dorsolateral prefrontal cortex (DLPFC) (Mann
& Currier, 2012, for a review).
Meanwhile, in MBI outcome studies that have used translational methods, healthy MBI
participants were found to recruit the DLPFC and ACC during task-based fMRI to a greater extent
12
than controls who received training to improve their concentration or no intervention, suggesting
a neural basis to observed improvements in attentional control with MBIs (Allen et al., 2012; Fox,
Dixon, Nijeboer, & Christoff, 2013). In fact, in contemporary, empirically-derived theories of
mechanisms of MBI treatment gains, e.g., the Liverpool Mindfulness Model (Malinowski, 2013),
attentional improvements are proffered to be fundamental and foundational to MBI-treatment
gains (Holzel et al., 2011; Malinowski, 2013).
Problem-Solving Deficits
As previously mentioned, Williams et al. (2006) predicated their use of MBCT to prevent
the recurrence of suicidal depression on data showing that subjects remitted from suicidal
depression evidence greater deteriorations in their problem solving abilities when sad, i.e.,
cognitive reactivity, than psychiatric controls (Williams et al., 2005) and that MBCT reduces
cognitive reactivity among community member participants (Raes et al., 2009). In fact, problem
solving deficits, as assessed using neuropsychological tasks and self-report measures, are generally
found to differentiate suicide attempters from psychiatric controls (e.g., Gibbs et al., 2009; King
et al., 2000, for an exception; Pollock & Williams, 1998; Pollock & Williams, 2004, for a review).
Problem solving deficits are also found to moderate the relationship between other risk factors for
suicidal behavior (e.g., life stress, emotional reactivity) and suicidal behavior such that problem
solving skills protect against suicide attempt and recurrent suicidal ideation among community
members who have risk factors for suicidal behavior (Dour, Cha, & Nock, 2011; Linda, Marroqun,
& Miranda, 2012). In alignment with such empirical findings, problem solving deficits are
conceptualized as both a dispositional factor elevating long-term risk of suicidal behavior and an
acute risk factor in the cognitive model of suicidal behavior (Wenzel & Beck, 2008). That is,
further deterioration in problem solving abilities subsequent to life stress is posited to instantiate
13
acute suicide attempt risk. Such problem solving deficits, and particularly exacerbation of
problem-solving deficits when stressed or in emotional distress, may be changed by MBIs.
Evidence from cross-sectional studies show that trait mindfulness in healthy subjects is associated
with greater persistence in stressful situations (Feldman, Dunn, Stemke, Bell, & Greeson, 2014)
and that remitted depressed subjects who self-report greater mindfulness can effectively employ
reflective pondering (i.e., cognitive problem solving) to regulate mood when sad, where those who
self-report less mindfulness show a positive relationship between self-reported tendencies to

engage in cognitive problem solving when sad and depressive symptoms (Brennan, Barnhofer,
Crane, Duggan, & Williams, 2015). Furthermore, findings from two experiments show improved
problem solving after brief mindfulness practice, but not subsequent to a listening task, among
community members (Ostafin & Kassman, 2012; Ren et al., 2011). Thus, cross sectional data and
findings from a few controlled experiments suggest mindfulness training may improve problem
solving, particularly under stress.
Stress Response
Dysregulated stress response, whether indicated by hypo-reactivity of the Hypothalamic-
Pituitary-Adrenal (HPA) axis or the parasympathetic nervous system (PNS), is also associated
with suicidal behavior and may be improved by MBI (Crowell et al., 2005; Mann et al., 2009;
Matousek, Dobkin, & Pruessner, 2010; Wilson & Chesin et al., unpublished data). Suicide
attempters with borderline personality disorder and adolescent self-injurers evidence lower
parasympathetic nervous system (PNS)-mediated cardiac control at-rest and during laboratory
stress tests than healthy and psychiatric controls (Crowell et al., 2005; Wilson & Chesin et al.,
unpublished data). Findings specifying HPA-axis dysfunction among suicide completers and
suicide attempters along with studies showing blunted cortisol response to social stress among
14
non-affected family members of suicide completers further support the relationship between
altered stress response and suicidal behavior (Mann et al., 2009; McGirr et al., 2010, for a review).
Several studies suggest that stress response may be improved by MBIs. For example, after
MBI, medical and psychiatric patients, and sometimes healthy volunteers, evidenced decreased
diurnal cortisol levels (Brand, Holsboer-Trachsler, Naranjo, & Schmidt, 2012; Marcus et al., 2003;
Matousek et al., 2010 for a review), with one study showing improvements in HPA-axis
functioning increased throughout the year following treatment (Carlson, Speca, Faris, & Patel,
2007). Improvements to resting-state PNS activity and PNS tone were also found among
community member and Veteran patient MBI participants (Bhatnagar et al., 2013; Kok, Waugh,
& Fredrickson, 2013). Other studies, however, have failed to link greater PNS-mediated stress
response to MBI or extensive meditation experience (Libby, Worhunsky, Pilver, & Brewer, 2012;
Lutz, Slagter, Dunne, & Davidson, 2008). Lutz et al. (2008) thus concluded, the impact of
meditation on emotion regulation might result from a complex pattern of interaction between
sympathetic and parasympathetic influences (p. 11). Others (e.g., Chiesa, Serretti, & Jakobsen,
2013; Kerr, Sacchet, Lazar, Moore, & Jones, 2013) reviewing translational neuroscientific studies
have reached similar overall conclusions, suggesting that some combination of enhanced
interoceptive experience and improved top-down regulatory processes (i.e., recovery to baseline)
explain MBI treatment gains.
Taken together, the benefits to attentional stability, problem-solving, and stress response
that are often conferred by mindfulness training provide additional rationale for testing MBCT-S
among high suicide-risk patients as suicidal individuals display specific deficits in these
neurocognitive and psychophysiological functions. In the aforementioned uncontrolled pilot study,
we tested whether attentional control improved with MBCT-S treatment and found that the
15
interference effect during performance on high-conflict Stroop task trials, i.e., relative slowing
during correct performance on high versus low-conflict trials, was lower among participants at
post-treatment than it was at pre-treatment (d = .75). This effect was not explained by
improvements to depression with treatment (Chesin et al., 2015).
DISCUSSION AND FUTURE DIRECTIONS
The rationale for developing and testing MBIs to reduce suicidal ideation and prevent
suicide attempt stems from Williams et al. (2006) reflections on applying traditional MBCT to
patients remitted from suicidal depression. More recently, a handful of studies have shown that
MBIs reduce suicidal ideation in community members and psychiatric subjects (Britton et al.,
2014; Chesin et al., 2015; Forkmann et al., 2014; Le & Gobert, 2013) and MBCT is acceptable to
and feasible with currently and formerly suicidal depressed patients (Barnhofer et al., 2009; Kenny
& Williams, 2007). We are in the process of testing MBCT-S in a fully-powered RCT among high
suicide-risk Veterans. Our sample members report (1) a suicidal event, i.e., suicidal ideation with
intent, suicide-related hospitalization, or suicide attempt (actual, interrupted, or aborted) within the
past 4 weeks and (2) have either been placed on the Veterans Affairs (VA) high-risk for suicide
list or have had a suicide attempt in the past year. All are also currently receiving VA mental health
treatment, which often include interventions from suicide prevention coordinators.
Next steps in treatment development include positing and testing mechanisms of treatment
gains so that MBIs aimed at reducing suicide risk can be refined. Processes and practices that are
key or superfluous to clinical improvement can be highlighted, and thus mindfulness and cognitive
treatment components to keep, augment, or discard can be identified. We suggested attentional
control, problem solving deficits and altered stress response may be factors associated with suicide
16
behavior risk that can be changed with MBCT-S based on data and evidence-based theories that
link these factors to suicide attempt risk among psychiatric populations (Gibbs et al., 2009; Keilp
et al., 2013; Mann et al., 2009) and show MBIs improve these factors (Kok et al., 2013;
Malinowski et al., 2013). In our RCT, attention regulation is being assessed and compared over
treatment between those receiving MBCT-S+TAU and TAU. Other factors may also be worthy of
consideration and testing as potential mechanisms of change in MBCT-S and other MBIs to
prevent suicidal behavior. For instance, Hepburn et al. (2009) found past-week thought
suppression was reduced among individuals who received MBCT when in remission from
depression that included suicidal thinking or behavior. Individuals assigned to the treatment-as-
usual waitlist control realized no such benefit to their past-week thought suppression over 8 weeks,
which was the duration of MBCT treatment in the trial.
CONCLUSIONS
Given the pressing need for effective interventions that engage suicidal individuals, we
have developed MBCT-S by integrating MBCT with SPI. We are currently testing MBCT-S as an
adjunctive treatment for suicidal Veterans. In this paper, we provided a rationale for developing
and testing MBIs for patients at risk of suicidal behavior. We showed the effectiveness of MBCT
for reducing symptoms in depressed patients, including those at risk for suicidal behavior. We also
reviewed the few studies showing MBIs reduce suicidal thinking in community and clinical
samples as well as studies showing MBIs effectively reduce vulnerabilities related to suicide
attempt. Finally, we suggested directions for future research aimed at informing further treatment
development and testing.
Acknowledgements
17
This project was supported by Grant PDF-0-076-11 awarded to MSC from the American
Foundation for Suicide Prevention (AFSP) and by Award # IIR 12-134 from the US Department
of Veterans Affairs, Health Services Research and Development Service. The content is solely the
responsibility of the authors and does not necessarily represent the official views of the AFSP, the
Department of Veterans Affairs, or the US Government.The authors have no financial involvement
(including employment, fees, shares, ownership) or affiliation with any organization whose
financial interests may be affected by material in the manuscript.

References
Allen, M., Dietz, M., Blair, K. S., van Beek, M., Rees, G., Vestergaard-Poulsen, P., Roepstorff,
A. (2012). Cognitive-affective neural plasticity following active-controlled mindfulness
intervention. The Journal of Neuroscience, 32(44), 1560115610.
doi:10.1523/jneurosci.2957-12.2012
Anestis, M. D., Bagge, C. L., Tull, M. T., & Joiner, T. E. (2011). Clarifying the role of emotion
dysregulation in the interpersonal-psychological theory of suicidal behavior in an
undergraduate sample. Journal of Psychiatric Research, 45(5), 603611.
Barnhofer, T., Crane, C., Hargus, E., Amarasinghe, M., Winder, R., & Williams, J. M. G. (2009).
Mindfulness-based cognitive therapy as a treatment for chronic depression: A preliminary
study. Behaviour Research and Therapy, 47(5), 366373. doi:10.1016/j.brat.2009.01.019
Beautrais, A. L., Joyce, P. R., Mulder, R. T., Fergusson, D. M., Deavoll, B. J., & Nightingale, S.
K. (1996). Prevalence and comorbidity of mental disorders in persons making serious
suicide attempts: A case-control study. American Journal of Psychiatry, 153, 10091014.
doi:10.1176/ajp.153.8.1009
Bhatnagar, R., Phelps, L., Rietz, K., Juergens, T., Russell, D., Miller, N., & Ahearn, E. (2013).
The effects of mindfulness training on post-traumatic stress disorder symptoms and heart
rate variability in combat veterans. The Journal of Alternative and Complementary
Medicine, 19, 860861. doi:10.1089/acm.2012.0602
Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., Devins, G.
(2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and
Practice, 11(3), 230241. doi:10.1093/clipsy.bph077
Borges, G., Nock, M. K., Abad, J. M., Hwang, I., Sampson, N. A., Alonso, J., Kessler, R.
(2010). Twelve-month prevalence of and risk factors for suicide attempts in the WHO
World Mental Health Surveys. Journal of Clinical Psychiatry, 71(12), 16171628.
doi:10.4088/jcp.08m04967blu
Bottlender, R., Jger, M., Strau, A., & Mller, H. J. (2000). Suicidality in bipolar compared to
unipolar depressed inpatients. European Archives of Psychiatry and Clinical
Neuroscience, 250(5), 257261. doi:10.1007/s004060070016
18
Brand, S., Holsboer-Trachsler, E., Naranjo, J. R., & Schmidt, S. (2012). Influence of mindfulness
practice on cortisol and sleep in long-term and short-term meditators. Neuropsychobiology,
65(3), 109118. doi:10.1159/000330362
Brennan, K., Barnhofer, T., Crane, C., Duggan, D., & Williams, J. M. (2015). Memory specificity
and mindfulness jointly moderate the effect of reflective pondering on depressive
symptoms in individuals with a history of recurrent depression. Journal of Abnormal
Psychology, 124, 246255. doi:10.1037/abn0000027
Britton, W. B., Lepp, N. E., Niles, H. F., Rocha, T., Fisher, N. E., & Gold, J. S. (2014). A
randomized controlled pilot trial of classroom-based mindfulness meditation compared to
an active control condition in sixth-grade children. Journal of School Psychology, 52(3),
263278. doi:10.1016/j.jsp.2014.03.002
Carlson, L. E., Speca, M., Faris, P., & Patel, K. D. (2007). One year prepost intervention follow-
up of psychological, immune, endocrine and blood pressure outcomes of mindfulness-
based stress reduction (MBSR) in breast and prostate cancer outpatients. Brain, Behavior,
and Immunity, 21(8), 10381049. doi:10.1016/j.bbi.2007.04.002
Cavanagh, J. T. O., Carson, A. J., Sharpe, M., & Lawrie, S. M. (2003). Psychological autopsy
studies of suicide: A systematic review. Psychological Medicine, 33(3), 395405.
Center for Disease Control and Prevention [CDC], National Center for Injury Prevention and
Control. (2014). Web-based injury statistics query and reporting system (WISQARS).
Retrieved from www.cdc.gov/ncipc/wisqars
Chadwick, P. (2014). Mindfulness for psychosis. The British Journal of Psychiatry, 204(5), 333
334.
Chartrand, H., Robinson, J., & Bolton, J. M. (2012). A longitudinal population-based study
exploring treatment utilization and suicidal ideation and behavior in major depressive
disorder. Journal of Affective Disorders, 141(23), 237245.
doi:10.1016/j.jad.2012.03.040
Chen, Y. W., & Dilsaver, S. C. (1996). Lifetime rates of suicide attempts among subjects with
bipolar and unipolar disorders relative to subjects with other axis I disorders. Biological
Psychiatry, 39(10), 896899. doi:10.1016/0006-3223(95)00295-2
Chesin, M. S., Benjamin-Phillips, C. A., Keilp, J., Fertuck, E., Brodsky, B. S., & Stanley, B. (2015,
October). Improvements in executive attention, rumination, cognitive reactivity and
mindfulness among high suicide-risk patients participating in adjunct mindfulness-based
cognitive therapy. Paper presented at the International Summit on Suicide Research, New
York, NY.
Chesin, M. S., Sonmez, C. C., Benjamin-Phillips, C. A., Beeler, B., Brodsky, B. S., & Stanley, B.
(2015). Preliminary effectiveness of adjunct mindfulness-based cognitive therapy to
prevent suicidal behavior in outpatients who are at elevated suicide risk. Mindfulness, 6,
13451355. doi:10.1007/s12671-015-0405-8
Chiesa, A., Serretti, A., & Jakobsen, J. C. (2013). Mindfulness: Topdown or bottomup emotion
regulation strategy? Clinical Psychology Review, 33(1), 8296.
doi:10.1016/j.cpr.2012.10.006
Crane, C., & Williams, J. M. G. (2010). Factors associated with attrition from mindfulness-based
cognitive therapy in patients with a history of suicidal depression. Mindfulness, 1(1), 10
20. doi:10.1007/s12671-010-0003-8
19
Crosby, A. E., Han, B., Ortega, L. A. G., Parks, S. E., & Gfoerer, J. (2011). Suicidal thoughts and
behaviors among adults aged 18 years-United States, 2008-2009. MMWR Surveillance
Summaries, 60, SS13.
Crowell, S. E., Beauchaine, T. P., McCauley, E., Smith, C. J., Stevens, A. L., & Sylvers, P. (2005).
Psychological, autonomic, and serotonergic correlates of parasuicide among adolescent
girls. Development and psychopathology, 17(04), 11051127.
doi:10.1017/S0954579405050522
Dobkin, P. L., Irving, J. A., & Amar, S. (2012). For whom may participation in a mindfulness-
based stress reduction program be contraindicated? Mindfulness, 3(1), 4450.
doi:10.1007/s12671-011-0079-9
Dour, H. J., Cha, C. B., & Nock, M. K. (2011). Evidence for an emotioncognition interaction in
the statistical prediction of suicide attempts. Behaviour Research and Therapy, 49(4), 294
298. doi:10.1016/j.brat.2011.01.010
Eisendrath, S. J., Delucchi, K., Bitner, R., Fenimore, P., Smit, M., & McLane, M. (2008).
Mindfulness-based cognitive therapy for treatment-resistant depression: A pilot study.
Psychotherapy and Psychosomatics, 77(5), 319320. doi:10.1159/000142525
Feldman, G., Dunn, E., Stemke, C., Bell, K., & Greeson, J. (2014). Mindfulness and rumination
as predictors of persistence with a distress tolerance task. Personality and Individual
Differences, 56, 154158. doi:10.1016/j.paid.2013.08.040
Forkmann, T., Wichers, M., Geschwind, N., Peeters, F., van Os, J., Mainz, V., & Collip, D. (2014).
Effects of mindfulness-based cognitive therapy on self-reported suicidal ideation: Results
from a randomised controlled trial in patients with residual depressive symptoms.
Comprehensive Psychiatry, 55, 18831890. doi:10.1016/j.comppsych.2014.08.043
Fox, K. C. R., Dixon, M. L., Nijeboer, S., & Christoff, K. (2013, June). Diverse meditation
practices recruit distinct neural networks: Meta-analytic evidence from functional
neuroimaging. Poster presented at the Summer Research Institute of the Mind & Life
Institute, Garrison, New York.
Galante, J., Iribarren, S. J., & Pearce, P. F. (2013). Effects of mindfulness-based cognitive therapy
on mental disorders: A systematic review and meta-analysis of randomised controlled
trials. Journal of Research in Nursing, 18(2), 133155. doi:10.1177/1744987112466087
Gao, K., Wu, R., Wang, Z., Ren, M., Kemp, D. E., Chan, P. K., Calabrese, J. R. (2015).
Disagreement between self-reported and clinician-ascertained suicidal ideation and its
correlation with depression and anxiety severity in patients with major depressive disorder
or bipolar disorder. Journal of Psychiatric Research, 60, 117124.
doi:10.1016/j.jpsychires.2014.09.011
Gibbs, L. M., Dombrovski, A. Y., Morse, J., Siegle, G. J., Houck, P. R., & Szanto, K. (2009).
When the solution is part of the problem: Problem solving in elderly suicide attempters.
International Journal of Geriatric Psychiatry, 24(12), 13961404. doi:10.1002/gps.2276
Hepburn, S. R., Crane, C., Barnhofer, T., Duggan, D. S., Fennell, M. J., & Williams, J. M. G.
(2009). Mindfulnessbased cognitive therapy may reduce thought suppression in
previously suicidal participants: Findings from a preliminary study. British Journal of
Clinical Psychology, 48(2), 209215. doi:10.1348/014466509x414970
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based
therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and
Clinical Psychology, 78(2), 169183. doi:10.1037/a0018555
20
Holzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., & Ott, U. (2011). How
does mindfulness meditation work? Proposing mechanisms of action from a conceptual
and neural perspective. Perspectives on Psychological Science, 6(6), 537559.
doi:10.1177/1745691611419671
Isomets, E. T. (2001). Psychological autopsy studies A review. European Psychiatry, 16(7),
379385. doi:10.1016/s0924-9338(01)00594-6
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life.
New York: Hyperion.
Keilp, J. G., Gorlyn, M., Oquendo, M. A., Burke, A. K., & Mann, J. J. (2008). Attention deficit in
depressed suicide attempters. Psychiatry Research, 159(12), 717.
doi:10.1016/j.psychres.2007.08.020
Keilp, J. G., Gorlyn, M., Russell, M., Oquendo, M. A., Burke, A. K., Harkavy-Friedman, J., &
Mann, J. J. (2013). Neuropsychological function and suicidal behavior: Attention control,
memory and executive dysfunction in suicide attempt. Psychological Medicine, 43(03),

539551. doi:10.1017/S0033291712001419
Kenny, M. A., & Williams, J. M. G. (2007). Treatment-resistant depressed patients show a good
response to mindfulness-based cognitive therapy. Behaviour Research and Therapy, 45(3),
617625. doi:10.1016/j.brat.2006.04.008
Kerr, C. E., Sacchet, M. D., Lazar, S. W., Moore, C. I., & Jones, S. R. (2013). Mindfulness starts
with the body: Somatosensory attention and top-down modulation of cortical alpha
rhythms in mindfulness meditation. Frontiers in Human Neuroscience, 7, 12.
doi:10.3389/fnhum.2013.00012
Khoury, B., Lecomte, T., Gaudiano, B. A., & Paquin, K. (2013). Mindfulness interventions for
psychosis: A meta-analysis. Schizophrenia Research, 150(1), 176184.
King, D. A., Conwell, Y., Cox, C., Henderson, R. E., Denning, D. G., & Caine, E. D. (2000). A
neuropsychological comparison of depressed suicide attempters and nonattempters. The
Journal of Neuropsychiatry and Clinical Neurosciences, 12(1), 6470.
doi:10.1176/jnp.12.1.64
Kok, B. E., Waugh, C. E., & Fredrickson, B. L. (2013). Meditation and health: The search for
mechanisms of action. Social and Personality Psychology Compass, 7(1), 2739.
doi:10.1111/spc3.12006
Kuyken, W., Byford, S., Taylor, R. S., Watkins, E., Holden, E., White, K., Teasdale, J. (2008).
Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. Journal of
Consulting and Clinical Psychology, 76(6), 966978. doi:10.1037/a0013786
Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R. S., Byford, S., Dalgleish, T. (2010).
How does mindfulness-based cognitive therapy work? Behaviour Research and Therapy,
48(11), 11051112. doi:10.1016/j.brat.2010.08.003
Le, T., & Gobert, J. (2013). Translating and implementing a mindfulness-based youth suicide
prevention intervention in a Native American community. Journal of Child and Family
Studies, 24, 112. doi:10.1007/s10826-013-9809-z
Libby, D. J., Worhunsky, P. D., Pilver, C. E., & Brewer, J. A. (2012). Meditation-induced changes
in high-frequency heart rate variability predict smoking outcomes. Frontiers in Human
Neuroscience, 6, 54. doi:10.3389/fnhum.2012.00054
Linda, W. P., Marroqun, B., & Miranda, R. (2012). Active and passive problem solving as
moderators of the relation between negative life event stress and suicidal ideation among
21
suicide attempters and non-attempters. Archives of Suicide Research, 16(3), 183197.

doi:10.1080/13811118.2012.695233
Lomas, T., Ridge, D., Cartwright, T., & Edginton, T. (2014). Engagement with meditation as a
positive health trajectory: Divergent narratives of progress in male meditators. Psychology
& Health, 29(2), 218236.
Lustyk, M. K., Chawla, N., Nolan, R., & Marlatt, G. A. (2009). Mindfulness meditation research:
Issues of participant screening, safety procedures, and researcher training. Advances in
Mind-Body Medicine, 24(1), 2030.
Lutz, A., Slagter, H. A., Dunne, J. D., & Davidson, R. J. (2008). Attention regulation and
monitoring in meditation. Trends in Cognitive Science, 12, 163169.
Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression:
Replication and exploration of differential relapse prevention effects. Journal of
Consulting and Clinical Psychology, 72(1), 3140. doi:10.1037/0022-006x.72.1.31
Malinowski, P. (2013). Neural mechanisms of attentional control in mindfulness meditation.

Frontiers in Neuroscience, 7, 8. doi:10.3389/fnins.2013.00008
Manicavasagar, V., Perich, T., & Parker, G. (2012). Cognitive predictors of change in cognitive
behaviour therapy and mindfulness-based cognitive therapy for depression. Behavioural
and Cognitive Psychotherapy, 40(02), 227232. doi:10.1017/S1352465811000634
Mann, J. J., Arango, V. A., Avenevoli, S., Brent, D. A., Champagne, F. A., Clayton, P., Wenzel,
A. (2009). Candidate endophenotypes for genetic studies of suicidal behavior. Biological
Psychiatry, 65(7), 556563. doi:10.1016/j.biopsych.2008.11.021
Mann, J. J., & Currier, D. (2012). Medication in suicide prevention: Insights from neurobiology of
suicidal behavior (the neurobiological basis of suicide). Boca Raton, FL: CRC Press.
Mann, J. J., Waternaux, C., Haas, G. L., & Malone, K. M. (1999). Toward a clinical model of
suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156(2), 181
189.
Marcus, M. T., Fine, P. M., Moeller, F. G., Khan, M. M., Pitts, K., Swank, P. R., Liehr, P.
(2003). Change in stress levels following mindfulness-based stress reduction in a
therapeutic community. Addictive Disorders & Their Treatment, 2(3), 6368.
Mathew, K. L., Whitford, H. S., Kenny, M. A., & Denson, L. A. (2010). The long-term effects of
mindfulness-based cognitive therapy as a relapse prevention treatment for major depressive
disorder. Behavioural and Cognitive Psychotherapy, 38(05), 561576.
doi:10.1017/S135246581000010X
Matousek, R. H., Dobkin, P. L., & Pruessner, J. (2010). Cortisol as a marker for improvement in
mindfulness-based stress reduction. Complementary Therapies in Clinical Practice, 16(1),
1319. doi:10.1016/j.ctcp.2009.06.004
McGirr, A., Diaconu, G., Berlim, M. T., Pruessner, J. C., Sabl, R., Cabot, S., & Turecki, G.
(2010). Dysregulation of the sympathetic nervous system, hypothalamicpituitaryadrenal
axis and executive function in individuals at risk for suicide. Journal of Psychiatry &
Neuroscience, 35, 399408.
Miklowitz, D. J., Alatiq, Y., Goodwin, G. M., Geddes, J. R., Fennell, M. J., Dimidjian, S.,
Williams, J. M. G. (2009). A pilot study of mindfulness-based cognitive therapy for bipolar
disorder. International Journal of Cognitive Therapy, 2(4), 373382.
Mller, H. J. (2003). Suicide, suicidality and suicide prevention in affective disorders. Acta
Psychiatrica Scandinavica, 108, 7380. doi:10.1034/j.1600-0447.108.s418.15.x
22
Munshi, K., Eisendrath, S., & Delucchi, K. (2012). Preliminary long-term follow-up of
mindfulness-based cognitive therapy-induced remission of depression. Mindfulness, 4,
354361. doi:10.1007/s12671-012-0135-0
Nock, M., Hwang, I., Sampson, N., & Kessler, R. (2010). Mental disorders, comorbidity and
suicidal behavior: Results from the National Comorbidity Survey Replication. Molecular
Psychiatry, 15(8), 868876. doi:10.1038/mp.2009.29
Nock, M. K., & Kessler, R. C. (2006). Prevalence of and risk factors for suicide attempts versus
suicide gestures: Analysis of the National Comorbidity Survey. Journal of Abnormal
Psychology, 115(3), 616.
Ostafin, B. D., & Kassman, K. T. (2012). Stepping out of history: Mindfulness improves insight
problem solving. Consciousness and Cognition, 21(2), 10311036.
doi:10.1016/j.concog.2012.02.014
Panos, P. T., Jackson, J. W., Hasan, O., & Panos, A. (2013). Meta-analysis and systematic review
assessing the efficacy of Dialectical Behavior Therapy (DBT). Research on Social Work
Practice, 24, 213223. doi:10.1177/1049731513503047
Perich, T., Manicavasagar, V., Mitchell, P. B., & Ball, J. R. (2013). The association between
meditation practice and treatment outcome in mindfulness-based cognitive therapy for
bipolar disorder. Behaviour Research and Therapy, 51(7), 338343.
doi:10.1016/j.brat.2013.03.006
Perich, T., Manicavasagar, V., Mitchell, P. B., Ball, J. R., & Hadzi-Pavlovic, D. (2013). A
randomized controlled trial of mindfulnessbased cognitive therapy for bipolar disorder.
Acta Psychiatrica Scandinavica, 127, 333343. doi:10.1111/acps.12033
Pollock, L. R., & Williams, J. M. (2004). Problem-solving in suicide attempters. Psychological
Medicine, 34(1), 163167.
Pollock, L. R., & Williams, J. M. G. (1998). Problem solving and suicidal behavior. Suicide and
Life-Threatening Behavior, 28(4), 375387.
Raes, F., Dewulf, D., Van Heeringen, C., & Williams, J. M. G. (2009). Mindfulness and reduced
cognitive reactivity to sad mood: Evidence from a correlational study and a non-
randomized waiting list controlled study. Behaviour Research and Therapy, 47(7), 623
627. doi:10.1016/j.brat.2009.03.007
Ren, J., Huang, Z., Luo, J., Wei, G., Ying, X., Ding, Z., Luo, F. (2011). Meditation promotes
insightful problem-solving by keeping people in a mindful and alert conscious state.
Science China Life Sciences, 54(10), 961965. doi:10.1007/s11427-011-4233-3
Segal, Z. V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., Levitan, R. D.
(2010). Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-
based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression.
Archives of General Psychiatry, 67(12), 12561264.
doi:10.1001/archgenpsychiatry.2010.168
Segal, Z. V., Williams, J. M. G., & Teasdale, J. G. (2002). Mindfulness-based cognitive therapy
for depression: A New approach to preventing relapse. New York, NY: Guilford.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy
for depression (2nd ed.). New York: Guilford.
Shonin, E., Van Gordon, W., & Griffiths, M. D. (2014). Do mindfulness-based therapies have a
role in the treatment of psychosis? Australian & New Zealand Journal of Psychiatry, 48(2),
124127. doi:10.1177/0004867413512688
23
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate
suicide risk. Cognitive and Behavioral Practice, 19(2), 256264.
doi:10.1016/j.cbpra.2011.01.001
Steinberg, C. A., & Eisner, D. A. (2015). Mindfulness-based interventions for veterans with
posttraumatic stress disorder. The International Journal of Behavioral Consultation and
Therapy, 9(4), 11.
Stravynski, A., & Boyer, R. (2001). Loneliness in relation to suicide ideation and parasuicide: A
populationwide study. Suicide and Life-Threatening Behavior, 31(1), 3240.
Teasdale, J. D., & Dent, J. (1987). Cognitive vulnerability to depression: An investigation of two
hypotheses. British Journal of Clinical Psychology, 26(2), 113126. doi:10.1111/j.2044-
8260.1987.tb00737.x
Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A.
(2000). Prevention of relapse/recurrence in major depression by mindfulness-based
cognitive therapy. Journal of Consulting and Clinical Psychology, 68(4), 615623.

doi:10.1037/0022-006x.68.4.615
ten Have, M., de Graaf, R., van Dorsselaer, S., Verdurmen, J., van't Land, H., Vollebergh, W., &
Beekman, A. (2009). Incidence and course of suicidal ideation and suicide attempts in the
general population. Canadian Journal of Psychiatry, 54(12), 824833.
U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and
National Action Alliance for Suicide Prevention. (2012). 2012 National strategy for
suicide prevention: Goals and objectives for action. Washington, DC: HHS.
van Aalderen, J. R., Donders, A. R. T., Giommi, F., Spinhoven, P., Barendregt, H. P., & Speckens,
A. E. M. (2012). The efficacy of mindfulness-based cognitive therapy in recurrent
depressed patients with and without a current depressive episode: A randomized controlled
trial. Psychological Medicine, 42(05), 9891001. doi:10.1017/S0033291711002054
Weber, B., Jermann, F., Gex-Fabry, M., Nallet, A., Bondolfi, G., & Aubry, J. M. (2010).
Mindfulness-based cognitive therapy for bipolar disorder: A feasibility trial. European
Psychiatry, 25(6), 334337.
Wenzel, A., & Beck, A. T. (2008). A cognitive model of suicidal behavior: Theory and treatment.
Applied and Preventive Psychology, 12(4), 189201. doi:10.1016/j.appsy.2008.05.001
Williams, J. M., van der Does, A. J., Barnhofer, T., Crane, C., & Segal, Z. S. (2008). Cognitive
reactivity, suicidal ideation and future fluency: Preliminary investigation of a differential
activation theory of hopelessness/suicidality. Cognitive Therapy and Research, 32(1), 83
104. doi:10.1007/s10608-006-9105-y
Williams, J. M. G., Barnhofer, T., Crane, C., & Beck, A. T. (2005). Problem solving deteriorates
following mood challenge in formerly depressed patients with a history of suicidal
Ideation. Journal of Abnormal Psychology, 114(3), 421431. doi:10.1037/0021-
843x.114.3.421
Williams, J. M. G., Duggan, D. S., Crane, C., & Fennell, M. J. V. (2006). Mindfulness-based
cognitive therapy for prevention of recurrence of suicidal behavior. Journal of Clinical
Psychology, 62(2), 201210. doi:10.1002/jclp.20223
Williams, J. M. G., Fennell, M., Barnhofer, T., Silverton, S., & Crane, R. (2015). Mindfulness and
the transformation of despair: Working with people at risk of suicide. New York: Guilford.
24
Table 1. Details of included MBI treatment studies
Study|participa Trial Design Interve Compar Outco Outcom Major Additio
nts ntion ison me e Finding nal
Conditi Measure Finding
on s
Suicide-related
Outcome,
Acceptability
and Feasibility
Studies
Barnh 31 Randomized adjunct TAU SI First No Accepta
ofer adult controlled MBCT five reductio bility
et al. outpati trial (RCT) items of ns in SI and
(2009 ents Beck in either feasibili
) with Scale group ty of
Major for during MBCT
Depres Suicide the high as
sive Ideation course indicate
Disord of d by
er treatmen drop-
(MDD t out,
) or attenda
residua nce and
25
l complia
depres nce
sive rates
sympto
ms
with a
history
of 3+
prior
episod
es and
suicida
ideatio
n (SI)
or
attemp
t in
epsiod
e(s)
Britto 101 Cluster (at Asian African SI or Two Proporti
n et healthy classroom history history self- items on on of
al. 6th level) RCT didactic didactic harm Youth students
26
(2014 grade plus 3- plus Self reportin
) student to 12- "nondid Report g SI or
s minute actic, self-
daily, experie harm
in-class ntial, receivin
mindful and g MBI
ness- novel decrease

meditat activity d during
ion that the
practice was course
s for matche of the
6 week d to the interven
s didactic tion.
content Proporti
of the on
class" reportin
(p. 269) g SI or
for self-
6 weeks harm in
compari
son
conditio
27
increase
d.
Chesi 18 Quasi- adjunct none SI Scale Signific Accepta
n et adult experimental MBCT- for ant bility
al. outpati study: S Suicide reductio and
(2015 ents uncontrolled, Ideation ns in SI feasibili
) with a pre-post with ty of

6- design MBCT- MBCT-
month S during S high
history the as
of course indicate
active of d by
SI with treatmen drop-
metho t out,
d or attenda
plan or nce,
suicide complia
attemp nce
t and rates
SI at and
study qualitati
entry ve data
28
Fork 130 RCT adjunct TAU SI One Signific
mann adult MBCT (waitlis item ant
et al. outpati t) from the reductio
(2014 ents Dutch ns in SI
) with version with
residua of the MBCT
l Inventor during
depres y of the
sive Depress course
symtpo ive of the
ms Sympto interven
with a ms tion. No
history changes
of 1+ in SI in
prior compari
episod son
es of group.
MDD
Kenn 50 Quasi- adjunct none Depre Beck Signific Accepta
y and adult experimental MBCT ssion Depress ant bility of
Willia mood- study: ion reductio MBCT
ms disorde uncontrolled, Inventor ns in high as
red y depressi indicate
29
(2007 outpati pre-post on with d by
) ents design MBCT drop-
who with no out rate
were in differen and
a ce in survey
depres magnitu data
sed de of
episod response
e and between
had a those
history with
of 3+ baseline
depres SI and
sive those
episod without
es or
episod
e(s)
lasting
1 year
+, 32
of
whom
30
reporte
d SI
Le 8 high Quasi- cultural none SI One Reducti Accepta
and school experimental ly- item ons in bility
Gober student study: adapted from the frequenc and
t s (aged uncontrolled, MBSR Patient y of SI feasibili
(2013 15-20) pre-post deliver Health during ty of

) who design ed as Questio the interven
self- an nnaire course tion
selecte elective of high as
d to class treatmen indicate
receive daily t d by
interve over observe drop-
ntion 8 week d, out rate
s though and
no qualitati
inferenti ve data
al
statistics
were
compute
31
Attentional
Control,
Problem-
Solving and
Stress
Response
Outcomes
Allen 61 RCT 6-week Active Attent Affectiv Attentio Data
et al. comm Mindfu control ional e Stroop nal from
(2012 unity lness Contr task, control fMRI
) membe Trainin ol slowing improve show
rs g when d among increase
course respondi those d left
ng to receivin Dorsola
incongr g teral
uent Mindful Prefront
versus ness al
congrue training Cortex
nt but not respons
stimuli active e during
control task
conditio preform
n. ance
32
over
time
that was
specific
to
Mindful
ness
training
group
Bhatn 8 Quasi- MBSR none Stress Heart Stress
agar Vetera experimental respon rate response
et al. ns with study: se variabili improve
(2013 combat uncontrolled, ty d over
) - pre-post (HRV), 1-month
realate design pNN50 follow-
d statistic up with
PTSD or MBSR
mean
number
of times
per hour
in
which
33
the
change
in
consecu
tive
normal
sinus
(NN)
intervals
exceede
d 50
millisec
onds
Carls 59 Quasi- eMdBi none Stress Salivary Signific Finding
on et adult experimental cSaRl respon cortisol, ant s from
al. cancer study: interve se through reductio addition
(2007 patient uenrcaonndt ntion out day ns al
) s rwohlleodw, (downw measur
withou epre - ard es of
t Axis 3pmosotndteh linear stress
I disor si+gnpast m effect) respons
in e,
average includin
34
daily g self-
cortisol report,
from measur
baseline es of
to 12- immune
month cell
follow- counts,
up intracell
ular
cytokin
product
ion,
blood
pressur
e and
heart
rate,
also
show
improv
ed
stress
35
respons
e over
12-
month
follow-
up with
MBSR
Libby 31 RCT 4-week Active Stress High- Stress
et al. adult Mindfu control respon frequen response
(2012 comm lness se cy (HF) ,
) unity Trainin HRV, includin
membe g for resting g
rs who Smokin state changes
smoke g and to HF-
d 10+ change HRV
cigaret from from
tes per baseline baseline
day during to
meditati meditati
on on and
resting
state
HF-
36
HRV, at
treatmen
terminat
ion not
different
between
groups
Marc 21 Quasi- MBSR none Stress Awaken Signific
us et adults experimental respon ing ant
al. in a study: se salivary reductio
(2003 residen uncontrolled, cortisol ns pre-
) tial pre-post to post-
therape design MBSR
utic in
comm awakeni
unity ng
cortisol
Raes 45 controlled MBCT Wait Cognit The Signific
et al. adult trial list ive Leiden ant
(2009 comm reactiv Index of reductio
) unity ity Depress ns in
ion cognitiv
37
membe Sensitiv e
rs ity- reactivit
Revised y over
8 weeks,
correspo
nding to
MBCT
duration
, in
MBCT
but not
wait-list
control
group.
Note. This table excludes reviews referenced in the "Possible Mechanisms of Action in MBIs for Suicidal Behavior Section."
38
Figure 1. Flow diagram of the MBI study/review selection process. 1Includes studies that
compared meditators to naive participants on problem solving.
39

Reviewing Mindfulness-Based Behaviors For Suicidal Ideation

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Archives of Suicide Research

ISSN: 1381-1118 (Print) 1543-6136 (Online) Journal homepage: http://www.tandfonline.com/loi/usui20

Reviewing Mindfulness-Based Interventions for

To link to this article: http://dx.doi.org/10.1080/13811118.2016.1162244

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Reviewing Mindfulness-Based Interventions for Suicidal

Megan Chesin, Ph.D.

Department of Psychology, William Paterson University, Wayne, NJ

Alejandro Interian, Ph.D.

Anna Kline, Ph.D.

Miriam Latorre, Psy.D.

Barbara Stanley, Ph.D.

Address correspondence to Megan S. Chesin, Ph.D., William Paterson University, Department of

Psychology, 300 Pompton Road, Wayne, NJ 07470. Tel. 973.720.3393. E-mail:

prevent suicidal behavior in high suicide-risk individuals.

MBIs with high suicide-risk individuals.

suicidal thinking and/or attempt.

Keywords: attention, mindfulness-based intervention, problem solving, safety planning, stress

response, suicidal outpatients

(Crosby et al., 2011).

(Gao et al., 2015).

has been primarily tested on patients with borderline personality disorder.

compared to remitted depressed individuals with no history of suicidal thinking (Williams,

Barnhofer, Crane, & Beck, 2005).

suicidal behavior, 2. review moderators of MBI treatment adherence and effectiveness to

To thoroughly capture published data on changes to suicidal behavior and psychological,

Search criteria employed included mindfulness-based AND suicid* OR mechanism OR

attention OR stress response OR problem solving. We also searched bibliographies of articles

phenomena. We included studies of varying levels of methodological sophistication, including, for

Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2002, 2013) is an 8-session,

focus of the intervention, which differentiates it from traditional CT approaches, is on changing

cognitive processing as opposed to content through mindfulness meditation practice. During

attentional stability is leveraged when participants practice acknowledging and attending to

assigned for homework.

maintenance of post-MBCT treatment reductions in acute depression for 34 years (Mathew,

Existing Evidence Supporting the Use of an MBI With Suicidal Patients

thoughts or self-harm behavior at post-study assessment than students in classrooms assigned to

size may account for the negative finding in this study.

POTENTIAL LIMITATIONS TO USING MBIS WITH SUICIDAL

of MBI adherence or effectiveness among community or patient participants. Studies of

demographic or clinical characteristics that change adherence or outcomes among MBI

behavior should be modified to increase acceptability, engagement and response.

Van Heeringen, & Williams, 2009; van Aalderen et al., 2012).

of an integrated Western treatment, sometimes experience meditation-induced de-realization, de-

2013). Meanwhile, among community members practicing meditation or participating in MBIs, it

of suicidal behavior. Unfortunately, empirical study of moderators of treatment adherence and

or indicate that the treatment is contraindicated.

POSSIBLE MECHANISMS OF ACTION IN MBIS FOR

Individuals who have attempted suicide demonstrate attentional dyscontrol, problem-

attentional control, problem solving and stress response.

& Currier, 2012, for a review).

Dixon, Nijeboer, & Christoff, 2013). In fact, in contemporary, empirically-derived theories of

attentional improvements are proffered to be fundamental and foundational to MBI-treatment

gains (Holzel et al., 2011; Malinowski, 2013).

problem-solving deficits when stressed or in emotional distress, may be changed by MBIs.

self-report less mindfulness show a positive relationship between self-reported tendencies to

solving, particularly under stress.

Dysregulated stress response, whether indicated by hypo-reactivity of the Hypothalamic-