Mindfulness in the Treatment of Suicidal Individuals

Network analysis of correlations between suicide exposure, depression, and anxiety symptoms in adolescents

BACKGROUND

Adolescents with a history of suicide exposure, defined as experiencing the suicide death of a family member, friend, or other acquaintances, are more likely to experience mental health issues such as depression or anxiety.

AIMS

This study aimed to explore prevalence rates and the network of adolescents' suicide exposure, depression, and anxiety symptoms, and to clarify the correlations between suicide exposure and symptoms of depression and anxiety.

METHOD

A total of 8,957 adolescents were included in this cross-sectional study. Data regarding general information, symptoms of depression and anxiety, and suicide exposure were collected from mid-September to early October 2021. Network analysis was employed to assess relationships between suicide exposure and individual symptoms of both depression and anxiety. Central symptoms were identified by strength; the flow network was visualized to identify symptoms directly related to suicide exposure.

RESULTS

The prevalence rates of suicide exposure, depression, and anxiety were 5.28%, 12.87%, and 10.48%. Results indicated that suicide exposure was associated with both depression and anxiety, and had the strongest positive association with suicidal ideation. Central symptoms of the network were sad mood, nervousness, fatigue, irritability, and uncontrollable worry. Bridge symptoms were suicidal ideation and irritability. Appetite changes, suicidal ideation, uncontrollable worry, sleep difficulties, and irritability were symptoms directly related to suicide exposure.

CONCLUSIONS

There were significant inter-symptom associations between suicide exposure, depression, and anxiety in adolescents. It is recommended that future studies explore whether targeted interventions and long-term monitoring concerning these inter-symptom associations can protect adolescents with suicide exposure.

Trajectories and predictors of suicidal ideation in clinical characteristics and pharmacological treatments for major depressive disorder: a study based on a national multi-centered prospective cohort

Suicidal ideation (SI) is a significant precursor and risk marker for suicide behaviors in major depressive disorder (MDD). Exploration of SI trajectory from a longitudinal framework are essential for treatment guidelines and clinical management of suicide risk. This study sought to explore SI trajectories and its associated clinical, sociodemographic characteristics, and initial treatment among patients with MDD. We used data from a non-interventional, national multi-centered prospective cohort study. 1 461 patients with MDD were included in the growth mixture modeling using SI at baseline, 2 weeks, 4 weeks, 8 weeks, 12 weeks, and 6 months, 9 months, and 12 months as the indicator. A multinomial regression was employed with SI trajectory as the outcome and anhedonia, depressive symptoms, atypical depressive symptoms, pharmacological treatments, and other covariates as the predictors. Four distinct SI trajectories were identified: a consistently low SI trajectory(50.7%), a persistently mild SI trajectory(20.6%), a fast declined SI trajectory(8.9%), and a slowly declined trajectory(19.8%). Compared to those with a consistently low SI trajectory, a higher score of anhedonia was associated with an increased risk of experiencing persistently mild (RRR = 1.20, 95%CI: 1.05, 1.38) and slowly declined SI (1.54, 95%CI: 1.32, 1.80). Severity of depressive symptom was also positively associated with the risk of experiencing persistently mild (1.15, 95%CI: 1.13, 1.18) and slowly declined SI (1.17, 95%CI: 1.14, 1.21). And the risk of experiencing slowly declined SI was higher for those use SSRI(1.49, 95%CI: 1.02, 2.31), and for those use antidepressant and antipsychotic/mood stabilizer combined therapy (3.78, 95%CI: 1.48, 9.61). The findings of this study are potentially useful for clinical practice as critical indicators of profiles and interventions for prognosis among patients with MDD. Further research is warranted to explore potential modifiable factors and the association between SI trajectories and suicide behavior.

Examining aspects of psychological flexibility within the integrated motivational-volitional model of suicidal behavior: A prospective investigation

BACKGROUND

According to the integrated motivational-volitional model of suicide, feelings of entrapment are related to the emergence of suicidal ideation (SI). However, this relation can be moderated by certain protective factors.

METHODS

This study examined whether aspects of psychological flexibility (i.e., experiential avoidance, experiential acceptance, harnessing) moderated the relation between aspects of entrapment and SI severity in college students experiencing SI (N = 553) both cross-sectionally and when SI severity was measured 1 week later (N = 247).

RESULTS

At baseline, experiential acceptance, but not experiential avoidance or harnessing, significantly moderated the relation between external entrapment and SI severity and internal entrapment and SI severity. No aspects of psychological flexibility prospectively moderated relations between entrapment and SI severity.

CONCLUSIONS

Aspects of psychological flexibility may influence immediate vulnerability to SI severity among young adults experiencing feelings of entrapment. Implications for clinical interventions influencing changes in psychological flexibility are discussed.

What aspects of mindfulness and emotion regulation underpin self-harm in individuals with borderline personality disorder?

BACKGROUND

Self-harm presents significant risk for individuals with borderline personality disorder (BPD). Both self-harm and BPD are associated with deficits in mindfulness and emotion dysregulation. Previous research suggests that thought suppression and emotional inexpressivity may underpin self-harm in people with BPD, suggesting potential links to self-harm functions common for those with BPD. More research is needed to strengthen our understanding of this relationship.

AIMS

This study examines how BPD symptoms, mindfulness, emotion dysregulation and self-harm functions are related.

METHODS

Australian community outpatients diagnosed with BPD (N = 110) completed measures of mindfulness, emotion dysregulation and self-harm functions. Serial mediation analyses were conducted to examine relationships between variables.

RESULTS

BPD symptoms, chronic emptiness, mindfulness skills, describing and non-reacting, emotion dysregulation areas of emotion regulation strategies and poor emotional clarity were associated with recent self-harm. Various combinations of describing, strategies and clarity mediated the path between emptiness and self-harm functions more likely to be endorsed by individuals with a diagnosis of BPD. Describing was associated with all but anti-suicide function, while strategies was associated with all but anti-dissociation.

CONCLUSION

The study highlights how individuals with BPD experiencing chronic emptiness may benefit from treatment targeting describing skills and adaptive emotion regulation strategies.

Dynamic bidirectional relation between state mindfulness and suicidal ideation among female college students: The moderating effect of trait mindfulness

Research has indicated that mindfulness is a protective factor against suicidal ideation. However, the dynamic reciprocal relation between them has been understudied. In this study, 110 female college students with suicidal ideation completed a measure of trait mindfulness and a 28-day diary of suicidal ideation and three-dimensional state mindfulness, including acting with awareness, present-moment attention, and nonjudgmental acceptance. Dynamic structural equation modeling was used to examine the dynamic and bidirectional effects between dimensions of state mindfulness and suicidal ideation and the moderating effect of trait mindfulness. Results showed that suicidal ideation predicted lower levels of present-moment attention the next day. More importantly, there was a dynamic and bidirectional relation between nonjudgmental acceptance and suicidal ideation for people with trait mindfulness higher than the average level (i.e., M + 0.15SD). Our findings suggested that studies and interventions on suicide should pay more attention to specific dimensions of state mindfulness and trait mindfulness.

The Mediating Roles of Affect Lability and Experiential Avoidance Between Distress Tolerance and Suicidal Ideation Among College Students

Objective: Suicidal ideation (SI) is highly prevalent among college students. Research has shown that college students are also more likely to experience low distress tolerance, affect lability, and experiential avoidance, which have been linked to SI. There is a critical need to examine the mechanisms that increase the risk of SI among college students. It is hypothesized that distress tolerance will be a strong predictor of SI, and affect lability as well as experiential avoidance will mediate this relationship. Participants and Methods: Participants (n = 820) from a Southeastern University completed an online survey, inquiring about demographic information, affect lability, SI, experiential avoidance, and distress tolerance. Data were analyzed utilizing structural equation modeling. Results: Distress tolerance was not directly related to SI. However, affect lability and experiential avoidance were found to mediate this relationship. Conclusions: Affect lability and experiential avoidance may be important predictors of SI among college students.

A preliminary investigation of the relationship between internalized stigma, experiential avoidance, and suicidal thoughts and behaviors in college students

Objective: Examine the relationship between internalized stigma, experiential avoidance (EA), and suicidal thoughts and behaviors (STBs) in a sample of college students, and explore whether EA accounts for part of the relationship between internalized stigma, EA, and STBs.Participants: College students (N=78) completed online questionnaires about demographic information, internalized stigma, EA, and STBs.Results: A simple mediation model evaluated the indirect effect of internalized stigma on STBs through EA, controlling for the presence of a mental health disorder diagnosis. Results: Internalized stigma, STBs, and EA were all positively correlated. EA partially mediated the relationship between internalized stigma and STBs.Conclusion: Despite decades of research and prevention efforts, STBs remain a pervasive problem. There is an urgent need to identify modifiable predictors of STBs. Internalized stigma is a risk factor for STBs, and recent research suggests EA might be a mechanism linking internalized stigma and STBs. Our findings suggest EA might represent a modifiable mechanism of change in the context of both anti-stigmatization and suicide prevention programs.

Pathways from childhood trauma to suicidal ideation: mediating through difficulties in emotion regulation and depressive symptoms

OBJECTIVE

Suicidal ideation is a clinical exigency heightening the risk of suicide at different levels of suicidal behavior. This study sought to explore crucial correlates of this phenomenon with a structural equation modeling approach. Accordingly, the mediating role of depressive symptoms and difficulties in emotion regulation between childhood trauma and suicidal ideation were explored.

METHOD

The sample consisted of 372 university students (57.3% females, M = 20.75, SD = 2.25) who completed self-report measures examining experiences of childhood trauma, depressive symptoms, difficulties in emotion regulation, and suicidal ideation. Structural equation modeling was employed, and mediation analysis was conducted. Confirmatory factor analysis was used to test the measurement model of each construct before evaluating the conceptual mediated model.

RESULTS

Findings indicate that depressive symptoms with difficulties in emotion regulation had the strongest association (r = 0.60, P = 0.001), then depressive symptoms and suicidal ideation (r = 0.58, P = 0.001), suicidal ideation with difficulties in emotion regulation (r = 0.45, P = 0.001) then suicidal ideation with childhood trauma (r = 0.39, P = 0.001), difficulties in emotion regulation with childhood trauma (r = 0.36 P = 0.001) and finally depressive symptoms and childhood trauma (r = 0.35, P = 0.001). Regarding indirect paths, difficulties in emotion regulation and depression function together (in a sequential path) to mediate the association between childhood trauma and suicidal ideation ( χ²(68) = 216.86, P < 0.01, CFI = 0.95, TLI = 0.93, RMSE = 0.077, CI [0.066 to 0.089], SRMR = 0.049).

CONCLUSION

Results demonstrate that childhood trauma, depressive symptoms, and difficulties in emotion regulation are linked to suicidal ideation, highlighting the necessity of recognizing and addressing suicidal ideation as well as the factors that contribute to suicidal ideation. Emotion regulation interventions can be effective in reducing the negative effects of childhood trauma and lowering the risk of suicide. These interventions can help in reducing depressive symptoms and improve overall mental well-being, leading to a lower risk of suicide.

Effects of Childhood Maltreatment on Self-Compassion: A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review aims to estimate the extent to which childhood maltreatment influences self-compassion in later life.

METHOD

Four English databases (Web of Science, PsycINFO, PubMed, and PsycARTICLES) and three Chinese databases (China National Knowledge Infrastructure, Wanfang, and Weipu) were systematically searched. We extracted data related to the associations between child maltreatment and self-compassion and pooled them using random effect models.

FINDINGS

A total of 20 eligible studies were included involving 6,877 participants in the analyses. Overall child maltreatment was negatively related to self-compassion (r = -.28, p < .001); emotional abuse and neglect were negatively related to self-compassion (r = -.28, p < .01; r = -.31, p < .01, respectively) at a moderate level; and physical abuse, sexual abuse, and physical neglect were negatively related to self-compassion (r = -.12, p < .01; r = -.10, p < .01; and r = -.22, p < .001, respectively) at a small level.

CONCLUSION

The results indicate that overall and subtypes of maltreatment are associated with decreased self-compassion, and child intervention programs focused on self-compassion should be designed to protect the well-being of individuals with a history of childhood maltreatment.

Suicide ideation and anhedonia among clinically stable adolescents with the recurrent depressive disorder during the COVID-19 pandemic: A network perspective

BACKGROUND

Anhedonia is a suicide risk factor among adolescent patients with recurrent depressive disorder (depression hereafter). This study examined associations between suicidal ideation (SI) and residual depressive symptoms (RSD), including anhedonia, among clinically stable adolescents with depression.

METHOD

A network analysis was performed to examine the association between RDS and SI among adolescents with depression. Node-specific predictive betweenness was computed to examine short paths between anhedonia and SI. Additionally, a Network Comparison Test (NCT) was conducted to examine gender differences in derived network model characteristics.

RESULTS

The network analysis identified close associations of PHQ9 ("Suicide ideation") with PHQ1 ("Anhedonia") as well as some other RDS including PHQ6 ("Guilt"), PHQ2 ("Sad mood") and PHQ8 ("Motor disturbances"). Additionally, PHQ2 ("Sad mood") and PHQ4 ("Fatigue") were the main bridge nodes linking anhedonia and SI. Comparisons of network models did not find significant differences in network global strength or edge weights.

LIMITATION

Causal relations between anhedonia and SI could not be determined due to the cross-sectional study design.

CONCLUSIONS

SI was directly related to Anhedonia in addition to Guilt, Sad mood and Motor disturbances. Sad mood and Fatigue were the main bridge nodes linking Anhedonia and SI. To reduce the risk of SI among clinically stable adolescents with depression during the COVID-19 pandemic, specific RDS including Anhedonia, Guilt, Sad mood, Motor disturbances and Fatigue should be targeted in interventions.

Adolescents' experiences of acceptance and commitment therapy for depression: An interpretative phenomenological analysis of good-outcome cases

Introduction

Acceptance and commitment therapy (ACT) has been shown to help treat depression. However, little is known about the patient's experiences with ACT. This study aimed to learn how it was used in adolescents with major depressive disorder who have achieved good treatment outcomes.

Methods

Five adolescents with major depressive disorder with good treatment outcomes of ACT were enrolled in the semi-structured qualitative interview and analyzed using systematic textual condensation and interpretative phenomenological analysis.

Results

Four primary themes emerged from the investigation. "Therapist relationships and characteristics" describes the therapist's receptiveness and respect for adolescents with depression and having a trustworthy and sincere therapist. "Spaces to explore and experience" describes the ongoing process and content of acceptance of negative emotions and mindfulness practices in the healing process. "Do important things" refers to values and committed action. The "time settings" include the frequency and duration of treatment.

Conclusion

Adolescents make positive changes with a receptive and respectful therapist by exploring themselves in a genuine and trusting therapeutic relationship. Improvement seems to come from being open to all thoughts and feelings and developing the ability to live in the present moment. Teenagers attach great importance to value-oriented behaviour. Therefore, treatment should target the critical areas of depressed adolescents to guide them towards recovery effectively.

An Ecological Momentary Intervention Study of Emotional Responses to Smartphone-Prompted CBT Skills Practice and the Relationship to Clinical Outcomes

The practice of therapeutic skills outside of sessions in which they are learned is one presumed key component of cognitive behavioral therapy (CBT). Yet, our understanding of how skills practice relates to clinical outcomes remains limited. Here, we explored patients' emotional responses to CBT skills practice in a pilot study pairing smartphone-app-delivered skills reminders and guided practice (ecological momentary intervention [EMI]) using ecological momentary assessment (EMA). Participants (n = 25) were adults recently hospitalized for a suicide attempt or severe suicidal thinking. They received brief inpatient CBT (1 to 3 sessions covering core CBT skills from the Unified Protocol), followed by 1 month of EMI and EMA after discharge. On average, participants reported modest reductions in negative affect after skills use (i.e., immediate responses; median time elapsed = 4.30 minutes). Additionally, participants tended to report less negative affect when the timepoint preceding the current assessment included EMI skills practice, rather than EMA alone (i.e., delayed responses; median time elapsed between prompts = 2.17 hours). Immediate effects were unrelated to longer-term clinical outcomes, whereas greater delayed effects were associated with lower symptom severity at follow-up. Future studies should further examine how CBT skills use in daily life may alleviate symptoms.

Relationship among self-injury, experiential avoidance, cognitive fusion, anxiety, and depression in Chinese adolescent patients with nonsuicidal self-injury

OBJECTIVE

To explore relationship among self-injury behavior, experiential avoidance, cognitive fusion, anxiety, and depression in Chinese adolescent patients with nonsuicidal self-injury (NSSI).

METHODS

Cognitive fusion questionnaire (CFQ), Acceptance and Action Questionnaire-2nd edition (AAQ-II), adolescent nonsuicidal self-injury behavior questionnaire (ANSAQ), Hamilton Anxiety Scale (HAMA), and Hamilton Depression Scale (HAMD) were used as research tools to investigate 120 subjects with NSSI and 130 healthy controls.

RESULTS

The scores of CFQ and AAQ-II in the NSSI group were significantly higher than those in the healthy control group (p < .001). The results of regression analysis showed that the experiential avoidance score of patients with NSSI could predict the score of self-injury questionnaire (β = 0.585, p < .001); when predicting anxiety, only CFQ (β = 0.361, p < .001) entered the equation, with an explanatory variation of 12.3%; when predicting depression, CFQ (β = 0.287, p < .01) entered the equation, with an explanatory variation of 7.4%.

CONCLUSION

A high level of cognitive fusion and experiential avoidance may be important factors for the maintenance of self-injury behavior in patients with NSSI.

The effects of alexithymia, experiential avoidance, and childhood sexual abuse on non-suicidal self-injury and suicidal ideation among Chinese college students with a history of childhood sexual abuse

BACKGROUND

Although previous studies have shown that childhood sexual abuse (CSA) experiences might be related to suicide-related thoughts and behaviours in later life, the effects of alexithymia and experiential avoidance (EA) on this relationship have remained unclear. The present study aimed to expand prior findings among Chinese college students with a history of CSA in order to further test the effects of alexithymia on the relationship between CSA and non-suicidal self-injury (NSSI) and suicidal ideation (SI), and its indirect effects on NSSI and SI through EA.

METHODS

The Childhood Sexual Abuse Questionnaire, the Toronto Alexithymia Scale-20, the Acceptance and Action Questionnaire-II, the Non-Suicidal Self-Injury Questionnaire, and the Symptom Checklist were completed by 6,834 college students (3,829 female).

RESULTS

Overall, 1404 (20.76%) Chinese college students reported experiences of CSA; students with CSA experiences reported higher rates of SI and NSSI than those without CSA (12.82% vs. 4.50%, 35.11% vs. 20.82%). CSA, alexithymia, and EA were positively related to NSSI and SI. The effect of alexithymia on the relationship between CSA and NSSI and SI were significant. The effects of EA on the relationship between alexithymia and NSSI and SI were significant, too.

LIMITATIONS

The major limitations of this study are its cross-sectional design and the use of self-report scales, especially retrospective self-reports (e.g., the Childhood Sexual Abuse Questionnaire).

CONCLUSIONS

This study cast light on the effects of alexithymia, EA, and CSA on NSSI and SI in Chinese college students with a history of CSA. These findings can contribute to the prevention and treatment of suicide-related thoughts and behaviours.

Risk Assessment and Crisis Intervention for Youth in a Time of Telehealth

For the last decade, there has been growing concern regarding the rising rates of youth engagement in self-injury and suicide. The worldwide outbreak of the coronavirus disease 2019 (COVID-19) has elevated these concerns due to increased risk factors pertaining to social, family, economic, and health stressors, in addition to changes to typical routines and support systems. Unfortunately, there are many barriers to at-risk youth being able to access evidence-based mental health services including cost, lack of trained providers, transportation issues, and physical distancing due to the pandemic. Providing school-based prevention and intervention programs that promote social, emotional, and behavioral well-being helps to address many of these barriers. This article highlights important considerations to providing these services in a school-based telehealth modality. Symptom clusters that put youth at risk of harm to self are described. Best practice therapeutic modalities that can be disseminated in a school-based telehealth modality, such as cognitive behavior therapy, dialectical behavior therapy, and mindfulness-based approaches, are reviewed. Although there is growing empirical literature for these school-based prevention and intervention approaches, additional research is needed to determine how to best support at-risk youth remotely.

Obsessive-Compulsive Disorder and Suicidal Experiences: The Role of Experiential Avoidance

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a disabling mental health problem that affects a significant proportion of the general population. Experiential avoidance appears to account for the development of anxiety and depressive symptoms. However, its relationship with OCD has yielded contradictory results. Furthermore, although OCD-specific thoughts and behaviors, including obsessing, checking, washing, and ordering, have been suggested to significantly predict suicidal ideation and behaviors, this line of research has received scant empirical attention. The overarching aim of this study was to explore the relationship between OCD, OCD-specific behaviors, experiential avoidance, and suicidal experiences.

METHODS

Overall, 1,046 adults from the community who completed self-report scales participated.

RESULTS

Strong links between overall OCD severity, obsessing, experiential avoidance, and suicidal experiences were established. Results from mediational analyses showed that overall OCD severity and individual obsessive-compulsive thoughts and behaviors were both directly and indirectly linked with suicidal experiences, via experiential avoidance. Obsessing was among the critical obsessive-compulsive symptoms leading to suicidal experiences.

CONCLUSIONS

These findings are important because they identify experiential avoidance as a potential key explanatory construct in accounting for the development of OCD and suicidal experiences. However, future research using longitudinal and/or experimental designs is needed to infer causality.

Psychological Flexibility in Depression Relapse Prevention: Processes of Change and Positive Mental Health in Group-Based ACT for Residual Symptoms

Relapse rates following a depressive episode are high, with limited treatments available aimed at reducing such risk. Acceptance and commitment therapy (ACT) is a cognitive-behavioral approach that has gained increased empirical support in treatment of depression, and thus represents an alternative in relapse prevention. Psychological flexibility (PF) plays an important role in mental health according to the model on which ACT is based. This study aimed to investigate the role of PF and its subprocesses in reducing residual symptoms of depression and in improving positive mental health following an 8-week group-based ACT treatment. Adult participants (75.7% female) with a history of depression, but currently exhibiting residual symptoms (N = 106) completed measures before and after intervention, and at 6 and 12-month follow-up. A growth curve model showed that positive mental health increased over 12-months. Multilevel mediation modeling revealed that PF significantly mediated these changes as well as the reduction of depressive symptoms, and that processes of acceptance, cognitive defusion, values and committed action, in turn, mediated increased PF.

Mindfulness and hemodynamics in asians: a literature review

INTRODUCTION

Mindfulness interventions have been increasingly incorporated into clinical settings. Evidence supporting mindfulness practices are predominantly established in Western populations. Neurophysiological evidence has not been established to support the effectiveness of mindfulness practice in Asian populations. Greater understanding of the neurophysiological mechanisms underlying mindfulness would enable hemodynamics as measured by fNIRS to be used to monitor mindfulness practice as an adjunct to psychotherapy with Asian clients.

METHOD

Research relating to fNIRS and hemodynamics for mindfulness in Asians was reviewed. The inclusion criteria for this review were recent publications in peer-reviewed journals from 2008 to 2018, with the search terms 'fNIRS', 'hemodynamics' and 'mindfulness', for studies in Asia.

FINDINGS

Databases included Medline, PubMed, PSYCINFO, Google Scholar and SCOPUS. Initial searches yielded 86 results. Five duplicated articles were removed, and remaining abstracts were screened; and assessed for eligibility against the structured performa. Three full text papers which fit the inclusion criteria were included in the current review.

CONCLUSION

This review highlighted the paucity of rigorous empirically validated research for hemodynamics as measured with fNIRS for mindfulness practice in Asia.

Profiles of Psychological Flexibility: A Latent Class Analysis of the Acceptance and Commitment Therapy Model

There exists uncertainty for clinicians over how the separate subcomponent processes of psychological flexibility, a core construct of the Acceptance and Commitment Therapy model, interact and influence distress experienced. The present study (N = 567) employed latent class analysis to (a) identify potential classes (i.e., subgroups) of psychological flexibility based on responses on measures of key subcomponent process and (b) examine whether such classes could reliably differentiate levels of self-reported psychological distress and positive and negative emotionality. We found three distinct classes: (a) High Psychological Flexibility, (b) Moderate Psychological Flexibility, and (c) Low Psychological Flexibility. Those in the Low Psychology Flexibility class reported highest levels of psychological distress, whereas those in the High Psychological Flexibility class reported lowest levels of psychological distress. This study provides a clearer view to clinicians of the profile of the broader spectrum of the psychological flexibility model to facilitate change in clients.

Smartphone Applications for Mindfulness Interventions with Suicidality in Asian Older Adults: A Literature Review

Elderly suicide is a rising concern. Despite the advent of mobile technology, there remained a gap in the evidence base as to whether smartphone applications could be used for mindfulness intervention for suicidality in Asian older adults. This paper aimed to review recent research relevant to smartphone applications that could be used in providing mindfulness interventions for suicidality to Asian older adults. The inclusion criteria for this review were papers published in peer-reviewed journals from 2008 to 2018 with the usage of specific search terms, namely, ‘smartphone application’, ‘mobile application’, and ‘mindfulness’, assessed against the inclusion criteria and screened by an experienced Asian clinician to be of clinical utility for mindfulness intervention for suicidality with Asian older adults. Initial search on databases yielded 236 results. A total of 35 full text papers that fit the inclusion criteria were assessed for eligibility and 10 papers were included in the current review. This review highlighted the paucity of rigorous empirically validated research into effective smartphone applications that can be used for mindfulness interventions for suicidality with Asian older adults.

Acceptance and Commitment Therapy for the Management of Suicidal Patients: A Randomized Controlled Trial

BACKGROUND

The management of suicidal crisis remains a major issue for clinicians, driving the development of new strategies to improve suicide prevention.

METHODS

We conducted a randomized controlled trial comparing a 7-week acceptance and commitment therapy (ACT) versus relaxation group, as adjunct to treatment as usual for adult outpatients suffering from a current suicidal behavior disorder. The primary outcome was the rate of change in the Columbia Suicide Severity Rating Scale suicidal ideation subscore (adding severity and intensity subscores). Secondary outcomes were the rates of change for depressive symptomatology, psychological pain, anxiety, hopelessness, anger, quality of life, and therapeutic processes. Assessments were performed in the 2 weeks preceding the beginning of the treatment (pretreatment assessment), and within 1 week (posttherapy assessment) and 3 months (follow-up assessment) after therapy completion.

RESULTS

Forty adults were included and randomized. The rate of change in ACT for suicidal ideation at the posttherapy assessment was higher than in the relaxation group (β [SE] = -1.88 [0.34] vs. -0.79 [0.37], respectively; p = 0.03). ACT effectiveness remained stable at the 3-month follow-up. We found a similar pattern of change for depressive symptomatology and anxiety, psychological pain, hopelessness, anger, and quality of life. Therapeutic processes improved more in the ACT group than in the relaxation group. Treatment adherence was high in the ACT group, all participants reported satisfaction with the program.

CONCLUSIONS

Through its effectiveness in reducing suicidal ideation and improving the clinical dimensions associated with suicidal risk in patients suffering from a suicidal behavior disorder, ACT could be developed as an adjunctive strategy in programs for suicide prevention.

Thwarted interpersonal needs mediate the relation between facets of mindfulness and suicide ideation among psychiatric inpatients

Previous research suggests a negative association between mindfulness and suicide ideation, yet limited research has examined the specific role of mindfulness on suicide ideation or attempted to link this construct with theory-driven risk factors for suicide among high-risk individuals. The current study examined the mediating role of thwarted interpersonal needs (i.e., thwarted belongingness and perceived burdensomeness) in the relation between facets of mindfulness and suicide ideation among psychiatric inpatients. Participants were 118 psychiatric inpatients who completed self-report assessments of mindfulness, thwarted belongingness, perceived burdensomeness, and suicide ideation. Results indicated that the additive effect of thwarted belongingness and perceived burdensomeness mediated the relation between the act with awareness, non-judging, and non-reactivity mindfulness facets, and suicide ideation. Facets of mindfulness appear to be differentially related to thwarted interpersonal needs and subsequent suicide ideation. Continued examination of specific facets of mindfulness, as they relate to suicide ideation, may highlight potentially important distinctions and better inform suicide risk assessment and treatment.

Efficacy of Acceptance and Commitment Therapy in Reducing Suicidal Ideation and Deliberate Self-Harm: Systematic Review

BACKGROUND

Since its emergence in the 1980s, acceptance and commitment therapy (ACT) has become a reputable evidence-based psychological therapy for certain disorders. Trials examining the efficacy of ACT are spread across a broad spectrum of presentations, such as chronic pain, anxiety, and depression. Nevertheless, ACT has very rarely been trialed as an intervention for suicidal ideation (SI) or deliberate self-harm (DSH).

OBJECTIVE

The objective of this review is to assess the efficacy of ACT in reducing SI and DSH and to examine the suitability of reported SI, DSH, and other measures in determining the efficacy of ACT.

METHODS

We systematically reviewed studies on ACT as intervention for SI and self-harm. Electronic databases, including MEDLINE, PubMed, EMBASE, PsycINFO, SCOPUS, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, were searched. The reference lists of included studies and relevant systematic reviews were examined to identify additional publications. Search terms were identified with reference to the terminology used in previous review papers on ACT and suicide prevention. The study design was not restricted to randomized controlled trials. Screening was completed by 2 reviewers, and all duplicates were removed. Publications were excluded if they were not published in English, were multicomponent therapy or were not based on ACT, or lacked a validated measure or structured reporting of SI/DSH outcomes.

RESULTS

After removing the duplicates, 554 articles were screened for relevance. Following the screening, 5 studies that used ACT as an intervention for suicidal or self-harming individuals were identified. The studies used diverse methodologies and included 2 case studies, 2 pre-post studies, and 1 mHealth randomized controlled trial.

CONCLUSIONS

The review found that ACT is effective in reducing SI in the 2 pre-post studies but not in other studies. However, given the small number and lack of methodological rigor of the studies included in this review, insufficient evidence exists for the recommendation of ACT as an intervention for SI or DSH.

Smartphone Apps for Mindfulness Interventions for Suicidality in Asian Youths: Literature Review

BACKGROUND

The advent of mobile technology has ushered in an era in which smartphone apps can be used as interventions for suicidality.

OBJECTIVE

We aimed to review recent research that is relevant to smartphone apps that can be used for mindfulness interventions for suicidality in Asian youths.

METHODS

The inclusion criteria for this review were: papers published in peer-reviewed journals from 2007 to 2017 with usage of search terms (namely "smartphone application" and "mindfulness") and screened by an experienced Asian clinician to be of clinical utility for mindfulness interventions for suicidality with Asian youths.

RESULTS

The initial search of databases yielded 375 results. Fourteen full text papers that fit the inclusion criteria were assessed for eligibility and 10 papers were included in the current review.

CONCLUSIONS

This review highlighted the paucity of evidence-based and empirically validated research into effective smartphone apps that can be used for mindfulness interventions for suicidality with Asian youths.

Anhedonia is associated with suicidal ideation independently of depression: A meta-analysis

BACKGROUND

Anhedonia is considered a suicide risk factor in patients with major affective disorders. Here, we wanted to quantify the association between anhedonia and current suicidal ideation according to the absence/presence of between-group differences for depressive scores and psychiatric disorders.

METHODS

We performed a meta-analysis of data on studies retrieved from Medline, Web of Science, and PsycINFO from 1965 to 2016 using, among others, the terms (suicid* or depression) and anhedonia.

RESULTS

We identified 15 observational case-control studies that investigated the anhedonia differences in individuals with and without current (i.e., within the past week, independently of the lifetime suicidality status) suicidal ideation (defined as thoughts of killing oneself). Overall, 657 subjects with and 6,690 subjects without current suicidal ideation could be compared. Anhedonia level was higher in the group with current suicidal ideation than in the group without, with a medium effect size (standardized mean difference = 0.57, z = 5.43, P < 0.001, 95% confidence interval, CI = 0.37-0.79). The association between anhedonia and current suicidal ideation remained significant when controlling for depression and psychiatric disorders. The anhedonia scales used in the selected studies did not allow investigating consummatory and motivational anhedonia separately.

CONCLUSION

Our major finding is the robust association between anhedonia and current suicidal ideation, independently of depression. This is highly relevant for the clinicians' daily practice and might help improving suicidal risk detection and the development of new therapeutic strategies for suicide prevention.

Mindfulness and Suicide Ideation in Iranian Cardiovascular Patients: Testing the Mediating Role of Patience

The aim of the present study was to explore the mediating role of patience on the relationship between mindfulness and suicide ideation. To do so, 110 patients with cardiovascular diseases were recruited from the outpatient Clinic of Imam Reza in the city of Shiraz in Iran. These patients completed The Five Facets Mindfulness Questionnaire, Patience Scale, and Suicide Ideation Questionnaire. Data were analyzed using structural equation modeling. Results indicated a significant positive relationship between mindfulness and patience ( r = .32, p < .001). There was a significant negative relationship between patience and suicide ideation ( r = −.36, p < .001). The results of mediating model showed that patience functioned as a mediator in the relationship between mindfulness and suicide ideation among patients with cardiovascular diseases ( β = −.33, p = .005). According to these findings, it can be claimed that mindfulness affects patients’ suicidal thoughts negatively through patience.

Mindfulness Moderates the Association Between Perceived Burdensomeness and Suicide Ideation in Adults With Elevated Depressive Symptoms

A conceptual model in which the associations between perceived burdensomeness and suicide ideation, and between thwarted belongingness and suicide ideation, are moderated by mindfulness was examined. Participants were 218 undergraduates (mean age = 20.81) with moderate-to-severe depressive symptoms. Mindfulness significantly moderated the association between perceived burdensomeness and suicide ideation; participants with thoughts of burdensomeness experienced lower levels of suicide ideation if they were high, as opposed to low, in mindfulness. Mindfulness did not significantly moderate the association between thwarted belongingness and suicide ideation. Implications for intervention and elaboration of the interpersonal psychological theory of suicide are discussed.

Affect lability predicts occurrence of suicidal ideation in bipolar patients: a two-year prospective study

OBJECTIVE

The aim of our study was to investigate, in bipolar patients, whether affect lability was associated with suicidal ideation incidence during 2-year follow-up, and which subtype of affect lability was associated with suicidal ideation.

METHOD

A total of 319 euthymic or mildly depressed bipolar outpatients recruited in the French FondaMental Advanced Centres of Expertise for Bipolar Disorder were divided into two subgroups according to the occurrence of suicidal ideation during a 2-year follow-up. Affect lability was assessed by the French version of the Affect Lability Scale.

RESULTS

Bipolar patients with high affect lability were more likely to report suicidal ideation during follow-up, even after adjustment for age, study level, rapid cycling, current depression level, anxiety disorder, and lifetime history SA (OR = 2.47; 95% CI [1.15-5.30], P = 0.01). The risk of suicidal ideation increased with the level of affect lability. More specifically, the propensity to switch from neutral to elation affect, from anxious to depressive affect (or inversely), and from neutral to anger affect predicted suicidal ideation.

CONCLUSION

Reducing affective lability could become a new therapeutic target of suicidal prevention in bipolar disorder.

Four Reasons Why Assisted Dying Should Not Be Offered for Depression

Recently, several authors have argued that assisted dying may be ethically appropriate when requested by a person who suffers from serious depression unresponsive to treatment. We here present four arguments to the contrary. First, the arguments made by proponents of assisted dying rely on notions of "treatment-resistant depression" that are problematic. Second, an individual patient suffering from depression may not be justified in believing that chances of recovery are minimal. Third, the therapeutic significance of hope must be acknowledged; when mental healthcare opens up the door to admitting hopelessness, there is a danger of a self-fulfilling prophecy. Finally, proponents of assisted dying in mental healthcare overlook the dangers posed to mental-health services by the institutionalization of assisted dying.

Exploring the Relationship between Experiential Avoidance, Coping Functions and the Recency and Frequency of Self-Harm

This study investigated the relationship between experiential avoidance, coping and the recency and frequency of self-harm, in a community sample (N = 1332, aged 16–69 years). Participants completed online, self-report measures assessing self-harm, momentary affect, experiential avoidance and coping in response to a recent stressor. Participants who had self-harmed reported significantly higher levels of experiential avoidance and avoidance coping, as well as lower levels of approach, reappraisal and emotional regulation coping, than those with no self-harm history. Moreover, more recent self-harm was associated with lower endorsement of approach, reappraisal and emotion regulation coping, and also higher levels of both avoidance coping and experiential avoidance. Higher experiential avoidance and avoidance coping also predicted increased lifetime frequency of self-harm. Conversely, increased approach and reappraisal coping were associated with a decreased likelihood of high frequency self-harm. Although some of the effects were small, particularly in relation to lifetime frequency of self-harm, overall our results suggest that experiential avoidance tendency may be an important psychological factor underpinning self-harm, regardless of suicidal intent (e.g. including mixed intent, suicidal intent, ambivalence), which is not accounted for in existing models of self-harm.

Change in Experiential Avoidance is Associated with Reduced Suicidal Ideation over the Course of Psychiatric Hospitalization

Growing empirical literature in recent years indicates that experiential avoidance plays a role in a wide variety of psychological disorders and psychotherapeutic interventions. This study explored the view of suicidal ideation as a form of experiential avoidance by examining the association between suicidal ideation and therapeutic change in a sample of 189 adult psychiatric inpatients. Results were consistent with predictions, showing a statistically significant association between scores on the Beck Scale for Suicidal Ideation and the Acceptance and Action Questionnaire-II (AAQ-II). It was further shown that change in AAQ-II scores over the course of hospitalization was associated with change in suicidality, independent of changes in depression severity and hopelessness. Moreover, treatment responders (patients whose suicidal ideation scores dropped significantly over the course of treatment) showed greater drops in experiential avoidance relative to nonresponders. These results are consistent with a view of suicidal ideation (and, by extension, suicide) as a form of experiential avoidance and potentially a therapeutic approach that specifically seeks to reduce experiential avoidance.

Resting respiratory sinus arrhythmia is related to longer hospitalization in mood-disordered repetitive suicide attempters

OBJECTIVES

Our aims were (1) to measure respiratory sinus arrhythmia (RSA), a high-frequency spectrum component of heart rate variability (HRV) in mood-disordered suicide attempters and (2) to investigate the relationship of RSA to symptoms and length of hospitalization.

METHODS

Forty-nine female repetitive-suicide attempters with depressive disorder or bipolar disorder were recruited in a general hospital setting. Manic or psychotic patients were excluded. Resting RSA values were calculated from electrocardiogram data, and severity of clinical presentation shortly after admission and length of hospital stay were assessed.

RESULTS

RSA was positively associated with a higher Beck Scale for Suicidal Ideation score (r = 0.33 P = 0.019). Stepwise multiple regression analysis showed a significant correlation between RSA and hospitalization length after adjusting other variables (beta coefficient = 3.00; P = 0.030). Patients with a higher resting RSA had more prolonged hospitalizations (hospitalization beyond 30 days) after controlling for other variables (odds ratio = 5.08, P = 0.017).

CONCLUSIONS

Interaction between the environment and the autonomic nervous system is complex. Further and more comprehensive research is needed.

Comorbid panic disorder as an independent risk factor for suicide attempts in depressed outpatients

OBJECTIVE

Although comorbid panic disorder is associated with more severe symptoms and poorer therapeutic response in depressive patients, the relationship between panic disorder and risk of suicide attempt has not been confirmed. This study aimed to examine the relationship between comorbid panic disorder and clinical characteristics associated with suicidal risk as well as the likelihood of suicide attempt.

METHOD

A total of 223 outpatients with current major depressive disorder participated in the study. Both subjects with panic disorder (33%) and those without panic disorder (67%) were compared based on history of suicide attempts, current psychopathologies, and traits of impulsivity and anger.

RESULTS

Subjects with panic disorder had higher levels of impulsivity, depression, and hopelessness and were more likely to report a history of suicide attempts. Subjects with panic disorder were younger at the time of first suicide attempt than those without panic disorder. Logistic regression analyses indicated that comorbid panic disorder was significantly associated with a history of suicide attempts after adjusting for other clinical correlates (odds ratio = 2.8; p < 0.01).

CONCLUSIONS

These findings suggest that comorbid panic disorder in patients with major depressive disorder may be associated with a more severe burden of illness and may independently increase the likelihood of suicide attempt.

Personality Traits of Suicidality Are Associated with Premenstrual Syndrome and Premenstrual Dysphoric Disorder in a Suicidal Women Sample

Objective

Both Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) might increase the risk of suicidal behavior. The aim of this study was to assess the relationship between personality dimensions specifically involved in suicidal vulnerability and PMS/PMDD.

Method

We collected data from 232 women consecutively hospitalized after a suicide attempt. We examined the relationship between impulsivity, aggressiveness/hostility, hopelessness, trait anger, affect intensity, emotional lability, and PMS/PMDD. Notably, we created an algorithm from the shortened Premenstrual Assessment form in order to assess PMDD status.

Results

The proportions of PMS and PMDD among female suicide attempters were 50% and 23% respectively. Women with PMS or PMDD were more likely to endorse most of these personality traits to than those without even after controlling for potential confounders. We found an impulsive-aggressive pattern of personality in women with PMS or PMDD, independently from the time of the menstrual cycle. Interestingly, trait anger remained associated with both PMS and PMDD independently of every other personality traits. The higher the anger level, the higher the risk was to suffer from both PMS and PMDD.

Conclusions

This study demonstrates a strong, independent association between PMS/PMDD and trait anger among a representative sample of female suicide attempters. It is of major interest for clinicians in view of addressing a substantial public health problem among women of reproductive age.

Effectiveness of the first French psychoeducational program on unipolar depression: study protocol for a randomized controlled trial

BACKGROUND

Major Depressive Disorder (MDD) is highly prevalent and was associated with greater morbidity, mortality (including suicide), and healthcare costs. By 2030, MDD will become the leading cause of disability in high-income countries. Notably, among patients with a previous experience of a major depressive episode, it was indeed estimated that up to 85 % of those patients will suffer from relapse. Two main factors were associated with a significantly higher risk of relapse: poor medication adherence and low self-efficacy in disease management. Interestingly, these issues could become the targets of psychoeducational programs for chronic diseases. Indded psychoeducational program for depression are recommended in international guidelines, but have not yet been proposed in France.

METHODS/DESIGN

We propose to evaluate the first French psychoeducational program for depression "ENVIE" in a multicenter randomized controlled trial. The group intervention will include 9 weekly sessions. Its aim is to educate patients on the latest knowledge on depression and effective treatments through didactic and interactive sessions. Patients will experiment the latest innovating psychological skills (from acceptance and commitment therapy) to cope with depressive symptoms and maintain motivation in behavioral activation. In total, 332 unipolar non-chronic (<2 years) outpatients with moderate to severe depression, without psychotic features, will be randomly allocated to the add-on ENVIE program (N = 166) or to a waiting list (N = 166). The follow-up will last 15 months and include 5 assessment visits. The primary endpoint will be the remission rate of the index episode at 15 months post-inclusion, defined by a Montgomery and Asberg Depression Rating Scale (MADRS) score ≤ 12 over an 8-week period, and without relapse during follow-up. We will also assess the response rate and relapse at 15 months post-inclusion, hospitalization rate and adherence to treatment during the follow-up period, quality of life and global functioning upon inclusion and at 9 and 15 months post inclusion.

DISCUSSION

If the proposed trial shows the effectiveness of the intervention, but also an increased remission rate in depressed outpatients at 15-months post-inclusion, in addition to improved treatment adherence in patients, it will further promotes arguments in favor of a wide dissemination of psychoeducational programs for depression.

TRIAL REGISTRATION

This trial is registered under number 2015-A00249-40 (PURE clinical trial: NCT02501226 ) (June 30th, 2015).

Suicide Attempt Characteristics Among Veterans and Active-Duty Service Members Receiving Mental Health Services: A Pooled Data Analysis

Past suicidal behaviors are among the strongest and most consistent predictors of eventual suicide and may be particularly salient in military suicide. The current study compared characteristics of suicide attempts in veterans (N = 746) and active-duty service members (N = 1,013) receiving treatment for acute suicide risk. Baseline data from six randomized controlled trials were pooled and analyzed using robust regression. Service members had greater odds of having attempted suicide relative to veterans, though there were no differences in number of attempts made. Service members also had higher rates of premilitary suicide attempts and nonsuicidal self-injury (NSSI). Veterans disproportionately attempted suicide by means of overdose. In veterans, combat deployment was associated with lower odds of lifetime suicide attempt, while history of NSSI was associated with greater attempt odds. Neither was significantly associated with lifetime suicide attempt in service members. Implications for suicide assessment and treatment are discussed.

Effectiveness of Acceptance and Commitment Therapy in treating depression and suicidal ideation in Veterans

OBJECTIVE

This paper examines the effects of Acceptance and Commitment Therapy for depression (ACT-D), and the specific effects of experiential acceptance and mindfulness, in reducing suicidal ideation (SI) and depression among Veterans.

METHOD

Patients included 981 Veterans, 76% male, mean age 50.5 years. Depression severity and SI were assessed using the BDI-II. Experiential acceptance and mindfulness were measured with the Acceptance and Action Questionnaire-II (AAQ-II) and the Five Facet Mindfulness Questionnaire, respectively.

RESULTS

Of the 981 patients, 647 (66.0%) completed 10 or more sessions or finished early due to symptom relief. For Veterans with SI at baseline, mean BDI-II score decreased from 33.5 to 22.9. For Veterans with no SI at baseline, mean BDI-II score decreased from 26.3 to 15.9. Mixed models with repeated measurement indicated a significant reduction in depression severity from baseline to final assessment (b = -10.52, p < .001). After adjusting for experiential acceptance and mindfulness, patients with SI at baseline demonstrated significantly greater improvement in depression severity during ACT-D treatment, relative to patients with no SI at baseline (b = -2.81, p = .001). Furthermore, increases in experiential acceptance and mindfulness scores across time were associated with a reduction in depression severity across time (b = -0.44, p < .001 and b = -0.09, p < .001, respectfully), and the attenuating effect of mindfulness on depression severity increased across time (b = -0.05, p = .042). Increases in experiential acceptance scores across time were associated with lower odds of SI across time (odds ratio = 0.97, 95% CI [0.95, 0.99], p = .016) and the attenuating effect of experiential acceptance on SI increased across time (odds ratio = 0.96, 95% CI [0.92, 0.99], p = .023). Overall the number of patients with no SI increased from 44.5% at baseline to 65% at follow-up.

CONCLUSIONS

Veterans receiving ACT-D demonstrated decreased depression severity and decreased odds of SI during treatment. Increases in experiential acceptance and mindfulness scores were associated with reduction in depression severity across time and increases in experiential acceptance scores were associated with reductions in SI across time.

Trait Gratitude and Suicidal Ideation and Behavior

Abstract. Background: Despite the progress of positive psychology, current knowledge regarding suicide protective factors is limited. Trait gratitude (a tendency to experience gratitude in daily life) may protect against suicidal ideation and behavior. Aims: The study tested a model of causal effects among gratitude, religiosity, reasons for living, coping, and social support as predictors of suicidal ideation, suicide threats, and suicide attempts after controlling for depression and stressful life events. Method: A sample of 165 college students were administered measures of gratitude, religiosity, reasons for living, social support, coping skills, stress, and depression. The study assessed lifetime and current suicidal ideation as well as lifetime suicide threat and attempt. Results: Both gratitude and religiosity, along with social support, coping skills, and reasons for living, correlated negatively with prior suicidal ideation, but not with prior attempted suicide. After controlling for risk factor (depression and stress), the impact of gratitude and religiosity was no longer statistically significant. Conclusion: Further research could help understand the role of positive emotions and human strengths, such as gratitude, in preventing and alleviating suicidal ideation and behavior.

What must you know and do to get good outcomes with DBT?

Because little research has been conducted on which therapist-client interactions lead to intermediate and end-point improvements in Dialectical Behavior Therapy (DBT), we have a small evidence-base from which to specify what therapists must know and do in order to obtain good outcomes using DBT. As with other evidence-based practices, dissemination of DBT has defaulted to assumptions and methods from the "psychotherapy technology model," which emphasizes transfer of the validated treatment package from the research clinic to routine settings with high fidelity (Morgenstern & McKay, 2007). However, serious limitations of the psychotherapy technology model require pursuit of alternative complementary models to guide dissemination. One complementary approach is to use well-designed practice-based training research. In this approach, therapists learn modular competencies linked to a highly structured yet flexible clinical decision-making framework. Modular training of therapist competencies emphasizes the continuity of the component therapist strategies across evidence-based protocols rather than emphasizing the packages or manuals as separate and distinct. Key hypotheses about the change processes responsible for client change and the associated treatment strategies used to influence these change processes should be specified and measured at the level of client, therapist, and service delivery setting. Adopting this approach may offer advantages that apply to the dissemination and implementation of DBT and other evidence-based practices (EBPs).