Improvements in Executive Attention,Rumination,Cognitive Reactivity,and Mindfulness Among High–Suicide Risk Patients Participating in Adjunct Mindfulness-Based Cognitive Therapy: Preliminary Findings

Abstract

Objective:

To test changes to cognitive functioning among high–suicide risk outpatients participating in an adjunct mindfulness-based intervention combining mindfulness-based cognitive therapy and safety planning (MBCT-S).

Design:

Ten outpatients with a 6-month history of suicide attempt or active suicidal ideation plus suicidal ideation at study entry received 9 weeks of adjunct group-based MBCT-S. Executive attention, sustained attention, visual memory, and semantic memory encoding were measured by neuropsychological assessment. Rumination, mindfulness, cognitive reactivity (defined as the tendency towards depressogenic information processing and thought content in response to mild mood deterioration), and self-compassion were assessed using self-report measures. Changes in pre- to post-treatment functioning on these constructs were analyzed by using dependent t-tests. Where significant improvements were found, correlations between changes to cognitive functioning and depression and suicidal ideation during treatment were calculated.

Results:

Executive attention improved with MBCT-S in high–suicide risk outpatients (Stroop interference effect = 0.39 [standard deviation (SD), 27] at baseline and 0.27 (SD, 0.15) at post-treatment, t[9] = 2.35, p = 0.04, d = 0.75). One mindfulness skill, acting with awareness, increased with MBCT-S (average change in Five Facet Mindfulness Questionnaire-acting with awareness subscale score with treatment, 3.3 [SD, 3.0], t[9] = 3.46, p < 0.01, d = 1.1). Self-reported rumination and cognitive reactivity to suicidality and hopelessness decreased among participants (Ruminative Responses Brooding subscale score change, −3.4 [SD, 1.1], t[9] = 10, p < 0.001, d = 3.2; Leiden Index of Depression Sensitivity–Revised-Hopelessness/Suicidality subscale score change, −3 [SD, 2.7], t[9] = 3.56, p < 0.01, d = 1.1). None of these changes were related to improvements in depression or reductions in suicidal ideation during treatment.

Conclusions:

Findings from the present pilot study suggest that treatment with MBCT-S may improve cognitive deficits specific to suicide ideators and attempters among depressed patients. Future controlled trials using follow-up assessments are needed to determine the specificity of these improvements in cognitive functioning to MBCT-S and their durability and to formally test whether the observed improvements in cognitive functioning explain MBCT-S treatment gains.

Introduction

Mindfulness-based cognitive therapy (MBCT) is a well-accepted, evidence-based treatment for preventing depressive relapse among chronically depressed individuals who are in remission when they begin treatment.^1,2 Studies also show that MBCT provided adjunctively to treatment as usual (TAU) (e.g., antidepressant medication) is effective for reducing acute depression in psychiatric patients.³ There is preliminary evidence that mindfulness-based interventions (MBIs) (i.e., time-limited interventions that target mental health symptoms or well-being and include secular derivatives of traditional meditation practices, such as MBCT) reduce suicidal thinking in adult and adolescent community members.^4
–6

Understanding of the cognitive outcomes among depressed patients who receive MBCT is limited. There is some,^7

–11 albeit not completely consistent,¹² evidence that MBCT increases mindfulness and reduces the negative effects of cognitive reactivity (i.e., the onset of depressogenic thought processes or content in response to mild feelings of sadness) in depressed and remitted participants. Greater improvements in self-reported and observed attention are sometimes, but not always,^13
–15 found among remitted or currently depressed participants assigned to MBCT as opposed to no treatment, TAU, or psychoeducation. Self-compassion, meanwhile, has been found to mediate the relationship between MBCT treatment and lower depressive symptom severity at follow-up in fully and partially remitted depressed patients.¹¹ Moreover, patients with chronic fatigue and subclinical depression who were randomly assigned to MBCT versus wait-list control realized significant decreases in depression and increases in self-compassion during treatment,¹⁶ and the superiority of MBCT for increasing self-compassion was maintained over 2 month follow-up.¹⁶

Other cognitive factors tested as outcomes in MBCT include rumination (i.e., engagement in enduring, maladaptive analysis of the causes and consequences of dysphoric mood) and memory, particularly autobiographical memory. Reductions in rumination specific to MBCT are often, but not always,^10,13 shown in controlled trials with unipolar depressed patients in full or partial remission.^7,9,17 Reductions in rumination, moreover, have been shown to explain MBCT treatment gains (i.e., improvements in depressive symptom severity at post-treatment) in currently and formerly depressed patients.¹² Whether memory improves with MBCT is unclear, with some,^18,19 but not all,^13,17 studies showing greater improvements in the specificity of autobiographical memory recall or free recall among remitted depressed patients and community member participants who received MBCT compared with TAU or no treatment.

The authors recently adapted MBCT^20,21 to address suicide-related concerns by combining it with the Safety Planning Intervention,²² a brief intervention wherein an individualized suicide crisis survival plan is developed. MBCT was developed to prevent suicidal behavior (MBCT-S) to overcome limits to existing treatment options for suicidal individuals. Most psychosocial treatments for depression are neither tailored nor tested for suicidal individuals. Moreover, in a recent meta-analysis delineating the effects of psychotherapy for depression on suicidal ideation (n = 13 studies), no reduction in suicidal ideation with depression treatment was found.²³ Meanwhile, cognitive–behavioral therapy and dialectical behavior therapy (DBT) are efficacious treatments for preventing suicide attempt.^24
–26 The generalizability of benefits from DBT is, however, limited to individuals with borderline personality disorder (BPD). Furthermore, attrition is a major barrier to successful psychotherapeutic intervention with suicidal patients. Sixty percent of patients who are discharged from acute-care settings subsequent to a suicide attempt consequently refuse or prematurely drop out of outpatient treatment.²⁷ Other barriers to treatment for suicidal individuals include attitudes and beliefs about seeking and engaging in traditional mental health treatment, such as low confidence in treatment effectiveness, concerns over the stigma associated with traditional mental health treatment, and financial and professional resource limitations.²⁸

Details of MBCT-S and clinical outcomes associated with the addition of MBCT-S to outpatient treatment have been described elsewhere.²⁹ This article reports on how MBCT-S affects cognitive functioning, broadly defined to include mindfulness, cognitive reactivity, attention, self-compassion, rumination, and memory. Given rather consistent empirical evidence that mindfulness, self-compassion, and rumination improve with MBCT, the hypothesis was that these cognitive functions would improve among sample members from pre- to post-treatment. Given mixed evidence for the effect of MBCT on cognitive reactivity, attention, and memory, making a priori hypotheses on the effect of MBCT-S on these cognitive functions was deferred. Ultimately, identifying cognitive processes that change with treatment and are related to clinical gains allows for treatment refinement because superfluous protocols and practices (i.e., those that do not target functions associated with clinical treatment gains) can be revised or discarded. In the interim, clinicians and participants may benefit from knowing the range of cognitive and affective variables that change with MBCT-S.

Materials and Methods

A quasi-experimental pre–post design was used to test changes in cognitive functioning among MBCT-S participants. Participants were recruited from an outpatient mood and personality disorders research clinic at a large, urban teaching hospital and the community between April 2013 and April 2014. Trained research assistants (RAs) or the MBCT-S treatment provider approached all interested individuals. Phone screening and follow-up in-person screening assessments were used to identify and enroll individuals who were age 18 years or older, were fluent in English, endorsed current suicidal ideation and a 6-month history of suicide attempt, interrupted or aborted suicide attempt or suicidal ideation with method or plan, engaged in individual mental health treatment (psychotherapy excluding DBT and acceptance and commitment therapy and/or psychiatric medication management), were currently or previously depressed, and were not currently meditating.

Only participants who enrolled in one of the two later MBCT-S groups that were conducted as part of this pilot study were asked to complete neuropsychological and self-report cognitive assessments. Participants in the first group that was run as part of this study were asked to provide significant written and verbal feedback during post-treatment assessments and a post-treatment focus group. Thus, it was considered too burdensome to additionally ask these participants to complete the battery assessing cognitive functions before and after treatment.

The study sample consisted of 10 MBCT-S participants who completed pre- and post-treatment neuropsychological tests and self-report assessments of cognitive functioning. Participants were mostly female (80%, n = 8) and ranged in age from 18 to 64 years (mean, 41.7; standard deviation [SD],16.3). At baseline, 90% of these participants (n = 9) were in a major depressive episode. The other participant was dysthymic. Sixty percent of participants (n = 6) also had a comorbid anxiety disorder. Fifty percent of participants (n = 5) had a comorbid BPD. Participants reported severe depression (mean Beck Depression Inventory-II³⁰ score, 31.2 [SD, 12.5]) and reported significant current suicidal ideation at baseline (mean Scale for Suicidal Ideation³¹ score, 10.2 [SD, 6.9]). Sixty percent (n = 6) were lifetime suicide attempters. Twenty percent (n = 2) had made a suicide attempt in the 6 months before study entry. Others had suicidal ideation with method (30%, n = 3) or plan (20%, n = 2) or had engaged in preparatory behavior (30%, n = 3) in the 6 months before their study entry. Seven participants (70%) were prescribed antidepressant and/or mood-stabilizing medications. No participants were psychotic, manic, or dependent on substances at baseline assessment, and all were free of organic or acute brain dysfunction by clinical history. All participants had above-average intelligence, as indicated by a Wechsler Adult Intelligence Scale, 3rd revision, Vocabulary subtest scaled score of 11 or greater (range, 11–18; mean, 14).

Participants completed an average of seven sessions and reported completing an average of 2 hours (over 5 days) of formal mindfulness-meditation practice each week. Participants additionally reported that they reviewed the safety plan twice weekly between sessions, on average. Participants for whom neuropsychological performance and self-reported cognitive functioning data were available did not differ demographically or clinically from the six individuals who completed MBCT-S but were not assessed for neurocognitive functioning at pre- and post-treatment. This study was approved by the local institutional review board. All participants gave written informed consent before completing baseline assessments and verbal informed consent before screening.

Self-report questionnaires

The Leiden Index of Depression Sensitivity–Revised (LEIDS-R)³² was used to assess cognitive reactivity. The LEIDS-R had excellent reliability in the current sample, with a Cronbach α of 0.90. All LEIDS-R subscales, except the harm avoidance subscale, also demonstrated adequate internal reliability, with Chronbach α of greater than or equal to 0.70 for each subscale. Because of low internal consistency, harm avoidance subscale scores were not analyzed.

The Five Facet Mindfulness Questionnaire (FFMQ)³³ was used to assess mindfulness skills. In the current sample, the subscales maintained good to excellent internal reliability. Chronbach αs were as follows: FFMQ-observing subscale, 0.87, FFMQ-describing subscale, 0.93; FFMQ-acting with awareness subscale, 0.85, FFMQ-nonjudging of inner experience subscale, 0.95; and FFMQ-nonreactivity to inner experience subscale, 0.79.

The Self Compassion Scale-Short³⁴ was used to assess self-compassion or self-kindness and patience in the face of feeling inadequate or distressed. Cronbach α in the current sample was 0.95, indicating that the scale maintained excellent internal reliability in this study.

The Response Style Questionnaire-Ruminative Responses Brooding Subscale (RRS-B)^35,36 was used to assess rumination. Internal reliability for the RRS-B was good, with Chronbach α of 0.82.

Neuropsychological tasks

Attention and memory were assessed using four tests that the authors previously used to test these domains in depressed individuals and suicide attempters. Alternate forms were used at pre- and postassessment as needed (e.g., in cases where stimuli were not presented randomly) to limit practice effects.

The computerized Stroop Task (Stroop)^37,38 was used to measure executive attention. The percentage increase in median reaction time between the block in which colored Xs were presented and the block in which incongruently colored color words (e.g., “blue” printed in red ink) were presented, the interference effect, was the primary outcome measure of executive attention from this task for this study. Ninety incongruent trials and 45 congruent trials were presented, with an intertrial interval of 50 milliseconds and a break between blocks.

The Continuous Performance Test-Identical Pairs Version (CPT)³⁹ was used to measure sustained attention. The signal detection index (d’), or the normed hit rate (i.e., number of correctly identified targets where the same four-digit number was presented twice in a row) minus the normed false alarm rate (i.e., number of incorrectly identified nontargets), was the primary measure of sustained attention in this study. One hundred and fifty (28 target) stimuli were presented at a rate of one per second with a 950-millisecond intertrial interval.

The Buschke Selective Reminding Test⁴⁰ was used to measure memory, and in particular, encoding as only selective reminding of words that were not recalled during the previous trial was provided during the intertrial interval. The total number of 12 words remembered across 12 trials was the primary measure of memory encoding in this study.

Benton Visual Retention Test (Benton VRT;⁴¹ Administration D)⁴² was used to measure visual memory. The number of errors made while reproducing 10 visual stimuli after a 10-second exposure followed by a 15-second delay was the primary measure of visual memory in this study.

Clinical and demographic data. Psychiatric diagnoses were assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV, Axis I Structured Clinical Interview (SCID),⁴³ or the MINI⁴⁴ and the SCID for DSM-IV, Axis II BPD module.⁴⁵ Suicide attempt history data was collected by using the Columbia University Suicide History Form.⁴⁶ All clinical interviews were conducted by trained masters- and doctoral-level clinicians with extensive training on these rating scales. All neuropsychological assessments were conducted by trained RAs or a doctoral-level supervisor. Whenever possible, the MBCT-S treatment provider did not conduct the outcome assessments. However, this was unavoidable during a handful of clinical and neuropsychological assessments. Best-estimate diagnoses and suicide attempt history classifications were made by consensus or the principal investigator using all available data sources. Other clinical and demographic information was collected during semi-structured interviews that were completed during screening or baseline assessments.

Statistical analysis

Analyses were conducted using SAS software, version 9.3 (SAS Institute Inc., Cary, NC). Descriptive statistics for demographic and clinical variables for the subsample were computed and compared with those of MBCT-S completers who were not assessed for cognitive functioning. To test whether the various facets of cognitive functioning improved with MBCT-S treatment, change scores on cognitive functioning measures were analyzed by using dependent t-tests or the nonparametric equivalent Wilcoxon signed-rank test, as appropriate. Where significant improvements were found, Pearson product-moment correlations between changes in depression, suicidal ideation, and cognitive functioning were calculated to test whether improvements in cognitive functioning were related to improvements in depressive symptoms or suicidal ideation.

Results

Forty-seven individuals were screened. Eighteen individuals enrolled and received MBCT-S treatment. Six of these individuals participated in the first group that was conducted as part of the study and were thus not assessed for cognitive functioning before or after treatment because of, as described above, concerns regarding participant burden. Two individuals, both in the latter groups, did not complete treatment because of the onset of physical illnesses that required priority treatments. Thus, a subsample of 10 MBCT-S completers provided the outcome data reported here.

Participants evidenced significant reductions in rumination and cognitive reactivity to hopelessness or suicidality from pre- to post-MBCT-S treatment. They also reported significant improvements in executive attention and their ability to act with awareness, a particular mindfulness skill. Specifically, with MBCT-S treatment, participants' Stroop interference effect decreased from 0.39 (SD, 0.27) to 0.27 (SD, 0.15; (t[9] = 2.35, p = 0.04, d = .75). RRS-B scores fell 3.4 points on average (SD, 1.1; t[9] = 10, p < 0.001, d = 3.2), and LEIDS-R-Hopelessness/Suicidality scores fell 3 points (SD, 2.7; t[9] = 3.56, p < 0.01, d = 1.1). FFMQ-acting with awareness scores increased by 3.3 points (SD, 3.0; t[9] = 3.46, p < .01, d = 1.1) (Table 1). Memory, sustained attention, self-compassion, and other types of cognitive reactivity and mindfulness skills did not significantly change with MBCT-S treatment (Table 1).

Table 1.

Changes in Cognitive Functioning with Mindfulness-Based Cognitive Therapy and Safety Planning

		Pre MBCT-S		Post MBCT-S		Analysis
Variable	Patients (n)	Mean	SD	Mean	SD	t	df	p-Value
Mindfulness (FFMQ)
Observing/noticing	10	24	6.2	26.6	4.0	1.82	9	0.10
Describing	10	30.9	4.9	32.6	5.7	1.61	9	0.14
Acting with awareness	10	20.2	2.6	23.5	4.2	3.46	9	0.007
Nonjudging of experience	10	14.9	6.2	19.6	8.4	1.88	9	0.09
Nonreactivity to inner experience	10	15.9	3.8	17.7	4.9	0.96	9	0.36
Cognitive reactivity (LEIDS-R)	10	77.3	10.8	71.5	19.0	1.46	9	0.18
Hopelessness/suicidality	10	15.7	2.8	12.7	4.6	3.56	9	0.006
Aggression	10	11.7	4.2	9.8	5.5	0.95	9	0.37
Rumination	10	20.5	2.4	19.3	4.1	1.18	9	0.27
Control/perfectionism	10	10.5	3.9	10.6	4.4	0.14	9	0.90
Acceptance/coping	10	4.2	3.7	4.8	5.0	0.46	9	0.66
Rumination (RRS-B)	10	16.7	2.9	13.3	2.5	10	9	<0.001
Self-compassion (SCS)	10	20.8	6.6	24.5	10.2	1.81	9	0.11
Executive attention (Stroop interference)	10^a	0.4	0.3	0.3	0.2	2.35	9	0.04
Sustained attention (CPT d')	9^a	2.2	0.9	2.2	05	0.42	8	0.68
Memory encoding (Buschke SRT Total)	9^a	112.7	20.3	109.0	22.0	0.93	8	0.38
Visual memory (Benton VRT errors)	8^a	3.1	3.3	7.3	7.9	W = 6.5	–	0.13^b

One participant completed the Stroop and no other neuropsychological tasks at postassessment. One participant was not able to complete the Benton at postassessment.

Wilcoxon signed-rank statistic reported due to non-normal data. Means and standard deviations reported to facilitate interpretation.

MBCTS, mindfulness-based cognitive therapy and safety planning; SD, standard deviation; FFMQ, Five Facet Mindfulness Questionnaire; LEIDS-R, Leiden Index of Depression Sensitivity–Revised; RRS-B, Response Style Questionnaire-Ruminative Responses Brooding Subscale; SCS, Self Compassion Scale-Short; CPT, Continuous Performance Test-Identical Pairs Version; SRT, Selective Reminding Test; VRT, Visual Retention Test.

Changes in cognitive functioning were not related to changes in depression or suicidal ideation over treatment (Table 2). Changes to suicidal ideation were positively correlated with changes in depression during treatment. (r = 0.80, p = 0.006) (Table 2).

Table 2.

Correlations Between Changes in Suicidal Ideation, Depression, and Cognitive Functioning During MBCT-S

Scale	1	2	3	4	5
1. Change BDI-II
2. Change SSI	0.08^a
3. Change FFMQ-acting with awareness	−0.58	−0.40
4. Change LEIDS-R hopelessness/suicidality	0.34	−0.08	−0.06
5. Change RRS-B	0.15	0.19	0.32	0.19
6. Change Stroop Interference	−0.14	−0.16	0.04	0.29	0.16

p < 0.01.

BDI-II, Beck Depression Inventory-II; SSI, Scale for Suicidal Ideation.

Discussion

Rumination and cognitive reactivity to hopelessness and suicidality were reduced and executive attention and the mindfulness skill acting with awareness were improved among 10 high suicide-risk outpatients who completed MBCT-S. Although these improvements in cognitive functioning were not associated with reductions in suicidal ideation, they were also not correlated with improvements in depression during MBCT-S, suggesting that the observed improvements in cognitive functioning were not simply the result of improved mood with treatment.

Improvements to executive attention are posited to be a putative and foundational mechanism of the enhanced well-being and reduced distress that are associated with mindfulness-meditation training and practice.^47,48 Findings from MBCT outcome studies using behavioral tasks to assess changes to executive attention among depressed patients, however, are mixed.^8,13,49 Executive attention improved with MBCT-S among high suicide-risk outpatients. Thus, findings from this study support ideas that changes to executive attention with brief MBI are possible. Similarly, in previous clinical trials, improvements in cognitive reactivity among MBCT patient and community member participants have sometimes, but not always, been reported.^11,50 Support for the effects of MBCT on rumination, a construct that overlaps somewhat, but not completely, with cognitive reactivity,⁵¹ are more consistent, with findings from several controlled trials showing fully and partially remitted patients report reductions in rumination with MBCT.^7,9,12,17 The current findings thus extend previous findings linking MBCT to decreased rumination and cognitive reactivity and suggest that rumination and cognitive reactivity to suicidality and hopelessness, in particular, improve with MBCT-S in suicidal depressed patients.

Importantly, executive attention, rumination, and cognitive reactivity to hopelessness or suicidal ideation are associated with suicidal thinking and behavior among depressed patients. Depressed attempters, compared to psychiatric controls, demonstrate deficits in executive attention in neuropsychological studies.^52,53 Among community members and psychiatric patients, greater rumination is reported among individuals with a history of suicide attempt⁵⁴ and current suicidal ideation.⁵⁵ Self-reported deficits inhibiting prepotent responses of hopelessness and suicidal thinking during sad mood (i.e., cognitive reactivity to hopelessness and suicidality) distinguish remitted depressed patients who have a history of suicide attempt or suicidal ideation from psychiatric controls.^56,57 Thus, findings from the current study provide initial evidence that MBCT-S effectively targets certain deficits associated with suicidal behavior among depressed patients.

A particular mindfulness skill— acting with awareness or the ability to focus on current thoughts, behaviors, or situations and avoid distraction³³—improved with MBCT-S among high suicide-risk participants. Acting with awareness, along with the other mindfulness skills of observing and accepting without judgment, have been shown to consistently improve with MBCT, but not TAU, among currently and remitted depressed patients.^7,12 Thus, the current findings extend results from prior studies and show that a specific mindfulness skill, the ability to act with awareness, is improved with MBCT-S in high–suicide risk patients.

No changes to sustained attention, self-compassion, or memory were found with MBCT-S treatment. The finding that sustained attention did not improve with MBCT-S aligns with findings from prior controlled studies that found no self-reported improvements to sustained attention among previously or currently depressed participants in MBCT.^13
–15 Thus, the current behavioral findings extend findings from prior studies that have assessed sustained attention using self-report measures. The finding that self-compassion did not improve with MBCT-S contrasts with findings from controlled trials showing specific improvements to self-compassion with MBCT among depressed patients or medical patients with significant depressive symptoms.^11,16 It is unclear why improvements in self-compassion were not found in this study. It may be that self-compassion does not improve among high suicide-risk patients with MBCT-S. On the other hand, it may be that the study was underpowered to detect improvements in self-compassion that result from MBCT-S and that improvements in such cognitive functions would be identified in larger study samples. In fact, a sample size of 20 would be needed, with α of 0.05 and 80% power, to detect a change equivalent to the medium effect size of MBCT on self-compassion reported by Kuyken et al.¹¹

MBCT-S was also not associated with enhanced memory performance among high suicide-risk patients. There is some, albeit not completely consistent, evidence that autobiographical memory recall specificity improves with MBCT.^18,19 Free recall after laboratory-induced social stress has not been found to improve with MBCT among partially and fully remitted depressed patients.¹⁷ Where prior studies probed affective, and for the most part autobiographical, memory recall, the current study measured verbal encoding and visual memory without affective interference. Thus, it may be the affective memory dynamics, but not cold cognition, and semantic recall, but not encoding, are affected by MBCT-based treatments. It could also be that a ceiling effect prevented the study from observing improvements in visual memory, in particular. Although specific deficits in visual memory have been found among depressed individuals who have a history of suicide attempt compared with those who do not,⁵³ on the basis of age- and IQ-corrected external norms, all but one of our participants performed 1 SD or more above the mean at baseline on the task assessing visual memory functioning.⁵⁸

The study sample was small. Larger studies are needed to confirm these findings. This study was not controlled. Thus, factors other than MBCT-S treatment may explain the improvements in cognitive functioning that were observed. As described in a previous publication,²⁹ the researchers did not maintain primary responsibility for treatment of participants in the MBCT-S trial. Instead, participants' individual therapists and psychiatrists did. Thus, while the investigators sought participants who did not expect their medication or psychosocial treatment to change during study participation, psychotropic medications were changed for three participants during the study. Specifically, a serotonin reuptake inhibitor (SSRI) was added to one participant's treatment regimen, and two others had their SSRI or mood stabilizer dosages decreased. No other changes to psychiatric medication or psychotherapy during study participation were reported. Notably, there is now good evidence that SSRIs and mood stabilizers do not affect performance on the neuropsychological tasks that probe attention and memory encoding among depressed patients.^59,60 Taken together with the few changes to nonstudy treatment that occurred over the course of treatment, it seems unlikely that changes to nonstudy medications caused the observed improvements in cognitive functioning. Future controlled trials are, however, needed to eliminate changes to nonstudy medication and other potential confounders that could explain the observed improvements in cognitive functioning with MBCT-S. Moreover, no follow-up data were collected. To understand the durability of MBCT-S effects on cognitive functioning, future controlled studies could also include follow-up assessments.

Despite the aforementioned limitations, this study had many strengths. The study population was unique. Most studies of cognitive outcomes with MBCT in recurrently depressed patients have included only remitted patients. In the few trials that tested changes to cognitive functioning with MBCT in partially remitted or currently depressed patients,^11,12 suicidal individuals were excluded. The current study measured attention and memory by using behavioral tasks. Most prior studies testing improvements to attention with MBCT in psychiatric patients have relied on the Mindful Attention and Awareness Scale,⁶¹ a self-report measure of attention. Thus, the current study provides unique insights into how cognitive functioning may change among suicidal and depressed patients with MBCT-based treatment.

Conclusions

This study had promising findings with respect to cognitive outcomes for participants in MBCT-S, a nine-session adjunct psychosocial treatment delivered mostly in a group format that combines MBCT adapted to target suicide-related concerns with the Safety Planning Intervention. Specifically, rumination and cognitive reactivity to hopelessness and suicidality decreased and executive attention and the mindfulness skill of acting with awareness improved among 10 high–suicide risk patients with MBCT-S. Future controlled trials are needed to confirm these findings.

Footnotes

Acknowledgments

This project was supported by grant PDF-0-076-11 awarded to M.C. from the American Foundation for Suicide Prevention. The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Foundation for Suicide Prevention.

Author Disclosure Statement

No competing financial interests exist.

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