The mindfulness trajectories of addressing suicidal behaviour: A systematic review

Abstract

Background and objectives:

Suicidal behaviour has been a persistent concern in medical as well as general settings. Many psychotherapeutic approaches have tried to address suicidal behaviour in different ways. Mindfulness-based interventions (MBIs) have garnered much attention in the last decade because of their treatment efficacy. This systematic review aimed to examine evidence-based research regarding the effectiveness of MBIs as a psychotherapy intervention on suicidality and to deliver suggestions that might help future research.

Method:

The identification of literature was made through an extensive search of the electronic databases, to extract studies relating to the efficacy of MBIs on addressing suicidal behaviour. Additional researches based on library sources were searched manually. The studies’ selection was based on a pre-determined inclusion and exclusion criteria as well as the quality of the studies.

Results:

The present review helped us identify 13 studies, including six randomised controlled trials, two controlled studies and five pre-post observational studies. The findings reported in the studies were mostly favourable to MBIs as an effective intervention strategy for suicidal behaviour.

Conclusion:

MBIs show promising effects as an intervention for suicidal behaviour. However, large scale, high-quality trials with active control, and long term intervention efficacy studies are needed to understand the mechanisms through which MBIs reduce suicidal behaviour.

Keywords

Mindfulness suicidality suicidal ideation systematic review mindfulness based cognitive therapy

Introduction

Suicidality or suicidal behaviours are the thoughts, gestures, behaviours of intentionally taking one’s own life. More precisely, these thoughts are characterised by suicidal ideation and suicidal plan. The DSM-5 differentiates between suicidal ideation, non-suicidal self-injury and suicidal attempts. The proposed criteria for suicidal behaviour disorder are marked by the presence of a suicide attempt within the last 24 months (DSM-5). There are no exact causes of such behaviour because suicidality is a complex phenomenon which can have multifaceted explanations. Previous research has focused on understanding psychological attributes that might play a role as precipitating factors or recurrence of suicidal attempts. Several researchers have linked suicidal behaviour to over-general memory (Evans et al., 1992); intrusive thoughts (Holmes et al., 2007); perceived self-discrepancy, and brooding (Crane et al., 2007). In most cases, the presence of suicidal thoughts and attempts has been attributed to an underlying psychiatric disorder, especially mood disorders (O’Connor & Nock, 2014; Rihmer & Kiss, 2002). It has been reported that about 27% of bipolar depressive individuals have suicidal thoughts and behaviour (Bottlender et al., 2000). The severity of depression at different levels is likely a predictor of suicidal tendencies (Uebelacker et al., 2010). In the context of schizophrenia, a study reported that approximately 50% of the patients, at some point, report suicidal thoughts or make an attempt during their illness. (Dassori et al., 1990). However, suicidality is not just limited to specific syndromes or psychiatric diagnoses, but it can occur among the general population without any diagnosable conditions (Strosahl & Chiles, 2006; Williams et al., 2005). Evidence of suicidal ideation in terminally ill, medical, and surgical patients in a hospitalised setting has also been reported (Ballard et al., 2008; Botega et al., 2010). Moreover, there have been numerous research studies on suicidal tendencies in college and school students (Mackenzie et al., 2011; Ziaei et al., 2017). The diversity in the diagnoses and the presence of suicidal phenomenon in non-clinical settings demands effective treatment strategies.

Developing effective clinical intervention strategies independently to address suicidal behaviour is one of the most significant challenges for healthcare professionals. Approaches like cognitive behaviour therapy have been influential in the context of depression and suicide. Dialectical behaviour therapy (DBT) commonly used for treating borderline personality disorder has also been useful in the context of self-injurious and suicidal behaviours in suicidal attempters (Linehan et al., 2006). However, DBT in acute suicidal crisis and suicidal ideation has not been found very effective (DeCou et al., 2019). Further, traditional mental health treatment/therapeutic approaches used to address suicidality were not free from limitations like premature dropouts, refusal to adherence, stigma and low confidence to treatment effectiveness (Bruffaerts et al., 2011; Lizardi & Stanley, 2010). In contrast to these intervention strategies, Mindfulness-based theraputic approaches have shown encouraging results in clinical settings and the general population. Mindfulness-based procedures use elements like awareness, acceptance, being non-judgmental about current experiences, which help to make individuals resilient against dysfunctional thinking and distressing emotional experiences (Hayes & Feldman, 2004; Kabat-Zinn, 1990). Mindfulness-based intervention (MBIs) as adjunctive treatment could improve treatment outcomes when psychiatric disorders are chronic and are marked by social and economic implications (Lish et al., 1994; Mintz et al., 1992; Wyatt and Henter, 1995).

Mindfulness-based techniques can modulate suicidal ideation in various ways. Several cross-sectional studies have demonstrated the effectiveness of mindfulness-based training in reducing suicidality risk (Anastasiades et al., 2017; Chesin & Jeglic, 2016). It has been asserted that mindfulness helps in accepting maladaptive thoughts and emotions, enabling suicidal individuals to re-engage themselves in goal-directed behaviour even during adverse situations (Garland et al., 2017; Kabat-Zinn, 1993; Mark et al., 2004). Researchers have suggested that mindfulness reduces cognitive rigidity, works on maladaptive cognitive styles of suicidal individuals, and improves their problem-solving capability (Greenberg et al., 2012). Additionally, suicidality has been associated with greater cognitive reactivity, which is marked by biased thinking, poor interpersonal problem solving, and slow information processing resulting from non-pathological mood deterioration (Williams et al., 2005). In addition, cognitive reactivity is an essential determinant of suicidal risk that can be minimised through mindfulness-based cognitive therapy (MBCT) in individuals with suicidal depression history (Williams et al., 2006).

Above mentioned studies have shown how mindfulness-based strategies work on the different modalities which might reduce suicidal risk and suicidal behaviour. Some of these have proved positive in symptom relief, and some have contributed to making the prognosis better. To date, very few reviews have attempted to understand the impact of mindfulness-based interventions (MBIs) independently on suicidality (Chesin et al., 2016b). Previously systematic reviews on mindfulness-based interventions have focused mostly on MBCT and its effects on suicidal ideation reported in psychiatric disorders and chronic conditions (Williams et al., 2006). Given that some authors have proposed that Mindfulness-based treatment can prove a promising approach for suicidal individuals, the available evidence must be reviewed. Therefore, in this paper, we aim to review the evidence-based studies which have used mindfulness-based interventions on people at risk of suicidal behaviour to understand their immediate and long term effects. The review will also focus on the measures being used and their applicability in the context of intervention outcomes. Furthermore, our review will explore possible mechanisms of actions and feasibility by which mindfulness-based interventions may lower suicidality in the psychiatric and non-psychiatric population.

Method

Eligibility of the studies

Inclusion criteria

The criteria for included studies are as follows:

(i) Population: Studies that reported suicidal ideation or attempts in participants with any psychiatric disorder, non-psychiatric disease (like cancer) and the general population were included.

(ii) Intervention: Studies that assessed the effectiveness of mindfulness-based psychotherapy techniques on suicidality were included.

(iii) Outcome: Studies that assessed suicide objectively either through scale or interview, as the outcome was included.

(iv) Comparators: The comparators included were any other form of psychotherapy, psychopharmacological interventions, treatment as usual (TAU) and without treatment as control.

(v) Design of the Study: Randomised control trials (RCT), non-randomised observational studies and pre-post intervention design studies were included. Studies reported in peer-reviewed journals were only included. Review articles, book chapters, conference papers, thesis and proposed protocols were not included. Only those studies were included, which were published in the English language.

Literature search

This present review followed the PRISMA guidelines (see Figure 1 for details) for the selection of the published studies on the topic. Bibliographic databases were searched for relevant literature by two independent researchers. The studies that reported the effect of MBIs on suicide and published in peer-reviewed journals with a time frame from January 2010 to March 2020 were taken into consideration. The following electronic databases were searched for potential researches: PubMed, Medline, ScienceDirect and PsychInfo. Additional searches were conducted for non-indexed citations, and the references of shortlisted papers were examined to find other potentially eligible papers.

Figure 1.

The PRISMA flowchart depicting study selection and eligibility process.

The keywords and terms used for searching were as follows: ‘mindfulness and suicide’, ‘mindfulness intervention and suicide’, ‘mindfulness-based therapy and suicide’, ‘mindfulness training and suicidal ideation’, ‘suicidal ideation and mindfulness meditation’ and ‘Mindfulness-based cognitive therapy and suicide’.

Study selection

The data extraction process rendered a total of 2,721 potentially relevant papers. Additionally, from library resources and through contact with experts helped in the identification of 31 more papers. Subsequently, 217 duplicates were identified and removed. The remaining 2,535 papers were screened based on their titles and abstracts. After that, 2,473 articles were not fitting into the inclusion criteria. Hence they were removed. The remaining 62 full-text articles were checked on the eligibility parameters. Out of these, 49 publications were excluded for several reasons like no use of mindfulness-based intervention (MBI), book chapters with insufficient data, proposed protocols and no empirical data. Finally, we included 13 studies for further analysis (see Table 1).

Table 1.

Showing the summary and salient features of the included studies.

SL NO	Study	N	Design	Population	Intervention name	Control	Intervention length	Major outcome measures	Main outcome
1.	Hargus et al. (2010)	27	RCT	Depressed Participants	MBCT	TAU	The MBCT treatment comprised of eight weekly sessions and sessions were about 2 hours in duration.	BDI II, Relapse Signature of Suicidality Interview (ReSSI), Relapse signature specificity measure, Relapse signature meta-awareness measure.	In comparison to TAU group there were significant pre-post score changes in meta-awareness and suicidal specificity in MBCT group.
2.	Le and Gobert (2015)	8	Mixed method	Young Native Americans	A tailored mindfulness based youth suicide intervention programme	None	Intervention spanned over 10 weeks. Weekly Four sessions were given and each session was about 55 minutes.	Healthy Self-Regulation, Teen Conflict Survey, Patient Health Questionnaire,	The intervention led to better self-regulation skills, lower mind wandering, increased awareness relaxation and calmness and decreased suicidal thoughts
3.	Forkmann et al. (2014)	130	RCT	Patients suffering from residual depressive symptoms	MBCT	Waitlisted control	The training comprised of eight weekly sessions lasting for about 2.5 hours in a group of 10 to 15 participants.	KIMS, HDRS, PSWQ, RSS, Inventory of Depressive Symptoms was used for suicidal ideation( Dutch Version)	MBCT group reported significant improvement in self-reported suicidal ideation in MBCT group. These changes in suicidal ideation were independent from change in depression.
4.	Serpa et al (2014)	79	Prospective, longitudinal observational study	Veterans (Veterans Health Administration medical facility)	MBSR	None	A group of 10 to 15 participants were trained weekly. The sessions spanned over 9 weeks.	FFMQ, PEG scale, PHQ-9, GAD-7 and Short Form-12 (SF-12)	The MBSR training brought about significant reductions in post-intervention anxiety, depression and suicidal ideation scores.
5.	Britton et al. (2014)	101	RCT	Sixth-grade students	Mindfulness meditation practice	Students from African History course with a matched experimental activity.	Meditation module lasting 6 weeks	Youth Self Report (YSR), STAI-C, CAMS-R,	Mindfulness based meditation significantly reduced suicidal ideation as well as self-harm thoughts.
6.	Barnhofer et al. (2015)	194	RCT	Previously Suicidal Patients	MBCT and CPE	Cognitive Psychoeducation and TAU group	Eight weekly 2-hour sessions were given and one pre class interview was conducted	BDI–II, and Suicidal Cognitions Scale	In comparison to TAU and CPE group the MBCT group showed weaker association between levels of depressive symptoms and suicidal cognitions The participants in the MBCT group displayed an overall reduction in suicidal cognitions.
7.	Chesin et al. (2015)	18	Quasi-experimental pre–post design	High suicide risk psychiatric outpatients	MBCT-S	None	9 weeks group based MBCT-S as an adjunctive therapy	BSSI, BDI-II, Beck Hopelessness Scale	MBCT S resulted into significant post intervention decreases in suicidal ideation as well as depression but no changes in hopelessness.
8.	Chesin et al. (2016a)	10	Quasi-experimental pre–post design	Outpatient with mood and personality disorder who had a suicidal attempt history in past 6 months and currently endorsed suicidal ideation	MBCT-S	None	7 sessions of mindfulness meditation practice and 2 sessions of safety planning intervention, over a period of 9 weeks in group	LEIDS-R, FFMQ, The Self Compassion Scale-Short, RRS-B, The computerised Stroop Task (Stroop), CPT, The Buschke selective reminding, Benton Visual Retention Test.	The treatment brought significant changes reductions in rumination, cognitive reactivity hopelessness and suicidality. There were significant improvements in attention, acting with awareness, memory and self-compassion. MBCT-S had no significant effect on trait mindfulness.
9.	Forkmann et al. (2016)	106	RCT	Outpatients with chronic depression	MBCT Intervention, CBASP Intervention	TAU, Another group was given CBASP	MBCT was conducted in eight weekly 2.5 hours group session. A pre class interview was conducted. CBASP Program consisted of two individual and group sessions in an eight weekly 2.5 hour sessions.	HAMD, BDI,	Significant reduction of suicidal ideation emerged on HAMD suicide item result for both MBCT group and CBASP group over the TAU group, while on BDI suicide item, results revealed only significant difference on MBCT group.
10	Collins et al. (2017)	92	Experimental design	Undergraduate student from Psychology class	Mindfulness Intervention, and Unfocused attention intervention	Four conditions: Two groups were without intervention that is, One group consisted of Low perceived burdensomeness (PB) thwarted belongingness (TB) and another group who has high scores in both PB and TB One high PB/TB group received brief mindfulness intervention another high PB/TB group was given an unfocussed attention intervention.	10 Minutes mindfulness audio exercise for both the intervention formats.	Freiburg Mindfulness inventory, interpersonal need questionnaire, Need to belong to the team, Kessler psychological distress scale, Self-injurious thought and behaviour interview (SITBI), and Intent, likelihood and readiness for suicide	The desire to escape response in all three high PB/TB conditions witnessed a linear increase in the initial stage of the task. In one condition which was given mindfulness intervention the linear increase was stabilised after a point which reduced the risk for suicidality in the comparison of other conditions.
11.	Nabipour et al. (2018)	30	Semi experimental with pre-test, post-test design	30 cancer patients	MBCT	15 participants were in experimental control group	Total 8 sessions of mindfulness based cognitive group therapy	Templer’s Death Anxiety, BSSI,	MBCT led to a significant reduction in suicidal thoughts and death anxiety. MBCT was effective on female cancer patients
12.	Lu et al. (2019)	49	RCT	Left behind children	Mindfulness training module	Waitlisted control group	8 week mindfulness training program	MAAS, SASC, SES, PANSI	The children showed significant improvements in mindfulness skills and reductions in social anxiety and suicide ideation in comparison to other group.
13.	Raj et al. (2019)	30	Pre–post design	School Students	MBCT	None	The sessions were given in groups which spanned over 16 weeks. Weekly one session was taken which lasted for about 45 min to an hour.	MSSI, BDI, Satisfaction with life scale, LOT-R.	There were significant improvements in scores of life satisfaction, life orientation and significant decrease in depression scores and suicidal ideation.

The Leiden Index of Depression Sensitivity–Revised (LEIDS-R), The Five Facet Mindfulness Questionnaire (FFMQ), GAD-7 (Generalised Anxiety Disorder-7 item scale), The Response Style Questionnaire-Ruminative Responses Brooding Subscale (RRS-B), The Continuous Performance Test-Identical Pairs Version (CPT), The Modified Scale for Suicidal Ideation (MSSI), Revised Life Orientation Test (LOT-R), Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Mindful Attention Awareness Scale (MAAS), The Social Anxiety Scale for Children (SASC), Self-Esteem Scale (SES), The Positive and Negative Suicide Ideation (PANSI), Cognitive Psychoeducation (CPE), Beck’s scale for suicidal ideation (BSSI), Kentucky inventory of Mindfulness Skill (KIMS), Hamilton Depression Rating Scale (HDRS), Penn State Worry Questionnaire (PSWQ), Rumination on Sadness Scale (RSS), Pain Enjoyment General Activity Scale (PEG Scale), Patient Health Questionnaire-9 (PHQ-9), modified version of the Spielberger State-Trait Anxiety Inventory – Child version (STAI-C), Cognitive and Affective Mindfulness Scale (CAMS-R)

Quality assessment

The Cochrane risk of bias tool was used with slight modifications to assess the quality and risk of bias assessment for randomised control trials and non-randomised control studies (Higgins et al., 2011). The results of the quality assessment of RCTs and Non-RCTs have been summarised in Table 2.

Table 2.

Quality assessment of RCTs and Non-RCTs using Cochrane Risk of Bias Tool.

Serial No	Studies	Random Sequence Generation	Allocation Concealment	Blinding of Participants and Therapist	Blinding of outcome assessment	Incomplete outcome data	Selective reporting	Remarks
1.	Hargus et al. (2010)	−	+	−	+	−	+	Process of randomising was not explained clearly. Interviewers were blind. Follow up results were not reported clearly
2.	Barnhofer et al. (2015)	−	?	+	+	−	−	No information on allocation. No blinding.
3.	Britton et al. (2014)	−	?	+	−	−	−	Researchers who were assessing were blinded throughout.
4.	Forkmann et al. (2014)	−	−	+	+	−	?	Randomisation was done by using blocks of five. Allocation was done through codes given in envelope.
5.	Forkmann et al. (2016)	−	−	?	−	−	?	Randomisation was done using blocks. Computer generated allocation by independent allocator. Raters were blinded, however participants information not clear.
6.	Lu et al. (2019)	−	?	+	+	−	−	No information on process of randomisation. Blinding information concealed.
7.*	Collins et al. (2014)	−	?	+	+	−	−	No blinding was followed
8.*	Nabipour et al. (2018)	−	+	+	+	−	−	No blinding, all outcome was clearly reported

+ = high risk; - = low risk; ? = uncertain.

Non RCT studies with control group.

The NHLBI tool was used to assess pre-post intervention studies’ quality without any control group (National Institutes of Health [NIH], 2014). This tool comprises 12 statements, each of which is rated either ‘yes’, ‘no’ or ‘uncertain’. Further, based on the overall rating, each study was classified as good, fair, or poor. Two reviewers rated each of the studies as per their observations on the given criteria. In case of disagreements, unanimity was achieved through discussion. The results of the quality assessments for pre-post studies have been summarised in Table 3.

Table 3.

Summary of quality assessment for pre-post no control group studies using NHLBI quality assessment tool (NIH, 2014).

Study	Criteria 1	Criteria 2	Criteria 3	Criteria 4	Criteria 5	Criteria 6	Criteria 7	Criteria 8	Criteria 9	Criteria 10	Criteria 11	Criteria 12	Quality
Le and Gobert (2015)	✓	✓	✓	#	<	✓	✓	<	✓	✓	<	<	Fair
Serpa et al. (2014)	✓	✓	✓	#	✓	✓	✓	<	<	✓	✓	<	Good
Chesin et al. (2015)	✓	✓	✓	✓	<	✓	✓	<	✓	✓	<	#	Fair
Chesin et al. (2016a)	✓	✓	✓	✓	<	✓	✓	<	✓	✓	<	#	Fair
Raj et al., 2019	✓	✓	✓	✓	#	#	✓	<	✓	✓	<	<	Fair

(✓ YES) (< NO) (# UNCLEAR).

Results

Table 1 summarises the salient features and key findings of the selected studies. The review’s focus was to include those studies that have examined the psychotherapeutic effects of MBIs on suicidal behaviour. The sample used in the studies ranged from patients either having depression or personality disorder (N = 6, 46.1%), school students (N = 2, 15.3%); left-behind children (N = 1, 7.69%), college students or youth (N = 2, 15.3%); cancer patients (N = 1, 7.69%) and veterans (N = 1, 7.69%). About the type of MBIs used, the majority of studies had given mindfulness-based cognitive therapy (N = 6). Two studies trained the participants on MBCT-S (mindfulness-based cognitive therapy, along with safety planning intervention for suicide). Other studies used MBSR (n = 1), mindfulness meditation practice (n = 1), mindfulness suicide prevention intervention (n = 1) and 10-minute mindfulness audio for focused attention (n = 1).

Summary of controlled studies (RCTs and non RCT controlled intervention studies)

The retrieved studies consisted of six randomised control trials (RCTs), and two studies used control arms but have not reported a formal randomisation procedure (Collins et al., 2017; and Nabipour et al., 2018). Collins et al. (2017) used a task-based experimental paradigm to see the comparative effects of a 10 minutes mindfulness audio exercise and unfocused attention exercise on perceived burdensomeness (PB) and thwarted belongingness (TB) scores of college graduates. In the initial stage, the high PB/TB group reflected an increased desire to escape, but in the later phase, the group that received mindfulness witnessed the intervention’s attenuation effects resulting in reduced suicidal desire. Nabipour et al. (2018) adopted a pre-post design and tested the effect of mindfulness on death anxiety and suicidal ideation on cancer patients. The eight MBCT training sessions resulted in a significant reduction of suicidal ideations and death anxiety in the experimental group. Hargus et al. (2010) studied depressed individuals who had experienced suicidal crises. It was seen that the group which received MBCT with TAU had significant post-treatment improvements in the meta-awareness. The authors concluded that this increased reflective ability after mindfulness might prevent future relapse. Forkmann et al. (2014) examined 130 patients who had residual depressive symptoms in a randomised controlled trial. These patients were randomly assigned to either a treatment group (MBCT) or a waitlisted arm. MBCT group showed significant post-treatment reductions in suicidal ideation.

Based on the cohen’s d scores, it was seen that MBCT had a moderate effect size on suicidal ideation. Another study conducted by Forkmann et al., (2016) on chronic depressive patients used an active control group that was given CBASP, and a TAU group. The results reveal that on HDRS suicide item, both the groups show no difference, but when the suicide item for BDI was analysed, the MBCT group showed a significantly larger effect than the CBASP group. The study concluded that MBCT could be an effective psychotherapeutic intervention for addressing suicidal ideation in chronic depression. Britton et al. (2014) also examined the effects of mindfulness-based training on sixth graders and found a significant reduction in post-intervention scores of suicidal ideation and self-harming thoughts compared to the control group. The interpretation of effect size estimations of the mindfulness intervention group had a low to moderate effect size benefit over the active control condition. It was concluded that mindfulness could be useful in addressing suicidal ideation and self-harming tendencies. Barnhofer et al. (2015) used an active control condition, whereby 194 patients with suicidal history were randomly divided into MBCT, CPE and TAU groups. The MBCT group showed a significant reduction in suicidal cognitions in comparison to other control groups. The conclusion drawn from the study was that mindfulness prevents the recurrence of depression by weakening the link between depressive tendencies and suicidal cognitions. Lu et al. (2019) examined left behind children assigned randomly either to a mindfulness intervention condition or a waitlisted arm. The ANCOVA results revealed moderate between-group effects size. The study concluded that mindfulness training could effectively lower suicidal ideation and reduces social anxiety in these children.

Summary of observational pre and post studies

The review had five observational pre and post-intervention studies that were based on findings of a single group. Chesin et al. (2015) used a nine-session MBCT-S intervention on psychiatric patients. The effect size of the intervention indicates moderate effects based on the scores on the depression scale. The findings indicate that MBCT-S helped in reducing depression as well as suicidal ideation in these individuals. In another study, Chesin et al. (2016a) examined the effect of a 9 weeks adjunctive MBCT-S intervention on executive functions and attention processes in high-risk suicide patients. The results suggested that MBCT-S may improve depressed patients’ cognitive deficits, specifically in people with suicidal ideations and attempters. The authors also posited that improving executive attention with brief MBIs may be possible. Raj et al. (2019) used MBCT on adolescents to understand life orientation changes, life satisfaction, depression and suicidal ideation. MBCT helped in reducing ideation and enhancing life orientation and life satisfaction among adolescents. One study on the Native American community (Le & Gobert, 2015) used an ideographic pre-post analysis to understand the efficacy of a translated Mindfulness-based youth suicide prevention program. The intervention resulted in reducing suicidal thoughts among the youth.

Quality assessment

In the RCTs and Non-RCTs, the quality ranged from fair to good. In the observational pre-post studies, one study qualified as good, whereas others (N = 4) qualified as ‘fair’ in the quality assessment. Inadequate description of participants’ characteristics and lack of proper assessment of effect size estimates were the common limitations found in the studies.

Discussion

The past decade has witnessed increased interest and popularity of MBIs due to their treatment efficacy in various clinical and non-clinical conditions. This systematic review aimed to understand the effect of mindfulness interventions on suicidal behaviour in various populations. Understanding the dynamics of mindfulness-based interventions in reducing suicidal behaviour can be imperative to prevent people at risk. The present review included 13 evidenced-based studies that were published from January 2010 to March 2020. These studies have examined various mindfulness-based techniques that can have a direct and indirect impact on suicidal behaviour. The treatment effects of MBIs have been investigated on both the clinically diagnosed patients having a suicidal history and individuals attending school/colleges having suicidal ideation. The evidence-based studies reviewed in this paper cumulatively indicate that MBIs may be beneficial psychotherapeutic approaches for people susceptible to suicidal behaviour.

Suicidality is not just determined by the presence of particular disorders or medical conditions but involves psychological factors that might cause such behaviour’s recurrence. Based on the review, it was found that mindfulness-based interventions have shown promising results in improving executive functioning (Chesin et al., 2016a), life orientation (Raj et al., 2019), over general memory (Hargus et al., 2010), ruminative responses (Forkmann et al., 2014; Chesin et al., 2016a), meta-awareness (Hargus et al., 2010), death anxiety (Nabipour et al., 2018) and attention (Britton et al., 2014; Chesin et al., 2016a). These attributes are equally important in understanding the psychological mechanisms through which suicidality can be addressed. However, studies that reported the moderating effects of MBIs on these variables are limited in number. Therefore, pathways through which these variables influence suicidal behaviour remain unaddressed. Further clinical trials are required to study the moderating effects of these attributes on suicidal behaviour. Since most of the studies focused on suicidal ideation, conclusive evidence regarding MBIs’ effectiveness on the recurrence of attempts also cannot be determined.

Mindfulness-based interventions have also been influential in the mechanisms proposed by theoretical models that directly correlate with suicidal behaviour. Collins et al. (2017) examined two important interpersonal factors of suicide that is, perceived burdensomeness and thwarted belongingness. (Joiner et al., 2009). Hargus et al. (2010) have emphasised autobiographical memories that act as triggers of suicidal behaviour which was given in a model proposed by Williams et al. (2007). These studies have established that MBIs have a positive impact on these factors. However, studies involving the impact of mindfulness training on these theoretical constructs are minimal.

The success of using mindfulness-based interventions is dependent on the proper assessment of suicidal behaviour as an outcome measure. Three studies have reported the pre and post effect of MBIs on an independent scale for suicidal ideation (Chesin et al., 2015;Nabipour et al., 2018; Raj et al., 2019). One study reported the effect of the intervention on a scale of suicidal cognition (Barnhofer et al., 2015) and another on a scale of positive and negative suicidal ideations (Lu et al., 2019). Two studies have used an interview to assess suicidal outcomes (Collins et al., 2017; Hargus et al., 2010). On the other hand, six studies have assessed suicidality based on the item given on a particular scale, which measures a different construct altogether like Beck depression inventory (Forkmann et al., 2016) or PHQ 9 (Serpa et al., 2014). Most of the studies have shown that MBIs significantly reduce suicidality. However, while tapping suicidal aspects from indirect measures, there is a possibility of overlapping results. In such cases, it becomes difficult to segregate whether the intervention is effective in suicidality or because of the overall construct. The conclusive evidence of MBIs on suicidal behaviour can be superior if a measure that is solely used for suicidal ideation/suicidal behaviour is included as the outcome variable.

To conclude about the efficacy of MBIs in decreasing suicidal behaviour, the variability of mindfulness techniques must be taken into account. The content of the training protocol varied across all the studies taken for review. Eleven studies described the mindfulness module being used, while the intervention protocol for two studies is not clear. Furthermore, the length of the interventions can also moderate their effectiveness. The range of intervention length varies from 10 minutes (Collins et al., 2017) to 16 weeks (Raj et al., 2019). Brief mindfulness-based interventions can enhance executive functioning and impact depressive cognition (Chesin et al., 2015). Most studies have given 8 to 9 weeks of mindfulness training. More extended protocols are susceptible to attrition rates, which can compromise the replicability of the intervention. A standard intervention format that addresses critical components of suicidal behaviour must have consensus in the literature regarding the best practices of mindfulness in this context.

While understanding the efficacy of the intervention, implementation fidelity is a crucial factor. Fidelity determines the degree to which an intervention is delivered as intended. Intervention fidelity is primarily determined by three factors that is, trainer’s competence, treatment differentiation and therapist adherence (Schoenwald et al., 2011). In most of the studies, the trainer’s characteristics and detail of the intervention protocol of the sessions had been given. In some studies, the mindfulness training was given by certified therapists. Some relied on trained research assistants and teachers to give the intervention, whereas few studies have not adequately described the trainer’s characteristics. In such a scenario, it is possible that some extraneous factors related to trainer’s characteristics might influence treatment efficacy. Some studies have also made an effort to report the participant’s experiences during the intervention process, which adds to the understanding of fidelity (Britton et al., 2014; Chesin et al., 2015; Le et al., 2015). The treatment differentiation and variability could not be assessed due to inadequate information. The threat of variation in treatment procedure of large scale clinical trials must follow specific guidelines.

This systematic review includes six studies that have used a randomised controlled design in understanding treatment efficacy on suicidal behaviour. Two studies using RCTs have used waitlisted controls (Forkmann et al. 2014; Lu et al. 2019), and one study used TAU groups alone for comparison (Hargus et al. 2010). Overall, the studies pointed out that mindfulness-based approaches help reduce suicidal behaviour. However, waitlisted designs carry a possibility to overinflate the relative efficacy of the MBIs intervention. On the contrary, three RCTs have used an active control group along with TAU (Barnhofer et al., 2015; Forkmann et al., 2016) or without a TAU group (Britton et al., 2014). As reported in these studies, MBIs have a remarkable effect in treating suicidal behaviour compared to active control. Thus, an active control group will bring clarity in the specificity of effects and actual differences in the interventions used. Similar outcomes that mindfulness-based therapies have a positive impact on reducing suicidal behaviour have been reported by the observational pre-post studies as well.

Most of the studies included in the review have focused upon the immediate effects of MBIs on suicidal behaviour with either no or limited follow-up span. There was a single study which had a longitudinal design (Serpa et al., 2014). Although the effect size reported in maximum studies show a moderate to the good effect of MBI’s on suicidality, there was insufficient evidence to understand the trajectories of skills use over time.

This review reports a few studies which have emphasised the adaptation of mindfulness-based interventions as per their culture and purpose (Chesin et al., 2015; Forkmann et al., 2016; Le & Gobert, 2015 and Lu et al., 2019). These studies point towards the possibility of cultural differences and their importance in shaping the individual’s behaviour. The interactions of shared beliefs, values, norms and language have a significant role in practicing psychotherapy (Jacob, 2013). Maximum studies reported in this review are from various countries. There are differences in western and eastern cultures, and each country has its own cultural endowment. Future researches using mindfulness-based paradigms will necessarily have to be tailored according to the individual and their sociocultural context.

Limitations and future recommendations

Few limitations of the review are that it did not include any unpublished literature, which could have added to the understanding of how mindfulness-based approaches work on suicidal behaviour. A formal meta-analytic review might supplement our preliminary analysis in vital and empirically sound ways. As is the case with all reviews, our assessment is susceptible to search bias. This systematic review strengthens our understanding of mindfulness-based approaches and their impact on suicidality. Further, due to the inclusion of studies from various regions, that is, America (N = 5), Europe (N = 4), Asia (N = 3) and Australia (N = 1), the cross-cultural aspects can be understood from this systematic review.

Given the new empirical research standards, the sample size of the many included studies is relatively small. More research with larger samples is required to understand the effect of mindfulness on suicidality. Future studies must look into understanding the specificity of treatment effects on suicidal behaviour. It can be understood promptly if an active control group is used along with MBIs. The choice of a validated outcome measure to assess suicidality will clarify the impact of the intervention on suicide. Future researches can make use of scales that assess suicidal outcomes to understand the treatment effects more aptly. Longitudinal studies might help understand the impact of MBIs on the recurrence of suicidal behaviour.

Conclusion

Based on the present systemic review, it can be concluded that mindfulness-based approaches are effective in reducing suicidal behaviour. It was also seen that MBIs have an impact on other psychological factors. These factors are extremely relevant as they influence suicidal cognitions. The review also mentions the methodological concerns such as sample size, design, treatment fidelity, use of active control and independent outcome measures that must be taken care of while implementing MBIs. It is suggested that studies can focus more on mindfulness-based strategies as preventive training procedures, especially in the non-clinical population.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Sunil K Verma

Tushar Singh

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