Mindfulness-Based Cognitive Therapy for Preventing Suicide in Military Veterans: A Randomized Clinical Trial

Alejandro Interian, PhD; Megan S. Chesin, PhD; Barbara Stanley, PhD; Miriam Latorre, PsyD; Lauren M. St. Hill, LSW; Rachael B. Miller, LCSW; Arlene R. King, PhD; Dianna R. Boschulte, PhD; Kailyn M. Rodriguez, BA; Anna Kline, PhD

J Clin Psychiatry 2021;82(5):20m13791

ABSTRACT

Objective: This study evaluated whether Mindfulness-Based Cognitive Therapy for Preventing Suicide Behavior (MBCT-S) effectively augmented treatment-as-usual enhanced for suicide prevention (eTAU).

Methods: From December 2013 through March 2018, veterans (N = 140) at high risk for suicide were recruited mostly (88.6%) during a suicide-related inpatient admission and randomly assigned to either (1) eTAU augmented with MBCT-S or (2) eTAU only. MBCT-S began during inpatient treatment (2 individual sessions emphasizing safety planning) and continued post-discharge (8 group sessions emphasizing mindfulness skills and elaborated safety planning). Four follow-up evaluations occurred over 12 months, and primary outcomes were (1) time to suicide event and (2) number of suicide events. Secondary outcomes were time to and number of suicide attempts, proportion with acute psychiatric hospitalization, and change in suicide-related factors (eg, depression, hopelessness, suicidal ideation).

Results: Relative to eTAU, MBCT-S did not significantly delay time to suicide event (hazard ratio = 0.86; 95% CI, 0.52–1.41; P = .54), but did reduce total number of suicide events (MBCT-S: 56 events; eTAU: 92 events; incident rate ratio = 0.59; 95% CI, 0.36-0.99; P < .05). There were no significant differences in time to or number of suicide attempts. In a post hoc analysis, however, MBCT-S significantly reduced the proportion of participants attempting suicide (P < .05). MBCT-S also reduced the proportion with a psychiatric hospitalization. No significant between-group differences emerged on any suicide-related factors.

Conclusions: Adding MBCT-S to system-wide suicide prevention efforts produced mixed findings on the primary outcome (suicide events) and promising findings on other important outcomes (suicide attempts, psychiatric hospitalizations). MBCT-S should continue to be examined in future research.

Trial Registration: ClinicalTrials.gov identifier: NCT01872338

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References (51)

Centers for Disease Control and Prevention. Suicide rising across the US. CDC Vital Signs. 2018. https://www.cdc.gov/vitalsigns/suicide/index.html
Office of Mental Health and Suicide Prevention. National Veteran Suicide Prevention Annual Report; 2019. US Department of Veterans Affairs. https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf
Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3(7):646–659. PubMed CrossRef
Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563–570. PubMed CrossRef
Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757–766. PubMed CrossRef
Stanley B, Brown GK, Brenner LA, et al. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry. 2018;75(9):894–900. PubMed CrossRef
Peterson K, Anderson J, Bourne D. Evidence Brief: Suicide Prevention in Veterans Supplemental Materials. 2018. US Department of Veterans Affairs. https://www.hsrd.research.va.gov/publications/esp/suicide-prevention-brief-exec.pdf
Bagley SC, Munjas B, Shekelle P. A systematic review of suicide prevention programs for military or veterans. Suicide Life Threat Behav. 2010;40(3):257–265. PubMed CrossRef
Rudd MD, Bryan CJ, Wertenberger EG, et al. Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry. 2015;172(5):441–449. PubMed CrossRef
Bryan CJ, Mintz J, Clemans TA, et al. Effect of crisis response planning vs contracts for safety on suicide risk in US Army Soldiers: a randomized clinical trial. J Affect Disord. 2017;212:64–72. PubMed CrossRef
Goodman M, Banthin D, Blair NJ, et al. A randomized trial of dialectical behavior therapy in high-risk suicidal Veterans. J Clin Psychiatry. 2016;77(12):e1591–e1600. PubMed CrossRef
Stanley B, Mann JJ. The need for innovation in health care systems to improve suicide prevention. JAMA Psychiatry. 2020;77(1):96–98. PubMed CrossRef
Valenstein M, Kim HM, Ganoczy D, et al. Higher-risk periods for suicide among VA patients receiving depression treatment: prioritizing suicide prevention efforts. J Affect Disord. 2009;112(1–3):50–58. PubMed CrossRef
Luxton DD, Trofimovich L, Clark LL. Suicide risk among US Service members after psychiatric hospitalization, 2001–2011. Psychiatr Serv. 2013;64(7):626–629. PubMed CrossRef
Forman EM, Berk MS, Henriques GR, et al. History of multiple suicide attempts as a behavioral marker of severe psychopathology. Am J Psychiatry. 2004;161(3):437–443. PubMed CrossRef
Chesin MS, Sonmez CC, Benjamin-Phillips CA, et al. Preliminary effectiveness of adjunct mindfulness-based cognitive therapy to prevent suicidal behavior in outpatients who are at elevated suicide risk. Mindfulness. 2015;6(6):1345–1355. CrossRef
Williams JMG, Duggan DS, Crane C, et al. Mindfulness-based cognitive therapy for prevention of recurrence of suicidal behavior. J Clin Psychol. 2006;62(2):201–210. PubMed CrossRef
Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cognit Behav Pract. 2012;19(2):256–264. CrossRef
Kline A, Chesin M, Latorre M, et al. Rationale and study design of a trial of Mindfulness-Based Cognitive Therapy for Preventing Suicidal Behavior (MBCT-S) in military veterans. Contemp Clin Trials. 2016;50:245–252. PubMed CrossRef
Chesin M, Interian A, Kline A, et al. Reviewing mindfulness-based interventions for suicidal behavior. Arch Suicide Res. 2016;20(4):507–527. PubMed CrossRef
Williams J, Van der Does A, Barnhofer T, et al. Cognitive reactivity, suicidal ideation and future fluency: preliminary investigation of a differential activation theory of hopelessness/suicidality. Cognit Ther Res. 2008;32(1):83–104. CrossRef
Kuyken W, Watkins E, Holden E, et al. How does mindfulness-based cognitive therapy work? Behav Res Ther. 2010;48(11):1105–1112. PubMed CrossRef
Chesin MS, Benjamin-Phillips CA, Keilp J, et al. Improvements in executive attention, rumination, cognitive reactivity, and mindfulness among high–suicide risk patients participating in adjunct mindfulness-based cognitive therapy: preliminary findings. J Altern Complement Med. 2016;22(8):642–649. PubMed CrossRef
van der Velden AM, Kuyken W, Wattar U, et al. A systematic review of mechanisms of change in mindfulness-based cognitive therapy in the treatment of recurrent major depressive disorder. Clin Psychol Rev. 2015;37:26–39. PubMed CrossRef
Grassia M, Gibb BE. Rumination and lifetime history of suicide attempts. Int J Cogn Ther. 2009;2(4):400–406. PubMed CrossRef
Mann JJ, Arango VA, Avenevoli S, et al. Candidate endophenotypes for genetic studies of suicidal behavior. Biol Psychiatry. 2009;65(7):556–563. PubMed CrossRef
Keilp JG, Gorlyn M, Russell M, et al. Neuropsychological function and suicidal behavior: attention control, memory and executive dysfunction in suicide attempt. Psychol Med. 2013;43(3):539–551. PubMed CrossRef
Posner K, Brodsky B, Yershova KV, et al. The classification of suicidal behavior. In: Nock MK, ed. The Oxford Handbook of Suicide and Self-Injury. Oxford: Oxford University Press; 2014:7–22.
Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(suppl 20):22–33, quiz 34–57. PubMed
Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266–1277. PubMed CrossRef
Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol. 1979;47(2):343–352. PubMed CrossRef
Beck AT, Steer RA, Brown G. Manual for the Beck Depression Inventory–II. San Antonio, TX: Psychological Coorporation; 1996.
Beck A, Steer R. Beck Hopelessness Scale: Manual. San Antonio, TX: Psychological Corp; 1993.
Stanley B, Green KL, Ghahramanlou-Holloway M, et al. The construct and measurement of suicide-related coping. Psychiatry Res. 2017;258:189–193. PubMed CrossRef
Simons JS, Gaher RM. The Distress Tolerance Scale: development and validation of a self-report measure. Motiv Emot. 2005;29(2):83–102. CrossRef
Interian A, Chesin M, Kline A, et al. Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) to classify suicidal behaviors. Arch Suicide Res. 2018;22(2):278–294. PubMed CrossRef
Matarazzo BB, Clemans TA, Silverman MM, et al. The self-directed violence classification system and the Columbia Classification Algorithm for suicide assessment: a crosswalk. Suicide Life Threat Behav. 2013;43(3):235–249. PubMed CrossRef
Interian A, Chesin M, Kline A, et al. Coping with suicidal urges: an important factor for suicide risk assessment and intervention. Arch Suicide Res. 2021;25(2):224–237. PubMed CrossRef
Zvolensky MJ, Vujanovic AA, Bernstein A, et al. Distress tolerance: theory, measurement, and relations to psychopathology. Curr Dir Psychol Sci. 2010;19(6):406–410. PubMed CrossRef
Katz I. Lessons learned from mental health enhancement and suicide prevention activities in the Veterans Health Administration. Am J Public Health. 2012;102(suppl 1):S14–S16. PubMed CrossRef
Segal Z, Williams J, Teasdale J. Mindfulness-Based Cognitive Therapy for Depression. 2nd ed. New York: Guilford Press; 2013.
Johnson LL, O’Connor SS, Kaminer B, et al. Suicide-focused group therapy for veterans. Mil Behav Health. 2014;2(4):327–336. CrossRef
Bishop SR, Lau M, Shapiro S, et al. Mindfulness: a proposed operational definition. Clin Psychol Sci Pract. 2004;11(3):230–241. CrossRef
Woods SL, Rockman P, Collins E. Mindfulness-Based Cognitive Therapy: Embodied Presence and Inquiry in Practice. Oakland, CA: New Harbinger Publications; 2019.
Latorre M, Chesin M, Zanetich K, et al. Mindfulness-Based Cognitive Therapy for Individuals at Risk of Suicide: Therapist Manual. VA New Jersey Healthcare System; 2013.
Segal ZV, Teasdale JD, Williams JM, et al. The mindfulness-based cognitive therapy adherence scale: inter-rater reliability, adherence to protocol and treatment distinctiveness. Clin Psychol Psychother. 2002;9(2):131–138. CrossRef
Williams JMG, Crane C, Barnhofer T, et al. Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: a randomized dismantling trial. J Consult Clin Psychol. 2014;82(2):275–286. PubMed CrossRef
Teasdale JD, Segal ZV, Williams JMG, et al. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol. 2000;68(4):615–623. PubMed CrossRef
Lizardi D, Stanley B. Treatment engagement: a neglected aspect in the psychiatric care of suicidal patients. Psychiatr Serv. 2010;61(12):1183–1191. PubMed CrossRef
Olfson M, Marcus SC, Bridge JA. Focusing suicide prevention on periods of high risk. JAMA. 2014;311(11):1107–1108. PubMed CrossRef
Hoge CW. Suicide reduction and research efforts in service members and veterans—sobering realities. JAMA Psychiatry. 2019;76(5):464–466. PubMed CrossRef