Research paperThe Effects of Mindfulness‐Based Cognitive Therapy and Cognitive Behavioral Analysis System of Psychotherapy added to Treatment as Usual on suicidal ideation in chronic depression: Results of a randomized-clinical trial
Introduction
Suicide is among the 10 leading causes of death in most countries (WHO, 2014) and the number of suicide attempts is estimated to be up to fifteen times higher than the number of actual deaths by suicide (Borges et al., 2010). About 40% of individuals who died by suicide experienced depressive illness before their death (Arsenault-Lapierre et al., 2004). Chronic depression, which represents approximately 20–30% of all depressive disorders, is known to have a higher risk for suicide compared to acute, episodic depression (e.g. Torpey and Klein, 2008, Arnow et al., 2003). Suicidal ideation (SI) in chronic depression tends to have a chronic course, too. In a community-based cohort study, Young et al. (2008) found that 51% of all patients with a chronic depression reported persisting SI within a follow-up interval of 32 months, while only 32% received either appropriate medication or counseling.
Although it seems plausible to assume that psychological treatments for depression not only affect depressed affect but also SI, this assumption has lately been called into question (Cuijpers et al., 2013). Recent research suggests that suicidal thoughts and behavior are not merely a part or a symptom of a depressive disorder but represent a separate nosological entity (Ahrens and Linden, 1996, Ahrens et al., 2000, Forkmann et al., 2013, Kendel et al., 2010, Leboyer et al., 2005, Van Orden et al., 2011). Cuijpers et al. (2013) found in a recent meta-analysis only three randomized controlled studies for adult depression in which SI and suicidal behavior was used as a clearly specified outcome measure. The pooled results indicated very small and non-significant effects of psychotherapy for depression on suicidality, but there was not enough statistical power to consider this a true effect. Moreover, in a meta-regression analysis with the effect size on SI as dependent variable and the effect size on depression as predictor, they found no significant association between both, thus indicating that the effect of treatments on suicidality was independent from the effect on depression. In addition to the studies identified by Cuijpers et al. (2013) two recent studies investigated the effect of psychotherapy for depression on SI. Weitz et al. (2014) found that Interpersonal Therapy (IPT) had some effectiveness for reducing SI. However, this effect vanished when controlling for change in depression. A recent pilot study by Ducasse et al. (2014) demonstrated that Acceptance and Commitment Therapy (ACT), a “third wave” behavioral therapy including mindfulness elements might significantly reduce SI. However, its generalizability is limited due to a small sample size and the absence of a control group.
One further psychotherapeutic approach that may be a treatment option not only for depression but also for SI is Mindfulness-based Cognitive Therapy (MBCT; Segal et al., 2002) originally designed for relapse prevention of remitted patients with a Major Depressive Disorder (MDD). MBCT is a group-based program combining intensive training in meditative practices with cognitive-behavioral elements targeted at depression. MBCT as a treatment option for suicidality is based on the idea, that once a person has suffered a suicidal crisis, suicidal thoughts are likely to become reactivated as part of a suicidal mode of mind whenever sad mood reappears (Williams and Swales, 2004). MBCT may target this process by enabling people to adopt a different, more decentered relationship with their own thoughts, feelings and body sensations, thus preventing these experiences from launching a downward mood spiral that could otherwise lead to another suicidal crisis. Several studies have shown that MBCT can reduce the risk of depressive relapse/recurrence in formerly depressed patients (Piet and Hougaard, 2011). Moreover, Barnhofer et al. (2009) examined the effects of MBCT plus Treatment as Usual (TAU: continuation of current medication and appointments with mental health practitioners) in comparison to TAU alone in 28 patients suffering from chronic depression with a history of SI and suicidal behavior. Results suggested a significant effect of MBCT on depression but not on SI. The effect size for the difference between pre- and post-treatment assessments of SI in the MBCT group was d=0.48. It might be that this effect would have reached significance in a larger sample with sufficient power. Furthermore, in a sample of patients with residual depressive symptoms, Forkmann et al. (2014) found a significant reduction in SI in a MBCT group (n=64), whereas no significant changes occurred in a wait-list control-group (n=66) by comparing baseline and post treatment assessments. This interaction effect was independent from the impact of changes in depression, rumination, and mindfulness skills. However, change in worry was a significant covariate of the specific reduction of suicidality in the MBCT group as compared to the control group. Yet, it remains unclear whether this effect holds true for a sample of chronic depressed patients.
A specific psychotherapeutic model that has been proposed as being effective for the treatment of chronic depression is the Cognitive Behavioral Analysis System of Psychotherapy (CBASP; McCullough, 2000). Concerning suicidality, the CBASP therapist received special techniques to deal and cope with suicidal behavior. With the background of the Significant Other History – a list consisting of significant persons and their impact on the patient's life – the patient and the therapist could get a deeper understanding of the suicidal thoughts and behavior (f. ex.: Because my father wanted to perform an abortion, I am feeling unwanted and tired of life). By using the Disciplined Personal Involvement, suicidal patients can learn that their suicidal thoughts and plans authentically concern and worry the therapist (such as: That you are thinking about killing yourself, really worries and shocks me). While using the Interpersonal Discrimination Exercise suicidal patients can realize that the therapist reacts mostly different in comparison with the significant others who for example have ignored or punished suicidal behavior. In addition, by conducting Situational Analysis with situations where suicidal thoughts or behavior appear patients could learn reconstructing suicidal thoughts and behavior to overcome helplessness and hopelessness and to reach their positive desired outcomes (f. ex. instead of withdrawal and suicidal thoughts or behavior asking for help). CBASP was originally developed for individual sessions. In recent years, it has been modified for inpatient settings and group formats (Brakemeier and Normann, 2012, Schramm et al., 2012).
In most of the outpatient studies CBASP proved to be an effective treatment, especially in combination with medication (Keller et al., 2000), in patients with childhood trauma (Nemeroff et al., 2003), early onset (Schramm et al., 2011), and with a long duration of treatment (Wiersma et al., 2014). In addition, in an open study with 70 treatment-resistant chronically depressed inpatients, the CBASP inpatient program significantly reduced depression severity between pre- and posttreatment assessments with strong effect sizes and high response rates (Brakemeier et al., 2011, Brakemeier et al., 2015). In a reanalysis of this study, suicidality as measured with the respective items of the Hamilton Depression Rating Scale (HAMD) and of the Beck Depression Inventory (BDI) was significantly reduced after the inpatient treatment and still after 6 and 12 months (Brakemeier, 2014).
The current study is a secondary analysis of a randomized controlled trial on the effect of MBCT and CBASP group treatment on depressive symptomatology in chronic depression conducted at two treatment sites (trial number NCT01065311; Michalak et al., 2015). The primary analysis has shown that in the overall sample as well as at one treatment site, MBCT was no more effective than TAU in reducing depressive symptoms, while it was significantly superior to TAU at the other treatment site. CBASP was significantly more effective than TAU in reducing depressive symptoms in the overall sample and at both treatment sites. However, it has to be noted that the analysis of differences between sites was a subsidiary question and it has to be kept in mind that statistical power for the interpretation of differences between sites is limited. The direct comparison of the effects of MBCT and CBASP revealed no significant difference but only a statistical trend favoring CBASP over MBCT. Both treatments had only small to medium effects on social functioning and quality of life.
The primary aim of the present investigation was to examine the effects of MBCT and CBASP – both conducted in the format of a group therapy – on SI compared to a TAU condition in chronic depressed patients while controlling for changes in other depressive symptoms. On the supposition that suicide behavior lies on a continuum from ideation through intent and planning to action, it seems appropriate to choose SI as the dependent variable of interest.
Section snippets
Sample
All outpatients had a current major depressive episode (MDE) as defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 2001) and experienced depressive symptoms for more than 2 years without remission. We included three subtypes of depressed patients: (a) patients with chronic major depression (i.e., current MDE lasting for more than two years); (b) patients meeting criteria for double depression (current MDE superimposed on an
Primary outcome analyses
According to the HAMD suicide item, 61.1% of the participants showed any kind of SI in the MBCT group, 65.7% in the CBASP group and 62.9% in the TAU group (χ2=.16, p=.92). According to the BDI suicide item, 77.8% of the participants in the MBCT group reported any kind of SI, 47.1% in the CBASP group and 75.8% in the TAU group (χ2=9.15, p=.01). In the MBCT group, 5 participants reported one or more past suicide attempt, in the CBASP group 8 and in the TAU group 6 (χ2=.75, p=.69).
Means and
Discussion
The results of the present study showed that both MBCT added to TAU and CBASP added to TAU have an additional effect on suicidality when measured with the HAMD suicide item. This effect was robust when controlling for changes in other depression symptoms. Sizes of the effects of MBCT and CBASP on suicidality were similar to those reported in prior studies (Barnhofer et al., 2009, Forkmann et al., 2014). However, it has to be noted that despite being robust, these effects of MBCT and CBASP on
Trial registration and funding
This trial was registered (NCT01065311) and was funded by the German Science Foundation (DFG: Mi 700/4-1).
References (56)
- et al.
Suicidal behavior - symptom or disorder?
Compr. Psychiatr.
(2000) - et al.
Assessing measures of suicidal ideation in clinical trials with a rapid-acting antidepressant
J. Psychiatr. Res.
(2015) - et al.
Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study
Behav. Res. Ther.
(2009) - et al.
Psychometric characteristics of the Scale for Suicide Ideation with psychiatric outpatients
Behav. Res. Ther.
(1997) - et al.
The effects of psychotherapy for adult depression on suicidality and hopelessness: a systematic review and meta-analysis
J. Affect. Disord.
(2013) - et al.
Dimensional assessment of depressive severity in the elderly general population: psychometric evaluation of the PHQ-9 using Rasch Analysis
J. Affect. Disord.
(2013) - et al.
Effects of mindfulness-based cognitive therapy on self-reported suicidal ideation: results from a randomised controlled trial in patients with residual depressive symptoms
Compr. Psychiatry
(2014) - et al.
Screening for depression: rasch analysis of the dimensional structure of the PHQ-9 and the HADS-D
J. Affect. Disord.
(2010) - et al.
Psychosocial characteristics of adolescents with a history of suicide attempt
J. Am. Acad. Child Psychiatry
(1993) - et al.
Comparison of the standard and structured interview guide for the Hamilton Depression Rating Scale in depressed geriatric inpatients
Am. J. Geriat. Psychiatry
(2001)
The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis
Clin. Psychol. Rev.
Sensitivity to detect change and the correlation of clinical factors with the Hamilton Depression Rating Scale and the Beck Depression Inventory in depressed inpatients
Psychiatry Res.
Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: a randomized pilot study
J. Affect. Disord.
Do depression treatments reduce suicidal ideation? The effects of CBT, IPT, pharmacotherapy, and placebo on suicidality
J. Affect. Disord.
Is there a suicidality syndrome independent of specific major psychiatric disorder? Results of a split half multiple regression analysis
Acta Psychiatr. Scand.
Diagnostic & Statistical Manual of Mental Disorders
Therapeutic reactance as a predictor of outcome in the treatment of chronic depression
J. Consult. Clin. Psychol.
Psychiatric diagnoses in 3275 suicides: a meta-analysis
BMC Psychiatry
Manual for the Beck Depression Inventory
Twelve-month prevalence of and risk factors for suicide attempts in the World Health Organization World Mental Health Surveys
J. Clin. Psychiatry
Feasibility and outcome of cognitive behavioral analysis system of psychotherapy (CBASP) for chronically depressed inpatients: a pilot study
Psychother. Psychosom.
Praxisbuch CBASP. Behandlung chronischer Depression
Overcoming treatment-resistance in chronic depression: outcome and feasibility of the Cognitive Behavioral Analysis System of Psychotherapy as an inpatient treatment program
Psychother. Psychosom.
Risk factors for suicide in psychiatric outpatients: a 20-year prospective study
J. Consult. Clin. Psychol.
Statistical Power for the Behavioural Science
Acceptance and Commitment Therapy for management of suicidal patients: a pilot study
Psychother. Psychosom.
A rating scale for depression
J. Neurol. Neurosurg. Psychiatry
Cited by (23)
Implementing mindfulness-based cognitive therapy on dynamics of suicidal behavior: Understanding the efficacy and challenges
2023, Handbook of Cognitive Behavioral Therapy by Disorder: Case Studies and Application for AdultsSuicidal behaviors are associated with loneliness and decrease during inpatient CBASP treatment for persistent depressive disorder
2022, Journal of Psychiatric ResearchCitation Excerpt :However, the effects of psychotherapy on SIB for PDD have not been investigated to the same extent as for BPD. One study showed outpatient CBASP treatment to reduce suicidal ideation (SI) as measured by the suicide specific item of the Hamilton Rating Scale for Depression (Forkmann et al., 2016). So far, effects of CBASP on specific characteristics of SI and on suicidal behavior (SB) in PDD were not reported and underlying risk factors for SIB in PDD remain unknown.
Machine learning methods for developing precision treatment rules with observational data
2019, Behaviour Research and TherapyCitation Excerpt :There is reason to believe based on the results of previous studies reviewed elsewhere (Kessler et al., 2019) that such models would find a substantial proportion of patients with such low SRB risk that they could reasonably be spared the burden of being subjected to more active suicide risk assessments; In a second tier, structured self-report suicide risk scales could be administered to the remaining patients for purposes of developing a second-tier ML prediction model designed to determine which of the remaining patients have a sufficiently high SRB risk to be considered for one of the special intensive types of psychotherapy (Jobes et al., 2017; Linehan et al., 2015; Rudd, 2012; Tighe, Nicholas, Shand, & Christensen, 2018) or combination therapies (Chesin et al., 2018; Forkmann, Brakemeier, Teismann, Schramm, & Michalak, 2016) known to have significant aggregate effects in reducing SRB. Numerous scales of this sort exist (Greist, Mundt, Gwaltney, Jefferson, & Posner, 2014; Quinlivan et al., 2016; Runeson et al., 2017).
Mindfulness-based interventions for major depressive disorder: A comprehensive meta-analysis of randomized controlled trials
2018, Journal of Affective DisordersCitation Excerpt :The follow-up duration was 12 months in one RCT (Manicavasagar et al., 2012), but only data at 6 months assessment were extracted in order to reduce the heterogeneity of the study duration. Two studies (Chiesa et al., 2015; Forkmann et al., 2016) reported both HAMD scores and BDI/BDI-II scores; in order to avoid inter-dependence, only HAMD scores were extracted. One RCT (Forkmann et al., 2016) had 3 study arms (2 control arms and one MBCT group); in order to not inflate the number of patients in the MBCT group we assigned half of MBCT group to each control arms.
Temporal relationships between changes in depression and suicidal ideation: A mediation analysis in a randomized double-blinded clinical trial
2023, Psychology and Psychotherapy: Theory, Research and Practice