Beruflich Dokumente
Kultur Dokumente
Research paper
Institute of Medical Psychology and Medical Sociology, University Hospital of RWTH Aachen University, Germany
Department of Clinical Psychology and Psychotherapy, Berlin University of Psychology, Germany
Department of Clinical Psychology and Psychotherapy, Ruhr-Universitt Bochum, Germany
d
Department of Psychiatry and Psychotherapy, University of Freiburg, Germany
e
Department of Psychology and Psychotherapy, Witten/Herdecke University, Germany
b
c
art ic l e i nf o
a b s t r a c t
Article history:
Received 8 October 2015
Received in revised form
5 January 2016
Accepted 24 January 2016
Available online 19 April 2016
Background: Suicidal ideation (SI) is common in chronic depression, but only limited evidence exists for
the assumption that psychological treatments for depression are effective for reducing SI.
Methods: In the present study, the effects of Mindfulness-based Cognitive Therapy (MBCT; group version) plus treatment-as-usual (TAU: individual treatment by either a psychiatrist or a licensed psychotherapist, including medication when indicated) and Cognitive Behavioral Analysis System of Psychotherapy (CBASP; group version) plus TAU on SI was compared to TAU alone in a prospective, bi-center,
randomized controlled trial. The sample consisted of 106 outpatients with chronic depression.
Results: Multivariate regression analyses revealed different results, depending on whether SI was assessed via self-report (Beck Depression Inventory suicide item) or via clinician rating (Hamilton Depression Rating Scale suicide item). Whereas signicant reduction of SI emerged when assessed via
clinician rating in the MBCT and CBASP group, but not in the TAU group while controlling for changes in
depression, there was no signicant effect of treatment on SI when assessed via self-report.
Limitations: SI was measured with only two single items.
Conclusions: Because all effects were of small to medium size and were independent of effects from other
depression symptoms, the present results warrant the application of such psychotherapeutical treatment
strategies like MBCT and CBASP for SI in patients with chronic depression.
& 2016 Elsevier B.V. All rights reserved.
Keywords:
Mindfulness-based Cognitive Therapy
Cognitive Behavioral Analysis System of
Psychotherapy
Suicidal ideation
Chronic depression
Persistent depression
RCT
1. 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 fteen 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 2030% 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
n
Corresponding author.
E-mail address: tforkmann@ukaachen.de (T. Forkmann).
http://dx.doi.org/10.1016/j.jad.2016.01.047
0165-0327/& 2016 Elsevier B.V. All rights reserved.
52
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 specied outcome measure.
The pooled results indicated very small and non-signicant 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 signicant association between both, thus indicating that the
effect of treatments on suicidality was independent from the effect
on depression. In addition to the studies identied 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
signicantly 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 Mindfulnessbased 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 signicant effect of MBCT on depression but not
on SI. The effect size for the difference between pre- and posttreatment assessments of SI in the MBCT group was d 0.48. It
might be that this effect would have reached signicance in a
larger sample with sufcient power. Furthermore, in a sample of
patients with residual depressive symptoms, Forkmann et al.
(2014) found a signicant reduction in SI in a MBCT group (n 64),
whereas no signicant changes occurred in a wait-list controlgroup (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 signicant covariate of the specic
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 specic 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 Signicant Other History a list
consisting of signicant 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
2. Methods
2.1. Sample
All outpatients had a current major depressive episode (MDE)
as dened 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 antecedent dysthymic disorder), or (c) patients with current MDE as
part of a recurrent major depression with incomplete recovery
between episodes during the last two years (i.e., depressive
symptoms present during the entire two year period). They were
recruited either by media announcements or through community
health care facilities as well as private practices. Patients were
recruited at two different sites in Germany: the Ruhr megalopolis
and the area of Freiburg im Breisgau. Exclusion criteria that were
used in previous studies on MBCT were applied (e.g., Teasdale
et al., 2000): history of schizophrenia or schizoaffective disorder,
current substance abuse, eating disorder, organic mental disorder,
borderline personality disorder, unable to engage with treatment
for physical, practical, or other reasons. Patients with borderline
personality disorders were excluded because their style of interaction might be too difcult to deal with within the group format
of MBCT or CBASP. Mean age of the patients was 54.0 years
(SD 13.24, N 35, 65.7% female) in the TAU group, 50.2 years
(SD 10.5, N 35, 63.9% female) in the CBASP group, and 48.4
years (SD 11.5, N 36, 58.2% female) in the MBCT group. Further
characteristics of the sample and a CONSORT ow diagram illustrating patient ow are presented in detail elsewhere (Michalak
et al., 2015).
53
2.5. Measures
2.4. Treatments
2.3. Randomization
At each trial site, patients were randomly assigned to either
TAU or to receive in addition to TAU either MBCT or CBASP.
Block randomization (block size 6) to the three conditions was
performed by an independent allocator using a computer-generated list of random numbers. After patient eligibility was assessed
and informed consent was obtained, patients were formally enrolled in the study. Thirty-six patients were allocated to MBCT, 35
to CBASP, and 35 to TAU.
54
can also be seen in Fig. 1, signicant differences between treatment groups at baseline were found for the BDI suicide item (F
(2100) 4.30; p 0.02).
Paired-samples t-tests revealed that both MBCT and CBASP
reduced suicidal symptoms if measured with the HAMD suicide
item. Suicidality as measured with the BDI suicide item was signicantly reduced by MBCT but not by CBASP. Effect sizes (Cohen's
d) showed medium effects of MBCT on SI both measured with the
HAMD suicide item (d 0.30) and the BDI suicide item (d 0.34).
Moreover, MBCT reduced depression both measured with the
HAMD (d 0.38) and BDI (d 0.52). CBASP affected SI only when
measured with the HAMD suicide item (d 0.50) but not when
measured with the BDI suicide item (d 0.07). However, due to
signicantly lower scores on the BDI suicide item in the CBASP
group than in the MBCT group at baseline, this could be due to a
oor effect in the CBASP group. Again, effects on depression were
of medium size (HAMD: d 0.78; BDI: d 0.60). TAU showed virtually no effects on suicidality but on depression when measured
with the HAMD (d 0.35; Table 1).
et al., 2015; see also Beck et al., 1997). For the HAMD suicide item,
convergent validity has also been shown with the Adult Suicide
Ideation Questionnaire (Reynolds, 1991). Predictive validity of both
the BDI and the HAMD suicide item for later suicidal behavior has
been shown to be good (Brown et al., 2000).
2.6. Data analyses
Analyses were conducted on the intention to treat sample.
Missing data was accounted for by using the last observation
carried forward (LOCF). Analyses of variance (ANOVA) and 2 tests
were used to examine whether treatment groups differed on suicidality at baseline. We conducted paired-samples t-tests and
calculated Cohen's effect size d to analyse whether suicidality as
measured with the HAMD and BDI suicide items were lower after
treatment than at baseline within each single treatment group
(Cohen, 1988). In order to reduce sampling error, effect sizes have
been corrected using a factor provided by Hedges and Olkin
(1985). Multivariate linear regression analyses were used to test
for signicant differences in reduction of suicidal symptoms between the treatment groups (MBCT, CBASP) and TAU. Change in
suicidal symptoms measured with the HAMD and the BDI suicide
items were the dependent variables. For the predictor variables,
dummy variables were used for the MBCT and the CBASP groups
with TAU as reference condition. Analyses were controlled for
changes in depression (measured with the HAMD and BDI total
scores exclusive of the respective suicide items) (model 1). In a
secondary set of multivariate linear regression analyses, we compared the treatment conditions MBCT and CBASP directly to each
other. MBCT was the reference condition.
All analyses were performed using IBM SPSS statistics 20.
3. Results
3.1. 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 (2 .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 (2 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 (2 .75, p .69).
Means and standard deviations of the HAMD and the BDI suicide items and the HAMD and BDI total scores without the inclusion of the suicide items pre and post treatment are displayed
in Table 1. Baseline scores on the HAMD suicide item did not differ
between treatment groups (F(2103) 0.48; p 0.62). However, as
Table 1
Descriptive statistics and pre-post changes of suicidal ideation in the MBCT, CBASP and TAU group.
MBCT
CBASP
Posta
Pre
M
SD
TAU
Posta
Pre
SD
0.03
0.04
0.01
0.00
0.34
0.50 0.56
0.46 0.66
0.30
1.03 0.89
0.57 0.92
0.38 24.71 6.69 18.03 9.76
0.52 30.27 7.52 24.43 11.34
SD
Posta
Pre
SD
0.70
4.12
5.50
3.55
0.49
0.00
0.00
0.00
0.07
0.91
0.50
0.89
0.78 23.11
0.60 29.77
SD
SD
0.72
0.88
0.77
0.90
1.06 1.00
6.33 20.91
7.86
7.42 28.64 10.24
0.49
1.23
2.87
1.65
0.62
0.23
0.01
0.11
0.04
0.18
0.35
0.12
a
Missing data was accounted for by using the last observation carried forward (LOCF). MBCT: Mindfulness-based Cognitive Therapy; CBASP: Cognitive Behavioral
Analysis System of Psychotherapy; TAU: Treatment as usual; BDI: Beck Depression Inventory; HAMD: Hamilton Depression Rating Scale; M: mean; SD: standard deviation.
b
suicide item excluded.
55
Fig. 1. Change in suicidal ideation as measured with the BDI suicide item in the
different treatment conditions.
Fig. 2. Change in suicidal ideation as measured with the HAMD suicide item in the
different treatment conditions.
2: F(267)7.08, p o0.01).
4. 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 suicidality were not large and it remains an open question whether both
treatments have similar effects on suicidal behavior. Furthermore,
future research must show whether MBCT and CBASP aids in
preventing suicidal relapse.
A different picture emerged when suicidality was assessed via
self-report (BDI suicidality item). In the MBCT group, a signicant
reduction in suicidality was found. However, this effect vanished
by controlling for changes in depression. One might speculate
whether this could potentially be caused by multiple testing or
whether it could be interpreted in line with the common assumption that suicidality is just an epiphenomenon of depression.
In the CBASP group, no signicant change in suicidality was found
when assessed with the BDI suicidality item. This might be at least
partly due to a oor effect. In the CBASP group, suicidality was
signicantly lower than in the MBCT group at baseline which
might have precluded signicant effects in the CBASP group. When
comparing both treatments directly to each other no different
Table 2
Effects of MBCT and CBASP on change in HAMD and BDI suicide scores compared to TAU (model 1) and compared to each other (model 2).
Dependent variable: change in HAMD suicide score
Model 1
Model 2
SD
adj. R2
SD
adj. R2
Intercept
change in depression
MBCT vs. TAU
CBASP vs. TAU
0.33
0.05
0.39
0.44
0.12
0.01
0.16
0.17
2.77
4.50
2.46
2.66
0.01
0.00
0.02
0.01
0.24
0.02
0.04
0.05
0.13
0.10
0.01
0.13
0.13
0.52
0.04
0.10
0.18
5.91
0.36
1.00
0.86
0.00
0.72
0.32
0.26
0.40
0.24
0.27
Intercept
change in depression
CBASP vs. MBCT
0.11
0.04
0.09
0.12
0.01
0.16
0.97
3.07
0.58
0.33
0.00
0.56
0.12
0.10
0.03
0.27
0.09
0.01
0.12
0.40
0.25
1.08
3.51
2.19
0.28
0.00
0.03
0.15
0.36
0.07
Note: MBCT: Mindfulness-based Cognitive Therapy; CBASP: Cognitive Behavioral Analysis System of Psychotherapy; TAU: Treatment as usual; HAMD: Hamilton Depression
Rating Scale; BDI: Beck Depression Inventory.
56
included two single items, one self- and one clinician-rated item.
Power of analyses was reasonable for the comparison of the group
therapy conditions (MBCT TAU and CBASP TAU) with TAU
alone, but might have been insufcient for the direct comparison
of CBASP to MBCT (secondary analysis). Although some effort has
been invested to maintain blindness of the raters (i.e., patients
were instructed not to mention their treatment condition or their
psychotherapist during the interviews, ratings and therapy were
conducted in different buildings) there was no direct measure of
blindness. Strengths of the study are the randomized-controlled
design, the inclusion of a control group, and two active treatments.
4.2. Summary and conclusion
In conclusion, results of the present randomized-controlled
trial suggest that both MBCT and CBASP may be successful psychotherapeutic approaches for the group-based treatment of SI in
chronically depressed patients. Incremental effects of both treatments above the effect of TAU were dependent on the way suicidality was assessed (self- vs. clinician-rated) but were independent from changes in depression. Future research should try
to reveal variables that mediate or moderate the effects of MBCT
and CBASP on SI in order to facilitate a deeper understanding of
the clinical mechanisms of action. Because all effects were of small
to medium size and were independent of effects from other depression symptoms, the present results warrant the application of
such psychotherapeutical treatment strategies like MBCT and
CBASP for SI in patients with chronic depression.
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