Can We Walk The Talk About Preventing Suicide?

I may have to rethink my resolve not to practice what I call the Walking Dead Meditation. I know I’ve made fun of it and, of course, the real name is the Walking Meditation. I learned about it in my Mindfulness-Based Stress Reduction (MBSR) class. It could be a great way to deepen my mindfulness practice given the often high stress level of my work.

In fact, I rediscovered what Jon Kabat-Zinn wrote about Walking Meditation in his book on mindfulness, “Full Catastrophe Living,” because I’m rereading my copy of it,  which I bought about 10 years ago and didn’t get much out of at the time [1]. In the book he describes it and admits that it looks pretty weird, suggesting that you practice it in private so people don’t get the wrong idea and suggest you seek psychiatric help.

Actually what I learned in class is that you can eventually learn to practice mindful walking without looking weird, although Kabat-Zinn also mentions a technique called Crazy Walk, which involves walking in random directions, even backwards, bumping into others, almost cartoon-like.

However, the general idea is that Walking Meditation is just another way to pay attention, although it’s not very much like simply going for a walk.

The reason this issue is arising is that, in my role as a general hospital psychiatric consultant, I do a great deal of walking all over our academic medical center, and it seems I’ve been walking to the intensive care units (ICUs) a lot more frequently over the last several years, sadly to assess suicide risk of patients who’ve ingested medications and other drugs in apparent suicide attempts.

It’s very painful. But the patients I see are alive to tell about their experience, giving me an opportunity to help them. My walks to the ICU can be accompanied by all sorts of speculations, questions, doubts, memories, and anxieties. A little mindfulness couldn’t hurt.

And pursuant to that, I just recently saw the news about reports suggesting a significant uptick in the occurrence rates of drug-related suicide attempts in the past few years, which tends to validate my clinical impression.

A related news report was relayed to me by colleagues, along with some other perspectives on suicide that led to important reflections. Can a blood test help predict suicide? I don’t know, but we’d all love to have something like it because of the suffering it causes to those who eventually commit suicide, and the devastating effect suicide has on all those who are left behind when someones takes his or her own life. If a blood test could predict suicidality with 80% accuracy, I would certainly welcome it [2].

However, there’s a fair amount of criticism of the test across the web, even suggesting that it’s not very good science. My colleagues here have conducted critically important research in this area. Between 1975-1991, they published 17 papers in major peer-reviewed journals. The results swing in different directions, sending hopes skyward one year and plummeting back to earth the next [3,4].

It made me wonder whether there is any way to predict suicide, as was concluded many years ago [5].

It also makes me wonder whether what’s being done with mindfulness research which could point the way out of the laboratory maze. In fact, there is some work indicating it might make sense to focus at least some energy on teaching people to care for themselves and influence the tendency to suicidality by teaching them to pay more non-judgemental attention to their bodies, thoughts, and emotions. It has risks, among them the possibility it could promote rumination, although there could also be considerable benefits as well [6,7].

Maybe we should be mindful of all of the resources we can bring to bear on the challenge of suicidality.

References:

1. Kabat-Zinn, J. and University of Massachusetts Medical Center/Worcester. Stress Reduction Clinic. (1991). Full catastrophe living : using the wisdom of your body and mind to face stress, pain, and illness. New York, N.Y., Pub. by Dell Publishing, a division of Bantam Doubleday Dell Pub. Group.

2. Guintivano, J., et al. (2014). “Identification and Replication of a Combined Epigenetic and Genetic Biomarker Predicting Suicide and Suicidal Behaviors.” Am J Psychiatry.
Objective: Reliable identification of individuals at high risk for suicide is a priority for suicide prevention. This study was conducted to identify genes exhibiting epigenetic variation associated with suicide and suicidal behaviors. Method: Genome-wide DNA methylation profiling was employed separately on neuronal and glial nuclei in a discovery set of postmortem brains from the National Institute of Child Health and Human Development to identify associations with suicide. Pyrosequencing-based validation was conducted in prefrontal cortical tissue in cohorts from the Stanley Medical Research Institute and Harvard Brain Bank at McLean Hospital and peripheral blood from three living groups. Functional associations with gene expression, stress and anxiety, and salivary cortisol were assessed. Results: The DNA methylation scan identified an additive epigenetic and genetic association with suicide at rs7208505 within the 3′ untranslated region of the SKA2 gene independently in the three brain cohorts. This finding was replicated with suicidal ideation in blood from three live cohorts. SKA2 gene expression was significantly lower in suicide decedents and was associated with genetic and epigenetic variation of rs7208505, possibly mediated by interaction with an intronic microRNA, miR-301a. Analysis of salivary cortisol measurements suggested that SKA2 epigenetic and genetic variation may modulate cortisol suppression, consistent with its implicated role in glucocorticoid receptor transactivation. SKA2 significantly interacted with anxiety and stress to explain about 80% of suicidal behavior and progression from suicidal ideation to suicide attempt. Conclusions: These findings implicate SKA2 as a novel genetic and epigenetic target involved in the etiology of suicide and suicidal behaviors.

3. Coryell, W. and M. Schlesser (2001). “The dexamethasone suppression test and suicide prediction.” Am J Psychiatry 158(5): 748-753.
OBJECTIVE: Despite the substantial risks of eventual suicide associated with major depressive disorder, clinicians lack robust predictors with which to quantify these risks. This study compared the validity of demographic and historical risk factors with that of the dexamethasone suppression test (DST), a clinically practical measure of hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis. METHOD: Seventy-eight inpatients with Research Diagnostic Criteria major depressive disorder or schizoaffective disorder, depressed type, entered a long-term follow-up study between 1978 and 1981, and, in addition, underwent a 1-mg DST. The number of suicides in this group during a 15-year follow-up period was determined, and the predictive validity of four demographic and historical risk factors reported in the literature to be consistently predictive of suicide in depressed patients was compared to the predictive validity of the DST results. RESULTS: Thirty-two of the 78 patients had abnormal DST results. Survival analyses showed that the estimated risk for eventual suicide in this group was 26.8%, compared to only 2.9% among patients who had normal DST results. None of the demographic and historical risk factors examined in the study significantly distinguished those who later committed suicide from those who did not. CONCLUSIONS: In efforts to predict and prevent suicidal behavior in patients with major depressive disorder, HPA-axis hyperactivity, as reflected in DST results, may provide a tool that is considerably more powerful than the clinical predictors currently in use. Research on the pathophysiology of suicidal behavior in major depressive disorder should emphasize the HPA axis and its interplay with the serotonin system.

4. Black, D. W., et al. (2002). “The relationship between DST results and suicidal behavior.” Ann Clin Psychiatry 14(2): 83-88.
The authors assessed the relationship between dexamethasone suppression test (DST) results and suicidal ideations and behavior. Four-hundred-twenty-three mood disorder patients admitted to a tertiary care medical center were administered the DST from 1978 to 1981. The patients were subsequently followed up to determine death status using a record-linkage method. More than 44% had abnormal cortisol suppression (nonsuppressors) at the index admission. Suppressors and nonsuppressors did not differ significantly with respect to frequency of suicidal ideations or completed suicides. Suppressors were significantly more likely than nonsuppressors to have a history of suicide attempts or to have a suicide attempt following hospital discharge. Using logistic regression, and controlling for several important variables including diagnosis, maximum postdexamethasone cortisol was not significantly associated with suicide, suicidal ideation, or suicide attempts. We conclude that an abnormal DST is not useful as a predictor of suicidal behavior.

5. Goldstein, R. B., et al. (1991). “The prediction of suicide: Sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders.” Archives of General Psychiatry 48(5): 418-422.
• Stepwise multiple logistic regression was utilized in an attempt to develop a statistical model that would predict suicide in a group of 1906 lowans with affective disorders admitted to a tertiary care hospital. The risk factors identified by this approach included the number of prior suicide attempts, suicidal ideation on admission, bipolar affective disorder (manic or mixed type), gender, outcome at discharge, and unipolar depressive disorder in individuals with a family history of mania. However, the model failed to identify any of the patients who committed suicide. The results appear to support the contention that, based on present knowledge, it is not possible to predict suicide, even among a high-risk group of inpatients.

6. Mark, J., et al. (2004). “The Use of Mindfulness-Based Approaches for Suicidal Patients.” Archives of Suicide Research 8(4): 315-329.
7. Williams, J. M. G., et al. (2006). “Mindfulness-Based cognitive therapy for prevention of recurrence of suicidal behavior.” Journal of Clinical Psychology 62(2): 201-210.
Once suicidal thoughts have emerged as a feature of depression they are likely to be reactivated as part of a suicidal mode of mind whenever sad mood reappears. This article reviews the methods and the usefulness of mindfulness-based cognitive therapy (MBCT) as a treatment for the prevention of the reactivation of the suicidal mode. MBCT integrates mindfulness meditation practices and cognitive therapy techniques. It teaches participants to develop moment-by-moment awareness, approaching ongoing experience with an attitude of nonjudgment and acceptance. Participants are increasingly able to see their thoughts as mental events rather than facts (metacognitive awareness). A case example illustrates how mindfulness skills develop with MBCT and how they relate to the cognitive processes that fuel suicidal crises. An ongoing controlled trial will provide further evidence, but pilot work suggests that MBCT is a promising intervention for those who have experienced suicidal ideation in the past. © 2005 Wiley Periodicals, Inc. J Clin Psychol: In Session 62: 201–210, 2006.

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