The incidence of mental illness is pervasive in the United States, a recent estimate suggesting it impacts more than one in five adults (NIMH, 2023). While “mental illness” is a category that embodies all diagnoses, a subset of this category, serious mental illness (i.e., schizophrenia spectrum and other psychotic disorders, major depressive disorder, bipolar disorder) receives considerable empirical attention due to significant associations of persistent psychosocial and functional impairment (Martínez-Martínez et al., 2020). According to recent data, approximately 5.5% of all adults (≥ 18 years old) in the United States reported SMI. Moreover, the prevalence of SMI varies across age and self-identified gender; SMI was reported to be higher among females (7.0%) compared to males (4.0%) and elevated among young adults (age 18-25; 11.4%) compared to older age groups (NIMH, 2023).
Suicide and SMI: The Impact of Experiencing Trauma
Suicidality (i.e., suicidal thoughts and behaviors) is considered a serious public health issue; prior to the COVID-19 pandemic, suicide was indicated among the top ten leading causes of death among adults (Xu et al., 2021). While suicidality is prevalent in the general population, extensive literature suggests suicidality (in particular, death by suicide) to be disproportionately common among individuals with SMI (Yates et al., 2019). Given this significant discrepancy, it is vital to explore mechanisms which may posit risk of suicidality among individuals with SMI to adequately inform prevention efforts (Edgcomb et al., 2021). One of the mechanisms that has been suggested to influence suicidality in various populations (including individuals with SMI) is trauma exposure and subsequent posttraumatic stress symptoms (PTSS) (Tarrier & Picken, 2011).
Individuals who die by or attempt suicide reported elevated rates of exposure to traumatic events (e.g., physical and sexual violence, accidents, natural disasters, serious injury and harm, etc.) and PTSS, underscoring the importance of a trauma-informed approach to suicide prevention (Harford, Yi, & Grant, 2014; Krysinska & Lester, 2010). Although exposure to traumatic experiences is relatively prevalent in the general population (Knipsheer et al., 2020) individuals with SMI disproportionately report more traumatic experiences and subsequent PTSS (Grubaugh et al., 2011). Along these lines, research suggests the experience of psychosis is in itself traumatic as it often involves significant distress due to symptoms of (often personalized) hallucinations and paranoid delusions in addition to external stressors of hospitalization (Bendall et al., 2008; Berry et al., 2013). Given the increased risk of trauma exposure and subsequent PTSS in addition to suicidality, (trauma-informed) interventions to target symptoms of PTSS may be especially beneficial to those with SMI. Despite, research in this area is nascent (as treatment studies have typically excluded individuals with SMI), studies of those with SMI have found that evidence-based treatments (i.e., Cognitive Restructuring, Prolonged Exposure and Eye Movement Desensitization and Reprocessing; van den Berg et al., 2015) targeting PTSS to be efficacious in reducing symptomology. However, there are often barriers (e.g., cost, time, etc.) to training and implementation of these treatments.
Can Implementing Mindfulness Alleviate PTSS and Suicidality Among Individuals with SMI?
Literature has implicated mindfulness, a therapeutic practice promoting present-moment awareness, self-compassion and nonjudgment of inner experiences (i.e., emotions, cognitions, physiological sensations, etc.) to be especially suitable in acute inpatient settings due to its short-term adaptability, feasibleness and effectiveness of targeting cognitions and behaviors associated with psychiatric crisis (Jacobson et al., 2011). Moreover, mindfulness-based interventions have been utilized as an adjunct to traditional PTSS-treatment in effort to mitigate PTSS and suicide risk (Cheng et al., 2018). Along these lines, facets of mindfulness (specifically, acting with awareness and nonjudgment of inner experiences) have been shown to be negatively associated with PTSD-related mechanisms specifically implicated in increasing suicide risk, such as avoidance and hyperarousal (Stanley et al., 2019). Given these interventions are suggested to be effective in reducing PTSS and suicidality, could these findings be applied to individuals with SMI?
Indeed, mindfulness-based interventions has its advantages (e.g., feasible, short-term and acceptable) in treating trauma-related symptoms and suicidality in various clinical populations, including inpatient (a treatment setting in which individuals with SMI are overrepresented). Acceptance and Commitment Therapy (ACT), a third-wave evidence-based treatment that uses mindfulness as a core tenet has been found to decrease trauma-related symptoms among those with SMI (Spidel, et al, 2018). One may then assume that a treatment that decreases symptoms related to suicidality (i.e., avoidance and hyperarousal) among individuals with SMI endorsing a history of trauma will exhibit a reduction in these symptoms leading to less suicidality. Along these lines, the first step of evidence-based treatments is indeed the ‘evidenced-based’ portion, thus more empirical research is needed to explore how to effectively reduce PTSS and suicidality by utilizing mindfulness-based intervention, given its advantages. Once efficacy is established, accelerating training and implementation of these interventions may promote healing from previous trauma and increase global functioning in a population deemed high-risk for suicide.
Ann Marie Kavanagh, PhD, is a Licensed Psychologist, Richard LaMonica, PhD, is a Licensed Psychologist and Chief of Psychology, and G. Mitchell Mazzone, MA, is a Psychology Extern at Pilgrim Psychiatric Center. For more information contact email@example.com or by phone at 631-761-3764.
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