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Psychological interventions to reduce suicidality in high-risk patients with major depression: a randomized controlled trial

Published online by Cambridge University Press:  23 November 2016

C. M. Celano*
Harvard Medical School, Boston, MA, USA Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
E. E. Beale
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
C. A. Mastromauro
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
J. G. Stewart
Harvard Medical School, Boston, MA, USA Department of Psychiatry, McLean Hospital, Belmont, MA, USA
R. A. Millstein
Harvard Medical School, Boston, MA, USA Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
R. P. Auerbach
Harvard Medical School, Boston, MA, USA Department of Psychiatry, McLean Hospital, Belmont, MA, USA
C. A. Bedoya
Harvard Medical School, Boston, MA, USA Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
J. C. Huffman
Harvard Medical School, Boston, MA, USA Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
*Address for correspondence: C. M. Celano, M.D., Massachusetts General Hospital/Blake 11, 55 Fruit Street, Boston, MA 02114, USA. (Email:



Positive psychological constructs have been associated with reduced suicidal ideation, and interventions to cultivate positive feelings have the potential to reduce suicide risk. This study compares the efficacy of a 6-week, telephone-based positive psychology (PP) intervention against a cognition-focused (CF) control intervention among patients recently hospitalized for depression and suicidal ideation or behavior.


A total of 65 adults with a current major depressive episode reporting suicidal ideation or a recent suicide attempt were enrolled from participating in-patient psychiatric units. Prior to discharge, participants were randomized to the PP (n = 32) or CF (n = 33) intervention. In both interventions, participants received a treatment manual, performed weekly PP (e.g. gratitude letter) or CF (e.g. recalling daily events) exercises, and completed weekly one-on-one telephone sessions over 6 weeks. Between-group differences in hopelessness (primary outcome), depression, suicidality and positive psychological constructs at 6 and 12 weeks were tested using mixed-effects models accounting for intensity of post-hospitalization psychiatric treatment.


Compared with PP, the CF intervention was associated with significantly greater improvements in hopelessness at 6 weeks (β = −3.15, 95% confidence interval −6.18 to −0.12, effect size = −0.84, p = 0.04), but not 12 weeks. Similarly, the CF intervention led to greater improvements in depression, suicidal ideation, optimism and gratitude at 6 and 12 weeks.


Contrary to our hypothesis, the CF intervention was superior to PP in improving hopelessness, other suicide risk factors and positive psychological constructs during a key post-discharge period among suicidal patients with depression. Further study of this CF intervention is warranted in populations at high suicide risk.

Original Articles
Copyright © Cambridge University Press 2016 

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Previous presentation: An abstract was presented at the 62nd Annual Meeting of the Academy of Psychosomatic Medicine, New Orleans, LA, 11–14 November 2015.


Abramson, LY, Metalsky, GI, Alloy, LB (1989). Hopelessness depression: a theory-based subtype of depression. Psychological Review 96, 358372.Google Scholar
Appleby, L, Shaw, J, Amos, T, McDonnell, R, Harris, C, McCann, K, Kiernan, K, Davies, S, Bickley, H, Parsons, R (1999). Suicide within 12 months of contact with mental health services: national clinical survey. British Medical Journal 318, 12351239.Google Scholar
Babyak, MA (2004). What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models. Psychosomatic Medicine 66, 411421.Google Scholar
Bagley, SL, Weaver, TL, Buchanan, TW (2011). Sex differences in physiological and affective responses to stress in remitted depression. Physiology and Behavior 104, 180186.Google Scholar
Beck, AT, Brown, G, Berchick, RJ, Stewart, BL, Steer, RA (1990). Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients. American Journal of Psychiatry 147, 190195.Google Scholar
Beck, AT, Brown, G, Steer, RA (1989). Prediction of eventual suicide in psychiatric inpatients by clinical ratings of hopelessness. Journal of Consulting and Clinical Psychology 57, 309310.Google Scholar
Beck, AT, Weissman, A, Lester, D, Trexler, L (1974). The measurement of pessimism: the hopelessness scale. Journal of Consulting and Clinical Psychology 42, 861865.Google Scholar
Berman, MG, Kross, E, Krpan, KM, Askren, MK, Burson, A, Deldin, PJ, Kaplan, S, Sherdell, L, Gotlib, IH, Jonides, J (2012). Interacting with nature improves cognition and affect for individuals with depression. Journal of Affective Disorders 140, 300305.Google Scholar
Blackwell, E, de Leon, CF, Miller, GE (2006). Applying mixed regression models to the analysis of repeated-measures data in psychosomatic medicine. Psychosomatic Medicine 68, 870878.Google Scholar
Bolier, L, Haverman, M, Westerhof, GJ, Riper, H, Smit, F, Bohlmeijer, E (2013). Positive psychology interventions: a meta-analysis of randomized controlled studies. BioMed Central Public Health 13, 119.Google Scholar
Bolton, JM, Gunnell, D, Turecki, G (2015). Suicide risk assessment and intervention in people with mental illness. British Medical Journal 351, h4978.Google Scholar
Brown, GK, Beck, AT, Steer, RA, Grisham, JR (2000). Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. Journal of Consulting and Clinical Psychology 68, 371377.Google Scholar
Brown, GK, Ten Have, T, Henriques, GR, Xie, SX, Hollander, JE, Beck, AT (2005). Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. Journal of the American Medical Association 294, 563570.Google Scholar
Calati, R, Courtet, P (2016). Is psychotherapy effective for reducing suicide attempt and non-suicidal self-injury rates? Meta-analysis and meta-regression of literature data. Journal of Psychiatric Research 79, 820.Google Scholar
Callahan, CM, Unverzagt, FW, Hui, SL, Perkins, AJ, Hendrie, HC (2002). Six-item screener to identify cognitive impairment among potential subjects for clinical research. Medical Care 40, 771781.Google Scholar
Curtin, SC, Warner, M, Hedegaard, H (2016). Increase in Suicide in the United States, 1999–2014. National Center for Health Statistics: Hyattsville, MD.Google Scholar
Fava, GA, Rafanelli, C, Cazzaro, M, Conti, S, Grandi, S (1998). Well-being therapy. A novel psychotherapeutic approach for residual symptoms of affective disorders. Psychological Medicine 28, 475480.Google Scholar
Goldacre, M, Seagroatt, V, Hawton, K (1993). Suicide after discharge from psychiatric inpatient care. Lancet 342, 283286.Google Scholar
Hayashi, N, Igarashi, M, Imai, A, Yoshizawa, Y, Utsumi, K, Ishikawa, Y, Tokunaga, T, Ishimoto, K, Harima, H, Tatebayashi, Y, Kumagai, N, Nozu, M, Ishii, H, Okazaki, Y (2012). Post-hospitalization course and predictive signs of suicidal behavior of suicidal patients admitted to a psychiatric hospital: a 2-year prospective follow-up study. BioMed Central Psychiatry 12, 186.Google Scholar
Henriksson, MM, Aro, HM, Marttunen, MJ, Heikkinen, ME, Isometsa, ET, Kuoppasalmi, KI, Lonnqvist, JK (1993). Mental disorders and comorbidity in suicide. American Journal of Psychiatry 150, 935940.Google Scholar
Heron, M (2013). Deaths: leading causes for 2013. National Vital Statistics Reports 65, 194.Google Scholar
Herzberg, PY, Glaesmer, H, Hoyer, J (2006). Separating optimism and pessimism: a robust psychometric analysis of the revised Life Orientation Test (LOT-R). Psychological Assessment 18, 433438.Google Scholar
Hirsch, JK, Conner, KR (2006). Dispositional and explanatory style optimism as potential moderators of the relationship between hopelessness and suicidal ideation. Suicide and Life-Threatening Behavior 36, 661669.Google Scholar
Hirsch, JK, Conner, KR, Duberstein, PR (2007 a). Optimism and suicide ideation among young adult college students. Archives of Suicide Research 11, 177185.Google Scholar
Hirsch, JK, Duberstein, PR, Chapman, B, Lyness, JM (2007 b). Positive affect and suicide ideation in older adult primary care patients. Psychology and Aging 22, 380385.Google Scholar
Huffman, JC, Beale, EE, Celano, CM, Beach, SR, Belcher, AM, Moore, SV, Suarez, L, Motiwala, SR, Gandhi, PU, Gaggin, HK, Januzzi, JL (2016 a). Effects of optimism and gratitude on physical activity, biomarkers, and readmissions after an acute coronary syndrome: the gratitude research in acute coronary events study. Circulation: Cardiovascular Quality and Outcomes 9, 5563.Google Scholar
Huffman, JC, Boehm, JK, Beach, SR, Beale, EE, DuBois, CM, Healy, BC (2016 b). Relationship of optimism and suicidal ideation in three groups of patients at varying levels of suicide risk. Journal of Psychiatric Research 77, 7684.Google Scholar
Huffman, JC, DuBois, CM, Healy, BC, Boehm, JK, Kashdan, TB, Celano, CM, Denninger, JW, Lyubomirsky, S (2014). Feasibility and utility of positive psychology exercises for suicidal inpatients. General Hospital Psychiatry 36, 8894.Google Scholar
Huffman, JC, Mastromauro, CA, Boehm, JK, Seabrook, R, Fricchione, GL, Denninger, JW, Lyubomirsky, S (2011). Development of a positive psychology intervention for patients with acute cardiovascular disease. Heart International 6, e14.Google Scholar
Inagaki, M, Kawashima, Y, Kawanishi, C, Yonemoto, N, Sugimoto, T, Furuno, T, Ikeshita, K, Eto, N, Tachikawa, H, Shiraishi, Y, Yamada, M (2015). Interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for a suicide attempt: a meta-analysis. Journal of Affective Disorders 175, 6678.Google Scholar
Ivtzan, I, Papantoniou, A (2014). Yoga meets positive psychology: examining the integration of hedonic (gratitude) and eudaimonic (meaning) wellbeing in relation to the extent of yoga practice. Journal of Bodywork and Movement Therapies 18, 183189.Google Scholar
Jeste, DV, Palmer, BW, Rettew, DC, Boardman, S (2015). Positive psychiatry: its time has come. Journal of Clinical Psychiatry 76, 675683.Google Scholar
Joormann, J, Siemer, M, Gotlib, IH (2007). Mood regulation in depression: differential effects of distraction and recall of happy memories on sad mood. Journal of Abnormal Psychology 116, 484490.Google Scholar
Koivumaa-Honkanen, H, Rissanen, T, Hintikka, J, Honkalampi, K, Haatainen, K, Tarja, S, Viinamaki, H (2011). Factors associated with life satisfaction in a 6-year follow-up of depressive out-patients. Social Psychiatry and Psychiatric Epidemiology 46, 595605.Google Scholar
Li, D, Zhang, W, Li, X, Li, N, Ye, B (2012). Gratitude and suicidal ideation and suicide attempts among Chinese adolescents: direct, mediated, and moderated effects. Journal of Adolescence 35, 5566.Google Scholar
Linehan, MM, Comtois, KA, Murray, AM, Brown, MZ, Gallop, RJ, Heard, HL, Korslund, KE, Tutek, DA, Reynolds, SK, Lindenboim, N (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy v. therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry 63, 757766.Google Scholar
Lyubomirsky, S, King, L, Diener, E (2005). The benefits of frequent positive affect: does happiness lead to success? Psychological Bulletin 131, 803855.Google Scholar
Lyubomirsky, S, Layous, K (2013). How do simple positive activities increase well-being? Current Directions in Psychological Science 22, 5762.Google Scholar
McCullough, ME, Emmons, RA, Tsang, JA (2002). The grateful disposition: a conceptual and empirical topography. Journal of Personality and Social Psychology 82, 112127.Google Scholar
O'Connor, RC, Fraser, L, Whyte, M, MacHale, S, Masterton, G (2008). A comparison of specific positive future expectancies and global hopelessness as predictors of suicidal ideation in a prospective study of repeat self-harmers. Journal of Affective Disorders 110, 207214.Google Scholar
Ostacher, MJ, Nierenberg, AA, Rabideau, D, Reilly-Harrington, NA, Sylvia, LG, Gold, AK, Shesler, LW, Ketter, TA, Bowden, CL, Calabrese, JR, Friedman, ES, Iosifescu, DV, Thase, ME, Leon, AC, Trivedi, MH (2015). A clinical measure of suicidal ideation, suicidal behavior, and associated symptoms in bipolar disorder: psychometric properties of the Concise Health Risk Tracking Self-Report (CHRT-SR). Journal of Psychiatric Research 71, 126133.Google Scholar
Peterson, C, Park, N, Seligman, ME (2005). Orientations to happiness and life satisfaction: the full life versus the empty life. Journal of Happiness Studies 6, 2541.Google Scholar
Price, MA, Butow, PN, Bell, ML, deFazio, A, Friedlander, M, Fardell, JE, Protani, MM, Webb, PM; AOCS – Quality of Life Study Investigators on behalf of the Australian Ovarian Cancer Study Group (2016). Helplessness/hopelessness, minimization and optimism predict survival in women with invasive ovarian cancer: a role for targeted support during initial treatment decision-making? Supportive Care in Cancer 24, 26272634.Google Scholar
Qin, P, Nordentoft, M (2005). Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Archives of General Psychiatry 62, 427432.Google Scholar
Raes, F, Williams, JM, Hermans, D (2009). Reducing cognitive vulnerability to depression: a preliminary investigation of MEmory Specificity Training (MEST) in inpatients with depressive symptomatology. Journal of Behavior Therapy and Experimental Psychiatry 40, 2438.Google Scholar
Reilly-Harrington, NA, Shelton, RC, Kamali, M, Rabideau, DJ, Shesler, LW, Trivedi, MH, McElroy, SL, Sylvia, LG, Bowden, CL, Ketter, TA, Calabrese, JR, Thase, ME, Bobo, WV, Deckersbach, T, Tohen, M, McInnis, MG, Kocsis, JH, Gold, AK, Singh, V, Finkelstein, DM, Kinrys, G, Nierenberg, AA (2016). A tool to predict suicidal ideation and behavior in bipolar disorder: The Concise Health Risk Tracking Self-Report. Journal of Affective Disorders 192, 212218.Google Scholar
Rush, AJ, Trivedi, MH, Ibrahim, HM, Carmody, TJ, Arnow, B, Klein, DN, Markowitz, JC, Ninan, PT, Kornstein, S, Manber, R, Thase, ME, Kocsis, JH, Keller, MB (2003). The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biological Psychiatry 54, 573583.Google Scholar
Seligman, ME, Rashid, T, Parks, AC (2006). Positive psychotherapy. American Psychologist 61, 774788.Google Scholar
Seligman, ME, Steen, TA, Park, N, Peterson, C (2005). Positive psychology progress: empirical validation of interventions. American Psychologist 60, 410421.Google Scholar
Serrano, JP, Latorre, JM, Gatz, M, Montanes, J (2004). Life review therapy using autobiographical retrieval practice for older adults with depressive symptomatology. Psychology and Aging 19, 270277.Google Scholar
Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, Hergueta, T, Baker, R, Dunbar, GC (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59 (Suppl. 20), 2233.Google Scholar
Sin, NL, Lyubomirsky, S (2009). Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis. Journal of Clinical Psychology 65, 467487.Google Scholar
Suarez, L, Beach, SR, Moore, SV, Mastromauro, CA, Januzzi, JL, Celano, CM, Chang, TE, Huffman, JC (2015). Use of the Patient Health Questionnaire-9 and a detailed suicide evaluation in determining imminent suicidality in distressed patients with cardiac disease. Psychosomatics 56, 181189.Google Scholar
Sumner, JA, Griffith, JW, Mineka, S (2010). Overgeneral autobiographical memory as a predictor of the course of depression: a meta-analysis. Behaviour Research and Therapy 48, 614625.Google Scholar
Trivedi, MH (2009). Tools and strategies for ongoing assessment of depression: a measurement-based approach to remission. Journal of Clinical Psychiatry 70 (Suppl. 6), 2631.Google Scholar
Trivedi, MH, Wisniewski, SR, Morris, DW, Fava, M, Gollan, JK, Warden, D, Nierenberg, AA, Gaynes, BN, Husain, MM, Luther, JF, Zisook, S, Rush, AJ (2011). Concise Health Risk Tracking scale: a brief self-report and clinician rating of suicidal risk. Journal of Clinical Psychiatry 72, 757764.Google Scholar
van der Velden, AM, Kuyken, W, Wattar, U, Crane, C, Pallesen, KJ, Dahlgaard, J, Fjorback, LO, Piet, J (2015). A systematic review of mechanisms of change in mindfulness-based cognitive therapy in the treatment of recurrent major depressive disorder. Clinical Psychology Review 37, 2639.Google Scholar
Watkins, ER, Baeyens, CB, Read, R (2009). Concreteness training reduces dysphoria: proof-of-principle for repeated cognitive bias modification in depression. Journal of Abnormal Psychology 118, 5564.Google Scholar
Watson, D, Clark, LA, Tellegen, A (1988). Development and validation of brief measures of positive and negative affect: the PANAS scales. Journal of Personality and Social Psychology 54, 10631070.Google Scholar
Yamokoski, CA, Scheel, KR, Rogers, JR (2011). The role of affect in suicidal thoughts and behaviors. Suicide and Life-Threatening Behavior 41, 160170.Google Scholar
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