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Mindfulness https://doi.org/10.1007/s12671-021-01815-1
ORIGINAL PAPER
Mindfulness, Self-compassion, Self-injury, and Suicidal thoughts and Behaviors: a Correlational Meta-analysis
Megan Per1 · Emma Schmelefske1 · Kyla Brophy1 · Sara Beth Austin2 · Bassam Khoury1
Accepted: 11 December 2021 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021
AbstractObjectives While extant research indicates an inverse association between self-compassion and mindfulness with non-suicidal self-injury (NSSI) and suicidal thoughts and behaviors (STBs), estimates of magnitude remain unknown. The present systematic review and meta-analysis aim to quantify the relationship between self-compassion and mindfulness with engagement in NSSI and STBs.Methods Literature searches in four electronic databases (PsycINFO, MEDLINE, Scopus, ProQuest Dissertations, and The-ses Global) were conducted. Effect sizes were estimated using pooled correlation coefficients and a random effects model. Meta-regressions with mixed-effect models were used to determine the moderators of the associations.Results Sixty-eight independent samples from 62 different articles (N = 53,797) met inclusion criteria. Analyses yielded a medium negative correlation between self-compassion and mindfulness with both NSSI and STBs. Among mindfulness facets, the nonjudging, acting with awareness, and describing facets demonstrated the largest significant correlations with both STBs and NSSI. The self-coldness dimension (vs self-warmth dimension) of self-compassion demonstrated the largest correlation to STBs. There was a stronger negative correlation between self-compassion and mindfulness with engagement in NSSI and STBs in adolescent samples (than in clinical and college student samples) and with STBs’ recency (reported within the past 12 months vs lifetime). Associations between NSSI and STBs with self-compassion and mindfulness were greater in lower-quality studies and studies with younger or male samples, although effect sizes remained modest.Conclusions Findings suggest that self-compassion and mindfulness may buffer against NSSI and STBs. Future study regarding the efficacy and effectiveness of self-compassion and mindfulness-based interventions among NSSI and STB populations is warranted.Meta-analysis registration PROSPERO CRD42020167823.
Keywords Suicide · Non-suicidal self-injury · Self-harm · Self-compassion · Mindfulness · Suicidal ideation · Suicide attempt
Suicide and related behaviors are serious and often over-looked worldwide public health problems (Bertolote & Fleischmann, 2002; World Health Organization, 2017). Annual suicide mortality exceeds 800,000 (World Health Organization, 2018)—an alarming rate that grossly underestimates the true death toll (Tøllefsen et al., 2012).
Age-adjusted suicide mortality has increased nearly 33% since 2000 (Hedegaard & Warner, 2021) and is projected to rise between 3 and 9% in the coming years (McIntyre & Lee, 2020a, 2020b). Suicide has remained among the top ten leading causes of death in North America for over three decades, with rates occurring over 2.5 times that of homi-cide (Centers for Disease Control and Prevention, 2018). For every completed suicide, approximately 140 people contemplate and 25–30 attempt to take their life (Centers for Disease Control and Prevention, 2021; Weissman et al., 1999). Suicide-related behaviors are associated with signifi-cant morbidity and health care costs (adjusted annual US rates of $93.5 billion; Shepard et al., 2016). Accurate suicide prediction and prevention have been limited by challenges
* Megan Per [email protected]
1 Department of Educational and Counselling Psychology, McGill University, Education Building, 3700 McTavish St (Room 614), QC H3A 1Y2 Montreal, Canada
2 The Family Institute, Northwestern University, Evanston, IL, USA
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within spanning methodology (Carpenter & Law, 2021), decades of inconsistent nomenclature (Goodfellow et al., 2020; Silverman et al., 2007), and an over-focus on psycho-pathology (e.g., mental illness, loneliness, hopelessness). Indeed, over 50 years of focused prevention efforts have negligibly impacted suicide rates, and significant knowledge gaps remain regarding underlying mechanisms and pathways to suicide (Franklin et al., 2017).
Non-suicidal self-injury (NSSI), defined as the deliberate and intentional destruction of one’s own bodily tissue with-out suicidal intent and for reasons not socially sanctioned (e.g., tattoos, body piercings; International Society for the Study of Self-Injury, 2007), is distinct from but closely associated with suicide. Those engaging in NSSI are at sig-nificantly increased risk for suicidal thoughts and behav-iors (STBs; Baer et al., 2020; Kiekens et al., 2018; Ribeiro et al., 2016). NSSI—a frequent precursor to STBs and co-occurring behavior (Hamza et al., 2012; Klonsky et al., 2013)—is arguably the most robust predictor of attempted suicide (Taliaferro & Muehlenkamp, 2014; Victor & Klon-sky, 2014). A large, multi-site study conducted over 10 years found that individuals who self-injure were between 30 and 100 times more likely to die by suicide than the general pop-ulation (Hawton et al., 2015). NSSI may increase acquired capacity for suicide via irreversible changes in habituation to physiological pain and fear of death (Bender et al., 2012). Researchers have called for greater study and understanding of risk and resilience factors uniquely associated with NSSI and STBs to better target prevention and intervention efforts (Franklin et al., 2017; Hasking et al., 2019).
Predominant NSSI and suicide risk models (for reviews, see Fox et al., 2015; Klonsky et al., 2018) have failed to translate into efficacious prevention and intervention initia-tives (Fox et al., 2020; Nielssen et al., 2017), in part due to a narrow over-focus on pathology that overlooks resilience and other protective factors as critical moderators of the risk-outcome relationship. Resilience is a multidimensional process involving transactions between intra- and interper-sonal resources that increase adaptive coping capacity in the face of adversity (Gallagher & Miller, 2018; Luthar & Cic-chetti, 2000). Incorporating resilience into suicide research is critical for contextualizing dynamics that underlie suicidal phenomena and outcomes (Shahram et al., 2021). Resilience serves as a crucial barrier to suicidality (Brailovskaia et al., 2019; Sher, 2019), and preliminary evidence suggests it accounts for greater variance in predicting STB remission than do risk factors (Teismann et al., 2016).
Holistic consideration of relationships between NSSI and STB risk and resilience factors add much-needed incre-mental validity in understanding these complex phenomena (Muehlenkamp & Brausch, 2019). Research on the rela-tionship between NSSI and STBs and traditional resilience proxies—i.e., life satisfaction (Muehlenkamp & Brausch,
2019), optimism and hope (Chang et al., 2017), treatment compliance, and mental health service utilization (Rufino et al., 2021)—has been mixed. Recent investigations suggest that cultural factors (e.g., cultural sanctions, cultural idioms related to distress) may play an extensive role in predicting NSSI and STBs (Tang et al., 2018) over and above tradition-ally studied protective factors (e.g., reasons for living; Chu et al., 2019).
Mindfulness and self-compassion, two related culturally adapted practices, have received increasing attention over the past two decades for their potential to buffer against NSSI and STBs (e.g., Bentley et al., 2017; Schmelefske et al., 2020; Van Vliet & Kalnins, 2011). Within a Western context, mindfulness is operationalized as the deliberate, non-judgmental awareness of the present moment (Kabat-Zinn, 2003). Employed widely in third wave therapies (e.g., Dialectical Behavior Therapy, and Acceptance and Commit-ment Therapy) and as standalone approaches (e.g., Mindful-ness-Based Stress Reduction, Mindfulness-Based Cognitive Therapy), mindfulness-based interventions perform as well as other evidence-based treatments for psychiatric condi-tions (i.e., depression, substance use disorders) associated with NSSI and STBs (Goldberg et al., 2018; Khoury et al., 2013a).
In a related area, an overlapping but distinct construct to mindfulness is self-compassion. While different definitions of self-compassion exist in the current literature (see review by Gilbert, 2017; Khoury, 2019; Strauss et al., 2016), self-compassion is broadly considered to be theoretically adja-cent to mindfulness (Khoury, 2019). A common operation-alization based on the Self-Compassion Scale (SCS; Neff, 2003b) involves three interconnected dimensions: holding painful thoughts in mindful awareness, showing kindness towards oneself in the face of distress, and understand-ing difficulties as part of a larger human experience (Neff, 2003a). Alternative conceptualizations of self-compassion include Gu et al., (2020) five-dimensional model (recogniz-ing suffering; understanding the universality of suffering; feeling for the person suffering; tolerating uncomfortable feelings; and motivation to act/alleviate suffering), and Gil-bert’s dual component framework combining sensitivity to one’s own suffering (compassionate engagement) with a commitment to alleviate and prevent it (or compassionate action; Gilbert & Mascaro, 2017; Gilbert et al., 2017).
Substantial evidence links mindfulness and self-com-passion to psychological health and well-being, suggest-ing an inverse correlation with psychological distress and psychopathology. Posited factors underlying these rela-tionships include facilitative effects of mindfulness and self-compassion on autonomic regulation (e.g., decreas-ing sympathetic hyperarousal and dorsal vagal activation), emotion-focused coping (e.g., promoting awareness and identification of affective states), and distress tolerance (e.g.,
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emotional acceptance; Basharpoor et al., 2021; Finlay-Jones et al., 2015; Inwood & Ferrari, 2018; Ogden et al., 2006). We know that there is a large body of electrophysiological, neurobiological, and psychological evidence which indicates that mindfulness and self-compassion affect mental health outcomes by enhancing emotion regulation capacity (Inwood & Ferrari, 2018; Lin et al., 2016; Lutz et al., 2014). We also know NSSI and STBs are linked to emotion dysregulation (Rajappa et al., 2012; You et al., 2018) and may function as attempts to regulate and manage distressing affective expe-riences. Indeed, for some, NSSI and STBs (Angelakis & Gooding, 2020, 2021; Brereton & McGlinchey, 2020; Ellis & Rufino, 2016) provide means of experiential avoidance—i.e., escape behaviors aimed to attenuate the form, frequency, and/or contexts associated with contacting/being present with aversive internal experiences (e.g., physiological sen-sations, emotions, thoughts, memories, action urges; Hayes et al., 1996, p. 1154). Thus, experiential avoidance can be understood as an emotion regulation strategy—one way to manage emotions is to avoid them.
Taken together, these findings suggest that mindfulness and self-compassion may target underlying functions of NSSI and STBs. Mindfulness and self-compassion are likely to increase psychological flexibility and expand coping rep-ertoires in ways that reduce reliance on escape via self-injury and STBs. Supporting this notion, a recent meta-analysis found that mindfulness-based interventions led to moderate reductions in suicidal ideation (Schmelefske et al., 2020) and other psychological outcomes associated with suicide (e.g., depression).
Despite growing interest in the clinical application and utility of mindfulness and self-compassion on NSSI and STBs, the relationships between these constructs remain unclear. Recently, there has been a systematic review on self-harm, suicidal ideation, and self-compassion (Cleare et al., 2019). While laudable, this review did not quantify these relationships, and examined suicidal ideation with-out accounting for key-related constructs such as NSSI and STBs. The present study addresses these important gaps and adds to the literature by aiming to (1) quantify the corre-lations between mindfulness, self-compassion, NSSI, and STBs; (2) examine the impact of specific moderators (age, gender, and study quality) on these relationships; and (3) compare the mean correlations between subgroups (popula-tion type, recency of STBs and NSSI).
Methods
Eligibility Criteria
Studies were eligible for inclusion in the review if they (1) reported data on completed measures of mindfulness
and/or self-compassion; (2) assessed for NSSI and/or STBs; (3) included original data; (4) reported correla-tion coefficients (or other statistics when correlation coefficients were not available, e.g., t-scores) between mindfulness or self-compassion and NSSI (defined as a deliberate non-suicidal act involving actual or poten-tial tissue damage without suicidal intent) or suicidal outcomes; (5) were available in English or French; and (6) were published in a peer-reviewed journal article or dissertation. Dissertations were included in an effort to reduce publication bias by potentially including stud-ies with null or negative results, which provides a more comprehensive picture of the available research (Paez, 2017). When information was missing, authors were contacted, and the study was included only if the neces-sary data were obtained. Studies not explicitly differ-entiating between self-injury with and without suicidal intent were excluded. There were no restrictions on study design or date; however, only baseline data were used in the analyses.
Search Strategy
Articles were identified for inclusion via searches through four electronic databases (PsycINFO, MEDLINE, Scopus, and ProQuest Dissertations, and Theses Global). The ini-tial search was conducted in PsycINFO (Ovid, 1806 to pre-sent) and was peer-reviewed by Dr. Alberto Chiesa, Uni-versity of Bologna. The search combined keywords and Boolean operators related to NSSI or suicide and mindful-ness or self-compassion. Several studies made use of the same dataset and data was extracted when they reported complementary data (e.g.,Watson-Singleton et al., 2018; Wu et al., 2019). See Fig. 1 for a flow diagram of search results.
Data assessing (1) NSSI and STBs and (2) mindful-ness and self-compassion outcomes were extracted. STBs and NSSI were measured continuously (e.g., frequency of thoughts and behaviors) and/or categorically (e.g., endorsement of specific thoughts and behaviors) across studies. Demographic information from included studies was extracted and reported, and comprised of (a) publi-cation characteristics (e.g., year of publication and name of authors); (b) study characteristics (e.g., sample size, sample type, geographic region); and (c) participant char-acteristics (e.g., mean age, percentage of female partici-pants, percentage of caucasian participants). Continuous moderators (i.e., age, percentage of female and study qual-ity) were examined with meta-regressions with the goal of investigating how outcomes were affected by the mod-erators. Subgroup analyses were conducted to compare
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the correlations of the different samples (e.g., clinical vs community).
Study Selection
Duplicates were removed using Endnote X8.2 and exported to Rayyan, an online screening tool for systematic reviews (Ouzzani et al., 2016). A non-blinded, standardized pro-tocol was used to determine inclusion eligibility using the aforementioned criteria by the first M. P. and second E. S. authors. M. P. and E. S. separately assessed 15% (k = 129) of the same articles following duplication removal. An inter-rater agreement of 97.42% was achieved initially. Follow-ing consideration of rationales for inclusion or exclusion, consensus was reached through discussion. Thereafter, M. P. and E. S. each independently assessed half of the remain-ing articles. Any disagreements between reviewers about whether a study should be included were resolved through consultation with the last author, B. K.
Statistical Analyses
Data were analyzed with Comprehensive Meta-Analysis, Ver-sion 3.070 (Borenstein & Rothstein, 1999). Pearson correla-tion coefficients of each sample were weighted by the inverse of the corresponding sampling variance and converted into Fisher’s transformation to account for sampling error (Hedges & Olkin, 2014; Rosenthal & Rubin, 1988). A random effect model more resilient to heterogeneity (Khoury et al., 2013b) was used for aggregated r values and moderation analyses. Classic fail-safe N analysis and funnel plots were computed to assess publication bias across studies. These analyses estimate the number of studies needed to cause significant aggregated r values to be insignificant. Study quality was assessed using the standardized critical appraisal tool (AXIS tool; Downes et al., 2016) designed for non-experimental research. Risk of bias was assessed by two independent reviewers (E. S. and M. P.), who resolved disagreement by discussion or by involving a third reviewer (B. K.).
Fig. 1 PRISMA flow diagram of screening process
Records iden�fied through database searching
(n = 1,296)
gnineercSIn
clude
dytilibigilE
noitacifitnedI
Records a�er duplicates removed(n = 841) original
Records screened(n = 841)
Records excluded(n = 641)
Full-text ar�cles assessed for eligibility(n = 200)
Full-text ar�cles excluded: (n = 138)
Did not report outcomes (n = 74)Did not provide correla�ons (n = 38)
Duplicate sample (n = 21)
Cannot locate (n = 2)
Studies included in quan�ta�ve synthesis (meta-
analysis)(n = 68 studies; 62 ar�cles)
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Results
Study Selection and Characteristics
One thousand two hundred and ninety-six articles were retrieved from the initial search on June 30, 2021. Removal of duplicates resulted in 841 articles. A total of 68 samples (62 different articles) were included in the meta-analysis. The combined number of participants was 53,797 and the mean size of the sample was 791.13 (SD = 3,168.35; range = 8–26,292). The mean age of the sample was 26.97 and 58.09% of the sample was female. The majority of the studies were conducted in North America (64.71%) and the majority of participants were Caucasian (58.93%). Of the included studies, the majority were college students (e.g., undergraduate students; 39.71%), followed by com-munity/non-clinical samples (23.53%), clinical samples (17.65%), then adolescents (16.18%). Risk of bias scores ranged from 6 to 15 (mean = 11.77, SD = 1.86). See Table 1 for detailed characteristics of individual studies.
Synthesis of Results
STBs showed a medium negative correlation (r = −.269) with combined self-compassion and mindfulness (k = 55; 95% CI [−.302, −.236], p < .001), with high heterogene-ity. Suicidal ideation had a medium negative correlation (r = −.302; k = 34; 95% CI [−.357, −.244], p < .001) with self-compassion and mindfulness combined and high heterogeneity. Suicide attempts had a small-to-medium negative correlation (r = −.209; k = 10; 95% CI [−.236, −.183], p < .001), with mindfulness and self-compassion combined and low heterogeneity.
The mindfulness facets and self-compassion dimensions were also analyzed in relationship to STBs. Of the 11 studies that analyzed the mindfulness facets and STBs, the nonjudg-ing (r = −.270; 95% CI [−.327, −.212], p < .001) and the acting with awareness facet (r = −.277; CI [−.329, −.0.223], p < .001) had a medium negative correlation, and moderate heterogeneity, with STBs. The describing facet had a small negative effect (r = −.137; 95% CI [−.194, −.080], p < .001) with STBs and moderate heterogeneity. The non-reacting and observing facets were not significant. Regarding the self-compassion dimensions, the self-warmth dimension had a small negative effect (r = −.166) and moderate heteroge-neity with STBs (k = 8; 95% CI [−.237, −.093], p < .001). The self-coldness dimension had a small-to-moderate effect (r = .239) and large heterogeneity with STBs (k = 7; 95% CI [−.427, −.031], p = .025).
The aggregated random effects model for the relation-ship between mindfulness and self-compassion outcomes,
and NSSI outcomes had a medium negative correlation (r = −.267) with self-compassion and mindfulness combined (k = 18; 95% CI [−.336, −.194], p < .001), with high het-erogeneity. Mindfulness and self-compassion combined had a medium negative correlation and high heterogene-ity for NSSI frequency (r = −.285; k = 9; 95% CI [−.395, −.167], p < .001). NSSI versatility had a small negative correlation (r = −.176) with self-compassion and mindful-ness combined (k = 3; 95% CI [−.250, −.100], p < .001), with small heterogeneity. Table 2 presents the combined random effects model, examining the relationship between NSSI and suicide outcomes with self-compassion and mindfulness. See Table 3 for the effect sizes for the self-compassion dimensions with suicide and NSSI outcomes.
The mindfulness facets and self-compassion dimensions were also analyzed in relationship to NSSI outcomes in four studies. Similar to suicide outcomes, only the describing (r = −.250; 95% CI [−.451, −.024], p = .030; small-to-medium effect), acting with awareness (r = −.347; 95% CI [−.548, −.108], p = .005; medium effect), and nonjudging (r = −.399; 95% CI [−.633, −.098], p = .011; medium-to-large effect) facets of mindfulness had a significant negative effect, and high heterogeneity, with NSSI outcomes. The non-reacting and observing facets were not significant. The self-warmth and self-coldness dimensions of self-compas-sion were not analyzed, as only two studies reported on these subscales.
Subgroup Analyses
Subgroup analyses of both STBs reported within the last 12 months (r = −.278; k = 31; 95% CI [−.320, −.235], p < .001) and lifetime history (r = −.256; k = 21; 95% CI [−.312, −.198], p < .001) of STBs had a medium negative correlation with self-compassion and mindfulness com-bined, with high heterogeneity. STBs within clinical sam-ples had a medium negative correlation with mindfulness and self-compassion (r = −.247; k = 11; 95% CI [−.350, −.139], p < .001), with medium heterogeneity. A small-to-medium negative correlation was found in community sam-ples (r = −.233; k = 13; 95% CI [−.293, −.171], p < .001), with high heterogeneity to self-compassion and mindfulness combined. College student samples had a medium negative correlation (r = −.287; k = 21; 95% CI [−.337, −.235], p < .001), with high heterogeneity, and adolescent samples had a medium negative correlation (r = −.335; k = 8; 95% CI [−.370, −.300], p < .001), with low heterogeneity, to self-compassion and mindfulness combined.
Subgroup analyses of combined NSSI outcomes reported within the last 12 months had a medium negative correla-tion (r = −.257; k = 8; 95% CI [−.352, −.156], p < .001), and lifetime NSSI history had medium negative correla-tion (r = −.260; k = 12; 95% CI [−.350, −.165], p < .001),
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1 3
Tabl
e 1
Cha
ract
erist
ics o
f inc
lude
d stu
dies
Stud
ySt
udy
desi
gnPu
blic
atio
n ty
pePa
rtici
pant
s (N
)C
ount
ryM
ean
age
(SD
)%
fem
ale
% C
auca
sian
Stud
y qu
ality
Out
com
esM
easu
res
Aal
sma
et a
l.,
(202
0)a
Pilo
t stu
dyJo
urna
l arti
cle
10th
–12t
h gr
ade
adol
esce
nts
(18)
USA
15.2
(1.3
)79
.137
.213
Min
dful
ness
an
d su
icid
al
idea
tion
(SI)
MA
AS-
A a
nd
SIQ
8th–
9th
grad
e ad
oles
cent
s (2
5)A
li (2
014)
Cro
ss-s
ectio
nal
Dis
serta
tion
Stud
ents
with
a
beha
vior
al
or e
mot
iona
l di
sord
er (1
2)
USA
16 (1
.28)
5066
.713
Self-
com
pas-
sion
(SC
) and
su
icid
ality
SCS
and
subs
et
ques
tions
from
th
e Y
RB
SS
Ana
stas
iade
s et
al.,
(201
7)C
ross
-sec
tiona
lJo
urna
l arti
cle
Fem
ale
unde
r-gr
adua
te
stude
nts (
928)
USA
19.9
2 (1
.58)
100
76.7
12M
indf
ulne
ss
and
SIM
AA
S an
d B
SS
Arg
ento
et a
l.,
(202
0)B
rief m
indf
ul-
ness
indu
ctio
nJo
urna
l arti
cle
Uni
vers
ity st
u-de
nts (
144)
Can
ada
20.1
7 (1
.98)
100
54.9
13M
indf
ulne
ss
and
NSS
ISM
S an
d IS
AS
Bas
harp
oor
et a
l., (2
016)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eU
nive
rsity
stu-
dent
s (15
0)Ir
an21
.25
(2.7
6)57
.33
N/A
8SC
and
SI
SCS
and
BSS
Boc
k et
al.,
(2
021)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eU
nive
rsity
stu-
dent
s (33
9)U
SA20
.26
(2.5
5)76
.461
.911
Min
dful
ness
an
d N
SSI
FFM
Q a
nd D
SHI
Bra
vo e
t al.,
(2
018)
aC
ross
-sec
tiona
lJo
urna
l arti
cle
Mili
tary
per
son-
nel (
407)
USA
32.7
4 (7
.5)
44.5
62.4
12M
indf
ulne
ss
and
suic
idal
ityFF
MQ
and
IDA
S:
suic
idal
ity
subs
cale
Col
lege
stud
ents
(3
10)
24.4
6 (8
.66)
41.3
047
.8
Bro
oks e
t al.,
(2
021)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eB
lack
col
lege
stu
dent
s (30
7)U
SA22
.4 (5
.6)
79.2
013
Min
dful
ness
, su
icid
ality
an
d SI
FFM
Q, B
SS a
nd
SBQ
-R
Bui
tron
et a
l.,
(201
7)C
ross
-sec
tiona
lJo
urna
l arti
cle
Und
ergr
adua
tes
with
mod
er-
ate
to se
vere
de
pres
sive
sy
mpt
oms
(218
)
USA
20.8
1 (3
.96)
78.0
063
.811
Min
dful
ness
an
d SI
FFM
Q a
nd A
SIQ
Cha
ssag
ne e
t al.,
(2
020)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eSt
uden
ts (1
034)
Fran
ceFe
mal
es: 2
0.1
(2)
Mal
es: 2
0.6
(2.2
)
79.1
1N
/A9
Min
dful
ness
an
d SI
Fren
ch v
ersi
on o
f th
e FF
MQ
and
3
item
s ass
ess-
ing
suic
ide
idea
tion
Che
ng e
t al.,
(2
018)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
ePs
ychi
atric
in
patie
nts w
ith
a hi
story
of
traum
a ex
po-
sure
(119
)
USA
33.3
(11)
42.9
44.5
12M
indf
ulne
ss,
SI, a
nd su
i-ci
de a
ttem
pts
(SA
)
FFM
Q, B
SS a
nd
med
ical
reco
rds
asse
ssin
g pr
evio
us su
icid
e at
tem
pts
Mindfulness
1 3
Tabl
e 1
(con
tinue
d)
Stud
ySt
udy
desi
gnPu
blic
atio
n ty
pePa
rtici
pant
s (N
)C
ount
ryM
ean
age
(SD
)%
fem
ale
% C
auca
sian
Stud
y qu
ality
Out
com
esM
easu
res
Che
sin
et a
l.,
(201
6)A
qua
si-e
xper
-im
enta
l pre
–po
st stu
dy
Jour
nal a
rticl
eH
igh–
suic
ide
risk
outp
a-tie
nts (
10)
USA
41.7
(16.
3)80
N/A
11M
indf
ulne
ss,
SC, a
nd su
ici-
dalit
y
FFM
Q, S
CS-
SF
and
LEID
S-R
: ho
pele
ssne
ss/
suic
idal
ity
subs
cale
Che
sin
and
Cas
-ca
rdi (
2019
)C
ross
-sec
tiona
lJo
urna
l arti
cle
Und
ergr
adua
te
stude
nts (
780)
USA
19.7
(2.9
)63
.542
.812
Min
dful
ness
, SI
, and
SA
MA
AS,
BSS
and
1
item
ass
essi
ng
prev
ious
suic
ide
atte
mpt
sC
ladd
er-M
icus
et
al.,
(201
8)In
terv
entio
nJo
urna
l arti
cle
Patie
nts w
ith
thre
e or
mor
e pr
evio
us
depr
essi
ve e
pi-
sode
s (11
5)
The
Net
herla
nds
47.5
3 (1
1.67
)70
.4N
/A13
Min
dful
ness
an
d su
icid
ality
KIM
S an
d LE
IDS-
R:
hope
less
ness
/su
icid
ality
su
bsca
leC
lear
e (2
019)
aC
ross
-sec
tiona
lD
isse
rtatio
nC
omm
unity
(61)
Scot
land
28.4
(9.5
)49
.280
.313
Min
dful
ness
, SC
, and
SI
SCS,
FFM
Q-S
F,
and
BPM
SLo
ngitu
dina
l su
rvey
stud
yU
nive
rsity
stu-
dent
s (51
4)22
.9 (5
.76)
75.7
9313
Expl
orat
ory/
pilo
t qua
lita-
tive
rese
arch
Indi
vidu
als w
ith
and
with
out
a hi
story
of
NSS
I
Ran
ge =
20–
4050
100
12
Col
lett
et a
l.,
(201
6)C
ross
-sec
tiona
lJo
urna
l arti
cle
Patie
nts w
ith
pers
ecut
ory
belie
fs (2
1)
UK
45.6
(12.
1)52
N/A
12SC
and
SI
SCS
and
BSS
Col
lins e
t al.,
(2
018)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eU
nive
rsity
stu-
dent
s (23
3)A
ustra
lia25
.98
(10.
47)
69.9
677
11M
indf
ulne
ss,
SI, a
nd su
i-ci
dal i
nten
tion
MA
AS,
SIT
BI
and
1 ite
m
asse
ssin
g su
i-ci
dal i
nten
tion
Dix
on-G
ordo
n et
al.,
(201
5)Pi
lot s
tudy
Jour
nal a
rticl
eW
omen
with
B
PD (1
9)N
orth
Am
eric
a34
.47
(11.
83)
100
63.2
13M
indf
ulne
ss
and
NSS
IFF
MQ
and
DSH
I
Dob
bins
(201
4)C
ross
-sec
tiona
lD
isse
rtatio
nO
lder
ado
les-
cent
s (11
1)U
SA18
.41
(.50)
59.6
5713
Min
dful
ness
an
d N
SSI
FFM
Q a
nd D
SHI
Fang
et a
l.,
(201
9)C
ross
-sec
tiona
lJo
urna
l arti
cle
Und
ergr
adua
te
med
ical
stu-
dent
s (26
33)
Chi
naN
/A60
.9N
/A15
Min
dful
ness
an
d su
icid
ality
MA
AS
and
SBQ
-R
Fang
(202
0)C
ross
-sec
tiona
lD
isse
rtatio
nU
nder
grad
uate
stu
dent
s (41
7)U
SA19
.37
(2.4
1)76
8814
SC a
nd S
ISC
S an
d A
SIQ
Fork
us e
t al.,
(2
019)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eM
ilita
ry v
eter
-an
s (20
3)N
/A35
.08
22.7
70.4
10SC
and
NSS
ISC
S an
d D
SHI
Mindfulness
1 3
Tabl
e 1
(con
tinue
d)
Stud
ySt
udy
desi
gnPu
blic
atio
n ty
pePa
rtici
pant
s (N
)C
ount
ryM
ean
age
(SD
)%
fem
ale
% C
auca
sian
Stud
y qu
ality
Out
com
esM
easu
res
Gar
isch
and
W
ilson
(201
5)Lo
ngitu
dina
l su
rvey
Jour
nal A
rticl
eSe
cond
ary
stu-
dent
s (11
62)
New
Zea
land
16.3
5 (0
.62)
4371
.1 id
entifi
ed
as N
Z Eu
ro-
pean
13M
indf
ulne
ss
and
NSS
ICA
MS-
R a
nd
DSH
I
Has
hem
i et a
l.,
(201
8)C
ross
-sec
tiona
lJo
urna
l arti
cle
Car
diov
ascu
lar
patie
nts (
110)
Iran
46.6
2 (1
5.45
)42
.2N
/A9
Min
dful
ness
an
d SI
FFM
Q a
nd 3
ite
ms a
sses
sing
su
icid
e id
eatio
nH
aski
ng e
t al.,
(2
019)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eU
nder
grad
uate
ps
ycho
logy
stu
dent
s (41
5)
Aus
tralia
20.9
9 (5
.33)
76.8
N/A
11SC
, NSS
I, an
d SI
SCS-
SF, I
SAS
and
2 ite
ms
asse
ssin
g su
i-ci
dal i
deat
ion
Hat
chel
et a
l.,
(201
9)C
ross
-sec
tiona
lJo
urna
l arti
cle
LGB
TQ y
outh
(9
34)
USA
15.9
1 (1
.18)
70.2
74.3
12SC
and
SI
SCS-
SF a
nd 2
ite
ms a
sses
sing
su
icid
al id
eatio
nJia
ng e
t al.,
(2
017)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eH
igh
scho
ol
stude
nts (
658)
Chi
na13
.58
(1.0
4)40
.1N
/A12
SC a
nd N
SSI
SCS
and
1 ite
m
asse
ssin
g N
SSI
Kan
iuka
et a
l.,
(202
0b)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eU
nder
grad
uate
stu
dent
s (33
8)U
SA21
.81
(5.3
3)67
879
SC a
nd su
ici-
dalit
ySC
S an
d SB
Q-R
Kan
iuka
et a
l.,
(202
0a, b
)C
ross
-sec
tiona
lJo
urna
l arti
cle
Sexu
al m
inor
ity
adul
ts (6
51)
Nor
th A
mer
ica
26.2
5 (7
.73)
46.2
79.6
13SC
and
SI
SCS-
SF a
nd
SID
AS
Kel
ley
et a
l.,
(201
9)C
ross
-sec
tiona
lJo
urna
l arti
cle
Mili
tary
vet
er-
ans (
189)
USA
43.1
4 (1
2.23
)3.
274
.111
SC a
nd su
ici-
dalit
ySC
S-SF
and
ID
AS:
suic
idal
-ity
subs
cale
Kel
liher
-Rab
on
et a
l. (2
021)
aC
ross
-sec
tiona
lJo
urna
l arti
cle
Com
mun
ity
(623
)U
SA35
.91
(11.
77)
5279
.511
SC a
nd su
ici-
dalit
ySC
S an
d SB
Q-R
Pers
ons w
ith
fibro
mya
lgia
(4
19)
47.6
6 (1
3.19
)95
.791
.712
Pers
ons w
ith
or re
cove
ring
from
can
cer
(235
)
61.2
8 (2
7.63
)64
.391
.912
Lam
is a
nd
Dvo
rak
(201
4)C
ross
-sec
tiona
lJo
urna
l arti
cle
Und
ergr
adua
te
stude
nts (
552)
USA
19.8
5 (1
.66)
77.2
79.2
9M
indf
ulne
ss
and
SIM
AA
S an
d SA
EI-2
8Li
u et
al.,
(2
020)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eA
dole
scen
ts’
post-
earth
-qu
ake
(499
)
Chi
na14
.94
(1.5
8)52
.90
14SC
and
suic
ide
risk
SCS
and
Chi
nese
ve
rsio
n of
the
YR
BSQ
Lu e
t al.,
(201
9)RC
T Jo
urna
l arti
cle
Left
behi
nd p
ri-m
ary
scho
ol
stude
nts (
49)
Chi
na11
.86
(.71)
22.4
5N
/A13
Min
dful
ness
an
d SI
risk
MA
AS
and
PAN
SI
Mindfulness
1 3
Tabl
e 1
(con
tinue
d)
Stud
ySt
udy
desi
gnPu
blic
atio
n ty
pePa
rtici
pant
s (N
)C
ount
ryM
ean
age
(SD
)%
fem
ale
% C
auca
sian
Stud
y qu
ality
Out
com
esM
easu
res
Mac
Isaa
c (2
019)
Cro
ss-s
ectio
nal
Dis
serta
tion
No
histo
ry o
f N
SSI (
194)
Hist
ory
NSS
I (8
3)
Can
ada
No
NSS
I: 21
.61
(5.8
5)N
SSI-
Dist
al
20.4
3 (1
.89)
NSS
I-Pr
oxim
al:
20.9
2 (2
.91)
No
NSS
I: 82
.47
NSS
I-D
istal
: 86
.36
NSS
I-Pr
ox-
imal
: 94
.87
No
NSS
I: 52
.06
NSS
I-D
istal
: 63
.63
NSS
I-Pr
oxim
al:
82.0
5
12M
indf
ulne
ss,
SC, a
nd N
SSI
MA
AS,
DSH
I, IS
AS
and
SCS-
SF
McM
ain
et a
l.,
(201
7) b
Ran
dom
ized
tri
alJo
urna
l arti
cle
Hig
h su
icid
e ris
k in
pat
ient
s w
ith B
PD (8
4)
Can
ada
29.6
7 (8
.62)
66N
/A14
Min
dful
ness
, N
SSI a
nd S
AK
IMS,
DSH
I and
LS
ASI
Moh
amm
ad-
khan
i et a
l.,
(201
5)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eM
ales
with
sub-
stan
ce a
buse
or
dep
ende
nce
in o
utpa
tient
se
tting
and
pr
ison
(348
)
Iran
N/A
00
6M
indf
ulne
ss
and
suic
ide
risk
MA
AS
and
SPS
Nag
y (2
017)
Expe
rimen
tal
Dis
serta
tion
Und
ergr
adua
te
psyc
holo
gy
stude
nts (
233)
USA
19.3
7 (2
.12)
74.2
73.8
14SC
and
NSS
ISC
S an
d IS
AS
Paul
us e
t al.,
(2
018)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eLa
tinos
atte
nd-
ing
com
mu-
nity
-bas
ed
prim
ary
heal
th
care
clin
ic
(391
)
USA
38.8
(11.
4)86
.70
10M
indf
ulne
ss
and
suic
idal
ityM
AA
S an
d ID
AS:
suic
idal
-ity
subs
cale
Per e
t al.,
(202
1)C
ross
-sec
tiona
lJo
urna
l arti
cle
Uni
vers
ity
stude
nts a
nd
com
mun
ity
(343
)
Can
ada
23.9
8 (7
.44)
82.2
49.0
113
SC, m
indf
ul-
ness
, and
N
SSI f
re-
quen
cy
SCS,
FFM
Q, a
nd
DSH
I
Poss
emat
o et
al.,
(2
016)
RCT
Jour
nal a
rticl
eVe
tera
ns w
ith
PTSD
in
prim
ary
care
(6
2)
USA
46.4
(16.
3)12
.982
.315
Min
dful
ness
an
d SI
MA
AS
and
PHQ
-9
Rab
on e
t al.,
(2
019)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eM
ilita
ry v
eter
-an
s (54
1)U
SA49
.9 (1
6.78
)30
.985
.213
SC a
nd su
ici-
dalit
ySC
S-SF
and
SB
Q-R
Riq
uino
(201
9)Pe
rform
ance
-ba
sed
task
Dis
serta
tion
Indi
vidu
als w
ith
a hi
story
of
enga
ging
in
NSS
I (30
)
USA
20.8
3 (2
.07)
63.3
73.3
12M
indf
ulne
ss,
SI, S
A, a
nd
freq
uenc
y of
N
SSI
FFM
Q a
nd S
ITB
I
Mindfulness
1 3
Tabl
e 1
(con
tinue
d)
Stud
ySt
udy
desi
gnPu
blic
atio
n ty
pePa
rtici
pant
s (N
)C
ount
ryM
ean
age
(SD
)%
fem
ale
% C
auca
sian
Stud
y qu
ality
Out
com
esM
easu
res
Rous
h et
al.,
(2
018)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
ePs
ychi
atric
in
patie
nts
(118
)
USA
36.1
7 (1
5.3)
46.6
80.5
14M
indf
ulne
ss
and
SIFF
MQ
and
BSS
Serr
ano
et a
l.,
(202
0)C
ross
-sec
tiona
lJo
urna
l arti
cle
Fire
fight
ers
(865
)U
SA38
.5 (8
.55)
5.3
75.1
12M
indf
ulne
ss
and
suic
idal
ityFF
MQ
and
SB
Q-R
Serv
aty-
Seib
et
al.,
(202
1)C
ross
-sec
tiona
lJo
urna
l arti
cle
Firs
t-yea
r un
iver
sity
stu-
dent
s (66
5)
USA
18.4
7 (.5
)63
.972
.211
SC, S
I, an
d su
i-ci
de a
ctio
nsSC
S-SF
and
SIS
Shor
ey e
t al.,
(2
016)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eW
omen
in a
su
bsta
nce
use
treat
men
t fa
cilit
y (8
1)
USA
32.3
(13.
95)
100
96.3
13M
indf
ulne
ss
and
SIM
AA
S an
d PA
I
Song
and
Bae
(2
020)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eK
orea
n co
llege
stu
dent
s (35
5)K
orea
21.5
9 (2
.07)
55.8
012
Min
dful
ness
, SA
and
SI
Kor
ean
vers
ion
of
the
FFM
Q a
nd
SSI
Stan
ley
et a
l.,
(201
9)C
ross
-sec
tiona
lJo
urna
l arti
cle
Fire
fight
ers
(831
)U
SA38
.37
(8.5
3)5.
575
.211
Min
dful
ness
an
d su
icid
ality
FFM
Q a
nd
SBQ
-RTa
naka
et a
l.,
(201
1)C
ross
-sec
tiona
lJo
urna
l arti
cle
Ado
lesc
ents
re
ceiv
ing
child
pr
otec
tion
ser-
vice
s (11
7)
Can
ada
18.1
(1)
N/A
2713
SC a
nd S
ASC
S an
d 1
item
as
sess
ing
sui-
cide
atte
mpt
s
Tuck
er e
t al.,
(2
014)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eU
nder
grad
uate
ps
ycho
logy
stu
dent
s (31
5)
USA
19.3
464
.881
7M
indf
ulne
ss
and
SIFF
MQ
and
H
DSQ
-SS
Tuna
and
Gen
-çö
z (2
021)
Mul
ti-m
etho
d,
labo
rato
ry-
base
d de
sign
Jour
nal a
rticl
eU
nder
grad
uate
stu
dent
s with
an
d w
ithou
t a
histo
ry o
f N
SSI (
70)
Turk
ey21
.07
(1.5
8)60
.00
10SC
and
NSS
ISC
S (T
urki
sh
trans
latio
n) a
nd
ISA
S
Um
phre
y et
al.,
(2
021)
Cro
ss-s
ectio
nal
Dis
serta
tion
Col
lege
stud
ents
(4
81)
USA
2971
60.7
10SC
and
SI
SCS
and
CH
RTS
Vig
na (2
016)
Cro
ss-s
ectio
nal
Dis
serta
tion
Hig
h sc
hool
stu-
dent
s (1,
882)
USA
N/A
50.1
68.9
8SC
, SI,
SA, a
nd
NSS
ISC
S-SF
, 3
item
s ass
ess-
ing
suic
ide
idea
tion,
suic
ide
atte
mpt
s, an
d N
SSI
Wan
g et
al.,
(2
018)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eG
ay m
en (4
45)
Switz
erla
ndN
/A0
N/A
13M
indf
ulne
ss,
SI, s
uici
de
plan
s, an
d SA
MA
AS
and
PSS
(3-it
ems)
Mindfulness
1 3
Tabl
e 1
(con
tinue
d)
Stud
ySt
udy
desi
gnPu
blic
atio
n ty
pePa
rtici
pant
s (N
)C
ount
ryM
ean
age
(SD
)%
fem
ale
% C
auca
sian
Stud
y qu
ality
Out
com
esM
easu
res
War
ner (
2015
)C
ross
-sec
tiona
lD
isse
rtatio
nC
olle
ge st
uden
ts
(26,
292)
USA
25.5
(7.8
)62
.869
.914
Min
dful
ness
an
d N
SSI
CAM
S-R
and
1
item
ass
essi
ng
NSS
IW
atso
n-Si
n-gl
eton
et a
l.,
(201
8)b
Ana
lyzi
ng sc
ale
psyc
hom
etric
pr
oper
ties,
cros
s-se
ctio
nal
Jour
nal a
rticl
eA
fric
an A
mer
i-ca
n cl
inic
al
sam
ple
(283
)
USA
37.2
4 (1
2.24
)52
014
SC, m
indf
ul-
ness
, and
SI
SCS,
FFM
Q B
SS
Wu
et a
l.,
(201
9)b
Long
itudi
nal
surv
eyJo
urna
l arti
cle
Seco
ndar
y sc
hool
stu-
dent
s (81
3)
Chi
na13
.15
(1.1
)43
.29
N/A
11SC
, NSS
I, SI
, an
d SA
SCS,
12
item
s as
sess
ing
NSS
I and
2
item
s ass
essi
ng
suic
ide
idea
tion
and
atte
mpt
Xav
ier e
t al.,
(2
016)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eA
dole
scen
ts
(643
)Po
rtuga
l15
.24
(1.6
4)51
.6N
/A12
SC a
nd N
SSI
SCS
and
RTSH
IA
(exc
lude
d su
icid
al in
tent
re
spon
ses)
Zeifm
an e
t al.,
(2
021)
Cro
ss-s
ectio
nal
Jour
nal a
rticl
eEt
hnic
ally
di
vers
e un
derg
radu
ate
stude
nts (
130)
Can
ada
21.0
4 (6
.3)
83.1
36.9
13SC
and
suic
i-da
lity
SCS
and
SBQ
-R
Zeng
et a
l.,
(201
7)C
ross
-sec
tiona
lJo
urna
l arti
cle
Old
er a
dults
(2
13)
Chi
na51
.72
(2.7
3)46
08
Min
dful
ness
an
d SI
MA
AS
and
SBQ
-RZh
ang
et a
l.,
(202
1)C
ross
-sec
tiona
lJo
urna
l arti
cle
Stud
ents
gra
de
7–9
(1,1
67)
Chi
na13
.34
(.95)
47.8
011
SC a
nd S
ISC
S an
d sh
ort
Chi
nese
ver
sion
of
the
ASI
Q
a Sepa
rate
sam
ples
repo
rted
in o
ne st
udy
b Dat
a re
ceiv
ed fr
om tw
o ar
ticle
s with
the
sam
e sa
mpl
eAb
brev
iatio
ns: A
SIQ
The
Adu
lt Su
icid
e Id
eatio
n Q
uesti
onna
ire, B
PMS
The
Brit
ish
Psyc
hiat
ric M
orbi
dity
Sur
vey,
BSS
Bec
k Su
icid
e Id
eatio
n Sc
ale,
CAM
S-R
Cog
nitiv
e an
d A
ffect
ive
Min
dful
-ne
ss S
cale
–Rev
ised
, CH
RTS
Con
cise
Hea
lth R
isk
Trac
king
Sca
le, D
SHI
Del
iber
ate
Self-
Har
m I
nven
tory
, FFM
Q F
ive
Face
t Min
dful
ness
Sca
le, F
ASM
The
Fun
ctio
nal A
sses
smen
t of
Self-
Mut
ilatio
n Sc
ale,
HD
SQ-S
S H
opel
essn
ess D
epre
ssio
n Sy
mpt
om Q
uesti
onna
ire–S
uici
dalit
y Su
bsca
le, I
DAS
Inve
ntor
y of
Dep
ress
ion
and
Anx
iety
Sym
ptom
s, IS
AS In
vent
ory
of S
tate
men
ts a
bout
Se
lf-In
jury
, KIM
S Th
e K
entu
cky
Inve
ntor
y of
Min
dful
ness
Ski
lls, L
EID
S-R
Leid
en I
ndex
of
Dep
ress
ion
Sens
itivi
ty-R
evis
ed, L
SASI
Life
time
Suic
ide
Atte
mpt
Sel
f-In
jury
Int
ervi
ew, L
-SAS
II
Life
time
Para
suic
ide
Cou
nt, M
AAS
The
Min
dful
ness
Atte
ntio
n A
war
enes
s Sca
le, M
AAS-
A Th
e M
indf
ulne
ss A
ttent
ion
Aw
aren
ess S
cale
-Ado
lesc
ents
, PAI
The
Per
sona
lity
Ass
essm
ent I
nven
tory
, PA
NSI
The
Pos
itive
and
Neg
ativ
e Su
icid
e Id
eatio
n, P
SS P
ayke
l Sui
cide
Sca
le, R
TSH
IA R
isk-
Taki
ng a
nd S
elf-
harm
Inv
ento
ry fo
r A
dole
scen
ts, S
AEI-
28 T
he S
uici
de A
nger
Exp
ress
ion
Inve
n-to
ry-2
8, S
BQ-R
Sui
cida
l Beh
avio
rs Q
uesti
onna
ire-R
evis
ed, S
CS
Self-
Com
pass
ion
Scal
e, S
HI S
elf-
harm
Inve
ntor
y, S
IDAS
The
Sui
cida
l Ide
atio
n A
ttrib
utes
Sca
le, S
IQ S
uici
de Id
eatio
n Q
uesti
on-
naire
, SIQ
-JR
Suic
ide
Idea
tion
Que
stion
naire
-Jun
ior H
igh
Scho
ol V
ersi
on, S
IS S
uici
dal I
deat
ion
Scal
e, S
MS
Stat
e M
indf
ulne
ss S
cale
, SPS
Sui
cide
Pro
babi
lity
Scal
e, S
SI T
he S
cale
for S
uici
de
Idea
tion,
YRB
SQ Y
outh
Ris
k B
ehav
ior S
urve
y Q
uesti
onna
ire, Y
RBSS
You
th R
isk
Beh
avio
r Sur
veill
ance
Sur
vey
Mindfulness
1 3
Tabl
e 2
Effe
ct si
zes f
or th
e re
latio
nshi
p be
twee
n m
indf
ulne
ss a
nd se
lf-co
mpa
ssio
n w
ith su
icid
e an
d N
SSI o
utco
mes
*ind
icat
es p
< .0
01a O
utco
mes
incl
ude:
freq
uenc
y, v
ersa
tility
, and
hist
ory.
Col
umn
nam
es: k
= n
umbe
r of s
tudi
es, r
= a
vera
ge P
ears
on C
orre
latio
n, Z
= W
ald
test,
CI =
con
fiden
ce in
terv
al o
f 95%
, Q =
Hed
ges’
Q
test
for h
omog
enei
ty; I
2 = h
eter
ogen
eity
ana
lysi
s in
perc
entil
e
Min
dful
ness
Self-
com
pass
ion
kr
Z95
% C
.I.Q
I2k
rZ
95%
C.I.
QI2
Com
bine
d su
icid
e ou
tcom
es35
−.2
30*
−12
.708
[−.2
64, −
.196
]12
1.14
971
.935
25−
.323
*−
10.7
94[−
.376
, −.2
67]
175.
726
86.3
42Su
icid
e id
eatio
n23
−.2
55*
−7.
230
[−.3
20, −
.188
]18
8.98
088
.359
15−
.364
*−
8.03
6[−
.442
, −.2
81]
154.
326
90.9
28Su
icid
e at
tem
pts
6−
.201
*−
10.8
35[−
.236
, −.1
65]
5.41
07.
584
4−
.223
*−
8.98
6[−
.269
, −.1
75]
1.65
90.
000
Com
bine
d N
SSI o
utco
mes
a11
−.2
28*
−4.
399
[−.3
24, −
.128
]18
4.98
194
.594
9−
.369
*−
5.25
4[−
.487
, −.2
38]
140.
012
94.2
86
Tabl
e 3
Effe
ct si
zes f
or th
e re
latio
nshi
p be
twee
n m
indf
ulne
ss fa
cets
and
self-
com
pass
ion
dim
ensi
ons w
ith su
icid
e an
d N
SSI o
utco
mes
The
self-
war
mth
and
self-
cold
ness
dim
ensi
on o
f the
SC
S w
ere
not a
naly
zed
as o
nly
two
studi
es re
porte
d su
bsca
les w
ith N
SSI o
utco
mes
FFM
Q F
ive
Face
t Min
dful
ness
Sca
le, S
CS
Self-
Com
pass
ion
Scal
e**
*p >
.001
; **p
>.0
1; *
p >
.05Su
icid
e ou
tcom
esN
SSI o
utco
mes
kr
Z95
% C
.I.Q
I2k
rZ
95%
C.I.
QI2
FFM
Q A
ctin
g w
ith aw
aren
ess
11−
.277
***
−9.
713
[−.3
29, −
.223
]25
.756
61.1
734
−.3
47**
−2.
793
[−.5
48, −
.108
]30
.163
90.0
54 D
escr
ibin
g11
−.1
37**
*−
4.63
1[−
.194
, −.0
80]
26.8
2862
.725
4−
.250
*−
2.16
6[−
.451
, −.0
24]
24.6
9687
.852
Non
judg
ing
11−
.270
***
−8.
759
[−.3
27, −
.212
]30
.072
66.7
474
−.3
99*
−2.
556
[−.6
33, −
.098
]50
.384
94.0
46 N
on-r
eact
ing
11−
.050
−1.
115
[−.1
38, .
038]
62.4
9383
.998
4−
.285
−1.
410
[−.6
05, .
114]
81.9
4296
.339
Obs
ervi
ng11
−.0
06−
.090
[−.1
31, .
119]
130.
045
92.3
104
−.0
26−
.236
[−.2
35, .
186]
20.9
2485
.662
SCS
Self-
war
mth
8−
.166
***
−.1
66[−
.237
, −.0
93]
15.6
7955
.353
Self-
cold
ness
7.2
39*
−2.
247
[−.4
27, −
.031
]89
.743
93.3
14
Mindfulness
1 3
self-compassion and mindfulness combined, both with high heterogeneity. Combined NSSI outcomes in community samples had a medium negative correlation (r = −.336) with self-compassion and mindfulness combined (k = 3; 95% CI [−.594, −.016], p = .04), with high heterogeneity. College samples had a small-to-medium negative correla-tion (r = −.220; k = 8; 95% CI [−.287, −.151], p < .001) and adolescent samples had a medium negative correlation (r = −.331; k = 4; 95% CI [−.397, −.262], p < .001), with self-compassion and mindfulness combined, both with high heterogeneity. Combined NSSI outcomes within clinical samples were non-significant. See Table 4.
Moderation Analyses
The relationship between STBs and mindfulness and self-compassion were negatively and weakly moderated by par-ticipants’ mean age (k = 48; β = −.009, SE = 0.0009, p < .001), gender (percentage of females in the sample; k = 51; β = −.004, SE = 0.0003, p < .001), and study quality (k = 55; β = −.024, SE = 0.002, p < .001). The relationship between NSSI outcomes and mindfulness and self-compassion was negatively moderated by mean age (k = 17; β = −.011, SE = 0.002, p < .001), gender (k = 17; β = −.004, SE = 0.0007, p < .001), and study quality (k = 18; β = −.022, SE = 0.004, p < .001).
Publication Bias Analysis
The effect size for all analyses corresponded to a z-value of −43.411 (p < .001); signifying at least 3,3291 studies with null effect would be needed to invalidate our findings. A funnel plot was generated showing that 5 studies would need to be added below the mean of the plot to achieve sym-metry, suggesting that present results may represent slight overrepresentation of the true relationship. Based on a ran-dom effects model, the new imputed mean would be −.286 (95% CI [−.318, −.253]). Although the imputed effect size is smaller than the original effect sizes, these results still suggest the effect sizes are valid and robust.
Discussion
Aggregating findings from 53,797 participants across 68 samples, this meta-analysis rigorously quantified rela-tionships between mindfulness, self-compassion, and suicide-related outcomes (NSSI and STBs) in the extant literature, and statistically evaluated important moderat-ing factors of these relationships. Our methodology and findings provide necessary clarification regarding the role of culturally adapted, resilience-based practices that may have clinical importance for preventing and treating NSSI Ta
ble
4 S
ub-g
roup
ana
lysi
s for
sam
ple
type
and
rece
ncy
of su
icid
e an
d N
SSI o
utco
mes
with
min
dful
ness
and
self-
com
pass
ion
com
bine
d
** in
dica
tes p
< .0
01; *
indi
cate
s p <
.05
Suic
ide
outc
omes
NSS
I out
com
es
kr
Z95
% C
.I.Q
I2k
rZ
95%
C.I.
QI2
Clin
ical
sam
ple
11−
.247
**−
4.40
7[−
.350
, −.1
39]
31.5
4368
.297
3−
.032
−.3
14[−
.231
, .16
8]2.
268
11.8
11C
omm
unity
13−
.233
**−
7.23
8[−
.293
, −.1
71]
70.9
8283
.094
3−
.336
*−
2.05
2[−
.594
, −.0
16]
33.8
2394
.087
Col
lege
stud
ents
21−
.287
**−
.10.
348
[−.3
37, −
.235
]17
3.95
188
.502
8−
.220
**−
6.12
0[−
.287
, −.1
51]
35.3
1480
.178
Ado
lesc
ent s
ampl
e8
−.3
35**
−17
.238
[−.3
70, −
.300
]8.
382
16.4
894
−.3
31**
−8.
929
[−.3
97, −
.262
]17
.014
82.3
67Li
fetim
e ou
tcom
es21
−.2
56*
−8.
358
[−.3
12, −
.198
]14
9.80
586
.649
12−
.260
**−
5.24
0[−
.350
, −.1
65]
89.8
7787
.761
With
in 1
2-m
onth
out
com
es31
−.2
78*
−12
.111
[−.3
20, −
.235
]16
0.27
581
.282
8−
.257
**−
4.87
7[−
.352
, −.1
56]
117.
980
94.0
67
Mindfulness
1 3
and STBs. As expected, we found a negative association between NSSI (r = −.267) and STB (r = −.269) out-comes with mindfulness and self-compassion combined. These results parallel findings from recent meta-analyses on experiential avoidance (Angelakis & Gooding, 2021) and self-criticism (Zelkowitz & Cole, 2019)—constructs often operationalized as inverse to mindfulness and self-compassion. Both studies found positive relationships and effect size estimates between experiential avoidance with STBs (moderate to large effect) and NSSI (small effect) and self-criticism with NSSI (moderate-to-large effect), providing convergent validation that mindfulness and self-compassion may serve key functions in the etiology and maintenance of suicide and engagement in NSSI.
Importantly, the significant negative relationships emerg-ing between mindfulness and self-compassion with suicide attempt history (r = −.209) and ideation (r = −.302) in the present study align with previous research demonstrating that mindfulness and self-compassion significantly lower the risk of STBs (Chesin & Jeglic, 2016; Lamis & Dvorak, 2014). Indeed, frequency of NSSI engagement (i.e., how often individuals report engaging in NSSI) had a medium negative effect (r = −.285) on mindfulness and self-com-passion. This finding suggests that those reporting NSSI his-tories tend to be less mindful and self-compassionate than those with no history. Similarly, NSSI versatility (i.e., how many methods one uses to engage in NSSI) had a small (r = −.176), negative relationship with mindfulness and self-compassion combined, denoting that those employing a greater diversity of NSSI methods endorse lower levels of mindfulness and self-compassion than those using fewer methods. While the importance of assessing NSSI frequency and methods has been well-documented (given their asso-ciation with suicide risk; see Paul et al., 2015; Turner et al., 2013), relationships between NSSI frequency and versatility have been largely ignored in meta-analyses (e.g., Batejan et al., 2015) prior to this study.
We also sought to systematically quantify the relation-ship between mindfulness facets and STBs. Nonjudging (r = −.270), acting with awareness (r = −.277), and describ-ing (r = −.137) were significantly negatively correlated with STBs, while observing and non-reacting facets were unrelated. Results between mindfulness facets and NSSI outcomes paralleled suicide findings, showing significant negative associations between NSSI and nonjudging (r = −.399), acting with awareness (r = −.347), and describing (r = −.250). Together, these results align with research to date demonstrating that, of the mindfulness facets, levels of non-judging and acting with awareness tend to be sig-nificantly lower among those with histories of self-injurious and STBs. These two facets have strong, negative associa-tions with other psychological health indicators, including affective symptoms (Carpenter et al., 2019), substance use
behaviors (Karyadi et al., 2014), and neuroticism (Hanley & Garland, 2017).
In terms of self-compassion, weighted mean correlations on SCS dimensions revealed that greater self-coldness (r = .239) and lower levels of self-warmth (r = −.166) were sig-nificantly linked to STBs. An insufficient number of studies reporting subscale data (i.e., two) prevented us from ana-lyzing self-warmth and self-coldness dimensions for NSSI outcomes; this paucity highlights an important avenue for future research. Given the mixed evidence pertaining to the validity of the SCS total score (Brenner et al., 2017; Brenner et al., 2018; Muris & Otgaar, 2020), our dimension-specific investigation provides a crucial and nuanced picture regard-ing the relationship between orthogonal dimensions of self-compassion important for suicide outcomes. The particularly robust relationship between self-coldness and STBs suggests that those reporting high levels of self-criticism, feelings of isolation, and identification with negatively labeled emotions (self-coldness) may be especially susceptible to STBs.
A third objective of this meta-analysis was to examine personal and temporal moderators by comparing mean correlations between sample characteristics and outcome recency, given evidence linking these with depressive symp-toms and suicide (Kelliher-Rabon et al., 2018). Results from the subgroup analyses revealed that individuals with a recent history (i.e., within the past 12 months) of STBs (r = −.278) scored slightly lower on measures of mindfulness and self-compassion than those with any STBs’ lifetime history (r = −.256). These findings may indicate that levels of mindful-ness and self-compassion may be lower among those cur-rently experiencing STBs. Surprisingly, NSSI lifetime (r = −.260) and within 12 months (r = −.257) revealed mini-mal differences among the correlations. Additional work is needed to establish causal relationships between mindful-ness and self-compassion on STBs and NSSI onset, mainte-nance, and recovery.
Regarding cohort age, both NSSI (r = −.331) and STBs (r = −.335) were negatively associated with self-compas-sion and mindfulness in studies utilizing adolescent sam-ples. Adolescence, a stressful developmental stage associ-ated with notable increases in NSSI and STBs prevalence (Andover et al., 2012; Brown & Plener, 2017), has been understudied within literature on NSSI/suicide and mind-fulness/self-compassion to date. Reflecting this dearth of research, only 16.18% (k = 11) of studies in our meta-analy-sis included adolescent samples. Nevertheless, our results—the observed medium effect size among younger samples and meta-regression on age—align with established links between both self-compassion and mindfulness with risk (mental illness, depression) and protective (secure attach-ment, connectedness) factors for NSSI and STBs in adoles-cents (Bluth & Blanton, 2014, 2015; Cunha et al., 2014; Neff & McGehee, 2010). We obtained similar results for STBs (r
Mindfulness
1 3
= −.287) and NSSI (r = −.220) outcomes for studies using college student samples. The college transition, marked by a unique confluence of academic, social, developmental stressors (Bewick et al., 2010; Morgan, 2017), is a time of heightened risk for STBs and NSSI (for review, see Swan-nell et al., 2014). Our findings supplement existing research indicating that mindfulness and self-compassion may serve as adaptive emotion regulation skills that help buffer col-lege students from STBs and NSSI (John & Gross, 2004; Vujanovic et al., 2010).
Negative correlations between mindfulness and self-compassion with NSSI (r = −.336) and STBs (r = −.233) emerged for studies on community samples. Among clini-cal samples, we only found a similar inverse relationship (r = −.247) between mindfulness/self-compassion and STB outcomes. Notably, the three included studies examining NSSI in clinical samples only assessed mindfulness (i.e., not self-compassion) and were nonsignificant. These find-ings—particularly the magnitude of effect for our pooled clinical sample—were surprising for several reasons. STBs and NSSI are more prevalent in clinical populations (Fox et al., 2015; Franklin et al., 2017; Horváth et al., 2020). Data suggest that those receiving mental health treatment experience more complex fears, blocks, and resistances to self-compassion than their non-treated peers (Gilbert & Mascaro, 2017; Kirby & Gilbert, 2019). Individuals with several psychiatric diagnoses also have lower levels of self-compassion compared with community samples (Castilho et al., 2015; MacBeth & Gumley, 2012). Similarly, mind-fulness is inversely related to psychopathology, including depression (Tomlinson et al., 2018). Future studies should continue to investigate the potential differences between mindfulness and self-compassion with NSSI within clini-cal and community samples given that mindfulness and compassion-based interventions are administered differ-ently between these clinical vs non-clinical groups (Kirby & Gilbert, 2019).
We identified two additional moderating variables: study quality and gender. Study quality score negatively moderated outcomes, with lower quality studies showing higher effect sizes (although this effect was weak). This methodologi-cal caveat limits interpretations of the relationship between mindfulness and self-compassion with STBs and NSSI and signals a need for higher quality, more rigorously designed investigations. For gender, there was a more robust relation-ship between mindfulness and self-compassion with STB and NSSI outcomes for males. Males tend to show mar-ginally higher levels of self-compassion than females, an effect qualified by ethnicity and gender role orientation (Yarnell et al., 2019). The evidence regarding gender dif-ferences in NSSI prevalence is mixed. Some researchers have found that females are more likely to engage in NSSI than males (e.g., Cheng et al., 2010; Whitlock et al., 2006),
while other researchers report negligible gender differences (e.g., Garisch & Wilson, 2015; Heath et al., 2008; Serras et al., 2010). Despite the mixed evidence regarding gender differences in prevalence, research has suggested gender differences may be found among the methods used and fre-quency of engagement in NSSI. There is evidence suggest-ing that women engage in NSSI more frequently (Garisch & Wilson, 2015; Hawton & Harriss, 2008) and are more likely to cut, whereas men are more likely to burn or self-hit (Kuentzel et al., 2012). Gender differences have been identified in STBs, with females exhibiting higher rates of suicidal ideation and attempts than their male peers, who are more than twice as likely to die by suicide (Cha et al., 2018; May & Klonsky, 2016; Miranda-Mendizabal et al., 2019). Recent evidence, however, indicates that the gender dispar-ity in suicide mortality has narrowed over the past 40 years, especially among younger age groups (Ruch et al., 2019). Given the established gender differences for specific STBs and NSSI outcomes, our gender moderator may reflect meta-analysis pooling outcomes (i.e., pooling NSSI frequency, NSSI as a dichotomous outcome, and NSSI versatility). It would be interesting to look at the extent to which gender influences the relationship between mindfulness and self-compassion with specific suicidal (i.e., ideation, attempts) and non-suicidal outcomes (frequency, methods used).
Limitations and Future Research
Important limitations must be considered when examining the results of this meta-analysis. While correlational research is an important first step in understanding the intersection of mindfulness and self-compassion with NSSI and STBs, replication, experimental study, and longitudinal research are needed to establish causality. Another major limitation of this meta-analysis pertains to the broad outcomes. For example, suicidal phenomena encompass a wide range of behaviors, from passive ideation, planning, and intent, to (fatal and non-fatal) attempts. Given a high degree of vari-ability in measures used, we pooled outcomes. Such hetero-geneity among measures has been highlighted in prior NSSI and STB reviews (Turner et al., 2014; Van Geel et al., 2014).
A majority of the studies (64.71%) included in this meta-analysis were conducted in North America, female (58.09%), and utilized Caucasian samples (58.93%) which limits the generalizability of our findings to other countries, ethnic groups, and gender identities. Important differences in NSSI and STBs have been documented for different countries and regions, racial/ethnic populations (Nock et al., 2008), and gender identities (Di Giacomo et al., 2018; Liu et al., 2019). This review underscores the overrepresentation of white, CIS-gendered, North American participants in the current literature. We encourage research in non-Western countries and among other underrepresented minority groups.
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It is noteworthy to mention that although no inclu-sion or exclusion criteria were set regarding which self-compassion measures studies used, all included studies assessing self-compassion used the SCS (Neff, 2003b), which operationalizes self-compassion as comprising three negative (self-judgment, isolation, overidentification) and three positive (self-kindness, common humanity, mindful-ness) subscales. Recent studies suggest that the negative self-compassion subscales may overlap with constructs assessing psychological difficulties, maladaptive coping, and psychopathology—these associations may inflate the relationship between self-compassion and these constructs (MacBeth & Gumley, 2012; Muris et al., 2018). Future researchers should examine mood and/or other psycho-pathology measures in tandem with self-compassion to account for presence of an inflation effect (Muris et al., 2018) or use alternate novel self-compassion measures (i.e., the Sussex-Oxford Compassion for the Self Scale; Gu et al., 2020) to better understand this relationship.
The negative relationship between self-compassion and mindfulness with NSSI and STBs found in this meta-analysis provides preliminary support that these constructs may serve as buffers to self-injurious behaviors. Further exploration via well-designed randomized controlled tri-als is needed to help identify with specificity the benefits and/or limitations of mindfulness- and self-compassion-based therapies for NSSI and STBs. Particular attention to the modification and reduction of harsh attitudes towards the self (self-coldness), to taking a non-evaluative stance towards inner experiences (nonjudging) and attending to the present moment (acting with awareness), could be particularly critical mindfulness components to explore in conjunction with self-injury and suicide.
Acknowledgements We would like to thank Carolina Bacalao (research assistant) for her work on data extraction and Alberto Chiesa, University of Bologna, for peer reviewing the search strategy.
Author Contribution M. P. designed, wrote, and executed the study, and analyzed the data. E. S. aided in the study design, data analysis, and revising of the final manuscript. K. B. and S. B. A. contributed to study design and assisted with writing, editing, and revising the final manuscript. B. K. provided support with the entire design and write-up of the study.
Declarations
Ethics Approval and Consent to Participate The manuscript describes meta-analyses. It does not contain clinical studies or patient data.
Informed Consent The manuscript describes meta-analyses.
Conflict of Interest The authors declare no competing interests.
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