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Since its emergence in the 1980s, acceptance and commitment therapy (ACT) has become a reputable evidence-based psychological therapy for certain disorders. Trials examining the efficacy of ACT are spread across a broad spectrum of presentations, such as chronic pain, anxiety, and depression. Nevertheless, ACT has very rarely been trialed as an intervention for suicidal ideation (SI) or deliberate self-harm (DSH).
The objective of this review is to assess the efficacy of ACT in reducing SI and DSH and to examine the suitability of reported SI, DSH, and other measures in determining the efficacy of ACT.
We systematically reviewed studies on ACT as intervention for SI and self-harm. Electronic databases, including MEDLINE, PubMed, EMBASE, PsycINFO, SCOPUS, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, were searched. The reference lists of included studies and relevant systematic reviews were examined to identify additional publications. Search terms were identified with reference to the terminology used in previous review papers on ACT and suicide prevention. The study design was not restricted to randomized controlled trials. Screening was completed by 2 reviewers, and all duplicates were removed. Publications were excluded if they were not published in English, were multicomponent therapy or were not based on ACT, or lacked a validated measure or structured reporting of SI/DSH outcomes.
After removing the duplicates, 554 articles were screened for relevance. Following the screening, 5 studies that used ACT as an intervention for suicidal or self-harming individuals were identified. The studies used diverse methodologies and included 2 case studies, 2 pre–post studies, and 1 mHealth randomized controlled trial.
The review found that ACT is effective in reducing SI in the 2 pre–post studies but not in other studies. However, given the small number and lack of methodological rigor of the studies included in this review, insufficient evidence exists for the recommendation of ACT as an intervention for SI or DSH.
Suicide is one of the leading causes of death worldwide, and the World Health Organization attributes over 800,000 deaths per year to suicide [
For the purpose of this review, suicide is defined as the act of deliberately killing oneself, and deliberate self-harm (DSH) is defined as any nonfatal suicidal behavior, such as intentional self-injury, poisoning, or self-harm with or without a fatal intent. Suicide and DSH are preventable, and therapeutic approaches that specifically target suicidal ideation (SI) provide successful results [
An evidence base for the “third wave” of CBTs, such as dialectical behavioral therapy (DBT), mindfulness-based CBT (MBCT), and acceptance and commitment therapy (ACT), has been established over the last 15 years [
ACT attempts to increase psychological flexibility mainly by targeting experiential avoidance—the tendency to avoid unwanted thoughts or emotions [
There is good reason to hypothesize that ACT may be effective in reducing SI and DSH by improving psychological flexibility [
To date, reviews of ACT for SI or DSH have not been published. A 2014 meta-analysis of the efficacy of ACT examined 60 RCTs that focused on psychiatric disorders, somatic disorders, and stress at work [
This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines [
The following electronic databases were systematically searched: MEDLINE, PubMed, EMBASE, PsycINFO, SCOPUS, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. A comprehensive set of search terms was identified with reference to terminology used in previous review papers for ACT [
Despite the emergence of ACT in the late 1990s, no date restrictions were placed on searches that were completed on December 11, 2017. A study was eligible for inclusion if it satisfied the following criteria: (1) The study used ACT as an intervention. Multicomponent therapy types were excluded because of our interest in examining the efficacy of ACT when used as a standalone therapeutic intervention. Interventions could be delivered to individuals or groups or through technology. (2) The study assessed suicidal behavior by using a validated measure or structured reporting. Suicidal behavior was defined in its broadest terms and ranged from SI to the various forms of self-harm indicated in the search terms. (3) The study is an original peer-reviewed article published in English. Given the recency of third-wave interventions, study design was not restricted to RCTs. Instead, all research designs were included (eg RCTs, quasiexperimental, pre–post, single group, and case studies). Finally, the age of participants was unrestricted.
After the removal of duplicates, 2 researchers (JT and JN) independently reviewed the relevance of all titles and abstracts that were returned by the search. Studies considered irrelevant by both the reviewers were excluded. The full texts of the remaining articles were then independently examined by the same 2 authors to confirm eligibility. Included articles and reasons for exclusion were compared to achieve consensus and, where necessary, disputes were settled by a third researcher (FS).
One author (JT) extracted the study characteristics and outcome variables, which were independently checked by JN. The following variables were extracted: author name, publication year, sample type, control group details, program format, participant age, program length, and follow-up interval. Outcome data on SI/DSH, depression, and psychological flexibility (acceptance and mindfulness) were also extracted.
The study quality and risk of bias of the included RCTs were assessed using the Cochrane Collaboration “Risk of Bias” tool [
The database search identified 590 articles and 1 article was found through a google scholar search. After removing duplicates (n=37), the titles and abstracts of the remaining 554 articles were screened for relevance, and 527 articles were excluded. The full texts of the 27 remaining articles were then examined, and 5 studies were finally included in the review (
Study selection flow diagram. ACT: acceptance and commitment therapy; DSH: deliberate self-harm.
The characteristics of the included studies are presented in
The risk of bias was evaluated for the 1 RCT study included in this review, as shown below (
This study [
Although a significant improvement in suicidality was reported postintervention in the ibobbly arm (
Summary of included studies.
Authors | Sample | Study intervention | Control condition | Suicide/Self-harm specific outcome variables | Length of intervention | Follow-up intervals | SIa/DSHb results |
Tighe et al (2017) | Aboriginal and Torres Strait Islander Australian youth ages 18-35 (N=61) | ACTc mHealth app (ibobbly) | Waitlist (6 weeks) | SI (DSI-SSd) |
Self-help app over 6 weeks | None | 30% reduction in SI but nonsignificant |
Walser et al (2015) | Veterans (N=981) | ACT-De (specifically designed for veterans) | None | SI (BDI-IIf, 1 SI Item) | 12-16 psychotherapy sessions | None | 20.5% reduction in prevalence of SI among participants |
Ducasse et al (2014) | Psychiatric patients (N=37) | ACT | None | SI (C-SSRSg), Scale for |
7 weekly 2 h sessions | 1 week and 3 months | Significant reductions in all SI measures at 1-week and 3-month follow-up |
Luoma & Valatte (2012) | Case studies (N=2) | ACT | None | Case study reports on suicidal ideation and self-harm. | 38 psychotherapy sessions (n=1) | 1 year (n=1) and unspecified (n=1) | Reductions in SI (N=2). |
Rassaque et al (2012) | Case studies (N=3) | ACT | None | Interviews and hospital ward reports measuring suicidal ideation and self-harm expression | 20 minute one-to-one sessions over 2 to 3 weeks | Unspecified | “a marked reduction in self-harm and suicidal ideation” (n=1), “changes in expression of self-harm or suicidal ideation” (n=2) |
aSI: suicidal ideation.
bDSH: deliberate self-harm.
cACT: acceptance and commitment therapy.
dDSI-SS: Depressive Symptom Inventory—Suicidality Subscale.
eACT-D: acceptance and commitment therapy for depression.
fBDI-II: Beck Depressive Inventory.
gC-SSRS: Columbia-Suicide Severity Rating Scale.
Outcome measures reported in the included studies. An "X" indicates the presence of the measure.
Measure | Tighe et al (2017) | Walser et al (2015) | Ducasse et al (2014) | Luoma and Valatte (2012) | Razzaque et al (2012) |
Scale for Suicidal Ideation | X | ||||
Suicidal Ideation (Self-Assessment Visual Analog scale) | X | ||||
Columbia-Suicide Severity Rating Scale (suicidal ideation subscore=severity and intensity items) | X | ||||
Suicidal Ideation | X | ||||
Beck Depressive Inventory-II | X | X | |||
Patient Health Questionnaire | X | ||||
Kessler 10 | X | ||||
Barrett Impulsivity Scale | X | ||||
Acceptance and Action Questionnaire | X | X | |||
Five-Facet Mindfulness Questionnaire | X | X (n=1) | |||
Mini International Neuropsychiatric Interview (French version) | X | ||||
Screening Interview for Axis II Disorder | X | ||||
Inventory of Depressive Symptomatology | X | ||||
Functioning Assessment Short Test | X | ||||
Pharmacological treatment and number of visits for psychiatric emergencies (previous 3 months) | X | ||||
Psychological pain on a visual analog scale | X | ||||
State-Trait Anxiety Inventory | X | ||||
Beck Hopelessness Scale | X | ||||
World Health Organization Quality of Life measure | X | ||||
Clinical Global Index | X |
Risk of bias for the randomized controlled study reported by Tighe et al (2017) [
Entry | Judgment | Support for judgment |
Random sequence generation (selection bias) | Low risk | Quote: “using block randomization stratified by gender (16 per block), using computer-generated randomization” Comment: Probably done. |
Allocation concealment (selection bias) | Low risk | Quote: “Each block randomization was performed offline by a member of the research team at the Black Dog Institute and sent to the research officer in Broome.” Comment: Probably done. |
Blinding of participants and personnel (performance bias) | High risk | Quote: “research officer in Broome who was responsible for and not blind to the intervention allocation” Comment: Probably not done. |
Blinding of outcome assessment (detection bias; patient-reported outcomes) | Low risk | No blinding of outcome assessment used. Outcome measures were self-reported and it is unlikely that the outcome measurement would be influenced by blinding. |
Incomplete outcome data addressed (attrition bias) | Low risk | Follow-up: minimal missing data. 2/31 missing from intervention group; 0/30 missing from control group. Reasons unlikely to be related to outcome. |
Selective reporting (reporting bias) | Low risk | Quote: “The study protocol has been published.” |
Walser et al (2015) [
The percentage of participants with no SI increased from 44% at baseline to 65% at follow-up because SI scores significantly decreased. Depression significantly reduced, as indicated by BDI-II scores. Specifically, scores decreased by 32% and 40% in participants with and without SI at baseline, respectively. Increases in mindfulness scores were associated with a reduction in depression severity across time (
In 2014, Ducasse et al [
The Columbia-Suicide Severity Rating Scale (C-SSRS) [
All scores between 3 visits significantly decreased (
Luoma and Villatte [
Anne (22) underwent ACT therapy while on a waitlist for DBT for assistance with intense emotional dysregulation, deliberate self-injury, and suicide risk. Anne had a history of suicide attempts, had been struggling with persistent suicidal thoughts, and met the criteria for multiple Axis I and II disorders. Over the course of therapy, significant increases on the FFMQ [
Considerably limited background information was provided for the second case study, which featured a 47-year-old male. Mark initiated therapy after attempting suicide shortly after losing his family in a motor vehicle accident. The authors reported that after 6 months of ACT, Mark no longer considered suicide as a viable option. However, the authors did not describe the psychological measures used in the case.
Razzaque’s study [
Violence and aggression toward others were measured in addition to self-harm expression and/or SI. Aggressive and abusive behaviors were recorded in regular nursing shift reports. No specific measure was used for the measurement of self-harm or SI. However, interviews and ward reviews were used to record changes in self-harm expression and SI. In addition to reductions in derogatory auditory hallucinations, self-harm and SI markedly reduced for the patient diagnosed with schizoaffective disorder. The aggressive and abusive behaviors of the 2 patients diagnosed with bipolar disorder reduced.
This review aimed to understand if ACT can successfully reduce SI or self-harm and to examine the suitability of the measures used in the included studies. The review found few empirical investigations on ACT that specifically target the reduction of SI/DSH, with only 1 RCT among the 5 studies. This is the first review we are aware of that has examined the impact of ACT on the reduction of SI/DSH.
All 5 studies examined SI by using various measures, and only the 2 case studies examined DSH. All studies reported a reduction in SI, and both case studies reported reductions in DSH over the course of the interventions. The degree of the reduction in SI varied: Tighe et al [
Although this review focuses on SI and DSH, the secondary measures of depression, acceptance, and mindfulness are crucial for evaluating the effectiveness of ACT. Among the 5 studies included in this review, 3 reported outcomes for depression. This review supports the existing body of evidence that highlights the effectiveness of ACT in this common presentation [
The 5 studies included 3 distinct cohorts of participants. The mHealth RCT by Tighe et al [
All 5 studies showed that ACT is associated with symptom changes. This result provides a rationale for the largescale systematic evaluation of the efficacy of ACT as an intervention for suicidal behavior. Tighe et al [
The number of studies included in this review is too small to support the claim that ACT can effectively assist in the reduction of SI/DSH. Given the limited research that has been conducted on this topic to date, the efficacy of ACT in reducing SI or DSH requires further testing, particularly through controlled trials. The early evidence presented in this review suggests that the potential mechanisms of action, such as changes in experiential avoidance and mindfulness, should receive focus.
Database search terms.
acceptance and commitment therapy
acceptance and commitment therapy for depression
Beck Depressive Inventory
Columbia-Suicide Severity Rating Scale
cognitive behavioral therapy
dialectical behavioral therapy
deliberate self-harm
Depressive Symptom Inventory—Suicidality Subscale
Five-Facet Mindfulness Questionnaire
Inventory of Depressive Symptomatology
Kessler Psychological Distress Scale
Mindfulness-Based Cognitive Therapy
Patient Health Questionnaire 9
randomized controlled trial
Suicidal Behavior Disorder
suicidal ideation
Scale for Suicidal Ideation
JT is on a University of New South Wales and Black Dog Institute PhD scholarship and was previously funded by a Young and Well Cooperative Research Centre PhD scholarship.
JT and JN reviewed all publications for relevance and FS settled disputes. All authors made substantial contributions to the review design, writing, and editing.
None declared.