Elsevier

General Hospital Psychiatry

Volume 36, Issue 1, January–February 2014, Pages 88-94
General Hospital Psychiatry

Psychiatric–Medical Comorbidity
Feasibility and utility of positive psychology exercises for suicidal inpatients

https://doi.org/10.1016/j.genhosppsych.2013.10.006Get rights and content

Abstract

Objective

The objective was to assess the feasibility and acceptability of nine positive psychology exercises delivered to patients hospitalized for suicidal thoughts or behaviors, and to secondarily explore the relative impact of the exercises.

Method

Participants admitted to a psychiatric unit for suicidal ideation or behavior completed daily positive psychology exercises while hospitalized. Likert-scale ratings of efficacy (optimism, hopelessness, perceived utility) and ease of completion were consolidated and compared across exercises using mixed models accounting for age, missing data and exercise order. Overall effects of exercise on efficacy and ease were also examined using mixed models.

Results

Fifty-two (85.3%) of 61 participants completed at least one exercise, and 189/213 (88.7%) assigned exercises were completed. There were overall effects of exercise on efficacy (χ2= 19.39; P= .013) but not ease of completion (χ2= 11.64; P= .17), accounting for age, order and skipped exercises. Effect (Cohen’s d) of exercise on both optimism and hopelessness was moderate for the majority of exercises. Exercises related to gratitude and personal strengths ranked highest. Both gratitude exercises had efficacy scores that were significantly (P= .001) greater than the lowest-ranked exercise (forgiveness).

Conclusion

In this exploratory project, positive psychology exercises delivered to suicidal inpatients were feasible and associated with short-term gains in clinically relevant outcomes.

Introduction

Patients who are psychiatrically hospitalized for a suicide attempt or suicidal ideation (SI) are at very high risk for suicide following discharge [1], [2], [3], with rates of suicide shortly postdischarge more than 100 times greater than the rate in the general population [4]. Despite this high risk of suicide, there has been relatively limited study of formal interventions to reduce suicidality during or shortly after psychiatric admission.

Existing interventions for suicidal patients (e.g., cognitive behavioral therapy [5], [6] and dialectical behavior therapy [7], [8]) typically target negative emotions and cognitions. However, positive cognitions and emotions also appear to be important in reducing suicide risk, and reducing negative emotions may not automatically increase positive psychological states. For example, optimism and depression are only moderately correlated (median r=−.43 in 10 studies [9]), signaling that these constructs are not simply two sides of the same coin.

Optimism, gratitude and other positive states have been associated with reductions in hopelessness, suicidal ideation and suicide attempts, often independent of depression [10], [11], [12], [13], [14], [15], [16]. Positive emotions in suicidal patients have been linked to improved problem-solving [17], and a study of patients hospitalized for self-harm found that low positive future orientation more strongly predicted recurrent self-harm after discharge than did global hopelessness [18]. Therefore, explicit targeting of positive cognitive and emotional states like gratitude and positive future orientation may have effects on suicide risk above and beyond standard approaches.

Positive psychology (PP) interventions could represent an innovative and effective adjunctive tool for patients at high suicide risk. PP-based exercises focus on cultivating or amplifying a specific positive cognition or emotion. Representative interventions focus on expressing optimism, generating gratitude and reestablishing life purpose [19], [20], [21], [22]. In contrast to more intensive interventions, PP exercises require minimal provider training, are often straightforward and enjoyable, and are accessible to a variety of patients, including those who cannot attend in-person appointments.

Overall, PP exercises have been successfully used by more than 4000 participants in over 50 clinical trials [20], [21], though typically in nonclinical populations. However, PP exercises, including those focusing on gratitude, mindfulness and using strengths, have led to (often persistent) improvements in mood symptoms in patients with depressive symptoms [19], [23], [24], and a prior intervention on meaningful goals in older adults with suicidal thoughts led to greater self-efficacy and psychological well-being [25].

Such interventions have the potential to be useful for patients in crisis. These exercises could be easily administered to hospitalized patients, with the goal of increasing positive psychological states by discharge, when suicide risk is high. In addition, these interventions could be used postdischarge, and an efficient exploration of feasibility in suicidal patients could also inform that future implementation. Still, it has been unclear whether PP exercises would be feasible or acceptable in a broad population of hospitalized suicidal patients, or whether they would impact clinical outcomes in this seriously ill cohort, with valid concerns that such exercises may be a “bridge too far.”

Accordingly, in this study, we examined as a primary aim the feasibility and acceptability of nine PP exercises in patients admitted to a psychiatric unit for SI or a suicide attempt. Secondarily, we sought to explore the self-reported efficacy of the exercises as a whole and to compare such efficacy ratings among individual exercises.

Section snippets

Study overview

This study assessed the feasibility of PP exercises among suicidal inpatients (clinicaltrials.gov identifier=NCT01398891). While hospitalized, participants completed one randomly assigned PP exercise daily under the guidance of a study trainer, self-assessed their optimism and hopelessness immediately before and after exercise completion, and rated the ease and utility of each exercise. Institutional Review Board approval was obtained prior to all study procedures.

Participants

Eligible participants were

Results

Fig. 1 displays the recruitment and enrollment flow for the study. Fifty-two (85.3%) of 61 consenting participants completed baseline measures and at least one exercise. Participants who completed at least one exercise did not differ significantly on any baseline characteristic from those who dropped out (all P> .10).

Table 1 displays the baseline characteristics of the 52 participants who completed at least one exercise. Major depressive disorder was the primary diagnosis in 82.7% (n= 43)

Discussion

In a population of suicidal patients with high levels of hopelessness and depression, on our primary aim, we found that administration of PP exercises was feasible and well accepted. Nearly 90% of assigned exercises were completed, a substantial finding considering that participants were in crisis and receiving additional intensive treatment. However, a small proportion of participants were unable to participate in exercise completion, suggesting that a subset of this population may be too

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    Funding: This work was supported in part by grant R01-DP00336 from the US Centers for Disease Control and Prevention to Dr. Herbert Benson. There was no other funding source.

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