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Cited by 209Suicide and Self-Harm StudiesPsychological Well-being and Life SatisfactionMental Health via Writing

Feasibility and utility of positive psychology exercises for suicidal inpatients

Huffman, Jeff C., DuBois, Christina M., Healy, Brian C., Boehm, Julia K., Kashdan, Todd B., Celano, Christopher M., Denninger, John W., Lyubomirsky, Sonja·2014·General Hospital Psychiatry
DOI 10.1016/j.genhosppsych.2013.10.006
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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 (χ(2)=19.39; P=.013) but not ease of completion (χ(2)=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.

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Written from the paper’s full text.

TL;DR

In suicidal psychiatric inpatients, nine positive psychology exercises were feasible and acceptable, with 52/61 (85.3%) participants completing at least one exercise and 189/213 (88.7%) assigned exercises completed. Exercises were associated with short-term improvements in optimism and hopelessness, with gratitude and personal strengths ranking highest and the forgiveness letter lowest.

Key findings

  • Feasibility: 52 (85.3%) of 61 consenting participants completed baseline measures and at least one exercise; 189/213 (88.7%) assigned exercises were completed, with a mean of 3.63 (S.D. 1.93) of 4.10 (S.D. 2.05) assigned exercises completed.
  • There was an overall effect of exercise on efficacy (χ²=19.39; df=8; P=.013) but not ease of completion (χ²=11.64; P=.17), accounting for age, exercise order, and skipped exercises.
  • Gratitude letter, counting blessings, and personal strengths had the highest efficacy/modified efficacy scores; forgiveness letter, best possible self (social relationships), and values-based activities had the lowest. The forgiveness letter had significantly lower adjusted mean modified efficacy than the gratitude letter (adjusted mean difference=1.9; 95% CI 0.8–3.0; P=.001) and counting blessings (adjusted mean difference=1.8; 95% CI 0.7–2.9; P=.001).
  • Pre-post optimism and hopelessness improved across exercises, with adjusted mean changes of 0.24–1.12 for optimism and 0.30–1.20 for hopelessness. Cohen’s d for each exercise other than the forgiveness letter ranged from 0.48 to 1.19 for both optimism and hopelessness; the forgiveness letter had a nonsignificant change in optimism (P=.38). Qualitative comments were mostly positive: 138/190 (72.3%).

Methods

  • Prospective exploratory pilot study on a 24-bed inpatient psychiatric unit; adults admitted for suicidal ideation or suicide attempt between May 2011 and February 2013 were enrolled. Of 61 consenting participants, 52 completed at least one exercise. Baseline measures included QIDS-SR, Beck Hopelessness Scale, and LOT-R; demographic and psychiatric characteristics came from chart review.
  • Participants completed one randomly assigned positive psychology exercise daily under a study trainer, with pre/post 5-point Likert ratings of optimism and hopelessness plus ratings of ease and utility. Nine exercises were used: gratitude letter, personal strengths, acts of kindness, important/enjoyable/meaningful activities, counting blessings, best possible self (social relationships), best possible self (accomplishments), forgiveness letter, and behavioral commitment to values-based activities.
  • Analyses used mixed-effects regression models with a patient-specific random effect and fixed effects for age and exercise order; modified efficacy and ease scores accounted for noncompleted exercises. Paired t tests and Cohen’s d assessed unadjusted pre-post changes, and qualitative responses were independently reviewed for themes.

Limitations

  • Stated in the paper: the sample was largely Caucasian and from a single psychiatric unit; there were no sham or control exercises; participants concurrently received psychological and psychopharmacological interventions; ratings may have been influenced by desire to justify participation or please researchers; and the study did not serially measure suicidality with a validated scale or obtain postdischarge outcomes, so ultimate impact on suicide risk cannot be claimed.
  • Evident from the text: this was a small exploratory pilot with no control group, limiting causal inference; outcomes were short-term self-report ratings; and missing exercise data required assumptions in modified efficacy/ease analyses.

Model-written summary. Check it against the paper before relying on it.

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Registry

Crossref · 10.1016/j.genhosppsych.2013.10.006

Cites

62 of 62 references verified0 citation errors · 0 not checkable

Statistics

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Claims the paper makes

0 of 40 cited sources checked · 0 supported · 0 flagged

  • Findingown data
    § a b s t r a c t · p. 2

    Effect (Cohen's d) of exercise on both optimism and hopelessness was moderate for the majority of exercises.

    “Effect (Cohen ' s d ) of exercise on both optimism and hopelessness was moderate for the majority of exercises.”
    Quote in the paperSubstantial claim
  • Findingown data
    § 3. Results · p. 5

    The majority of qualitative comments were positive (138 of 190 comments [72.3%]).

    “The majority of qualitative comments were positive (138 of 190 comments [72.3%]), with most comments focusing on the high ease of”
    Quote in the paperNot a substantial claim
  • Findingown data
    § 3. Results · p. 5

    The forgiveness letter had a nonsignificant change in optimism (P=.38).

    “which had a nonsigni fi cant change in optimism ( P =.38).”
    Quote in the paperNot a substantial claim
  • Findingown data
    § 3. Results · p. 5

    Participants had moderate to severe hopelessness at enrollment (BHS=11.37 [S.D. 5.80]; cutoff for high suicide risk=9).

    “and moderate to severe hopelessness (BHS=11.37 [S.D. 5.80]; cutoff for high suicide risk=9 [50]).”
    Quote in the paperNot a substantial claim
  • Findingown data
    § 3. Results · p. 5

    Individual exercise completion ranged from 77% (best possible self social relationships) to 100% (counting blessings).

    “Individual exercise completion ranged from 77% ( best possible self social relationships ) to 100% ( counting blessings ).”
    Quote in the paperSubstantial claim
  • May combine two claims. 20
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 19

  • May combine two claims.

    Findingown data
    § 3. Results · p. 5

    Pre-post optimism improved across exercises, with adjusted mean change between 0.24 and 1.12.

    “Pre -post optimism and hopelessness improved across exercises, with adjusted mean change between 0.24 and 1.12 for optimism and between 0.30 and 1.20 for hopelessness.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data
    § 3. Results · p. 5

    There was no significant effect of exercise on ease of completion (χ2=11.64; P=.17), accounting for age, order and skipped exercises.

    “There was no signi fi cant effect of exercise on modi fi ed ease scores ( χ 2 =11.64; df=8; P =.17).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § 3. Results · p. 5

    Major depressive disorder was the primary diagnosis in 82.7% (n=43) patients.

    “Major depressive disorder was the primary diagnosis in 82.7% ( n =43)patients.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § 3. Results · p. 5

    The most common reported reason for exercise noncompletion was insufficient time (n=9).

    “The most common reported reason for exercise noncompletion was insuf fi cient time ( n =9).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § 3. Results · p. 5

    Pre-post hopelessness improved across exercises, with adjusted mean change between 0.30 and 1.20.

    “Pre -post optimism and hopelessness improved across exercises, with adjusted mean change between 0.24 and 1.12 for optimism and between 0.30 and 1.20 for hopelessness.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 4. Discussion · p. 6

    Administration of positive psychology exercises was feasible and well accepted in a population of suicidal inpatients with high levels of hopelessness and depression.

    “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.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 3. Results · p. 5

    The forgiveness letter had a significantly lower adjusted mean modified efficacy score than the gratitude letter (adjusted mean difference=1.9 [95% CI 0.8-3.0]; P=.001) and counting blessings (adjusted mean difference=1.8 [95% CI 0.7-2.9]; P=.001), independent of age and exercise order.

    “the forgiveness letter had a signi fi cantly lower adjusted mean modi fi ed ef fi cacy score than the gratitude letter (adjusted mean difference=1.9 [95% con fi dence interval {CI} 0.8 -3.0]; P =.001) and counting blessings (adjusted mean difference=1.8 [95% CI 0.7 -2.9]; P =.001) independent of age and exercise order; these effects remain signi fi cant after Bonferroni correction.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: For uncompleted exercises, assuming no pre-post change and assigning the lowest utility score is appropriate for the modified efficacy score.

  • May combine two claims.

    Findingown data
    § 4. Discussion · p. 7

    Exercises focused on life purpose and optimism had lower efficacy ratings than most other exercises, though with Cohen's d > .4 on optimism and hopelessness in all cases.

    “exercises focused on life purpose and optimism had lower ef fi cacy ratings than most other exercises (though with Cohen ' s d N .4 on optimism and hopelessness in all cases).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 4. Discussion · p. 7

    The personal strengths exercise was associated with substantial improvements in this population and was perceived as easy to complete.

    “The exercise focusing on a personal strength was also associated with substantial improvements in this population and was perceived as easy to complete”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 4. Discussion · p. 7

    The gratitude letter and counting blessings exercises had high utility scores and were associated with substantial improvements in optimism.

    “exercises on gratitude -the gratitude letter and counting blessings -had high utility scores and were associated with substantial improvements in optimism.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation
    § 4. Discussion · p. 7

    Many patients experienced a resurgence of anger or sadness when recalling a past slight and found it difficult to move past these feelings in the midst of crisis.

    “Qualitatively, many patients experienced a resurgence of anger or sadness when recalling a past slight and found it dif fi cult to move past these feelings in the midst of crisis [58].”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § 2.6. Procedures · p. 4

    We chose hopelessness and optimism as key outcome measures due to their established links to suicidality; hopelessness has been associated with completed suicide, independent of severity of mood symptoms.

    “We chose hopelessness and optimism as key outcome measures due to their established links to suicidality [10 -12]. Hopelessness has been associated with completed suicide, independent of severity of mood symptoms [46,47]”
    Quote in the paperSubstantial claim0 of 5 sources checked
    • cites [10] [10] [Hirsch JK, Conner KR, Duberstein PR. Optimism and suicide ideation among young adult college students. Arch Suicide Res 2007;11:177 -85.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0050) - source

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    • cites [11] [11] [Hirsch JK, Duberstein PR, Conner KR, Heisel MJ, Beckman A, Franus N, et al. Future orientation and suicide ideation and attempts in depressed adults ages 50 and over. Am J Geriatr Psychiatry 2006;14:752 -7.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0055) - source

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    • cites [12] [12] [Hirsch JK, Duberstein PR, Conner KR, Heisel MJ, Beckman A, Franus N, et al. Future orientation moderates the relationship between functional status and suicide ideation in depressed adults. Depress Anxiety 2007;24:196 -201.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0060) - source

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    • cites [46] [46] [Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: a 10year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 1985;142:559 -63.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0220) - source

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    • cites [47] [47] [Hill RD, Gallagher D, Thompson LW, Ishida T. Hopelessness as a measure of suicidal intent in the depressed elderly. Psychol Aging 1988;3:230 -2.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0225) - source

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    Premisecitation
    § a b s t r a c t · p. 2

    Optimism, gratitude and other positive states have been associated with reductions in hopelessness, suicidal ideation and suicide attempts, often independent of depression.

    “Optimism, gratitude and other positive states have been associated with reductions in hopelessness, suicidal ideation and suicide attempts, often independent of depression [10 -16].”
    Quote in the paperSubstantial claim0 of 7 sources checked
    • cites [10] [10] [Hirsch JK, Conner KR, Duberstein PR. Optimism and suicide ideation among young adult college students. Arch Suicide Res 2007;11:177 -85.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0050) - source

      Not checked in the free run.

    • cites [11] [11] [Hirsch JK, Duberstein PR, Conner KR, Heisel MJ, Beckman A, Franus N, et al. Future orientation and suicide ideation and attempts in depressed adults ages 50 and over. Am J Geriatr Psychiatry 2006;14:752 -7.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0055) - source

      Not checked in the free run.

    • cites [12] [12] [Hirsch JK, Duberstein PR, Conner KR, Heisel MJ, Beckman A, Franus N, et al. Future orientation moderates the relationship between functional status and suicide ideation in depressed adults. Depress Anxiety 2007;24:196 -201.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0060) - source

      Not checked in the free run.

    • cites [13] [13] [Li D, Zhang W, Li X, Li N, Ye B. Gratitude and suicidal ideation and suicide attempts among Chinese adolescents: direct, mediated, and moderated effects. J Adolesc 2012;35:55 -66.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0065) - source

      Not checked in the free run.

    • cites [14] [14] [Yamokoski CA, Scheel KR, Rogers JR. The role of affect in suicidal thoughts and behaviors. Suicide Life Threat Behav 2011;41:160 -70.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0070) - source

      Not checked in the free run.

    • cites [15] [15] [Heisel MJ, Flett GL. Purpose in life, satisfation with life, and suicide ideation in a clinical sample. J Psychopathol Behav Assess 2004;26:127 -35.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0075) - source

      Not checked in the free run.

    • cites [16] [16] [Seidlitz L, Conwell Y, Duberstein P, Cox C, Denning D. Emotion traits in older suicide attempters and non-attempters. J Affect Disord 2001;66:123 -31.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0080) - source

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    Study design and conductnone given
    § 2.6. Procedures · p. 4

    The order of exercise assignment for each participant was determined via random number generator.

    “The order of exercise assignment for each participant wasdetermined via random number generator.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § a b s t r a c t · p. 3

    PP exercises have been successfully used by more than 4000 participants in over 50 clinical trials, though typically in nonclinical populations.

    “Overall, PP exercises have been successfully used by more than 4000 participants in over 50 clinical trials [20,21], though typically in nonclinical populations.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [20] [20] [Sin NL, Lyubomirsky S. Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly metaanalysis. J Clin Psychol 2009;65:467 -87.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0100) - source

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    • cites [21] [21] [Bolier L, Haverman M, Westerhof GJ, Riper H, Smit F, Bohlmeijer E. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health 2013;13:119.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0105) - source

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    Premisecitation
    § a b s t r a c t · p. 2

    Optimism and depression are only moderately correlated (median r = -.43 in 10 studies), signaling that these constructs are not simply two sides of the same coin.

    “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.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] [9] [DuBois CM, Beach SR, Kashdan TB, Nyer MB, Park ER, Celano CM, et al. Positive psychological attributes and cardiac outcomes: associations, mechanisms, and interventions. Psychosomatics 2012;53:303 -18.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0045) - source

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    Interpretationreasoning
    § a b s t r a c t · p. 3

    These exercises could be easily administered to hospitalized patients, with the goal of increasing positive psychological states by discharge, when suicide risk is high.

    “These exercises could be easily administered to hospitalized patients, with the goal of increasing positive psychological states by discharge, when suicide risk is high.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § a b s t r a c t · p. 3

    Such interventions have the potential to be useful for patients in crisis.

    “Such interventions have the potential to be useful for patients in crisis.”
    Quote in the paperSubstantial claim

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    Premisecitation
    § 1. Introduction · p. 2

    Patients who are psychiatrically hospitalized for a suicide attempt or suicidal ideation are at very high risk for suicide following discharge, with rates of suicide shortly postdischarge more than 100 times greater than the rate in the general population.

    “Patients who are psychiatrically hospitalized for a suicide attempt or suicidal ideation (SI) are at very high risk for suicide following discharge [1 -3], with rates of suicide shortly postdischarge more than 100 times greater than the rate in the general population [4].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [1] [1] [Appleby L, Dennehy JA, Thomas CS, Faragher EB, Lewis G. Aftercare and clinical characteristics of people with mental illness who commit suicide: a case -control study. Lancet 1999;353:1397 -400.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0005) - source

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    • cites [2] [2] [Appleby L, Shaw J, Amos T, McDonnell R, Harris C, McCann K, et al. Suicide within 12 months of contact with mental health services: national clinical survey. BMJ 1999;318:1235 -9.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0010) - source

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    • cites [3] [3] [Goldacre M, Seagroatt V, Hawton K. Suicide after discharge from psychiatric inpatient care. Lancet 1993;342:283 -6.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0015) - source

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    • cites [4] [4] [Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry 2005;62:427 -32.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0020) - source

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    Study design and conductnone given
    § 2.7. Statistical analyses · p. 4

    The first approach analyzed all available data assuming that noncompletion of an exercise was uninformative about the missing value.

    “The fi rst approach analyzed all available data assuming that noncompletion of an exercise was uninformative about the missing value and therefore used the efficacy score and ease as described above.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning
    § 2.7. Statistical analyses · p. 4

    We compared scores across the exercises on all outcome variables using mixed-effects regression models with a patient-specific random effect and fixed effects for age and exercise order.

    “we compared scores across the exercises on all outcome variables (change in hopelessness, change in optimism, utility, ease, efficacy score ) using mixed-effects regression models with a patient-speci fi c random effect and fi xed effects for age and exercise order.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given
    § 2.7. Statistical analyses · p. 4

    Open-ended qualitative responses were transcribed and independently reviewed for themes by two staff members with experience in qualitative research, with disagreements resolved via discussion and review of the primary material.

    “Finally, open-ended qualitative responses were transcribed and independently reviewed for themes by two staff members with experience in qualitative research. A list of themes was generated and combined, with disagreements resolved via discussion and review of the primary material.”
    Quote in the paperNot a substantial claim

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    Interpretationown data
    § a b s t r a c t · p. 2

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

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

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning
    § 2.7. Statistical analyses · p. 4

    A second approach created a modified efficacy score that assumed no pre-post change and assigned the lowest utility score when an exercise was not completed.

    “a second approach created a modified efficacy score that assumed no pre -post change and assigned the lowest utility score when an exercise was not completed.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation
    § 2.6. Procedures · p. 4

    We chose to utilize this guided self-help approach to provide participants some support and guidance around exercise completion without developing an intervention that would require extensive training, schooling or cost, aligned with suggestions to create interventions packaged for wide dissemination.

    “We chose to utilize this guided self-help approach (rather than creating a psychotherapeutic intervention) to provide participants some support and guidance around exercise completion without developing an intervention that would require extensive training, schooling or cost. These factors are aligned with suggestions to create interventions packaged for wide dissemination [48].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [48] [48] [Kazdin AE, Blase SL. Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on psychological science 2011;6: 21 -37.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0230) - source

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    Study design and conductnone given
    § 4. Discussion · p. 7

    Participants concurrently received psychological and psychopharmacological interventions during admission.

    “Participants concurrently received psychological and psychopharmacological interventions during admission”
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    Study design and conductown data
    § 4. Discussion · p. 7

    The sample was a largely Caucasian population on a single psychiatric unit.

    “Our sample was a largely Caucasian population on a single psychiatric unit.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § 4. Discussion · p. 7

    Asking patients to take on 'big' issues such as life purpose or imagining an optimal future might have been more difficult for some patients at this stage.

    “Asking patients to take on ' big ' issues such as life purpose or imagining an optimal future might have been more dif fi cult for some patients at this stage.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given
    § 4. Discussion · p. 7

    There were no sham or control exercises.

    “There were no sham or control exercises.”
    Quote in the paperSubstantial claim

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    Premisecitation
    § 4. Discussion · p. 7

    Prior work found the personal strengths exercise to be associated with prolonged improvement in depressive symptoms.

    “consistent with prior work fi nding this exercise to be associated with prolonged improvement in depressive symptoms [19].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] [19] [Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. Am Psychol 2005;60:410 -21.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0095) - source

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    Premisecitation
    § 4. Discussion · p. 7

    Prior work has linked gratitude to lower levels of depression, hopelessness and suicidal thoughts/attempts.

    “prior work that has linked gratitude to lower levels of depression, hopelessness and suicidal thoughts/attempts [13,52 -56]”
    Quote in the paperNot a substantial claim0 of 6 sources checked
    • cites [13] [13] [Li D, Zhang W, Li X, Li N, Ye B. Gratitude and suicidal ideation and suicide attempts among Chinese adolescents: direct, mediated, and moderated effects. J Adolesc 2012;35:55 -66.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0065) - source

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    • cites [52] [52] Rosmarin DH, Krumrei EJ, Pargament KI. Are gratitude and spirituality protective factors against psychopathology?. Int J Existential, Psychol Psychother 2010;3. -

      Not checked in the free run.

    • cites [53] [53] [Lyubomirsky S, Tkach C, DiMatteo MR. What are the differences between happiness and self-esteem? Soc Indic Res 2006;78:363 -404.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0250) - source

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    • cites [54] [54] [Fredrickson BL, Tugade MM, Waugh CE, Larkin GR. What good are positive emotions in crises? A prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th, 2001. J Pers Soc Psychol 2003;84:365 -76.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0255) - source

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    • cites [55] [55] [Wood AM, Maltby J, Gillett R, Linley PA, Joseph S. The role of gratitude in the development of social support, stress, and depression: two longitudinal studies. J Res Pers 2008;42:854 -71.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0260) - source

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    • cites [56] [56] [Ng MY, Wong WS. The differential effects of gratitude and sleep on psychological distress in patients with chronic pain. J Health Psychol 2013;18:263 -71.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0265) - source

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    Study design and conductnone given
    § 4. Discussion · p. 7

    Patients may have felt compelled to rate higher improvements in symptoms after exercise completion than before, either to justify their participation or to please the researchers.

    “patients may have felt compelled to rate higher improvements in symptoms after exercise completion than before, either to justify their participation or to please the researchers”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning
    § 4. Discussion · p. 7

    Ratings were completed in the narrow window between exercise initiation and completion, minimizing potential noise from other interventions.

    “although ratings were completed in the narrow window between exercise initiation and completion, minimizing potential ' noise ' from other interventions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 4. Discussion · p. 7

    A study found a gratitude letter to reduce depressive symptoms in mildly, but not more severely, depressed participants.

    “a study that found a gratitude letter to reduce depressive symptoms in mildly, but not more severely, depressed participants [57]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [57] [57] [Sin NL, Della Porta MD, Lyubomirsky S. Tailoring positive psychology interventions to treat depressed individuals. In: Donaldson SI, Csikszentmihalyi M, Nakamura J, editors. Applied positive psychology: improving everday life, health, schools, work, and society. New York: Routledge; 2011. p. 79 -96.](http://refhub.elsevier.com/S0163-8343(13)00298-3/rf0270) -

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data
    § 4. Discussion · p. 7

    The study did not serially measure suicidality via a validated scale or obtain postdischarge outcomes.

    “we did not serially measure suicidality via a validated scale or obtain postdischarge outcomes”
    Quote in the paperSubstantial claim
35 of 35

  • The paper relies on this without support.

    There has been relatively limited study of formal interventions to reduce suicidality during or shortly after psychiatric admission.

    “Despite this high risk of suicide, there has been relatively limited study of formal interventions to reduce suicidality during or shortly after psychiatric admission.”

  • The paper relies on this without support.

    It is unclear whether positive psychology 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.

    “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. '”

  • The paper relies on this without support.

    Positive psychology 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.

    “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.”

  • The paper relies on this without support.

    Clinical implementation of positive psychology exercises in this setting would likely occur across diagnoses rather than in a single diagnostic cohort.

    “given that clinical implementation of the exercises in this setting would likely occur across diagnoses rather than in a single diagnostic cohort.”

  • The authors state this as an assumption.

    Noncompletion of an exercise was uninformative about the missing value.

    “The fi rst approach analyzed all available data assuming that noncompletion of an exercise was uninformative about the missing value and therefore used the efficacy score and ease as described above.”

  • The authors state this as an assumption.

    For uncompleted exercises, assuming no pre-post change and assigning the lowest utility score is appropriate for the modified efficacy score.

    “a second approach created a modified efficacy score that assumed no pre -post change and assigned the lowest utility score when an exercise was not completed.”

  • The paper relies on this without support.

    The modified efficacy index and ease scores are valid measures of exercise efficacy and ease.

    “Modi fi ed ef fi cacy index and ease scores accounted for participants who were assigned but did not complete an exercise.”
7 of 7

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The study was powered at 96% to detect a moderate immediate effect (Cohen d = 0.5) of positive psychology exercises on optimism and positive affect.

    “Assuming the moderate (Cohen d = 0.5) immediate effect of positive psychology exercises on optimism and positive affect that was seen in our prior positive psychology intervention studies, 35 the study was powered at 96% for”

    From Feasibility and acceptability of a positive psychological intervention for patients with type 2 diabetes (2016) · cites this paper as [35]

    The Results (p. 5) report immediate improvements in optimism after the exercises, with Cohen’s d ranging from 0.48 to 1.19 for most exercises. The paper measured hopelessness, not positive affect, so it does not support that part of the cited premise. The 96% power figure describes the citing study’s own design, not a finding attributed to this source. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • Some evidence suggests that integrated, multi-session PAIs may be beneficial for individuals with mild-to-moderate depression or other health-related conditions.

    “Although some evidence suggests that integrated, multi-session PAIs may be beneficial for individuals with mild-to-moderate depression68 or other health-related conditions (e.g., cardiovascular disease69, suicide70, and HIV71)”

    From Upregulating the positive affect system in anxiety and depression: Outcomes of a positive activity intervention: <scp>Taylor et al.</scp> (2017) · cites this paper as [70]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Hopelessness confidence interval is not centered on its mean

    Minor

    A 95% confidence interval for the reported paired mean improvement should be approximately symmetric around 0.50. The stated endpoints have a midpoint of 0.685, indicating an error in the mean or an endpoint.

    Reported 0.5 · recomputed 0.685

1 of 1

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3 of the 65 references couldn’t be matched to a known paper.

Cited by

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Related

Authors
Huffman, J. C., DuBois, C. M., Healy, B. C., Boehm, J. K., Kashdan, T. B., Celano, C. M., Denninger, J. W., & Lyubomirsky, S.
Affiliations
  • Harvard University (US)
  • Massachusetts General Hospital (US)
  • Chapman University (US)
  • George Mason University (US)
  • University of California, Riverside (US)
Corresponding author
Huffman, Jeff C.
ORCID
Venue
General Hospital Psychiatry
Publisher
Elsevier BV
Published
2014-01
Volume
36
Issue
1
Pages
88-94
ISSN
0163-8343 (ISSN-L)
DOI
10.1016/j.genhosppsych.2013.10.006
OpenAlex
W2111863514
Semantic Scholar
7c42f5e5c5cf8c6e16b0b8f1ca48047ffdae691c
Cited by
209
References
65
Citations by year
2026: 3 · 2025: 9 · 2024: 7 · 2023: 22 · 2022: 14 · 2021: 15 · 2020: 8 · 2019: 16 · 2018: 66 · 2017: 14 · 2016: 17 · 2015: 10 · 2014: 8
FWCI
12.86
Type
journal article
Language
en
Open access
closed
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • General Hospital Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
National Center for Chronic Disease Prevention and Health Promotion (R01-DP00336)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Psychology › Social Psychology › Psychological Well-being and Life Satisfaction
  • Social Sciences › Psychology › Social Psychology › Mental Health via Writing
Keywords
suicidal ideation, suicidal behavior, hospitalized patients, feasibility, acceptability, optimism, hopelessness, gratitude, personal strengths, forgiveness, psychiatric hospitalization
MeSH terms
Suicide Prevention, Adult, Attitude, Feasibility Studies, Humans, Inpatients, Male, Middle Aged, Psychotherapy, Treatment Outcome, Suicidal Ideation, Hope

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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