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

The DOI matches its Crossref record; 62 of the 65 references it cites were found in a registry or an index; none of the 40 sources its claims cite is checked for support yet.

Feasibility and utility of positive psychology exercises for suicidal inpatients

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.

Overview

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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.

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Integrity signals

Registry

Crossref · 10.1016/j.genhosppsych.2013.10.006

Cites

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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.”
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Metadata

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.
Venue
General Hospital Psychiatry
Publisher
Elsevier BV
Published
2014-01
Volume
36
Issue
1
Pages
88-94
ISSN
0163-8343 (ISSN-L)
OpenAlex
W2111863514
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
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

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