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Relation
Ducasse D, Dassa D, Courtet P, et al. Gratitude journal for the management of suicidal inpatients: a randomized controlled trial. (Link removed). 2019;36(5):400-411.
Draft
Randomized controlled trial
Objective
To assess whether a daily gratitude diary has an influence on mood parameters or suicidal ideation in inpatients with suicidal tendencies.
Participant
The study included 201 French-speaking adults between 18 and 65 years old who were admitted to an inpatient psychiatric unit after attempting suicide or expressing active suicidal ideation. Exclusion criteria were schizophrenia, eating disorders, and current bipolar symptoms.
intervention
Study participants were randomly assigned to a 7-day program in which they were asked to complete a daily gratitude diary (intervention; n=101) or a food diary (control condition; n=100).
The journal instructions were as follows:
Diary of gratitude
“Every night, write in your journal what you may be grateful for in your life and focus on the benefits or “gifts” you have received in your day, week, or life. It's about simple everyday joys, people, moments of beauty in nature or acts of kindness by others. We don't usually think of them as gifts, but today we'll look at them from that perspective. Take a moment to really enjoy them, think about their value, and then write them down in your journal.”
Food diary
“Write down in your diary every night what you ate that day.”
Target parameters
The primary outcome assessed for intervention effectiveness was between-group differences in mean change in current psychological pain from the start to the end of the 7-day intervention. Between-group differences for mean change in suicidal ideation, hopelessness and optimism, and depression and anxiety from enrollment to completion of the 7-day intervention were assessed. In addition, the average change in current psychological pain, suicidal ideation, and hopelessness and optimism was assessed from immediately before to immediately after completing the daily diary.
Key insights
The average length of inpatient stay for study participants was 6 days, and participants completed an average of just over 5.5 days of diary entries.
Both groups showed improvement in all psychological parameters during their hospital stay (P<0.001), including current psychological pain, current suicidal ideation, depression, state anxiety, current hopelessness, and current optimism. However, there were no statistical differences between groups in terms of suicidal ideation and current hopelessness. Measures of current psychological pain were trending (P=0.05) toward greater improvement in the gratitude group. The mean change in depression, anxiety and optimism was significantly higher in the gratitude group than in the control group (food diary) (P=0.008,P= 0.003 andP=0.01). Participants found the gratitude intervention more useful than the food diary.
This Ducasse study shows that simply keeping a daily diary, as these study participants did, can make a difference in a short period of time, even for very disturbed people.
Individuals in the gratitude group experienced statistically significant (P<0.001) Improvements in psychological pain, hopelessness and optimism. Those in the food diary group had significant improvements in psychological pain ratings (P=0.02). Differences between groups favored the gratitude journal (compared to the food journal) for all outcomes (P<0.001).
Practice implications
That a safe and almost free (notebook and pen required) intervention could produce a statistically significant improvement in the psychological status of suicidal patients deserves our attention. We might assume that this would work as well or better for people in less extreme states. Admittedly, completing a gratitude journal once a day for 5.5 days did not significantly reduce suicidal ideation in these patients. However, it did significantly reduce their depression and anxiety, and although the reduction in psychological pain did not reach significance, only advocates won't read thisPValue of 0.05 as close enough to be useful.
Perhaps a longer trial would have had an additional measurable effect. These results are impressive considering how bad these people must have felt when they were admitted to the hospital.
Evoking gratitude as a worthy therapeutic intervention has become a widespread belief and research focus in recent years. In 2008, Lambert et al. a study (N=171) to test the relationship between gratitude, life satisfaction and materialism. After experimentally inducing either gratitude or envy, they found that a state of high gratitude led to increased satisfaction with life and lower materialism compared to a state of low gratitude (envy).1In 2003, Emmons et al. across 3 studies that examined the connection between gratitude and well-being. They found that in all 3 studies, participants in their “gratitude” group showed increased well-being on many outcome measures compared to comparison groups.2In a 2008 study of 221 adolescents (a challenging cohort in which positive outcomes are expected), Emmons and colleagues reported an association between "counting one's blessings" and self-reported improvements in affect, gratitude, optimism, and life satisfaction.3
Something as simple as sending a thank you note is obviously helpful if you want to build rapport with your peers or colleagues. Expressing gratitude in addition to a simple message encourages building a lasting relationship.4In fact, expressing gratitude to a person changes one's perspective on a relationship and makes it stronger.5
In 2015, David Brooks wrote in theNew York Timesnoted the following:
Gratitude occurs when a kindness exceeds expectations, when it is undeserved. Gratitude is a kind of laughter of the heart that comes after a surprising act of kindness. Most people are grateful sometimes - after someone saves you from a mistake or brings you food during an illness. But some people seem to be grateful. They seem to be grateful virtually all the time... This kind of dispositional gratitude is worth analyzing because it creates a mentality that counterbalances the mainstream threads of our culture.6
If we could, we would shift the mindset of all our patients (and ourselves) toward greater gratitude, because we easily sense that they (and we) could be happier and healthier. This Ducasse study shows that simply keeping a daily diary, as these study participants did, can make a difference in a short period of time, even for very disturbed people.
This Ducasse study is interesting for several reasons. The first is the authors' decision to implement a “control intervention” – having patients keep food diaries. We have asked our new patients to keep food diaries for almost 30 years. This study suggests that if we had asked our patients to list good things in their lives rather than what they ate, they might have already come to their visit happier.
The patients participating in this study were in extreme distress, and the fact that such a simple intervention had an impact on their mood is quite extraordinary. I can think of few other interventions that could have done this so quickly and safely.