Reference
Ducasse D, Dassa D, Courtet P, et al. Gratitude diary for the management of suicidal inpatients: a randomized controlled trial. Depress Anxiety. 2019;36(5):400-411.
Design
Randomized controlled trial
Objective
To assess whether a daily journal of gratitude has any impact on parameters of mood or suicidal ideation in inpatients with suicidal tendencies.
Participants
The study included 201 French-speaking adults between 18 and 65 years old who had been admitted to an inpatient psychiatric unit after attempting suicide or expressing active suicidal ideation. Exclusion criteria included schizophrenia, eating disorders, and current bipolar symptoms.
Intervention
Study participants were randomly assigned to a 7-day program that asked them to fill out a daily gratitude diary (intervention; n=101) or a food diary (control condition; n=100).
The diary instructions were as follows:
Gratitude Journal
“Every evening, write in your journal the things for which you may be grateful in your life, and focus on the benefits or ‘gifts’ received in your day, week, or in your life. It deals with simple everyday pleasures, people, moments of beauty of nature, or acts of kindness from others. We do not usually consider them as a gift but, today, think of it from this perspective. Take a moment to really savor them, think about their value, then write them down in your diary.”
Food Diary
“Every evening, write in your journal the food you have eaten within the day.”
Outcome Measures
The primary outcome assessed for intervention effectiveness was between-group differences for mean change of current psychological pain, from the beginning to the end of the 7-day intervention. Between-group differences for mean change of suicidal ideation, hopelessness and optimism, and depression and anxiety from inclusion to the completion of the 7-day intervention were assessed. Also, the mean change of current psychological pain, suicidal ideation, and hopelessness and optimism from immediately before to immediately after daily journal completion was evaluated.
Key Findings
The mean length of inpatient stay for study participants was 6 days, and participants completed a mean of just over 5.5 days of journal entries.
Both groups exhibited improvement in all psychological measures 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 between-group differences in suicidal ideation and current hopelessness. Measures of current psychological pain were trending (P=0.05) toward greater improvement in the gratitude group. Mean change of depression, anxiety, and optimism were significantly higher in the gratitude group than in the control (food diary) group (P=0.008, P=0.003, and P=0.01, respectively). Participants found the gratitude intervention to be more useful than the food diary.
It appears from this Ducasse study that the simple act of keeping a daily diary, as these study participants did, can make a difference over a short time frame even with highly distraught 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 assessment (P=0.02). Between-group differences favored gratitude diary (vs food diary) for all outcomes (P<0.001).
Practice Implications
That a safe and almost free (notebook and writing implement required) intervention could produce a statistically significant improvement in the mental status of suicidal patients is worth our attention. We might assume this would work as well or better in people in less extreme states. Granted, completing a gratitude journal once a day for 5.5 days did not significantly decrease suicidal ideation among these patients. However, it did significantly reduce their depression and anxiety and, while the reduction in psychological pain did not reach significance, only sticklers will not read the P value of 0.05 as close enough to be meaningful.
Perhaps a longer trial might have produced additional measurable effect. These results are impressive considering how poorly these people must have been feeling when they were hospitalized.
Eliciting gratitude as a worthy therapeutic intervention has become a popular belief and research focus in recent years. In 2008, Lambert et al designed 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 high gratitude condition yielded increased satisfaction with life and reduced materialism compared to a low gratitude (envy) condition.1 In 2003 Emmons et al reported on 3 studies that explored relationships between gratitude and well-being. They found that, across the 3 studies, their “gratitude” group participants displayed heightened well-being on many outcome measures relative to comparison groups.2 In a 2008 study of 221 adolescents (a challenging cohort to expect to see any positive outcomes in), Emmons and colleagues reported an association between “counting one’s blessings” and self-reported improvements in affect, gratitude, optimism, and life satisfaction.3
Doing something as simple as sending a thank-you note is apparently helpful if you want to build a relationship with peers or colleagues. Expressing thanks in addition to a simple message encourages the formation of an ongoing relationship.4 In fact, expressing thanks to a person changes one’s own view of a relationship, making it stronger.5
In 2015 David Brooks, writing in the New York Times, observed the following:
Gratitude happens when some kindness exceeds expectations, when it is undeserved. Gratitude is a sort of laughter of the heart that comes about after some surprising kindness. Most people feel grateful some of the time—after someone saves you from a mistake or brings you food during an illness. But some people seem grateful dispositionally. They seem thankful practically all of the time … This kind of dispositional gratitude is worth dissecting because it induces a mentality that stands in counterbalance to the mainstream threads of our culture.6
If we could, we would shift the attitude of all of our patients (and ourselves) toward greater gratitude as we easily intuit that they (and we) might be happier and healthier. It appears from this Ducasse study that the simple act of keeping a daily diary, as these study participants did, can make a difference over a short time frame even with highly distraught people.
This Ducasse study is of interest for several reasons. The first is the authors’ choice for a “control intervention”—having the patients keep diet diaries. We asked our new patients to keep diet diaries for nearly 30 years. This study suggests that if we had asked our patients to list good things in their lives instead of what they had eaten, they might have arrived at their visit feeling happier already.
The patients enrolled in this study were in extreme distress, and the fact that such a simple intervention had any impact on their moods is rather extraordinary. Few other interventions come to mind that could have done this so quickly and so safely.
