Suicidology Online 2020; VOL. 11:1 ISSN 2078-5488 Original Research Emotional Responses to Psychiatric Hospitalization among Inpatients Admitted With and Without Suicidality Rivka T. Cohen ,1, Michelle Schoenleber 2, Kim L. Gratz 3, and Matthew T. Tull 3 1 Department of Psychology, University of Pennsylvania, Philadelphia, PA 2 Department of Psychology, St. Norbert College, De Pere, WI 3 Department of Psychology, University of Toledo, Toledo, OH Submitted: April 1st, 2019; Accepted: April 28th, 2020; Published: June 4th, 2020 Abstract: Although commonly used to stabilize individuals reporting suicide risk, psychiatric hospitalization can heighten suicidality following discharge, and unpleasant emotions elicited by hospitalization could contribute to increased risk for suicidal behaviors. However, limited research has examined the relation between suicidality and emotional responses to psychiatric hospitalization. This preliminary investigation examined differences in emotional responses to psychiatric hospitalization both during hospitalization and post-discharge among 21 inpatients admitted with and without suicidality. Participants reported levels of trait emotions and state emotional responses to hospitalization at intake (retrospectively), on-unit, and at 1-2 weeks post-discharge. Results indicated that hospitalization elicited more varied unpleasant emotions for inpatients with versus without suicidality. Additionally, inpatients with suicidality reported a post-discharge rebound in hospitalization- related anger and minimal alleviation of hospitalization-related guilt. Results suggest that more direct means of targeting these emotions during and shortly after hospitalization may be beneficial for patients admitted with suicidality. Keywords: Emotion, Suicide, Suicidality, Inpatient, Hospitalization Copyrights belong to the Author(s). Suicidology Online (SOL) is a peer-reviewed open-access journal publishing under the Creative Commons Licence 4.0. Suicide is the second leading cause of death for approximately 7 and 3 times higher for male and Americans aged 10-34 and remains a major health female patients, respectively, in the first 28 days concern throughout the lifespan (Centers for Disease following discharge from inpatient psychiatric care, Control, 2014). Brief psychiatric hospitalization is relative to the remaining 48 weeks of the first year commonly used for crisis management for acutely post-discharge. Moreover, at least within some suicidal individuals and can promote short-term patient populations (i.e., patients with borderline stabilization (Mellesdal, Mehlum, Wentzel-Larsen, personality disorder), there is evidence that the use Kroken, & Arild Jørgensen, 2010). Yet, despite of inpatient psychiatric hospitalization and crisis potential benefits, evidence suggests that patients services is associated with increased risk for suicide may be at elevated risk for suicide following attempts (Coyle, Shaver, & Linehan, 2018; see also inpatient psychiatric hospitalization. Specifically, in a Paris, 2004). population-based study, Goldacre, Seagroatt, and One understudied factor that may potentially Hawton (1993) found that the suicide rate was contribute to heightened post-discharge suicide risk is the emotionally evocative and sometimes stigmatizing nature of psychiatric hospitalization Rivka T. Cohen itself (Link, 1987; Moses, 2011; Paris, 2004). Address: University of Pennsylvania Psychiatric hospitalization may elicit unpleasant 425 S. University Ave. Philadelphia, PA 19104 emotions that are themselves associated with E-mail: [email protected] suicidality (including suicidal ideation, plans, or 53 Suicidology Online 2020; VOL. 11:1 ISSN 2078-5488 attempts), including self-conscious emotions (e.g., in the development of hypotheses for future guilt, shame; Hendin & Haas, 1991) and high-arousal research. unpleasant emotions (e.g., anger, anxiety; Hendin, Maltsberger, Haas, Szanto, & Rabinowicz, 2004). This Method may be especially true for patients admitted with suicidality, given demonstrated associations Participants between suicidal thoughts and behaviors and both Twenty-four patients (61.9% female; mean age = heightened emotional reactivity (Nock, Wedig, 38.9±12.3) were recruited from an inpatient Holmberg, & Hooley, 2008) and the tendency to psychiatric unit in the southern United States. experience anger, guilt, and shame (Brezo, Paris, & Patients identified by unit nursing staff as not having Turecki, 2006; Kelley et al., 1996). Thus, in addition experienced symptoms of psychosis in the last 24 to having a recent history of suicidality, this subset of hours were approached by study personnel. All 24 patients may be prone to hospitalization-related patients who were approached and participated unpleasant emotions that further exacerbate suicide were also screened for the presence of psychosis in risk. Unfortunately, research has yet to explore the past 24-hours by study personnel; no patients psychiatric hospitalization-related emotions or their screened positive for those symptoms. Two patients persistence post-discharge among patients with and were excluded for random responding (i.e., selecting without suicidality. numbers at random on the measures without The goal of this study was to conduct an initial reading the items). A third patient withdrew during investigation comparing emotional responses to the initial assessment, resulting in a final sample of psychiatric hospitalization among two groups of 21. Included participants were 66.7% White and patients: those admitted for suicidality (including 33.3% African-American. Although 61.9% completed suicidal ideation, plans, and/or attempts) and those at least some college/technical school, participants admitted for reasons unrelated to suicide. We also were predominantly unemployed (61.9%) and low- examined changes in emotions over time during income (66.6% earning <$19,999/year). hospitalization and post-discharge, hypothesizing Based on chart review, 13 participants were that psychiatric hospitalization would prompt more admitted for suicidal ideation/intent/attempts intense self-conscious and high-arousal unpleasant (Suicidality Group) and 8 participants were admitted emotions for patients admitted with versus without for other reasons and denied suicidality at admission suicidality. Further, we predicted that unpleasant (Non-suicidality Group). Additional documented hospitalization-related emotions would be more reasons for admission in both groups included persistent (i.e., remain higher post-discharge) among depression, mania, substance misuse, and psychosis patients admitted with suicidality. Given the dearth at the time of admission (see Table 1), though, as of research in this area, it was our hope that this detailed above, individuals reporting active study would provide preliminary data that could aid psychosis in the past 24 hours were excluded. Table 1. Diagnoses within Suicidality vs. Non-Suicidality Groups. Suicidality Group Non-Suicidality Group Diagnosis N = 13; n (%) N = 8; n (%) Unipolar Depression 7 (53.8%) 3 (37.5%) Any Anxiety Disorder 5 (38.5%) 0 (0.0%) Bipolar Spectrum Disorder 4 (30.8%) 2 (25.0%) Substance Use Disorder 4 (30.8%) 3 (37.5%) Posttraumatic Stress Disorder 2 (15.4%) 0 (0.0%) Schizophrenia 1 (7.7%) 2 (25.0%) Borderline Personality Disorder 1 (7.7%) 0 (0.0%) Note: Diagnoses obtained from information available in participants’ hospital charts. Percentages do not add up to 100% due to comorbid diagnoses. Measures analyses, composites were created (c.f. Schoenleber Trait emotions. The negative affect subscale of the et al., 2016) assessing trait anger (hostile, irritable; Positive and Negative Affect Schedule (PANAS-NA; α=.58), anxiety (nervous, scared, afraid; α=.66), guilt Watson, Tellegen, & Clark, 1988), supplemented (blameworthy, guilty about my actions; α=.46), with 6 additional items (indicated in italics below), sadness (sad), and shame (worthless, inadequate, was used to assess trait unpleasant emotions. In flawed, dissatisfied with myself, ashamed of myself; order to include trait emotions as covariates in α=.63). 54 Suicidology Online 2020; VOL. 11:1 ISSN 2078-5488 State hospitalization-related emotions. The Topic- current version of the T-REX to assess state Related Emotion Examination (T-REX) was used to hospitalization-related emotions following assess state hospitalization-related emotions of discharge. anger (αs=.47-.54), anxiety (α=.58-.82), guilt (α=.31- .62), sadness (α=.68-.74), and shame (α=.58-.86). Data Analytic Plan The T-REX is a modified version of the state emotion One-way analyses of variance (ANOVAs) examined questionnaire used to assess emotional responding between-group differences in each emotion at each during a test of pain pressure perception, which time-point, and paired-sample t-tests examined demonstrated acceptable internal consistency within-group emotion changes. Moreover, a set of 2 (Schoenleber, Berenbaum, & Motl, 2014). Each X 2 (Time X Group) mixed repeated-measures emotion was assessed via 3 items capturing the analyses of covariance (ANCOVAs) examined subjective, cognitive, and behavioral components of between-group differences in emotion trajectories, the emotion. All items were rated on a 0 (not at all) accounting for trait levels of the emotion. ANCOVAs to 4 (extremely) scale, with the middle of the scale (a were conducted for each pair of time points (i.e., rating of 2) corresponding to a moderate level of the intake to on-unit, on-unit to follow-up), separately, reported