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1.  Relationship among Medical Student Resilience, Educational Environment and Quality of Life 
PLoS ONE  2015;10(6):e0131535.
Resilience is a capacity to face and overcome adversities, with personal transformation and growth. In medical education, it is critical to understand the determinants of a positive, developmental reaction in the face of stressful, emotionally demanding situations. We studied the association among resilience, quality of life (QoL) and educational environment perceptions in medical students.
We evaluated data from a random sample of 1,350 medical students from 22 Brazilian medical schools. Information from participants included the Wagnild and Young’s resilience scale (RS-14), the Dundee Ready Educational Environment Measure (DREEM), the World Health Organization Quality of Life questionnaire – short form (WHOQOL-BREF), the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI).
Full multiple linear regression models were adjusted for sex, age, year of medical course, presence of a BDI score ≥ 14 and STAI state or anxiety scores ≥ 50. Compared to those with very high resilience levels, individuals with very low resilience had worse QoL, measured by overall (β=-0.89; 95% confidence interval =-1.21 to -0.56) and medical-school related (β=-0.85; 95%CI=-1.25 to -0.45) QoL scores, environment (β=-6.48; 95%CI=-10.01 to -2.95), psychological (β=-22.89; 95%CI=-25.70 to -20.07), social relationships (β=-14.28; 95%CI=-19.07 to -9.49), and physical health (β=-10.74; 95%CI=-14.07 to -7.42) WHOQOL-BREF domain scores. They also had a worse educational environment perception, measured by global DREEM score (β=-31.42; 95%CI=-37.86 to -24.98), learning (β=-7.32; 95%CI=-9.23 to -5.41), teachers (β=-5.37; 95%CI=-7.16 to -3.58), academic self-perception (β=-7.33; 95%CI=-8.53 to -6.12), atmosphere (β=-8.29; 95%CI=-10.13 to -6.44) and social self-perception (β=-3.12; 95%CI=-4.11 to -2.12) DREEM domain scores. We also observed a dose-response pattern across resilience level groups for most measurements.
Medical students with higher resilience levels had a better quality of life and a better perception of educational environment. Developing resilience may become an important strategy to minimize emotional distress and enhance medical training.
PMCID: PMC4486187  PMID: 26121357
2.  Tinnitus-Related Distress and the Personality Characteristic Resilience 
Neural Plasticity  2014;2014:370307.
It has been suggested that personality traits may be prognostic for the severity of suffering from tinnitus. Resilience as measured with the Wagnild and Young resilience scale represents a positive personality characteristic that promotes adaptation to adverse life conditions including chronic health conditions. Aim of the study was to explore the relation between resilience and tinnitus severity. In a cross-sectional study with a self-report questionnaire, information on tinnitus-related distress and subjective tinnitus loudness was recorded together with the personality characteristic resilience and emotional health, a measure generated from depression, anxiety, and somatic symptom severity scales. Data from 4705 individuals with tinnitus indicate that tinnitus-related distress and to a lesser extent the experienced loudness of the tinnitus show an inverse correlation with resilience. A mediation analysis revealed that the relationship between resilience and tinnitus-related distress is mediated by emotional health. This indirect effect indicates that high resilience is associated with better emotional health or less depression, anxiety, and somatic symptom severity, which in turn is associated with a less distressing tinnitus. Validity of resilience as a predictor for tinnitus-related distress is supported but needs to be explored further in longitudinal studies including acute tinnitus patients.
PMCID: PMC4121180  PMID: 25120934
3.  The Mediating Role of Resilience in the Relationship between Big Five Personality and Anxiety among Chinese Medical Students: A Cross-Sectional Study 
PLoS ONE  2015;10(3):e0119916.
The psychological distress of medical students is a major concern of public health worldwide. However, few studies have been conducted to evaluate anxiety symptoms of medical students in China. The purpose of this study was to investigate the anxiety symptoms among Chinese medical students, to examine the relationships between big five personality traits and anxiety symptoms among medical students, and to explore the mediating role of resilience in these relationships.
This multicenter cross-sectional study was conducted in June 2014. Self-reported questionnaires consisting of the Zung Self-Rating Anxiety Scale (SAS), Big Five Inventory (BFI), Wagnild and Young Resilience Scale (RS-14) and demographic section were distributed to the subjects. A stratified random cluster sampling method was used to select 2925 medical students (effective response rate: 83.57%) at four medical colleges and universities in Liaoning province, China. Asymptotic and resampling strategies were used to explore the mediating role of resilience.
The prevalence of anxiety symptoms was 47.3% (SAS index score≥50) among Chinese medical students. After adjusting for the demographic factors, the traits of agreeableness, conscientiousness and openness were all negatively associated with anxiety whereas neuroticism was positively associated with it. Resilience functioned as a mediator in the relationships between agreeableness/conscientiousness/openness and anxiety symptoms.
Among Chinese medical students, the prevalence of anxiety symptoms was high and resilience mediated the relationships between big five personality traits and anxiety symptoms. Identifying at-risk individuals and undertaking appropriate intervention strategies that focus on both personality traits and resilience might be more effective to prevent and reduce anxiety symptoms.
PMCID: PMC4368674  PMID: 25794003
4.  Efficacy of vilazodone on anxiety symptoms in patients with major depressive disorder 
Anxiety symptoms are prevalent in patients with major depressive disorder. A post-hoc analysis of two phase III trials was conducted to evaluate the efficacy of vilazodone on depression-related anxiety. Using the 17-item Hamilton Depression Rating Scale (HAMD17) Anxiety/Somatization subscale, patients were classified as anxious or nonanxious. Improvements in depressive symptoms were based on least squares mean changes in HAMD17 and Montgomery–Asberg Depression Rating Scale total scores. Anxiety symptoms in the anxious subgroup were evaluated using Hamilton Anxiety Rating Scale (HAMA) total and subscale (Psychic Anxiety, Somatic Anxiety) scores, HAMD17 Anxiety/Somatization subscale and item (Psychic Anxiety, Somatic Anxiety) scores, and the Montgomery–Asberg Depression Rating Scale Inner Tension item score. Most of the pooled study population [82.0% (708/863)] was classified with anxious depression. After 8 weeks of treatment, least squares mean differences between vilazodone and placebo for changes in HAMA total and HAMD17 Anxiety/Somatization subscale scores were −1.82 (95% confidence interval −2.81 to −0.83; P<0.001) and −0.75 (95% confidence interval −1.17 to −0.32; P<0.001), respectively. Statistically significant improvements with vilazodone were also found on all other anxiety-related measures, except the HAMA Somatic Anxiety subscale. Vilazodone may be effective in treating patients with major depressive disorder who exhibit somatic and/or psychic symptoms of anxiety.
PMCID: PMC4186734  PMID: 24978955
antidepressants; anxiety/anxiety disorders; clinical trials; depression; mood disorders
5.  Trauma and mental health of medics in eastern Myanmar’s conflict zones: a cross-sectional and mixed methods investigation 
Conflict and Health  2013;7:15.
In conflict and disaster settings, medical personnel are exposed to psychological stressors that threaten their wellbeing and increase their risk of developing burnout, depression, anxiety, and PTSD. As lay medics frequently function as the primary health providers in these situations, their mental health is crucial to the delivery of services to afflicted populations. This study examines a population of community health workers in Karen State, eastern Myanmar to explore the manifestations of health providers’ psychological distress in a low-resource conflict environment.
Mental health screening surveys were administered to 74 medics, incorporating the 12-item general health questionnaire (GHQ-12) and the posttraumatic checklist for civilians (PCL-C). Semi-structured qualitative interviews were conducted with 30 medics to investigate local idioms of distress, sources of distress, and the support and management of medics’ stressors.
The GHQ-12 mean was 10.7 (SD 5.0, range 0–23) and PCL-C mean was 36.2 (SD 9.7, range 17–69). There was fair internal consistency for the GHQ-12 and PCL-C (Cronbach’s alpha coeffecients 0.74 and 0.80, respectively) and significant correlation between the two scales (Pearson’s R-correlation 0.47, P<0.001). Qualitative results revealed abundant evidence of stressors, including perceived inadequacy of skills, transportation barriers, lack of medical resources, isolation from family communities, threats of military violence including landmine injury, and early life trauma resulting from conflict and displacement. Medics also discussed mechanisms to manage stressors, including peer support, group-based and individual forms of coping.
The results suggest significant sources and manifestations of mental distress among this under-studied population. The discrepancy between qualitative evidence of abundant stressors and the comparatively low symptom scores may suggest marked mental resilience among subjects. The observed symptom score means in contrast with the qualitative evidence of abundant stressors may suggest the development of marked mental resilience among subjects. Alternatively, the discrepancy may reflect the inadequacy of standard screening tools not validated for this population and potential cultural inappropriateness of established diagnostic frameworks. The importance of peer-group support as a protective factor suggests that interventions might best serve healthworkers in conflict areas by emphasizing community- and team-based strategies.
PMCID: PMC3750555  PMID: 23899166
Burma; Myanmar; Trauma; Mental health; PTSD; Conflict; Healthworkers; Medics; Anxiety; Depression; Burnout; Vicarious traumatization
6.  Depressive Symptoms and Resilience among Pregnant Adolescents: A Case-Control Study 
Background. Data regarding depression and resilience among adolescents is still lacking. Objective. To assess depressive symptoms and resilience among pregnant adolescents. Method. Depressive symptoms and resilience were assessed using two validated inventories, the 10-item Center for Epidemiologic Studies Short Depression Scale (CESD-10) and the 14-item Wagnild and Young Resilience Scale (RS), respectively. A case-control approach was used to compare differences between adolescents and adults. Results. A total of 302 pregnant women were enrolled in the study, 151 assigned to each group. Overall, 56.6% of gravids presented total CESD-10 scores 10 or more indicating depressed mood. Despite this, total CESD-10 scores and depressed mood rate did not differ among studied groups. Adolescents did however display lower resilience reflected by lower total RS scores and a higher rate of scores below the calculated median (P < .05). Logistic regression analysis could not establish any risk factor for depressed mood among studied subjects; however, having an adolescent partner (OR, 2.0 CI 95% 1.06–4.0, P = .03) and a preterm delivery (OR, 3.0 CI 95% 1.43–6.55, P = .004) related to a higher risk for lower resilience. Conclusion. In light of the findings of the present study, programs oriented at giving adolescents support before, during, and after pregnancy should be encouraged.
PMCID: PMC3065659  PMID: 21461335
7.  Investigation of perceived social support in mothers of infants hospitalized in neonatal Intensive Care Unit 
Hippokratia  2013;17(2):130-135.
Purpose: To identify the degree of perceived social support by mothers of infants hospitalized in neonatal intensive care unit (NICU) and to investigate effects depression and anxiety levels on the perceived social support.
Method: The study included 50 mothers of infants hospitalized in NICU. Demographic and clinical characteristics of the mothers were collected using a personal data form designed by the study researchers via face-to-face interviews. The Multidimensional Scale of Perceived Social Support Scale (MSPSS) was used to evaluate the degree of perceived social support by the mothers and Hospital Anxiety and Depression (HAD) Scale was used to assess their anxiety and depression levels.
Results: The mean age of the mothers was 29.1 ± 4.2 years. There was a significant correlation between the scores of the anxiety and depression subscales (r=0.772; p<0.001), whereas these scores were not significantly correlated with MSPSS total score. The scores MSPSS subscales were significantly correlated with each other, as well as with MSPSS total score. Friend subscale score and depression subscale score were positively correlated with education level (r=0.295, p=0.038 and r=0.407, p=0.003, respectively). The family and spouse subscale scores and MSPSS total score were significantly higher assisted conception technique group compared with the spontaneous conception group (p=0.020, p=0.010 and p=0.016, respectively). The family and spouse subscale scores and MSPSS total score were significantly lower in the mothers with depression subscale score of ≥7 than in the mothers with depression subscale score of <7 (p=0.010, p=0.038 and p=0.018, respectively). In the linear regression model, only education level was found to be a significant factor affecting depression level (p=0.006).
Conclusion: The mothers of infants hospitalized in the NICU with higher education levels had higher depression level and perceived social support from friends. Informing the family members and providing psychological support independent from the duration of gestation are of paramount importance.
PMCID: PMC3743616  PMID: 24376317
Newborn; social support; depression; anxiety
8.  The relationship of parental rearing behavior and resilience as well as psychological symptoms in a representative sample 
Recalled parental rearing behavior is one of the factors influencing the strength of resilience. However, it is unclear whether resilience is a relatively stable personality trait or has a relational character whose protective strength changes over the course of life. Therefore, the association between recalled parental rearing and resilience as well as symptoms of anxiety and depression was investigated in respect to age and gender.
N = 4,782 healthy subjects aged 14-92 (M = 48.1 years) were selected by the random-route sampling method. In this sample, an ultra-short form of the Recalled Parental Rearing Behavior Questionnaire, the German short version of the resilience scale, and two screening instruments for depression and anxiety (PHQ-2, GAD-2) were filled out. Structural equation modelling was used to analyze the data estimated with the maximum likelihood method approach.
The data revealed that rejection and punishment were clearly associated with lower resilience. Moreover, resilience had a strong connection to the symptoms of anxiety and depression. Resilience had the same quality of association in both men and women with respect to anxiety and depression. Furthermore, the effect of resilience did not vary across several age groups even though challenges may differ over a lifetime.
Recalled parental rearing behavior such as rejection and punishment as well as control and overprotection exert a significant association on the strength of resilience. Resilience has an effect independent of gender and does not affect people of different age groups differently.
PMCID: PMC4289338  PMID: 25381113
Recalled parental rearing behavior; Resilience; Anxiety; Depression
9.  Hopefulness predicts resilience after hereditary colorectal cancer genetic testing: a prospective outcome trajectories study 
BMC Cancer  2010;10:279.
Background -
Genetic testing for hereditary colorectal cancer (HCRC) had significant psychological consequences for test recipients. This prospective longitudinal study investigated the factors that predict psychological resilience in adults undergoing genetic testing for HCRC.
Methods -
A longitudinal study was carried out from April 2003 to August 2006 on Hong Kong Chinese HCRC family members who were recruited and offered genetic testing by the Hereditary Gastrointestinal Cancer Registry to determine psychological outcomes after genetic testing. Self-completed questionnaires were administered immediately before (pre-disclosure baseline) and 2 weeks, 4 months and 1 year after result disclosure. Using validated psychological inventories, the cognitive style of hope was measured at baseline, and the psychological distress of depression and anxiety was measured at all time points.
Results -
Of the 76 participating subjects, 71 individuals (43 men and 28 women; mean age 38.9 ± 9.2 years) from nine FAP and 24 HNPCC families completed the study, including 39 mutated gene carriers. Four patterns of outcome trajectories were created using established norms for the specified outcome measures of depression and anxiety. These included chronic dysfunction (13% and 8.7%), recovery (0% and 4.3%), delayed dysfunction (13% and 15.9%) and resilience (76.8% and 66.7%). Two logistic regression analyses were conducted using hope at baseline to predict resilience, with depression and anxiety employed as outcome indicators. Because of the small number of participants, the chronic dysfunction and delayed dysfunction groups were combined into a non-resilient group for comparison with the resilient group in all subsequent analysis. Because of low frequencies, participants exhibiting a recovery trajectory (n = 3 for anxiety and n = 0 for depression) were excluded from further analysis. Both regression equations were significant. Baseline hope was a significant predictor of a resilience outcome trajectory for depression (B = -0.24, p < 0.01 for depression); and anxiety (B = -0.11, p = 0.05 for anxiety).
Conclusions -
The current findings suggest that hopefulness may predict resilience after HCRC genetic testing in Hong Kong Chinese. Interventions to increase the level of hope may be beneficial to the psychological adjustment of CRC genetic testing recipients.
PMCID: PMC2891641  PMID: 20537192
10.  The Early Psychological Impacts of the Deepwater Horizon Oil Spill on Florida and Alabama Communities 
Environmental Health Perspectives  2011;119(6):838-843.
Although public concern has focused on the environmental impact of the Deepwater Horizon oil spill, the public health impact on a broad range of coastal communities is minimally known.
We sought to determine the acute level of distress (depression, anxiety), mechanisms of adjustment (coping, resilience), and perceived risk in a community indirectly impacted by the oil spill and to identify the extent to which economic loss may explain these factors.
Using a community-based participatory model, we performed standardized assessments of psychological distress (mood, anxiety), coping, resilience, neurocognition, and perceived risk on residents of fishing communities who were indirectly impacted (n = 71, Franklin County, Florida) or directly exposed (n = 23, Baldwin County, Alabama) to coastal oil. We also compared findings for participants who reported income stability (n = 47) versus spill-related income loss (n = 47).
We found no significant differences between community groups in terms of psychological distress, adjustment, neurocognition, or environmental worry. Residents of both communities displayed clinically significant depression and anxiety. Relative to those with stable incomes, participants with spill-related income loss had significantly worse scores on tension/anxiety, depression, fatigue, confusion, and total mood disturbance scales; had higher rates of depression; were less resilient; and were more likely to use behavioral disengagement as a coping strategy.
Current estimates of human health impacts associated with the oil spill may underestimate the psychological impact in Gulf Coast communities that did not experience direct exposure to oil. Income loss after the spill may have a greater psychological health impact than the presence of oil on the immediately adjacent shoreline.
PMCID: PMC3114820  PMID: 21330230
disasters; environmental epidemiology; occupational health; petroleum products; risk perception
11.  A confirmatory bifactor analysis of the hospital anxiety and depression scale in an Italian community sample 
The Hospital Anxiety and Depression Scale (HADS) is a widely used self-report measure to assess emotional distress in clinical populations. As highlighted in recent review studies, the latent structure of the HADS is still an issue. The aim of this study was to analyze the factorial structure of the HADS in a large community sample in Italy, and to test the invariance of the best fitting model across age and gender groups.
Data analyses were carried out on a sample of 1.599 participants proportionally stratified according to the Italian census population pyramid. Participants aged 18 to 85 years (females = 51.8%), living in eight different regions of Italy, voluntarily participated in the study. The survey questionnaire contained the HADS, Health Status questions, and sociodemographic variables.
Confirmatory factor analysis indicated that a bifactor model, with a general psychological distress factor and two orthogonal group factors with anxiety and depression, was the best fitting one compared to six alternative factor structures reported in the literature, with overall good fit indices [Non-normed Fit Index (NNFI) = .97; Comparative Fit Index (CFI) = .98; Root Mean-Square Error of Approximation (RMSEA) = .04]. Multi-group analyses supported total invariance of the HADS measurement model for males and females, and for younger (i.e., 18–44 years old) and older (i.e., 45–85 years old) participants. Our descriptive analyses showed that females reported significant higher anxiety and general distress mean scores than males. Moreover, older participants reported significant higher HADS, anxiety and depression scores than younger participants.
The results of the present study confirmed that the HADS has good psychometric properties in an Italian community sample, and that the HADS scores, especially the general psychological distress one, can be reliably used for assessing age and gender differences. In keeping with the most recent factorial studies, our analysis supported the superior fit of a bifactor model. However, the high factor loadings on the general factor also recommend caution in the use of the two subscales as independent measures.
PMCID: PMC4054905  PMID: 24902622
Measurement; Validity; Hospital anxiety and depression scale; Confirmatory factor analysis; Bifactor model
12.  Gender differences in patients with dizziness and unsteadiness regarding self-perceived disability, anxiety, depression, and its associations 
It is known that anxiety and depression influence the level of disability experienced by persons with vertigo, dizziness or unsteadiness. Because higher prevalence rates of disabling dizziness have been found in women and some studies reported a higher level of psychiatric distress in female patients our primary aim was to explore whether women and men with vertigo, dizziness or unsteadiness differ regarding self-perceived disability, anxiety and depression. Secondly we planned to investigate the associations between disabling dizziness and anxiety and depression.
Patients were recruited from a tertiary centre for vertigo and balance disorders. Participants rated their global disability as mild, moderate or severe. They filled out the Dizziness Handicap Inventory and the two subscales of the Hospital Anxiety Depression Scale (HADS). The HADS was analysed 1) by calculating the median values, 2) by estimating the prevalence rates of abnormal anxiety/depression based on recommended cut-off criteria. Mann-Whitney U-tests, Chi-square statistics and odds ratios (OR) were calculated to compare the observations in both genders. Significance values were adjusted with respect to multiple comparisons.
Two-hundred and two patients (124 women) mean age (standard deviation) of 49.7 (13.5) years participated. Both genders did not differ significantly in the mean level of self-perceived disability, anxiety, depression and symptom severity. There was a tendency of a higher prevalence of abnormal anxiety and depression in men (23.7%; 28.9%) compared to women (14.5%; 15.3%). Patients with abnormal depression felt themselves 2.75 (95% CI: 1.31-5.78) times more severely disabled by dizziness and unsteadiness than patients without depression. In men the OR was 8.2 (2.35-28.4). In women chi-square statistic was not significant. The ORs (95% CI) of abnormal anxiety and severe disability were 4.2 (1.9-8.9) in the whole sample, 8.7 (2.5-30.3) in men, and not significant in women.
In men with vertigo, dizziness or unsteadiness emotional distress and its association with self-perceived disability should not be underestimated. Longitudinal surveys with specific pre-defined co-variables of self-perceived disability, anxiety and depression are needed to clarify the influence of gender on disability, anxiety and depression in patients with vertigo, dizziness or unsteadiness.
PMCID: PMC3352112  PMID: 22436559
13.  Feasibility of brief psychological distress screening by a community-based telephone helpline for cancer patients and carers 
BMC Cancer  2010;10:14.
Up to one-third of people affected by cancer experience ongoing psychological distress and would benefit from screening followed by an appropriate level of psychological intervention. This rarely occurs in routine clinical practice due to barriers such as lack of time and experience. This study investigated the feasibility of community-based telephone helpline operators screening callers affected by cancer for their level of distress using a brief screening tool (Distress Thermometer), and triaging to the appropriate level of care using a tiered model.
Consecutive cancer patients and carers who contacted the helpline from September-December 2006 (n = 341) were invited to participate. Routine screening and triage was conducted by helpline operators at this time. Additional socio-demographic and psychosocial adjustment data were collected by telephone interview by research staff following the initial call.
The Distress Thermometer had good overall accuracy in detecting general psychosocial morbidity (Hospital Anxiety and Depression Scale cut-off score ≥ 15) for cancer patients (AUC = 0.73) and carers (AUC = 0.70). We found 73% of participants met the Distress Thermometer cut-off for distress caseness according to the Hospital Anxiety and Depression Scale (a score ≥ 4), and optimal sensitivity (83%, 77%) and specificity (51%, 48%) were obtained with cut-offs of ≥ 4 and ≥ 6 in the patient and carer groups respectively. Distress was significantly associated with the Hospital Anxiety and Depression Scale scores (total, as well as anxiety and depression subscales) and level of care in cancer patients, as well as with the Hospital Anxiety and Depression Scale anxiety subscale for carers. There was a trend for more highly distressed callers to be triaged to more intensive care, with patients with distress scores ≥ 4 more likely to receive extended or specialist care.
Our data suggest that it was feasible for community-based cancer helpline operators to screen callers for distress using a brief screening tool, the Distress Thermometer, and to triage callers to an appropriate level of care using a tiered model. The Distress Thermometer is a rapid and non-invasive alternative to longer psychometric instruments, and may provide part of the solution in ensuring distressed patients and carers affected by cancer are identified and supported appropriately.
PMCID: PMC2826295  PMID: 20067645
14.  “I know it when I see it.” The complexities of measuring resilience among parents of children with cancer 
Promoting parent resilience may provide an opportunity to improve family-level survivorship after pediatric cancer; however, measuring resilience is challenging.
The “Understanding Resilience in Parents of Children with Cancer” was a cross-sectional, mixed-methods study of bereaved and non-bereaved parents. Surveys included the Connor-Davidson Resilience scale, the Kessler-6 psychological distress scale, the Post-Traumatic Growth Inventory, and an open-ended question regarding the on-going impact of cancer. We conducted content analyses of open-ended responses and categorized our impressions as “resilient,” “not resilient,” or “unable to determine.” “Resilience” was determined based on evidence of psychological growth, lack of distress, and parent-reported meaning/purpose. We compared consensus-impressions with instrument scores to examine alignment. Analyses were stratified by bereavement status.
Eighty-four (88%) non-bereaved, and 21 (88%) bereaved parents provided written responses. Among non-bereaved, 53 (63%) were considered resilient, 15 (18%) were not. Among bereaved, 11 (52%) were deemed resilient, 5 (24%) were not. All others suggested a mixed or incomplete picture. Rater-determined “resilient” parents tended to have higher personal resources and lower psychological distress (p=<0.001–0.01). Non-bereaved “resilient” parents also had higher post-traumatic growth (p=0.02). Person-level analyses demonstrated that only 50–62% of parents had all 3 instrument scores aligned with our impressions of resilience.
Despite multiple theories, measuring resilience is challenging. Our clinical impressions of resilience were aligned in 100% of cases; however, instruments measuring potential markers of resilience were aligned in approximately half. Promoting resilience therefore requires understanding of multiple factors, including person-level perspectives, individual resources, processes of adaptation and emotional well-being.
PMCID: PMC4264630  PMID: 24756554
Cancer; Oncology; Pediatrics; Parents; Resilience; Psychosocial Outcomes
15.  05. Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study 
Focus Area: Integrative Algorithms of Care
Burnout, attrition, and low work satisfaction of primary care physicians are growing concerns and can have a negative influencee on health care. Interventions for clinicians that improve work-life balance are few and poorly understood.
We undertook this study as a first step in investigating whether an abbreviated mindfulness intervention could increase job satisfaction, quality of life, and compassion among primary care clinicians.
A total of 30 primary care clinicians participated in an abbreviated mindfulness course. We used a single-sample, pre-post design. At 4 points in time (baseline, and 1 day, 8 weeks, and 9 months postintervention), participants completed a set of online measures assessing burnout, anxiety, stress, resilience, and compassion. We used a linear mixed-effects model analysis to assess changes in outcome measures.
Participants had improvements compared with baseline at all 3 follow-up time points. At 9 months postintervention, they had significantly better scores (1) on all Maslach Burnout Inventory burnout subscales—Emotional Exhaustion (P = .009), Depersonalization (P = .005), and Personal Accomplishment (P <.001); (2) on the Depression (P = .001), Anxiety (P = .006), and Stress (P = .002) subscales of the Depression Anxiety Stress Scales-21; and (3) for perceived stress (P = .002) assessed with the Perceived Stress Scale. There were no significant changes on the 14-item Resilience Scale and the Santa Clara Brief Compassion Scale.
In this uncontrolled pilot study, participating in an abbreviated mindfulness training course adapted for primary care clinicians was associated with reductions in indicators of job burnout, depression, anxiety, and stress.
Modified mindfulness training may be a time-efficient tool to help support clinician health and well-being, which may have implications for patient care.
PMCID: PMC3875079
Most longitudinal studies of depressive symptoms reported mean symptom scores that tend to obscure interindividual heterogeneity in the symptom experience. The identification of subgroups of patients with distinct trajectories of depressive symptoms may help identify high risk individuals who require an intervention. This study aimed to identify subgroups of breast cancer patients (n=398) with distinct trajectories of depressive symptoms in the first six months after surgery, as well as predictors of these trajectories.
Growth mixture modeling was used to identify the latent classes based on Center for Epidemiological Studies-Depression scale scores completed prior to and monthly for six months after surgery.
Four latent classes of patients with distinct depressive symptom trajectories were identified: Resilient (38.9%), Subsyndromal (45.2%), Delayed (11.3%), and Peak (4.5%). Patients in the Subsyndromal class were significantly younger than patients in the Resilient class. Compared to the Resilient class, Subsyndromal, Delayed, and Peak classes had higher mean trait and state anxiety scores prior to surgery. Except for axillary lymph node dissection (ALND), disease- and treatment-related characteristics did not differ across the classes. A greater proportion of women in the Subsyndromal class had an ALND compared to those in the Resilient class.
Breast cancer patients experience different trajectories of depressive symptoms after surgery. Of note, over 60% of these women were classified into one of three distinct subgroups with clinically significant levels of depressive symptoms. Identification of phenotypic and genotypic predictors of symptom trajectories after cancer treatment warrants additional investigation.
PMCID: PMC3217116  PMID: 21728421
breast cancer; depression; anxiety; growth mixture modeling; latent profiles; psychological distress
17.  Development of salutogenetic factors in mental health - Antonovsky’s sense of coherence and Bandura’s self-efficacy related to Derogatis’ symptom check list (SCL-90-R) 
The paper analyses how resilience factors and mental health problems interrelate in a 3-year-longitudinal study with 16–19 year olds.
Resilience was measured with a 13-item short version of the Life-Orientation-Scale by Antonovsky (sense-of-coherence, SOC) and a 10-item self-efficacy-scale (SWE) by Jerusalem and Schwarzer. Mental health problems were measured with Derogatis Symptom Check list (SCL-90-R). The data set included 155 participants and was analyzed using Structural Equation Modeling (SEM) designed to examine mutual influence in longitudinal data with Mplus software.
The descriptive data analysis indicates (1) negative correlations between SOC and SCL-90-R at both age 16 and 19 in all subscales but somatization and likewise (2) between self-efficacy and SCL-90-R. (3) SOC correlates positively with SWE at age 16 and 19.
Results of SEM analysis were based on the assumption of two latent variables at two points in time: resilience as measured with mean SOC and mean self-efficacy scores and health problems measured with sub scale scores of SCL-90-R – both at ages 16 and 19. The first SEM model included all possible paths between the two latent variables across time. We found (4) that resilience influences mental health problems cross-sectionally at age 16 and at age 19 but not across time. (5) Both resilience and mental health problems influenced their own development over time. A respecified SEM model included only significant paths. (6) Resilience at age 16 significantly influences health problems at age 16 as well as resilience at age 19. Health problems at age 16 influence those at age 19 and resilience at age 19 influences health problems at age 19.
(a) SOC and self-efficacy instruments measure similar phenomena. (b) Since an influence of resilience on mental health problems and vice versa over time could not be shown there must be additional factors important to development. (c) SOC and self-efficacy are both very stable at 16 and 19 years. This refutes Antonovsky’s assumption that SOC achieves stability first around the age of 30. SOC and self-efficacy are protective factors but they seem to form in (early) childhood.
PMCID: PMC3655857  PMID: 23656898
Resilience - mental health; Salutogenesis; Sense of coherence; Self-efficacy; Symptom-check list (SCL-90); Longitudinal development; Cross-lagged design
18.  Alexithymia, anger and psychological distress in patients with myofascial pain: a case-control study 
Aims: The aim of this study was to investigate psychological distress, anger and alexithymia in a group of patients affected by myofascial pain (MP) in the facial region.
Methods: 45 MP patients [mean (SD) age: 38.9 (11.6)] and 45 female healthy controls [mean (SD) age: 37.8 (13.7)] were assessed medically and psychologically. The medically evaluation consisted of muscle palpation of the pericranial and cervical muscles. The psychological evaluation included the assessment of depression (Beck Depression Inventory—short form), anxiety [State-Trait Anxiety Inventory Form Y (STAI-Y)], emotional distress [Distress Thermometer (DT)], anger [State-Trait Anger Expression Inventory—2 (STAXI-2)], and alexithymia [Toronto Alexithymia Scale (TAS)].
Results: the MP patients showed significantly higher scores in the depression, anxiety and emotional distress inventories. With regard to anger, only the Anger Expression-In scale showed a significant difference between the groups, with higher scores for the MP patients. In addition, the MP patients showed significantly higher alexithymic scores, in particular in the Difficulty in identifying feelings (F1) subscale of the TAS-20. Alexithymia was positively correlated with the Anger Expression-In scale. Both anger and alexithymia showed significant positive correlations with anxiety scores, but only anger was positively correlated with depression.
Conclusion: A higher prevalence of depressive and anxiety symptoms associated with a higher prevalence of alexithymia and expression-in modality to cope with anger was found in the MP patients. Because the presence of such psychological aspects could contribute to generate or exacerbate the suffering of these patients, our results highlight the need to include accurate investigation of psychological aspects in MP patients in normal clinical practice in order to allow clinicians to carry out more efficacious management and treatment strategies.
PMCID: PMC3728491  PMID: 23914181
myofascial facial pain; anxiety; depression; anger; alexithymia
19.  Effects of age on symptom burden, mental health and quality of life amongst people with HIV in the UK 
Journal of the International AIDS Society  2014;17(4Suppl 3):19511.
The evolving HIV epidemic, coupled with advances in HIV treatment, has resulted in an ageing HIV-diagnosed population. It has been suggested that adverse physical and psychological effects of HIV may be higher among older people. However, few studies have examined the effect of older age on well-being for people with HIV.
Materials and Methods
The ASTRA study included 3258 HIV-diagnosed individuals (2248 MSM; 373 heterosexual men; 637 women) recruited from eight UK clinics in 2011–12 (64% response rate). Participants completed a questionnaire that included standard inventories on symptoms and health-related quality of life (HrQoL). Associations of age group with: physical symptom distress (reporting significant distress for ≥1 of 26 symptoms), depression and anxiety (score ≥10 on PHQ-9 and GAD-7, respectively) and HrQoL problem (reporting problems on ≥1 of 5 Eurqol-5D domains) were assessed; adjustment was made for gender/sexuality and time with diagnosed HIV.
Of all participants, 87% were taking ART, 76% had VL ≤50c/mL and 19% had CD4 <350/mm3. Mean age was 45 years (range 18–88) with 5% <30, 23% 30–39, 43% 40–49, 22% 50–59 and 7% ≥60 years. The most prevalent distressing physical symptoms were: lack of energy/tiredness (26%), difficulty sleeping (24%), muscle-ache/joint pain (21%) and pain (18%). With older age, there was no clear trend in prevalence of physical symptom distress, but prevalence of depression and anxiety decreased, while prevalence of HrQoL problems increased. This pattern remained after adjustment for gender/sexuality and time diagnosed with HIV. The increase with age in overall prevalence of HrQoL problem was due to increased problems for “mobility,” “self-care” and “performing usual activities” domains, not an increase in “depression/anxiety.” Longer time with diagnosed HIV was strongly associated with higher prevalence of all symptoms measures and HrQoL problem (p<0.001 for trend, adjusted models).
Physical and psychological symptoms are common among people living with HIV, but the burden of these symptoms is not highest among the older age group. While HrQoL tended to worsen with older age, physical symptom distress did not, and mental health improved. This may reflect greater resilience in older adults, or the potential for “successful ageing”: maintaining mental health despite age-related health losses.
PMCID: PMC4224843  PMID: 25394020
20.  Resilience of health-care workers in the UK; a cross-sectional survey 
Working for the UK National Health Service (NHS) requires working for organisations under financial pressures and frequent restructures, which can lead to anxiety over continuing employment and income. There are currently no studies to date that have examined the influence of personal resilience across all professions and demographics in the NHS. This study aims to quantify resilience within an NHS trust and explore the contribution of demographic variables of gender, age, years of service, pay grade, hours worked, job role, and division worked to the resilience response of employees. The study also explores the relationship between resilience levels and absence rates, as a marker for health and well-being amongst NHS staff.
This study consists of a cross-sectional on-line survey of staff employed in an NHS Trust. All trust employees were asked to complete a Resilience Scale (RS-25), and demographic questions including age, sex, length of service, NHS pay grade (banding), division, job role and number of hours worked per week. Trust level sickness absence rates were also collected during this period. Results were analysed using descriptive statistics, bivariate comparisons and chi-squared tests.
Data was gained from 845 employees; a significant association between gender and resilience found females scoring higher on the resilience scale; x2(5) =18.30, p < 0.05. A weak positive correlation between age and resilience found older employees displaying a higher level of resilience; r = 0.11, p <0.05. Results also suggest employees working between 18.75-37.5 hours a week have higher levels of resilience. Ancillary staff scored low on resilience compared to all other staff groups which showed moderate resilience. Clinical staff scored lower on resilience compared to both administrative staff and clinical staff with line management responsibilities. No correlations were found between absence rates and resilience.
This study gives a snapshot of the resilience of employees in a NHS trust. It is the first of its kind to take into consideration all job roles, divisions and the banding system within a trust. The results also indicate that resilience levels may not be a mediating factor for the health and well-being of NHS staff.
PMCID: PMC4449529  PMID: 26029246
21.  A survey of resilience, burnout, and tolerance of uncertainty in Australian general practice registrars 
Burnout and intolerance of uncertainty have been linked to low job satisfaction and lower quality patient care. While resilience is related to these concepts, no study has examined these three concepts in a cohort of doctors. The objective of this study was to measure resilience, burnout, compassion satisfaction, personal meaning in patient care and intolerance of uncertainty in Australian general practice (GP) registrars.
We conducted a paper-based cross-sectional survey of GP registrars in Australia from June to July 2010, recruited from a newsletter item or registrar education events. Survey measures included the Resilience Scale-14, a single-item scale for burnout, Professional Quality of Life (ProQOL) scale, Personal Meaning in Patient Care scale, Intolerance of Uncertainty-12 scale, and Physician Response to Uncertainty scale.
128 GP registrars responded (response rate 90%). Fourteen percent of registrars were found to be at risk of burnout using the single-item scale for burnout, but none met the criteria for burnout using the ProQOL scale. Secondary traumatic stress, general intolerance of uncertainty, anxiety due to clinical uncertainty and reluctance to disclose uncertainty to patients were associated with being at higher risk of burnout, but sex, age, practice location, training duration, years since graduation, and reluctance to disclose uncertainty to physicians were not.
Only ten percent of registrars had high resilience scores. Resilience was positively associated with compassion satisfaction and personal meaning in patient care. Resilience was negatively associated with burnout, secondary traumatic stress, inhibitory anxiety, general intolerance to uncertainty, concern about bad outcomes and reluctance to disclose uncertainty to patients.
GP registrars in this survey showed a lower level of burnout than in other recent surveys of the broader junior doctor population in both Australia and overseas. Resilience was also lower than might be expected of a satisfied and professionally successful cohort.
PMCID: PMC3563610  PMID: 23294479
Adaptation; Psychological; Burnout; Professional; Job satisfaction; Uncertainty
22.  Dynamics of resilience in forced migration: a 1-year follow-up study of longitudinal associations with mental health in a conflict-affected, ethnic Muslim population 
BMJ Open  2015;5(2):e006000.
The concept of ‘resilience’ is of increasing interest in studies of mental health in populations facing adversity. However, lack of longitudinal data on the dynamics of resilience and non-usage of resilience-specific measurements have prevented a better understanding of resilience-mental health interactions. Hence, the present study was conducted to investigate the stability of levels of resilience and its associations with sociodemographic and mental health exposures in a conflict-affected internal-migrant population in Sri Lanka.
A prospective follow-up study of 1 year.
Puttalam district of North Western province in postconflict Sri Lanka (baseline in 2011, follow-up in 2012).
An ethnic Muslim population internally displaced 20 years ago (in 1990) from Northern Sri Lanka, aged 18 or above and currently in the process of return migration.
It was hypothesised that levels of resilience would be associated with mental health outcomes. Resilience was measured on both occasions using the 14-item Resilience Scale (RS-14), social support by the Multidimensional Social Support Scale and Lubben Social Network Scale and common mental disorders by the Patient Health Questionnaire (PHQ).
Of 450 participants interviewed at baseline in 2011, 338 (75.1%) were re-interviewed in 2012 after a 1-year follow-up. The mean resilience scores measured by RS-14 were 80.2 (95% CI 78.6 to 81.9) at baseline and 84.9 (83.5 to 86.3) at follow-up. At both time points, lower resilience was independently associated with food insecurity, lower social support availability and social isolation. At both time points, there were significant associations with common mental disorders (CMDs) in unadjusted analyses, but they only showed independence at baseline. The CMD prevalence, maintenance and incidence at follow-up was 8.3%, 28.2% and 2.2%, respectively.
In this displaced population facing a potential reduction in adversity, resilience was more strongly and robustly associated with economic and social factors than with the presence of mental disorder.
PMCID: PMC4336461  PMID: 25687898
23.  Stress Management and Resilience Training Among Department of Medicine Faculty: A Pilot Randomized Clinical Trial 
Physician distress is common and related to numerous factors involving physicians’ personal and professional lives. The present study was designed to assess the effect of a Stress Management and Resiliency Training (SMART) program for increasing resiliency and quality of life, and decreasing stress and anxiety among Department of Medicine (DOM) physicians at a tertiary care medical center.
Forty DOM physicians were randomized in a wait-list controlled clinical trial to either the SMART intervention or a wait-list control group for 8 weeks. The intervention involved a single 90 min one-on-one training in the SMART program. Primary outcome measures assessed at baseline and week 8 included the Connor Davidson Resilience Scale (CDRS), Perceived Stress Scale (PSS), Smith Anxiety Scale (SAS) and Linear Analog Self Assessment Scale (LASA).
Thirty-two physicians completed the study. A statistically significant improvement in resiliency, perceived stress, anxiety, and overall quality of life at 8 weeks was observed in the study arm compared to the wait-list control arm: CDRS: mean ± SD change from baseline +9.8 ± 9.6 vs. -0.8 ± 8.2, t(30) = 3.18, p = 0.003; PSS: -5.4 ± 8.1 vs. +2.2 ± 6.1, t(30) = -2.76, p = 0.010; SAS: -11.8 ± 12.3 vs.+ 2.9 ± 8.9, t(30) = -3.62, p = 0.001; and LASA: +0.4 ± 1.4 vs. -0.6 ± 1.0, t(30) = 2.29, p = 0.029.
A brief training to enhance resilience and decrease stress among physicians using the SMART program was feasible. Further, the intervention provided statistically significant improvement in resilience, stress, anxiety, and overall quality of life. In the future, larger clinical trials with longer follow-up and possibly wider dissemination of this intervention are warranted.
PMCID: PMC3138987  PMID: 21279454
stress; resilience; wellness; physicians; burnout
24.  Resilience as a Possible Predictor for Psychological Distress in Chronic Spinal Cord Injured Patients Living in the Community 
Annals of Rehabilitation Medicine  2012;36(6):815-820.
To investigate whether higher resilience level predicts low levels of psychological distress in chronic SCI patients living in the community.
Thirty seven patients (mean age 41.5±10.9, male : female=28 : 9) with chronic spinal cord injury (duration 8.35±7.0 years) living in the community are included, who were hospitalized for annual checkups from November, 2010 to May, 2011. First, their spinal cord injury level, completeness and complications were evaluated. The patients completed questionnaires about their educational status, religion, employment status, marital status, medical and psychological history and also the following questionnaires: Hospital Anxiety and Depression Scale (HADS), Connor-Davidson Resilience Scale (CD-RISC), Alcohol Use Disorders Identification Test-alcohol consumption questions (AUDIT-C) and Health-related quality of life (EQ-5D). The patients were divided into two subgroups: patients with HADS ≥13 are classified as high psychological distress group and others as low psychological distress group. We compared the two groups to find statistically significant differences among the variables.
CD-RISC, EQ-5D and employment status are significantly different between two groups (p<0.05). In a forward stepwise regression, we found that EQ-5D had a greater contribution than CD-RISC to the psychological distress level.
In addition to health-related quality of life, resilience can be suggested as a possible predictor of psychological distress in chronic SCI patients.
PMCID: PMC3546184  PMID: 23342314
Resilience; Predictor; Spinal cord injuries
25.  Validity of the Italian adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus-sufferers 
The aim of this study was to determine the validity of the Italian translation of the Tinnitus Handicap Inventory (THI) by Newman et al. in order to make this self-report measure of perceived tinnitus handicap available both for clinical and research purposes in our country and to contribute to its cross-cultural validation as a self-report measure of perceived severity of tinnitus. The Italian translation of the Tinnitus Handicap Inventory (THI) was administered to 100 outpatients suffering from chronic tinnitus, aged between 20 and 82 years, who attended the audiological tertiary centres of the University Hospital of Modena and the Regional Hospital of Treviso. No segregation of cases was made on audiometric results; patients suffering from vertigo and neurological diseases were excluded. Pyschoacoustic characteristics of tinnitus (loudness and pitch) were determined and all patients also completed the MOS 36-Item Short Form Health Survey to assess self-perceived quality of life and the Hospital Anxiety and Depression Scale as a measure of self-perceived levels of anxiety and depression. The THI-I showed a robust internal consistency reliability (Cronbach’s alpha = 0.91) that was only slightly lower than the original version (Tinnitus Handicap Inventory-US; Cronbach’s alpha = 0.93) and its Danish (Cronbach’s alpha = 0.93) and Portuguese (Cronbach’s alpha = 0.94) translations. Also its two subscales (Functional and Emotional) showed a good internal consistency reliability (Cronbach’s alpha = 0.85 and 0.86, respectively). On the other hand, the Catastrophic subscale showed an unacceptable internal consistency reliability as it is too short in length (5 items). A confirmatory factor analysis failed to demonstrate that the 3 subscales of the THI-I correspond to 3 different factors. Close correlations were found between the total score of the Italian translation of the Tinnitus Handicap Inventory and all the subscales of the MOS 36-Item Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale scores indicating a good construct validity. Moreover, these statistically significant correlations (p < 0.005) confirmed that the self-report tinnitus handicap is largely related to psychological distress and a deterioration in the quality of life. On the other hand, it was confirmed that the tinnitus perceived handicap is totally independent (p > 0.05) from its audiometrically-derived measures of loudness and pitch thus supporting previous studies that focused on the importance of non-auditory factors, namely somatic attention, psychological distress and coping strategies, in the generation of tinnitus annoyance. Finally the results of the present study suggest that the THI-I maintains its original validity and should be incorporated, together with other adequate psychometric questionnaires, in the audiological examination of patients suffering from tinnitus and that psychiatric counselling should be recommended for the suspected co-morbidity between tinnitus annoyance and psychological distress.
PMCID: PMC2644986  PMID: 18646574
Tinnitus; Anxiety; Depression; Quality of life

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