Resilience in the context of general practice

The topic of resilience is highly topical. More papers are also being published on this topic in the primary care field.
First, study populations of patients with chronic diseases are being investigated to determine the role of resilience factors. And secondly, the resilience of healthcare professionals is also the subject of research projects. The PERMA model is an evidence-based approach that summarizes key resilience factors and is applicable in a variety of contexts.

Resilience refers to the ability to cope with or recover from difficult life events without long-term negative consequences and to adapt in a positive way [1]. In general practice, resilience can be considered in various ways – on the one hand, in relation to the management of physical or mental illness, but also with regard to the resilience of professionals in dealing with occupational stress and, last but not least, with regard to the neurobiological basis of resilience mechanisms [1]. It is important to understand here that the experience of overstress cannot be derived unilaterally from the intensity of the stresses, but always results from the relationship between stresses on the one hand and coping skills on the other.

Strengthening psychological resilience is closely linked to well-being. Accordingly, strengthening well-being can also contribute to a higher degree of resilience. Seligman’s PERMA model summarizes important factors for well-being as follows [2]:

Positiveemotions
Engagement(using strengths, experiencing flow)
Relationships
Meaning/Sense
Accomplishment(experiencing self-efficacy, succeeding)

Resilience research in patients with chronic diseases.

With patients in mind, some recent study findings are singled out as examples. In the context of gastrointestinal disorders, there are numerous findings on resilience as a protective factor with respect to the development of psychological comorbidities. This is also reflected in a study by Philippou et al. in patients with inflammatory bowel disease (IBD) [3]. Given that anxiety and depression are relatively common comorbidities in IBD and correlate with poorer treatment outcomes, a questionnaire-based data collection was conducted in 288 IBD patients. According to study authors, the results (box) suggest that IBD patients with higher resilience may have better coping mechanisms, thus buffering the development of anxiety.

Philippou et al. 2022: Resilience in CED patients
In addition to the Connor-Davidson Resilience Scale (CD-RISC), the Generalized Anxiety Disorder 7 (GAD-7) and the Patient Health Questionnaire-9 were used. A possible relationship between the severity of anxiety and depression and the level of resilience was analyzed using multivariable linear regression analysis. This showed that high levels of resilience were associated with lower levels of anxiety. The severity of anxiety (GAD-7) quantifiably decreased (by 0.04 units; p=0.0003) for each point by which the resilience score (CD-RISC) increased. In contrast to anxiety, the relationship between resilience and depression did not remain statistically significant in multivariate analysis.

according to [3]

In the study by Ghulam et al. was a secondary analysis [4]. Data were found to be inconsistent overall, but in three studies from a Swedish registry of conscripts (“Swedish military conscription cohort”), low resilience scores were associated with higher CVD risk [5–7] (box) .

Age- and sex-adjusted results from an Italian cross-sectional study (n=10 821) suggest a similar relationship. In the highest resilience group, the prevalence of CVD was lower compared to the lowest resilience group (3.5% vs. 4.7%; p<0.011) [8].

In contrast, in a longitudinal analysis of 2 765 postmenopausal African American women, resilience score was not associated with CVD incidence: The lowest PR quartile compared to the highest showed HR=0.95 (95% CI 0.63-1.42; p=0.66) [9].

Ghulam et al. 2022: Resilience and CVD
The lower tertile of resilience scores was associated with the following factors compared to the upper tertile:
– Risk of stroke (hazard ratio [HR]=1.16; 95% CI 1.04-1.29; n=237 879).
– Coronary heart disease (HR=1.17; 95% CI; 1.10-1.25; n=237 980).
– Heart failure (HR=1.41; 95% CI 1.30-1.53 ; n=1 784 450).

to [4–7]

Stresses and strains in everyday medical practice: promoting resilience pays off

Being a general practitioner is an exhausting profession and the stress can have a negative impact on psychological well-being but also on patient health care [1]. Resilience as a dynamic event can help to mitigate this.

In a recent study by Kaleta et al [10], resilience of family physicians was inversely related to emotional distress. In addition, clinicians with a tendency to evaluate ambiguous information positively (“positive interpretation bias”) had higher resilience scores, and such bias proved to be a significant independent predictor of resilience – controlled for depression, anxiety, and stress – in a hierarchical regression.

Recent research suggests that interventions to promote resilience in physicians have been associated with relevant benefits. The results of a study by Angelopoulou et al. 2022 show that physicians can benefit in terms of their personal resilience if they participate for more than one week in a measure specifically designed for this purpose [11].

Take-Home Messages

In a study published in 2022 by Philippou et al. high resilience in IBD patients was associated with lower anxiety, and the severity of anxiety decreased analogously to the increase in resilience [3].
In a study also published last year by Ghulam et al. possible associations of resilience with cardiovascular disease and metabolic disorders have been investigated [4].
Resilience is also an increasingly relevant topic for healthcare professionals, such as physicians – and not just in the general medical setting. Scientific research indicates, among other things, that resilience is negatively correlated with emotional distress and that interventions to promote resilience have beneficial effects [10,11].

Literature:

“Resilience in General Practice,” Hot Topic: Psychosomatics, Prof. Claas Lahmann, MD, Praxis Update, Berlin, April 28-29, 2023.
Seligman M: Flourish. New York, NY; Free Press: 2011.
Philippou A, et al: High Levels of Psychological Resilience are Associated with Decreased Anxiety in Inflammatory Bowel Disease. Inflamm Bowel Dis 2022;28: 888-894.
Ghulam A, et al: Psychological Resilience, Cardiovascular Disease, and Metabolic Disturbances: A Systematic Review. Front Psychol 2022;13: 817298.
Bergh C, et al: Stress resilience in male adolescents and subsequent stroke risk: cohort study. J Neurol Neurosurg Psychiatry 2014; 85: 1331-1336.
Bergh C, et al: Stress resilience and physical fitness in adolescence and risk of coronary heart disease in middle age. Heart 2015; 101: 623-629.
Robertson J, et al: Mental disorders and stress resilience in adolescence and long-term risk of early heart failure among Swedish men. Int J Cardiol 2017; 243: 326-331.
Bonaccio M, et al: Mediterranean-type diet is associated with higher psychological resilience in a general adult population: findings from the Moli-sani study. Eur J Clin Nutr 2018; 72: 154-160.
Felix AS, et al: Stress, resilience, and cardiovascular disease risk among black women: results from the Women’s health initiative. Circ Cardiovasc Qual Outcomes 2019; 12: e005284.
Kaleta FO, et al: Cognitive mechanisms and resilience in UK-based general practitioners: cross-sectional findings. Occup Med (Lond) 2023;73(2): 91-96.
Angelopoulou P, Panagopoulou E: Resilience interventions in physicians: A systematic review and meta-analysis. Appl Psychol Health Well Being 2022; 14(1): 3-25.