Background
Resilience can be defined as the maintenance or quick recovery of mental health during or after periods of stressor exposure, which may result from a potentially traumatising event, challenging life circumstances, a critical life transition phase, or physical illness. Healthcare professionals, such as nurses, physicians, psychologists and social workers, are exposed to various work‐related stressors (e.g. patient care, time pressure, administration) and are at increased risk of developing mental disorders. This population may benefit from resilience‐promoting training programmes.
Objectives:
To assess the effects of interventions to foster resilience in healthcare professionals, that is, healthcare staff delivering direct medical care (e.g. nurses, physicians, hospital personnel) and allied healthcare staff (e.g. social workers, psychologists).
Search methods:
We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results.
Selection criteria:
Randomised controlled trials (RCTs) in adults aged 18 years and older who are employed as healthcare professionals, comparing any form of psychological intervention to foster resilience, hardiness or post‐traumatic growth versus no intervention, wait‐list, usual care, active or attention control. Primary outcomes were resilience, anxiety, depression, stress or stress perception and well‐being or quality of life. Secondary outcomes were resilience factors.
Data collection and analysis:
Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post‐test only).
Main results:
We included 44 RCTs (high‐income countries: 36). Thirty‐nine studies solely focused on healthcare professionals (6892 participants), including both healthcare staff delivering direct medical care and allied healthcare staff. Four studies investigated mixed samples (1000 participants) with healthcare professionals and participants working outside of the healthcare sector, and one study evaluated training for emergency personnel in general population volunteers (82 participants). The included studies were mainly conducted in a hospital setting and included physicians, nurses and different hospital personnel (37/44 studies).
Participants mainly included women (68%) from young to middle adulthood (mean age range: 27 to 52.4 years). Most studies investigated group interventions (30 studies) of high training intensity (18 studies; > 12 hours/sessions), that were delivered face‐to‐face (29 studies). Of the included studies, 19 compared a resilience training based on combined theoretical foundation (e.g. mindfulness and cognitive‐behavioural therapy) versus unspecific comparators (e.g. wait‐list). The studies were funded by different sources (e.g. hospitals, universities), or a combination of different sources. Fifteen studies did not specify the source of their funding, and one study received no funding support.
Risk of bias was high or unclear for most studies in performance, detection, and attrition bias domains.
At post‐intervention, very‐low certainty evidence indicated that, compared to controls, healthcare professionals receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.45, 95% confidence interval (CI) 0.25 to 0.65; 12 studies, 690 participants), lower levels of depression (SMD −0.29, 95% CI −0.50 to −0.09; 14 studies, 788 participants), and lower levels of stress or stress perception (SMD −0.61, 95% CI −1.07 to −0.15; 17 studies, 997 participants). There was little or no evidence of any effect of resilience training on anxiety (SMD −0.06, 95% CI −0.35 to 0.23; 5 studies, 231 participants; very‐low certainty evidence) or well‐being or quality of life (SMD 0.14, 95% CI −0.01 to 0.30; 13 studies, 1494 participants; very‐low certainty evidence). Effect sizes were small except for resilience and stress reduction (moderate). Data on adverse effects were available for three studies, with none reporting any adverse effects occurring during the study (very‐low certainty evidence).
Authors' conclusions:
For healthcare professionals, there is very‐low certainty evidence that, compared to control, resilience training may result in higher levels of resilience, lower levels of depression, stress or stress perception, and higher levels of certain resilience factors at post‐intervention.
The paucity of medium‐ or long‐term data, heterogeneous interventions and restricted geographical distribution limit the generalisability of our results. Conclusions should therefore be drawn cautiously. The findings suggest positive effects of resilience training for healthcare professionals, but the evidence is very uncertain. There is a clear need for high‐quality replications and improved study designs.
Background
Resilience can be defined as maintaining or regaining mental health during or after significant adversities such as a potentially traumatising event, challenging life circumstances, a critical life transition or physical illness. Healthcare students, such as medical, nursing, psychology and social work students, are exposed to various study‐ and work‐related stressors, the latter particularly during later phases of health professional education. They are at increased risk of developing symptoms of burnout or mental disorders. This population may benefit from resilience‐promoting training programmes.
Objectives:
To assess the effects of interventions to foster resilience in healthcare students, that is, students in training for health professions delivering direct medical care (e.g. medical, nursing, midwifery or paramedic students), and those in training for allied health professions, as distinct from medical care (e.g. psychology, physical therapy or social work students).
Search methods:
We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results.
Selection criteria:
Randomised controlled trials (RCTs) comparing any form of psychological intervention to foster resilience, hardiness or post‐traumatic growth versus no intervention, waiting list, usual care, and active or attention control, in adults (18 years and older), who are healthcare students. Primary outcomes were resilience, anxiety, depression, stress or stress perception, and well‐being or quality of life. Secondary outcomes were resilience factors.
Data collection and analysis:
Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post‐test only).
Main results:
We included 30 RCTs, of which 24 were set in high‐income countries and six in (upper‐ to lower‐) middle‐income countries. Twenty‐two studies focused solely on healthcare students (1315 participants; number randomised not specified for two studies), including both students in health professions delivering direct medical care and those in allied health professions, such as psychology and physical therapy. Half of the studies were conducted in a university or school setting, including nursing/midwifery students or medical students. Eight studies investigated mixed samples (1365 participants), with healthcare students and participants outside of a health professional study field.
Participants mainly included women (63.3% to 67.3% in mixed samples) from young adulthood (mean age range, if reported: 19.5 to 26.83 years; 19.35 to 38.14 years in mixed samples). Seventeen of the studies investigated group interventions of high training intensity (11 studies; > 12 hours/sessions), that were delivered face‐to‐face (17 studies). Of the included studies, eight compared a resilience training based on mindfulness versus unspecific comparators (e.g. wait‐list).
The studies were funded by different sources (e.g. universities, foundations), or a combination of various sources (four studies). Seven studies did not specify a potential funder, and three studies received no funding support.
Risk of bias was high or unclear, with main flaws in performance, detection, attrition and reporting bias domains.
At post‐intervention, very‐low certainty evidence indicated that, compared to controls, healthcare students receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.43, 95% confidence interval (CI) 0.07 to 0.78; 9 studies, 561 participants), lower levels of anxiety (SMD −0.45, 95% CI −0.84 to −0.06; 7 studies, 362 participants), and lower levels of stress or stress perception (SMD −0.28, 95% CI −0.48 to −0.09; 7 studies, 420 participants). Effect sizes varied between small and moderate. There was little or no evidence of any effect of resilience training on depression (SMD −0.20, 95% CI −0.52 to 0.11; 6 studies, 332 participants; very‐low certainty evidence) or well‐being or quality of life (SMD 0.15, 95% CI −0.14 to 0.43; 4 studies, 251 participants; very‐low certainty evidence).
Adverse effects were measured in four studies, but data were only reported for three of them. None of the three studies reported any adverse events occurring during the study (very‐low certainty of evidence).
Authors' conclusions:
For healthcare students, there is very‐low certainty evidence for the effect of resilience training on resilience, anxiety, and stress or stress perception at post‐intervention.
The heterogeneous interventions, the paucity of short‐, medium‐ or long‐term data, and the geographical distribution restricted to high‐income countries limit the generalisability of results. Conclusions should therefore be drawn cautiously. Since the findings suggest positive effects of resilience training for healthcare students with very‐low certainty evidence, high‐quality replications and improved study designs (e.g. a consensus on the definition of resilience, the assessment of individual stressor exposure, more attention controls, and longer follow‐up periods) are clearly needed.
Background: Many existing scales for microstressor assessment do not differentiate between objective (ie, observable) stressor events and stressful cognitions or concerns. They often mix items assessing objective stressor events with items measuring other aspects of stress, such as perceived stressor severity, the evoked stress reaction, or further consequences on health, which may result in spurious associations in studies that include other questionnaires that measure such constructs. Most scales were developed several decades ago; therefore, modern life stressors may not be represented. Ecological momentary assessment (EMA) allows for sampling of current behaviors and experiences in real time and in the natural habitat, thereby maximizing the generalization of the findings to real-life situations (ie, ecological validity) and minimizing recall bias. However, it has not been used for the validation of microstressor questionnaires so far.
Objective: The aim is to develop a questionnaire that (1) allows for retrospective assessment of microstressors over one week, (2) focuses on objective (ie, observable) microstressors, (3) includes stressors of modern life, and (4) separates stressor occurrence from perceived stressor severity.
Methods: Cross-sectional (N=108) and longitudinal studies (N=10 and N=70) were conducted to evaluate the Mainz Inventory of Microstressors (MIMIS). In the longitudinal studies, EMA was used to compare stressor data, which was collected five times per day for 7 or 30 days with retrospective reports (end-of-day, end-of-week). Pearson correlations and multilevel modeling were used in the analyses.
Results: High correlations were found between end-of-week, end-of-day, and EMA data for microstressor occurrence (counts) (r≥.69 for comparisons per week, r≥.83 for cumulated data) and for mean perceived microstressor severity (r≥.74 for comparisons per week, r≥.85 for cumulated data). The end-of-week questionnaire predicted the EMA assessments sufficiently (counts: beta=.03, 95% CI .02-.03, P<.001; severity: beta=.73, 95% CI .59-.88, P<.001) and the association did not change significantly over four subsequent weeks.
Conclusions: Our results provide evidence for the ecological validity of the MIMIS questionnaire.
Keywords: daily hassles; ecological momentary assessment; microstressor; validation.
Highly arousing, affective stimuli have adverse effects on cognition and performance. Perception of affective stimuli is, however, highly subjective and may impact on the interaction of emotion and cognition. Here, we tested the impact of high- versus low-threatening stimuli on response inhibition as a function of perceived threat intensity. Response inhibition was probed using a stop-signal paradigm in 62 healthy adults. We used stop-signals that had previously been paired with an unpleasant electrodermal stimulation (i.e., high-threat stimuli) or that had never been paired with electrodermal stimulation (i.e., low-threat stimuli). High-threat stimuli did not affect stopping performance in general. Only participants who perceived the high-threat stimuli as highly painful showed impaired response inhibition on high-threat trials relative to low-threat trials. Participants who perceived the high-threat as mildly painful, however, showed improved response inhibition on high-threat trials. This effect was not moderated by the current anxious state. This suggests that the impact of negative affective stimuli on cognition critically depends on subjective threat perception. Ratings of affective stimuli should be included in studies probing the emotion–cognition interaction because subjective perception might strongly impact on that interaction.
Resilienz bezeichnet die Aufrechterhaltung bzw. rasche Wiederherstellung der psychischen Gesundheit während oder nach stressvollen Lebensumständen. Aktuelle Forschungsergebnisse legen nahe, dass Resilienz dynamisch ist und trainiert werden kann. Obwohl Interventionen zur Stärkung der Resilienz häufig zur Gesundheitsförderung bei verschiedenen Zielgruppen eingesetzt werden, ist deren Effektivität jedoch kaum systematisch untersucht. Diese Übersichtsarbeit beurteilt narrativ die Ergebnisse 4 systematischer Reviews und Metaanalysen zu Resilienzinterventionen bei Erwachsenen und fasst die Evidenz aus den randomisiert-kontrollierten Primärstudien (N=44) zusammen. Insgesamt erzielten die Resilienzinterventionen kleine bis moderate Effekte bzgl. der Steigerung von Resilienz und der Verbesserung der psychischen Gesundheit. Trotz methodischer Schwächen scheinen Resilienzinterventionen wirksam zu sein und könnten somit eine gute Ergänzung zu aktuellen Präventionsmaßnahmen darstellen.
Background: Few data are available on the characteristics of inpatient treatment and subsequent outpatient treatment for depression in Germany. In this study, we aimed to characterize the inpatient and outpatient treatment phases, to determine the rates of readmission and mortality, and to identify risk factors.
Methods: We carried out a descriptive statistical analysis of routine administrative data from a large health-insurance carrier (BARMER). All insurees aged 18 to 65 who were treated in 2015 as inpatients on a psychiatry and psychotherapy service or on a psychosomatic medicine and psychotherapy service with a main diagnosis of depression were included in the analysis. Risk factors for readmission and death were determined with the aid of mixed logistic regression.
Results: Of the 22 893 patients whose data were analyzed, 78% had been hospitalized on a psychiatry and psychotherapy service and 22% on a psychosomatic medicine and psychotherapy service. The median length of hospital stay was 42 days. Follow-up care in the outpatient setting failed to conform with the recommendations of the pertinent guidelines in 92% of the patients with a main diagnosis of severe depression during hospitalization, and in 50% of those with moderate depression. 21% of the patients were readmitted within a year. The mortality at one year was 961 per 100 000 individuals (adjusted for the age and sex structure of the German population), or 3.4 times the mortality of the population at large. In the regression model, more treatment units during hospitalization and subsequent treatment with psychotherapy were associated with a lower probability of readmission, while longer hospitalization with subsequent pharmacotherapy or psychotherapy was associated with lower mortality.
Conclusion: The recommendations of the national (German) S3 guidelines for the further care of patients who have been hospitalized for depression are inadequately implemented at present in the sectored structures of in- and outpatient care in the German health care system. This patient group has marked excess mortality.
Resilience is the maintenance and/or quick recovery of mental health during and after periods of adversity. It is conceptualized to result from a dynamic process of successful adaptation to stressors. Up to now, a large number of resilience factors have been proposed, but the mechanisms underlying resilience are not yet understood. To shed light on the complex and time-varying processes of resilience that lead to a positive long-term outcome in the face of adversity, the Longitudinal Resilience Assessment (LORA) study has been established. In this study, 1191 healthy participants are followed up at 3- and 18-month intervals over a course of 4.5 years at two study centers in Germany. Baseline and 18-month visits entail multimodal phenotyping, including the assessment of mental health status, sociodemographic and lifestyle variables, resilience factors, life history, neuropsychological assessments (of proposed resilience mechanisms), and biomaterials (blood for genetic and epigenetic, stool for microbiome, and hair for cortisol analysis). At 3-monthly online assessments, subjects are monitored for subsequent exposure to stressors as well as mental health measures, which allows for a quantitative assessment of stressor-dependent changes in mental health as the main outcome. Descriptive analyses of mental health, number of stressors including major life events, daily hassles, perceived stress, and the ability to recover from stress are here presented for the baseline sample. The LORA study is unique in its design and will pave the way for a better understanding of resilience mechanisms in humans and for further development of interventions to successfully prevent stress-related disorder.