Can we improve resilience in patients with schizophrenia to help recovery? Resilience is increasingly being recognized as a factor in vulnerability and recovery in schizophrenia. But what is resilience and how do we measure it? Is it influenced by cultural factors? At ECNP 2017, we explored the current state of knowledge about resilience in schizophrenia and looked ahead to future efforts in this area.
Origins and definitions
Prof John Kane, The Zucker Hillside Hospital, USA, took us back to the beginning. The origins of the concept of resilience can be traced back to an influential group of investigators who started to describe the significance of children developing well despite their risk status or exposure to adversity. Others were subsequently inspired to study competence and mental health in children threatened with significant adversity. The goal was to improve the chances of future generations of children who face such risks.
Prof Hiroyuki Uchida, Department of Neuropsychiatry, Tokyo, Japan, noted that the term 'resilience' was originally derived from the field of physics and is defined by the Oxford Dictionary as 'the ability of a substance or object to spring back into shape'.
‘Resilience is the capacity of a dynamic system to withstand or recover from significant challenges that threaten its stability, viability or development’
Contemporary models of resilience are dynamic and emphasize the involvement of multiple systems. Prof Kane said that ‘resilience is the capacity of a dynamic system to withstand or recover from significant challenges that threaten its stability, viability or development’. In addition to the traditional focus on developmental and psychological aspects, the newer definition provides a framework to study the genetic, epigenetic and neurochemical aspects of resilience.
Scales to measure resilience?
While there is still no ‘gold standard’ for assessing resilience in schizophrenia, a number of scales have been developed. The first, the Connor-Davidson Resilience Scale, was introduced in 2003. Since then, other scales have followed. Researchers have suggested that the diversity in how resilience is conceptualized, measured and interpreted likely reflects the multidimensional nature of the concept itself. Few clinical trials, however, have incorporated such measures of resilience. Further research is needed to better understand its role in treatment acceptance and response, as well as its impact on long-term outcomes.
Cultural differences
Is the degree and quality of resilience directly or indirectly influenced by culture?
Prof Alex Hofer, Medical University Innsbruck, Austria, presented a cross-sectional, cultural comparison study in Austria and Japan, which looked at resilience, internalized stigma, self-esteem and hopelessness in people with schizophrenia.
Four groups were investigated - patients with schizophrenia in Innsbruck (52 patients) and Tokyo (60), and 137 healthy controls in the same two areas. Patients with DSM-IV schizophrenia were clinically stable without hospitalization or change in psychopharmacological treatment for at least 6 months.
They detected a significant country effect. Japanese subjects in general reported significantly lower resilience and self-esteem scores as well as higher hopelessness scores. Compared to healthy controls, both Austrian and Japanese patients displayed significantly lower degrees of resilience, self-esteem and hope.
Patients from different cultures may have different needs to reach recovery
Compared to Japanese patients, Austrian patients showed a markedly higher correlation between subjective elements of recovery (hopelessness [BHS]) and objective domains of recovery (psychopathology [PANSS total]). This finding suggests that patients from different cultures may have different needs to reach recovery.
Prof Hofer also showed new unpublished data that indicates that spiritual well-being is strongly positively correlated with resilience in patients with schizophrenia.
Cognitive therapies to target resilience
Prof Til Wykes, King's College, London, UK, presented evidence for cognitive therapy success in schizophrenia. These therapies are relevant because they are aimed at improving personal resources such as self-esteem, self-efficacy, coping skills and cognition. Potential resilience outcomes include preventing onset and relapse, reducing recovery time and improving recovery. She proposed that the aim of all cognitive therapies may be to combat demoralization.
The aim of all cognitive therapies may be to combat demoralization
Prof Uchida also described treatments to enhance resilience and promote recovery, and proposed that the combination of psychotherapy and pharmacotherapy is better than either one alone.
Key:
BHS, Beck Hopelessness Scale; PANSS, Positive and Negative Syndrome Scale.
