Could Resilience Predict the Outcome of Psychiatric Rehabilitation Patients?

doi:10.4236/ojd.2013.22002

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Open Journal of Depression

2013. Vol.2, No.2, 7-10

Published Online May 2013 in SciRes (http://www.scirp.org/journal/ojd) http://dx.doi.org/10.4236/ojd.2013.22002

Could Resilience Predict the Outcome of Psychiatric

Rehabilitation Patients?

——A Pilot Study*

Birk Engmann#

Department of Neurology and Psychosomatics, Brandis Rehabilitation Centre, Am Wald, Brandis, Germany

Email: #[email protected]

Received March 12th, 2013; revised April 17th, 2013; accepted April 25th, 2013

bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the

original work is properly cited.

Background: Individual resistance to burdens such as stress, adversity, and even disasters is called “resil-

ience”. Whereas most studies of resilience investigate post-traumatic stress disorder, fewer studies treat

anxiety and depressiveness in mentally healthy populations. The present pilot study investigates whether

resilience lessens the severity of depressive symptoms. Aim was to figure out whether further research is

needed on the relation of resilience both to depression and to rehabilitation from it in regard to fitness for

work. Design/Setting/Population: A retrospective, non-blind, non-randomized analysis of charts of 503

stationary inpatient-patients was performed. Patients without age limits who suffered from diseases of the

depressive spectrum (F32, F33) and also adjustment disorder (F43.2), dysthymia (F34.1), and neuras-

thenia (F48) according to ICD 10 were included. BDI and resilience scale, state of fitness or unfitness for

work, were analysed with correlation analysis and descriptive statistics by the SPSS program. Results:

Analysis revealed that resilience and depressive symptoms are inversely related. The higher the resilience

the lower the BDI score, indicating a lower burden of depressive symptoms. Resilience also seems to in-

fluence important outcome factors of rehabilitation such as reintegration in work and remission of depres-

sive symptoms. Patients who either were fit for work at the beginning of rehabilitation or were dismissed

as fit for work had higher resilience scores than those who were unfit for work. Conclusion: This pilot

study encourages further investigation of the relation of resilience not only to depressive disorders, but

also to rehabilitation and social reintegration after depression.

Keywords: Resilience; Rehabilitation; Depression; BDI

Introduction

Psychic diseases are being diagnosed more often, and be-

coming more prominent in absenteeism from work. Therefore,

investigating factors which affect rehabilitation from psychic

disease may help to assess outcome. Resilience could be one of

such factors. According to Rutter (2006), “resilience is an in-

teractive concept that refers to a relative resistance to environ-

mental risk experiences, or the overcoming of stress or adver-

sity. As such, it differs from both social competence and posi-

tive mental health. Resilience differs from traditional concepts

of risk and protection in its focus on individual variations in

response to comparable experiences”. Others such as Luthar et

al. (2006) and Cicchetti (2010) emphasize an additional influ-

ence of neurobiological and genetic factors.

Most of the studies focused on the relationship of posttrau-

matic stress disorder and resilience, such as Mealer et al. (2012)

who showed that nurses with higher resilience could better cope

with circumstances at intensive care units. Also, coping with

disasters such as bombings was investigated. According to a

study of disaster survivors in North and Cloninger (2012), de-

pression was not a robust marker of low resilience in a study of

disaster survivors. Contrary to that, occurrence of posttraumatic

stress disorder was associated with low resilience. A similar

finding is in Ahmand et al. (2010), which points out that earth-

quake survivors with higher resilience scores had less post-

traumatic symptom levels. Peres et al. (2011) investigated po-

lice officers with traumatic memories by fMRI scan. Policemen

with high resilience, or those who were in a psychotherapy

group, had decreased amygdala activity during traumatic mem-

ory retrieval in comparison to those without current psycho-

therapy.

Fewer studies dealt with the question of how depressive dis-

orders relate to resilience. Hjemdal et al. (2011) compared re-

silience with anxiety and depression scales in psychically

healthy teenagers in highschools in Norway. The authors show-

ed that higher resilience is connected with lower scores for

depression, anxiety, stress and compulsory behaviour. Pierini

and Stuifbergen (2010) investigated resilience factors and de-

pressiveness in patients with post-polio syndrome. They found

spiritual growth as the main predictor of lesser depressive

symptoms. A Korean study compared a healthy population with

psychiatric outpatients. “Greater resilience was found to be

associated with less perceived stress, anxiety and depression

*Conflict of interest: The author declares that there is no conflict of interest.

#Corresponding author.

B. ENGMANN

and with higher levels of positive affect and purpose in life”,

according to the authors (Jung et al., 2012).

In somatic diseases, resilience also improves outcome as

shown in a study by Strauss et al. (2007) of cancer patients with

fatigue who received radiation therapy. Furthermore, elderly

people with higher resilience have fewer subjective body com-

plaints, as reported in a study by Leppert et al. (2005).

All in all, previous studies with regard both to psychic and

somatic symptoms showed the beneficial influence of resilience

for a lower burden of psychic symptoms.

The present study investigates following hypotheses:

1) Patients with high resilience have lower BDI score at be-

ginning of rehabilitation.

2) Patients with high resilience have more remissions of de-

pressive symptoms within 3 weeks of starting rehabilitation

than patients with low resilience.

3) Patients with high resilience are more likely to be classi-

fied as “fit for work” after rehabilitation.

Methods

This is a pilot study to assess further needs and possibilities

for investigation. A retrospective, non-blind, non-randomized

analysis of charts of stationary patients, i.e. only inpatient, no

outpatient or daycare rehabilitation, from August 2011 to De-

cember 2011, was performed. In total, 503 cases fulfilled crite-

ria for inclusion and exclusion (see below). The duration of

rehabilitation lasted from 3 weeks to 5 weeks. All patients re-

ceived multimodal treatment of both psychotherapy in one-

to-one and group conversations, and furthermore, physio-

therapy.

Included in the analysis were all diseases of the depressive

spectrum (F32, F33) and also adjustment disorder (F43.2),

dysthymia (F34.1), and neurasthenia (F48) according to ICD 10.

Excluded were depressive states in bipolar disorders (F30, F31),

schizophrenia (F20-F29), alcohol and drug addiction (F10-F19),

brain diseases such as dementia or Parkinson’s.

In Brandis hospital, BDI and resilience scale are standard

tests for all patients. Remission or response in BDI is used as an

outcome marker of a successful rehabilitation.

The following assessment criteria of Beck Depression In-

ventory (BDI) were used:

BDI ≤ 10: no depressive symptoms.

BDI = 11 - 17: mild to moderate depressive symptoms.

BDI ≥ 18: clinically relevant depressive symptoms (Haut-

zinger et al., 1995).

Remission is defined as BDI ≤ 10. Response is defined as

BDI score reduction of 50%.

BDI’s were filled out at beginning of rehabilitation and after

3 weeks.

For the assessment of resilience, the 11-item resilience scale

RS-11 was used. This is a short version of 25-item resilience

scale of Wagnild and Young (1993). It was modified and trans-

lated into German by Schumacher et al. (2005). Minimal score

which stands for lowest resilience is 11 (1 point for each item),

highest score is 77 (7 points for each item) which stands for a

very high resilience. Patients filled out this resilience scale at

beginning of rehabilitation.

Statistical analysis was conducted with SPSS.

Results

34.4% (n = 173) of the patients were male, 65.6% (n = 330)

were female (total: n = 503).

Minimum age was 19 years, maximum age 84 years. Mean

age 51.8 years, median age 52.0 years (SD: 11.2). During reha-

bilitation psychiatric medication was altered in 21.8% (n = 110)

of the subjects. Medication was stable in 77.8% (n = 393). No

data in 0.4% (n = 2).

Is there a correlation between resilience and BDI score at be-

ginning of rehabilitation? In 448 of 503 cases all data were

available. Pearson correlation coefficient is −0.628 (p <

0.0001).

The graph (Figure 1) shows a good reverse correlation be-

tween resilience score and BDI at beginning of rehabilitation.

Another question is “does resilience influence duration of

absenteeism from work by sick note?”

At the beginning of rehabilitation (Figure 2), 46.5% (n = 235)

of the patients were absent from work by sick note, and only

32.3% (n = 163) were fit for work. Others were old age and

disability pensioners (20.8%, n = 105).

At dismissal from rehabilitation 48.9% (n = 247) were still

counted as being unfit for work, and 29.9% were dismissed as

fit for work (pensioners 20.8%, n = 105).

Before rehabilitation, the longest period of being unfit for

work by a sick note was 1540 days, the minimal was 2 days,

and the mean was 212.5 days, and the median was 180.0 days

(SD: 161.7). That means that the average amount of time that a

person was unfit for work by a sick note before rehabilitation

was approximately 4 months!

Is there a relation between fit or unfit for work and res-

ilience?

First, resilience scores were tested for normal distribution by

Kolmogorov-Smirnov-Test (2-tailed p = 0.370; near by alpha =

0.4) which was fulfilled.

The mean resilience score in the whole sample (448 patients,

57 missing) is 46.8 (median 47, SD: 15.5).

Patients who came to rehabilitation unfit for work had a mean

resilience score of 43.1 (median 43.5, SD: 14.8; n = 214, miss-

ing resilience score in 21 subjects). Contrary to that, patients who

came fit for work to rehabilitation had a mean resilience score of

51.1 (median 52.0, n = 145, SD: 14.6; missing resilience score

in 18 subjects).

BDI intitial

6050403020100

initia l re s i lien c e score

Figure 1.

Correlation between BDI and resilience score at beginning of rehabili-

tation.

B. ENGMANN

unfit for work at admission

pensioner or othersnoyesMissing

Count

300

200

100

Figure 2.

Status of being fit or unfit for work at the beginning of rehabilitation.

Similar findings exist for dismissal. In patients who were re-

leased unfit for work from rehabilitation mean resilience score

was 42.97 (median 43.0, n = 223, SD: 14.8; missing resilience

score in 14 subjects). Patients who were released fit for work

had a mean resilience score of 51.99 (median 52.50, n = 136,

SD: 14.1; missing resilience score in 15 subjects).

In conclusion, there is a trend that patients who either came

fit for work or left rehabilitation fit for work had higher resil-

ience scores.

Does resilience predict outcome of depressive symptoms?

Patients who had a remission after 3 weeks rehabilitation had

a mean resilience score of 53.56 (median 54.0, SD: 12.3; n = 61,

0 missing).

Patients who had a response but no remission after 3 weeks

rehabilitation had a mean resilience score of 40.11 (median

39.0, n = 17, SD: 7.7; 0 missing).

Patients who had neither remission nor response (“no effort”)

had a mean resilience score of 41.77 (median 42.0, n = 252, SD:

14.4; 4 missing).

In conclusion, a trend could be described that patients with

remission are accompanied by higher resilience compared to

patients with response or “no effort”.

Discussion

The mean resilience score (46.8) in the whole sample is

lower than the medium resilience score of a healthy population

(58.03 according to Schumacher et al., 2005).

The study revealed a good reverse correlation between resil-

ience and BDI. The higher the resilience the lower the BDI

score, indicating a lower burden of depressive symptoms.

Two outcome items were investigated in relation to resilience:

being fit or unfit for work and remission of depressive symp-

toms. There is a trend that patients who either were fit for work

at the beginning of rehabilitation or were dismissed as fit for

work had higher resilience scores that those who were unfit for

work. The same is for patients with higher resilience who were

more likely to have a remission than those with lower resilience.

This finding could only be described as a trend because number

of subjects in subgroups differs to a high degree and thus could

lead to bias.

Patients with depressive disorders in rehabilitation have al-

ready been absent from work approximately 4 months before

the beginning of rehabilitation. This raises a question of when

symptoms may be considered chronic.

It is interesting that there is no major effect of rehabilitation

in relation to whether patients are fit or unfit for work before

and after rehabilitation and the outcome is counterintuitive, in

that there was a slight increase of patients judged unfit for work

after rehabilitation. Perhaps this outcome may be explained by

differences between the physicians responsible for admitting

the patient and the physicians of the rehabilitation clinic, in that

they may have different criteria for being fit for work. Another

question is if different approaches of involved physicians affect

ICD-10 criteria and thus inclusion criteria. Other limitation

factors could be the relatively small sample size, or the severity

of the disease which goes with prolonged absenteeism from

work before rehabilitation. Furthermore the study has no fol-

low-up to assess the duration of absenteeism after dismissal nor

does it contain information about how many patients had been

included in a gradual reintegration program (called “stufen-

weise Wiedereingliederung” or “Hamburg model”) in the old

working place. This program deems one unfit for work until

one achieves a full number of working hours. Such a program

avoids the oversimplification of defining the value of rehabili-

tation entirely by results present at the time of dismissal.

Another factor which weakens the results of the present

study is that psychiatric medications were altered during reha-

bilitation. In addition to it, even cases with no alteration during

rehabilitation could benefit from delayed effects of a medica-

tion which had been started before rehabilitation. Moreover,

patients did not receive a completely “superposable” psycho-

logical and physical treatment. Also, different age groups could

lead to a bias in the study.

In conclusion, the present pilot study encourages further in-

vestigation of the relation of resilience to depressive disorders,

and rehabilitation from them, and reintegration in social life.

Acknowledgements

Professor Dr. Wilfried Mau, Institute of Rehabilitation Me-

dicine, University of Halle, Germany, and Professor Dr. Ger-

hard Schmid-Ott, Berolina Clinic, Bad Oeynhausen, Germany,

for introduction to the topic of resilience.

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