Review Article

Scales and Interventions for Resilience among Treatment-Seeking Patients with Depression: A Systematic Review

Introduction

Sigmund Freud once explained the concept of vulnerability through a crystal principle, which takes the example of a crystal that shatters once it falls on the ground only through the weakest structural planes (intrinsic cleavages), even when that is invisible. Patients with mental illness are also hypothesized to have similar weak structures in their mind, for example, individuals with depression may have undergone multitude of adversities in their life, but the symptoms may arise with an insignificant cause or without any significant change.¹ So various mental illnesses are believed to arise from an individual’s particular psychological weaknesses. While resilience is a concept understood to be psychologically adapting to stress and adversities to maintain emotional homeostasis.^2,3

Resilience is a multidimensional construct; it cannot be understood linearly. For simplicity, it could be termed as a phenomenon that gives the ability an individual to psychologically bounce back from adversity. This particular ability seems to vary between patients, as seen through genetic studies,⁴ Deoxyribonucleic acid (DNA) studies showing differences in stress responses being mediated through genetic factors in the reactivity from the sympathetic nervous system,⁵and the lowered reuptake of serotonin being mediated by a single base substitution in the long form of 5-HTTLPR gene promoting the risk of depression.⁶ Psychological factors such as having loving caretakers, a positive worldview, positive emotional regulation, a better coping system, sound social support, seeing problems in a positive view, spiritual support, attention to physical health, and disciplined focus help to deal with adversities better than otherwise.⁷

A resilient individual will talk to health professionals regarding depressive symptoms and will seek help. Building resilience in depressive individuals will encourage them to talk about depressive symptoms with significant others.^8,9 In a cross-sectional study done on 100 depressive and recurrent depressive disorder patients from ten hospitals in Tokyo, took the subjects who were eligible if they were outpatients 18 years of age or older, who fulfilled the criteria for a depressive episode (F32) or recurrent depressive disorder (F33) and who were capable of providing informed consent. It was reported that lower levels of resilience showed higher depressive symptomatology. The study also found as the severity of depression increased, irrespective of assessing objectively or subjectively, both were negatively associated with resilience.¹⁰

More interventions concerning building resilience are necessary for depressive disorders and reduction of depressive symptomatology. In fact, in a pilot study that was done for the improvement of resilience levels and reduction of depressive symptoms in college students, during a stressful period, the intervention involved a month-long psychoeducational intervention of weekly two-hour sessions, along with a cognitive behavioral therapy component. The intervention on assessment at the end of the four-week intervention revealed that there is a significant improvement in resilience scores and a significant reduction in depressive symptomatology. The study indicates that non-pharmacological interventions could be promoted for improvement of resilience and in turn, reduction of symptoms.¹¹

A systematic review would yield extensive literature search for screening out the specific group of scales and intervention under the preview of the study. Moreover, there are no systematic reviews which enlist the scales and interventions of resilience which has been administered specifically to treatment seeking depressive patients. By understanding this specific group of interventions for building resilience among clinically diagnosed depressive individuals, the nurses receive greater understanding for managing individuals with depression effectively.

It is understood that depression is a grave disorder, and the challenges that the health professional has to deal with could be resolved majorly by an improved resilience level. Resilience could be assessed easily and enhanced non-invasively. Moreover, the studies done for the assessment and development of resilience, especially with individuals who are clinically diagnosed with depressive disorders are limited. So, this review tries to explore systematically the clinical scales as well as interventions that have been used in studies for the assessment and development of resilience, specifically on patients who were clinically diagnosed with depression. This systematic review will include inclusive evidence about the clinical scales and interventions necessary for resilience in depression.

Materials and Methods

The systematic review has been conducted as per the criteria of Preferred Reporting Items of Systematic Review (PRISMA)¹² and was registered in the PROSPERO registry for systematic review (reg no. CRD42022308942).

Data Sources and Article Selection

The search strategy adopted for recognizing all the available and pertinent articles was done by utilizing three separate medical databases (PubMed, Google Scholar, and Science Direct) with the keywords (Resilience or Resiliencies or Resiliency or Resiliency traits or psychological resilience or psychological resiliencies or psychological resiliency) AND (depression or bipolar depression or unipolar depression or depressive disorder or primary depression or clinical depression) AND (interventions or interventional or methods or management). The literature search was limited to articles published from 1990 to date, only in English Language.

The current review had identified 8689 articles from different databases, out of which, 4111 articles were retrieved for screening, which found that only 86 articles were qualifying the eligibility criteria. 19 articles were excluded as their full texts could not be retrieved. Further screening showed that only 13 studies were eligible for inclusion to the review ().

Close

Figure 1. Prisma flowchart of literature search showing identification, screening and final inclusion of articles

Inclusion and Exclusion Criteria

Inclusion criteria for the articles are:

Population: Patients who are clinically diagnosed with Bipolar and Unipolar Depression. The population is not restricted to any country.

Outcome: Clinical scales for evaluation, and interventions for enhancing resilience among patients with depression.

Setting: Hospital admissions, clinical setting, primary health care.

Study designs: Randomized controlled trials (RCTs), Quasi-experimental, observational studies, narrative reviews

Exclusion criteria for the articles are:

• Studies that show the presence of depression or anxiety as a co-morbidity to other medical illnesses.

• Studies published in any language other than English

• Studies that were done on paediatric patients

The stages of article selection were:

Stage 1: Identification: All the articles that were retrievable from the selected databases were exported to Mendeley Reference Software. The articles which were found to be duplicates were removed initially through the software.

Stage 2: Screening: Two independent reviewers screened the title and abstracts of the retrieved articles and excluded the studies which were not conducted on individuals who are clinically diagnosed with depressive disorder or on measures of resilience. Any disputes by the two reviewers were sorted by the third reviewer.

Stage 3: Eligibility: The remaining articles whose full texts could not be retrieved were also excluded. The full text of the articles for the rest was read by the reviewers and checked for its eligibility criteria. The articles found to be ineligible were excluded.

Stage 4: Quality Assessment: The quality of the selected articles was assessed with Joanna Briggs Institute Critical appraisal tools. Three RCTs were assessed with the Joanna Briggs Institute (JBI) Checklist of Randomised Control Trials which had 13 items assessing the randomization, blinding, allocation, similarity in outcome assessment between groups, use of proper statistical analyses, etc. Three Quasi-Experimental studies were assessed with the JBI Checklist of Quasi-Experimental designs which had 9 items assessing the clarity of cause and effect, homogeneity of participants, presence of control, usage of proper statistical analyses, etc. The rest of the eight observational studies were assessed with the JBI Checklist for Analytical Cross-Sectional Studies which had 8 items assessing the clarity of sample description, setting, objectivity in measuring outcomes, identification of confounding variables, checking validity, and reliability of measurement tools and usage of proper statistical analyses, etc. Responses like ‘Yes’, ‘No’, ‘Unclear’, or ‘Not Applicable’ was provided for the rating of each item of the quality appraisal tools.

Results

The different stages of the retrieval, checking eligibility, and selection of articles have been depicted in a PRISMA flowchart (). A total number of 8689 articles were identified from three different databases, i.e., PubMed (2122), Google Scholar (1250), and Science Direct (5317). Of the identified articles 4578 articles were excluded before the screening, the majority of the articles (4467) could not be retrieved from the database itself and 111 articles were found to be duplicate articles, giving 4111 articles for screening.

Subsequently, 4025 articles were excluded from the study either due to the absence of any resilience measures or conducted in individuals who had not been clinically diagnosed with depression, or both. Out of the remaining 86 articles that were screened, 19 articles were further excluded as the full text of the articles could not be retrieved. Then, the 67 articles were reviewed thoroughly for assessing their eligibility by the reviewers. Further, on assessment it was noticed that 21 other studies were also not done on individuals who are clinically diagnosed with depression, 19 studies were done on individuals who were all below the age of 18 years, and eight studies were narrative reviews that did not mention any clinical scale or intervention, 2 studies were done on animals, 1 study was in Spanish and 3 other articles were found to be duplicates.¹³

The final 13 studies that were included for analysis were done in 8 different countries like the USA (three),^11,14,15 Italy (three)^16–18 India (two),^19,20 Australia (one),²¹ Sweden (one),²² Egypt (one),²³ Netherland (one)²⁴ and Thailand (one).²⁵

The data synthesis is done by following the extracted studies for review and put under the headings:

• Details of publication (Author and year of publication)

• Type of study (design)

• Mode of Completion (Self-report or interview schedule)

• Subject Characteristics (type of participants)

• Name of the clinical scale used (measuring scale)

The data that has been extracted after the review of the included articles regarding the clinical scales and interventions for resilience among patients with depression, has been presented in a form of narrative synthesis (Table 1).

Clinical Scales for Measuring Resilience Among Individuals with Depression

This search yielded six different resilience scales that have been utilized for the assessment of individuals with clinical depression. The research articles comprised two Randomised control studies, three quasi-experimental studies, and eight observational studies that yielded the six resilience scales.

The Resilience Scale by G.M. Wagnild and Young

This scale measures components of resilience in different domains of young patients’ lives, ranging from planning and thinking ahead to the level of independence. The scale is a 25-item Likert scale, with each item rated with a seven-point rating, from 1 (disagree) to 7 (agree). The scores range from 25 to 175, suggesting higher scores with higher resilience. The scale also consists of three sub-components, i.e., Personal Competence, Health and wellness, and Acceptance of self and life.^24,25

Connor Davidson Resilience Scale (CD-RISC)

CD-RISC is a self-reporting 25-item rating scale, developed by Kathryn M. Conner and Jonathan R.T. Davidson, for testing resilience in all age groups. It is a five-point scale ranging from not at all true (0) to true nearly all the time (4). The scores range from 0 to 100, indicating higher resilience for higher scores. CD-RISC is officially authorized with three versions of the same, such as CD-RISC-25, CD-RISC-10, and CD-RISC-2. The CD-RISC-25 reflects on five factors such as high standards, tenacity, and competence (8 items), handling negative emotions, trusting one’s instincts, and perceived benefits of stress (7 items), positive attitude to change, and secure relationships (5 items), perceived control (3 items) and finally spirituality (2 items).^{14-16,23,26,27}

Bharathiar University Resilience Scale (BURS)

BURS is a 30-item self-reporting Likert scale with 5-point response options, ranging from “not at all appropriate” (1) to “most appropriate” (5). The 30 items are set as personal statements which the participants are expected to mark as the most appropriate response in their regard. BURS is considered to measure seven domains of resilience, such, (i) duration of getting back to normalcy, (ii) perception of the effect of past negative events, (iii) response to risk factors, (iv) response to negative events, (v) openness to experience, (vi) flexibility and (vii) confidence in coping with future. The total scores of all the items are summed up to establish the level of psychological resilience of the respondent, with the scores ranging from 30 to 150.^19,20

Ego-resiliency Scale (ER89)

This scale has been created by Block and Kremen in 1989, to measure psychological resilience. Psychological resilience is the adaptability of the mind to bounce back from any negative emotional experience and be able to function in flexibility under stressful environmental states. ER89 is a 14-item Likert scale with four-point response options, such as, does not apply at all (1) to applies very strongly (4). The range of scores goes from 14-56, with higher scores indicating higher psychological resilience.²¹

Resilience Scale for Adults (RSA)

RSA is one of the resilience scales which approaches the measurement of resilience directly. This scale constitutes six factors for the measurement of resilience, with four factors for personal characteristics, that is, perception of self, planned future, social competence, and structured style; one factor for family characteristics, i.e., family cohesion and one factor for social characteristics, i.e., social resources. The scale is a 33-item scale with a seven-point semantic differential rating scale, with two polar opposite attributes at both ends of the scale for each item. For example, appreciating my qualities and despising my qualities would be the two ends of the response option and varies with each item. The range of scores is from 33 to 231, with higher resilience indicated by a higher score.^17,28,29

There are many more scales which has been used to assess resilience,³⁰but in the review, these were the only scales that have been mentioned to be used on adults who are clinically diagnosed depressive patients (Table 2).

Interventions for Improving Resilience Among Patients with Depression

In the case of interventions, the review identified six different interventions from three randomized control trials and three Quasi-experimental studies. These interventions have proven to be effective in raising resilience among patients with clinically diagnosed depression. (Table 3)

CBT-Based Guided Self Help Bibliotherapy

Guided self-help would provide a modest level of support by a coach or a clinician in completing a therapy. For instance, Bibliotherapy is a creative method to inculcate reading specific texts to treat. Cognitive behavioural therapy (CBT) has been a proven effective therapy in the conventional treatment regimen for reducing depressive symptoms. So, CBT-based Bibliotherapy which utilizes a guided self-help mode seems to be effective in enhancing resilience among patients with depression. It contains eight modules, with reading, writing, and activities to be completed in one week, for eight weeks. The completion of the assignments would require participants to challenge negative thoughts and behaviors to improve their resilience.²⁵

Training for Awareness, Resilience and Action (TARA)

TARA is a neuropsychiatric intervention based upon the mindfulness approach, yet primarily focusing on emotional self-regulation than acceptance of emotional experience. The intervention consists of 12 sessions, that is completely online delivered, and has been divided into four modules, such as, (i) calming down and creating a sense of safety (1^st-3^rd session)- yoga-based movement and breathing exercise are trained primarily to reduce amygdala hyperactivity, (ii) Attending to and caring about our inner experience (4^th-6^th session)- emotional labeling and interoceptive attention is trained for shifting attention from negative self-referencing to present moment sensory awareness, (iii) recognizing, regulating and communicating emotions (7^th to 9^th session)-practicing of empathetic listening, effective communication and compassionate responses to reduce interpersonal stress and regulation of emotions and (iv) core values, goal setting and committed action (10^th to 12^th session) – training to identify and recognize the experiential avoidance to identify the core values and be guided in participant’s actions in their lives. Overall, this intervention aims to provide an ability for patients with depression, to have cognitive control over emotional experiences, in dealing with day-to-day life activities.^22,31

Pranayama

Pranayama is considered to be a basic component of Hatha Yoga, which primarily consists of control of Prana (vital energy needed for the survival of our physical self), by breathing techniques. Anuloma Viloma is a type of pranayama, which is believed to restore autonomic nervous system imbalances, maintain the balance of the pineal gland and even activate the frontal lobe of the brain to provide tranquillity, clarity, and concentration. So, Anuloma Viloma provides calmness and better awareness without any side effects. The practice is provided for 30 minutes, followed by 15 minutes of discussion with the participants. Long-term practice of pranayama would initiate a process known as telencephalisation, which is shifting towards conscious breathing from regular unconscious breathing leading to the involvement of the cerebral cortex and surrounding areas of the brain, even concerned with emotions.¹⁹

Carnatic Music and Pranayama

In this intervention, both Carnatic music and Pranayama was utilized together. For Carnatic music, three ragas were chosen, namely, Atana, Mohanam, and Neelambari. Each raga was played to the participants for 10 minutes each and was combined with 15 minutes of Pranayama after. The Intervention was given for 12 sessions, with two sessions per week for 6 weeks. Each session was of 45 minutes duration overall. The ragas were played through recorded flute music and Pranayama was similar to the previous intervention mentioned. The study has assumed that the vibrations in the ragas were able to resonate with participants’ moods and health. The concept of Raga Chikitsa that is, healing through the use of raga is believed to balance nature that is in imbalance and help in the healing process.²⁰

Attentional Bias Modification

This intervention is based on the idea that patients with depression have a more attentional bias toward negative information and difficulty disengaging, as compared to positive or neutral information. The negative attentional bias has been linked with ineffective emotion regulation in states of stress and decreased resilience. So, through attentional bias modification, it is expected to alter the symptoms of depressive disorders. Participants will engage in eight training sessions for a period of two weeks, in which 50 pairs of pictures are created that have negative and positive images or scenes, equally. A white fixation arrow is introduced during the display of the contrasting images to the participants, and 90% of the time, the arrow is placed over the positive images, modifying the attention towards the same. Regular breaks and feedback are included for the sustenance of motivation in the participants.²⁴

Resilience Training-Based Nursing Intervention

This intervention was of eight sessions with one session of one hour each per week for eight weeks. Each session would include a revision (10 minutes), practice of relaxation technique (10 minutes), structured presentation (15 minutes), group discussion (15 minutes) and finally ending with a summarisation and feedback by the participants (15 minutes). Each session involved different topics for presentation which was structured for uniformity and was consistent with a pre-written manual. The first session involved training on topics regarding different aspects of depression (causes, signs, symptoms, fears, and stigma), the second session was on resilience (factors, process, and relationship with depression), and the third and fourth sessions aimed to build resilience, whereas the fifth session focussed on building and utilizing healthy coping strategies, the sixth session dealt with increasing social support, whereas the seventh session aimed to enhance problem-solving techniques and flexibility and finally the eight sessions focussed on practicing stress management techniques, increasing positivity and dealing difficult emotions.²³

Discussion

From our systematic review, we identified 13 articles that met our inclusion criteria for the review. In this, there were three RCTs, three quasi-experimental studies, and seven observational studies. From the identified articles, we have yielded five different clinical scales as well as six interventions that were especially utilized on patients who were clinically diagnosed with depressive disorders for resilience. The most extensively used scale seems to be CD-RISC 25, mostly because it has strong psychometric properties and its applicability in clinical settings. The CD-RISC 25 is sensitive to clinical interventions as it identifies resilient characteristics that are enhanced by an individual’s adaptive pursuits.³²Apart from the five scales that were identified, the Brief resilience scale was also accounted for by the reviewers, but its non-applicability in clinical scenarios led us to remove it from the analysis. Even then, Brief Resilience Scale was just a six-item rating scale where the participants are expected to respond to a five-point response option. The authors believed that six items are sufficient to assess resilience, as resilience could never be assessed directly. They have utilized coping styles, social relationships, and health-related outcomes as their factors to evaluate the level of resilience.^33,34

Different measures differ in the means of assessing resilience, as resilience by default is a complex construct to appraise. For example, as we consider that early childhood trauma and neglect being a central concept of maladaptation, and further poor resilience in individuals,¹⁰ certain studies have shown that some neglected and abused children did show better resilience in different areas of functioning and positive adjustment towards particular developmental tasks.^35-38 So, the idea of measuring resilience on account of their protective factors and developmental tasks is questionable, as the evaluation of the resilience of individuals with similar adversities would show varied resilience levels.³⁹ On account of featuring prevalence of resilience among populations with common stressors could show diversity in values, i.e., different scales would infer the results differently.⁴⁰

Whereas, in a network analysis, risk and protective factors for the remitted depressive patients were explored, such as residual symptomatology, emotional regulation, cognitive control, and resilience. This previous study showed that resilience was taking a central role in connecting all the factors and proving to be a key factor in connecting all the other risk and protective factors. Resilience stands out to be a successful coping factor when it comes to the stress from remission of depression.⁴¹ Therefore, the health team members must be vigilant to assess the patients with depression regarding the levels of resilience and its impact on symptomatology. By focussing on resilience, the patient would also participate in the treatment process actively and generate a sense of insight to his advantage.⁴²

In the case of interventions, six different interventions were identified after a comprehensive search from three RCTs and quasi-experimental studies each. The review did not show any pharmacological agents as interventions to improve resilience, even though there are pharmacological enhancements of neurochemical systems for resilience also being reviewed. The effect of pharmacology on depressive patients is yet to be proven.⁴³ The non-pharmacological interventions that have been identified in the review, are also not measured for their level of effectiveness in our review, even though individual studies have shown their effect on significantly improving resilience in depressive individuals. The Pranayama and Carnatic music are the interventions that would require prior training and certification, or expert assistance to conduct in its apposite manner. The rest of the interventions include self-help assignments for reading, writing, and comprehension, otherwise, previously structured manuals are being followed, which are easier to replicate by any member of the health team.

TARA program also includes yogic practices and breathing techniques, regardless, the authors have not mentioned any prior requirement of specific training for the same. Nonetheless, the authors have mentioned that the whole program of TARA needs to replicate with TARA-trained facilitators.²² Attention bias modification treatment (ABMT) seems to be a promising intervention concerning depressive symptomatology. As ABMT seems to be a more focused and limited sort of intervention, the extraneous factors affecting the outcome also seem to be less, as compared to a CBT or Pharmacological intervention. Moreover, the control group of ABMT is also very tight, as they are also subjected to similar cues, number of sessions, or effects which might show a lesser group effect size of ABMT, as compared to its counterparts.⁴⁴

The effect of resilience is also evident in the quality of life among the depressive population.^45-48 So deliberate assessment of resilience, as a part of the treatment protocol, needs to be mandated, along with the inclusion of non-pharmacological interventions, led by nursing personnel in a psychiatric setting for patients with depression, shall act as an effective change in depressive symptomatology, and more importantly the quality of life. Health team personnel must also take up research projects involving interventions for resilience or systematic reviews involving meta-analyses of the same to add to our evidence base for the enhancement of resilience in a clinically depressed population. Limitations of the study were that only three databases were considered and google scholar is more of a search engine than a database, which narrowed the scope of review, lack of access to some full texts that could have been relevant, and not involving grey literature in the review.

Conclusion

The systematic review was able to synthesize clinical scales and interventions that have been used to improve resilience among patients with clinical depression, in the last two decades. Five clinical scales and six non-pharmacological interventions were identified through the review. Among patients, enhancing resilience could improve their prognosis and boost their quality of life. Considering the 13 articles that were included in the review, we can conclude that the latest interventions for resilience have the potential to bring well-being to the soaring population of depressive disorders.

Acknowledgments

We are extremely thankful to Dr. Vishnu Renjith and Ms. Neethu Maria Joseph for retrieving full texts of inaccessible articles and proof reading our article.

Authors’ Contribution

Conceptualization: K Jayakrishnan, Athar Javeth.

Data curation: K Jayakrishnan, Arunjyoti Baruah, Athar Javeth.

Formal analysis: K Jayakrishnan, Athar Javeth.

Investigation: K Jayakrishnan, Athar Javeth.

Methodology: K Jayakrishnan, Arunjyoti Baruah, Pankaj Kumar, Athar Javeth.

Project administration: K Jayakrishnan.

Software: K Jayakrishnan, Athar Javeth.

Supervision: Arunjyoti Baruah.

Validation: Arunjyoti Baruah, Pankaj Kumar.

Visualization: K Jayakrishnan, Arunjyoti Baruah, Pankaj Kumar.

Writing–original draft: K Jayakrishnan, Athar Javeth.

Writing–review & editing: K Jayakrishnan, Arunjyoti Baruah, Pankaj Kumar.

COI-statement

All the authors declare no conflicts of interest with research or writing of the paper.

Data Availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethical Approval

We did not require ethical approval as neither data has been collected nor any intervention has been conducted on humans/animals.

Funding

No funding has been received for this systematic review.

Research Highlights

References

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