Building resilience through psychotherapy

In reviewing the main targets and outcomes of psychotherapy research, Cuijpers1 notes emphasis upon symptom reduction, improvements in quality of life, and intermediate outcomes that depend upon theoretical framework. Critical unmet needs include little attention to patient‐defined outcomes, negative outcomes (worsening of symptoms), and economic outcomes (cost‐utility). Measuring symptom reduction over relatively short periods of time does not address illness course (incident episode, relapse and recurrence). Furthermore, little psychotherapy research has addressed outcomes grounded in an understanding of brain circuits and systems, or explored potential mechanisms of action through measurement of biomarkers. Cuijpers’ emphasis on capturing and integrating different perspectives, from neurobiologists to payors, is critical to further advances in psychotherapy research and practice.

I would like to suggest that greater attention to the construct of resilience in psychotherapy research could be scientifically fruitful and clinically useful for addressing the unmet needs highlighted by Cuijpers.

What is meant by “resilience” , and how can it be measured? Resilience is the ability to adapt, to thrive in the face of adversity, and to bounce back from life's challenges. One measurement widely used, the Connor‐Davidson Resilience Scale (CD‐RISC), has clinically relevant characteristics. For example, of specific relevance to unmet needs in psychotherapy research, Laird et al2 recently reported an exploratory factor analysis of CD‐RISC scores in depressed participants in clinical trials sponsored by the US National Institute of Mental Health at the University of California, Los Angeles. The authors found a four‐factor solution, which they named “grit” , “adaptive coping” , “accommodative coping” , and “spirituality” .

Having a strong sense of purpose and not being easily discouraged were typical of items loading on “grit” . Preference to take a lead in problem solving was characteristic of “adaptive coping”, while cognitive flexibility, cognitive reframing, a sense of humor, and acceptance in the face of uncontrollable stress loaded on “accommodative coping”. Belief that “things happen for a reason” and that “sometimes fate or God can help me” characterized “spirituality”. In a multivariate model, the greatest variance in total resilience scores was explained by less depression, less apathy, higher quality of life, non‐White race, and – somewhat counterintuitively – greater medical comorbidity.

These data provide a rationale for a hypothesis that captures many of Cuijpers’ under‐investigated targets and outcomes: psychotherapeutic interventions designed to help patients build resilience (grit, active coping/problem‐solving, accommodative coping, and spirituality) will prove effective in preventing and treating depression (and other common mental disorders). Behavioral activation may be a plausible mediator of depression prevention and treatment efficacy, because it is grounded conceptually in resilience and provides a patient‐centered antidote to the antithesis of resilience – that is, learned helplessness.

What are the experimental data supporting the notion that interventions designed to enhance resilience effectively prevent and treat depression?

A meta‐analysis from Cuijpers’ group3 estimated an incident rate reduction of 21% in the occurrence of major depressive episodes during 1‐2 years, compared with care‐as‐usual or waitlist control, through the use of brief learning‐based behavioral or depression‐specific psychotherapies (such as cognitive behavioral therapy, interpersonal psychotherapy, and problem‐solving therapy). The 38 randomized controlled trials (RCTs) in the meta‐analysis were studies from high‐income countries of either “indicated” depression prevention (enrolling participants with mild or subsyndromal symptoms), or “selective” depression prevention (enrolling participants with medical or neurological conditions such as stroke or age‐dependent macular degeneration, placing them at risk for developing major depression).

Only one RCT of depression prevention has been conducted in a low‐ or middle‐income country4. The “DIL” intervention (standing for “Depression in Later Life” , and meaning “heart” in Hindi), delivered by lay counsellors to primary care patients in rural and urban Goa, India, was grounded in problem‐solving therapy, but also included (as a result of extensive formative research to better capture patient‐defined targets and outcomes) brief behavioral treatment for insomnia, education in better self‐care for commonly comorbid medical disorders like diabetes, and assistance in accessing medical and social services. Over one year, we observed reduction in incident episodes of major depression in DIL compared to care‐as‐usual (4.4% vs. 14.4%; log rank p=0.04) and in the burden of depressive and anxiety symptoms (p<0.001).

Consistent with the hypothesis that building resilience may protect against, or reduce, depression, problem‐solving psychotherapy teaches key facets, or tools, of resilience – active coping skills and enhanced engagement with life, combatting apathy and learned helplessness (the opposites of resilience). DIL participants reported engaging in pleasurable social and physical activities, a countermeasure to the paralyzing “tension” and worry that plagued their daily lives. They took a more active hand in managing their health, and came to feel less helpless and more in control of their lives. The DIL intervention built resilience in the form of active coping and behavioral activation, especially for dealing with health problems and their attendant threat of losing independence and degrading quality of life.

The efficacy of cognitive behavioral therapy and interpersonal psychotherapy both in preventing and treating depression3 points to the importance of engaging in other resilience‐building practices, such as accommodative coping (cognitive reframing and flexibility, humor), and social support. Common mental disorders like depression occur within an interpersonal context, and social connections support while loneliness destroys brain health. The Harvard Study of Adult Development5 found that people who are well connected with family, friends and community are happier, physically more healthy, and live longer.

Social and interpersonal support fostered by psychotherapy nourishes the ability to adapt and to thrive in the face of adversity, while depression erodes adaptability. To this point, Jeste et al6 showed that resilience counters the adverse effects of depression on self‐rated health and successful aging. Further, regarding accommodative coping and spirituality, a psychotherapy for persistent impairing grief (rooted in both cognitive behavioral therapy and interpersonal psychotherapy) supports resilience and adaptation by strengthening both loss‐ and restoration‐focused coping, and effectively resolves what ICD‐11 now terms “prolonged grief disorder”7.

It is time for neurobiology to inform psychotherapy development, targets, and outcomes8. Psychotherapy research needs data on biomarkers of risk and resilience to common mental disorders, such as major depression. Biomarkers may signal moderators of response, enabling the targeting of interventions to at‐risk persons. They may also indicate mediators of response variability. Possible pathways through which psychotherapeutic interventions to enhance resilience might lower the risk for incident and recurrent episodes of depression include decreased inflammation, reduced oxidative stress, increased vascular and metabolic health, and increased neuroprotection. These represent fundamental hallmarks of aging at the molecular and cellular level, affected by depression, and expressed as senescence‐associated secretory phenotypes9.

Do psychotherapeutic interventions that enhance resilience affect these pathways and, thereby, reduce the risk for and burden of depression? Addressing the interplay between behavioral factors (resilience‐promoting) and biological variables (associated with molecular signatures of brain and systemic health and with the reward and executive control circuits of the brain) may tell us how psychotherapies work. Attention to workforce issues and modes of delivery to streamline psychotherapy and to enhance scalability in the Research Domain Criteria era8, 9, with sensitivity to differing cultural milieus, may further serve to optimize cost‐utility.