A randomized controlled trial of a self-guided, multimedia, stress management and resilience training program

Psychological intervention programme for developing resilience in the military personnel. A randomized controlled trial

Military gendarmes are frequently exposed to events with traumatic impact, with negative effects on emotional and physical health. The present research aims to analyse the effectiveness of Military Resilience Training (MRTR), a psychological intervention programme developed to reduce perceived stress, increase the perception of adaptive resources and strengthen resilience. Ninety-eight participants who met the inclusion criteria were enroled in a single-blind randomized controlled trial. The psychological training programme was implemented in the intervention group (n = 48) for a duration of 5 months. The participants in the control group (n = 50) were scheduled to start the training later. The levels of perceived stress, adaptive resources and resilience were measured in all participants, from the intervention and the control group, before and after the intervention, and at a 3-month follow-up. The effects of the intervention (Cohen's d) were very high for adaptive resources (d = 0.99), self-schemes (d = 1.33), family support (d = 0.70), and partner support (d = 0.66), average for resilience (d = 0.53) and stress (d = 0.49), with very high effects on military task demands (d = 1.19) and averages for friction with authority (d = 0.51). The effects were obtained only in the intervention group, and all gains were maintained at follow-up. This study provides evidence of the effectiveness of MRTR, a psychological intervention implemented in the military gendarmerie population. In the short and long term, MRTR has significant effects in reducing perceived stress, increasing the perception of adaptive resources and strengthening the resilience of military gendarmes.

Improving the mental health of working women with work-life conflict: A protocol development for an explanatory mixed method study

BACKGROUND

Today, one problem facing working women is the conflict between work and life, and the resultant stress has a great impact on their mental health. A well-known model for stress management is Lazarus and Folkman's model. The primary goal of the present study is to improve working women's mental health through stress management.

MATERIALS AND METHODS

The present study employs a mixed approach and is conducted in 4 phases. The target population is women working in Birjand University (South Khorasan province/Eastern Iran). The first step is to describe the research population of a cross-sectional study. The measurement instrument used is Carlson's standard work-life conflict measurement questionnaire. The sample size in this step is 319. The second step is to conduct a qualitative study by interviewing working women with work and life conflict. The sampling will continue until data saturation and then the data will be analyzed through a content analysis. The third step will be the development of a questionnaire based on Lazarus and Folkman's model using the information obtained from the qualitative step. This questionnaire will be then validated in the target research population. Moreover, an exploratory factor analysis, a confirmatory factor analysis and a reliability test will be run. The last step is to carry out an educational intervention to measure the effect of the intervention on stress management and general health in working women with work and life conflict. The measurement instruments used in this step are Cohen's Perceived Stress Questionnaire, General Health Questionnaire, and a researcher-made stress management questionnaire.

CONCLUSION

It seems that the educational intervention of stress management with educational content designed based on the needs of the audience, can be effective in controlling and managing the stress caused by women's work-life conflict.

TRIAL REGISTRATION

IRCT (IRCT20210918052508N1) from the Iranian Registry of Clinical Trials in 2021-09-21.

A Guided, Internet-Based Stress Management Intervention for University Students With High Levels of Stress: Feasibility and Acceptability Study

BACKGROUND

Transitioning to adulthood and challenges in university life can result in increased stress levels among university students. Chronic and severe stress is associated with deleterious psychological and physiological effects. Digital interventions could succeed in approaching and helping university students who might be at risk; however, the experiences of students with internet-based stress management interventions are insufficiently understood.

OBJECTIVE

This study aims to explore the feasibility; acceptability; and changes in perceived stress, depressive symptoms, and quality of life from baseline to posttest assessment of a 5-session, internet-based stress management intervention guided by an e-coach, developed for university students experiencing high levels of stress.

METHODS

A single-arm study was conducted. Students were recruited from different channels, mainly from a web survey. Students were eligible if they (1) scored ≥20 on the Perceived Stress Scale-10, (2) were aged ≥18 years, and (3) were studying at one of the participating universities. Feasibility and acceptability of the intervention were investigated using several indications, including satisfaction (Client Satisfaction Questionnaire-8) and usability (System Usability Scale-10). We also investigated the indicators of intervention adherence using use metrics (eg, the number of completed sessions). Our secondary goal was to explore the changes in perceived stress (Perceived Stress Scale-10), depressive symptoms (Patient Health Questionnaire-9), and quality of life (EQ-5D-5L scale) from baseline to posttest assessment. In addition, we conducted semistructured interviews with intervention completers and noncompleters to understand user experiences in depth. For all primary outcomes, descriptive statistics were calculated. Changes from baseline to posttest assessment were examined using 2-tailed paired sample t tests or the Wilcoxon signed rank test. Qualitative data were analyzed using thematic analysis.

RESULTS

Of 436 eligible students, 307 (70.4%) students started using the intervention. Overall, 25.7% (79/307) completed the core sessions (ie, sessions 1-3) and posttest assessment. A substantial proportion of the students (228/307, 74.3%) did not complete the core sessions or the posttest assessment. Students who completed the core sessions reported high satisfaction (mean 25.78, SD 3.30) and high usability of the intervention (mean 86.01, SD 10.25). Moreover, this group showed large reductions in perceived stress (Cohen d=0.80) and moderate improvements in depression score (Cohen d=0.47) and quality of life (Cohen d=-0.35) from baseline to posttest assessment. Qualitative findings highlight that several personal and intervention-related factors play a role in user experience.

CONCLUSIONS

The internet-based stress management intervention seems to be feasible, acceptable, and possibly effective for some university students with elevated stress levels. However, given the high dropout rate and qualitative findings, several adjustments in the content and features of the intervention are needed to maximize the user experience and the impact of the intervention.

TRIAL REGISTRATION

Netherlands Trial Register 8686; https://onderzoekmetmensen.nl/nl/trial/20889.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.invent.2021.100369.

Effectiveness of an online mental health strengthening module to build resilience and overcome stress for transitional aged medical students

Introduction

Transitional-aged youths (17-to-24-years-old) are prone to mental-health problems. Students in higher education, especially medical students, are more exposed to stressors and thus need training to increase resilience. However, there have been limited mental-health strengthening modules specifically developed for medical students of transitional age, and none in Indonesia. This study intends to test the effectiveness of an online mental-health strengthening module in altering resilience.

Methods

A pragmatic randomized trial with repeated measurements was employed to evaluate biopsychosocial outcomes of resilience. The intervention module was delivered in 4 weeks to 105 eligible students. Participants were divided into intervention group (n = 52) and control group (n = 53). Outcomes were measured in the 4th, 8th, and 12th weeks. Primary outcome was resilience level as measured by Connor-Davidson Resilience Scale (CD-RISC). Perceived Stress Scale (PSS), Depression Anxiety Stress Scale (DASS) were utilized to measure stress, depression and anxiety. Knowledge and attitude toward mental-health were also measured through validated questionnaires. Stress levels of participants were measured biologically by measuring salivary cortisol and alpha-amylase levels at the baseline and 12th-week.

Results

Compared to the control group, there were no significant difference in resilience score of the intervention group compared to control group [F(1, 103) = 2.243, P = .137]; however, there was a significant main effect of time [F(3, 309) = 18.191, P < .001] and interaction effect between intervention and time in resilience score [F(3, 309) = 5.056, P = .002]. Additionally, compared to the control group, there were significant increases in knowledge [F(1, 103) = 66.805, P < .001], attitudes and behavior towards mental-health [F(1, 103) = 5.191, P = .025], and a significant decrease in stress perception score [F(1, 103) = 27.567, P < .001]. The mean salivary delta cortisol during pre-test and post-test at week 12 in the intervention group showed significant difference (P < .001). However, there was no significant difference in the mean delta salivary alpha-amylase between pre-test and post-test at week 12, both in the intervention and control groups.

Conclusion

The mental-health strengthening module was accepted and applicable to first-year medical students and was found to be effective in increasing resilience from various biopsychosocial aspects. It is also advisable to have similar modules throughout the medical school to maintain sustainability.

Effects of Resilience Training on Resilient Functioning in Chronic Stress Situations among Cadets of the Swiss Armed Forces

Research on resilient functioning has gained increasing interest, and some recent studies interpreted resilience in the sense of resilient functioning to stress. In the present study, we investigated the associations between resilient functioning and coping strategies, stress reactivity, self-efficacy, and well-being, and we examined whether resilient functioning could be improved through a training intervention. The participants were 110 male cadets from two infantry officers' schools of the Swiss Armed Forces. The schools were divided into an intervention and control group. The participants in the intervention group took part in the resilience training intervention, whereas the participants in the control group performed military training as usual. Data were assessed before and after the intervention period. Results showed that resilient functioning was positively associated with task-oriented coping and well-being and negatively associated with emotion-oriented coping and stress reactivity. Furthermore, resilient functioning significantly improved in the intervention group from pre- to post-intervention. The results suggested that specific interventions have the power to increase resilient functioning.

Resilience to depression: Implication for psychological vaccination

From the vulnerability perspective, we often ask the question "why someone suffers from depression?" Despite outstanding achievements along this line, we still face high occurrence or recurrence and unsatisfied therapeutic efficacy of depression, suggesting that solely focusing on vulnerability perspective is insufficient to prevent and cure depression. Importantly, although experiencing same adversity, most people do not suffer from depression but manifest certain resilience, which could be used to prevent and cure depression, however, the systematic review is still lack. Here, we propose the concept "resilience to depression" to emphasize resilient diathesis against depression, by asking the question "why someone is exempted from depression?" Research evidence of resilience to depression has been reviewed systematically: positive cognitive style (clear purpose in life, hopefulness, et al.), positive emotion (emotional stability, et al.), adaptive behavior (extraversion, internal self-control, et al.), strong social interaction (gratitude and love, et al.), and neural foundation (dopamine circuit, et al.). Inspired by these evidence, "psychological vaccination" could be achieved by well-known real-world natural-stress vaccination (mild, controllable, and adaptive of stress, with help from parents or leaders) or newly developed "clinical vaccination" (positive activity intervention for current depression, preventive cognitive therapy for remitted depression, et al.), both of which aim to enhance the resilient psychological diathesis against depression, through events or training. Potential neural circuit vaccination was further discussed. This review calls for directing attention to resilient diathesis against depression, which offers a new thinking "psychological vaccination" in both prevention and therapy of depression.

Efficacy of Virtual Cognitive Behavioral Therapy on COVID-19 Pandemic Related Anxiety in a Middle Eastern Country: An Interventional Study

Introduction

Emotional stress and anxiety during COVID-19 pandemic has gained a lot of attention. The capacity to withstand from the manipulated thinking and COVID-19 related stress and anxiety depends on the resilience level of an individual. Cognitive behavioral therapy (CBT) has patronizing benefits for people affected with altered mental health. Relieving COVID-19 related anxiety using CBT has beneficial impact on health and improves quality of life of people.

Objective

Aimed to relieve the anxiety of Omani population during COVID-19 pandemic using CBT.

Methods

This research utilized a pre-experimental one group pre-test post-test design. A non-probability convenient sampling technique was used to select 96 Omani people who fulfilled the inclusion criteria. The pre-anxiety level was assessed using CAS (Corona virus Anxiety Scale). The participants who scored above nine in the scale were given three sessions of CBT. Post-anxiety level was assessed using CAS after three CBT sessions.

Results

The study revealed that the level of anxiety reduced during post-test (6.35) after intervention when compared to pre-test (13.22). The CBT intervention was effective in reducing the anxiety in the post-test at p ≤ .000.

Conclusion

CBT is effective in reducing COVID-19 related anxiety among the Omani population. Therefore, this strategy is highly recommended in people having mental health issues.

Efficacy of the Mental Health App Intellect to Reduce Stress: Randomized Controlled Trial With a 1-Month Follow-up

BACKGROUND

Excessive stress is a major global health concern, particularly in young adults. Short skills-focused self-guided interventions (SGIs) on smartphones are a scalable way to improve stress-coping skills at the population level.

OBJECTIVE

In this randomized controlled trial, we aimed to examine the possible efficacy of a recently developed stress-coping SGI (Intellect) in improving psychological distress, relative to an active control group and 2 potential moderators of this predicted relationship (ie, psychological mindedness [PM] and coping self-efficacy [CSE]).

METHODS

University students (N=321) were randomly assigned to either an 8-day SGI on stress-coping or an active control group. Self-reported measures were obtained at baseline, after the intervention, and at the 1-month follow-up. The primary outcome was psychological stress (Psychological Stress Measure-9). Secondary outcomes were anxiety (Generalized Anxiety Disorder-7) and depressive symptoms (Patient Health Questionnaire-9). PM and CSE were assessed as potential moderators at baseline.

RESULTS

The final sample (n=264) included 188 (71.2%) female, 66 (25%) male, 7 (2.7%) nonbinary, and 3 (1.1%) others participants with a mean age of 22.5 (SD 5.41) years. The intervention group reported significantly lower perceived stress (partial eta-squared [ηp²]=0.018; P=.03) and anxiety (ηp²=0.019; P=.03) levels after intervention relative to the active control group. The effects on perceived stress levels remained statistically significant at the 1-month follow-up (ηp²=0.015; P=.05). Students with the lowest CSE and highest PM experienced the fastest decline in perceived stress levels (β=6.37, 95% Cl 2.98-9.75). Improvements in anxiety levels were not observed at 1-month follow-up. Similarly, no intervention effects were found for depression levels at postintervention and follow-up periods.

CONCLUSIONS

This study provides evidence that the Intellect stress-coping SGI is effective in reducing perceived stress and anxiety levels among university students. Mobile health apps are brief, scalable, and can make important contributions to public mental health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04978896; https://www.clinicaltrials.gov/ct2/show/NCT04978896.

Internet-delivered cognitive behavioral interventions to reduce elevated stress: A systematic review and meta-analysis

Background

Face-to-face cognitive behavioral therapy (CBT) is the most promising treatment to reduce stress, but access to CBT is limited. Internet-delivered CBT (ICBT) enables large-scale dissemination at low costs. Evidence suggests that ICBT can reduce stress in subclinical and mixed diagnostic samples, but less is known about the effect of ICBT in targeted samples suffering from elevated perceived stress or stress-related disorders.

Objective

To investigate the efficacy of ICBT specifically aimed at reducing stress in adults with elevated perceived stress or stress-related disorders.

Methods

We searched for randomized controlled trials comparing ICBT with a control group in PubMed, Web of Science, and PsycInfo between 2010 and 2021. A meta-analysis of 14 comparisons (total N = 1831) was performed, and Cohen's d was calculated to assess the difference between intervention and control groups at posttest for the primary outcome self-rated stress. Effects on secondary outcomes of anxiety and depression were also investigated.

Results

The pooled mean effect size for self-rated stress at posttest was d = 0.78 [CI 95 % 0.66-0.90]. For anxiety and depression, the effects were d = 0.69 [95 % CI 0.52-0.86] and d = 0.65 [95 % CI 0.56-0.75] respectively. The heterogeneity of results between studies was overall low to moderate. Subgroup analyses were not conducted due to the limited number of studies eligible for inclusion.

Conclusions

Results provide evidence of the efficacy of ICBT to reduce stress, anxiety, and depressive symptoms in adults suffering from elevated stress or stress-related disorders. Findings have important implications for the development of safe and evidence-based treatment guidelines in the face of a rapid digital expansion.This study was preregistered at Open Science Framework (osf.io) with DOI 10.17605/OSF.IO/BQAZ3.

The construction of a new Clinical Quality of Life Scale (CLINQOL)

Whilst the variables in quality of life and well-being can be separated into objective and subjective domains, there remains a dearth of multiple utility instruments that assess their impact upon quality of life. To address this, ten domains were identified in a preliminary exploratory literature search, and an exploratory review generated enough facets to represent each domain, with items developed to form a composite scale. A principal components analysis run on data collected from 210 participants produced seven factors: relationships, work, money, health, leisure, and life management, with the remaining four domains subsuming into a seventh composite subjective factor (mental state). Final items were collated into the new Clinical Quality of Life Scale (CLINQOL) and were tested against the Assessment of Quality of Life Instrument, the Personal Wellbeing Index-Adult, Positive and Negative Affect Scale, the Satisfaction with Life scale, and the Mindfulness Attention Awareness Scale. The CLINQOL demonstrated suitable reliability, with items within each category forming internally consistent subscales. The full scale score demonstrated satisfactory test-retest reliability and concurrent validity, correlating with all measures. Findings suggest that the CLINQOL captures critical clinical factors, and may be an acceptable instrument to assess quality of life and well-being.

A Technology-Assisted Telephone Intervention for Work-Related Stress Management: Pilot Randomized Controlled Trial

Background

Stress management interventions combining technology with human involvement have the potential to improve the cost-effectiveness of solely human-delivered interventions, but few randomized controlled trials exist for assessing the cost-effectiveness of technology-assisted human interventions.

Objective

The aim of this study was to investigate whether a technology-assisted telephone intervention for stress management is feasible for increasing mental well-being or decreasing the time use of coaches (as an approximation of intervention cost) while maintaining participants’ adherence and satisfaction compared with traditional telephone coaching.

Methods

A 2-arm, pilot randomized controlled trial of 9 months for stress management (4-month intensive and 5-month maintenance phases) was conducted. Participants were recruited on the web through a regional occupational health care provider and randomized equally to a research (technology-assisted telephone intervention) and a control (traditional telephone intervention) group. The coaching methodology was based on habit formation, motivational interviewing, and the transtheoretical model. For the research group, technology supported both coaches and participants in identifying behavior change targets, setting the initial coaching plan, monitoring progress, and communication. The pilot outcome was intervention feasibility, measured primarily by self-assessed mental well-being (WorkOptimum index) and self-reported time use of coaches and secondarily by participants’ adherence and satisfaction.

Results

A total of 49 eligible participants were randomized to the research (n=24) and control (n=25) groups. Most participants were middle-aged (mean 46.26, SD 9.74 years) and female (47/49, 96%). Mental well-being improved significantly in both groups (WorkOptimum from “at risk” to “good” Â>0.85; P<.001), and no between-group differences were observed in the end (Â=0.56, 95% CI 0.37-0.74; P=.56). The total time use of coaches did not differ significantly between the groups (366.0 vs 343.0 minutes, Â=0.60, 95% CI 0.33-0.85; P=.48). Regarding adherence, the dropout rate was 13% (3/24) and 24% (6/25), and the mean adherence rate to coaching calls was 92% and 86% for the research and control groups, respectively; the frequency of performing coaching tasks was similar for both groups after both phases; and the diligence in performing the tasks during the intensive phase was better for the research group (5.0 vs 4.0, Â=0.58, 95% CI 0.51-0.65; P=.03), but no difference was observed during the maintenance phase. Satisfaction was higher in the research group during the intensive phase (5.0 vs 4.0, Â=0.66, 95% CI 0.58-0.73; P<.001) but not during the maintenance phase.

Conclusions

The technology-assisted telephone intervention is feasible with some modifications, as it had similar preliminary effectiveness as the traditional telephone intervention, and the participants had better satisfaction with and similar or better adherence to the intervention, but it did not reduce the time use of coaches. The technology should be improved to provide more digested information for action planning and templates for messaging.

Trial Registration

ClinicalTrials.gov NCT02445950; https://www.clinicaltrials.gov/ct2/show/study/NCT02445950

Resilience Interventions Conducted in Western and Eastern Countries-A Systematic Review

Previous research has demonstrated the efficacy of psychological interventions to foster resilience. However, little is known about whether the cultural context in which resilience interventions are implemented affects their efficacy on mental health. Studies performed in Western (k = 175) and Eastern countries (k = 46) regarding different aspects of interventions (setting, mode of delivery, target population, underlying theoretical approach, duration, control group design) and their efficacy on resilience, anxiety, depressive symptoms, quality of life, perceived stress, and social support were compared. Interventions in Eastern countries were longer in duration and tended to be more often conducted in group settings with a focus on family caregivers. We found evidence for larger effect sizes of resilience interventions in Eastern countries for improving resilience (standardized mean difference [SMD] = 0.48, 95% confidence interval [CI] 0.28 to 0.67; p < 0.0001; 43 studies; 6248 participants; I2 = 97.4%). Intercultural differences should receive more attention in resilience intervention research. Future studies could directly compare interventions in different cultural contexts to explain possible underlying causes for differences in their efficacy on mental health outcomes.

Does Training Motivation Influence Resilience Training Outcome on Chronic Stress? Results from an Interventional Study

Resilience is understood as an acquired skill which aids in coping with acute and chronic stress. Accordingly, the present study aimed to determine the effect of resilience training on mental health problems during chronic stress. To this end, we conducted a quasi-experimental study with 127 male cadets (mean age: 21 years) of the Swiss Armed Forces officers' school. Whereas the intervention group (IG) received resilience training in addition to the standard officer's education program, the control group (CG) completed the officers' school as usual. Data assessment included pre- and post- measurement of chronic stress, symptoms of depression, and vital exhaustion in both groups. Motivation for training was collected before the first training session. Those who received the resilience training reported no change in chronic stress, whereas participants in the CG showed a significant increase in chronic stress over time (η_p² = 0.025). Furthermore, significant differences between IG and CG were only found for symptoms of depression: Participants in the IG reported significantly decreased symptoms of depression, while this was not the case for participants in the CG. Within the IG, participants' training motivation strongly influenced the effectiveness of the resilience training. More specifically, motivated individuals were more likely to benefit from the resilience training than unmotivated ones. Outcome data suggest that resilience training appeared to favorably affect chronic stress and related mental health symptoms; however, the motivation for the training seemed to be an essential prerequisite.

Assessing the Effects of the COVID-19 Pandemic on Nontraditional Students' Mental Health and Well-Being

The current study sought to measure how the COVID-19 pandemic affected the mental health and well-being of college students, particularly nontraditional students. Participants (n = 321) completed a series of surveys assessing their level of depression, anxiety, sleep disturbances, insomnia, and well-being. Participants also indicated their nontraditional student characteristics, level of resilience, and additional life stressors due to the pandemic. Statistical analyses found that participants reported higher levels of depression, anxiety, sleep disturbances, and insomnia, with corresponding lower levels of well-being across all students, compared with prepandemic levels. Results showed that while nontraditional students indicated an increased number of life stressors during the pandemic compared with their traditional peers, nontraditional students also demonstrated higher levels of resilience. Nontraditional students appear to be more successful at managing stressful life events due to the increased resilience that comes with age and experience, which can better prepare them to persevere and overcome challenges.

Clinical wisdom in the age of computer apps: a systematic review of four functions that may complement clinical treatment

Mental health clinicians perform complex tasks with patients that potentially could be improved by the massive computing power available through mobile apps. This study aimed to analyse commercially available mobile and computer applications (apps) focused on treating psychiatric disorders. Apps were analysed by two independent raters for whether they took advantage of computer power to process data in a fashion that augments four main elements of clinical treatment including (1) assessment/diagnosis, (2) treatment planning, (3) treatment fidelity monitoring, and (4) outcome tracking. The evidence base for each of these apps was also explored via PsychINFO, Research Gate and Google Scholar. Searches of the Google Play Store, the Apple App Store, and the One Mind PsyberGuide found 722 apps labelled for mental health use, of which 163 apps were judged relevant to clinical work with patients with psychiatric disorders. Fifty-nine of these were determined to contain a computer-driven function for at least one of the four main elements of clinical treatment. The most common element was assessment/diagnosis (55/59 apps), followed by outcome tracking (34/59 apps). Six apps updated treatment plans using user input. Only one app tracked treatment fidelity. None of the apps contained computer-driven functions for all four elements. Twelve apps were supported in randomized clinical trials to show greater efficacy compared with either wait-list or other active treatments. Results showed that these four clinical elements can be meaningfully augmented, but the full potential of computer processing appears unreached in mental health-related apps.

Key learning aims

(1)

Evaluating the Role of Breathing Guidance on Game-Based Interventions for Relaxation Training

Working in a fast-paced environment can lead to shallow breathing, which can exacerbate stress and anxiety. To address this issue, this study aimed to develop micro-interventions that can promote deep breathing in the presence of stressors. First, we examined two types of breathing guides to help individuals learn deep breathing: providing their breathing rate as a biofeedback signal, and providing a pacing signal to which they can synchronize their breathing. Second, we examined the extent to which these two breathing guides can be integrated into a casual game, to increase enjoyment and skill transfer. We used a 2 × 2 factorial design, with breathing guide (biofeedback vs. pacing) and gaming (game vs. no game) as independent factors. This led to four experimental groups: biofeedback alone, biofeedback integrated into a game, pacing alone, and pacing integrated into a game. In a first experiment, we evaluated the four experimental treatments in a laboratory setting, where 30 healthy participants completed a stressful task before and after performing one of the four treatments (or a control condition) while wearing a chest strap that measured their breathing rate. Two-way ANOVA of breathing rates, with treatment (5 groups) and time (pre-test, post-test) as independent factors shows a significant effect for time [F(4, 50) = 18.49, p < 0.001, η t i m e 2 = 0 . 27 ] and treatment [F(4, 50) = 2.54, p = 0.05, η² = 0.17], but no interaction effects. Post-hoc t-tests between pre and post-test breathing rates shows statistical significance for the game with biofeedback group [t(5) = 5.94, p = 0.001, d = 2.68], but not for the other four groups, indicating that only game with biofeedback led to skill transfer at post-test. Further, two-way ANOVA of self-reported enjoyment scores on the four experimental treatments, with breathing guide and game as independent factors, found a main effect for game [ F ( 1 , 20 ) = 24 . 49 , p < 0 . 001 ,   η g a m e 2 = 0 . 55 ], indicating that the game-based interventions were more enjoyable than the non-game interventions. In a second experiment, conducted in an ambulatory setting, 36 healthy participants practiced one of the four experimental treatments as they saw fit over the course of a day. We found that the game-based interventions were practiced more often than the non-game interventions [t (34) = 1.99, p = 0.027, d = 0.67]. However, we also found that participants in the game-based interventions could only achieve deep breathing 50% of the times, whereas participants in the non-game groups succeeded 85% of the times, which indicated that the former need adequate training time to be effective. Finally, participant feedback indicated that the non-game interventions were better at promoting in-the-moment relaxation, whereas the game-based interventions were more successful at promoting deep breathing during stressful tasks.

Pre-deployment programmes for building resilience in military and frontline emergency service personnel

BACKGROUND

Military personnel and frontline emergency workers may be exposed to events that have the potential to precipitate negative mental health outcomes such as depression, symptoms of post-traumatic stress and even post-traumatic stress disorder (PTSD). Programmes have been designed to build psychological resilience before staff are deployed into the field. This review presents a synthesis of the literature on these "pre-deployment resilience-building programmes".

OBJECTIVES

The objective of this review was to assess the effectiveness of programmes that seek to build resilience to potentially traumatic events among military and frontline emergency service personnel prior to their deployment. These resilience programmes were compared to other interventions, treatment as usual or no intervention.

SEARCH METHODS

Studies were identified through searches of electronic databases including Ovid MEDLINE, Embase, PsycINFO, Web of Science and Google Scholar. The initial search took place in January 2019, with an updated search completed at the end of September 2020.

SELECTION CRITERIA

Only studies that used a randomised controlled trial (RCT)/cluster-RCT methodology were included. The programmes being evaluated must have sought to build resilience prior to exposure to trauma. Study participants must have been 18 years or older and be military personnel or frontline emergency workers.

DATA COLLECTION AND ANALYSIS

Studies that met the inclusion criteria were assembled. Data extracted included methods, participants' details, intervention details, comparator details, and information on outcomes. The primary outcomes of interest were resilience, symptoms of post-traumatic stress and PTSD. Secondary outcomes of interest included acute stress disorder, depression, social support, coping skills, emotional flexibility, self-efficacy, social functioning, subjective levels of aggression, quality of sleep, quality of life and stress. Assessment of risk of bias was also completed. A total of 28 studies were included in a narrative synthesis of results.

MAIN RESULTS

All 28 included studies compared an experimental resilience building intervention versus a control or no intervention. There was a wide range of therapeutic modalities used, including cognitive behavioural therapy (CBT) informed programmes, biofeedback based programmes, stress-management programmes, mindfulness and relaxation programmes, neuropsychological-based programmes, and psychoeducational-informed programmes. The main outcomes are specified here, secondary outcomes such as depression, social support, coping skills, self-efficacy, subjective levels of aggression and stress are reported in text. No studies reported on the following pre-specified outcomes; acute stress disorder, emotional flexibility, social functioning, quality of sleep and quality of life. Resilience Eight studies reported resilience as an outcome. We narratively synthesised the data from these studies and our findings show that five of these interventions had success in building resilience in their respective samples. Two of the studies that reported significant results utilised a CBT approach to build resilience, while the other three successful programmes were mindfulness-based interventions. Symptoms of post-traumatic stress Our narrative synthesis of results included eight studies. Two of the eight studies produced significant reductions in symptoms of post traumatic stress compared to controls. These interventions used neuropsychological and biofeedback intervention models respectively. PTSD caseness Four studies reported PTSD caseness as an outcome. Our narrative synthesis of results suggests that evidence is mixed as to the effectiveness of these interventions in reducing clinical diagnosis of PTSD. One study of a neuropsychology-orientated Attention Bias Modification Training (AMBT) programme had success in reducing both symptoms of post-traumatic stress and numbers of participants receiving a diagnosis of PTSD. A stress-management programme reported that, when baseline differences in rates of pre-deployment mental health issues were controlled for, participants in the control condition were at 6.9 times the risk of a diagnosis of PTSD when compared to the intervention group. Given the diversity of intervention designs and theoretical orientations used (which included stress-management, neuropsychological and psychoeducational programmes), a definitive statement on the efficacy of pre-deployment programmes at reducing symptoms of post-traumatic stress and PTSD cannot be confidently offered.

AUTHORS' CONCLUSIONS

While a number of evaluations of relevant programmes have been published, the quality of these evaluations limits our ability to determine if resilience-building programmes 'work' in terms of preventing negative outcomes such as depression, symptoms of post-traumatic stress and diagnoses of PTSD. Based on our findings we recommend that future research should: a) report pre-/post-means and standard deviation scores for scales used within respective studies, b) take the form of large, RCTs with protocols published in advance, and c) seek to measure defined psychological facets such as resilience, PTSD and stress, and measure these concepts using established psychometric tools. This will provide more certainty in future assessments of the evidence base. From a clinical implications point of view, overall there is mixed evidence that the interventions included in this review are effective at safe guarding military personnel or frontline emergency workers from experiencing negative mental health outcomes, including PTSD, following exposure to potentially traumatic events. Based on this, practitioners seeking to build resilience in their personnel need to be aware of the limitations of the evidence base. Practitioners should have modest expectations in relation to the efficacy of resilience-building programmes as a prophylactic approach to employment-related critical incident traumas.

My Health Too: Investigating the Feasibility and the Acceptability of an Internet-Based Cognitive-Behavioral Therapy Program Developed for Healthcare Workers

Background: The COVID-19 crisis has had a considerable mental health impact on healthcare workers. High levels of psychological distress are expected to have a significant impact on healthcare systems, warranting the need for evidence-based psychological interventions targeting stress and fostering resilience in this population. Online cognitive behavioral therapy (CBT) has proved to be effective in targeting stress and promoting resilience. However, online CBT programs targeting stress in healthcare workers are lacking. Objective: The aim of our study is to evaluate the feasibility and acceptability of an internet-based CBT intervention, the My Health Too program we developed during the first COVID-19 epidemic peak in France. Methods: We recruited 10 participants among Alsace region hospital staff during the first peak of the pandemic in France. They were given 1 week to test the website and were then asked to answer an internet survey and a semi-structured phone interview. Results: We conducted a thematic analysis of the content from the phone interviews. Major themes were identified, discussed and coded: the technical aspects, the content of the website and its impact on participants' emotions and everyday life. Overall, the participants reported finding the website easy to use and interactive. They described the resources as easy to understand, readily usable, and useful in inducing calm and in helping them practice self-compassion. Conclusion: Our results suggest that the My Health Too online CBT program is highly feasible and acceptable to healthcare workers during the highly stressful times of the pandemic peak. The feedback provided helped to improve the program whose efficacy is to be tested.

Effectiveness of a Mobile Device-Based Resilience Training Program in Reducing Depressive Symptoms and Enhancing Resilience and Quality of Life in Parents of Children With Cancer: Randomized Controlled Trial

BACKGROUND

Caring for children with cancer can be a stressful experience for parents and may have negative effects on their physical and psychological well-being. Although evidence has shown that resilience is associated with positive psychological well-being, few interventions have been specifically designed to enhance the resilience of parents of children with cancer.

OBJECTIVE

The aim of this study is to examine the effectiveness of a mobile device-based resilience training program in reducing depressive symptoms and enhancing resilience and quality of life (QoL) in parents of children with cancer.

METHODS

Parents of children diagnosed with cancer were recruited from the pediatric oncology wards of 3 tertiary hospitals in China. The participants were randomly assigned to either the experimental group (52/103, 50.5%) to undergo an 8-week mobile device-based resilience training program or to the control group (51/103, 49.5%) to receive an 8-week program of placebo information. The study outcomes included resilience, depressive symptoms, and QoL, as measured by the Connor-Davidson Resilience Scale, the Self-Rating Depression Scale, and the Short Form of the 6-Dimension Health Survey, respectively. All data were collected at baseline and at 2 and 6 months of follow-up. The data analysis followed the intention-to-treat principle. A generalized estimating equation was used to examine the effects of the intervention.

RESULTS

The participants were mostly female (72/103, 69.9%), and their mean age was 33.6 (SD 5.2) years. The participants in the experimental group showed significantly higher levels of resilience (mean 67.96, SD 15.8 vs mean 58.27, SD 19.0; P<.001) and lower levels of depressive symptoms (mean 40.17, SD 9.9 vs mean 46.04, SD 10.9; P<.001) than those in the control group at 6 months of follow-up. The intervention showed statistically significant effects in improving resilience (β=6.082; P=.01) and decreasing depressive symptoms (β=-2.772; P=.04) relative to the control group. The QoL score in the experimental group was higher than that in the control group at 6 months of follow-up (mean 0.79, SD 0.2 vs mean 0.76, SD 0.3; P=.07); however, no statistically significant intervention effect was detected (β=.020; P=.38).

CONCLUSIONS

The mobile device-based resilience training program effectively enhanced resilience and alleviated depressive symptoms in parents of children with cancer. It is highly recommended that health care professionals incorporate this resilience training program when providing psychological care to parents of children with cancer.

TRIAL REGISTRATION

Clinical.Trials.gov NCT04038242; http://clinicaltrials.gov/ct2/show/NCT04038242.

The Q-Life experience: An evaluation of an employee resilience program

BACKGROUND

Many employers are turning to training programs to help them cope or flourish in life. Many programs on the market have not been validated.

OBJECTIVE

The objective was to evaluate the effect building awareness and skill development can have on sustaining high resilience within a group of employees.

METHODS

524 participants completed the 44 itemed Q-Life assessment. A CFA model was conducted to determine whether the Q-Life score, adequately describes the data. 116 employees signed up to the Q-Life experience with 64 completing all requirements.

RESULTS

The RMSEA index was less than 0.08, RMSEA = 0.07, 90%CI = [0.07, 0.07], which is indicative of a good model fit. The mean of score for resilience on the first test (M = 249.91) was significantly lower than the mean of post-test (M = 264.91).

CONCLUSIONS

The results indicated that the model demonstrated acceptable fit to the data and can be used as an assessment tool for the Q-Life. The Q-Life experience showed significant improvement in resilience.

Use of a Self-guided Computerized Cognitive Behavioral Tool During COVID-19: Evaluation Study

BACKGROUND

Internet-based programs can help provide accessible and inexpensive behavioral health care to those in need; however, the evaluation of these interventions has been mostly limited to controlled trials. Data regarding patterns of use and effectiveness of self-referred, open-access online interventions are lacking. We evaluated an online-based treatment designed to address stress, depression, and conflict management, the Dartmouth PATH Program, in a freely available and self-guided format during the COVID-19 pandemic.

OBJECTIVE

The primary aim is to determine users' levels of stress and depression, and the nature of problems and triggers they reported during the COVID-19 pandemic. A secondary objective is to assess the acceptability and usability of the PATH content and determine whether such a program would be useful as a stand-alone open-access resource. The final objective is understanding the high dropout rates associated with online behavioral programs by contrasting the use pattern and program efficacy of individuals who completed session one and did not return to the program with those who came back to complete more sessions.

METHODS

Cumulative anonymous data from 562 individuals were analyzed. Stress triggers, stress responses, and reported problems were analyzed using qualitative analysis techniques. Scores on usability and acceptability questionnaires were evaluated using the sign test and Wilcoxon signed rank test. Mixed-effects linear modeling was used to evaluate changes in stress and depression over time.

RESULTS

A total of 2484 users registered from April through October 2020, most of whom created an account without initiating a module. A total of 562 individuals started the program and were considered in the data analysis. The most common stress triggers individuals reported involved either conflicts with family or spouses and work or workload. The most common problems addressed in the mood module were worry, anxiousness, or stress and difficulty concentrating or procrastination. The attrition rate was high with 13% (21/156) completing the conflict module, 17% (50/289) completing session one of the mood module, and 14% (16/117) completing session one of the stress module. Usability and acceptability scores for the mood and stress modules were significantly better than average. In those who returned to complete sessions, symptoms of stress showed a significant improvement over time (P=.03), and there was a significant decrease in depressive symptoms over all time points (P=.01). Depression severity decreased on average by 20% (SD 35.2%; P=.60) between sessions one and two.

CONCLUSIONS

Conflicts with others, worry, and difficulty concentrating were some of the most common problems people used the programs to address. Individuals who completed the modules indicated improvements in self-reported stress and depression symptoms. Users also found the modules to be effective and rated the program highly for usability and acceptability. Nevertheless, the attrition rate was very high, as has been found with other freely available online-based interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02726061; https://clinicaltrials.gov/ct2/show/NCT02726061.

Psychosocial issues in isolated and confined extreme environments

PALINKAS, L.A., and P. SUEDFELD. Psychosocial Issues in Isolated and Confined Extreme Environments. NEUROSCI BIOBEHAV REV (1) XXX-XXX, 2020. Psychosocial elements of behavior and performance will significantly impact the outcomes of long duration missions in space, ranging from individual and team decrements to positive benefits associated with successful adaptation. This paper reviews our current understanding of the individual, interpersonal and organizational issues related to living and working in isolated and confined extreme (ICE) environments. Individual issues include changes in emotions and cognitive performance; seasonal syndromes linked to changes in the physical environment; and positive effects of adapting to ICE environments. Interpersonal issues include processes of crew cohesion, tension and conflict; interpersonal relations and social support; the impact of group diversity and leadership styles on small group dynamics; and crew-mission control interactions. Organizational issues include the influence of organizational culture and mission duration on individual and group performance, crew autonomy, and managerial requirements for long duration missions. Improved screening and selection, leadership, coping and interpersonal skills training, and organizational change are key elements to optimizing adjustment to the environment and preventing decrements during and after long duration missions.

A Live Video Mind-Body Treatment to Prevent Persistent Symptoms Following Mild Traumatic Brain Injury: Protocol for a Mixed Methods Study

Background

Every year, approximately 42 million people sustain a mild traumatic brain injury (mTBI, also known as concussion), with particularly high rates among college-aged individuals. A substantial proportion of these people (44%-64%) develop persistent symptoms that are challenging to treat, costly, and associated with significant disability. Anxiety has emerged as a risk factor for progression from acute to persistent mTBI symptoms.

Objective

This study aims to develop, adapt, and establish the feasibility of the Toolkit for Optimal Recovery after Concussions (TOR-C), an innovative mind-body program aimed at preventing persistent symptoms among young adults with mTBI and comorbid anxiety. Here, we describe the proposed study design, methodology, measurement, and treatment manuals.

Methods

In phase 1, we will conduct individual, live video qualitative interviews (up to n=20) with college-aged individuals with mTBI and comorbid anxiety to inform adaptation of the intervention and study procedures. In phase 2, an open pilot of the live video TOR-C (n=5) with exit interviews will be conducted to explore the initial feasibility, acceptability, and credibility of the program and to refine the study procedures. Phase 3 will involve conducting a feasibility randomized controlled trial (N=50) of the TOR-C versus a health education control (Health Enhancement for Concussions; HE-C), both delivered via live video, to establish feasibility of recruitment procedures (screening, eligibility, and enrollment) and data collection; feasibility, credibility, and acceptability of the live video TOR-C and HE-C (adherence, retention, fidelity, and satisfaction) following prespecified benchmarks; and a signal of improvement in outcomes.

Results

Phase 1 of the study has been approved by the Massachusetts General Hospital Institutional Review Board. Study completion is anticipated by early 2025.

Conclusions

We will develop and test the first mind-body intervention focused on prevention of persistent symptoms following mTBI in young adults with comorbid anxiety problems. This will allow us to establish feasibility markers in postconcussive symptoms, anxiety, disability, and fear avoidance to inform a future efficacy trial of the TOR-C versus HE-C.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25746

Assessing the Efficacy and Acceptability of a Web-Based Intervention for Resilience Among College Students: Pilot Randomized Controlled Trial

BACKGROUND

College students are at elevated risk for developing mental health problems and face specific barriers around accessing evidence-based treatment. Web-based interventions that focus on mental health promotion and strengthening resilience represent one possible solution. Providing support to users has shown to reduce dropout in these interventions. Further research is needed to assess the efficacy and acceptability of these interventions and explore the viability of automating support.

OBJECTIVE

This study investigated the feasibility of a new web-based resilience program based on positive psychology, provided with human or automated support, in a sample of college students.

METHODS

A 3-armed closed pilot randomized controlled trial design was used. Participants were randomized to the intervention with human support (n=29), intervention with automated support (n=26), or waiting list (n=28) group. Primary outcomes were resilience and well-being, respectively measured by the Connor-Davidson Resilience Scale and Pemberton Happiness Index. Secondary outcomes included measures of depression and anxiety, self-esteem, and stress. Outcomes were self-assessed through online questionnaires. Intention-to-treat and per-protocol analyses were conducted.

RESULTS

All participants demonstrated significant improvements in resilience and related outcomes, including an unexpected improvement in the waiting list group. Within- and between-group effect sizes ranged from small to moderate and within-group effects were typically larger for the human than automated support group. A total of 36 participants began the program and completed 46.46% of it on average. Participants were generally satisfied with the program and found it easy to use.

CONCLUSIONS

Findings support the feasibility of the intervention. Preliminary evidence for the equal benefit of human and automated support needs to be supported by further research with a larger sample. Results of this study will inform the development of a full-scale trial, from which stronger conclusions may be drawn.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN) 11866034; http://www.isrctn.com/ISRCTN11866034.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.invent.2019.100254.

Autonomous Psychological Support for Isolation and Confinement

INTRODUCTION: Isolated and confined environments (ICEs), such as spaceflight, are challenging psychologically. We have been evaluating self-directed tools to sustain and improve psychological well-being in these settings. The Expedition Application for Peak Psychological Performance (Expedition-APPP) is an interactive media-based set of self-directed tools that address conflict resolution, stress management, and depression treatment. Virtual reality (VR) of nature scenes is a tool to improve attention and relieve stress by providing users with an immersive nature experience. We evaluated both Expedition-APPP and VR in an ICE.METHODS: The Expedition-APP was evaluated during three, and nature VR during two, deployments at the HI-SEAS habitat, where crews of six were isolated for 812 mo. Participants used both the Expedition-APPP and VR and shared their feedback and experiences after the deployments in semistructured interviews. These interviews were evaluated using qualitative analysis techniques to gather generalizable insights into implementing autonomous mental health programs for people living and working in ICEs.RESULTS: Expedition-APPP modules provided a shared culture, language, and tools for working through challenges. VR allowed for access to emotions and experiences that were unavailable in the habitat. Suggestions for improvement included making refresher training easily available and providing a wider range of content to address different individuals coping styles.DISCUSSION: Both the Expedition-APPP and VR were appreciated and used, although a wider range of content and experiences was desired by participants.Lyons KD, Slaughenhaupt RM, Mupparaju SH, Lim JS, Anderson AA, Stankovic AS, Cowan DR, Fellows AM, Binsted KA, Buckey JC. Autonomous psychological support for isolation and confinement. Aerosp Med Hum Perform. 2020; 91(11):876885.

Efficacy of an online cognitive behavioral therapy program developed for healthcare workers during the COVID-19 pandemic: the REduction of STress (REST) study protocol for a randomized controlled trial

BACKGROUND

The acknowledgment of the mental health toll of the COVID-19 epidemic in healthcare workers has increased considerably as the disease evolved into a pandemic status. Indeed, high prevalence rates of depression, sleep disorders, and post-traumatic stress disorder (PTSD) have been reported in Chinese healthcare workers during the epidemic peak. Symptoms of psychological distress are expected to be long-lasting and have a systemic impact on healthcare systems, warranting the need for evidence-based psychological treatments aiming at relieving immediate stress and preventing the onset of psychological disorders in this population. In the current COVID-19 context, internet-based interventions have the potential to circumvent the pitfalls of face-to-face formats and provide the flexibility required to facilitate accessibility to healthcare workers. Online cognitive behavioral therapy (CBT) in particular has proved to be effective in treating and preventing a number of stress-related disorders in populations other than healthcare workers. The aim of our randomized controlled trial study protocol is to evaluate the efficacy of the 'My Health too' CBT program-a program we have developed for healthcare workers facing the pandemic-on immediate perceived stress and on the emergence of psychiatric disorders at 3- and 6-month follow-up compared to an active control group (i.e., bibliotherapy).

METHODS

Powered for superiority testing, this six-site open trial involves the random assignment of 120 healthcare workers with stress levels > 16 on the Perceived Stress Scale (PSS-10) to either the 7-session online CBT program or bibliotherapy. The primary outcome is the decrease of PSS-10 scores at 8 weeks. Secondary outcomes include depression, insomnia, and PTSD symptoms; self-reported resilience and rumination; and credibility and satisfaction. Assessments are scheduled at pretreatment, mid-treatment (at 4 weeks), end of active treatment (at 8 weeks), and at 3-month and 6-month follow-up.

DISCUSSION

This is the first study assessing the efficacy and the acceptability of a brief online CBT program specifically developed for healthcare workers. Given the potential short- and long-term consequences of the COVID-19 pandemic on healthcare workers' mental health, but also on healthcare systems, our findings can significantly impact clinical practice and management of the ongoing, and probably long-lasting, health crisis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04362358 , registered on April 24, 2020.

Psychological interventions to foster resilience in healthcare students

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.

Psychological interventions to foster resilience in healthcare professionals

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.

Creating value with eHealth: identification of the value proposition with key stakeholders for the resilience navigator app

BACKGROUND

For a stress-management app to be persuasive and impactful, designers and developers should obtain a clear perspective of the value proposition according to key stakeholders before development. However, this is often not the case. In order to increase the chance of creating an impact by means of the Resilience Navigator app, this study aims to identify key stakeholders and work with them to gain an in-depth understanding of the value proposition of this stress-management app.

METHODS

The approach used in this study builds on the approaches taken by Van Limburg et al. and Van Woezik et al. An initial list of stakeholders was identified by means of a literature scan. Stakeholders on this initial list took an online survey to identify key stakeholders with a ranking system. Semi-structured interviews were conducted with a subset of key stakeholders to identify the value proposition using the value proposition canvas as a framework for data collection. Finally, the value proposition was validated by key stakeholders during focus groups.

RESULTS

The key stakeholders identified included employees, employers, participation councils within organisations, HR advisors, product owners, company doctors, and business analysts. The interviews produced a list of approximately one hundred values from which fifteen core values were distilled. One example is to take into account time constraints experienced by users during stress periods. In general, the Resilience Navigator app's main goal is to increase awareness of personal stress levels and causes of stress. In addition, the sub-goal is to increase skills for effective stress management. The focus groups validated the idea that the most important values were reflected in the value proposition and had been appropriately translated into design elements, according to key stakeholders.

CONCLUSIONS

A thorough, bottom-up identification and validation of the value proposition for the Resilience Navigator app was obtained, reflecting key stakeholders' varying ideas on this piece of eHealth technology. The results will facilitate the continued development of the Resilience Navigator app from the value specification phase to the design phase. In the design phase, the remaining assumptions regarding the app's value proposition should be tested using rapid prototyping.

Efficacy of a self-applied online program to promote resilience and coping skills in university students in four Spanish-speaking countries: study protocol for a randomized controlled trial

BACKGROUND

There is evidence of a high prevalence of depression and anxiety in university students. Therefore, college time is a key period where prevention of mental disorders through interventions that promote resilience and mental health can be relevant. Currently, there are interventions available, but these are insufficient for those who need them. Online interventions are tools that can facilitate global accessibility and are easy for young people to use. CORE (Cultivating Our Resilience) is a self-administered online program, based on Ryff's psychological well-being model, to promote resilience and coping skills in university students at risk of developing symptoms of depression or anxiety. The objective is to evaluate the effectiveness of this intervention protocol in comparison with an active control condition targeting healthy lifestyle, and a waiting list control condition. The study will be conducted in four populations of Spanish-speaking university students (Spain, Argentina, Colombia, and Mexico).

METHODS

The study design is a randomized controlled trial (RCT). At least 324 university students will be randomly assigned to three conditions: 1) CORE, a 6-week training program to improve resilience; 2) HLP, a 6-week training to promote a healthy lifestyle; and 3) WL, waiting list control condition. The primary outcome measure will be the Connor-Davidson resilience scale. Additionally, measures of anxiety, depression, quality of life and socio-demographic variables (age, sex, incomes, marital status, among others) will be collected. Participants will be evaluated at pre-treatment, after each module, 6 weeks after allocation, and at 3-month follow-up. Intention-to-treat and per-protocol analyses will be performed.

DISCUSSION

The results of this study will contribute to research on Internet-administered interventions and the implementation of a protocol that includes a series of components designed to improve resilience and coping skills, increase psychological well-being, and prevent depression and anxiety disorders in Spanish-speaking university students. In addition, avenues will be opened up for new research on the effectiveness of these interventions focused on the prevention and promotion of mental health in Spanish-speaking countries.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov NCT03903978 on April 2, 2019.

A New Mental Health Mobile App for Well-Being and Stress Reduction in Working Women: Randomized Controlled Trial

BACKGROUND

Although the availability and use of mobile mental health apps has grown exponentially in recent years, little data are available regarding their efficacy.

OBJECTIVE

This study aimed to evaluate the effectiveness of an app developed to promote stress management and well-being among working women compared with a control app.

METHODS

Female employees at a private hospital were invited to participate in the study via mailing lists and intranet ads. A total of 653 individuals self-enrolled through the website. Eligible participants were randomized between control (n=240) and intervention (n=250) groups. The well-being mobile app provides an 8-week program with 4 classes per week (including a brief theoretical portion and a 15-min guided practice). The active control app also provided 4 assessments per week that encouraged participants to self-observe how they were feeling for 20 min. We also used the app to conduct Web-based questionnaires (10-item Perceived Stress Scale and 5-item World Health Organization Well-Being Index) and ask specific questions to assess subjective levels of stress and well-being at baseline (t₁), midintervention (t₄=4 weeks after t₁) and postintervention (t₈=8 weeks after t₁). Both apps were fully automated without any human involvement. Outcomes from the control and intervention conditions at the 3 time points were analyzed using a repeated measures analysis of variance.

RESULTS

Among the randomized participants (n=490), 185 participants were excluded at the 4-week follow-up and another 79 at the 8-week follow-up because of noncompliance with the experimental protocol. Participants who did not complete t₄ and t₈ assessments were equally distributed between groups (t₄: control group=34.6% [83/240] and intervention group=40.8% [102/250]; P=.16; t₈: control group=29.9% [47/157] and intervention group=21.6% [32/148]; P=.10). Both groups showed a significant increase in general well-being as a function of time (F_2,426=5.27; P=.006), but only the intervention group presented a significant increase in work-related well-being (F_2,426=8.92; P<.001), as well as a significant reduction in work-related and overall stress (F_2,426=5.50; P=.004 and F_2,426=8.59; P<.001, respectively).

CONCLUSIONS

The well-being mobile app was effective in reducing employee stress and improving well-being.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02637414; https://clinicaltrials.gov/ct2/show/NCT02637414.

The Need for a Neutral Speaking Period in Psychosocial Stress Testing

Abstract. Tasks such as the Trier Social Stress Test, narrative recall, and some cognitive challenges require participants to speak in order to measure acute physiological responses to induced stress. Typically, the physiological measures during the stressed state are compared to a silent baseline period. This does not differentiate between stress that is induced by emotion and stress due to the physical act of vocalization. We modified a psychosocial stress task for 41 participants to add a period of neutral speaking. We hypothesized that there would be significant differences in physiological measures between the silent baseline and neutral speaking periods, and that these differences would explain a substantial proportion of the stress response traditionally attributed to emotion. Blood pressure, skin conductance level, respiration rate, salivary alpha-amylase, and high frequency heart rate variability showed significant changes during the neutral speaking period compared to a silent baseline, demonstrating the need for this control. Of the magnitude of physiological response which would have typically been attributed to emotion, 36–77% was due to vocalization alone. In stress-inducing tasks that require speaking, care should be taken in study design to account for the physiological impact of speech.

A systematic review of prevention programs targeting depression, anxiety, and stress in university students

BACKGROUND

Given the prevalence of anxiety, depression, and stress among university students, it is important to assess the effectiveness of prevention programs for these problems. Beyond examining effect sizes, applying a common elements approach can enhance our understanding of which practice elements are most frequently included in symptom-reducing programs.

METHOD

This review examined effective (i.e., outcome-producing) prevention programs targeting depression, anxiety, and/or stress in university students. Programs could be delivered in a group-based, online/computer-delivered, or self-administered format and at the universal, selective, or indicated prevention level.

RESULTS

The resulting sample of 62 articles covered 68 prevention programs for college, graduate, or professional students across 15 countries. Average effect sizes for programs were moderate (overall g = 0.65), regardless of delivery format or prevention level. The most common practice elements (overall and for programs producing large effects) were: psychoeducation (72%), relaxation (69%), and cognitive monitoring/restructuring (47%). Many programs were limited by: (a) symptom target-outcome mismatches, (b) disproportionately female samples, and (c) inconsistently reported adherence data.

LIMITATIONS

Commonness of practice elements across outcome-producing interventions does not imply their extensiveness nor unique contribution to effectiveness. Coding was based on information in articles rather than manuals, and inter-rater reliability was moderate for some practice elements.

CONCLUSION

The outcome-producing prevention programs in our sample had common practice elements and produced moderate reduction in symptoms overall. Future research of depression, anxiety, and stress prevention programs for university students can investigate practice elements' unique and combined impact on outcomes, further explore under-tested practice elements, and use findings to inform intervention design.

Childhood Adversity and Schizophrenia: The Protective Role of Resilience in Mental and Physical Health and Metabolic Markers

OBJECTIVE

To determine the impact of childhood adversity and current (adulthood) resilience on mental and physical health and markers of metabolic function among adults with schizophrenia and nonpsychiatric comparison participants (NCs).

METHODS

We conducted a cross-sectional study of 114 participants with schizophrenia (DSM-IV-TR criteria) and 101 NCs aged 26-65 years during 2012-2017. Sociodemographic, clinical, and laboratory measures were examined. Childhood Trauma Questionnaire was used to retrospectively assess emotional abuse/neglect, physical abuse/neglect, and sexual abuse experienced during childhood. Connor-Davidson Resilience Scale was employed to measure resilience.

RESULTS

Persons with schizophrenia reported more severe childhood trauma, lower resilience, and worse mental and physical health and had worse metabolic biomarker levels than NCs. Trauma severity correlated with worse depression in the NCs (r = 0.34), but not in the schizophrenia group (r = 0.02). In both groups, trauma severity was associated with worse physical well-being, higher fasting insulin levels, and greater insulin resistance (P ≤ .02). Notably, resilience appeared to counteract effects of trauma and diagnosis on mental and physical health. The schizophrenia subgroup with high resilience and severe trauma reported mental and physical well-being and had glycosylated hemoglobin levels and insulin resistance scores that were comparable to those of NCs with low resilience and severe trauma.

CONCLUSIONS

To our knowledge, this is the first study to quantitatively assess effects of both childhood trauma and resilience in schizophrenia on health, notably metabolic function. Interventions to bolster resilience in the general population and in people with schizophrenia may improve outcomes for those with a history of childhood adversity.

Digital Mental Health Interventions for Depression, Anxiety, and Enhancement of Psychological Well-Being Among College Students: Systematic Review

BACKGROUND

College students are increasingly reporting common mental health problems, such as depression and anxiety, and they frequently encounter barriers to seeking traditional mental health treatments. Digital mental health interventions, such as those delivered via the Web and apps, offer the potential to improve access to mental health treatment.

OBJECTIVE

This study aimed to review the literature on digital mental health interventions focused on depression, anxiety, and enhancement of psychological well-being among samples of college students to identify the effectiveness, usability, acceptability, uptake, and adoption of such programs.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number CRD42018092800), and the search strategy was conducted by a medical research librarian in the following databases: MEDLINE (Ovid), EMBASE (Elsevier), PsycINFO (EbscoHost), the Cochrane Library (Wiley), and Web of Science (Thomson Reuters) from the date of inception to April 2019. Data were synthesized using a systematic narrative synthesis framework, and formal quality assessments were conducted to address the risk of bias.

RESULTS

A total of 89 studies met the inclusion criteria. The majority of interventions (71/89, 80%) were delivered via a website, and the most common intervention was internet-based cognitive behavioral therapy (28, 31%). Many programs (33, 37%) featured human support in the form of coaching. The majority of programs were either effective (42, 47%) or partially effective (30, 34%) in producing beneficial changes in the main psychological outcome variables. Approximately half of the studies (45, 51%) did not present any usability or acceptability outcomes, and few studies (4, 4%) examined a broad implementation of digital mental health interventions on college campuses. Quality assessments revealed a moderate-to-severe risk of bias in many of the studies.

CONCLUSIONS

Results suggest that digital mental health interventions can be effective for improving depression, anxiety, and psychological well-being among college students, but more rigorous studies are needed to ascertain the effective elements of these interventions. Continued research on improving the user experience of, and thus user engagement with, these programs appears vital for the sustainable implementation of digital mental health interventions on college campuses.

Assessing the efficacy and acceptability of an internet-delivered intervention for resilience among college students: A pilot randomised control trial protocol

BACKGROUND

Exposure to new stressors places college students at increased risk for developing mental health problems. Preventive interventions aimed at enhancing resilience have the potential to improve mental health and well-being in college students and internet-delivery may improve access to these interventions. However, few studies have evaluated the efficacy of online interventions for resilience in college students. The present study seeks to assess the feasibility [initial efficacy and acceptability] of a newly developed internet-delivered intervention for resilience provided with human or automated support, in a sample of college students.

METHOD

A pilot randomised controlled trial including three groups: 1) an intervention group with human support; 2) an intervention group with automated support; and 3) a waiting list control group. The intervention, Space for Resilience, is based on positive psychology and consists of seven modules, delivered over a period of eight weeks. Primary outcomes measures will include the Connor-Davidson Resilience Scale (CD-RISC) and the Pemberton Happiness Index (PHI). Secondary outcomes measures will include the Brief Resilience Scale (BRS), the Patient Health Questionnaire - 4 items (PHQ-4), the Rosenberg Self-Esteem Scale (RSES), and the Perceived Stress Scale - 4 items (PSS-4). Acceptability will be examined using the Satisfaction with Treatment (SAT) questionnaire. Analysis will be conducted on an intention-to-treat basis.

DISCUSSION

The study seeks to establish the initial efficacy and acceptability of an internet-delivered intervention for resilience with human support and automated support. Apart from determining the impact of the intervention on acceptability and effectiveness, this study will be a first to explore more clearly the relative benefits of different support modes.

An Internet based intervention for improving resilience and coping strategies in university students: Study protocol for a randomized controlled trial

BACKGROUND

The literature shows a high prevalence of depression and anxiety in young people. The university represents a change in the lives of students, and is considered a stress factor. Therefore, it is particularly relevant to develop interventions specifically addressed to students and foster supportive environments and resilient communities. As students are "digital natives", online interventions offer several potential advantages in doing this. This study aims to develop and evaluate the efficacy of an Internet-based intervention (CORE: Cultivating our Resilience), based on the Ryff model of well-being, to promote resilience and coping skills, decrease symptoms of depression and anxiety, and increase overall wellbeing in young people confronting a crucial life event (the university). This paper summarizes the study protocol.

METHOD

The design of the planned study is a randomized controlled trial. A minimum of 464 participants will be randomly assigned to two conditions: 1) an unguided Internet-based intervention to enhance resilience (N = 232); 2) a care-as-usual condition (CAU) (N = 232). The primary outcome will be the Connor-Davidson resilience scale. Secondary outcomes will - among others - include other relevant clinical measures, such as anxiety and depressive symptoms, quality of life, and social support. Outcomes will be assessed 4 and 8 weeks, and 6 and 12-months follow-ups. Intention-to-treat and per-protocol analyses will be performed.

DISCUSSION

The results of this study will contribute to the growing research on Internet-delivered interventions. The expected results may have a major impact on the prevention of mental disorders and possible negative consequences in at-risk populations, such as college students.

Resilience@Work Mindfulness Program: Results From a Cluster Randomized Controlled Trial With First Responders

Background

A growing body of research suggests that resilience training can play a pivotal role in creating mentally healthy workplaces, particularly with regard to protecting the long-term well-being of workers. Emerging research describes positive outcomes from various types of resilience training programs (RTPs) among different occupational groups. One specific group of workers that may benefit from this form of proactive resilience training is first responders. Given the nature of their work, first responders are frequently exposed to stressful circumstances and potentially traumatic events, which may impact their overall resilience and well-being over time.

Objective

This study aimed to examine whether a mindfulness-based RTP (the Resilience@Work [RAW] Mindfulness Program) delivered via the internet can effectively enhance resilience among a group of high-risk workers.

Methods

We conducted a cluster randomized controlled trial (RCT) comprising 24 Primary Fire and Rescue and Hazmat stations within New South Wales. Overall, 12 stations were assigned to the 6-session RAW Mindfulness Program and 12 stations were assigned to the control condition. A total of 143 active full-time firefighters enrolled in the study. Questionnaires were administered at baseline, immediately post training, and at 6-month follow-up. Measurements examined change in both adaptive and bounce-back resilience as well as several secondary outcomes examining resilience resources and acceptance and mindfulness skills.

Results

Mixed-model repeated measures analysis found that the overall test of group-by-time interaction was significant (P=.008), with the intervention group increasing in adaptive resilience over time. However, no significant differences were found between the intervention group and the control group in terms of change in bounce-back resilience (P=.09). At 6-month follow-up, the group receiving the RAW intervention had an average increase in their resilience score of 1.3, equating to a moderate-to-large effect size compared with the control group of 0.73 (95% CI 0.38-1.06). Per-protocol analysis found that compared with the control group, the greatest improvements in adaptive resilience were observed among those who completed most of the RAW program, that is, 5 to 6 sessions (P=.002).

Conclusions

The results of this RCT suggest that mindfulness-based resilience training delivered in an internet format can create improvements in adaptive resilience and related resources among high-risk workers, such as first responders. Despite a number of limitations, the results of this study suggest that the RAW Mindfulness Program is an effective, scalable, and practical means of delivering online resilience training in high-risk workplace settings. To the best of our knowledge, this is the first time a mindfulness-based RTP delivered entirely via the internet has been tested in the workplace.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12615000574549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368296 (Archived by WebCite at http://www.webcitation.org/75w4xtrpw).

The Emerging Empirical Science of Wisdom: Definition, Measurement, Neurobiology, Longevity, and Interventions

After participating in this activity, learners should be better able to:• Assess the empirical literature on wisdom• Evaluate a proposed model of wisdom development ABSTRACT: This article seeks to provide an overview of the empirical literature on wisdom in terms of its definitions and measurements, possible neurobiological basis, and evolutionary value, as well as changes with aging and potential clinical interventions to enhance components of wisdom. Wisdom may be defined as a complex human trait with several specific components: social decision making, emotion regulation, prosocial behaviors, self-reflection, acceptance of uncertainty, decisiveness, and spirituality. These components appear to be localized primarily to the prefrontal cortex and limbic striatum. Emerging research suggests that wisdom is linked to better overall health, well-being, happiness, life satisfaction, and resilience. Wisdom likely increases with age, facilitating a possible evolutionary role of wise grandparents in promoting the fitness of the species. Despite the loss of their own fertility and physical health, older adults help enhance their children's well-being, health, longevity, and fertility-the "Grandma Hypothesis" of wisdom. We propose a model of wisdom development that incorporates genetic, environmental, and evolutionary aspects. Wisdom has important implications at both individual and societal levels, and warrants further research as a major contributor to human thriving. There is a need for a greater emphasis on promoting wisdom through our educational systems from elementary to professional schools.

Building Resilience: The Conceptual Basis and Research Evidence for Resilience Training Programs

The relationship between adverse experiences and later development has been explored by many researchers, leading to the conceptualization of resilience as a factor explaining the normal or optimal development of some individuals exposed to adversity. Today many different interventions exist aiming to improve the ability of individuals to respond to adversity. In this narrative literature review, we evaluate the literature surrounding resilience and resilience training, discussing the quality of the evidence supporting resilience training, theoretical and practical differences between types of training, and the impact of resilience and psychological training on outcome measures across a variety of settings. The results of our review show that the quality of the literature is mixed, resilience training is not well differentiated from other forms of training, and that the impact of psychological training on later functioning depends heavily on the type of outcome measured and the setting of the training. Further research must be conducted prior to the implementation of resilience training programs in order to assure their efficacy and effectiveness in proposed contexts.

The Stressed Executive: Sources and Predictors of Stress Among Participants in an Executive Health Program

Background

Stress is highly prevalent in the U.S. society, especially in executives, and is a well-documented risk factor for a wide range of medical disorders. Knowledge of common sources of stress and predictive factors may help identify executives at risk of high stress and allow us to appropriately refer them for stress management treatment.

Objective

The primary aim of this study was to identify common sources of stress, predictors of high stress, and other correlates among executives.

Methods

This was a cross-sectional survey of executives who requested a stress management consult at our institution. We abstracted the data from a 14-item intake survey as well as from the patient interview.

Results

Of the 839 executives, 827 executives (98.6%) who were referred for individual stress management consults completed the stress-related questions of the survey; 51.3% of these executives reported having a high stress level. Study participants mostly struggled with the well-being measures of sleep, anxiety, energy level, and diet. The majority reported that their main stressor was work related (n = 540, 64.4%) followed by family related (n = 371, 44.2%), health related (n = 170, 20.3%), and work–life balance (n = 62, 7.4%). In unadjusted analysis, high stress was associated with younger age (P = .006), lower quality-of-life scores (P < .001), and less physical activity (P < .001). In multivariable analyses, the strongest predictors for high stress level were younger age (odds ratios [OR] = 0.84, P = .045) and worse quality-of-life indicators such as anxiety (OR = 2.72, P < .001), diet (OR = 0.78, P = .02), and sleep (OR = 0.74, P < .003).

Conclusion

These findings suggest that executives with a high level of stress might be best helped through a multimodality stress management program. Our findings merit replication in larger studies and more definitive confirmation with prospective clinical trials.

Mindfulness-Based Resilience Training in the Workplace: Pilot Study of the Internet-Based Resilience@Work (RAW) Mindfulness Program

Background

The impact of mental illness on society is far reaching and has been identified as the leading cause of sickness absence and work disability in most developed countries. By developing evidence-based solutions that are practical, affordable, and accessible, there is potential to deliver substantial economic benefits while improving the lives of individual workers. Academic and industry groups are now responding to this public health issue. A key focus is on developing practical solutions that enhance the mental health and psychological resilience of workers. A growing body of research suggests resilience training may play a pivotal role in the realm of public health and prevention, particularly with regards to protecting the long-term well-being of workers.

Objective

Our aim is to examine whether a mindfulness-based resilience-training program delivered via the internet is feasible and engaging to a group of high-risk workers. Additionally, we aim to measure the effect of the Resilience@Work Resilience@Work Mindfulness program on measures of resilience and related skills.

Methods

The current pilot study recruited 29 full-time firefighters. Participants were enrolled in the 6-session internet-based resilience-training program and were administered questionnaires prior to training and directly after the program ended. Measurements examined program feasibility, psychological resilience, experiential avoidance, and thought entanglement.

Results

Participants reported greater levels of resilience after Resilience@Work training compared to baseline, with a mean increase in their overall resilience score of 1.5 (95% CI -0.25 to 3.18, t₁₄=1.84, P=.09). Compared to baseline, participants also reported lower levels of psychological inflexibility and experiential avoidance following training, with a mean decrease of -1.8 (95% CI -3.78 to 0.20, t₁₃=-1.94, P=.07). With regards to cognitive fusion (thought entanglement), paired-samples t tests revealed a trend towards reduction in mean scores post training (P=.12).

Conclusions

This pilot study of the Resilience@Work program suggests that a mindfulness-based resilience program delivered via the Internet is feasible in a high-risk workplace setting. In addition, the firefighters using the program showed a trend toward increased resilience and psychological flexibility. Despite a number of limitations, the results of this pilot study provide some valuable insights into what form of resilience training may be viable in occupational settings particularly among those considered high risk, such as emergency workers. To the best of our knowledge, this is the first time a mindfulness-based resilience-training program delivered wholly via the internet has been tested in the workplace.

Digital apothecaries: a vision for making health care interventions accessible worldwide

Evidence-based psychological interventions are growing in number but are not within reach of many individuals who could benefit from them. The recent revolution in digital technologies now makes it possible to reach people around the globe with digital interventions in the form of web sites, mobile applications, wearable devices, and so on. Although a plethora of digital interventions are available online few are evidence-based and individuals have little guidance to decide among the multitude of options. We propose the development of "digital apothecaries," that is, online repositories of evidence-based digital interventions. As portals to effective interventions, digital apothecaries would be useful to individuals who could access evidence-based interventions directly, to health care providers, who could identify specific digital tools to suggest to or use with their patients, and to researchers, who could study a range of tools with large samples, enabling comparative tests and evaluation of moderators of effects. We present a taxonomy of types of in-person and digital interventions ranging from traditional therapy without the use of digital tools to totally automated self-help interventions. This taxonomy highlights the potential of blending digital tools into health care systems to expand their reach. Digital apothecaries would provide access to evidence-based digital interventions (both free and paid versions), provide data on effectiveness (including effectiveness for diverse populations), and encourage the development and testing of more such tools. Other issues discussed include: criteria for inclusion of interventions into digital apothecaries; how digital tools could enhance health care for diverse populations; and cautionary notes regarding potential negative unintended consequences of the adoption of digital interventions into the health care system. In particular, we warn about the potential misuse of evidence-based digital interventions to justify reducing access to live providers. Digital apothecaries bring with them the promise of reducing health disparities by reaching large numbers of individuals across the world who need health interventions but are not currently receiving them. The health care field is encouraged to mindfully develop this promise, while being alert not to cause inadvertent harm.

[Internet-based resilience training and prevention of mental disorders]

BACKGROUND

Resilience is associated with a positive and resource-oriented perspective. Therefore, it seems especially attractive for health promotion and prevention. In recent years, interventions to foster resilience have been increasingly developed, which train resilience factors and are mainly conducted in a face to face group format.

OBJECTIVE

The question is raised what potential internet-based interventions (i-interventions) that train resilience factors have for health promotion and prevention.

MATERIAL AND METHODS

Based on a narrative overview, the possibilities for i‑interventions that train resilience factors for health promotion and prevention are investigated and the state of research is described.

RESULTS

The effects of the i‑interventions presented here, which aim at fostering resilience, on measures of mental health and well-being are heterogeneous and vary between low to high effects. Stronger evidence for the efficacy of these measures exists for more general i‑interventions that also train resilience factors but are conceptualized for the prevention of specific disorders, such as depression or for stress reduction.

DISCUSSION

Given the heterogeneous nature of intervention contents, theoretical foundations and therapeutic methods used, the heterogeneity of the evidence is discussed. In addition, perspectives for the further development of resource-oriented resilience interventions are outlined.

The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder

Mindfulness-Based interventions have increased in popularity in psychiatry, but the impact of these treatments on disorder-relevant biomarkers would greatly enhance efficacy and mechanistic evidence. If Generalized Anxiety Disorder (GAD) is successfully treated, relevant biomarkers should change, supporting the impact of treatment and suggesting improved resilience to stress. Seventy adults with GAD were randomized to receive either Mindfulness-Based Stress Reduction (MBSR) or an attention control class; before and after, they underwent the Trier Social Stress Test (TSST). Area-Under-the-Curve (AUC) concentrations were calculated for adrenocorticotropic hormone (ACTH) and pro-inflammatory cytokines. MBSR participants had a significantly greater reduction in ACTH AUC compared to control participants. Similarly, the MBSR group had a greater reduction in inflammatory cytokines' AUC concentrations. We found larger reductions in stress markers for patients with GAD in the MBSR class compared to control; this provides the first combined hormonal and immunological evidence that MBSR may enhance resilience to stress.