Psychological Resilience, Cardiovascular Disease, and Metabolic Disturbances: A Systematic Review

Psychological resilience, cardiovascular disease, and mortality - Insights from the German Gutenberg Health Study

OBJECTIVE

Psychological distress is associated with a higher risk of cardiovascular disease (CVD) and mortality, whereas psychological resilience may confer a protective effect. However, evidence on these relationships remains limited. This study aimed to examine the associations between psychological resilience, CVD, and all-cause mortality within a large general population cohort.

METHODS

Data from 12,675 participants in the German Gutenberg Health Study were analyzed. Psychological resilience was assessed using the Brief Resilient Coping Scale (BRCS). CVD prevalence and mortality data were obtained from medical records and registry updates. Logistic and Cox regression analyses examined the associations between resilience, CVD, and mortality, with adjustments for socio-demographics, lifestyle, and clinical factors.

RESULTS

Cross-sectionally, lower resilience was linked to higher odds of any CVD (odds ratio (OR) 1.030, 95 % confidence interval [CI] 1.009-1.051). Participants with low resilience had 38 % higher odds of CVD and 61 % higher odds of peripheral artery disease compared to those with high resilience. Longitudinally, low resilience was associated with the highest all-cause mortality risk (log-rank test, p < 0.0001). This association remained significant in Cox models after adjusting for confounders (hazard ratio (HR) 1.362, 95 % CI 1.002-1.852).

CONCLUSIONS

Lower psychological resilience is associated with increased CVD prevalence and all-cause mortality. These findings highlight resilience as a potential target for cardiovascular risk assessment and intervention. Incorporating resilience measures in clinical practice may help identify vulnerable individuals who could benefit from strategies to enhance adaptive coping, improving cardiovascular and overall health outcomes.

The Effect of Dietary Acid Load on Cardiometabolic Risk, Psychological Resilience and Sleep Quality in Adolescents with Obesity

Objective

Mild metabolic acidosis may adversely affect cardiovascular risk factors, and diet-dependent acid-base load may impair mental health and sleep quality. The aim of this study was to investigate the effects of dietary acid load (DAL) on cardiometabolic risk factors, psychological resilience, and sleep quality in adolescents with obesity.

Methods

Obese adolescents participated in the study. Biochemical parameters, anthropometric measurements and blood pressures were measured. Three-day retrospective food intake records were collected from the adolescents, and potential renal acid load (PRAL), net endogenous acid production (NEAP), and DAL were derived from food intake records. Psychological resilience was assessed by the Child and Youth Resilience Measure (CYRM-12) and sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI).

Results

A total of 205 adolescents with obesity (105 males, 100 females) aged 13-18 years participated. Body mass index, fat mass, fat percentage, fasting insulin, triglyceride, systolic blood pressure, homeostasis model assessment for insulin resistance (HOMA-IR) and PSQI scores were significantly higher and psychological resilience levels were significantly lower in high tertiles of DAL (p<0.05). Adolescents in the lowest tertile of DAL scores had higher consumption of whole grains, vegetables, dairy, legumes, and higher intakes of potassium and calcium than adolescents in the highest tertile of the DAL scores (p<0.05). Red meat, and white meat consumption and sodium intake were higher in adolescents in the high tertiles (p<0.05). Energy intakes were found to be significantly lower in the first tertile of PRAL and DAL scores compared to the other tertiles (p<0.05). A linear regression model ahowed an increase in NEAP, PRAL and DAL scores led to a decrease in psychological resilience score and an increase in PSQI and HOMA-IR scores (p<0.05).

Conclusion

High DAL was associated with high cardiometabolic risk, insulin resistance, and low psychological resilience and poor sleep quality.

Nursing Future Horizon: Simultaneous Continual Nursing Model and Homemade Dialogue Tool for Controlling Cardiac Function and Blood Pressure in Hypertensive Heart Diseases

Background

Hypertension (HTN) is a chronic condition that requires ongoing management to maintain health and prevent organ damage. Skilled nurses are essential in promoting lifestyle changes and personalizing medications, especially for patients in cardiac rehabilitation, which can lead to better cardiac function and manageable blood pressure.

Purpose

To examine the effects of a continuous nursing model merged with homemade dialogue tools on cardiac function and blood pressure control in patients with HTN and heart disease.

Methodology

From March 2019 to June 2021, a compelling study involved 82 patients randomly assigned to either a control or experiment group. The control group received routine health education and follow-up calls as standard care. However, the experiment group benefited from an innovative pictorial dialogue tool designed under the Cardiac Rehabilitation and Secondary Prevention Chinese guidelines to enhance understanding and adherence to crucial health practices, potentially leading to better cardiac function and boosting blood pressure control in patients.

Results

Considering the designed nursing model, satisfaction with care increased from 48 to 63%. The systolic and diastolic blood pressures were also reduced from 144.45 ± 3.27 to 129.63 ± 3.06 mmHg and 89.46 ± 4.57 to 79.51 ± 3.53 mmHg, respectively. Furthermore, an appropriate cardiac function was approached in the research category by inclining the left ventricular ejection fraction and cardiac index up to 77.43 ± 4.17% and 19.25 ± 1.56 L/min/m2, respectively.

Conclusion

The simultaneous nursing model combined with a self-developed picture-viewing tool effectively improved cardiac rehabilitation, blood pressure control, patient satisfaction, care coordination, treatment compliance, and quality of life in patients with hypertension and heart disease.

Implications

The combined continuous nursing model and homemade dialogue tools led to higher patient satisfaction and lower blood pressure compared to standard nursing care after three months. This approach improved cardiac rehabilitation and overall patient satisfaction.

Mediation role of health behaviours in the relation between mental resilience and cardiovascular risk in young adults with a diagnosed congenital heart defect

INTRODUCTION

With age, patients with a congenital heart defect are under higher risk of cardiovascular diseases and more complex selfcare requirements.

AIM OF THE STUDY

The analysis of the mediation role of health-oriented behaviours in the relation between mental resilience and the cardiovascular risk in young adults with congenital heart defects.

MATERIALS AND METHODS

This is an observational study with a cross-sectional design. The research was based on the examination of 201 patients with congenital heart defects using the medical record analysis, the method of estimating and the diagnostic survey method. The other examination tools included the Cardiovascular Disease Risk Factors Scale, the Resilience Assessment Scale (SPP-25) and the Health Behaviour Inventory (HBI).

RESULTS

The examination confirmed that 50% of patients were susceptible to a cardiovascular disease due to the prevalence of three risk factors. The general indicator of the intensity of health-related behaviours amounted to 83.16 ± 12.94. The lowest intensity of all health behaviours was observed for eating habits (3.14 ± 0.83). The highest score of mental resilience was reported in terms of openness to new experience and sense of humour (15.31 ± 3.05), whereas the lowest was related to optimism and mobilization capability in difficult situations (12.97 ± 3.46). The higher the perseverance and determination (β = -0.16; p < 0.001), openness and sense of humour (β = -0.09; p < 0.01), tolerance to failure and perceiving life as a challenge (β = -0.09; p < 0.01), optimism and the mobilization capability in difficult situations (β = -0.08; p < 0.01) and overall mental resilience scale measurement (β = -0.11; p < 0.001), the lower the cardiovascular risk. In short, higher psychological resilience was associated with higher intensity of health-related behaviours. Greater intensity of health behaviours and higher indices of eating habits, prophylactic behaviours and health practices fostered lower risk of CVDs.

CONCLUSIONS

Health-related behaviours play a mediation role between mental resilience and the cardiovascular risk in the group of young adults with congenital heart defects. Psychological resilience as a preventive and promotional factor of mental health appears to be of a very essential value while developing health promoting programmes aimed at decreasing the cardiovascular risk in patients with a congenital heart defect. The evaluation of mental resilience may provide better understanding of the patient and ensure proper health care.

Influencing Factors of Self-Management Behavior Among Chinese Patients With Chronic Disease: A Cross-Sectional Study

AIMS

This study aimed to describe the self-management behavior levels and further explore its influencing factors among patients with chronic disease.

DESIGN

A cross-sectional study.

METHODS

460 convenient samples of patients with chronic disease in Zhejiang Province were investigated using a demographic characteristics questionnaire, the Lubben Social Network Scale (LSNS-6), and the Chronic Disease Self-Management Behavior Scale between October and December 2023. Data were analyzed using descriptive analysis, t-test, one-way analysis of variance, Pearson correlation analysis, Spearman correlation, and hierarchical multiple regression analysis.

RESULTS

The mean score of the self-management behavior of the patients with chronic disease was 32.27 (standard deviation [SD] = 8.67). Hierarchical multiple regression analysis indicated that self-management behavior among patients with chronic disease was influenced by the individual factor (frequency of health check-ups), the family factors (number of children, spouse status, and family network), and the social factor (place of residence).

CONCLUSIONS

The self-management behavior among patients with chronic disease was at a moderate level and needed further improvement. The self-management behavior among patients with chronic disease was influenced by three kinds of factors. Specifically, for the individual factor, patients who had a higher frequency of health check-ups reported better self-management behavior; for the family factors, patients who had no spouse, few children, and a strong family network showed better self-management behavior; for the social factor, patients living in urban areas had better self-management behavior.

The lived experience of resilience in chronic disease among adults in Asian countries: a scoping review of qualitative studies

BACKGROUND

Chronic diseases pose significant threats to persons' well-being and mental health leading to stress, anxiety and depression without effective resilience strategies. However, experiences to gain resilience in living with chronic disease in the context of Asian countries remain insufficiently explored. This review seeks to provide a comprehensive summary of qualitative evidence that explores the lived experience that cultivates resilience in chronic diseases among adults within Asian countries.

METHODS

A comprehensive review of five databases - Web of Sciences, Ebsco (Medline), PubMed, Science Direct, and Scopus was carried out, following the Joanna Brings Institute (JBI) standards and employing PRISMA Extension for Scoping Review (PRISMA-ScR) reporting guideline. The review encompassed studies published in English from January 2013 to December 2023. Four reviewers assessed the literature's eligibility and extracted relevant lived experiences to address the research question based on prior studies. Subsequently, a content analysis was performed.

RESULTS

Of the 3651 articles screened, 12 were included in this review. Three key themes emerged: (1) Sociocultural norms shaped resilience, delved into the culturally-mediated childhood development, traditional cultural beliefs, social relationships and supports and spirituality (2) Positive emotions nurtured resilience highlighted optimistic about becoming healthy, self-efficacy in self-care, endurance during hardship, self-reflection on health, acceptance of having disease, and appreciation of life while (3) Problem-solving strategies fostered resilience underlined improve disease literacy, ability to deal with disease challenges and engage in meaningful activities.

CONCLUSION

Our review addresses important research gaps on sociocultural norms that shaped resilience in chronic disease despite a small number of research. Therefore, this warrants further studies on how the traditional cultures and beliefs influence resilience among the Asian population living with chronic disease. Further research should thoroughly describe the qualitative methodologies and theoretical framework to provide more comprehensive information on the experience of resilience in chronic disease.

Biological links between psychological factors and adolescent depression: childhood trauma, rumination, and resilience

BACKGROUND

The psychosocial factors play an important role in the development of depression in adolescents. we used metabolomics techniques to explore the links among childhood trauma, rumination, resilience, and adolescent depression.

METHODS

We selected 57 adolescent depression patients and 53 healthy adolescents. The Childhood Trauma Questionnaire (CTQ), Hamilton Depression Scale (HAMD), Resilience Scale (CD-RISC), and Redundant Thinking Response Scale (RRS) were employed for the purpose of psychological assessment. The patients were regrouped according to their scores using the 27% high-low grouping method. Blood specimens were collected from all adolescents and metabolic data were obtained using LC-MS.

RESULTS

We found no statistically significant difference between the groups in terms of age, gender, and body mass index (BMI). HAMD, CTQ, and RRS scores were significantly higher in the adolescent depression group (MDD) than in the adolescent healthy control group (HC), and CD-RISP scores were significantly lower than in the HC group (P < 0.001). There were significant differences between the low childhood trauma group (LCT) and high childhood trauma group (HCT), the low rumination group (LRR) and high rumination group (HRR), and the low resilience group (LPR) and high resilience group (HPR) (P < 0.001). RRS, CTQ and HAMD scores were positively correlated, RRS and CTQ scores were positively correlated, CD-RIS was negatively correlated with HAMD, RRS and CTQ scores (P < 0.01). More importantly, we found that DHEAS and LPA (22:6) were identified as significant differential metabolites in both the depressed and normal groups, as well as in the high and low childhood trauma groups. N-Acetyl-L-aspartic acid and DHEAS were identified as significant differential metabolites in both the depressed and normal groups, as well as in the high and low childhood rumination groups. Pseudouridine and LPA(22:6) were identified as significant differential metabolites in both the depressed and normal groups, as well as in the high and low childhood resilience groups.

CONCLUSION

Psychological factors (childhood trauma, rumination, resilience) are biologically linked to the development of depression in adolescents. The impact of rumination on adolescent depression may be associated with DHEA. The impact of childhood trauma and resilience on adolescent depression may be associated with LPA (22:6).

Psychometric validation of the Cardiac Distress Inventory - Short Form among people with cardiac diseases in Hong Kong

Objectives

Cardiac patients experience various somatic and psychosocial symptoms and stress is an important prognostic factor of cardiac rehabilitation. This study evaluated the psychometric properties of the 12-item Cardiac Distress Inventory - Short Form (CDI-SF) in the Chinese context.

Methods

A total of 227 patients with cardiac diseases were recruited in a specialist outpatient clinic in Hong Kong between Aug 2022 and July 2023. The participants completed the CDI-SF and validated measures on psychosocial functioning and quality of life. Exploratory factor analysis and partial correlation analysis were conducted to examine the factorial validity, reliability, and convergent validity of the CDI-SF with reference to validating measures.

Results

The 1-factor model showed adequate model fit with excellent composite reliability (ω = .92) and substantial factor loadings (λ = .64 -.94, p <.01). The CDI-SF factor was negatively associated with age (r = -.21, p <.01) and showed positive and strong partial correlations (r = .59 -.69, p <.01) with impact of event, depression, and burnout, and negative partial correlations (r = -.43 to -.54, p <.01) with resilience and quality of life.

Conclusion

Our study provides the first results on the psychometric properties of the CDI-SF among cardiac patients in Hong Kong. The psychometric results support the CDI-SF as a precise, valid, and reliable measure of cardiac distress in the Chinese context.

Factors Influencing Preoperative Psychological Resilience in Patients With Traumatic Lower Extremity Fractures

BACKGROUND

The psychological resilience of patients with traumatic lower extremity fractures is relevant and has been studied in the postoperative rehabilitation phase; yet, few studies have focused on the early preoperative phase.

OBJECTIVE

This study aims to explore preoperative psychological resilience in patients with traumatic lower extremity fractures.

METHODS

This single-center cross-sectional survey design study was conducted over 5 months from December 2022 to April 2023 in a tertiary hospital in Shanghai, China. We used a convenience sampling method to assess psychological resilience in traumatic lower extremity fracture patients electronically. We administered the online surveys using the Questionnaire Star applet prior to surgery using the following tools: (a) general information questionnaire, (b) Numerical Rating Scale, (c) Connor-Davidson Resilience Scale, and (d) General Self-Efficacy Scale.

RESULTS

A total of N = 175 patients were studied, of which n = 166 patients fully completed the survey for a response rate of 95%. Patients with traumatic lower extremity fractures demonstrated a low degree of psychological resilience preoperatively (M = 49.28, SD = 13.64). Patients' psychological resilience and self-efficacy showed a significant positive correlation (r = .577). Factors associated with patients' psychological resilience in multivariate linear analyses included level of education, medical insurance, and self-efficacy (p < .05).

CONCLUSION

We found that preoperative psychological resilience in patients with traumatic lower-extremity fractures is poor and influenced by various factors; thus, future efforts should focus on providing timely, targeted interventions.

Traffic-related pollution and symptoms of depression and anxiety among Chinese adults: A population-based study

BACKGROUND

Limited understanding exists regarding the associations of traffic-related pollution with depression and anxiety symptoms in individuals residing within low- and middle-income countries.

METHODS

Data for this study were extracted from the Psychology and Behavior Investigation of Chinese Residents (PBICR) survey, implemented between June 20 and August 31, 2023. We determined residential proximity to major roadways through self-reports and evaluated depression symptoms using the Patient Health Questionnaire-9 (PHQ-9), along with anxiety symptoms assessed through the Generalized Anxiety Disorder-7 (GAD-7). We examined the associations between residential proximity to major roadways and depression and anxiety symptoms using logistic regressions and generalized linear models, while controlling for potential confounding variables.

RESULTS

This study comprised a total of 22,723 participants. The adjusted odds ratios (OR) for depression symptoms were 1.34 (95 % confidence interval (CI) 1.20, 1.51), 1.29 (95 % CI 1.17, 1.43), 1.34 (95 % CI 1.20, 1.49), and 1.32 (95 % CI 1.17, 1.49) among individuals residing within <50 m, 50-100 m, 101-200 m, and 201-300 m, respectively, in comparison to those residing >300 m from a major roadway. Individuals residing <50 m, 50-100 m, 101-200 m, and 201-300 m from a major roadway exhibited adjusted OR for anxiety symptoms of 1.49 (95 % CI 1.30, 1.69), 1.21 (95 % CI 1.07, 1.37), 1.38 (95 % CI 1.21, 1.56), and 1.38 (95 % CI 1.20, 1.59), respectively, in contrast to those residing >300 m.

CONCLUSIONS

This study provides valuable insights into the associations between environmental factors and mental health. The findings underscore the importance of integrating environmental considerations into comprehensive mental health frameworks, especially for individuals residing near high-traffic areas.

Sex differences in the relationship between brain gray matter volume and psychological resilience in late adolescence

Psychological resilience reflects an individual's ability to adapt and cope successfully in adverse environments and situations, making it a crucial trait in resisting stress-linked mental disorders and physical diseases. Although prior literature has consistently shown that males are more resilient than females, the sex-linked neuroanatomical correlates of psychological resilience are largely unknown. This study aims to explore the sex-specific relation between psychological resilience and brain gray matter volume (GMV) in adolescents via structural magnetic resonance imaging (s-MRI). A cohort of 231 healthy adolescents (121/110 females/males), aged 16 to 20 completed brain s-MRI scanning and Connor-Davidson Resilience Scale (CD-RISC) and other controlling behavioral tests. With s-MRI data, an optimized voxel-based morphometry method was used to estimate regional GMV, and a whole-brain condition-by-covariate interaction analysis was performed to identify the brain regions showing sex effects on the relation between psychological resilience and GMV. Male adolescents scored significantly higher than females on the CD-RISC. The association of psychological resilience with GMV differed between the two sex groups in the left ventrolateral prefrontal cortex extending to the adjacent anterior insula, with a positive correlation among males and a negative correlation among females. The sex-specific association between psychological resilience and GMV might be linked to sex differences in the hypothalamic-pituitary-adrenal axis and brain maturation during adolescence. This study may be novel in revealing the sex-linked neuroanatomical basis of psychological resilience, highlighting the need for a more thorough investigation of the role of sex in future studies of psychological resilience and stress-related illness.

Hypertension at the nexus of veteran status, psychiatric disorders, and traumatic brain injury: Insights from the 2011 Behavioral Risk Factor Surveillance System

Variable military service-related experiences, such as combat exposure, psychiatric disorders (PD), and traumatic brain injuries (TBI), may differentially affect the likelihood of having health care professional-identified high blood pressure (i.e., hypertension).

PURPOSE

Compare the odds of self-reported hypertension among non-combat and combat veterans with and without PD/TBI to non-veterans and each other.

METHODS

We used data from men from the 2011 Behavioral Risk Factor Surveillance System and distinguished: non-veterans (n = 21,076); non-combat veterans with no PD/TBI (n = 3,150); combat veterans with no PD/TBI (n = 1,979); and veterans (combat and non-combat) with PD and/or TBI (n = 805). Multivariable, hierarchical logistic regression models included exogenous demographic, socioeconomic attainment and family structure, health behavior and conditions, and methodological control variables.

RESULTS

One-third of men reported having been told at least once by a medical professional that they had high blood pressure. Bivariate analyses indicated that each veteran group had a higher prevalence of self-reported hypertension than non-veterans (design-based F = 45.2, p<0.001). In the fully adjusted model, no statistically significant differences in the odds of self-reported hypertension were observed between non-veterans and: non-combat veterans without PD/TBI (odds ratio [OR] = 0.92); combat veterans without PD/TBI (OR = 0.87); veterans with PD and/or TBI (OR = 1.35). However, veterans with PD and/or TBI had greater odds of reporting hypertension than both combat and non-combat veterans without PD/TBI (p<0.05).

DISCUSSION

Military service-related experiences were differentially associated with a survey-based measure of hypertension. Specifically, veterans self-reporting PD and/or TBI had significantly higher odds of self-reporting hypertension (i.e., medical provider-identified high blood pressure).

Role of Resilience in the Psychological Recovery of Women With Acute Myocardial Infarction

Background Psychological well-being is important among individuals with myocardial infarction (MI) given the clear links between stress, depression, and adverse cardiovascular outcomes. Stress and depressive disorders are more prevalent in women than men after MI. Resilience may protect against stress and depressive disorders after a traumatic event. Longitudinal data are lacking in populations post MI. We examined the role of resilience in the psychological recovery of women post MI, over time. Methods and Results We analyzed a sample from a longitudinal observational multicenter study (United States, Canada) of women post MI, between 2016 and 2020. Perceived stress (Perceived Stress Scale-4 [PSS-4]) and depressive symptoms (Patient Health Questionnaire-2 [PHQ-2]) were assessed at baseline (time of MI) and 2 months post MI. Demographics, clinical characteristics, and resilience (Brief Resilience Scale [BRS]) were collected at baseline. Low and normal/high resilience groups were established as per published cutoffs (BRS scores <3 or ≥3). Mixed-effects modeling was used to examine associations between resilience and psychological recovery over 2 months. The sample included 449 women, mean (SD) age, 62.2 (13.2) years, of whom 61.1% identified as non-Hispanic White, 18.5% as non-Hispanic Black, and 15.4% as Hispanic/Latina. Twenty-three percent had low resilience. The low resilience group had significantly higher PSS-4 and PHQ-2 scores than the normal/high resilience group at all time points. In adjusted models, both groups showed a decrease in PSS-4 scores over time. Conclusions In a diverse cohort of women post MI, higher resilience is associated with better psychological recovery over time. Future work should focus on developing strategies to strengthen resilience and improve psychological well-being for women with MI. Registration URL: https://clinicaltrials.gov/ct2/show/NCT02905357; Unique identifier: NCT02905357.

Examination of relationship factors between psychological resilience and social support in adolescent obesity

PURPOSE

Childhood obesity is one of the most severe public health problems, and psychiatric conditions have been associated with obesity. In this study, we aimed to investigate psychological resilience and possible related factors in adolescents with obesity.

METHOD

The study included 90 adolescents with obesity and 100 healthy adolescents of similar age. Data were collected using a sociodemographic information form, the Child and Youth Resilience Measure-28 (CYRM-28), and the Multidimensional Scale of Perceived Social Support. Scale scores were compared by Pearson's correlation coefficient test with SPSS-23. Multiple linear regression was performed to describe the relationships between variables.

RESULTS

The adolescents participating in the study were similar in terms of age and gender. Psychological resilience and social support in the obesity group were lower than in the control group (p < 0.05). A negative relationship was found between body mass index (BMI) and resilience levels of adolescents with obesity, and a positive relationship was found between social support and resilience levels (p = 0.027 and p < 0.001, respectively). The perceived family and significant other social support subscale scores of adolescents in the obesity group were significantly lower than in the control group (p = 0.037 and p = 0.023, respectively). The most related variable with the CYRM-28 was the level of perceived social support: standardized β = 0.409; t(151) = 5.626; p < 0.001.

CONCLUSION

A higher BMI has a negative effect on psychological resilience, and family support tends to be lower in these cases. New studies are needed to clarify whether this result is one of the causes of obesity or one of its consequences.

Further Examination of the Psychometric Properties of the Current Experiences Scale and Model of Resiliency

Background

Stress-related disease is increasing, with high resilience proposed as protective. Whilst the Current Experiences Scale (CES) shows promise as a measure of resilience, its psychological correlates and relationship to psychological stress remain unclear.

Objectives

(1) Further explore the psychometric properties of the CES, (2) identify modifiable psychological factors associated with the CES and (3) test a previously published model for the influence of adaptive strategies and stress management factors on resiliency and stress.

Methods

N = 455 individuals (mean age = 47.8, 65.1% female) completed measures of adaptive strategies: mindfulness (Cognitive and Affective Mindfulness Scale-Revised), positive affect (Positive and Negative Affect Schedule) and gratitude (The Gratitude Questionnaire), stress management skills: coping (Measure of Current Status-A), depression (Patient Health Questionnaire-8) and anxiety (General Anxiety Disorder Assessment) and outcomes: resilience (CES) and stress (Perceived Stress Scale). Cronbach's alpha and confirmatory factor analysis (CFA) examined the psychometric properties of the CES. Multivariable regression identified psychological variables associated with resilience. Structural equation modelling (SEM) tested the previously published model for resilience.

Results

The CES and its subscales showed good internal consistency (ɑ = .75-.93). The 23-item CES produced excellent results for model fit (Root Mean Square Error of Approximation (RMSEA) = .07, Standardized Root Mean Square Residual (SRMR) = .06, Comparative Fit Index (CFI) = .99; Tucker-Lewis Index (TLI) = .99). Higher gratitude (P < .0001), mindfulness (P < .0001), positive affect (P < .0001) and coping (P < .0001) were associated with higher resilience. Depression (P = .23) and anxiety (P = .34) were not. A model of resilience which included gratitude, mindfulness, positive affect and coping as determinants of resilience and perceived stress performed well (RMSEA = .03, SRMR = .02, CFI = .99; TLI = .99).

Conclusions

The CES was validated in a large sample. The association of gratitude, mindfulness, positive affect and coping with resilience may guide practitioners seeking to design resilience-enhancing programs.