Resilience, prevention and positive psychiatry

Traditionally, the focus of psychiatry has been to assess the clinical presentation of so-called ‘disorders of the mind’ and define diagnoses in order to establish successful therapeutic strategies. However, psychiatrists have become aware of the fact that this is not enough. Indeed, only a small percentage of patients discharged from hospital after their first episode of mania or psychosis, for example, had full syndromal and functional recovery in the long-term.1 Furthermore, social and vocational recovery is even more difficult to reach than clinical compensation.1 As a consequence, a shift towards a relatively new paradigm called ‘positive psychiatry’ is necessary. Not only prevention in general and primary prevention in particular, but also mental health promotion should be the focus of this approach. In clinical practice, positive psychiatry should promote well-being, personal growth and the reduction of perceived stress. Its background relies on certain psychobiological traits, mainly resilience, optimism and coping strategies, which can be promoted, and also on environmental factors, such as family dynamics, social support, and access to medical and psychological care.2 The three levels of prevention in mental health could be feasible targets of positive psychiatry interventions. Firstly, primary prevention is aimed at preventing the occurrence of a disease. This is done by preventing exposures to hazards or increasing resistance to a disease. An example of this is provided by the global pandemic situation. The ongoing vaccination campaign against the SARS-CoV-2 is aimed at preventing infection in an increasingly large part of the population. Nowadays, a similar, even though less extensive, effort is conducted in mental health to improve mental well-being in adolescents by enhancing resilience capacities in the face of future stressful events.3 This should be particularly promoted in individuals at higher risk of developing a psychiatric disorder, such as siblings of individuals suffering from a psychiatric condition. Interestingly, Kessing et al.4 in a recent nationwide population-based longitudinal study identified that the rates of presentation of any psychiatric disorder in siblings of patients suffering from bipolar disorder (BD) were increased not only in their 20 s but also above 60 years of age. As a consequence, preventive strategies should be provided not only during adolescence but should be implemented throughout life. In the case of individuals that have already experienced psychiatric symptoms, secondary prevention aims to reduce the impact of a disease that has already occurred. Providing targeted help and support to patients in their early stages is of paramount importance.5 Social, clinical and cognitive factors associated with more resilient trajectories of psychosocial functioning in the long-term in patients that presented a first episode of psychosis have been identified, providing insights for early interventions. Hence, less severe depressive and negative symptoms, a better premorbid adjustment and a diagnosis of BD and related disorders in comparison with schizophrenia and other psychoses were identified as clinical features associated with mild impairment and improving psychosocial functioning in the course of the disease.6 An important aspect of this ‘new’ paradigm in psychiatry is that not only the clinical condition but also other characteristics of the individual should be the focus of early interventions. An example is cognitive reserve, which is gaining momentum since it contributes to neuropsychological and functional outcomes in patients, particularly in those at the earlier stages of disease.7 Indeed, cognitive reserve represents a measure of ‘intellectual resilience’ since it was conceptualized as the contribution of premorbid intelligence quotient, years of education and leisure activities in promoting more efficient cognitive networks and therefore, allowing better clinical, cognitive and psychosocial outcomes over the long-term.8 Not only personal skills but also the social environment plays a major role in individual functioning. In particular, the family environment, being the first environment with which the individual comes into contact, can exert its effect as a protective or a risk factor depending on the family dynamics. Two years after a first psychotic episode,9 worse psychosocial functioning in psychotic patients has been seen to be associated with lower rates of active-recreational and achievement orientated family environment and with higher rates of moral-religious emphasis and control in the family. Similarly, in those suffering from a mood disorder, worse psychosocial functioning was associated with higher rates of conflict. This might have important implications for early interventions programs that should engage not only patients but also their caregivers. Again, the COVID-19 pandemic provides a useful example of how positive psychological traits are important even when stressful and unpleasant conditions occur. Particularly, resilience is a topic of increasing interest since it could provide a new framework to understand trajectories of mental illness, particularly in terms of improved mental health outcomes. Resilience is a dynamic process of adaptation to challenging life conditions encompassing several aspects of personal resources and can be identified as the ‘emotional version’ of cognitive reserve. A recent study10 evaluated mental health outcomes associated with bad resilience and predictors of good resilience in a sample of psychiatric patients and in the general population after the lockdown measures have been imposed by the Spanish government to overcome the contagion situation. Whilst the presence of depressive symptoms was associated with bad resilience, having pursued hobbies and conducted home tasks as well as a higher level of organization in the family were predictors of good resilience in psychiatric patients. Interestingly, a controlling family was associated with bad resilience even in those participants without a psychiatric condition. Therefore, therapeutic interventions aimed at enhancing resilience,10 healthy life-style behaviours,11 coping strategies12 and peaceful family environment might have important implications in terms of mental health outcomes, not only in those patients already suffering from a psychiatric condition but also in the general population. Both primary and secondary preventive interventions aimed at promoting good mental health in young people, improved quality of life, insight, cognitive and social skills, physical and sexual health as well as academic and occupational functioning.13 Nonetheless, the quality of the evidence of interventions aimed at increasing subjective well-being and aspects of positive psychiatry is still low.14 Finally, tertiary prevention aimed at supporting patients with mental health disorders to have a good quality of life and better psychosocial outcomes, has also demonstrated to have an impact on prognosis. Indeed, patients who receive care through specialized treatment programmes have better illness outcomes than do those without this support.15 Interventions applying positive psychiatry concepts should be improved and provided to the different subjects being the targets of all prevention levels. Positive psychiatry can open new avenues of treatment strategies, which go beyond the traditional psychiatry approach.2 Firstly, when applied to the general population, these interventions might promote good mental health and avoid ‘medicalisation’. Moreover, in those individuals at higher risk of developing a psychiatric disorder, the occurrence of the disease can be prevented or softened. Finally, patients both in the early and in the late stages of the disease can benefit from these interventions, since they could reduce disabling symptoms, improve psychosocial functioning and allow the patients to feel empowered to manage their own life, avoiding stigma, enhancing awareness and increasing quality of life. This is indeed the time to bring together positive psychiatry and precision psychiatry. Dr. Vieta has received grants and served as consultant, advisor or CME speaker for the following entities (unrelated to the present work): AB-Biotics, Abbott, Allergan, Angelini, Dainippon Sumitomo Pharma, Ferrer, Gedeon Richter, Janssen, Lundbeck, Otsuka, Sage, Sanofi-Aventis and Takeda. Dr. Verdolini has no conflict of interest to declare.