Role of resiliency in weathering COVID pandemic weighed in VA mental health study

Resiliency matters a lot when it comes to overcoming the stress that accompanied the COVID-19 pandemic, according to a research letter published today in JAMA Network.

Researchers with the Department of Veterans Affairs and the Yale School of Medicine concluded in their longitudinal study that distress among 2,289 veterans who participated in the study shot up 51% in the first year of the pandemic, with younger and female veterans showing the highest increases, possibly because of them dealing with additional factors such as school closings and work and relationship disruptions.

“Nevertheless, two years later, distress prevalence returned to pre-pandemic levels, which aligns with prior work suggesting resilience is the modal response to stressful events,” the research letter said.

One expert said those positive results should perhaps be tempered by basic questions such as: What exactly is resiliency, and how do we measure it?

Elspeth Cameron Ritchie, M.D., the chairperson of psychiatry at Medstar Washington Hospital, spent much of her career in the Army before retiring from the service in 2010. Ritchie, who was not involved in the study, told Fierce Healthcare that resiliency has long been a buzzword in the military.

“There have been lots of programs to enhance resiliency, but there was very little proof that any of them work,” she said.

She cited a RAND report that detailed some of the problems with resiliency programs in the military.

In addition, even amid the focus on resiliency, the suicide rate among veterans continues to rise. The suicide rate among veterans rose 95.3% between 2001 and 2020, according to the American Addiction Centers.

One marker of distress in the military that Ritchie pointed to is attrition, or the number of people who leave.

"We know that unit cohesion and morale and a sense of bonding decreases attrition,” said Ritchie. “In the primary care setting—for both children and adults—what can help with distress is to encourage people to do things that will increase their bonding with others. That varies from person to person. But you can ask that question: ‘What are your social supports? Is there a way we can make them stronger?’”

Researchers in the JAMA Network piece divided the study into three phases: pre-pandemic (fall 2019), peri-pandemic (fall 2020) and post-onset (summer 2022). Peri-pandemic included the fall and winter surge of 2020, before vaccines became available.

And, by the post-onset stage, the majority of adults in the U.S. had been vaccinated and many mask and social distancing mandates had been dropped.

The veterans were placed into categories according to whether they screened positive for distress:

  • Resistant, those with no positive screens
  • Persistent, those who tested positive in each time frame
  • Remitted, those who tested positive at the pre-pandemic stage only
  • Resilient, those with a positive screen at the peri-pandemic only
  • Exacerbated, those with positive screens at the peri-pandemic and two-year post-onset stage, but not at the pre-pandemic stage

The study found: “In the full sample and all sex and age subgroups except veterans aged 65 years or older, distress significantly increased from the pre-pandemic to peri-pandemic period (weighted estimate, 51% increase) but returned to pre-pandemic levels two years later.”

Ian C. Fischer, Ph.D,, of the VA Connecticut Healthcare System and the research letter’s corresponding author, told Fierce Healthcare in an email that he and his co-authors were not surprised by the resiliency of the veterans.

“An emerging body of research suggests that, when faced with difficult experiences and situations, most people tend to come out OK—at least when given some time,” said Fischer.

He noted that symptoms of distress spiked in the entire U.S. population during the pandemic’s first year, and not just with veterans.

“This makes sense—we all remember how uncertain those times were, as well as how scary it was and how lonely it could be having to isolate from loved ones,” said Fischer. “However, over time—approximately two years after the onset of the pandemic in the case of our study—levels of distress returned to those observed during the pre-pandemic period.”

Veterans and civilians both adjust to new challenges well, even long challenges such as the pandemic, said Fischer.

“August 2022, when our most recent data was collected, was also a time when COVID-19 infection rates in the United States were better controlled and lockdown orders were no longer in place, so it could also indicate that many people no longer viewed COVID as a threat the way they did back during the height of the pandemic in 2020,” Fischer said.

These encouraging findings should not detract from the fact that a significant minority of veterans continue to experience mental health difficulties, he said.

Fischer and his co-authors did identify “a subset of veterans whose mental health continued to deteriorate (2.5%; approximately 450,000 veterans). Indeed, those who, prior to the pandemic, experienced difficulties with substance use and had a lifetime history of mental health disorders, such as major depressive disorder or PTSD, experienced a worsening of mental health during the pandemic.”

The research was done as part of the ongoing National Health and Resilience in Veterans Study, which seeks to measure resilience to stress and trauma among veterans.

Ritchie said, “We’re all going to agree that it’s important to be resilient, and we have kind have a gut check of what that means, whether it’s bouncing back from bad events, or being optimistic. See, a challenge here becomes you want to talk about strengths. It’s easier for psychiatrists to learn about vulnerabilities.”

Providers might want to remind patients of the challenges that they’ve faced and overcome in the past, she said.

“The best thing to promote resilience in the military is getting through bootcamp,” says Ritchie. “Because there’s a lot about teaching you how to overcome obstacles, whether it’s an obstacle course, as you’re climbing over the top of it, or whether you have to get down and do 100 pushups that are included army training.”