In this episode of Mental Health Pathfinders, host Erin Connors speaks with Nina Kraguljac, M.D., about what resilience really means through a mental health lens. Dr. Kraguljac discusses why resilience is not a fixed character trait, how it can be strengthened over time, and why meaning, hope, agency, and social connection play such an important role in helping people navigate adversity. She also shares insights from the State of Ohio Adversity and Resilience Study, a first-in-the-nation effort to better understand the psychological, social, environmental, and biological factors that shape resilience and mental health.

Transcript

Erin Connors (00:03) Hello and welcome to this episode of Mental Health Pathfinders. I'm your host, Erin Connors. In this time when there is so much uncertainty in the world and recent APA public opinion polls continue to show that people are feeling higher levels of stress and anxiety, how can psychiatrists help patients manage that uncertainty, maintain hope, and foster resilience? Well, joining us today to talk about this very important topic is Dr. Nina Kragulyak, Professor and Vice Chair for Strategy and Innovation in the Department of Psychiatry and Behavioral Health at The Ohio State University. And she is also Chair of the APA's Council on Research. Thank you so much for joining us today.

Nina Kraguljac (00:43) Thanks Erin for having me, I appreciate it.

Erin Connors (00:46) Absolutely. when you think about resilience as a psychiatrist, how do you define that?

Nina Kraguljac (00:53) Yes, so resilience is a positive psychology concept that basically describes the ability to bounce back from adversity. So adversity is unfortunately something that almost everybody has to deal with at some point in their lives, ⁓ some more so than others. like typically there's not much to control over whether you have to experience adversity or not. So what is interesting, though, is that some people develop a mental illness or distress or anxiety or depression after they experience significant adversity. However, other people seem to just be moving on with their lives and like without any significant impact on their daily functioning or well-being. So even if it's the same stressor, people react differently to any type of adversity, which is really not well understood. why this happens, why some people get ill and why some people do well in the face of the same type of adversity.

Erin Connors (02:00) Is this something that can be built over time in certain patients?

Nina Kraguljac (02:04) Yeah, so actually resilience is something that can be built in everybody. It doesn't have to be somebody who has a mental illness. Resilience, we now know it's a dynamic process that can be ⁓ built over time. For example, we know that as people get older and visor, they usually have higher levels of psychological resilience. They tend to adapt and cope better with adversity. But we also are starting to try to understand what are the factors in the environment socially, psychologically, really makes an impact on somebody's ability to be resilient.

Erin Connors (02:49) And this is something you're really digging into right now, especially people living with serious mental illness. It's something that Ohio is really focusing in on. It's a program called SOAR. Talk a little bit about that.

Nina Kraguljac (03:02) Yes, absolutely. So SOAR is the State of Ohio Adversity and Resilience Study that is led by the Ohio State University in collaboration with a number of academic medical centers, universities and states where we're really tasked to try to better understand what makes somebody resilient and what type of adversity. do people experience in general, especially after COVID, we've seen an increase in number of people who are experiencing anxiety, depression, substance use, alcohol use, even suicide. But in psychiatry, what we typically do is like, we react once a bad thing has happened, right? Once somebody has developed a mental illness. However, where we ought to be is we need to... rescue people before they fall in the river and not just fish them out once they have fallen in. So it's really very important for us to better understand how resilience happens, how it builds, what we can do to intervene and promote well-being and resilience. So that was the main goal of the SWOR study. where we look at a number of environmental, social, psychological, and biological factors that really inform us about resilience and about mental illness. So the study has broadly two parts. The first part is a statewide survey that we've conducted in 15,000 people in Ohio. across all 88 counties in Ohio, including rural and ⁓ urban and suburban areas. So to really ask the questions like, how are you doing? How is your mental health? Are you suffering from anxiety, depression, alcohol use? Do you think about suicide? But also talking about like, what kind of resources do you have available if you're not feeling well? What gives you meaning? What gives you hope? How do you cope with adversity? How does your social network look like? So in this first part, we really wanted to broadly characterize the state of mental health in Ohio and the state of resilience in Ohio as well. The second part of the study is a more mechanistic study where we really are trying to understand what happens in the brain when people experience adversity and what happens to you as a human being when you experience adversity. So we enrolled almost 3000 people where we did ⁓ MRI brain imaging, EEG, so looking at brain waves. We also did a lot of cognitive testing, like how good is your cognition? Do you have any impairment there? ⁓ psychiatric assessments. so that we can really better understand what is going on. Two other components we had is we do a blood draw so that we can understand genetic factors and things like inflammation, how those have an impact on your mental health and on resilience. And then we also did ⁓ what's called EMA, it's Ecological Momentary Assessments, where basically participants get a survey from us on a regular basis. over a span of four weeks. And we asked things like, how was your day? How are you feeling? Are you having any suicidal thoughts? Right? Like, what were the good things? How do you rate your mood? So that we really can get a very broad and deep snapshot. So where the survey is the broad assessment across the population on resilience and the brain health studies, the deep phenotyping study where we're truly trying to get at that like biological mechanisms and trying to understand how the brain deals with adversity and what's different in people who are resilient and those who are not.

Erin Connors (07:20) This sounds like such important work. there any other states doing this that you know of is or is this unique for Ohio?

Nina Kraguljac (07:27) Now, this is a first in the nation study that does characterization of adversity and resilience as broadly. It took a lot of ⁓ support, both from the state and from the Ohio State University, as well as other collaborating ⁓ centers. And of course, the participants were very generous with their time. They were really open with their struggles. They were really helpful and a lot of people felt like they were able to actually contribute to a bigger mission. So it's been really delightful to be able to work on a study that's that important and that will teach us so much. so the.

Erin Connors (08:12) That's fascinating. Yes. How long will this go on? Will this continue to go on?

Nina Kraguljac (08:16) Yes, so we are currently in the second wave of the study, like doing the two-year follow-up, and we're hoping to do it longitudinally over years and decades. Basically, what the study is inspired by is the Framingham study, which basically ⁓ longitudinally followed people in Framingham, Connecticut for decades, and it really transformed our understanding on how heart disease works. What are risk factors for heart disease? What type of interventions can we do? Right? The Framingham study, like, for example, showed us that high blood pressure is a big risk factor, right? So based on that, now we're preventing heart disease by treating high blood pressure. And we're hoping to do the same for the mind here, where we can then really to preventative efforts, but also early interventions and secondary interventions similar to what has been done in the Framingham study.

Erin Connors (09:22) you talk with patients about resilience in a way that's supportive to help them?

Nina Kraguljac (09:27) Yes, so I think it's important for our patients to understand that adversity is something that everybody experiences. And especially, I'm thinking about people with significant trauma. Like I do consultations in the hospital sometimes where we have accident victims or burn victims. And of course they struggle. With that, people oftentimes have trouble sleeping, they have anxiety, like right after the incident. What I'm trying to tell them is this is a very normal reaction to a very abnormal situation. So, and my job is to help them through it and build resilience so that they can get back to feeling well and doing well and being able to function in life. So resilience is not a character trait and the lack of resilience is not a character flaw. So that's really, really important to, for people to understand like facing adversity is difficult. It's not easy. And it's not surprising when you're having a hard time and not just moving on as if nothing happened. However, being able to better understand people who have this ability to move on with little impact will really inform us as to how we think about mental health and how we think about treating people or preventing ⁓ development of mental illnesses.

Erin Connors (11:05) We often hear when people are dealing with serious mental illness, they sometimes back away from their community, from the people that are around them. But it sounds like this, when you're facing adversity, you need to stick with the people that can support you a lot too.

Nina Kraguljac (11:18) Yes, so we just like, you know, started analyzing our data from the survey. And it's very obvious that there is some factors that are really important for people to be resilient. One of the main factors is having meaning and hope in life. Like being able to... have meaning to know why you're on earth, that that fosters resilience, how you think you have control over a situation, it's a term called self-efficacy. So basically, do you feel like you can control your behaviors, the situation? And then also cognitive appraisal of stressful events. That means is, do I believe that I have agency, like how do I evaluate the stressor, is the stressor manageable? And that's different for everybody. So people who feel like their stressors can be managed, and they can have agency, usually do better. And then to the point that you're making loneliness is a significant factor. And as we know, loneliness has become more prominent as people are not as connected to their communities, don't have as much family support. And we're showing that it's really, really important to have your social network and talk to the people and be able to ask for help when you need it.

Erin Connors (12:53) Yeah, and I think for listeners that are feeling overwhelmed, that's a really important point that they should be able to reach out. Any other advice you have for people that might be feeling a little overwhelmed?

Nina Kraguljac (13:04) Yes, absolutely. You're not alone. Many, many people feel like that. And it's not a testament to your character if you ask for help. The thing that I've learned as a psychiatrist is that people oftentimes in situations where somebody, one of their loved ones, one of their friends faces significant adversity, feel very helpless. Right? So what I've experienced is like you actually doing your community a favor when you ask for help, because it allows them to do something and not just helplessly stand by and see you suffer. So really don't conceptualize asking for help as a flaw or as a weakness, just really conceptualize it as you're giving your loved ones, your friends, your community an opportunity. to do something, to be helpful, to be part of your journey.

Erin Connors (14:06) Dr. Nina Kragulyak, thank you for the important work that you're doing and for joining us here today. And to our listeners, you can find more episodes like this on a range of mental health topics on APA's Medical Mind Channel, available on all major podcasting platforms.

Nina Kraguljac (14:12) Thank you so much.