Journal of Affective Disorders 207 (2017) 434–441

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Effects of resilience on quality of life in patients with bipolar disorder

a b,c,⁎ b,c b,c a,c
crossmark
Dongyun Lee , Boseok Cha , Chul-Soo Park , Bong-Jo Kim , Cheol-Soon Lee ,
So-Jin Leeb,c, Ji-Yeong Seoa, Young Ah Chod, Jong Hun Hae, Jae-Won Choif
a
Department of Psychiatry, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
b
Department of Psychiatry, Gyeongsang National University Hospital, Jinju, Republic of Korea
c
Department of Psychiatry, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
d
Biomedical Research Institute, Gyeongsang National University Hospital, Jinju, Republic of Korea
e
Department of Microbiology, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
f
Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea

A R T I C L E I N F O A BS T RAC T

Keywords: Background: Few studies have examined the effects of resilience on quality of life (QOL) in patients with
Resilience bipolar disorder (BD). Therefore, this study investigated the association between resilience and QOL in patients
Quality of life with BD and compared it to the relationship between resilience and QOL in healthy individuals.
Bipolar disorder Methods: Participants were 68 euthymic patients with BD and 68 age-, sex-, and length of education-matched
controls. Sociodemographic characteristics and clinical variables of the two groups were obtained using face-to-
face interviews, and all participants completed the Connor-Davidson Resilience Scale, the World Health
Organization QOL-Brief Form.
Results: The QOL of the BD group was significantly impaired compared with that of the controls. Degree of
resilience, number of depressive episodes, Clinical Global Impression scores, degree of impulsivity, and length
of education were significantly correlated with QOL in the BD group. Resilience was significantly associated with
overall QOL, physical subdomains of QOL, psychological subdomains of QOL, social subdomains of QOL, and
environmental subdomains of QOL in the BD group, even after controlling for confounders. In the control
group, resilience was significantly associated with overall QOL, the physical subdomains of QOL, psychological
subdomains of QOL, and social subdomains of QOL.
Limitations: The number of participants in each group was 68, which is a relatively small sample size.
Conclusions: Resilience in patients with BD was independently and positively correlated with various areas of
QOL. Various strategies to reinforce resilience in patients with BD are needed to improve the low QOL in this
population.

1. Introduction
Bipolar disorder (BD) is a chronic illness characterized by the
repeated recurrence of depressive episodes that alternate with hypo-
manic or manic episodes. Due to the chronic nature of BD, improve-
ments in the functional outcomes and quality of life (QOL) of patients
with BD are as important as the long-term treatment of their symptoms
(Arnold et al., 2000; Cooke et al., 1996; Michalak et al., 2006; Robb
et al., 1997). QOL not only varies across individuals, even within the
same environment (Lawford and Eiser, 2001), but is also influenced by
a variety of factors, including age, sex, and history of physical disease
(Min et al., 2002). Studies investigating the general population and
patients with posttraumatic stress disorder have shown that a past
history of psychological trauma, such as war and rape, is associated
with a low QOL (Coker et al., 2000; St Cyr et al., 2014). Additionally,
the effects of past lifetime traumas, recent severe traumas (such as
earthquakes), and daily life stress can also negatively impact QOL
(Alriksson-Schmidt et al., 2007; Xu and Ou, 2014).
Compared with healthy individuals, the QOL of patients with BD is
significantly impaired during both the euthymic and symptomatic
phases of the illness. Female of gender, short length of education,
unemployment, poor economic standing, and poor social support were
associated with low QOL of patients with BD (IsHak et al., 2012; Sierra
et al., 2005; Yen et al., 2008). Additionally, mood symptoms, comor-
bidities, early onset of illness, impulsivity, and neurocognitive deficits
were associated with lower QOL in patients with BD (Brissos et al.,
2008; Cotrena et al., 2016; IsHak et al., 2012; Kim et al., 2013;
Mackala et al., 2014; Pattanayak et al., 2012). Moreover, childhood

⁎
Corresponding author at: Department of Psychiatry, Gyeongsang National University Hospital, 79 Gangnam-ro, Jinju, Gyeongnam, 660-702, Republic of Korea.
E-mail address: cbs324@gmail.com (B. Cha).

http://dx.doi.org/10.1016/j.jad.2016.08.075
Received 6 April 2016; Received in revised form 12 August 2016; Accepted 27 August 2016
Available online 11 October 2016
0165-0327/ © 2016 Elsevier B.V. All rights reserved.
D. Lee et al.
trauma that includes physical, emotional, and/or sexual abuse is a risk
factor for early onset of illness, a long duration of illness, the frequent
recurrence of depressive episodes, suicide attempts, and oversensitivity
to pain (Erten et al., 2014; Etain et al., 2013; Sierra et al., 2005). Each
of these factors can negatively affect the course of BD and change the
attitude toward and way of life of an individual with BD, which would
ultimately impair QOL.
Because past traumatic events negatively affect QOL in both the
general population and patients with BD, it can be assumed that the
ability to cope with trauma or adversity is a protective factor for QOL.
Resilience is the ability of an individual to appropriately cope with a
stressful situation or adversity (Alim et al., 2008), and acts as a
protective factor that prevents the manifestation of negative emotions,
such as depression and anxiety, in stressful situations (Skrove et al.,
2013). In healthy individuals, QOL is influenced by a variety of
individual characteristics, and resilience can mediate the relationship
between these characteristics and QOL (Lawford and Eiser, 2001).
Pediatric cancer patients, juveniles with mobility disability, and people
who had recently experienced an earthquake exhibited improvements
in QOL following participation in a resilience reinforcement program
(Alriksson-Schmidt et al., 2007; Chou and Hunter, 2009; Xu and Ou,
2014). In patients with depressive and anxiety disorders, resilience is
related to the factors associated with a high QOL, including purpose of
life, spirituality, and optimism (Min et al., 2013). However, studies on
resilience in patients with BD are rare (Choi et al., 2015) and no studies
have investigated the relationship between resilience and QOL in this
population.
Patients with BD are more readily exposed to traumatic events than
controls due to disruptive behavior and impulsivity during both the
symptomatic and euthymic phase of illness (Choi et al., 2015; Otto
et al., 2004; Quarantini et al., 2010). Furthermore, when facing trauma
or stress, because patients with BD use immature coping strategies and
engage in risk taking, they are at high risk for posttraumatic stress
disorder (PTSD) (Fletcher et al., 2013; Quarantini et al., 2010).
Therefore, resilience might be more important in patients with BD
than in healthy individuals. Moreover, considering that trauma or
stress, as well as PTSD, in patients with BD may be associated with low
QOL (Quarantini et al., 2010), the determination of whether resilience
is associated with QOL in patients with BD has important clinical
implications in terms of improving the QOL of these patients.
Previous studies investigating QOL in patients with BD have either
failed to account for factors that could influence QOL, such as age, sex,
length of education, mood symptoms, and impulsivity (Sylvia et al.,
2013), or lacked a comparison group of controls (Victor et al., 2011).
The present study investigated the independent relationship between
resilience and QOL in euthymic patients with BD, while controlling for
sociodemographic variables and clinical features that can affect QOL,
and compared it with that of controls.
2. Methods
2.1. Participants
The sample for this study was drawn from the subjects included in a
long-term follow-up project investigating the psychological character-
istics of mood disorder patients that began in March 2013 in the
psychiatric outpatient clinic at Gyeongsang National University
Hospital (GNUH) in South Korea, which will continue for a total of 5
years (PI: CBS). We previously published a paper about the relation-
ship between resilience and impulsivity in the subjects from the
aforementioned long-term follow-up project (Choi et al., 2015). The
participants in the present study were recruited from the outpatient
clinic at GNUH, and included euthymic patients with BD who had
remitted from their most recent depressive, hypomanic, or manic
episode as a result of outpatient or inpatient treatment. All patients
in the BD group were between 20 and 65 years of age and were
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Journal of Affective Disorders 207 (2017) 434–441
diagnosed based on the criteria of the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) (American
Psychiatric Association, 2000) for BD I, BD II, or BD not otherwise
specified (NOS). For the present study, a remission was defined as a
Clinical Global Impression (CGI) score ≤2, no affective symptoms (i.e.,
no depressive mood and no elated/irritable mood) and no more than
two symptoms meeting DSM-IV-TR criteria for a major depressive,
manic/hypomanic episode lasting 2 months or more during the follow-
up observation period (Tohen et al., 2009). Patients with an intellectual
disability, dementia, a mood disorder due to a general medical
condition, a personality disorder, or a current substance use disorder
(alcohol use disorder or drug use disorder) were excluded from the
present study. Because this study was part of a prospective long-term
follow-up study, the subjects with substance use disorder or personality
disorder were excluded in light of the poor adherence to treatment and
high dropout rates associated with the two diseases. Ultimately, a total
of 68 euthymic patients with BD were recruited for this study.
The control group was initially comprised of 139 healthy indivi-
duals who visited the Health Promotion Center at the Gyeongsang
National University Medical Center for a regular health check-up,
agreed to participate in the study, and completely filled out the
questionnaires at their initial recruitment. Of these 139 individuals,
132 individuals were screened who were between 20 and 65 years of
age, had no record of being treated for psychiatric illnesses including
alcohol use disorder, and had no current depressive symptoms
according to the Center for Epidemiological Studies for Depression
Scale (CES-D). Of these 132 individuals, the data of 68 who were age-,
sex-, and length of education-matched with the BD group were
included in the study analyses. This study was approved by the
Institutional Review Board and written informed consent was obtained
from each participant after a complete explanation of the study.
2.2. Measures
Trained psychiatrists conducted face-to-face interviews with the
participants from the BD and control groups to collect information on
age, sex, length of education, occupation, marital status, cigarette
smoking (pack years), history of alcohol use, chronic medical diseases
(e.g., diabetes, hypertension, cardiovascular diseases, and cerebrovas-
cular diseases), and time spent on physical exercise. Additionally, the
clinical variables of the BD patients, including age of onset, number of
depressive episodes, number of manic episodes, history of suicide
attempts, and number of hospitalizations, were investigated. All
participants filled out the Connor-Davidson Resilience Scale (CD-
RISC), World Health Organization Quality of Life-Brief Form
(WHOQOL-BREF), and Barratt Impulsiveness Scale (BIS) self-assess-
ment questionnaires.
The CD-RISC is a 25-item self-assessment scale that measures the
resilience of an individual using a 5-point Likert-type scale that ranges
from 0 to 4 for each item (Connor and Davidson, 2003). The sum of the
item scores determines an individual's level of resilience, such that a
higher summed score indicates a higher degree of resilience. The CD-
RISC has a five-factor structure (Baek et al., 2010; Connor and
Davidson, 2003). Factor 1 consists of eight items to assess personal
competence, high standards, and tenacity. Factor 2 is composed of
seven items related to trust in one's instincts, tolerance of negative
affect, and post-traumatic growth (or strengthening effects after over-
coming stress). Factor 3 has five items assessing positive acceptance of
change, and secure relationships. Factor 4 has three items to evaluate
control. Factor 5 comprises two items pertaining to spirituality.
Previous studies reported divergent validity in patients with general-
ized anxiety disorder (Connor and Davidson, 2003) and psychiatric
outpatients (Jung et al., 2012). The Korean version of the CD-RISC
exhibits significant internal consistency (Cronbach’s α=0.92) and
satisfactory reliability and validity, including divergent validity (Jung
et al., 2012).
D. Lee et al.
The WHOQOL-BREF is a QOL assessment tool developed by the
WHO (WHOQOL Group, 1998) that consists of 26 items: four
subscales that assess the physical (7 items), psychological (6 items),
social (3 items), and environmental (8 items) subdomains, and 2 items
that reflect overall QOL and general health. Each item is rated on a 5-
point Likert-type scale that ranges from 0 to 4, and the QOL total score
is the sum of the score for each item divided by 26. The physical
domain comprises seven items related to pain and discomfort, energy
and fatigue, sleep and rest, mobility, activity, dependency on medica-
tion or treatment, and work capacity. The psychological domain has six
items to assess positive feelings, thinking, self-esteem, bodily image,
negative feelings, and spirituality. The social domain consists of three
items covering personal relationships, social support, and sexual
activity. The environmental domain is made up of eight items evaluat-
ing physical security, home environment, financial resources, avail-
ability and quality of health and social care, opportunities for acquiring
information and skills, physical environment, and participation in and
opportunities for recreation and transport (Min et al., 2002). A
previous study showed appropriate divergent validity for WHOQOL-
BREF in patients with psychiatric diseases, including bipolar disorder
and major depressive disorder, compared with healthy subjects
(Carpiniello et al., 2006). Another study compared QOL between
groups according to depressive severity, and reported appropriate
divergent validity for WHOQOL-BREF in patients with major depres-
sion (Berlim et al., 2005). The WHOQOL-BREF has been translated
into Korean and validated (Cronbach’s α=0.92) (Min et al., 2002).
The BIS evaluates impulsivity on three subscales: attention im-
pulsivity, motor impulsivity, and non-planning impulsivity (Patton
et al., 1995). This measure includes 30 items that are rated on a 4-
point Likert-type scale ranging from 1 to 4, such that a higher score
indicates a higher degree of impulsivity. The BIS was translated into
Korean in 2012 and has a high internal consistency (Cronbach's
α=0.78), as well as confirmed reliability and validity (Lee et al., 2012).
2.3. Statistical analyses
The patients with BD were matched to 68 control subjects using
propensity score matching for age, sex, and length of education
(Austin, 2011). We used t-tests to compare the sociodemographic
characteristics that were continuous variables, total scores on the CD-
RISC, and the total and subscale scores on the WHOQOL-BREF
between the BD and control groups. Chi-square tests were used to
compare the sociodemographic characteristics that were categorical
variables between the two groups. A Pearson correlation analysis was
performed to evaluate the correlations between the BD and control
groups regarding the total and subscale scores on the WHOQOL-BREF,
total scores on the CD-RISC, total scores on the BIS, and the
continuous variables. Because the correlations between the CGI scores
and the total and subscale scores on the WHOQOL-BREF for the BD
group and the correlations between time spent on physical exercise and
the total and subscale scores on the WHOQOL-BREF for the control
group were non-linear, a Spearman correlation analysis was used to
evaluate the correlations between these variables.
A univariate regression analysis was conducted to examine the
correlations between the total and subscale scores on the WHOQOL-
BREF and the nominal sociodemographic variables (sex, occupation,
marital status, chronic medical diseases, history of alcohol use dis-
order, and history of suicide attempts) of the two groups. Additionally,
a multiple regression analysis was performed using the total and
subscale scores of the WHOQOL-BREF for each group as the depen-
dent variables and the CD-RISC scores as the independent variable.
Impulsivity negatively affects QOL (Kim et al., 2013) and physical
exercise positively affect QOL, in patients with BD (as well as in healthy
individuals) (Awick et al., 2015; Sylvia et al., 2013). Thus, when the
multiple regression analysis was performed, a range of factors that
could act as confounders were included as independent variables (age,
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Journal of Affective Disorders 207 (2017) 434–441
sex, length of education, physical exercise, BIS total score, number of
depressive episodes, CGI score and subtype of BD) (IsHak et al., 2012;
Sierra et al., 2005; Sylvia et al., 2013; Victor et al., 2011). In the
multiple regression analysis for the control group, age, sex, length of
education, physical exercise, and BIS total score were controlled for.
To investigate whether the association between resilience and QOL
was modified according to diagnostic group status (BD vs. controls), we
conducted a separate multiple regression analysis, including diagnostic
group and the interaction term of diagnostic group*resilience (BD/
Control status*CD-RISC scores) as covariates, for all subjects.
Furthermore, two separate analyses was performed in the BD group.
First, because of the conceptual overlap between several items of the
WHOQOL-BREF, CD-RISC and the actual symptoms of the BD group,
even subsyndromal depressive symptoms might exaggerate the asso-
ciation between resilience and QOL in the BD group. To minimize the
influence of this conceptual overlap on the outcomes, we modified the
WHOQOL-BREF and CD-RISC scales, excepting the following items
related to actual symptoms of BD: WHOQOL-BREF: positive feelings
(psychological subdomain), thinking (psychological subdomain), en-
ergy (physical subdomain), sleep (physical subdomain), self-esteem
(psychological subdomain), and negative feelings (psychological sub-
domain); CD-RISC: tolerance of negative affect (14th and 19th items).
Pearson's correlation analysis and multiple regression analysis were
then performed using the scores of the two modified scales with other
variables remaining constant. Second, to determine whether the
severity of manic episodes plays a role in outcomes in the BD I
subgroup, a separate multiple regression analysis was performed that
included the number of manic episodes together with other confoun-
ders as covariates for 41 patients with BD I.
During the t-tests, Pearson correlation analyses, Spearman correla-
tion analyses, and multiple regression analyses, the effect sizes of each
analysis were determined using Cohen's d, Pearson's r, Spearman's rho,
and Cohen's f 2 values, respectively (Murphy et al., 2009). All statistical
analyses were conducted using SPSS version 21.0 (IBM Corporation,
Armonk, NY, USA) and two-tailed p values < 0.05 were considered to
indicate statistical significance.
3. Results
3.1. Sociodemographic characteristics and clinical features
The BD group comprised 68 patients: 41 (60.29%) had BD I, 20
(29.41%) had BD II, and 7 (10.29%) had BD NOS. The BD group had a
mean age of 38.12 ( ± 11.33) years, and a higher unemployment rate (p
< 0.001) and more pack years of cigarette smoking (p < 0.05) than the
control group. The mean age of onset in the BD group was 24.82 ( ±
8.47) years and the numbers of depressive episodes and hospitaliza-
tions were 3.82 ( ± 4.25) and 1.98 ( ± 2.61), respectively. Of the 68
patients with BD, 10 (14.71%) had a history of suicide attempts and 9
(13.24%) had a lifetime history of alcohol use disorder. The mean CGI
score for the BD group was 1.53 ( ± 0.50). The sociodemographic
characteristics and clinical features of the participants are presented in
Table 1.
3.2. Comparison of QOL and resilience scores between the BD and
control groups
The total score and physical, psychological, and social subscale
scores on the WHOQOL-BREF were significantly lower in the BD group
than in the control group. Likewise, the CD-RISC total score in the BD
group was significantly lower than that of the control group (Table 2).
3.3. Correlation between QOL and clinical features
Table 3 presents the correlations between QOL and the clinical
variables in the BD and control groups. In both groups, the total score
D. Lee et al. Journal of Affective Disorders 207 (2017) 434–441

Table 1 Table 3
Demographic characteristics of the BD and control groups. Correlations between scores on the WHOQOL-BREF and the clinical features of the BD
and control groups.
BD Control P
(N =68) (N =68) WHOQOL-BREF

Age (years)a 38.12 ± 11.33 38.38 ± 11.90 0.895 Total Physical Psychological Social Environmental
Male (N, %) 38 (55.88) 36 (52.94) 0.731
Length of education (years)a 13.79 ± 3.10 14.03 ± 2.46 0.617 BD (N = 68)
Marital status (N, %) 0.413 Age −0.01 0.08 0.10 −0.04 −0.17
Single 25 (36.76) 21 (30.88) Length of 0.26* 0.20 0.18 0.02 0.37**
Married 40 (58.82) 46 (67.65) education
Separated/divorce/widowed 3 (4.41) 1 (1.47) Cigarette −0.20 −0.10 −0.12 −0.22 −0.28*
Unemployment (N, %) 13 (19.12) 0 (0) < 0.001 smoking
Cigarette smoking (pack*year)a 4.60 ± 11.04 0.96 ± 3.63 0.012 Physical 0.06 0.08 0.02 −0.05 0.11
Physical exercise (hours/ 184.97 ± 227.62 122.94 ± 225.43 0.119 exercise
week)a Age of onset 0.00 0.10 0.05 −0.03 −0.12
Chronic medical diseases (N, 9 (13.24) 3 (4.41) 0.070 Number of −0.35** −0.32* −0.33** −0.48** −0.17
%) depressive
episodes
BD, bipolar disorder; SD, standard deviation. Number of −0.10 0.00 −0.04 −0.16 −0.18
a hospitaliza-
Mean ± SD.
tions
CGI score −0.32**,a −0.31*,a −0.31*,a −0.28*,a −0.23a
and four subscale scores on the WHOQOL-BREF exhibited significant BIS total −0.64*** −0.56*** −0.62*** −0.50*** −0.54***
positive correlations with the CD-RISC scores. The effect sizes of the score
correlations between the total score and four subscale scores on the CD-RISC 0.82*** 0.77*** 0.77*** 0.59*** 0.64***
WHOQOL-BREF and the CD-RISC scores in the BD group and the
Control (N =
control group were large and medium, respectively. In particular, the
68)
effect sizes of the correlations on the total score and the physical and Age −0.14 −0.19 0.02 −0.02 −0.14
environmental subscale scores of the WHOQOL-BREF against the CD- Length of 0.23 0.16 0.03 0.07 0.33**
RISC scores in the BD group were roughly twice those of the control education
group. Cigarette 0.09 0.12 0.18 0.20 −0.05
smoking
In a separate correlation analysis that included the scores of the Physical 0.34**,a 0.18a 0.29*,a 0.19a 0.33**,a
modified WHOQOL-BREF and the modified CD-RISC, correlation exercise
coefficients between CD-RISC scores and total, and all subscale, BIS total −0.42*** −0.25* −0.35** −0.40** −0.38**
WHOQOL-BREF scores decreased more in the BD group than in the score
CD-RISC 0.48** 0.37** 0.52** 0.46** 0.32**
control group, compared to the correlation coefficients in each group
obtained using the original scale scores. However, CD-RISC scores WHOQOL-BREF, World Health Organization Quality of Life-Brief Form; CD-RISC,
were still significantly correlated with total, and all subscale, Connor-Davidson Resilience Scale; BIS, Barratt Impulsiveness Scale; BD, bipolar
WHOQOL-BREF scores in both groups. In addition, the correlation disorder; CGI, Clinical Global Impression.
*
coefficients between the total, and physical and environmental sub- p < 0.05.
**
scale, WHOQOL-BREF scores and the CD-RISC scores in the BD group p < 0.01.
***
p < 0.001.
were still roughly twice as large as those of the controls (r=0.64 vs. a
Spearman's rho.
r=0.39, r=0.60 vs. r=0.26, and r=0.52 vs. r=0.30, respectively).
Fig. 1 presents the correlations between the WHOQOL-BREF total 3.4. . Association of resilence with QOL using multiple regression
scores and CD-RISC total scores in the BD group. analyses
A univariate regression analysis of the BD group revealed that the
social subscale score on the WHOQOL-BREF was significantly corre- In the BD group, the CD-RISC score was predictive of the
lated with employment (β=1.64, p=0.04) and history of alcohol use WHOQOL-BREF total score (β=0.67, p < 0.001) and explained 73%
disorder (β=−1.85, p=0.04). None of the other QOL subscales and of the variance in the latter (adjusted R2=0.73, F=15.82, df=11, p <
nominal variables (i.e., sociodemographic variables) was significantly 0.001) when age, sex, length of education, physical exercise, BIS total
correlated in the univariate regression analysis. score, number of depressive episodes, CGI score and subtype of BD
were controlled for. The CD-RISC score was also significantly asso-
ciated with all four of the subscale scores on the WHOQOL-BREF.
In the control group, the CD-RISC score significantly estimated the

Table 2
Comparison of scores on the WHOQOL-BREF and the CD-RISC between the BD and control groups.

BD Control t P Cohen's d
(N=68) (N =68)

WHOQOL-BREF
Total 3.21 ± 0.73 3.56 ± 0.39 −3.53 < 0.001 0.70
Physical 23.22 ± 5.74 26.21 ± 3.23 −3.74 0.001 0.73
Psychological 18.50 ± 5.01 21.04 ± 3.11 −3.56 < 0.001 0.67
Social 9.25 ± 2.58 10.63 ± 1.48 −3.83 0.122 0.74
Environmental 26.13 ± 6.60 27.59 ± 4.09 −1.56 0.001 0.15
CD-RISC 60.53 ± 18.43 69.30 ± 11.13 −3.35 0.001 0.64

WHOQOL-BREF, World Health Organization Quality of Life-Brief Form; CD-RISC, Connor-Davidson Resilience Scale; BD, bipolar disorder.

437
D. Lee et al. Journal of Affective Disorders 207 (2017) 434–441

Fig. 1. Correlation between the World Health Organization Quality of Life-Brief Form
(WHOQOL-BREF) total scores and Connor-Davidson Resilience Scale (CD-RISC) scores
in euthymic patients with bipolar disorder (BD).
WHOQOL-BREF total score (β=0.40, p < 0.01) and explained 44% of
the variance in the latter (adjusted R2=0.44, F=9.56, df=6, p < 0.001).
The CD-RISC score was significantly associated with the QOL scores in
the physical, psychological, and social subdomains but did not have a
significant correlation with the environmental subdomain (Table 4).
In the analysis including the interaction term, group*resilience was
significantly associated with the total score (β=−0.76, p < 0.01) and
physical subdomain score (β=−0.95, p < 0.01) of the WHOQOL-BREF
for all subjects. This indicates that bipolar diagnostic status moderated
the relationship between resilience and QOL.
In a separate multiple regression analysis including the scores of
the modified WHOQOL-BREF and the modified CD-RISC, CD-RISC
scores were significantly associated with total (β=0.42, p < 0.001), and
physical (β=0.47, p < 0.001), psychological (β=0.27, p < 0.05), social
(β=0.26, p < 0.05), and environmental subscales (β=0.34, p < 0.01)
WHOQOL-BREF scores in the BD group; in the control group, CD-
RISC scores were significantly associated with scores on the WHOQOL-
BREF total (β=0.32, p < 0.01), psychological (β=0.39, p < 0.05), and
social subscales (β=0.38, p < 0.05) except physical and environmental
subscales.
In a separate analysis of the 41 patients with BD I, after controlling
for confounders, including the number of manic episodes, CD-RISC
scores were significant predictors of total (β=0.75, p < 0.001), and
physical (β=0.75, p < 0.001), psychological (β=0.78, p < 0.001), social
(β=0.47, p < 0.01), and environmental subscale (β=0.71, p < 0.001)
WHOQOL-BREF scores.
4. . Discussion
This study investigated the correlation between resilience and QOL
in patients with BD while controlling for a number of sociodemo-
graphic and clinical factors that can affect QOL. To the best of our

Table 4
Multiple regression analyses estimating the associations of scores on the WHOQOL-BREF and CD-RISC.

WHOQOL-BREF

Totala Physicalb Psychologicalc Sociald Environmentale

BD (N =68) B SE β B SE β B SE β B SE β B SE β

CD-RISC 0.03 0.00 0.67*** 0.22 0.04 0.70*** 0.16 0.03 0.59*** 0.06 0.02 0.43** 0.20 0.04 0.55***
BIS total score −0.02 0.01 −0.28** −0.08 0.05 −0.16 −0.14 0.05 −0.32** −0.06 0.03 −0.25 −0.15 0.07 −0.27*
Age 0.00 0.01 −0.04 −0.03 0.06 −0.05 0.05 0.05 0.09 −0.03 0.03 −0.13 −0.07 0.08 −0.11
Sex −0.04 0.12 −0.03 0.00 1.13 0.00 −1.81 0.94 −0.18 0.96 0.58 0.19 0.35 1.38 0.03
Education 0.01 0.02 0.04 0.00 0.19 0.00 −0.04 0.16 −0.02 −0.09 0.10 −0.10 0.36 0.23 0.16
Physical exercise 0.00 0.00 0.02 0.00 0.00 0.06 0.00 0.00 −0.05 0.00 0.00 −0.01 0.00 0.00 0.08
Age of onset 0.00 0.01 −0.02 0.07 0.08 0.11 −0.04 0.07 −0.07 0.01 0.04 0.02 −0.08 0.10 −0.10
Number of depressive episode −0.01 0.01 −0.06 −0.02 0.13 −0.02 −0.06 0.10 −0.05 −0.16 0.07 −0.27* 0.05 0.15 0.03
CGI score −0.07 0.11 −0.05 −0.87 1.07 −0.07 −0.19 0.89 −0.02 −0.50 0.55 −0.10 −0.50 1.31 −0.04
BD I −0.02 0.19 −0.02 1.51 1.83 0.13 −2.09 1.52 −0.20 −0.19 0.95 −0.04 0.09 2.24 0.01
BD II 0.17 0.20 0.10 2.42 1.89 0.19 −0.90 1.57 −0.08 0.35 0.97 0.06 1.94 2.31 0.14

Totalf Physicalg Psychologicalh Sociali Environmentalj

Control (N = 68) B SE β B SE β B SE β B SE β B SE β

CD-RISC 0.01 0.00 0.40** 0.11 0.04 0.37** 0.11 0.03 0.38** 0.05 0.02 0.41** 0.09 0.04 0.24
BIS total score −0.01 0.01 −0.26* −0.04 0.05 −0.09 −0.09 0.05 −0.21 −0.05 0.02 −0.24 −0.16 0.06 −0.30*
Age −0.01 0.00 −0.18 −0.07 0.03 −0.25* −0.01 0.03 −0.05 −0.01 0.02 −0.06 −0.04 0.04 −0.13
Sex −0.11 0.07 −0.15 −1.09 0.72 −0.17 −1.77 0.63 −0.29** 0.29 0.33 0.10 0.01 0.84 0.00
Education 0.05 0.02 0.30** 0.28 0.15 0.21 0.17 0.13 0.13 0.07 0.07 0.11 0.56 0.17 0.35**
Physical exercise 0.00 0.00 0.23* 0.00 0.00 0.15 0.00 0.00 0.22* 0.00 0.00 0.02 0.00 0.00 0.21*

WHOQOL-BREF, World Health Organization Quality of Life-Brief Form; CD-RISC, Connor-Davidson Resilience Scale; BD, bipolar disorder; CGI, Clinical Global Impression; BIS,
Barratt Impulsiveness Scale; β, standardized regression coefficient; B, unstandardized regression coefficient; SE, standard error.
*
p < 0.05.
**
p < 0.01.
***
p < 0.001
a
Adjusted R2 =0.73, F =15.82, df =11, p < 0.001, Cohen's f2 =3.41.
b
Adjusted R2 =0.59, F =9.16, df =11, p < 0.001, Cohen's f2 =1.98.
c
Adjusted R2 =0.64, F =10.98, df =11, p < 0.001, Cohen's f2 =2.37.
d
Adjusted R2 =0.45, F =5.52, df =11, p < 0.001, Cohen's f2 =1.19.
e
Adjusted R2 =0.53, F =7.44, df =11, p < 0.001, Cohen's f2 =1.60.
f
Adjusted R2 =0.44, F =9.56, df =6, p < 0.001, Cohen's f2 =0.96.
g
Adjusted R2 =0.23, F =4.31, df =6, p < 0.001, Cohen's f2 =0.43.
h
Adjusted R2 =0.36, F =7.30, df =6, p < 0.001, Cohen's f2 =0.73.
i
Adjusted R2 =0.23, F =4.32, df =6, p < 0.001, Cohen's f2 =0.43.
j
Adjusted R2 =0.32, F =6.09, df =6, p < 0.001, Cohen's f2 =0.61.

438
D. Lee et al.
knowledge, this study is the first to investigate the relationship between
resilience and QOL in patients with BD and to provide evidence
showing that resilience in BD patients had a positive association with
QOL. Furthermore, these findings demonstrated that resilience was
associated with more subdomains of QOL in the BD group than in the
control group. Also, the correlation between resilience and QOL in the
BD group was stronger than that in the control group.
This study found that resilience had positive associations with
overall QOL, as well as with all of the subdomains of QOL in patients
with BD. The individual characteristics associated with resilience may
explain the positive correlation between resilience and QOL. First,
when faced with stressful situations, individuals with high levels of
resilience utilize active coping strategies rather than avoidant coping
strategies (Feder et al., 2009); therefore, BD patients that have a high
level of resilience may be more likely to actively seek professional help
when experiencing pain or physical discomfort compared with BD
patients with a low level of resilience. Such, patients may also be more
likely to refresh themselves through pursuing various leisure activities,
from which they can restore energy for activities of daily life; in turn,
this may lead to a high QOL score in the physical subdomain (Feder
et al., 2009; Michalak et al., 2006). Second, when faced with psycho-
logical trauma or a negative stimulus, individuals with high levels of
resilience experience optimistic and positive feelings due to cognitive
reappraisal (Feder et al., 2009); as a result, they can make a positive
assessment regarding their life, which enhances the capacity for self-
regulation, even in a stressful situation (Feder et al., 2009). Positive
self-assessments and self-respect are associated with resilience and
may be related to a high psychological QOL (Michalak et al., 2006).
Moreover, spirituality is related to high levels of resilience (Feder et al.,
2009) and can improve psychological QOL in patients with BD
(Michalak et al., 2006). Third, appropriate social relationships and
social support are necessary to maintain a satisfactory QOL in patients
with BD (Michalak et al., 2005). Individuals with a high level of
resilience possess a greater degree of social competence and display
more openness to social support than do individuals with a low level of
resilience (Feder et al., 2009). Resilience and QOL are correlated in the
general population, and the social competence of, and social support
available to, an individual mediate the relationship between these two
factors (Alriksson-Schmidt et al., 2007; Xu and Ou, 2014). The fact that
social competence and social support are associated with resilience
may explain the correlation between the social subdomain of QOL and
resilience in patients with BD.
Patients with BD not only have a lower QOL compared with
controls but also compared with patients with other psychiatric
illnesses, including depressive disorder, anxiety disorder, and sub-
stance-related disorders (Michalak et al., 2005; ten Have et al., 2002).
The present study found that the QOL of euthymic patients with BD
was lower than that of controls in all subdomains of QOL, except the
environmental subdomain, which is line with the results of previous
research (Erten et al., 2014; Yen et al., 2008).
In this study, the interaction term of diagnostic group*resilience
was significant on multiple regression analysis, indicating that there
was a stronger relationship between resilience and QOL in the BD
group than in the control group. On the other hand, for the separate
correlation and multiple regression analyses that used the scores of the
modified WHOQOL-BREF and the modified CD-RISC, the strength of
the correlation between resilience and QOL decreased more in the BD
group than in control group. This suggests that subsyndromal affective
symptoms may have confounded our result regarding the association
between resilience and QOL in the BD group. However, although the
strength of the correlation between resilience and QOL was markedly
reduced in the BD group, the same pattern of statistical significance, for
correlation between resilience and QOL, persisted in the BD group; by
contrast, the statistical significance of correlation between resilience
and the physical subdomain of QOL disappeared in the control group
in a multiple regression analysis. This suggests that resilience had an
439
Journal of Affective Disorders 207 (2017) 434–441
influence on a wider range of subdomains of QOL in the BD group than
in the control group and that resilience was more important for the
maintenance of a good QOL in BD patients than in healthy individuals.
Nonetheless, the present finding, that resilience was more closely
related to QOL in BD patients than in controls, needs to be confirmed
by follow-up studies.
QOL is an indicator of the recovery of social functioning during the
long-term course of BD (Yatham et al., 2004). Improved QOL is a
crucial treatment goal, in addition to remission or recovery from an
affective episode in patients with BD (Harvey, 2006). Resilience is a
predictor for the recurrence of a depressive episode, and a lower
resilience is associated with more frequent recurrences of depressive
episodes in patients with BD (Choi et al., 2015). In this study, the
frequency of recurrence of depressive episodes was negatively corre-
lated with the social domain component of QOL. Additionally, the
strength of the correlations between resilience and diverse domains of
QOL was stronger in the BD group than in the control group. The
results of the present study indicate that resilience is closely associated
with the course of the illness and with outcomes such as QOL in
patients with BD. Therefore, clinicians need to systematically evaluate
resilience in clinical practice to predict long-term outcomes for patients
with BD more effectively.
When patients with depression and/or anxiety disorders engage in
treatment programs designed to enhance resilience, they exhibit
improvements in their depressive and anxiety symptoms, and the
course of illness and QOL are positively affected (Min et al., 2013).
Resilience can be improved through resilience-enhancing programs
and/or the provision of social support (Alriksson-Schmidt et al., 2007;
Southwick and Charney, 2012; Xu and Ou, 2014). In conjunction with
previous findings, the present results indicate that resilience in BD
patients can positively affect their QOL and, thus, the development and
validation of resilience-enhancing programs that are appropriate for
patients with BD are needed.
In this study, there was a difference between the BD and control
groups regarding the correlation between time spent on physical
exercise and QOL. Similar to previous findings (Awick et al., 2015),
the present study found that the weekly time spent on physical exercise
was positively correlated with QOL in the control group. On the other
hand, there were no correlations between time spent on physical
exercise and any of the QOL subdomains in the BD group in this
study, which is in contrast to previous findings showing that these
variables are positively correlated (Sylvia et al., 2013). It is possible
that this discrepancy was due to differences in the regularity of physical
exercise between the groups because there is a positive relationship
between one's daily routine and QOL (Michalak et al., 2005). Patients
with BD may find it difficult to maintain a daily routine, and it has been
shown that many patients with BD do not exercise regularly (Sylvia
et al., 2013). From this point of view, the patients with BD who
participated in the present study might have exercised less regularly
than the participants in the control group. A recent prospective study
revealed that individuals who exercised regularly had higher QOL
scores than those who exercised irregularly (Henchoz et al., 2014) and
a previous study comparing an aerobic walking group and a strength-
ening and flexibility group found that only the aerobic walking group
had a high mental aspect in terms of QOL (Awick et al., 2015). The
present study did not assess the types of exercise that the participants
engaged in, but it is possible that the two study groups differed in this
regard and that this affected the results.
In this study, the number of depressive episodes experienced by the
patients with BD had a negative correlation with the social subdomain
of QOL. Patients with bipolar depression exhibit lower QOL scores than
those with unipolar depression (Judd et al., 2008; Sierra et al., 2005)
and, for a patient with BD, depressive episodes can aggravate family
relationships and cause greater impairments in social and occupational
functioning than manic episodes, which could have a negative effect on
QOL (Calabrese et al., 2004). Additionally, the number of depressive
D. Lee et al.
episodes and degree of impairment in social functioning, which is
associated with the social subdomain of QOL, are negatively correlated
in patients with BD (MacQueen et al., 2000). Therefore, the present
findings suggest that the prevention of depressive episodes in patients
with BD may be very important for the improvement of social
functioning and subsequent enhancements in social QOL.
This study has several limitations that should be noted. First, the
number of participants in each group was 68, which is a relatively small
sample size. Further study is needed to replicate our results in a large
sample of patients. Second, because we used only the CGI scale and
DSM-IV-TR criteria for major depressive and hypomanic/manic epi-
sodes to determine whether BD patients were clinically in remission
state, some BD patients may have not remitted from their mood
episodes or may have subsyndromal mood symptoms. Third, neither
patients with BD nor controls were evaluated by a structured diagnostic
interview. Fourth, the findings of this study may not apply to all
patients with BD, as BD patients with comorbid substance use disorder
and/or comorbid personality disorder were excluded from this study.
Fifth, because the study participants were recruited from a tertiary
university hospital, it may be difficult to generalize the results of this
study. Despite these limitations, the inclusion of euthymic patients with
BD in this study and the comparison of their characteristics with those
of a control group are an advantage when interpreting the results.
Additionally, various clinical factors that can affect QOL were con-
trolled for in this study.
In conclusion, the results of this study indicate that resilience in
patients with BD was independently and positively correlated with QOL
and suggest that resilience affected more various areas of QOL in BD
patients than in the control group. Considering that patients with BD
are at higher risk of exposure to trauma or stressful life events, and are
more susceptible to stress than healthy individuals (Choi et al., 2015;
Otto et al., 2004; Quarantini et al., 2010), this study suggests that the
promotion of resilience is important for improving outcomes such as
QOL. In the present study, because we did not include a measure of
negative life experiences, against which individuals may need to show
resiliency, we do not know whether, objectively the patients with BD
were experiencing more negative events than controls; furthermore,
the moderating effects of resilience on the relationship between
negative life experiences and QOL in patients with BD could not be
assessed. Future studies should investigate whether resilience acts as a
protective factor against the negative impact of stressful life experi-
ences and/or trauma on QOL in patients with BD.
Role of the Funding Source
This study was not supported by any grant.
Conflicts of Interest
All authors declare that they have no conflicts of interest.
Acknowledgements
The authors would like to thank Jihoon Jang and Inyoung Ahn for
their assistance in collecting data.
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