A New Direction for Geriatric Psychiatry: Wellness

In his farewell address in May as the outgoing president of the American Psychiatric Association, Dr. Dilip Jeste emphasized the need for a “positive psychiatry of aging.” Until recently, psychiatry has largely conceptualized health and well-being as the absence of illness and symptoms. In Jeste’s view, “quality of life and psychosocial functioning depend less on physical health and more on positive psychological traits like resilience, optimism, social engagement, and wisdom.” He predicted that in the future psychiatry will go beyond treating psychiatric symptoms to “seek to enhance the well-being of people with mental or physical illness.”

This isn’t simply feel-good rhetoric. There are currently 40 million Americans over the age of 65. By 2030 the predicted number is 72 million. The U.S. needs us over 65ers to be as healthy as possible for our own well-being, but also so we can contribute to society in accord with our capacities and place less of an economic strain on younger generations. In place of the feared “silver tsunami,” Jeste wants the elderly to be – and be seen as – a “golden boom.”This February, Jeste and colleagues published an important study in the American Journal of Psychiatry – “Association Between Older Age and More Successful Aging: Critical Role of Resilience and Depression.” One thousand and six community-dwelling older adults in the San Diego area were interviewed and filled out an extensive questionnaire. The average age was 77.3. To their surprise, the researchers found that subjective satisfaction with quality of life increased with age, despite decreased physical and cognitive functioning.

This finding is consistent with a 2008 article by economists David Blanchflower and Andrew Oswald – “Is well-being U-shaped over the life cycle?”, which found that happiness among Americans and Europeans is lowest in midlife and highest in young adulthood and the over 65 period. We don’t know why our species, on average, should become happier as we age, but the data is quite convincing. Blanchflower and Oswald offer three speculations:

  • Individuals might learn to adapt to their strengths and weaknesses, and in mid-life quell their infeasible aspirations.
  • Cheerful people might live longer than the miserable for reasons not currently understood, and the well-being U-shape in age traces out a selection effect.
  • A comparison process might be at work: I have seen school friends die and come eventually to value my blessings during my remaining years.

Jeste’s San Diego study demonstrated that a) less depression and b) more resilience were associated with self-rated successful aging. In everyday language, resilience is the ability to “bounce back,” “land on our feet,” and, ideally, “learn from experience” when we encounter adversity. These findings are consistent with what common sense would predict, but establishing them as proven fact rather than plausible speculation has important implications for public health and clinical practice.

The researchers found that elders in the bottom third of physical functioning who were in the top third of resilience had self-ratings equivalent to those who were physically healthy but had low resilience. Similarly, elders in the bottom third of physical functioning but with minimal or no depression rated their aging as high as those who were physically healthy but had moderate to severe depression.

Depression and resilience are related – resilience wards off depression and depression diminishes resilience – but they act as independent factors in relation to self-rated success in aging. And most important from the perspective of public health – both are modifiable by similar community level interventions and self guided steps – as made clear by Enhancing Resilience, a publication of the American Psychological Association (APA).

At the community level, interventions that reduce isolation and increase connectedness simultaneously reduce the frequency of depression and promote resilience. Hy Kempler’s post about retirement learning programs and my post about the advantages of phased retirement are examples of community level “antidepressants”/”resilience enhancers”.

At the individual level, the APA recommendations risk being dismissed as clichés: “avoid seeing crises as insurmountable problems;” “maintain a hopeful outlook;” “nurture a positive view of yourself;” and more. The two things to say in defense of these oft-repeated suggestions are that 1) unlike medications, they don’t have harmful side effects, and that 2) a substantial body of research demonstrates that these forms of cognitive reframing reduce depression and anxiety in patients and in normal populations. Health workers can be trained to offer skillful coaching to patients seen in general medical settings and non-health professionals with extensive contact with the elderly can be similarly trained.

When my beloved father-in-law, at 91, was close to the end of his life, he was hospitalized with congestive heart failure. He became quite “depressed” and actually asked me to help him die. He was ordinarily a remarkably resilient, upbeat person. His cardiologist wanted to start him on antidepressant medication, but neither I, his psychiatrist son-in-law, nor his granddaughter, a distinguished psychologist, thought he was suffering from a depressive illness. We asked another cardiologist to see him, and when his heart medications were tweaked and his shortness of breath improved the “depression” was replaced with appropriate sadness at the approaching the end of his life combined with continued interest in his family and appreciation of the love he received.

Dr. Jeste is on the right track with his campaign for a positive psychiatry of aging!

James Sabin, M.D., 74, is an organizer of Over 65 and a clinical professor of psychiatry at Harvard Medical School.