Positive psychiatry comes of age

Positive psychiatry is the science and practice of psychiatry that focuses on psycho-bio-social study and promotion of well-being and health through enhancement of positive psychosocial factors (such as resilience, optimism, wisdom, and social support) in people with illnesses or disabilities as well as the in community at large (Jeste and Palmer, 2015). It is based on the principles that there is no health without mental health and that mental health can be improved through preventive, therapeutic, and rehabilitative interventions to augment positive psychosocial factors. Positive psychiatry is not a naïve, feel-good pseudoscience that views the world through rose-colored glasses. It is an evidence-based approach to understanding normal behavior as well as psychopathology and to improving well-being by measuring and enhancing positive psychosocial factors (Jeste et al., 2015).

Today most of the articles in most of the geriatric psychiatry journals are focused on neuropsychiatric disorders and disabilities in later life. This is not surprising as these conditions are indeed associated with clinically significant functional impairments and are a major cause of adverse mental, physical, social, and financial outcomes for the patients and their families. Research on and treatment of these maladies should, therefore, be a priority for our field. However, a near exclusive focus on disorders is not just unhelpful but also counter-productive for psychiatry in general and geriatric psychiatry in particular.

With rapidly growing numbers of older people across the globe, healthcare systems that are dependent on individual-level treatment of diseases are painfully inefficient and unsustainable. There is now a growing consensus that prevention is the key to revolutionizing healthcare. This has led to a discussion about promoting healthy lifestyle, such as physical activity, calorie restriction, and stopping smoking and substance use. Changing the lifestyle involves changing a person's behavior. Who are the experts in interventions to modify behavior? The answer is mental health practitioners. We treat the most serious behavior problems such as delusions, hallucinations, and suicidal behaviors. We have at least reasonable knowhow about biological and psychotherapeutic tools for helping modify unhealthy behaviors.

As important as healthy lifestyle but rarely attended to in the arena of preventive healthcare is the role of positive personality traits such as resilience, optimism, compassion, self-efficacy, and wisdom as well as social and environmental support. There is strong empirical evidence for the association of these positive factors with better mental and physical health, cognitive function, and even longevity. Who are the experts in assessing and enhancing these positive psychosocial factors? Once again, it is mental health experts. Thus, positive psychiatry should be at the center of the new healthcare system.

This issue of International Psychogeriatrics is the first ever issue of our journal with the theme of positive psychiatry. The current issue contains three data-based research articles (Bailly et al., 2018; Ihle et al., 2018; Montross-Thomas et al., 2018) from France, USA, and Switzerland, respectively. These papers report stability of spirituality in older adults followed over a five-year period (Bailly et al., 2018), response of hospice patients to the diagnosis of terminal illness by cultivating wisdom through a balance between active acceptance of the current situation and continued push for a galvanized growth (Montross-Thomas et al., 2018), and significant contributions of close friends and leisure activity engagement to better cognitive performance in old age (Ihle et al., 2018). There are accompanying commentaries (Baiyewu, 2018; Forlenza and Vallada, 2018; Pachana and Mitchell, 2018) from Nigeria, Brazil, and Australia, respectively, which discuss both limitations and implications of those studies.

In the future, as we continue publishing many papers on neuropsychiatric diseases of aging, we will also include, from time to time, articles on topics related to positive psychiatry. We hope to have papers and commentaries from different parts of the world with articles on various positive topics including successful aging, mind-body interventions, and age-friendly communities, among others. I welcome input from our readers.

Thanks to pioneers like Seligman (Seligman and Csikszentmihalyi, 2000), positive psychology is now well accepted even by lay public. Yet, there are few papers on positive constructs such as optimism, resilience, and wisdom in psychiatric journals and few chapters on these topics in psychiatric textbooks. The goal of positive psychiatry is to enrich psychiatric literature and practice by incorporating positive psychosocial factors in the study and treatment of people with and without mental illnesses. Moreover, being a branch of medicine, positive psychiatry will emphasize health as well as biology along with psychology, sociology, and (in the case of psychogeriatrics) gerontology.

Positive psychiatry is not a geographically localized phenomenon but a global movement. There is now a formal section on Positive Psychiatry in the World Psychiatric Association and a Caucus on Positive Psychiatry in the American Psychiatric Association. Other national organizations are beginning to get involved too. During the last few years, a number of symposia in this area have been presented at different national and international conferences. At least two books have been published (Jeste and Palmer, 2015; Summers and Jeste, 2018) and several others are in the works.

In terms of measurements, we already have access to a number of reliable and validated self-report inventories for various positive factors (Eglit et al., 2018). Self-report measures have been criticized for having both conscious (e.g. deliberate deception) and unconscious (e.g. impression management) biases in human introspection and subsequent reporting. However, research has shown a significant association between subjective and objective measures of constructs such as well-being. Self-report inventories for internal states such as happiness and subjective recovery are inherently tied to an individual's introspective feelings rather than to an external biological proxy, at least at the present time. For example, most of us will agree that the best way to determine individuals’ level of happiness is by asking them about their current inner experiences and feelings rather by measuring cerebrospinal fluid levels of catecholamines (although these may correlate with subjective happiness).

Positive psychiatry applies even more importantly to people with serious mental illnesses such as schizophrenia and major depression, serious physical illnesses such as cancer and HIV-AIDS, and serious cognitive disorders including dementias or major neurocognitive disorders (Palmer et al., 2014; Cohen et al., 2017; Sharma et al., 2017; Moore et al., 2018). In one study, Mohr and colleagues (2011) measured religiosity and spirituality in 115 outpatients with schizophrenia and related disorders, using semi-structured clinical interviews, and then followed the cohort for three years. The investigators found that participants who engaged in healthy religious coping strategies and who valued spirituality experienced less severe negative symptoms and better interpersonal functioning and quality of life than other patients.

In addition to their effects on emotional and cognitive health, positive psychosocial factors are closely related to physical health and specific biomarkers of health as well (Edmonds et al., 2018). Empirical evidence supports links between biomarkers and measures of positive psychiatry, including allostatic load, telomere length, inflammation, and genes (Schutte et al., 2016; Wiley et al., 2017), although such research in people with serious mental illnesses has so far been sparse. One study reported that self-efficacy moderated the relationship between subjective stress and interleukin-6 levels among dementia caregivers (Mausbach et al., 2007). In a two-year randomized controlled trial in adults with chronic schizophrenia, Eack et al. (2010) showed that, compared to a control group, a multimodal intervention approach – cognitive enhancement therapy – not only improved cognitive performance but also seemed to protect against gray matter loss on MRI.

Chronological aging is associated with increases in both physical and cognitive impairments. However, a large number of older adults report “successful aging” (Jeste et al., 2013). This concept was originally defined as absence of significant disease burden, but – consistent with the positive psychiatry movement – more recent data suggest that successful aging does not require absence of illness, but rather the overall positive psychological outlook of the individual. There is a frequently observed paradox of aging – as physical health declines, mental well-being improves. The importance of emotional health in aging is illustrated by the “positivity effect” – i.e., a tendency for older adults to experience a higher ratio of positive to negative emotions relative to younger adults (Mather and Carstensen, 2005). While there is considerable research on the so-called longevity genes, positive personality traits including resilience, optimism, and wisdom may also be of relevance for exceptional longevity (Scelzo et al., 2018).

There is also a wealth of neurobiological data showing that, contrary to traditional beliefs, neuroplasticity continues into old age (albeit to a lesser degree than in youth), enabling new learning and adaptation in the context of appropriate environmental stimulation. Mechanisms underlying brain plasticity in older adults include neural compensation for age-related decline through recruitment of additional brain circuits in the performance of tasks, increased dendritic arborization, synaptic proliferation, greater vascularity, and formation of new neurons in specific regions – e.g., hippocampal dendate gyrus (Gage, 2002).

There is an urgent need for promoting research in positive psychiatry. Likewise, on the clinical side, while clinicians will generally need to ask standard questions about symptoms and functional impairments, it is imperative that they also undertake a deliberate assessment of positive psychosocial factors. To translate the experimental results to a clinical setting will require development of a training and administrative infrastructure to support such assessments and interventions in positive psychiatry.

An important caveat to the theory and practice of positive psychiatry is the realization that the relationship between positive factors and overall functioning/well-being may exist in an inverted U shape. Enhancing these characteristics leads to functional improvements up to a certain point, beyond which increases can have adverse consequences. For example, excessive optimism can precipitate risky medical and health-related choices, ultimately leading to negative outcomes. Similarly, extreme happiness may be associated with a lack of attention to prophylactic healthful behaviors, leading to increased morbidity and even mortality. Excess of certain positive factors is intuitively related to the symptom profiles of psychiatric disorders such as bipolar disorder and narcissistic personality disorder. However, most individuals with serious mental illnesses are far more likely to have lower rather than higher levels of positive factors including optimism, resilience, happiness, personal mastery, coping self-efficacy, and social engagement, compared to people without these disorders (Palmer et al., 2014). Consequently, enhancing these traits is likely to improve well-being in a sizable proportion of people with psychiatric disorders.

The future of positive psychiatry is bright and we should look forward to its continued development and integration into the discipline of general psychiatry more broadly. This will be especially critical for geriatric psychiatry. International Psychogeriatrics will provide an excellent forum for publishing critically reviewed articles on positive psychiatry of aging to complement those on mental illnesses in older people.