Positive Psychiatry: An Interview With Dilip V. Jeste, MD

[[{"type":"media","view_mode":"media_crop","fid":"46030","attributes":{"alt":"©2013 AMERICAN PSYCHIATRIC ASSOCIATION TV","class":"media-image media-image-right","id":"media_crop_5790356502342","media_crop_h":"347","media_crop_image_style":"-1","media_crop_instance":"5307","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"167","media_crop_w":"289","media_crop_x":"1","media_crop_y":"3","style":"float: right;","title":"©2013 AMERICAN PSYCHIATRIC ASSOCIATION TV","typeof":"foaf:Image"}}]]Past President (2013-2014) of the American Psychiatric Association, Dr Jeste is Senior Associate Dean for Healthy Aging, Distinguished Professor of Psychiatry and Neurosciences, and Director of the Sam and Rose Stein Institute for Research in Aging at the University of California in San Diego. Renato Alarcón, an Editorial Board member of Psychiatric Times, recently interviewed Dr Jeste. The focus of their talk was positive psychiatry-an emerging field in psychiatry that Dr Jeste has explored in a recently published book.¹

How would you define positive psychiatry?

Traditionally, psychiatry has been defined as a branch of medicine that focuses on the study and treatment of mental illness. The goals of clinical psychiatry are usually restricted to symptom reduction and relapse prevention. Yet, there is a growing recognition that medicine should encompass not only treatment of symptoms, but also promotion of well-being.

Positive psychiatry is the science and practice of psychiatry that seeks to understand and enhance well-being through assessments and interventions involving positive psychosocial characteristics in people with mental or physical illnesses. As a branch of medicine, positive psychiatry is rooted in biology and seeks to decipher underlying biological underpinnings of those characteristics while enhancing health and well-being through psychosocial/behavioral and biological interventions. It is not restricted to mental illness, but applicable to all of medicine. It thus provides an opportunity to take psychiatry to the front and center of the health care system.

Could you give us a brief historical outline of this new approach in psychiatry?

The concepts of positive psychiatry date back at least to 1906 when William James, a physician and psychologist, recommended a new approach to study and apply psychological principles underlying the success of the “mind-cure,” based on positive emotions and beliefs. These views were mostly ignored until the Humanistic Psychology movement of Abraham Maslow and his colleagues in the mid-20th century, which focused on studying healthy, creative individuals. Martin Seligman and his colleagues pioneered the remarkably influential positive psychology movement in the late 1990s. It called for reorienting science toward understanding and building positive individual qualities such as optimism, courage, and interpersonal skills. Positive psychology and positive psychiatry are not competitors, but allies; they partially overlap in some concepts and goals, but each brings its unique insights and skills, which are all strengths and positive constructs as well as lifestyle factors.

What have been your experiences in articulating the main theoretical and practical principles of positive psychiatry?

I have been studying schizophrenia in older people for many years. Some of my colleagues thought this topic was a career buster, as it combined 2 conditions with inevitable and progressive declines-aging and schizophrenia. Yet, my group found that, with aging, a number of older patients with chronic schizophrenia experienced significant improvement in their psychopathology and seemed to be happier despite physical illnesses.^2,3 This was “wellness within illness.”

In a separate study of a randomly selected sample of hundreds of adults across the later life span, we observed that aging was associated with physical decline but improvement in subjective well-being, happiness, and life satisfaction.⁴

In these studies, the improvement in mental health was associated with resilience, optimism, absence of depressive symptoms, and low level of perceived stress. These findings demonstrated the relevance of positive psychological traits. Over the years I have also been continually impressed with the positive effects of behavioral/psychosocial interventions. Brain imaging and other biomarker studies have shown that such interventions affect function and brain structure in later life. Therefore, I came to the conclusion that our field needed a major shift in its thinking and practice.

How does positive psychiatry apply to everyday clinical practice?

Positive psychosocial characteristics such as resilience, optimism, and social engagement have been associated with better health outcomes, yet they have rarely been addressed. An assessment of these characteristics and use of interventions to enhance them in patients should become a part of routine clinical practice and training programs. Positive psychiatry is meant to be an addition to (and not a replacement for) current psychiatric practice, as it gives the clinician a number of new avenues of intervention. For example, practicing optimism or kindness and using character strengths improve depressive symptoms and also enhance well-being. Yoga and mindfulness can reduce stress and inflammation and thus improve immune function and health. All patients must be encouraged to practice a number of well-known but not systematically used lifestyle interventions, such as exercise, meditative practices, healthy diet, and good sleep hygiene. Such interventions can decrease depression, anxiety, obesity, and other conditions. Similarly, positive parenting techniques and involvement in sports or the arts can alleviate oppositional and other conflictive behaviors in children and adolescents.

How do DSM-5 or ICD-10 criteria come into play with positive psychiatry-is a different diagnostic perspective and categorical or dimensional approach needed?

Currently, there is no substitute for using DSM-5 and ICD-10 diagnoses that are required by Medicare and private health insurers and also for communication with various other health care systems. The positive psychiatry approach involves additional notations about the patient’s level of well-being and perceived stress along with strengths, including resilience, optimism, and social engagement. Validated rating scales for these measures are available and practical. This more complete depiction of a patient’s mental health is of much greater value for holistic management than just a DSM-5 diagnosis. The information obtained from these ratings may be shared with the patient and his or her family, and revisited during subsequent visits to document progress.

What about treatment-does positive psychiatry entail a reformulation of psychotherapies?

Positive psychiatry’s principles can be incorporated in a reformulation of behavioral or psychosocial interventions, whether they are supportive, psychodynamic, cognitive-behavioral, or another type. The goal is to enhance positive psychosocial characteristics to improve well-being, in addition to reducing symptoms and preventing relapse-which are at the core of traditional psychiatry.

There are, however, a few limitations to positive psychiatry-such as the potential social/political and ethical implications of the unbridled promotion of positive psychosocial characteristics. For example, one may appropriately object to the notion that optimism should be universally promoted through biological or other interventions. Therefore, a balanced approach to behavior modification is warranted.

What are the main similarities and differences between positive psychiatry and preventive psychiatry or preventive medicine?

Secondary and tertiary preventions are a part of traditional psychiatry and medicine. Primary prevention overlaps considerably with positive psychiatry. Prevention has a long history in community psychiatry. Such efforts have focused mainly on youth (eg, certain conduct or behavioral disorders, stress- or trauma-related disorders) but have recently expanded to young, middle-aged, and even older adults in areas such as prevention of postpartum psychosis, post–myocardial infarction depression, post-stroke depression, PTSD and, to a lesser extent, some types of dementia.

Modifications of unhealthy lifestyle behaviors with physical exercise, proper nutrition, activity participation, and regular health screenings and vaccinations are among the most powerful and modifiable predictors of health throughout the lifespan. In addition to the positive effects of healthy behaviors on the cardiovascular system, improvements in brain structure and functioning can also be attained.

Resilience is being discussed more frequently nowadays. Is the main therapeutic objective of positive psychiatry to strengthen resilience?

Seeking to enhance a person’s resilience is important, but it’s not the sole objective of positive psychiatry. Resilience is associated with better health outcomes, including a lower risk of all-cause mortality and longer life. Among physically ill patients, resilience is associated with better physical and emotional health and well-being, less pain, improved health-related quality of life, self-care, and treatment and exercise adherence.

There is an urgent need for research on how resilience can be increased with therapy in different groups of patients, and what the mediators and moderators of such improvement are. To enable a better understanding of mind-body interactions, valid measures of both psychological (eg, levels of resilience and well-being using standardized rating scales) and biological (eg, oxidative stress) markers are warranted. It may be possible to use neurobiological approaches to enhance resilience in the context of anxiety and mood disorders. With the increased understanding of the neural circuitry underlying resilience, new interventions may also be developed-individuals might be trained to modulate their own brain activity with the help of real-time functional MRI–based neurofeedback.

What can be done to make positive psychiatry part of the curriculum in medical training?

For the principles of positive psychiatry to take hold, they should be explicitly taught and modeled within each step of the medical education process. Positive psychiatry needs to be an integral component of the didactic and clinical learning experiences of students and trainees. In addition to new didactic courses, concerted effort is needed to weave these principles into existing rotations and to reinforce them during supervision.

The Accreditation Council of Graduate Medical Education recently delineated specific “milestones” to be achieved and assessed for all psychiatry residents across a number of competencies. Positive psychiatry principles were not specifically described, but because several of the milestones are broad, resident training and evaluation could logically include these principles. The milestones for child psychiatry are currently in development and will hopefully include more specific language with regard to positive psychiatry and wellness. Similar considerations would also apply to the training of non-physician professionals involved in mental health care.

To what extent can positive psychiatry contribute to better management of psychiatric and medical conditions?

Positive interventions may complement medication or psychotherapy in patients with partial response and help prevent relapse. They are convenient and cost-effective, and there is considerably less stigma associated with them. Research on interventions aimed at promoting positive psychosocial characteristics is in its early stages but seems highly promising. Treatment trials have shown behavioral strategies can buttress resilience and change attitudes toward aging; for example, meditation can reduce alcohol consumption, biological manifestations of stress, and mortality rates in older adults. Psychosocial or behavioral interventions are numerous and diverse and can include writing gratitude letters, practicing optimistic thinking or acts of kindness, and applying mindfulness and forgiveness therapy. Cognitive behavioral therapy enhances optimism and facilitates reappraisal of traumatic events in a more positive light. In turn, optimism may increase adherence to pharmacotherapy in formerly pessimistic individuals.

How can public policies contribute to achieving the goals of positive psychiatry?

The health care system is changing rapidly, and health care funding will need to shift from resource-intensive treatment to illness prevention and integration of positive psychiatry into medical practice. Policies specific to promoting the goals of positive psychiatry include making self-reported well-being (including personal strengths) a primary outcome measure; mandating reporting of lifestyle factors (physical and cognitive activities, diet, sleep, socialization, smoking, alcohol use); and charting the use of preventive measures, including vaccination and regular health screening.

What are the main research areas in the field of positive psychiatry?

Empirical psychiatric and neuroscience research in positive psychiatry is a recent phenomenon. There is tremendous potential for further progress. The first step should be better operationalization and standardized, validated assessment of positive psychosocial outcomes as well as characteristics, using measures with good psychometric properties. It would be helpful to develop a Strength Index for an individual, based on his or her positive psychosocial characteristics, which could be considered alongside commonly used risk indices, such as the Framingham Index for cardiovascular risk or scales for assessing suicide risk. This could include some of the items from the Character Strengths Inventory.

The potential for biological treatments in positive psychiatry needs further research. Biological interventions may be developed on the basis of improved understanding of neuroplasticity as well as gene variations related to positive traits. In addition, findings from animal and human studies might eventually yield new pharmacological agents that can maximize the adaptive function of the hypothalamic-pituitary-adrenal axis as well as monoamine, neuropeptide, and other neurochemical stress-response systems.

There is a dearth of cultural research in this arena. We know that different cultures vary in their attitudes toward aging, conceptualization of mental illness, the role of spirituality, etc. The impact of these differences on positive outcome measures and positive psychosocial characteristics deserves serious study. Empirical investigations in this area would be valuable in understanding the differences in well-being and even longevity across countries and continents.

How do you see the future of positive psychiatry?

I see a bright future. Clinicians will evaluate not just the symptoms and diagnoses but also the levels of well-being and positive psychosocial characteristics among their patients, and they will employ psychotherapeutic/behavioral (and more biological) interventions to enhance those traits. They will focus on positive outcomes such as improved well-being and recovery. They will also train their counterparts outside mental health to implement similar interventions in people suffering from or at high risk for physical illnesses.

A greater emphasis on positive outcomes, attributes, and strengths will reduce the stigma of mental illness, which would help in recruiting more health care professionals and trainees into psychiatry. Thus, instead of being narrowly defined as a medical subspecialty restricted to medical management of mental illnesses, the psychiatry of the future will develop into a core component of the overall health care system.

Clearly, much more work is needed to make positive psychiatry a norm in psychiatric practice. However, its recent growth is quite promising for the feasibility and viability of its concepts and aspirations. Success will depend on the outcome of empirical research and on a combined effort and commitment from researchers, clinicians, and funding agencies, as well as public support.

Disclosures:

Dr Alarcón is Emeritus Professor and Consultant in the department of psychiatry and psychology at Mayo Clinic College of Medicine in Rochester, Minnesota, and an Editorial Board member of Psychiatric Times. He reports no conflicts of interest concerning this article.

References:

1. Jeste DV, Palmer BW, eds. Positive Psychiatry. Arlington, VA: American Psychiatric Publishing; 2015.

2. Jeste DV, Twamley EW, Eyler Zorrilla LT, et al. Aging and outcome in schizophrenia. Acta Psychiatr Scand. 2003;107:336-343.

3. Palmer BW, Martin AS, Depp CA, et al. Wellness within illness: happiness in schizophrenia. Schizophr Res. 2014;159:151-156.

4. Jeste DV, Savla GN, Thompson WK, et al. Association between older age and more successful aging: critical role of resilience and depression. Am J Psychiatry. 2013;170:188-196.