With the number of older people with mental illness expected to triple over the next 25 years, old age psychiatry faces a daunting challenge as well as a unique opportunity to redefine itself. The prevalent approach to treating psychiatric disorders will not suffice. We need a new positive psychiatry of ageing. This new model would focus, not simply on symptom relief, but on recovery Reference Leamy, Bird, Le, Williams and Slade1 and promotion of successful ageing. It would view old age, not as a period of inevitable biopsychosocial decline, but as one with continued neuroplasticity leading to neuroregeneration. In addition, this new model would not only incorporate principles of prevention for conditions such as depression following open-heart surgery or strokes, but also employ interventions to enhance positive psychological traits including resilience, optimism, social engagement and wisdom. Positive psychiatry has the potential to improve patient (and non-patient) outcomes, reduce healthcare costs and reinvigorate what could become the boom field in psychiatry. We discuss the rationale and the proposed model for positive psychiatry of ageing.
Widening gap between demand and supply
Today there are 550 million people in the world older than 65 years; in 2040, there will be 1.4 billion. 2 In no field will this seismic demographic shift be felt more strongly than in geriatric psychiatry. Reference Burns and McKeith3 We anticipate a notable increase in incidence and prevalence of mental illness in older adults, especially among Baby Boomers, who have a greater acceptance and recognition of psychiatric disorders along with an elevated risk of mood and substance use disorders compared with earlier generations. Yet, while the need for geriatric mental health professionals will grow, we already know their supply is decreasing. The number of US board-certified geriatric psychiatrists has dropped during the past decade. This workforce shortage appears to be due as much to the economics of geriatric healthcare (expensive, yet poorly reimbursed) as to negative attitudes towards ageing and pessimism about the prognosis of psychiatric disorders. Remedial actions are urgently needed to expand the geropsychiatry workforce.
Recovery and successful ageing
Contemporary empirical data paint a brighter picture of the course of psychopathology and disability among older people with serious mental illness than the traditional conceptualisation. Older adults with schizophrenia are more likely to adhere to medication and less likely to misuse substances or have a psychotic relapse than their younger counterparts. A minority of older persons with schizophrenia experience sustained remission or recovery, the predictors of which include social support, early initiation of treatment, better premorbid functioning and having been married. There also are numerous individuals who have had lifelong struggles with mental illness, but led outstanding lives of courage, dignity, and contribution to the society, especially in their later years. Prominent examples include William Carlos Williams, a physician who had several major depressive episodes from age 16 through 75, but wrote Pulitzer Prize-winning poetry after age 50, and John Nash, the Noble Laureate who had schizophrenia but showed remarkable improvement in later life.
There is a growing recognition that medicine should encompass not only treatment of symptoms, but also promotion of well-being. For old age psychiatry, this would mean attention to ‘successful ageing’. Reference Doyle, McKee and Sherriff4 But, what is successful ageing? We found 29 different definitions of successful ageing in 28 published studies on this topic. Reference Depp and Jeste5 The most commonly used definitions include objective criteria for establishing an absence of physical, cognitive and social disability. Reference Rowe and Kahn6 Traditional notions of successful ageing emphasise staying youthful with high-level physical functioning – that is, how much one has not aged. However, a better way to conceptualise successful ageing may be to emphasise desirable traits associated with older age, such as wisdom, which is comprised of insight, compassion, emotional regulation and rational decision-making. Reference Jeste and Harris7 Also, objective criteria ignore subjective aspects of successful ageing. Studies show that a large proportion of older adults with chronic physical illness, who would not meet objective disability-based criteria, perceive themselves as ageing successfully. Reference Strawbridge, Wallhagen and Cohen8 Subjective assessments of successful ageing are meaningful because an individual is best positioned to know the subtleties of the range of relevant factors in her or his own life, to assign weights to these factors with appropriate values in view of personal goals and preferences, and to contextualise those elements within the overall trajectory of past and anticipated future life. Our studies suggest that different domains of ageing – physical, cognitive, and psychosocial functioning – influence self-rated successful ageing, Reference Vahia, Thompson, Depp, Allison and Jeste9 which is the ultimate downstream outcome of importance to the individual.
Neuroplasticity of ageing
In the past two decades, neuroscience research has challenged many long-held concepts about brain development, clearly demonstrating that neuroplasticity, with associated brain growth and development, can continue into old age. These positive outcomes are related less to the genes inherited than to the behaviour, attitude and environment which affect expression of those genes. Although there has been strong emphasis in the scientific literature on the value of calorie restriction and physical activity for enhancing longevity and functioning, scant attention has been paid to the potential role of positive psychological attributes in facilitating successful ageing. Yet, a number of studies have demonstrated that optimism, resilience and social engagement are associated with not only better mental health but also greater longevity in older adults. Empirical research supports a model in which positive psychological traits interact with and feed into each individual's evaluation of the degree of successful ageing, and are a stronger predictor of self-rated successful ageing than physical health is. Reference Strawbridge, Wallhagen and Cohen8,Reference Vahia, Thompson, Depp, Allison and Jeste9 The mechanisms underlying these findings are presently unclear, and uncovering them should be part of a new research agenda.
Positive psychological traits and prevention
Positive psychology has received considerable attention in recent years; Reference Duckworth, Steen and Seligman10 yet, the focus of psychiatry, as a branch of medicine, has been limited primarily to diagnosis and treatment of individuals with severe psychopathology. As medicine begins to appreciate the importance of wellness and positive psychosocial factors in the management and prevention of pathology, positive psychiatry (and especially, positive old age psychiatry) will increasingly take centre stage within medicine and healthcare. Treatment trials have shown beneficial effects of behavioural strategies buttressing resilience, changing attitudes towards ageing, or incorporating meditation on outcome measures such as alcohol consumption, biological response to stress, and mortality rates in older adults.
Is prevention in geriatric psychiatry an oxymoron? Emerging evidence suggests that prevention in later life can be practical and cost-effective. For example, depression following strokes, myocardial infarction and bypass surgery can be treated and even prevented, with a significant reduction in morbidity and mortality. Likewise, interventions aimed at altering partially malleable risk factors such as social isolation, physical disability and sleep problems can prevent or at least delay the onset of depression. Similarly, the risk of older victims of natural disasters, wars or tragic events developing post-traumatic stress disorder can be decreased with counselling.
Proposed role for old age psychiatry
The proposed role of old age psychiatrists would be threefold: as clinicians, as educators and as researchers. As clinicians, they will optimise the use of pharmacotherapy and employ psychotherapeutic/behavioural interventions including cognitive–behavioural therapy, work rehabilitation and intergenerational programmes to enhance everyday functioning in older adults with mental illness. They also would train their non-psychiatrist colleagues in implementing similar interventions in people with or at risk for physical illnesses. As educators, geriatric psychiatrists will seek to combat stereotypes of old age and promote the concept of successful psychosocial ageing for the general population. Reduction in ageism will also help in recruiting more healthcare professionals and trainees into old age psychiatry. As researchers, an exciting area of investigation will be identifying and then seeking to modify biopsychosocial factors or processes underlying positive psychological traits. For example, there has been tantalising research on the gene variations related to resilience and optimism, Reference Charney11 as well as genetic mutations associated with specific variants of frontotemporal dementia characterised clinically by a loss of behavioural characteristics involved in wisdom. Developing biological treatments focusing on such processes may help enhance those positive traits in people with neuropsychiatric disorders. Another critical need in the field today is for psychotropic medications that are efficacious, safe and affordable for older adults with serious mental illness.
If effective interventions to strengthen the positive psychosocial factors were provided to all older psychiatric patients, we could see a significant increase in the number of seriously mentally ill older adults who achieve recovery. Reference Leamy, Bird, Le, Williams and Slade1 Similarly, through well-designed and implemented preventive strategies, positive psychiatry has the potential to improve health outcomes and reduce morbidity as well as mortality.
In summary, positive old age psychiatry can, in the near future, develop into a core component of the overall healthcare system aimed at promoting successful ageing. We should welcome the growing ranks of the ageing population as a golden wave in which older people, including those with mental and physical illness, can be happy and productive, and make important contributions to their own welfare as well as that of younger generations. Admittedly, this will be an ambitious undertaking. However, our goal must be to ensure that successful psychosocial ageing becomes the norm rather than the exception.