‘ Happiness-deficit disorder ’ ? Prevention is better than cure

He sighed. Then, in a resolutely cheerful voice, ‘Anyhow,’ he concluded, ‘there’s one thing we can be certain of; whoever he may have been, he was happy when he was alive. Everybody’s happy now.’ ‘Yes, everybody’s happy now,’ echoed Lenina. They had heard the words repeated a hundred and fifty times every night for twelve years. 1 Happiness matters. People value happiness more than material possessions 2 and being happy is associated with greater health, higher earnings and a longer life. 3 In Bhutan, gross national happiness has been a key element in the country’s economic planning since the 1970s. 4-6


Studies on happiness and related factors
In recent decades, systematic study of the social and psychological correlates of individual happiness has shown that happiness is associated with a range of specific circumstances, including a stable family upbringing, being employed, good physical and mental health, personal freedom and personal values, including religious belief. 8appiness is related to income in a more or less linear fashion, but whereas extreme poverty is generally incompatible with happiness, increases in income above US$20 000 per head (adjusted for purchasing power parity) produce minimal incremental happiness. 9e relationship between happiness and age is complex, with some evidence suggesting that it is U-shaped, namely that happiness declines as mid-life approaches but increases in later life. 10This relationship is not entirely clear, however, as the U shape is not apparent in studies which do not use controls. 11Some research identifies a peak in happiness at 65 years 12 and there is significant evidence to suggest that changes in happiness through the life cycle relate to changing preferences and circumstances rather than age per se. 11t is clear, however, that individual happiness is strongly related to the happiness of others: a 20-year follow-up study by Fowler & Christakis 13 demonstrated identifiable clusters of happy and unhappy people within a larger social network and showed that individuals who are surrounded by happy people or are at the centre of happy networks are more likely to become happy in the future.Finally, happiness is associated with genetic inheritance and although this association is both substantial and robust, it is as yet poorly understood. 8

Difficulties with defining happiness
One of the methodological difficulties which recur in studies of happiness is the definition of happiness and the methods used to measure it.Whereas definitions of happiness are likely to vary significantly between individuals and one individual's happiness-related behaviour may be at odds with the happiness of others, recent research has tended to conceptualise happiness as hedonic well-being (which refers to pleasure and joy) as opposed to eudaimonic well-being (which refers to satisfaction and fulfilment). 14,15A balance is, however, needed, as approaches to happiness based solely on 'feeing good' in the short term are unlikely to be consistent with long-term life satisfaction; psychological approaches such as 'acceptance and commitment therapy' may offer useful cognitive techniques for achieving such a balance. 16o address, at least in part, interindividual variation in concepts of happiness, many social surveys do not attempt to reach a shared definition of happiness, but rather rely on participants' own and rate happiness simply on a linear scale.For example, the European Social Survey uses the question 'How happy would you say you are?' (where 0 means 'extremely unhappy' and 10 means 'extremely happy') (www.europeansocialsurvey.org). 17,18gainst this background, there is increasing interest in ways in which human happiness can be increased 3 and, more specifically, ways in which governments can intervene in order to increase happiness among their citizens. 6lthough it would be an exaggeration to suggest that the dystopian vision of Aldous Huxley's Brave New World 1 has come to pass, it is nonetheless timely to evaluate the extent to which evidence supports current interventions aimed at increasing happiness and, in particular, the roles of mental health professionals, individual citizens and governments in the new politics of happiness.

The roles of mental health professionals in enhancing happiness
Psychiatrists and other mental health professionals are in daily contact with people who are unhappy as a result of mental illness and various forms of psychological distress.On this basis, one of the key contributions psychiatrists can make to increasing human happiness is through effective treatment of mental illness.This may involve direct delivery of care, supervision of treating teams, working with managers to improve services, or advocating for mental healthcare that is accessible, acceptable to individuals and reflects the evolving evidence base for various interventions, as well as patient choice.
In relation to depression and anxiety, recent years have seen increased emphasis on the role of psychological therapies in reducing symptomatology, increasing wellness and helping people back to work.These interventions are both therapeutic and cost-effective.Lord Layard points out that a course of psychological treatment for anxiety or depression costs approximately £750 and, as well as reducing the individual's troubling symptoms, greatly increases the possibility of a return to work, resulting in an average increased economic output of £1880 per person within 2 years. 19As a result, this particular form of mental healthcare will reduce the individual's symptoms, pay for itself within 2 years and increase economic output.
Against this background, along with long waiting lists for evidence-based psychological therapies and a need to increase patient choice, the National Health Service (NHS) developed a dedicated Improving Access to Psychological Therapies (IAPT) programme (www.iapt.nhs.uk), which trains 'psychological well-being practitioners' and provides free psychological therapy in accordance with guidelines from the National Institute for Health and Clinical Excellence (NICE) at IAPT centres throughout England.Initiatives such as this are far from simple, however, and there is likely to be a steep learning curve before they are optimally effective -if they prove lastingly effective.Long-term empirical evaluations of programme outcomes are both necessary and eagerly awaited, and should help inform similar policy initiatives elsewhere.It is clearly imperative that such initiatives be matched by proportionate and complementary developments in primary care and secondary mental health services, so as to create a 'joined-up' service that is effective, efficient, even and coherent.

The roles of the individual
Several of the recently identified correlates of happiness are not amenable to purposive change at individual level; these include genetic inheritance and one's own upbringing.Other correlates of individual happiness appear more amenable to change: an awareness of the role of good physical and mental health, for example, may lead to changes in lifestyle and outlook which may increase happiness.An awareness of the importance of happy communities may help the individual to optimise the social circumstances in which their future happiness is to evolve.
Individuals may also benefit from an awareness of the importance of personal values and this may lead to useful psychological or behavioural changes.Such changes are most likely to optimise happiness and satisfaction when they relate to personal (often universal) values (e.g.being a good parent, partner, doctor, scientist) and involve behavioural activation in accord with what matters to the individual (i.e.valued directions), consistent with the approaches of many cognitive-behavioural therapists and psychological well-being practitioners.Such changes may focus on individuals facing issues they are avoiding, accepting a certain amount of suffering and not simply pursuing pleasure (which may be a form of avoidance and create long-term problems).Some of these approaches may also prove to be useful transdiagnostic interventions across mental disorders.

Happiness and income
Increasing individual happiness by addressing financial situations is a more complex matter.Although there is strong evidence associating happiness with increasing income (at least to a certain point), it appears that relative income may be even more important.Solnick & Hemenway 20 demonstrated that a majority of people would choose an annual salary of US$50 000 when other people are receiving US$25 000, compared with US$100 000 when others are receiving US$200 000.At an individual level, then, it is reasonable to advise against comparing one's income with those of others, in the interests of happiness.There is, however, a strong human tendency to compare oneself with others (in terms of attractiveness, wealth, ability) and this may reflect an evolved safety strategy, by which one knows where one stands in relation to others before engaging with them.Addressing this tendency to compare may call for a more sophisticated psychological intervention than simple advice and may require cognitive reframing, reorientation to valued directions and behavioural modification.

The roles of government
Notwithstanding increasing governmental interest in individual happiness, 6 the literature to date provides robust support for just two ways in which governments may increase happiness: deepening democracy and providing effective physical and mental healthcare.

Deepening democracy
Democracy is strongly associated with happiness.Dorn et al 21 found that a one-point increase in a country's Freedom House Index of Democracy score (a seven-point scale) 22 increases the probability that a subsistence income earner in that country is 'very happy' by as much as an increase of the equivalence income by US$7000 per year.Consistent with this, Frey & Stutzer 23,24 reported a significant relationship between individual rights to vote in referendums and life satisfaction: comparing Swiss cantons with the most extensive referendum rights with those with the least extensive rights, the difference in satisfaction levels was equivalent to the difference associated with a doubling of income. 23nglehart et al 25 reported that both democratisation and free choice are significant independent predictors of happiness over time.Free choice alone explains 30% of the change in subjective well-being.Similarly, Schyns 26 reported a significant bi-variable correlation between happiness and cultural freedom and, on multivariable analysis, a significant partial correlation between happiness and cultural freedom in 'rich' countries.
On this basis, there is strong evidence to support the idea that deepening and strengthening democracy may increase happiness.Individuals can also play a role in this process by becoming politically active themselves: Klar & Kasser, 27 in their study of college students in the USA, found that that activism is positively associated with well-being.In an ever-deepening democracy, such individual activism would likely contribute to enhanced political representation and more effective democratic governance; this could potentially create a virtuous cycle of individual activism, democratisation, increasing equality and subsequently increased happiness. 28

Providing effective physical and mental healthcare
Poor physical health is strongly associated with unhappiness and the greater the symptom level, the greater the unhappiness. 29Poor mental health is associated with both anhedonia and reduction in happiness, as well as a range of other distressing psychological symptoms. 8,30These findings suggest that effective healthcare can play an important role in increasing individual happiness.Because government plays a key role in the funding and delivery of healthcare in many countries, providing effective healthcare is a second way in which government may intervene to increase happiness.
There is a certain danger, however, in reframing individual unhappiness as a psychological disorder and potentially creating a new and spurious 'mental illness': happiness-deficit disorder (i.e.unhappiness).This would be regrettable: the rapid expansion of diagnostic categories in recent decades has been a complex, contested matter 31 and the more recent emergence of concepts such as 'naturedeficit disorder' highlights the potency of reframing any specific behaviour or phenomenon as a psychological disorder. 32,33In an era of evidence-based practice, it is imperative that mental healthcare focus on clearly demonstrated, diagnosed disorders, evidence-based interventions, robust assessments of outcome, and patient preference.Adhering to these principles will optimise the contribution mental healthcare can make to the happiness of individuals affected by mental illness, their families, and society as a whole.

Do what you can. Then stop
Happiness research points to several strategies which may increase happiness: . psychiatrists and other mental health professionals may increase happiness by delivering and promoting effective, evidence-based mental healthcare, informed by patient choice .individuals may increase their own happiness by optimising physical and mental health; recognising the importance of personal values and happy communities; and optimising their financial situation, with an awareness that increasing income does not increase happiness infinitely and comparison with others is likely to decrease happiness .government may increase happiness by deepening democracy and providing effective physical and mental healthcare.
Once these measures are understood and implemented, it is important to recognise that guidance on interventions systematically to increase happiness have probably reached the limits of current empirical knowledge.There is, moreover, a paucity of evidence to demonstrate that all of the above interventions will truly increase happiness: demonstrating correlations is certainly an important step, but it is just the first step; the next steps are to design, implement and test specific interventions.
Given the extraordinary enthusiasm that governments increasingly show for happiness research, 6,34,35 there is a danger that governmental interventions aimed at increasing happiness may extrapolate research findings beyond a reasonable point.Although some of the interventions suggested in this paper and elsewhere (e.g.deepening democracy) may have other benefits to justify their costs (e.g.better representation, increasing social capital), interventions with the sole aim of increasing happiness require a much stronger evidence base to justify their implementation for this aim alone.
It is especially important that the emergent political literature on happiness clearly articulate the limits of potential governmental intervention and the strong individual dimension to the pursuit of happiness.Creating optimal general social conditions conducive to happiness would appear to be the most reasonable focus for government policy in this regard: even the United States Declaration of Independence did not articulate a right to happiness itself, but rather, a right to 'the pursuit of EDITORIAL Kelly Happiness-deficit disorder Happiness' -and this is something that government can play an important role in facilitating at societal level.On this basis, there may be certain strategies (e.g.revising educational curricula to include cognitive skills conducive to well-being) which merit government support, provided there is evidence of effectiveness. 36Such initiatives might also be consistent with the current UK government's concept of the 'Big Society', which seems to focus on empowering individuals and communities and reinvigorating civic society. 37,38he manner in which the pursuit of happiness is conducted at individual level is, by contrast, an intensely individual matter and there is little role for government at this level.In addition, some individuals may choose not to seek out happiness in an explicit fashion, preferring simply to engage in such diverse activities as deepening skills, developing passionate interests, pursuing hobbies, building a career, committing to religion, engaging in education, composing poems, admiring flowers, sitting quietly and discovering relationships.These activities may not be undertaken with the express desire to increase happiness, but may, in words commonly attributed to American writer Henry David Thoreau, quietly open the door to greater happiness: 'Happiness is like a butterfly: the more you chase it, the more it will elude you, but if you turn your attention to other things, it will come and sit softly on your shoulder.' 39here is also the matter of human nature to be considered: regardless of social factors such as democratic governance and equality of income, people behave in individual, idiosyncratic and unpredictable fashions, which may, on occasion, appear egocentric, flawed and illogical to others.In addition, countries commonly seen as the most egalitarian and socially ordered (e.g.Scandinavian countries) tend to have the highest suicide rates, 40 despite relatively high ratings for individual happiness; 18 this 'happiness/suicide paradox' merits further study.The recent initiative from the UK Office for National Statistics to consider how best to measure well-being is a useful first step in this direction. 41t the level of the individual, however, government needs to recognise the limits of central intervention in relation to happiness and, at a certain point, in the words of Chinese poet Lao Tzu: 42 Act for the people's benefit.Trust them; leave them alone.