Psychological protective factors across the lifespan: implications for psychiatry

Although there are many challenges in operationally defining and measuring positive psychological constructs, there is accumulating evidence that optimism, resilience, positive attitudes toward aging, and spirituality are related to reduced risk for morbidity and mortality in older age. This article reviews the definition, measurement, associations, and putative mechanisms of selected positive psychological constructs on subjective and objective indicators of health with a focus on the latter half of the lifespan.

Correlates of spirituality in older women

INTRODUCTION

The role of spirituality in the context of mental health and successful aging is not well understood. In a sample of community-dwelling older women enrolled at the San Diego site of the Women's Health Initiative study, we examined the association between spirituality and a range of variables associated with successful cognitive and emotional aging, including optimism, resilience, depression, and health-related quality of life (HRQoL).

METHODS

A detailed cross-sectional survey questionnaire on successful aging was completed by 1973 older women. It included multiple self-reported measures of positive psychological functioning (e.g., resilience and optimism), as well as depression and HRQoL. Spirituality was measured using a five-item self-report scale constructed using two items from the Brief Multidimensional Measure of Religiosity/Spirituality and three items from Hoge's Intrinsic Religious Motivation Scale.

RESULTS

Overall, 40% women reported regular attendance in organized religious practice, and 53% reported engaging in private spiritual practices. Several variables were significantly related to spirituality in bivariate associations; however, using model testing, spirituality was significantly associated only with higher resilience, lower income, lower education, and lower likelihood of being in a marital or committed relationship.

CONCLUSIONS

Our findings point to a role for spirituality in promoting resilience to stressors, possibly to a greater degree in persons with lower income and education level. Future longitudinal studies are needed to confirm these associations.

An analysis of the intended use of atypical antipsychotics in dementia

In this article, the authors explore trends in intended usage of atypical antipsychotics to treat dementia following the United States Food and Drug Administration advisory safety warning issued in April 2005. Analysis suggests that physician-reported intended usage of antipsychotics to treat dementia has declined by nearly 50 percent over the past five years. When reviewing the products intended for use in the treatment of patients with dementia, atypical intended usage has declined considerably while the intended usage of anti-Alzheimer's disease treatments has grown to replace those shares.

Is late-onset schizophrenia a subtype of schizophrenia?

OBJECTIVE

To determine whether late-onset schizophrenia (LOS, onset after age 40) should be considered a distinct subtype of schizophrenia.

METHOD

Participants included 359 normal comparison subjects (NCs) and 854 schizophrenia out-patients age >40 (110 LOS, 744 early-onset schizophrenia or EOS). Assessments included standardized measures of psychopathology, neurocognition, and functioning.

RESULTS

Early-onset schizophrenia and LOS groups differed from NCs on all measures of psychopathology and functioning, and most cognitive tests. Early-onset schizophrenia and LOS groups had similar education, severity of depressive, negative, and deficit symptoms, crystallized knowledge, and auditory working memory, but LOS patients included more women and married individuals, had less severe positive symptoms and general psychopathology, and better processing speed, abstraction, verbal memory, and everyday functioning, and were on lower antipsychotic doses. Most EOS-LOS differences remained significant after adjusting for age, gender, severity of negative or deficit symptoms, and duration of illness.

CONCLUSION

Late-onset schizophrenia should be considered a subtype of schizophrenia.

Successful cognitive and emotional aging

We review the definitions, determinants, and ways of enhancing successful cognitive and emotional aging. Objective definitions of successful aging based on physical health emphasize outcomes including freedom from disability and disease, whereas subjective definitions center on well-being, social connectedness, and adaptation. Most older people do not meet objective criteria for successful aging, while a majority meet the subjective criteria. Older people with severe mental illness are not excluded from successful aging. The determinants of successful aging include complex interactions of lifestyle behaviors and social environment with genes. Depression interferes with nearly all determinants of successful aging. Evidence-based means of enhancing successful aging include calorie restriction, physical exercise, cognitive stimulation, social support, and optimization of stress. Future directions for successful aging research and implications for geriatric psychiatry are discussed.

Exergames for subsyndromal depression in older adults: a pilot study of a novel intervention

OBJECTIVES

Subsyndromal depression (SSD) is several times more common than major depression in older adults and is associated with significant negative health outcomes. Physical activity can improve depression, but adherence is often poor. The authors assessed the feasibility, acceptability, and short-term efficacy and safety of a novel intervention using exergames (entertaining video games that combine game play with exercise) for SSD in older adults.

METHODS

Community-dwelling older adults (N = 19, aged 63-94 years) with SSD participated in a 12-week pilot study (with follow-up at 20-24 weeks) of Nintendo's Wii sports, with three 35-minute sessions a week.

RESULTS

Eight-six percent of enrolled participants completed the 12-week intervention. There was a significant improvement in depressive symptoms, mental health-related quality of life (QoL), and cognitive performance but not physical health-related QoL. There were no major adverse events, and improvement in depression was maintained at follow-up.

CONCLUSIONS

The findings provide preliminary indication of the benefits of exergames in seniors with SSD. Randomized controlled trials of exergames for late-life SSD are warranted.

Subthreshold depression and successful aging in older women

OBJECTIVES

Subthreshold depression (StD) is common in older adults and is associated with poor self-rated health. However, the impact of StD on broader indicators of successful aging, such as positive psychological constructs, cognitive functioning, or quality of well-being, has not been assessed. The authors compared persons with scores above and below a predetermined threshold on the Center for Epidemiological Studies Scale for Depression (CES-D) with nondepressed (ND) persons on measures of multiple domains associated with successful aging.

DESIGN

Cross-sectional survey-based psychological assessments.

PARTICIPANTS

A total of 1,979 community-dwelling older women participating in the Women's Health Initiative study.

MEASUREMENTS

ND was defined as a CES-D score below 8, StD as a score between 8 and 15, and CES-D Depression (CD) as a score of 16 or above. The study questionnaire consisted of multiple self-reported measures of positive psychological functioning (e.g., optimism and resilience), cognitive functioning and complaints, and quality of well-being. The authors also obtained a history of diagnosis, treatment, and hospitalization related to mental health problems.

RESULTS

Overall 20.2% of women met CES-D criteria for StD and 7% for CD. Women with StD had worse self-rated successful aging, worse physical and emotional functioning, lower optimism, more negative attitudes toward aging, lower personal mastery and self-efficacy, and greater anxiety and hostility than ND women but scored better on all these measures than women with CD. Subjects with StD also had higher self-reported rates of previous diagnosis, treatment, and hospitalization for mental health problems than the ND group. Subjects with StD with depressed mood and/or anhedonia were largely similar to those without these symptoms.

CONCLUSIONS

Mild-moderate levels of depressive symptoms that likely fall under a general category of StD were common and were associated with worse functioning on virtually every component of successful aging that the authors examined. StD represents a clinical entity that may affect the longitudinal course of successful aging for large numbers of persons and is a potential target for clinical intervention.

Successful Aging: Focus on Cognitive and Emotional Health

We review the definitions, predictors, and biobehavioral determinants of successful aging, as well as the evidence for and mechanisms of underlying selected interventions to enhance cognitive and emotional health in older adults. Defining successful aging has proven difficult, with discrepancies seen among biomedical, psychological, and lay perspectives. Although consensus is lacking, a number of studies have examined the genetic, lifestyle, and social determinants of operationalized determinants of successful aging; qualitative examinations of the meaning of the construct have also been conducted. The determinants coincide with fundamental aspects of aging. Recent clinical trials suggest that caloric restriction, physical activity, cognitive intervention, stress reduction, and social programs may enhance cognitive and emotional health in older people.

A pilot study to assess attitudes, behaviors, and inter-office communication by psychiatrists and primary care providers in the care of older adults with schizophrenia

INTRODUCTION

There is a lack of assessment tools and empirical data concerning clinician attitudes and behaviors with respect to the health care of older adults with schizophrenia. We develop a survey instrument of physician attitudes, behavior, and inter-office communication, and provide preliminary data on physician-related issues in the provision of health care to this population.

METHODS

A semi-structured 20-item survey instrument was administered to a stratified convenience sample of 24 primary care physicians (PCPs) and 27 psychiatrists working in the New York metropolitan area. Using open ended and multiple choice items, scales, summed scores, and case vignettes, we assessed attitudes, experiences, and procedures in treating medical illnesses in older persons with schizophrenia. All scales had internal consistency reliabilities of >0.70.

RESULTS

There were no differences between PCPs and psychiatrists in reported and anticipated behavior towards older adults with symptoms of schizophrenia, and both groups displayed favorable views. However, both groups had slightly negative stereotypes and attitudes concerning these patients. PCPs reported receiving information from psychiatrists slightly more than 0 to 10 percent of the time.

CONCLUSIONS

Our preliminary findings indicated more favorable attitudes and behaviors by PCPs than had been anticipated based on earlier research with younger patients. The data suggest that the failure of older schizophrenia patients to receive adequate treatment may not be due primarily to clinicians' negative attitudes and behaviors, and that problems with communication may play a more important role.

Adequacy of medical treatment among older persons with schizophrenia

OBJECTIVE

This study used Krause's model of illness behavior in later life to examine factors associated with adequacy of medical treatment in a racially diverse sample of older patients (age 55 and over) with schizophrenia.

METHODS

In a cross-sectional community study, 119 persons were identified from a sample of 198 persons with schizophrenia age 55 or older who developed the disorder before age 45; for comparison, 57 persons were identified from a group of 113 without the disorder. The groups were compared for treatment of one or more of four common medical disorders. Thirteen independent variables were inserted into Krause's model for the comparisons. A dependent variable was created to indicate whether persons received medication treatment for all of their medical disorders (high-treatment group).

RESULTS

Significant differences were found between the schizophrenia and control groups in the proportion receiving treatment for the four physical conditions (.61 versus .83, respectively, p=.004). By logistic regression, four of 13 variables for the schizophrenia group were significantly associated (p<.01) with being in the high-treatment group: absence of depression, lower frequency of medical visits, fewer positive symptoms, and more negative symptoms.

CONCLUSIONS

Although older patients with schizophrenia and their age peers had similar levels of physical disorders and rates of health visits, the former received less adequate treatment. More aggressive management of comorbid depression and positive symptoms of schizophrenia may help in improving the health of this population.

Comparison of the Conceptualization of Wisdom in Ancient Indian Literature with Modern Views

The study of wisdom has recently become a subject of growing scientific interest, although the concept of wisdom is ancient. This article focuses on conceptualization of wisdom in the Bhagavad Gita, arguably the most influential of all ancient Hindu philosophical/religious texts. Our review, using mixed qualitative/quantitative methodology with the help of Textalyser and NVivo software, found the following components to be associated with the concept of wisdom in the Gita: Knowledge of life, Emotional Regulation, Control over Desires, Decisiveness, Love of God, Duty and Work, Self-Contentedness, Compassion/Sacrifice, Insight/Humility, and Yoga (Integration of Personality). A comparison of the conceptualization of wisdom in the Gita with that in modern scientific literature shows several similarities, such as rich knowledge about life, emotional regulation, insight, and a focus on common good (compassion). Apparent differences include an emphasis on control over desires and renunciation of materialistic pleasures. Importantly, the Gita suggests that at least certain components of wisdom can be taught and learned. We believe that the concepts of wisdom in the Gita are relevant to modern psychiatry in helping develop psychotherapeutic interventions that could be more individualistic and more holistic than those commonly practiced today, and they aim at improving personal well-being rather than just psychiatric symptoms.