To flourish or not: positive mental health and all-cause mortality

Integrating Children's Mental Health into Primary Care

Children's mental health problems are among global health advocates' highest priorities. Nearly three-quarters of adult disorders have their onset or origins during childhood, becoming progressively harder to treat over time. Integrating mental health with primary care and other more widely available health services has the potential to increase treatment access during childhood, but requires re-design of currently-available evidence-based practices to fit the context of primary care and place a greater emphasis on promoting positive mental health. While some of this re-design has yet to be accomplished, several components are currently well-defined and show promise of effectiveness and practicality.

Positive mental health in outpatients with affective disorders: Associations with life satisfaction and general functioning

BACKGROUND

Positive mental health (PMH) is an integral and essential component of health that encompasses emotional, psychological and social well-being. The Keyes' two continua model of mental health and illness posits that mental health status is not merely the absence of mental health problems, and it can be enhanced regardless of a diagnosis of mental illness. The present study hypothesized that mentally ill patients with higher levels of PMH would be associated with better life satisfaction and general functioning.

METHODS

218 outpatients with affective disorders at a tertiary psychiatric hospital were recruited and administered the multidimensional Positive Mental Health instrument, which was validated and developed in Singapore to measure PMH. Depression and anxiety severity were also assessed. Associations of positive mental health with life satisfaction and general functioning were investigated in linear regression models.

RESULTS

PMH scores varied largely within patients with depressive and anxiety disorders but did not differ statistically across the two diagnoses, except for emotional support. PMH was associated with both life satisfaction and general functioning with little evidence of confounding by sociodemographic and clinical status.

LIMITATIONS

The cross-sectional design of the study could not examine causal relationships. Findings may be restrictive to treatment-seeking population with specific affective disorders.

CONCLUSION

Our study provides evidence to support the notion that a good mental health state is not simply the absence of a mental disorder. Mentally ill patients can also have high levels of PMH that possibly have a moderating or mediating effect on the relationship between patients' clinical symptoms and life satisfaction or general functioning.

Loneliness, eudaimonia, and the human conserved transcriptional response to adversity

BACKGROUND

Chronic social adversity activates a conserved transcriptional response to adversity (CTRA) marked by increased expression of pro-inflammatory genes and decreased expression of antiviral- and antibody-related genes. Recent findings suggest that some psychological resilience factors may help buffer CTRA activation, but the relative impact of resilience and adversity factors remains poorly understood. Here we examined the relative strength of CTRA association for the two best-established psychological correlates of CTRA gene expression-the risk factor of perceived social isolation (loneliness) and the resilience factor of eudaimonic well-being (purpose and meaning in life).

METHODS

Peripheral blood samples and validated measures of loneliness and eudaimonic well-being were analyzed in 108 community-dwelling older adults participating in the longitudinal US Health and Retirement Study (56% female, mean age 73). Mixed effect linear model analyses quantified the strength of association between CTRA gene expression and measures of loneliness and eudaimonic well-being in separate and joint analyses.

RESULTS

As in previous studies, separate analyses found CTRA gene expression to be up-regulated in association with loneliness and down-regulated in association with eudaimonic well-being. In joint analyses, effects of loneliness were completely abrogated whereas eudaimonic well-being continued to associate with CTRA down-regulation. Similar eudaimonia-dominant effects were observed for positive and negative affect, optimism and pessimism, and anxiety symptoms. All results were independent of demographic and behavioral health risk factors.

CONCLUSIONS

Eudaimonic well-being may have the potential to compensate for the adverse impact of loneliness on CTRA gene expression. Findings suggest a novel approach to targeting the health risks associated with social isolation by promoting purpose and meaning in life.

Flourishing: American Indian Positive Mental Health

Positive mental health (PMH) is an important construct for understanding the full continuum of mental health. Some socially disadvantaged populations experience a paradoxically high level of PMH despite negative social experiences including discrimination. The purpose of this study is to examine the prevalence and culturally salient correlates of PMH among a cross-sectional sample of 218 American Indian adults living with type 2 diabetes mellitus. Although 17.1 percent of individuals in this sample met Patient Health Questionnaire (PHQ-9) criteria for depression, 51.5 percent were in flourishing PMH. Perceived discrimination was negatively associated with PMH, and participation in traditional cultural activities was positively associated with PMH. Traditional cultural activities did not appear to buffer the impact of discrimination on PMH. This study contributes to strengths-based research with American Indian communities, furthers our understanding of correlates of PMH, and documents comparatively high rates of flourishing mental health in our sample relative to previously published studies with diverse samples.

Purpose in life predicts allostatic load ten years later

OBJECTIVE

Living a purposeful life is associated with better mental and physical health, including longevity. Accumulating evidence shows that these associations might be explained by the association between life purpose and regulation of physiological systems involved in the stress response. The aim of this study was to investigate the prospective associations between life purpose and allostatic load over a 10-year period.

METHODS

Analyses were conducted using data from the Midlife in the United States (MIDUS) survey. Assessment of life purpose, psychological covariates and demographics were obtained at baseline, while biomarkers of allostatic load were assessed at the 10-year follow-up.

RESULTS

We found that greater life purpose predicted lower levels of allostatic load at follow-up, even when controlling for other aspects of psychological well-being potentially associated with allostatic load. Further, life purpose was also a strong predictor of individual differences in self-health locus of control-i.e., beliefs about how much influence individuals can exert on their own health-which, in turn, partially mediated the association between purpose and allostatic load. Although life purpose was also negatively linked to other-health locus of control-i.e., the extent to which individuals believe their health is controlled by others/chance-this association did not mediate the impact of life purpose on allostatic load.

CONCLUSION

The current study provides the first empirical evidence for the long-term physiological correlates of life purpose and supports the hypothesis that self-health locus of control acts as one proximal psychological mechanism through which life purpose may be linked to positive biological outcomes.

Association Between Stressful Life Events and Depression; Intersection of Race and Gender

BACKGROUND

Although stressful life events (SLEs) and depression are associated, we do not know if the intersection of race and gender modifies the magnitude of this link. Using a nationally representative sample of adults in the USA, we tested if the association between SLE and major depressive episode (MDE) depends on the intersection of race and gender.

METHODS

Data came from the National Survey of American Life (NSAL), 2003, a cross-sectional survey that enrolled 5899 adults including 5008 Blacks (African-Americans or Caribbean Blacks), and 891 Non-Hispanic Whites. Logistic regression was used for data analysis. Stressful life events (past 30 days) was the independent variable, 12-month MDE was the dependent variable, and age, educational level, marital status, employment, and region of country were controls.

RESULTS

In the pooled sample, SLE was associated with MDE above and beyond all covariates, without the SLE × race interaction term being significant. Among men, the SLE × race interaction was significant, suggesting a stronger association between SLE and MDE among White men compared to Black men. Such interaction between SLE × race could not be found among women.

CONCLUSIONS

The association between SLE and depression may be stronger for White men than Black men; however, this link does not differ between White and Black women. More research is needed to better understand the mechanism behind race by gender variation in the stress-depression link.

Efficacy of a Multicomponent Positive Psychology Self-Help Intervention: Study Protocol of a Randomized Controlled Trial

Background

Positive psychology interventions have been found to enhance well-being and decrease clinical symptomatology. However, it is still unknown how flourishing can also be increased. Although multicomponent interventions seem to be necessary for this purpose, different formats can be used. A cost-effective approach could be a positive psychology-based self-help book with tailored email support to reach large target groups and to prevent dropout.

Objective

This study will evaluate the efficacy of a comprehensive multicomponent self-help intervention with or without email support on well-being and flourishing, and will seek to determine the working mechanisms underlying the intervention.

Methods

In this 3-armed, parallel, randomized controlled trial, 396 participants with low or moderate levels of well-being and without clinical symptomatology will be randomly assigned to (1) a self-help book condition with weekly email support, (2) a self-help book condition without email support but with a weekly information email, or (3) a waiting list control condition. Online measurements will be assessed at baseline, at post-test (3 months after baseline), and at 6 and 12 months after baseline.

Results

The primary outcomes are well-being and flourishing (ie, high levels of well-being). Secondary outcomes are the well-being components included in the intervention: positive emotion, use of strengths, optimism, self-compassion, resilience, and positive relations. Other measures include depressive and anxiety symptoms, personality traits, direct medical and non-medical costs, life-events, and client satisfaction.

Conclusions

This study will add knowledge to the efficacy and cost-effectiveness of a multicomponent positive psychology intervention. We will also explore who can benefit most from this intervention. If the intervention is found to be effective, our results will be especially relevant for public mental health services, governments, and primary care.

Trial Registration

The Netherlands Trial Register NTR4297; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4297 (Archived by WebCite at http://webcitation.org/6Uwb5SUUM).

Staying Connected: Sustaining Collaborative Care Models with Limited Funding

Providing psychiatric services in the primary care setting is challenging. The multidisciplinary, coordinated approach of collaborative care models (CCMs) addresses these challenges. The purpose of the current article is to discuss the implementation of a CCM at a free medical clinic (FMC) where volunteer staff provide the majority of services. Essential components of CCMs include (a) comprehensive screening and assessment, (b) shared development and communication of care plans among providers and the patient, and (c) care coordination and management. Challenges to implementing and sustaining a CCM at a FMC in Virginia attempting to meet the medical and psychiatric needs of the underserved are addressed. Although the CCM produced favorable outcomes, sustaining the model long-term presented many challenges. Strategies for addressing these challenges are discussed.

Older users' perspectives on the benefits of preventive home visits

In this article we explore older people's perspectives on the benefits of preventive home visits (PHVs), after long-term follow-up. PHVs are health services intended to promote older people's health and independence, prevent disease, and postpone functional decline. We applied an explorative and descriptive design and analyzed qualitative research interviews of 10 PHV users who had received multiple visits for at least 6 years. We sought manifest and latent content in our analysis. The participants reported benefits falling within four main categories: to feel safe, to manage everyday life, to live well, and to be somebody. Two latent themes emerged: living with an underlying, realistic concern about an uncertain future, and striving to maintain oneself as a person. The perceived benefits of PHVs differed significantly from the outcome measures commonly used in randomized, controlled trials. PHV interventions should have a longitudinal approach and support each person's current needs and valued goals.

Psychological well-being and the human conserved transcriptional response to adversity

Research in human social genomics has identified a conserved transcriptional response to adversity (CTRA) characterized by up-regulated expression of pro-inflammatory genes and down-regulated expression of Type I interferon- and antibody-related genes. This report seeks to identify the specific aspects of positive psychological well-being that oppose such effects and predict reduced CTRA gene expression. In a new confirmation study of 122 healthy adults that replicated the approach of a previously reported discovery study, mixed effect linear model analyses identified a significant inverse association between expression of CTRA indicator genes and a summary measure of eudaimonic well-being from the Mental Health Continuum – Short Form. Analyses of a 2- representation of eudaimonia converged in finding correlated psychological and social subdomains of eudaimonic well-being to be the primary carriers of CTRA associations. Hedonic well-being showed no consistent CTRA association independent of eudaimonic well-being, and summary measures integrating hedonic and eudaimonic well-being showed less stable CTRA associations than did focal measures of eudaimonia (psychological and social well-being). Similar results emerged from analyses of pooled discovery and confirmation samples (n = 198). Similar results also emerged from analyses of a second new generalization study of 107 healthy adults that included the more detailed Ryff Scales of Psychological Well-being and found this more robust measure of eudaimonic well-being to also associate with reduced CTRA gene expression. Five of the 6 major sub-domains of psychological well-being predicted reduced CTRA gene expression when analyzed separately, and 3 remained distinctively prognostic in mutually adjusted analyses. All associations were independent of demographic characteristics, health-related confounders, and RNA indicators of leukocyte subset distribution. These results identify specific sub-dimensions of eudaimonic well-being as promising targets for future interventions to mitigate CTRA gene expression, and provide no support for any independent favorable contribution from hedonic well-being.

Changes and interactions of flourishing, mindfulness, sense of coherence, and quality of life in patients of a mind-body medicine outpatient clinic

BACKGROUND

Stress-related, behavioral or chronic diseases require a holistic therapeutic approach. Mind-body medicine (MBM) uses the interaction between mind, body, behavior, and the environment to affect physical and psychological health and function. This integrative strategy can be applied in clinical settings, e.g., in an outpatient clinic, to improve well-being as well as clinical outcomes. We hypothesized an improvement of flourishing, mindfulness, sense of coherence, and quality of life through a comprehensive MBM program. In addition, we hypothesized correlations between the measures themselves as well as between the measures influenced by the intervention.

METHODS

We conducted a longitudinal cohort study in an outpatient clinic setting (n = 48 patients, with various diagnoses). A questionnaire battery, consisting of SF-12, Flourishing Scale (FS, FS-D), Freiburg Mindfulness Inventory (FMI), and Sense of Coherence Scale (SOC9), was used and applied in a pre-to-post format over a period of 18 weeks. The intervention was a 12-week MBM group program, with 1 session of 7 h per week.

RESULTS

The pre-post comparison of the measures showed significant improvements in psychological health, flourishing, mindfulness, and coherence. We were able to verify correlations between the measures themselves, apart from physical health. Coherence correlated with psychological health, influenced by the intervention. Further analyses showed associations between coherence, mindfulness, and flourishing.

CONCLUSIONS

The MBM program improved measures of psychological health and decreased the level of suffering from chronic disease. MBM led to an improvement of disease coping and appraisal of individual ailments, thereby enhancing quality of life. Personal flourishing, coherence, and mindfulness seem to interact with each other.

Material, psychosocial and sociodemographic determinants are associated with positive mental health in Europe: a cross-sectional study

OBJECTIVES

To investigate the association between psychosocial, sociodemographic and material determinants of positive mental health in Europe.

DESIGN

Cross-sectional analysis of survey data.

SETTING

34 European countries.

PARTICIPANTS

Representative Europe-wide sample consisting of 21 066 men and 22 569 women aged 18 years and over, from 34 European countries participating in the third wave of the European Quality of Life Survey (2011-2012).

OUTCOME

Positive mental health as measured by the WHO-5-Mental Well-being Index, while the lowest 25% centile indicated poor positive mental health.

RESULTS

The prevalence of poor positive mental health was 30% in women and 24% in men. Material, as well as psychosocial, and sociodemographic factors were independently associated with poor positive mental health in a Europe-wide sample from 34 European countries. When studying all factors together, the highest OR for poor positive mental health was reported for social exclusion (men: OR=1.73, 95% CI 1.59 to 1.90; women: OR=1.69, 95% CI 1.57 to 1.81) among the psychosocial factors. Among the material factors, material deprivation had the highest impact (men: OR=1.96, 95% CI 1.78 to 2.15; women: OR=1.93, 95% CI 1.79 to 2.08).

CONCLUSIONS

This study gives the first overview on determinants of positive mental health at a European level and could be used as the basis for preventive policies in the field of positive mental health in Europe.

Wellness without fairness: The missing link in psychology

To promote human welfare, psychologists must advance two important goals: wellness and fairness. Hitherto, research on wellness or well-being has discovered connections among overall satisfaction with life and important facets of life, such as relationships, income, and physical health, but the connections among various types of wellness and specific aspects of fairness remain obscure. Research on justice in psychology, in turn, has focused largely on the impact of distributive, procedural, and interactional justice on job performance and not so much on wellness outcomes. I argue that psychologists must explore in depth the association among various types of wellness, such as interpersonal, occupational, physical, and psychological, and diverse kinds of fairness, such as distributive, procedural, interpersonal, cultural, developmental, retributive, and intrapersonal. The pursuit of wellness without fairness will not yield the outcomes individuals and communities need. We must make more explicit the relationship between justice or injustice and flourishing in life.

The Impact of the Unified Protocol for Emotional Disorders on Quality of Life

It has become increasingly clear that mental health is more than just the absence of psychopathology and that there is clinical utility in examining positive aspects of mental health. The present study examined the effects of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders on quality of life in a randomized controlled trial that included individuals with a diverse range of emotional disorders. Results indicated that the Unified Protocol produced significant increases in quality of life when examining both within-individual effect sizes and between-conditions effect sizes compared to a waitlist condition. Furthermore, results indicated that post-treatment levels of quality of life predicted levels of functional impairment independently of diagnostic severity. These results provide further evidence of the importance of examining indicators of mental health in conjunction with markers of psychopathology and provide promising evidence that the Unified Protocol may promote improved mental health in addition to treating psychopathology.