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From depression to flourishing: Emo3onal well-‐being in later life and the ideal of complete mental health.
Guy Potter, PhD Associate Professor Duke University Medical
Bryan Alzheimer’s Disease Research Center
DISCLOSURES
! Research funding
! Na0onal Ins0tute of Mental Health
! Ins0tute for Occupa0onal Safety and Health, Federal Republic of Germany
! Industry rela0onships ! Takeda Pharmaceu0cals, neuropsychologist for clinical trial to delay onset of mild cogni0ve impairment due to Alzheimer’s disease (AD)
Key facts about depression • ~19 million Americans have a depression-‐related disorder
(9.5%) – 9.2 million of these have Major Depression
• 84 billion dollars in annual costs (personal & job produc0vity)
• 9th leading cause of death (suicide alone) • 2nd leading cause of global disease burden by 2020 • Informal care costs in geriatric depression es0mated at
$9 billion, second only to demen0a ($18 billion)
Source: NIMH, World Health Organization, Washington University School of Medicine
What is depression? • DSM-‐V (a.k.a. “core symptoms”; occur most of the day nearly every day)
– Depressed mood (sadness)
– Loss of interest in all or almost all ac0vi0es or pleasure (anhedonia)
What is Depression?
• DSM-‐V (cont.) – Appe0te change or weight loss – Insomnia or hypersomnia – Psychomotor agita0on or retarda0on – Loss of energy or fa0gue – Feelings of worthlessness or excessive guilt – Difficulty with thinking, concentra0on, or decision making
– Recurrent thoughts of death or suicide – Preoccupa0on with soma0c symptoms, health status, or physical limita0ons
What is depression? For Major Depressive Episode (MDE), these symptoms: – Produce social impairment
– Are not related to substance abuse
– Are not related to bereavement
What is Depression? • Minor depression is common
– 15% of older persons – Causes ↑ use of health services, excess disability, poor health outcomes, including ↑ mortality
• Major depression is not common – 1%–2% of physically healthy community dwellers – Elders less likely to recognize or endorse depressed mood
Where depression occurs • Community-‐Dwelling: 1-‐9%
• Primary Care Seangs: 10–12%
• Hospitalized: 11–45%
• Nursing Home: 10-‐26%
Permanent Placement: 43%
Medical Illness and Depression
• Cardiac disease (17-‐27%) • Cerebrovascular disease (14-‐29%) • Alzheimer’s disease (20-‐50%) • Parkinson’s disease (4-‐75%) • Diabetes (26%) • Pain (30-‐54%)
• Vascular medical condi0ons are par0cularly high in geriatric depression (Taylor et al., 2004)
• Depression can be a cause or outcome of medical condi0ons
Evans et al., 2005
Age of first depression onset Early-‐onset • Index episode in childhood or early adult life
• First degree rela0ves with depression
• Less physical illness • More psychiatric comorbidity (SUD; personality disorders)
• Sad mood
Late-‐onset • Index episode aher age 60
• Less gene0c predisposi0on
• Poorer treatment response
• Increased mortality • Abnormal brain imaging • Less psych comorbidity • Apathy and anhedonia
Depression and the brain
• Underac0ve leh frontal
• Overac0ve right frontal
• Overac0ve amygdala (fear circuitry)
• Smaller hippocampus (possibly due to stress)
Vascular depression • Damage to brain structures alter circuits that regulate mood and mo0va0on
• Stroke • Small vessel disease • Risk factors:
– hypertension – bad diet – diabetes – low ac0vity level
Depression in older adults
• Depression is under-‐recognized and undertreated in the older adult
• Untreated depression can delay recovery or worsen the outcome of other medical illnesses via increased morbidity or mortality
• Depression is NOT a part of normal aging
Disengagement Theory Older people and society mutually withdraw from one another as older people approach death (Cummings and Henry, 1961)
! People in late adulthood focus more on their inner lives, preparing for the inevitable.
! Government or industry now supports them through pensions or charity rather than vice versa.
! Family members expect less from them.
! Older people and society prepare to let go of one another.
Consequences and complica3ons of inadequately treated depression
Recurrence, par0al recovery, and chronicity . . .
↑ disability ↑ use of health care resources ↑ morbidity and mortality ↑ suicide (one fourth of
all suicides occur in persons ≥ 65)
Treatment Goals: improve mood, func3on, and quality of life
– Acute Phase (reverse current episode) • Dura0on: about 3 months: Goal is complete recovery from signs and sx of acute episode
– Con0nua0on Phase (prevent a relapse) • Dura0on: 4-‐6 months: Goal is to prevent relapse as sx con0nue to decline and func0onality improves
– Maintenance Phase (prevent future recurrence) • Dura0on: 3 months or longer: Goal is to prevent recurrence of a new depressive episode
Treatment approaches • Pharmacotherapy
• Psychotherapy – medita0on
• Electroconvulsive therapy (ECT) – other brain s0mula0on
• Lifestyle changes – exercise – social support
Treatment: Pharmacotherapy • An0depressants
– SSRI’s • Celexa (citalopram) • Lexapro (escitalopram) • Prozac (fluoxe0ne) • Paxil (paroxe0ne) • Zoloh (sertraline)
– Current first line of drugs – Bemer tolerated than tricyclics – Generally few cogni0ve side effects
Treatment: Psychotherapy • Acceptance-‐Commitment
Therapy (ACT) • Cogni0ve-‐behavioral (CBT) • Interpersonal (IPT) • Short-‐term psychodynamic • Life review, reminisce • Problem-‐solving • Suppor0ve • Bereavement therapy • Behavioral (e.g. ac0va0on) • Marital therapy
Mindfulness • Paying amen0on…to the present moment…inten0onally…and non-‐judgmentally – Effects in lowering stress & improving health
– Mindfulness-‐based cogni0ve therapy (MBCT) effec0ve in relapse reduc0on
Treatment: ECT • For depression with
pronounced psycho0c features and resistance to standard medical therapy
• Effec0ve for treatment of major depression & mania; response rates exceed 70% in older adults
• Unilateral vs. bilateral
• Some cogni0ve side effects
Treatment: Neuros3mula3on • Transcranial magne0c s0mula0on (TMS) – s0mula0on through magne0c field
– non-‐invasive – newer and evolving in sophis0ca0on of targe0ng, but has efficacy for depression
– currently indicated for individuals who fail to respond to medica0on
Treatment: Exercise • Walking or jogging at 70%-‐85% of maximal aerobic intensity is probably as effec0ve as drug therapy for trea0ng mild depression
• medica0ons may act more quickly
• Exercising 3 0mes per week is at least as effec0ve as 5 0mes per week
• Increase in brain volume (hippocampus)
• Increase blood flow
• There may be some effec0veness in strength training and flexibility, but more research needed.
Social support • Meaningful social rela0onships provide a buffer against depression – social network size – social engagement – marriage
– faith community
• Subjec0ve percep0on of social support is important
Challenges of current depression treatments
• Pallia0ve, not cura0ve – relief of symptoms, not causes – may return if treatment discon0nued (medica0on or brain s0mula0on)
• 65% barrier1: an aggregate of medica0on studies suggest 65% of pa0ent report symptom relief (compared to 40-‐50% placebo)
• Side effects 1 amributed to Mar0n Seligman
Complete mental health
1. Absence of mental illness • No disorders: depression, anxiety, bipolar,
substance use, suicidal idea0on
2. Presence of almost daily happiness or life sa0sfac0on in prior month
3. Posi0ve social well-‐being • Suppor0ve rela0onships • Psychological well-‐being
Keyes 2005. “Mental Illness and/or Mental Health…? J. Consult. Clin. Psych.
Self-‐Acceptance
Posi0ve Rela0ons with Others
Environmental Mastery Purpose in Life
Autonomy
Personal Growth
Social Coherence Social Contribu0on
Social Growth
Social Integra0on
Social Acceptance
Posi3ve Func3oning Posi3ve Feeling
Social Well-‐Being Psychological Well-‐Being
Sa0sfac0on
Happiness
Family Tree of Mental Health
Emo0onal Well-‐Being
Interest in Life
I Me We Us
Adapted from C. Keyes
Complete mental health
Moving from a risk reduc0on approach to a competence enhancing approach
Complete mental health
Moving from a risk reduc0on approach to a competence enhancing approach
↓ symptoms
The Two Con0nua Model ©2010 CLM Keyes and the Winnipeg Regional Health Authority
Flourishing
Point Prevalence of Complete Mental Health U.S. Adult Popula3on, ages 35-‐84 in 2005
(MIDUS follow-‐up, n = 1,760)
Associa3on of Prevalence Screen for Depression (PHQ-‐9) by Diagnosed as Flourishing (MHC-‐SF)
at n=13 Par3cipa3ng Universi3es in 2007 Healthy Minds Study
Pearson r = -‐ .50 p < .05 (one-‐tailed)
Factors to flourish aeer depression
• Being married
• Having a confidant • Having no disabling pain • Quality sleep marked by a lack of insomnia
• No childhood adversity • No history of substance abuse • Regular exercise • Using spirituality to cope with stress
Fuller-‐Thompson et al., Psychiatry Research 242 (2015)
Flourishing model (Huppert & So)
Core features • Posi0ve emo0ons
• Engagement • Meaning & purpose
Addi3onal features • Self-‐esteem
• Op0mism • Resilience • Vitality • Self-‐determina0on • Posi0ve rela0onships
PERMA model of well-‐being • P -‐ Posi0ve Emo0on • E -‐ Engagement
• R -‐ Rela0onships • M -‐ Meaning
• A -‐ Accomplishments
Posi3ve psychology
• Posi3ve Psychology is the scien0fic study of the strengths that enable individuals and communi0es to thrive.
• Founded on the belief that people want to lead meaningful and fulfilling lives, to cul0vate what is best within themselves, and to enhance their experiences of love, work, and play
Adapted from Posi0ve Psychology Center website: pss.sas.upenn.edu
Posi3ve psychology exercises
Gra3tude leger/visit: • Write a lemer of gra0tude to someone who has had a posi0ve impact on you. If feasible, you might consider delivering the lemer to the person. Encouraged to read the lemer to the individual
Posi3ve psychology exercises
What-‐Went-‐Well Exercise (aka Three Good Things, Three Blessings):
• Write down three things that went well for you each day.
• Include an explana0on for why these good things occurred.
• Do this exercise for 1 month
Seligman et al. (2005) Am Psychol. 60(5):410-‐21. Posi3ve psychology progress: empirical valida3on of interven3ons
Posi3ve psychology exercises Gie of 3me: • Offer the “gih” of your 0me to three different people this week. – helping someone around their house – sharing a meal with someone who is lonely.
• These “gihs” should be in addi0on to your planned ac0vi0es.
Posi3vity ra3o • Posi3ve comments toward others should outnumber nega3ve comments – Separates flourishing from languishing individuals (Frederickson, American Psychologist, 2013)
– Also consistent with literature on successful marriages (John Gomman)
– Although the claim to a specific mathema0cal ra0o (2.9) has been disproven, evidence s0ll supports the general principal of “more is bemer, to a point”
Aging gracefully emo3onally " Be part of a social organiza0on
" Spend 0me with other people every day " Maintain ra0o of three pleasant ac0vi0es to one nega0ve ac0vity
" Adapt, or adopt a new ac0vity, if enjoyable ac0vity can no longer be performed at same level
" Seek help for depressive symptoms " Enhance the role of spirituality in your life
Gary Small The Memory Bible
How do I know if I’m flourishing?
hmps://www.authen0chappiness.sas.upenn.edu
(or type Authen0c Happiness into ) )
Click Ques0onnaire Center link
