Past President (2013-2014) of the American Psychiatric Association, Dr Jeste is Senior Associate Dean for Healthy Aging, Distinguished Professor of Psychiatry and Neurosciences, and Director of the Sam and Rose Stein Institute for Research in Aging at the University of California in San Diego. Renato Alarcón, an Editorial Board member of Psychiatric Times, recently interviewed Dr Jeste. The focus of their talk was positive psychiatry—an emerging field in psychiatry that Dr Jeste has explored in a recently published book.1
How would you define positive psychiatry?
Traditionally, psychiatry has been defined as a branch of medicine that focuses on the study and treatment of mental illness. The goals of clinical psychiatry are usually restricted to symptom reduction and relapse prevention. Yet, there is a growing recognition that medicine should encompass not only treatment of symptoms, but also promotion of well-being.
Positive psychiatry is the science and practice of psychiatry that seeks to understand and enhance well-being through assessments and interventions involving positive psychosocial characteristics in people with mental or physical illnesses. As a branch of medicine, positive psychiatry is rooted in biology and seeks to decipher underlying biological underpinnings of those characteristics while enhancing health and well-being through psychosocial/behavioral and biological interventions. It is not restricted to mental illness, but applicable to all of medicine. It thus provides an opportunity to take psychiatry to the front and center of the health care system.
Could you give us a brief historical outline of this new approach in psychiatry?
The concepts of positive psychiatry date back at least to 1906 when William James, a physician and psychologist, recommended a new approach to study and apply psychological principles underlying the success of the “mind-cure,” based on positive emotions and beliefs. These views were mostly ignored until the Humanistic Psychology movement of Abraham Maslow and his colleagues in the mid-20th century, which focused on studying healthy, creative individuals. Martin Seligman and his colleagues pioneered the remarkably influential positive psychology movement in the late 1990s. It called for reorienting science toward understanding and building positive individual qualities such as optimism, courage, and interpersonal skills. Positive psychology and positive psychiatry are not competitors, but allies; they partially overlap in some concepts and goals, but each brings its unique insights and skills, which are all strengths and positive constructs as well as lifestyle factors.
What have been your experiences in articulating the main theoretical and practical principles of positive psychiatry?
I have been studying schizophrenia in older people for many years. Some of my colleagues thought this topic was a career buster, as it combined 2 conditions with inevitable and progressive declines—aging and schizophrenia. Yet, my group found that, with aging, a number of older patients with chronic schizophrenia experienced significant improvement in their psychopathology and seemed to be happier despite physical illnesses.2,3 This was “wellness within illness.”
In a separate study of a randomly selected sample of hundreds of adults across the later life span, we observed that aging was associated with physical decline but improvement in subjective well-being, happiness, and life satisfaction.4
In these studies, the improvement in mental health was associated with resilience, optimism, absence of depressive symptoms, and low level of perceived stress. These findings demonstrated the relevance of positive psychological traits. Over the years I have also been continually impressed with the positive effects of behavioral/psychosocial interventions. Brain imaging and other biomarker studies have shown that such interventions affect function and brain structure in later life. Therefore, I came to the conclusion that our field needed a major shift in its thinking and practice.
How does positive psychiatry apply to everyday clinical practice?
Positive psychosocial characteristics such as resilience, optimism, and social engagement have been associated with better health outcomes, yet they have rarely been addressed. An assessment of these characteristics and use of interventions to enhance them in patients should become a part of routine clinical practice and training programs. Positive psychiatry is meant to be an addition to (and not a replacement for) current psychiatric practice, as it gives the clinician a number of new avenues of intervention. For example, practicing optimism or kindness and using character strengths improve depressive symptoms and also enhance well-being. Yoga and mindfulness can reduce stress and inflammation and thus improve immune function and health. All patients must be encouraged to practice a number of well-known but not systematically used lifestyle interventions, such as exercise, meditative practices, healthy diet, and good sleep hygiene. Such interventions can decrease depression, anxiety, obesity, and other conditions. Similarly, positive parenting techniques and involvement in sports or the arts can alleviate oppositional and other conflictive behaviors in children and adolescents.
How do DSM-5 or ICD-10 criteria come into play with positive psychiatry—is a different diagnostic perspective and categorical or dimensional approach needed?
Currently, there is no substitute for using DSM-5 and ICD-10 diagnoses that are required by Medicare and private health insurers and also for communication with various other health care systems. The positive psychiatry approach involves additional notations about the patient’s level of well-being and perceived stress along with strengths, including resilience, optimism, and social engagement. Validated rating scales for these measures are available and practical. This more complete depiction of a patient’s mental health is of much greater value for holistic management than just a DSM-5 diagnosis. The information obtained from these ratings may be shared with the patient and his or her family, and revisited during subsequent visits to document progress.
What about treatment—does positive psychiatry entail a reformulation of psychotherapies?
Positive psychiatry’s principles can be incorporated in a reformulation of behavioral or psychosocial interventions, whether they are supportive, psychodynamic, cognitive-behavioral, or another type. The goal is to enhance positive psychosocial characteristics to improve well-being, in addition to reducing symptoms and preventing relapse—which are at the core of traditional psychiatry.
Dr Alarcón is Emeritus Professor and Consultant in the department of psychiatry and psychology at Mayo Clinic College of Medicine in Rochester, Minnesota, and an Editorial Board member of Psychiatric Times. He reports no conflicts of interest concerning this article.
1. Jeste DV, Palmer BW, eds. Positive Psychiatry. Arlington, VA: American Psychiatric Publishing; 2015.
2. Jeste DV, Twamley EW, Eyler Zorrilla LT, et al. Aging and outcome in schizophrenia. Acta Psychiatr Scand. 2003;107:336-343.
3. Palmer BW, Martin AS, Depp CA, et al. Wellness within illness: happiness in schizophrenia. Schizophr Res. 2014;159:151-156.
4. Jeste DV, Savla GN, Thompson WK, et al. Association between older age and more successful aging: critical role of resilience and depression. Am J Psychiatry. 2013;170:188-196.