Emotional Health and Happiness in Late Life

A symptom-based approach to understanding emotional health in old age leads to the traditional medical view that mental health is simply the absence of mental illness. Depressive illness, recognizable in older adults by symptoms that include sad, downcast moods, tearfulness, recurrent thoughts of death or suicide, diminished pleasure, feelings of hopelessness or worthlessness, restlessness, indecisiveness, and lack of initiative is one example of a common psychiatric disorder in late life that is often underdiagnosed (Reynolds, Alexopoulos, & Katz, 2002). Depression can be triggered from environmental circumstances such as loneliness, bereavement, retirement, disability of a spouse, and feeling unwanted or no longer useful (Cummings, 1998). Depression in older adults can also be caused by medical conditions or be a response to physical illness (Frazer, Leicht, & Baker, 1996; Weintraub, Furlan, & Katz, 2002). The prevalence of major depression in the older adults who live in the community is relatively low (between 1 and 3%), but the numbers go up in primary care settings (10%) and in acute care settings (15%) (Reynolds, Alexopoulos, Katz, & Lebowitz, 2001). Untreated depression can lead to suicide (especially in white men over 75), alcohol abuse, excess disability from chronic illness, cognitive impairment, and overutilization of health care services (Reynolds et al., 2002). In the Medical Outcomes Study major depressive illness was found to be as debilitating as advanced coronary artery disease (Wells & Burnam, 1991).

Depression in late life is a treatable condition and should not be viewed as an inevitable state in old age. Increasing evidence demonstrates that a variety of forms of psychotherapy and psychological interventions are as effective in older adults as compared to the response of younger adults (Pinquart & Soerensen, 2001; Zarit & Knight, 1996). Medication management has also been used successfully with older adults in treating depression. The combination of antidepressant medications with at least monthly interpersonal psychotherapy has demonstrated outcomes superior to treatments using only one of these treatments in preventing the recurrence of late life depression (Reynolds et al., 1999).

For individuals who have had bouts of depression early in life or in middle age, efforts to avoid relapse are critical to healthy aging. In order to prevent relapse of major depression in old age, the National Institutes of Health consensus panel on diagnosis and treatment of depression in late life recommends that older adults diagnosed with depression be treated with antidepressant medication for at least 6 months for the first episodes of depression and that treatment be maintained for at least one year for recurrent depressive episodes (Reynolds et al., 2001).

Relatively few studies are available regarding primary prevention of depression in old age. We found one prospective study that examined the efficacy of a psycho-educational program in lowering rates of medical utilization by the newly widowed (Cummings, 1998). The use of medical services of 323 recently widowed older adults enrolled in a bereavement group were compared over a 2 year period to that of a group of 278 widowed patients who were on a waiting list and served as the contrast group. The patients who received the intervention attended 14 small group psycho-educational sessions (two hours long) that focused on increasing a sense of self-efficacy, defeating learned helplessness, and restoring meaning to life. Homework involving relaxation and mental imagery, permission to cry, visitation of the grave of the deceased, and making an effort to eat properly and keep up good grooming was assigned after each session.

The bereavement program prevented a surge in medical care utilization for the widowed older adults during the two years after the death of a spouse, resulting in cost savings of about $1,400 (in 1982 to 1992 dollars) per patient compared to the medical costs incurred by the contrast group. Extrapolated over the large number of recently widowed each year, such preventive interventions could potentially save millions of dollars under the Medicare program not to mention helping to reduce emotional suffering. This study did not specifically measure ratings of mood, but the data indicate that physical symptoms of ill health requiring medical attention were avoided.

Based upon knowledge of risk factors for late life depression, Reynolds et al. (2001) suggested three directions for prevention of depression. These include cognitive-behavioral therapy for chronic primary insomnia because of its risk in triggering depression; interpersonal, cognitive-behavioral or problem-solving therapy for patients with chronic illness; and social rhythm stabilizing therapy for recent widows and widowers. Bibliotherapy, a type of self-administered treatment that is delivered via written material, has been used effectively for the treatment of depression in older adults and should not be overlooked as a potentially powerful tool to also prevent depression (Scogin, 1998; Scogin, Jamison, & Gochneaur, 1989).

The lifespan psychological viewpoint of aging defines emotional health as more than the lack of symptoms of mental illness. This perspective examines behaviors, lifestyle, and thought patterns that lead to qualities such as vitality and vibrancy in late life. Recent literature suggests that maintaining emotional stability, having an adaptive coping style, and being actively engaged with life are intrinsic factors of successful aging (Perls, Silver, & Lauerman, 1999; Rowe & Kahn,1998; Vaillant, 2002).

These broad aspects of psychological health and well-being suggest that perceptions and expectations play a major role in late life emotional health and satisfaction. In the Harvard study of adult development, three cohort groups (a total sample of 824 young people) were followed for 60 to 80 years (Vaillant, 2002). The researchers classified well-being in late life along a continuum from the happy-well to the sad-sick. The objective good health of the individual was not necessarily related to happiness in old age; rather it was the subjective perception of how healthy the individual was that determined his/her happiness. Such findings are a tribute to the ability of humans to adapt to adversity (Seligman, 2002).

Positive affect early in life may impact not only life satisfaction in old age but also actual length of life according to the results of the Nun Study (Danner, Snowdon, & Friesen, 2001). Positive emotional content found in handwritten autobiographies of 180 Catholic nuns was strongly associated with longevity 60 years later. For summaries of the on-going findings from the Nun Study, refer to their website, www.nunstudy.org.

So what can a middle-aged person do to prevent depression in old age, create and maintain the qualities associated with healthy aging, and possibly impact the length of life? The relatively new movement in American psychology known as positive psychology provides one source of theoretical ideas on this topic. Seligman (2002) presents a practical equation for happiness: H (enduring happiness) = S (your set range, i.e., your genetically determined level of positive affectivity) + C (circumstances of your life) + V (factors under voluntary control, such as thoughts and feelings about the past including gratitude, willingness to forgive, and optimism about the future). His book and website (www.authentichappiness.com) contain questionnaires for self-assessment of many psychological variables such as optimism, gratitude, and 24 signature personal strengths.

In order to lift a depressed mood and offset the negative impact of hassles in life, behavior therapists recommend increasing the frequency of pleasant interactions and events (Teri, 1991). This strategy is based upon the behavioral view that depression results from a dearth of pleasant interactions and an excess amount of negative person-environment interactions. Seligman (2002) suggests that happiness (part of successful aging) can be increased momentarily through experiencing pleasures (e.g., having a back rub, indulging in a long hot bath, smelling roses, eating a favorite food, watching an exciting sport event or concert, and playing with a pet). For enduring happiness, gratifications (e.g., meaningful activities that require skill, concentration, feedback, deep involvement, and a sense of flow) need to be part of life as well.

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