Positive Psychiatry
In this column, I want to share my views on what I envision as the central role that psychiatry will play in the future health care system—the face of “positive psychiatry.” Positive psychological traits including resilience, optimism, wisdom, self-efficacy, social engagement, and others are valued highly by society in general. However, they are typically neglected or even dismissed in most of the biomedical sciences as imprecise, amorphous, feel-good concepts not worth focusing on as they are not relevant to traditional medicine or conventional research. This attitude persists despite a growing number of studies suggesting that such positive traits are tightly linked to human biology and are associated with significant positive health outcomes exemplified by longevity, better functioning, and reduced susceptibility to psychiatric disorders like depression, as well as to cardiovascular, metabolic, and other physical diseases.
Over the last two decades, positive psychology has received considerable attention, prominently in the writings of Martin Seligman. However, the focus of psychiatry, as a branch of medicine, has been restricted primarily to diagnosis and treatment of individuals with severe psychopathology. Neuroscience too has been largely interested in studies of neurobiology of psychiatric disorders. Psychiatric textbooks, journals, and conferences, as well as funded grants, mostly address psychiatric diseases and their treatments. I believe that, as the medical field begins to appreciate the value of positive psychosocial factors in the prevention and management of pathology, positive psychiatry will increasingly take a central stage within medicine and health care.
Biology: Positive psychiatry is rooted in biology, specifically neuroscience, genetics, and epigenetics, involving interactions among genes, environment, and structure and function of the brain. For instance, genetic-association studies have linked optimism to the oxytocin receptor gene, as well as to the 5HTTLPR variation in SLC6A4, a gene responsible for serotonin transport. Other studies have shown that 5HTTLPR and hypothalamic-pituitary-adrenal axis genes are related to resilience. Beyond genes, advances have been made in identifying brain circuits putatively involved in positive traits. Thus, successful coping with stress has been tied to adaptive changes in brain circuits regulating reward, fear, emotional reactivity, and social behavior. Similarly, neurocircuitry of wisdom may involve the prefrontal cortex (especially dorsolateral, ventromedial, and anterior cingulate) and the limbic striatum—the newest and the oldest parts of the brain, respectively, from a phylogenetic or evolutionary perspective. This type of research has implications for developing biological interventions to enhance positive traits. | |||||
Relationship to Improved Health Outcomes: A number of studies have demonstrated that positive psychological traits are associated with improved mental and physical health and longevity. For example, optimism has been associated with significantly reduced risk of developing serious health conditions, including depression and cardiovascular disease. The mechanisms underlying these findings are unclear. Some investigations suggest that optimists tend to adhere to a healthier lifestyle. Health behaviors such as dieting, not smoking, exercising, practicing good dental hygiene, conducting breast self-exams, and even using seatbelts have been linked to one’s level of perceived self-efficacy. Some investigations have found that spirituality is associated with less risky health behaviors, improved depression in terminally ill AIDS patients, and decreased levels of cortisol. Resilience has been reported to be a significant predictor of longevity, particularly in older adults. People in their 90s who endorsed higher levels of resilience had a 43 percent higher likelihood of living up to 100 years compared with their peers with lower resilience. Finally, numerous articles show the buffering effect of social engagement on depressive symptoms, cardiovascular health, cancer recovery, and dementia. These relationships are likely to be bidirectional—for example, greater social engagement reduces the risk of severe depression, and vice versa. | |||||
Interventions: There already has been some research on psychosocial treatments that sought to strengthen positive characteristics in individual subjects. A few interventions aiming to improve social engagement, while not specifically targeting depression, were reported to have antidepressant effects in older people. Management strategies buttressing resilience led to lower alcohol consumption in adolescents as well as older adults. One study demonstrated that increasing optimism resulted in increased adherence to pharmacotherapy in formerly pessimistic individuals. Studies of longer-term effects of meditation have reported reduced mortality rates in older adults at risk for negative cardiovascular outcomes, compared with control groups. Taken together, existing evidence suggests that the armamentarium of psychosocial/behavioral treatments should be expanded to include interventions focusing on enhancing positive psychosocial traits in people with mental or other kinds of medical illnesses. | |||||
As psychiatrists, we definitely can recognize the importance of positive psychological traits and design strategies for enhancing them not only in psychiatric patients but also in general health care settings. Such an emphasis is the basis for positive psychiatry, which strives to optimize health outcomes by promoting positive psychosocial factors. By strengthening the development of positive traits through psychotherapeutic, behavioral, psychosocial, and eventually biological interventions, positive psychiatry has the potential to improve health outcomes and reduce morbidity as well as mortality. It should increasingly become an important approach to enhancing general well-being of individuals and communities alike, thereby decreasing the general costs of health care. Thus, instead of being narrowly defined as a medical subspecialty restricted to management of mental illnesses, the psychiatry of the future will develop into a core component of the overall health care system. The future of our field is brighter and more exciting than ever! 
