EXPERT ANALYSIS AT THE 2015 PSYCH CONGRESS
SAN DIEGO (FRONTLINE MEDICAL NEWS) – According to Dr. Dilip V. Jeste, aging presents mankind with a paradox: Physical health may decline, but psychosocial functioning often improves with age, even in people with serious illnesses.
In a longitudinal study conducted for more than 2 decades by Dr. Jeste and his associates at the University of California, San Diego, researchers are following more than 1,400 community-based middle-aged and older adults with schizophrenia and 300-plus healthy controls with comprehensive clinical, neuropsychological, and functional evaluations. To date, they have observed accelerated physical aging among patients with schizophrenia, compared with controls, with a high morbidity and a lifespan shorter by 20 years, tied in most cases to heart disease and other afflictions common in older age. (Schizophr Bull. 2011;37[3]:451-5. doi:1093/schbul/sbr026).
They also have observed mild cognitive deficits at baseline, but a normal rate of age-associated impairment, as well as improving mental health, a reduction in psychotic symptoms, substance abuse, psychotic relapses, and increased treatment adherence, “because they have learned from experience that when they stop treatment, they have a relapse, and may become suicidal, agitated, and in need of hospitalization,” Dr. Jeste, a distinguished professor of psychiatry and neurosciences at UCSD, said at the annual U.S. Psychiatric and Mental Health Congress. “They don’t want that. Older people with schizophrenia get hospitalized not because of their psychosis, but because of the physical problems.”
More recently, he and his associates have been using biomarkers of aging to longitudinally study 140 outpatients with schizophrenia and 120 healthy controls aged 26-65 years. Data from the full sample have not yet been published, but the mean age of study participants was 50 years and 52% were male. Compared with controls, patients with schizophrenia had worse scores on psychopathology, physical functioning, and cognitive performance, “which is what you would expect.”
However, the researchers also observed shorter telomeres in some patients with schizophrenia. A telomere is a segment of DNA at the end of chromosomes. “Every time a cell divides, the telomere becomes shorter,” explained Dr. Jeste, who also is director of UCSD’s Stein Institute for Research on Aging . “After multiple cell divisions, the telomere disappears, and the cell dies.” The researchers found that women controls had significantly longer telomeres, compared with male controls (unpublished data). “That is consistent with the fact that women live longer than men,” he said. “That’s not surprising. What was surprising is that we did not see this gender difference in patients with schizophrenia. That means that women with schizophrenia have shorter telomeres than women controls. At this time, we don’t know what to make of this finding, but we will pursue it.”
The researchers also observed that the more severe the Calgary Depression Scale scores among patients, the shorter their telomeres, suggesting potential seriousness of depression in schizophrenia.
In an earlier study of 145 community-based middle-aged and older persons with schizophrenia, predictors of sustained remission were having social support, being (or having been) married at least once, greater cognitive/personality reserve, and early initiation of treatment, but not age or duration of illness ( Am J Psychiatry. 2004;161[8]1490-3 ). “It’s worth keeping in mind that even older people with schizophrenia can have sustained remission,” Dr. Jeste said. He cited the late John Nash, Ph.D. , – the Nobel Prize winning mathematician whose life story was the subject of the movie “A Beautiful Mind”– as someone who can function “at a very high level in spite of a serious illness like schizophrenia.”
This also occurs in adults with HIV and cancer, he continued. A “substantial proportion” of these patients demonstrate high ratings on mental well-being, despite worse physical health and more stressors (J Clin Psychiatry. 2013 May;74[5]:e417-23. doi: 10.4088/JCP.12m08100 ), (Psychooncology. 2015 Feb;24[2]:241-4. doi: 10.1002/pon.3600 ) and (Schizophr Res. 2014 Oct;159[1]:151-6. doi: 10.1016/j.schres.2014.07.02 ). Predictors of well-being in these patients include high levels of resilience and optimism, and low levels of depression and perceived stress.
These same “successful aging” traits were observed in a longitudinal study of a randomly selected community-based sample of 2,100 San Diego County residents aged 21-100. Known as the SAGE study, Dr. Jeste and his associates set out to test hypotheses regarding different domains of successful aging: physical, cognitive, and psychosocial. They found that aging is associated with declining levels of physical function yet improving mental health. Moreover, the study participants reported being more satisfied with life as they advance in age. The most significant correlates to self-reported well-being, happiness, and satisfaction in life were high levels of resilience and optimism, and low levels of depression and perceived stress (Am J Psychiatry. 2013 Feb;170[2]:188-96. doi: 10.1176/appi.ajp.2012.12030386 ).
“People think that as we get older we become more depressed, pessimistic, and negative,” Dr. Jeste said. “That’s not true. In our study we found no decrease in optimism bias with aging.”
Other published research supports this notion. A meta-analysis of 83 studies found a significantly positive association between optimism and better cardiovascular and cancer outcomes, better physiological markers such as immune function, better pregnancy-related outcomes, less pain, and improved mortality (Ann Behav Med. 2009 Jun;37[3]:239-56. doi: 10.1007/s12160-009-9111-x ). Another meta-analysis of 148 studies involving more than 300,000 subjects found a 50% increased likelihood of survival for individuals with stronger social relationships ( PLoS Med. 2010;7[7]:31000361 ).
Dr. Jeste went on to discuss a growing interest in the association of wisdom with aging. He defined wisdom as “a complex, multidimensional trait involving integration of several components that is useful to society and self.” Common components include social decision-making, emotional regulation, prosocial behaviors such as compassion, insight, tolerance of divergent views, and decisiveness amid uncertainty. To date, he said, studies in the medical literature have found no automatic increase in wisdom with age, but some older people show higher levels of specific components of wisdom, including better social reasoning and experience-based decision-making, and “positivity,” which Dr. Jeste defined as “having fewer negative emotions, better emotional regulation, positive biases in memory, and less regret.”
In the opinion of Dr. Jeste, such findings in medical research warrant a greater emphasis on positive aspects of health such as well-being, successful aging, and behavioral strategies for prevention – a concept known as “positive psychiatry.” “Enhancing positive psychological traits such as optimism, resilience, social engagement, and wisdom should become a key component of any medical treatment,” he said. For example, current strategies for successful aging in people with schizophrenia include optimal pharmacotherapy and psychosocial interventions, “but they are not enough,” he said. “Calorie restriction and physical exercise are critical, because we know that many of our patients are obese, partly because of sedentary habits and partly because of the medication.”
In an interview, Dr. Carl C. Bell, a psychiatrist at Jackson Park Hospital in Chicago, said the concepts behind positive psychiatry are long overdue. “Psychiatry needs to come out of the dark ages and realize that we psychiatrists should not only focus on patients’ psychopathology but also their psychoresilience, psychocreativity, and psychohealth,” Dr. Bell said. “The glass is neither half-empty nor half-full; it is both. Until we realize that wisdom, we are doing our patients a disservice.”
The practice of psychiatry “should go beyond prescribing medication” concluded Dr. Jeste, who is the principal coeditor of “Positive Psychiatry: A Clinical Handbook” (Arlington, Va.: American Psychiatric Publishing, 2015). “We need to get interested in patients’ lifestyle. We need to ask them about their level of physical activity, diet and nutrition, cognitive activity, sleep habits, socialization, and what they do for recreation and leisure.”
Dr. Jeste reported having no financial disclosures.
