Depression and cognitive decline among older adults are intertwined public health concerns that impact longevity and quality of life (John et al., Reference John, Patel and Rusted2019). Older adults are at unique risk of depression, given that aging comes with a range of life transitions that can decrease social support, social and physical functioning, and engagement in activities that increase personal meaning. These transitions can exacerbate expected cognitive decline; for example, via decreased physical activity and mental engagement. Although some of these impacts are transient; i.e. due to the depressive symptoms themselves, other cognitive impairments persist: older adults with depression and mild cognitive impairment tended to continue to show cognitive impairment and functional impairment following remission of depressive symptoms (Lee et al., Reference Lee, Potter and Wagner2007). Simultaneously, age- or illness-related cognitive decline can increase depressive symptom severity through multiple mechanisms including negative impacts on personal image and self-esteem and decreased efficacy or perceived efficacy using previously effective coping skills.
Steffens et al. (Reference Steffens, Manning and Wu2022) are among the first to incorporate an important third variable, neuroticism. The authors chosen neuroticism as a target in this study due to its association with risk of cognitive decline and dementia among older adults with depression (Terracciano et al., Reference Terracciano, Aschwanden and Passamonti2021; Manning and Chan, Reference Manning, Chan and Steffens2017). Steffens et al.’s study evaluated 68 people over 60 with depression, who could either participate in study-provided sertraline treatment for 12 weeks or continue with external medication or psychotherapy for the duration of the study. The authors report the relationship between self-ratings of depression (the MADRAS) and neuroticism (NEO-PI) and a standardized cognitive assessment (CERAD). They found that higher baseline depression was significantly associated with higher baseline neuroticism and that reductions in depression over one year were also associated with reductions in neuroticism over the same year, although this was not significant. The authors followed the participants over three years, a notable feat that significantly adds to the literature especially in terms of understanding concurrent changes in neuroticism and cognitive performance. Reductions in neuroticism over one year were associated with changes in cognitive performance over three years, with depression and demographic variables included as covariates, meaning that regardless of 1-year change in depression, improvements in neuroticism over one year were associated with less cognitive decline over three years. The authors’ model found that a 20-point improvement in neuroticism would yield, on average, a 3-point retainment of cognitive performance. This is a small-to-medium effect and represents 3% of the possible total for the CERAD, but as the authors remind us, given the participants’ average age, and the typical trajectory for dementia onset, it may be too soon to see evidence of larger effects in a sample of this size. Further, a little can go along way; by slowing dementia onset by two years, some researchers have projected an overall 25% reduction in disease prevalence (Brookmeyer et al., Reference Brookmeyer, Gray and Kawas1998).
This work, along with the work of others, creates a growing picture of the mechanisms of depression and cognitive decline in older adults and provides a path forward for prevention and intervention. The simplest, and yet perhaps most important, finding is the accumulating knowledge that intervening in depression and cognitive decline among older adults is feasible. There can be a perception among stakeholders that these issues are unavoidable for those in older age. While there is much work left to untangle regarding the origins and mechanisms of dementia and related brain disease, it is clear that there is much we can do to protect against depression and cognitive decline and intervene for older adults who are experiencing these significant issues.
Steffens et al.’s work extends clinical understanding of ability to intervene with a particularly important lesson: even traits like neuroticism, often considered unchangeable, are actually malleable for many people. The average participant in this sample did report notable change in the NEO-PI neuroticism subscale (about 14 points). This central finding indicates that standard psychiatric care can improve neuroticism, which is associated with a range of negative outcomes including higher incidence of dementia (Terracciano et al., Reference Terracciano, Aschwanden and Passamonti2021) and depression and anxiety (Caselli et al., Reference Caselli, Langlais and Dueck2018). However, there was significant variability among the sample, meaning that some older adults did not report improvement in neuroticism. One question that merits future study is whether treatment recommendations might be different for older people with treatment responsive neuroticism versus those whose neuroticism does not change in response to standard care. Participants whose neuroticism does not improve with standard care might require more intensive or tailored approaches. Mindfulness approaches are promising, with one study showing enduring improvements in neuroticism at 15-month follow-up among people with chronic depression who participated in Mindfulness-Based Cognitive Therapy (Spinhoven et al., Reference Spinhoven, Huijbers and Ormel2017) and another finding that health service trainees experienced continued decreases in neuroticism six years after completing Mindfulness-Based Stress Reduction (Hanley et al., Reference Hanley, de Vibe and Solhaug2019).
As clinicians and clinical researchers pursue methods to prevent and intervene in the intertwined impacts of depression, cognitive decline, and neuroticism among older adults, positive psychiatry lights a path forward. Mindfulness-based strategies certainly fit within the positive psychiatry approach, but it also encapsulates a much broader approach to care. This emerging approach uses interdisciplinary theories and clinical strategies to focus on enhancing the well-being, personal meaning, quality of life, and associated outcomes of people experiencing mental and physical health concerns. Importantly for this case, positive psychiatry is appropriate for older adults regardless of whether they are at risk of depression and cognitive decline or already experiencing these concerns; regardless of whether their neuroticism is responsive to usual care or not.
The greatest strength of the positive psychiatry approach is that every person, regardless of illness severity, is welcome underneath its umbrella, able to pursue a life that is meaningful, enjoyable, and empowering even if elements of illness persist (Treichler et al., Reference Treichler, Lee and Jeste2021a). This recovery-oriented approach does not wait for symptoms like depression to abate to set other goals, but rather sees those other goals as essential to the now: older adults experiencing significant depression and cognitive decline can and should fully participate in all aspects of their lives. This includes making decisions about mental health care itself, which people regardless of illness severity can and should be meaningfully and powerfully engaged in at all stages (Treichler et al., Reference Treichler, Rabin and Cohen2021b).
The recovery model generally applies to older adults, with the addition of components related to empowering these adults through their established sense of identity, including through new coping skills that support and reinforce that identity, and coping strategies specifically for the impact of illness (Daley et al., Reference Daley, Newton and Slade2013). Additionally, for older adults with dementia, components include acknowledgement of how strategies may need to change over time and support may need to increase as dementia progresses while still working to orient living practices around self-identity (Daley et al., Reference Daley, Newton and Slade2013). This is often oppositional to the beliefs and expectations of many stakeholders, including patients themselves along with family members, clinicians, and others, who may expect that so-called pursuit of happiness is reserved for those who are already doing reasonably well in their mental health, a metaphorical “cherry on top.”
Indeed, traditional Western medicine does tend to operate this way, attempting to triage based on perceived severity before considering questions like personal meaning. In acute and emergent situations, this is certainly a logical strategy that is often effective, at least in the short term. However, for people with chronic, severe mental health concerns, like many people with depression and cognitive decline, this can mean that personal meaning, quality of life, and other things that make life worth living never make it to the top of the priority list in care. Additionally, for older adults, physical health issues may become common and in ongoing need of attention. At the same time, the transitions that older adults experience often mean that new consideration of questions like personal meaning is needed to enhance mental health and life satisfaction. For example, older adults living in senior housing communities report being at unique risk of loneliness due to age-related losses and isolation, leading to loss of meaning and feelings of emptiness (Paredes et al., Reference Paredes, Lee and Chik2020). Taken together, the long-term mental health needs of older adults require prioritization in order to see long-term prevention and intervention benefits, and positive psychiatry provides a clear pathway to achieve that regardless of current symptom severity or comorbidity.
Although positive psychiatry is a relatively new subdiscipline, the evidence is clear that investment in associated clinical approaches provides significant benefits for a range of older adults (Lam et al., Reference Lam, Aftab and Lee2020). Recovery-oriented skill-based interventions for older adults with psychosis and related serious mental illnesses improve social functioning, community integration, and quality of life (Bartels and Pratt, Reference Bartels and Pratt2009). A placebo-controlled study of four online interventions for older adults with depression found that three of the interventions resulted in greater happiness and two decreased depression (Proyer et al., Reference Proyer, Gander and Wellenzohn2014). An innovative study of older adults with depression living in long-term care in Taiwan found that a social robot intervention decreased depression and loneliness while increasing quality of life (Chen et al., Reference Chen, Moyle and Jones2020). Development of positive psychiatry interventions for dementia is a growing area, with several resilience interventions and a recovery-oriented assessment approach both showing promise (e.g. Whelan et al., Reference Whelan, Teahan and Casey2020). Among older adults without current mental health concerns or evidence of cognitive decline, participation in positive psychiatry interventions still provides clear benefits. For example, adults over 60 living in senior housing communities who participated in a brief, 3 session resilience-oriented intervention showed improvements in resilience, perceived stress, and wisdom (Treichler et al., Reference Treichler, Glorioso and Lee2020). In addition to the use of standard clinical assessments, as used by Steffens et al. (this issue), use of positive psychiatry assessments is needed to evaluate these approaches because clinical outcomes and recovery-oriented outcomes are commonly related but distinct (Treichler et al., Reference Treichler, Li and O’Hare2019).
Therefore, Steffens et al. (Reference Steffens, Manning and Wu2022) continue to provide hope through its clear evidence that depression and cognitive decline among older adults are both preventable and intervenable, even for people with enduring neuroticism. Further, neuroticism itself is malleable through usual care practices, decreasing depression, anxiety, and risk of dementia. Investing in further research to understand the specific needs of older adults whose neuroticism is not responsive to usual care practice, and investing in positive psychiatry intervention research and implementation of effective strategies will increase quality of life for older adults of all symptom presentations and severity levels.
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Depression and cognitive decline among older adults are intertwined public health concerns that impact longevity and quality of life (John et al., Reference John, Patel and Rusted2019). Older adults are at unique risk of depression, given that aging comes with a range of life transitions that can decrease social support, social and physical functioning, and engagement in activities that increase personal meaning. These transitions can exacerbate expected cognitive decline; for example, via decreased physical activity and mental engagement. Although some of these impacts are transient; i.e. due to the depressive symptoms themselves, other cognitive impairments persist: older adults with depression and mild cognitive impairment tended to continue to show cognitive impairment and functional impairment following remission of depressive symptoms (Lee et al., Reference Lee, Potter and Wagner2007). Simultaneously, age- or illness-related cognitive decline can increase depressive symptom severity through multiple mechanisms including negative impacts on personal image and self-esteem and decreased efficacy or perceived efficacy using previously effective coping skills.
Steffens et al. (Reference Steffens, Manning and Wu2022) are among the first to incorporate an important third variable, neuroticism. The authors chosen neuroticism as a target in this study due to its association with risk of cognitive decline and dementia among older adults with depression (Terracciano et al., Reference Terracciano, Aschwanden and Passamonti2021; Manning and Chan, Reference Manning, Chan and Steffens2017). Steffens et al.’s study evaluated 68 people over 60 with depression, who could either participate in study-provided sertraline treatment for 12 weeks or continue with external medication or psychotherapy for the duration of the study. The authors report the relationship between self-ratings of depression (the MADRAS) and neuroticism (NEO-PI) and a standardized cognitive assessment (CERAD). They found that higher baseline depression was significantly associated with higher baseline neuroticism and that reductions in depression over one year were also associated with reductions in neuroticism over the same year, although this was not significant. The authors followed the participants over three years, a notable feat that significantly adds to the literature especially in terms of understanding concurrent changes in neuroticism and cognitive performance. Reductions in neuroticism over one year were associated with changes in cognitive performance over three years, with depression and demographic variables included as covariates, meaning that regardless of 1-year change in depression, improvements in neuroticism over one year were associated with less cognitive decline over three years. The authors’ model found that a 20-point improvement in neuroticism would yield, on average, a 3-point retainment of cognitive performance. This is a small-to-medium effect and represents 3% of the possible total for the CERAD, but as the authors remind us, given the participants’ average age, and the typical trajectory for dementia onset, it may be too soon to see evidence of larger effects in a sample of this size. Further, a little can go along way; by slowing dementia onset by two years, some researchers have projected an overall 25% reduction in disease prevalence (Brookmeyer et al., Reference Brookmeyer, Gray and Kawas1998).
This work, along with the work of others, creates a growing picture of the mechanisms of depression and cognitive decline in older adults and provides a path forward for prevention and intervention. The simplest, and yet perhaps most important, finding is the accumulating knowledge that intervening in depression and cognitive decline among older adults is feasible. There can be a perception among stakeholders that these issues are unavoidable for those in older age. While there is much work left to untangle regarding the origins and mechanisms of dementia and related brain disease, it is clear that there is much we can do to protect against depression and cognitive decline and intervene for older adults who are experiencing these significant issues.
Steffens et al.’s work extends clinical understanding of ability to intervene with a particularly important lesson: even traits like neuroticism, often considered unchangeable, are actually malleable for many people. The average participant in this sample did report notable change in the NEO-PI neuroticism subscale (about 14 points). This central finding indicates that standard psychiatric care can improve neuroticism, which is associated with a range of negative outcomes including higher incidence of dementia (Terracciano et al., Reference Terracciano, Aschwanden and Passamonti2021) and depression and anxiety (Caselli et al., Reference Caselli, Langlais and Dueck2018). However, there was significant variability among the sample, meaning that some older adults did not report improvement in neuroticism. One question that merits future study is whether treatment recommendations might be different for older people with treatment responsive neuroticism versus those whose neuroticism does not change in response to standard care. Participants whose neuroticism does not improve with standard care might require more intensive or tailored approaches. Mindfulness approaches are promising, with one study showing enduring improvements in neuroticism at 15-month follow-up among people with chronic depression who participated in Mindfulness-Based Cognitive Therapy (Spinhoven et al., Reference Spinhoven, Huijbers and Ormel2017) and another finding that health service trainees experienced continued decreases in neuroticism six years after completing Mindfulness-Based Stress Reduction (Hanley et al., Reference Hanley, de Vibe and Solhaug2019).
As clinicians and clinical researchers pursue methods to prevent and intervene in the intertwined impacts of depression, cognitive decline, and neuroticism among older adults, positive psychiatry lights a path forward. Mindfulness-based strategies certainly fit within the positive psychiatry approach, but it also encapsulates a much broader approach to care. This emerging approach uses interdisciplinary theories and clinical strategies to focus on enhancing the well-being, personal meaning, quality of life, and associated outcomes of people experiencing mental and physical health concerns. Importantly for this case, positive psychiatry is appropriate for older adults regardless of whether they are at risk of depression and cognitive decline or already experiencing these concerns; regardless of whether their neuroticism is responsive to usual care or not.
The greatest strength of the positive psychiatry approach is that every person, regardless of illness severity, is welcome underneath its umbrella, able to pursue a life that is meaningful, enjoyable, and empowering even if elements of illness persist (Treichler et al., Reference Treichler, Lee and Jeste2021a). This recovery-oriented approach does not wait for symptoms like depression to abate to set other goals, but rather sees those other goals as essential to the now: older adults experiencing significant depression and cognitive decline can and should fully participate in all aspects of their lives. This includes making decisions about mental health care itself, which people regardless of illness severity can and should be meaningfully and powerfully engaged in at all stages (Treichler et al., Reference Treichler, Rabin and Cohen2021b).
The recovery model generally applies to older adults, with the addition of components related to empowering these adults through their established sense of identity, including through new coping skills that support and reinforce that identity, and coping strategies specifically for the impact of illness (Daley et al., Reference Daley, Newton and Slade2013). Additionally, for older adults with dementia, components include acknowledgement of how strategies may need to change over time and support may need to increase as dementia progresses while still working to orient living practices around self-identity (Daley et al., Reference Daley, Newton and Slade2013). This is often oppositional to the beliefs and expectations of many stakeholders, including patients themselves along with family members, clinicians, and others, who may expect that so-called pursuit of happiness is reserved for those who are already doing reasonably well in their mental health, a metaphorical “cherry on top.”
Indeed, traditional Western medicine does tend to operate this way, attempting to triage based on perceived severity before considering questions like personal meaning. In acute and emergent situations, this is certainly a logical strategy that is often effective, at least in the short term. However, for people with chronic, severe mental health concerns, like many people with depression and cognitive decline, this can mean that personal meaning, quality of life, and other things that make life worth living never make it to the top of the priority list in care. Additionally, for older adults, physical health issues may become common and in ongoing need of attention. At the same time, the transitions that older adults experience often mean that new consideration of questions like personal meaning is needed to enhance mental health and life satisfaction. For example, older adults living in senior housing communities report being at unique risk of loneliness due to age-related losses and isolation, leading to loss of meaning and feelings of emptiness (Paredes et al., Reference Paredes, Lee and Chik2020). Taken together, the long-term mental health needs of older adults require prioritization in order to see long-term prevention and intervention benefits, and positive psychiatry provides a clear pathway to achieve that regardless of current symptom severity or comorbidity.
Although positive psychiatry is a relatively new subdiscipline, the evidence is clear that investment in associated clinical approaches provides significant benefits for a range of older adults (Lam et al., Reference Lam, Aftab and Lee2020). Recovery-oriented skill-based interventions for older adults with psychosis and related serious mental illnesses improve social functioning, community integration, and quality of life (Bartels and Pratt, Reference Bartels and Pratt2009). A placebo-controlled study of four online interventions for older adults with depression found that three of the interventions resulted in greater happiness and two decreased depression (Proyer et al., Reference Proyer, Gander and Wellenzohn2014). An innovative study of older adults with depression living in long-term care in Taiwan found that a social robot intervention decreased depression and loneliness while increasing quality of life (Chen et al., Reference Chen, Moyle and Jones2020). Development of positive psychiatry interventions for dementia is a growing area, with several resilience interventions and a recovery-oriented assessment approach both showing promise (e.g. Whelan et al., Reference Whelan, Teahan and Casey2020). Among older adults without current mental health concerns or evidence of cognitive decline, participation in positive psychiatry interventions still provides clear benefits. For example, adults over 60 living in senior housing communities who participated in a brief, 3 session resilience-oriented intervention showed improvements in resilience, perceived stress, and wisdom (Treichler et al., Reference Treichler, Glorioso and Lee2020). In addition to the use of standard clinical assessments, as used by Steffens et al. (this issue), use of positive psychiatry assessments is needed to evaluate these approaches because clinical outcomes and recovery-oriented outcomes are commonly related but distinct (Treichler et al., Reference Treichler, Li and O’Hare2019).
Therefore, Steffens et al. (Reference Steffens, Manning and Wu2022) continue to provide hope through its clear evidence that depression and cognitive decline among older adults are both preventable and intervenable, even for people with enduring neuroticism. Further, neuroticism itself is malleable through usual care practices, decreasing depression, anxiety, and risk of dementia. Investing in further research to understand the specific needs of older adults whose neuroticism is not responsive to usual care practice, and investing in positive psychiatry intervention research and implementation of effective strategies will increase quality of life for older adults of all symptom presentations and severity levels.