Pfund et al. (Reference Pfund2022) examine the protective effects of sense of purpose among a cohort of 595 older adults aged 65–78 years enrolled in the St. Louis Personality and Aging Network study. Their main finding that greater sense of purpose was negatively related to subjective cognitive decline (SCD) and appeared to attenuate the effects of loneliness on perceived cognitive decline adds to a growing “Positive Psychiatry” (Jeste et al., Reference Jeste, Palmer, Rettew and Boardman2015) literature establishing the alimentary effects of opportunities for generative social contributions in the late-life course (Wilkins et al., Reference Wilkins2022). So too do the results substantiate the known deleterious effects of loneliness, disconnection, and age segregation for elders and suggest that loss of purpose may be a key part of the causal matrix leading to decrements in cognitive functioning (Dahlberg, Reference Dahlberg2022).
There are admittedly methodological challenges in measuring idiosyncratic aspects of the human experience such as “sense of purpose” and “wisdom” or reducing them to narrow operational definitions and standardized scales that fail to capture their complex and somewhat ineffable qualities. This process of reification can give a false sense of solidity. Is it possible that the most important aspects of human existence are in fact incommensurable? Mixed methods studies integrating qualitative data (interviews/ethnography/photovoice, etc.) may offer even greater sensitivity in appreciating the complex human mechanisms at play beneath statistical correlations linking purpose, loneliness, depression, and cognitive decline. Qualitative data invites narrative, through which human beings may speak explicitly and implicitly to the relationships among these variables and offer even greater illumination than the interaction effects identified in this study via statistical analysis. Further, such stories might reveal important cultural variations in concepts of purpose. In Japan, for example, the popular concept of “ikigai”—“that which makes life worth living”—blends purpose with joy and meaning.
Additional to these conceptual limitations, the newly invented predisease category “SCD” on which the authors rely is itself controversial and lacking validity and clear utility. The history of the related term, mild cognitive impairment, another supposed “precursor” to dementia invented two decades ago, illustrates the dangers of propagating such concepts for use in research and then applying them prematurely in clinical practice to help professionals but not necessarily patients and families. It is obvious that progressive cognitive decline exists on a continuum, but less obvious why we must arbitrarily label segments of the curve. It is also clear there is extremely high variability in the progression of people given those labels, with studies consistently showing a substantial number of people with precursor diagnoses do not progress to Alzheimer’s. The unproven presupposition that early treatment is always better leads to labeling people with milder symptoms earlier in the process. Consequently, this leads to overdiagnosis, “medicalization,” and stigma, with all their inherent dangers for the elderly, rather than progressing along a presumed march to progress. All that is to say that, as with “sense of purpose,” there is empirical risk in relying on prematurely reified concepts like “SCD,” and further work will be needed to replicate and clarify this study’s findings. Moreover, while the researchers stratified participants by race, it would have been even more useful to examine the cohort based on socioeconomic status (or even proxy markers like education) to investigate how class position might itself confer resilience against lack of purpose and brain aging. Those limitations aside, studies like this help put a degree of statistical weight behind commonsense assumptions about the human condition and thus reinforce our understanding of what may be protective against dementia.
In this particular moment, such increased focus on psychosocial pathways of brain health is much needed, as, over the past two decades, the biotechnological search for an anti-Alzheimer’s drug has yielded a 100% fail rate. The high-profile story of Biogen’s aducanumab, a monoclonal antibody against amyloid that was disastrously approved by the FDA in 2021 despite lack of clear clinical efficacy, serious and at times lethal side effects (brain swelling/bleeds, atrophy, headaches, and falls), and substantial cost (originally priced at $56,000 before being reduced to $28,000) has helped reveal the folly of overinflated expectations for markets and biotechnology to produce cures via a single-mechanism drugs (Whitehouse et al., Reference Whitehouse2022). While we may not be able to decisively intercede in brain aging processes via pharmaceutical interventions, we can certainly improve the cultural/structural milieus in which people age to better facilitate exposure to protective factors like purpose.
Indeed, in contrast to the litany of failed Alzheimer’s drugs, one of the most hopeful storylines to arise in dementia research in recent years is that brain aging, while perhaps not “curable” appears amenable to prevention. The Lancet Commission on Dementia Prevention, Intervention, and Care (Livingston et al., Reference Livingston2020) and others (Lee et al., Reference Lee2022) have converged on estimates that around 40% of dementia cases could theoretically be prevented or delayed if key risk factors (obesity, diabetes, hypertension, depression, physical inactivity, smoking, poor sleep, hearing/visual loss, etc.) are addressed. Moreover, studies have shown that, despite popular cultural scripts dramatizing the rising tide of Alzheimer’s, dementia rates in the US, Canada, and four Western European countries have been declining in the past decade (Wolters et al., Reference Wolters2020). As we (George and Whitehouse, Reference George and Whitehouse2021) and others (Livingston et al., Reference Livingston2020) have argued, this surprising brain health phenomenon appears linked to public health and policy measures implemented by Western governments in the mid-20th century that provided better care and treatment for vascular risk factors associated with brain health (via expanded healthcare systems, effective smoking cessation campaigns), increased access for tens of millions to the cognitive-reserve building and purpose-reinforcing resource of higher education (e.g. GI Bill and Pell grants in the US), and used regulatory measures (e.g. Clean Air Act) to reduce population-level exposures to known neurotoxins like lead from gasoline.
While Pfund et al. focus on the protective effects of “purpose” as an isolated individual lifestyle risk factor, it is imperative to maintain a larger societal frame in considering what “buffers” brain aging at a broader scale (not to mention more rigorously define what “buffering,” itself a chemical metaphor used by the researchers) actually means. In our recent book, we propose that thinking be expanded from individual-level “cognitive reserve” (the foci of this study) to “population reserve”—i.e. a frame that permits broader conceptualization of structural interventions like those mentioned above that may, in improving societal milieus, exponentially increase brain health across populations. A muscular regulatory act like de-leading gasoline via the Clean Air Act transcends our individual risk calculus and becomes a “brain health intervention” undertaken by the state that arguably “buffers dementia risk” for tens of millions of citizens (McFarland et al., Reference McFarland, Hauer and Reuben2022).
As we deal with our own current crisis of lead in drinking water throughout much of the US (Pell and Schneyer, Reference Pell and Schneyer2016), we must think about how we can adapt our increasingly unhealthy societies to promote brain health. Given the aforementioned actions of Western democracies in the post-war social democratic era of the 20th century that appear to have potentiated reduced dementia rates for elders today, it is not a stretch to think contemporary state-driven policies provisioning free or affordable college, vocational training and universal healthcare, and lead-free public water infrastructure would make generational impacts on brain health. So too would evolving in the direction of age- and dementia-friendly communities offer opportunities for millions more elders to volunteer with civil society organizations and thereby increase social roles and sense of purpose, reduce loneliness/depression, and potentially enhance population reserve. We have both been involved in establishing and evaluating three intergenerational charter schools in Cleveland, OH, where elders, including people living with dementia, are invited as learning partners for urban elementary school children. Consistent with the study by Pfund et al., we found that participants from assisted living homes who volunteered at the schools for 6 months—thus serving as community-embedded “mentors” rather than being institutional “dementia victims”—experienced lower stress (George and Singer, Reference George and Singer2011) and increased sense of purpose (George and Whitehouse, Reference George and Whitehouse2010).
We must ask: is the current material organization of society fostering robust opportunities for purpose, meaningful integration, and brain health? Elders still struggle with age segregation and diminution of opportunities for social interaction and contribution within a political-economic order prizing productivity and youth. But it is also necessary to think across the whole life-course. Indeed, we are living in an era defined by rising deaths of despair (DoD), i.e. mortality linked to suicide, alcohol-related liver disease, and drug overdose. Excess deaths from despair-related illnesses have steadily risen since 1999, disproportionately affecting rural white men and women with low educational attainment in midlife and contributing to an unprecedented fall in average US lifespan (Case and Deaton, Reference Case and Deaton2015; George et al., Reference George2021). More recently, death rates among people aged 25–64 years from despair-related illnesses have begun extending across racial, ethnic, and gender lines, as well as into cities and suburbs (although higher burden remains in the industrial Midwest and Appalachia and for those with lower educational attainment) (Case and Deaton, Reference Case and Deaton2021; Woolf and Schoomaker, Reference Woolf and Schoomaker2019). In 2020, there were 186,763 such deaths—the highest ever recorded (Warren, Reference Warren2022). Researchers are now noting a rise in DoD in other Western countries that have more aggressively adopted US-style economic organization defined by privatization, deregulation, cuts to social services, tax cuts for the wealthy, and deunionization (Case and Deaton, Reference Case and Deaton2020).
Despair is antithetical to purpose, and the increasing presence of despair-driven illness—in which millions of modern citizens appear to be seeking (lethal) numbness and escape from the pain of their lives—suggests that our current array of societal structures, institutions, and processes are perpetuating anomie, alienation, a loss of hope, and loss of meaningful social roles rather than supporting human flourishing. Worst affected are those lacking college degrees in regions disproportionately ravaged by global trade-related deindustrialization who have faced immense difficulty adapting to service- and knowledge-based economies. Indeed, the hyper-capitalist policies unleashed in the 1970s and still dominant today—a span political-scientists refer to as the neoliberal era—have disrupted the social fabric of towns, accelerating income/wealth inequality, deepening precarity, atomization, and loneliness for the working class, and forestalling a purposeful and dignified existence for many. COVID-19 and the realities of social distancing, lockdown, masking, and regarding others as potential vectors of disease have exacerbated these trends. If we are to ensure purposeful, materially secure lives for future generations, we must identify potential levers of structural change capable of disrupting this growing crisis of despair. If not, “purpose” will be a psychosocial, brain protective resource enjoyed only by a well-positioned cultural elite.
To a great extent, this paper illustrates problems with psychiatry at large. We conclude by blending Dilip’ Jeste’s aforementioned concept of “Positive Psychiatry” and Awais Aftab’s focus on “Critical Psychiatry” (Aftab and Waterman, Reference Aftab and Waterman2021) into a “Critical Positive Psychiatry.” Dominant biological psychiatry focuses on labeling pathology and adopts a medical model of largely pharmacological treatments. Undervalued ecopsychosocial psychiatry (George and Whitehouse, Reference George and Whitehouse2021) encompasses consideration of broader cultural and ecological factors with focus on prevention using behavioral interventions. Positive psychiatry centers prevention and resilience by highlighting individual mental strengths and health. Like positive psychology (and movements like positive aging), it runs the risk of uncritically dismissing structurally driven distress as manifested in conditions like DoD. Positivity without balance and self-reflection risks losing its potential to objectively critique and analyze a complex world. Critical psychiatry asks us to look at the concepts and methods used in research just as we have attempted to do in this commentary. Whose interests are served by inventions of new categories? Whose power is served by quantification/reification? What do dominant categories obscure?
For the future, qualitative approaches beginning with the stories and perceptions of people affected by the mental health challenges of aging would be a better place to start. What words surface in these narratives that deserve attention? Being grounded in the experiences of real people might allow the emergence of approaches based on individual and cultural stories. The keys to mental health should emerge from society and nature and not be excessively imposed by theoretically, methodologically, and statistically driven professionals.
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Pfund et al. (Reference Pfund2022) examine the protective effects of sense of purpose among a cohort of 595 older adults aged 65–78 years enrolled in the St. Louis Personality and Aging Network study. Their main finding that greater sense of purpose was negatively related to subjective cognitive decline (SCD) and appeared to attenuate the effects of loneliness on perceived cognitive decline adds to a growing “Positive Psychiatry” (Jeste et al., Reference Jeste, Palmer, Rettew and Boardman2015) literature establishing the alimentary effects of opportunities for generative social contributions in the late-life course (Wilkins et al., Reference Wilkins2022). So too do the results substantiate the known deleterious effects of loneliness, disconnection, and age segregation for elders and suggest that loss of purpose may be a key part of the causal matrix leading to decrements in cognitive functioning (Dahlberg, Reference Dahlberg2022).
There are admittedly methodological challenges in measuring idiosyncratic aspects of the human experience such as “sense of purpose” and “wisdom” or reducing them to narrow operational definitions and standardized scales that fail to capture their complex and somewhat ineffable qualities. This process of reification can give a false sense of solidity. Is it possible that the most important aspects of human existence are in fact incommensurable? Mixed methods studies integrating qualitative data (interviews/ethnography/photovoice, etc.) may offer even greater sensitivity in appreciating the complex human mechanisms at play beneath statistical correlations linking purpose, loneliness, depression, and cognitive decline. Qualitative data invites narrative, through which human beings may speak explicitly and implicitly to the relationships among these variables and offer even greater illumination than the interaction effects identified in this study via statistical analysis. Further, such stories might reveal important cultural variations in concepts of purpose. In Japan, for example, the popular concept of “ikigai”—“that which makes life worth living”—blends purpose with joy and meaning.
Additional to these conceptual limitations, the newly invented predisease category “SCD” on which the authors rely is itself controversial and lacking validity and clear utility. The history of the related term, mild cognitive impairment, another supposed “precursor” to dementia invented two decades ago, illustrates the dangers of propagating such concepts for use in research and then applying them prematurely in clinical practice to help professionals but not necessarily patients and families. It is obvious that progressive cognitive decline exists on a continuum, but less obvious why we must arbitrarily label segments of the curve. It is also clear there is extremely high variability in the progression of people given those labels, with studies consistently showing a substantial number of people with precursor diagnoses do not progress to Alzheimer’s. The unproven presupposition that early treatment is always better leads to labeling people with milder symptoms earlier in the process. Consequently, this leads to overdiagnosis, “medicalization,” and stigma, with all their inherent dangers for the elderly, rather than progressing along a presumed march to progress. All that is to say that, as with “sense of purpose,” there is empirical risk in relying on prematurely reified concepts like “SCD,” and further work will be needed to replicate and clarify this study’s findings. Moreover, while the researchers stratified participants by race, it would have been even more useful to examine the cohort based on socioeconomic status (or even proxy markers like education) to investigate how class position might itself confer resilience against lack of purpose and brain aging. Those limitations aside, studies like this help put a degree of statistical weight behind commonsense assumptions about the human condition and thus reinforce our understanding of what may be protective against dementia.
In this particular moment, such increased focus on psychosocial pathways of brain health is much needed, as, over the past two decades, the biotechnological search for an anti-Alzheimer’s drug has yielded a 100% fail rate. The high-profile story of Biogen’s aducanumab, a monoclonal antibody against amyloid that was disastrously approved by the FDA in 2021 despite lack of clear clinical efficacy, serious and at times lethal side effects (brain swelling/bleeds, atrophy, headaches, and falls), and substantial cost (originally priced at $56,000 before being reduced to $28,000) has helped reveal the folly of overinflated expectations for markets and biotechnology to produce cures via a single-mechanism drugs (Whitehouse et al., Reference Whitehouse2022). While we may not be able to decisively intercede in brain aging processes via pharmaceutical interventions, we can certainly improve the cultural/structural milieus in which people age to better facilitate exposure to protective factors like purpose.
Indeed, in contrast to the litany of failed Alzheimer’s drugs, one of the most hopeful storylines to arise in dementia research in recent years is that brain aging, while perhaps not “curable” appears amenable to prevention. The Lancet Commission on Dementia Prevention, Intervention, and Care (Livingston et al., Reference Livingston2020) and others (Lee et al., Reference Lee2022) have converged on estimates that around 40% of dementia cases could theoretically be prevented or delayed if key risk factors (obesity, diabetes, hypertension, depression, physical inactivity, smoking, poor sleep, hearing/visual loss, etc.) are addressed. Moreover, studies have shown that, despite popular cultural scripts dramatizing the rising tide of Alzheimer’s, dementia rates in the US, Canada, and four Western European countries have been declining in the past decade (Wolters et al., Reference Wolters2020). As we (George and Whitehouse, Reference George and Whitehouse2021) and others (Livingston et al., Reference Livingston2020) have argued, this surprising brain health phenomenon appears linked to public health and policy measures implemented by Western governments in the mid-20th century that provided better care and treatment for vascular risk factors associated with brain health (via expanded healthcare systems, effective smoking cessation campaigns), increased access for tens of millions to the cognitive-reserve building and purpose-reinforcing resource of higher education (e.g. GI Bill and Pell grants in the US), and used regulatory measures (e.g. Clean Air Act) to reduce population-level exposures to known neurotoxins like lead from gasoline.
While Pfund et al. focus on the protective effects of “purpose” as an isolated individual lifestyle risk factor, it is imperative to maintain a larger societal frame in considering what “buffers” brain aging at a broader scale (not to mention more rigorously define what “buffering,” itself a chemical metaphor used by the researchers) actually means. In our recent book, we propose that thinking be expanded from individual-level “cognitive reserve” (the foci of this study) to “population reserve”—i.e. a frame that permits broader conceptualization of structural interventions like those mentioned above that may, in improving societal milieus, exponentially increase brain health across populations. A muscular regulatory act like de-leading gasoline via the Clean Air Act transcends our individual risk calculus and becomes a “brain health intervention” undertaken by the state that arguably “buffers dementia risk” for tens of millions of citizens (McFarland et al., Reference McFarland, Hauer and Reuben2022).
As we deal with our own current crisis of lead in drinking water throughout much of the US (Pell and Schneyer, Reference Pell and Schneyer2016), we must think about how we can adapt our increasingly unhealthy societies to promote brain health. Given the aforementioned actions of Western democracies in the post-war social democratic era of the 20th century that appear to have potentiated reduced dementia rates for elders today, it is not a stretch to think contemporary state-driven policies provisioning free or affordable college, vocational training and universal healthcare, and lead-free public water infrastructure would make generational impacts on brain health. So too would evolving in the direction of age- and dementia-friendly communities offer opportunities for millions more elders to volunteer with civil society organizations and thereby increase social roles and sense of purpose, reduce loneliness/depression, and potentially enhance population reserve. We have both been involved in establishing and evaluating three intergenerational charter schools in Cleveland, OH, where elders, including people living with dementia, are invited as learning partners for urban elementary school children. Consistent with the study by Pfund et al., we found that participants from assisted living homes who volunteered at the schools for 6 months—thus serving as community-embedded “mentors” rather than being institutional “dementia victims”—experienced lower stress (George and Singer, Reference George and Singer2011) and increased sense of purpose (George and Whitehouse, Reference George and Whitehouse2010).
We must ask: is the current material organization of society fostering robust opportunities for purpose, meaningful integration, and brain health? Elders still struggle with age segregation and diminution of opportunities for social interaction and contribution within a political-economic order prizing productivity and youth. But it is also necessary to think across the whole life-course. Indeed, we are living in an era defined by rising deaths of despair (DoD), i.e. mortality linked to suicide, alcohol-related liver disease, and drug overdose. Excess deaths from despair-related illnesses have steadily risen since 1999, disproportionately affecting rural white men and women with low educational attainment in midlife and contributing to an unprecedented fall in average US lifespan (Case and Deaton, Reference Case and Deaton2015; George et al., Reference George2021). More recently, death rates among people aged 25–64 years from despair-related illnesses have begun extending across racial, ethnic, and gender lines, as well as into cities and suburbs (although higher burden remains in the industrial Midwest and Appalachia and for those with lower educational attainment) (Case and Deaton, Reference Case and Deaton2021; Woolf and Schoomaker, Reference Woolf and Schoomaker2019). In 2020, there were 186,763 such deaths—the highest ever recorded (Warren, Reference Warren2022). Researchers are now noting a rise in DoD in other Western countries that have more aggressively adopted US-style economic organization defined by privatization, deregulation, cuts to social services, tax cuts for the wealthy, and deunionization (Case and Deaton, Reference Case and Deaton2020).
Despair is antithetical to purpose, and the increasing presence of despair-driven illness—in which millions of modern citizens appear to be seeking (lethal) numbness and escape from the pain of their lives—suggests that our current array of societal structures, institutions, and processes are perpetuating anomie, alienation, a loss of hope, and loss of meaningful social roles rather than supporting human flourishing. Worst affected are those lacking college degrees in regions disproportionately ravaged by global trade-related deindustrialization who have faced immense difficulty adapting to service- and knowledge-based economies. Indeed, the hyper-capitalist policies unleashed in the 1970s and still dominant today—a span political-scientists refer to as the neoliberal era—have disrupted the social fabric of towns, accelerating income/wealth inequality, deepening precarity, atomization, and loneliness for the working class, and forestalling a purposeful and dignified existence for many. COVID-19 and the realities of social distancing, lockdown, masking, and regarding others as potential vectors of disease have exacerbated these trends. If we are to ensure purposeful, materially secure lives for future generations, we must identify potential levers of structural change capable of disrupting this growing crisis of despair. If not, “purpose” will be a psychosocial, brain protective resource enjoyed only by a well-positioned cultural elite.
To a great extent, this paper illustrates problems with psychiatry at large. We conclude by blending Dilip’ Jeste’s aforementioned concept of “Positive Psychiatry” and Awais Aftab’s focus on “Critical Psychiatry” (Aftab and Waterman, Reference Aftab and Waterman2021) into a “Critical Positive Psychiatry.” Dominant biological psychiatry focuses on labeling pathology and adopts a medical model of largely pharmacological treatments. Undervalued ecopsychosocial psychiatry (George and Whitehouse, Reference George and Whitehouse2021) encompasses consideration of broader cultural and ecological factors with focus on prevention using behavioral interventions. Positive psychiatry centers prevention and resilience by highlighting individual mental strengths and health. Like positive psychology (and movements like positive aging), it runs the risk of uncritically dismissing structurally driven distress as manifested in conditions like DoD. Positivity without balance and self-reflection risks losing its potential to objectively critique and analyze a complex world. Critical psychiatry asks us to look at the concepts and methods used in research just as we have attempted to do in this commentary. Whose interests are served by inventions of new categories? Whose power is served by quantification/reification? What do dominant categories obscure?
For the future, qualitative approaches beginning with the stories and perceptions of people affected by the mental health challenges of aging would be a better place to start. What words surface in these narratives that deserve attention? Being grounded in the experiences of real people might allow the emergence of approaches based on individual and cultural stories. The keys to mental health should emerge from society and nature and not be excessively imposed by theoretically, methodologically, and statistically driven professionals.
Acknowledgement
We would like to acknowledge Dilip Jeste and Awais Aftab for their contributions to the conceptualization of this article.
Conflict of interest
The authors report no conflict of interest.