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Happiness and health in psychiatry: what are their implications?

Abstract

Background

Happiness is a lasting state and is associated with the absence of negative emotions, the presence of positive emotions, life satisfaction, social engagement and objectives in life. Researchers have demonstrated the benefits of happiness in many aspects of life, but few studies have been conducted within psychiatry.

Objectives

To develop a critical literature review of studies on happiness and health in order to bring some further and useful information to psychiatry updating the article “Happiness: a review” published in 2007 in Revista de Psiquiatria Clínica.

Methods

Computational searching was undertaken of digital data basis (PubMed and SciELO) using the keywords “happiness” and “health”. One hundred twenty-seven papers published between 2004 and 2014 were found, but only 76 had the keywords in the title or abstract and with this were selected.

Results

Personality traits, such as self-direction; being married; being involved in physical and leisure activities; higher educational backgrounds and intelligence quotient; religiosity, volunteering and altruism; good physical and mental health; were positively related to happiness.

Discussion

Analysis of the concept of happiness and its associated emotions may be more complex than describing the symptoms of psychiatric disorders. Despite this, the study of happiness brings several positive implications for psychiatry.

Happiness and health; subjective well-being; happiness; mental health


Introduction

Happiness is the main objective of human existence1Fowler JH, Christakis NA. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ. 2008;337:a2338.. According to many authorities including Greek philosopher Aristotle, all human behavior aims to achieve happiness2Allmark P. Health, happiness and health promotion. J Appl Philos 2005;22(1):1-15.,3Aristóteles. Ética à Nicômaco. 1ª ed. Tradução do grego: Antonio de Castro Caeiro. São Paulo: Atlas; 2009. 280p.. However, Seneca pointed out that reaching happiness is a challenging task, since it is difficult to find what makes life happy; and, many times, the more happiness is searched for, more elusive it becomes4Sêneca. Da vida retirada, da tranquilidade da alma e da felicidade. 1ª ed. Tradução: Lúcia Sá Rebello. Porto Alegre: L&PM Pocket; 2009.. In this sense, Socrates explained to Fedro that reflection about the truth would nourish the soul; whereas philosophy would be the adequate tool to achieve this goal5Platão. Fedro. 3ª ed. Tradução: Carlos Alberto Nunes. Belém: EDUFPA; 2011..

Happiness was first investigated as an object of philosophical study. Only in the middle of the last century some empirical studies within the health and associated fields of knowledge started to appear6Tay L, Kuykendall L. Promoting happiness: the malleability of individual and societal subjective wellbeing. Int J Psychol. 2013;48(3):159-76.,7Veenhoven R. Questions on happiness: classical topics, modern answers, blind spots. In: Strack F, Argyle M, Schwarz N, editors. Subjective wellbeing, an interdisciplinary perspective. London: Pergamon Press; 1991. p. 7-26.. For this reason, the World Health Organization (WHO) has included and emphasized happiness as an important factor within the concept of health1Fowler JH, Christakis NA. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ. 2008;337:a2338.,8Cloninger CR, Zohar AH. Personality and the perception of health and happiness. J Affect Disord. 2011;128(1-2):24-32.,9WHO. The world health report 2001. Mental health: new understanding, new hope. Geneva: World Health Organization; 2001. 5p.. Most studies on happiness are in the field of psychology1010 Graham C. Happiness and health: lessons – and questions – for public policy. Health Aff (Millwood). 2008;27(1):72-87. and economics1010 Graham C. Happiness and health: lessons – and questions – for public policy. Health Aff (Millwood). 2008;27(1):72-87.,1111 Karlsson M, Lyttkens CH, Nilsson T. Health. Happiness. Inequality. Expert Rev Pharmacoecon Outcomes Res. 2010;10(5):497-500.. In psychology, for example, the concept of positive psychology has emerged1212 Barak Y, Achiron A. Happiness and neurological diseases. Expert Rev Neurother. 2009;9(4):445-59.,1313 Scorsolini-Comin F, Santos MA. O estudo científico da felicidade e a promoção da saúde: revisão integrativa da literatura. Rev Latino-Am Enfermagem. 2010;18(3):188-95.; according to Seligman (2011), this is an area that studies what is right in humans as their positive attributes, that is, their active psychological characteristics and strengths. Positive psychology advocates that promoting mental health involves the promotion of psychological resources, improving the quality of life and preventing mental disorders, especially those disorders that have a strong environmental burden, thereby promoting happiness. Thus, the contributions of positive psychology can and should be considered by psychiatric clinicians and those in general medicine1515 Cloninger CR. The science of well-being: an integrated approach to mental health and its disorders. World Psychiatry. 2006;5(2):71-6.,1616 Hershberger PJ. Prescribing happiness: positive psychology and family medicine. Fam Med. 2005;37(9):630-4..

In this context, happiness can be defined as a fundamental emotion characterized as a lasting state which is combined with: (i) the absence of negative emotions; (ii) the presence of positive emotions; (iii) life satisfaction; (iv) social engagement and (v) objectives in life8Cloninger CR, Zohar AH. Personality and the perception of health and happiness. J Affect Disord. 2011;128(1-2):24-32.,1717 Allen D, Carlson D, Ham C. Well-being: new paradigms of wellness – inspiring positive health outcomes and renewing hope. Am J Health Promot. 2007;21(3):1-9, iii.

18 Ferraz RB, Tavares H, Zilberman ML. Happiness: a review. Rev Psiquiatr Clin. 2007;34(5):234-42.
-1919 Bekhet AK, Zauszniewski JA, Nakhla WE. Happiness: theoretical and empirical considerations. Nurs Forum. 2008;43(1):12-23.. Another concept that has been largely used for defining happiness within the specialized literature is subjective well-being6Tay L, Kuykendall L. Promoting happiness: the malleability of individual and societal subjective wellbeing. Int J Psychol. 2013;48(3):159-76.,8Cloninger CR, Zohar AH. Personality and the perception of health and happiness. J Affect Disord. 2011;128(1-2):24-32.,1313 Scorsolini-Comin F, Santos MA. O estudo científico da felicidade e a promoção da saúde: revisão integrativa da literatura. Rev Latino-Am Enfermagem. 2010;18(3):188-95.,1919 Bekhet AK, Zauszniewski JA, Nakhla WE. Happiness: theoretical and empirical considerations. Nurs Forum. 2008;43(1):12-23.. It is relevant to mention that the concept ofquality of life is a broader terminology, also involving happiness itself1919 Bekhet AK, Zauszniewski JA, Nakhla WE. Happiness: theoretical and empirical considerations. Nurs Forum. 2008;43(1):12-23..

In order to use a holistic approach to promote health (i.e., taking into account all factors that influence health), it is important to understand how a healthy person behaves and how positive emotions can contribute to this process. In this sense, as proposed by Seligman (2011), treatment is not just fixing what is broken; rather, it involves nurturing what is best within ourselves1919 Bekhet AK, Zauszniewski JA, Nakhla WE. Happiness: theoretical and empirical considerations. Nurs Forum. 2008;43(1):12-23.. Undoubtedly, the actual psychiatric medical model that mainly focuses on the diagnosis and treatment of mental disorders, has been immensely helpful to many patients; nevertheless, it is believed that it is necessary to move forwards, and this will bring benefits to all, including those with a psychiatric diagnosis1515 Cloninger CR. The science of well-being: an integrated approach to mental health and its disorders. World Psychiatry. 2006;5(2):71-6..

Based on this, the main goal of this paper is to conduct a critical literature review concerning happiness and health which may be useful for the expansion of psychiatric practice, and also to update the article published in 2007 in the Revista de Psiquiatria Clínica titled “Happiness: a review”1818 Ferraz RB, Tavares H, Zilberman ML. Happiness: a review. Rev Psiquiatr Clin. 2007;34(5):234-42..

Methods

Computer searches were carried out within the PubMed data basis, using the keywords “happiness” and “health”, during August, 2014; and in the SciELO data basis with the same keywords during November, 2014. Filters were applied, requiring that the keywords appeared in the title or abstract and that the articles had been published between September 2004 and February 2014. From the PubMed, initially 80 papers were related to this topic. After a preliminary analysis, ten papers were excluded from this sample because of the following reasons: (i) four did not cite the word happiness either in their titles or in their abstracts; (ii) two concerned topics only related to, but did not directly concern, happiness and health; (iii) four were informative articles (Figure 1). Regarding the SciELO data basis, 47 papers were found; however, only six contained the word happiness in their titles and/or abstracts.

Figure 1
Flowchart of search data.

In addition to these searches, another was performed using the reference lists of the papers already selected. This was rewarding in allowing us to identify the classic work provided by significant authors in this field, such as Martin Seligman, Robert Clonniger anda Ruut Veenhoven, as well as the importance in this context of the WHO (Table 1).

Table 1
Papers from 2013 to 2014 selected for this review

Based on the results from these searches, it was possible to identify six core aspects related to the keywords “happiness” and “health”, namely:

  1. Aspects of happiness;

  2. Biology of happiness;

  3. Psychology of happiness;

  4. Sociodemography of happiness;

  5. Health, mental health and happiness;

  6. Positive implications for psychiatry.

Each of these aspects is described further in the following section.

Results

Aspects of happiness

The scientific literature often refers to two types of happiness: psychological well-being and hedonic well-being. The term psychological well-being, or eudaimonia, has been used to refer to a combination of character strengths involving self-direction (e.g., autonomy, purpose of life, environmental and self-acceptance), cooperatives (i.e., positive relationships with others) and self-transcendence (i.e., personal growth and self-realization)8Cloninger CR, Zohar AH. Personality and the perception of health and happiness. J Affect Disord. 2011;128(1-2):24-32.,1212 Barak Y, Achiron A. Happiness and neurological diseases. Expert Rev Neurother. 2009;9(4):445-59.. Hedonic well-being, or hedonia, is associated with: (i) a pleasurable life; (ii) life satisfaction; (iii) presence of positive feelings and (iv) absence of negative feelings2020 Ryff CD, Singer BH, Love GD. Positive health: connecting well-being with biology. Philos Trans R Soc Lond B Biol Sci. 2004;359(1449):1383-94.. It can be said, therefore, that psychological well-being is connected to the personal fulfillment of one’s own potential, while hedonic well-being is linked to the experience of satisfaction.

Although these are two different ways to experience happiness, they are strongly related8Cloninger CR, Zohar AH. Personality and the perception of health and happiness. J Affect Disord. 2011;128(1-2):24-32.,1212 Barak Y, Achiron A. Happiness and neurological diseases. Expert Rev Neurother. 2009;9(4):445-59.,2020 Ryff CD, Singer BH, Love GD. Positive health: connecting well-being with biology. Philos Trans R Soc Lond B Biol Sci. 2004;359(1449):1383-94.. However, from a historical point of view, they have different origins. Aristotle postulated that every human being had unique capabilities, called daimon, that should be recognized and developed3Aristóteles. Ética à Nicômaco. 1ª ed. Tradução do grego: Antonio de Castro Caeiro. São Paulo: Atlas; 2009. 280p.. Similar to this idea are the concepts/theories of: (i) self-actualization, described by Maslow; (ii) the individualization theory developed by Jung; and (iii) Antonovsky’s theory of existential coherence; all are related to the concept of eudaimonia2020 Ryff CD, Singer BH, Love GD. Positive health: connecting well-being with biology. Philos Trans R Soc Lond B Biol Sci. 2004;359(1449):1383-94.,2121 Ventegodt S, Flensborg-Madsen T, Andersen NJ, Merrick J. The life mission theory VII. Theory of existential (Antonovsky) coherence: a theory of quality of life, health, and ability for use in holistic medicine. ScientificWorldJournal. 2005;5:377-89.. It is relevant to note that Epicurus provided the basis for the later development of hedonism2020 Ryff CD, Singer BH, Love GD. Positive health: connecting well-being with biology. Philos Trans R Soc Lond B Biol Sci. 2004;359(1449):1383-94.. The biological differences between each type are discussed further below.

Besides these two types of happiness, it is important to distinguish two types of emotions or affects that are connected to the understanding of happiness: positive affect and negative affect. These are independent variables and may or may not be in opposition1818 Ferraz RB, Tavares H, Zilberman ML. Happiness: a review. Rev Psiquiatr Clin. 2007;34(5):234-42.; it is possible to feel positive and negative emotions at the same time, as well as being in a neutral state. These emotions/affects might seem to have different determinants, consequences and correlations1414 Kobau R, Seligman MEP, Peterson C, Diener E, Zack MM, Chapman D, et al. Mental health promotion in public health: perspectives and strategies from positive psychology. Am J Public Health. 2011;101(8):e1-9., and it is relevant to note that happiness itself is related to the frequency of positive emotions and not to their intensity1414 Kobau R, Seligman MEP, Peterson C, Diener E, Zack MM, Chapman D, et al. Mental health promotion in public health: perspectives and strategies from positive psychology. Am J Public Health. 2011;101(8):e1-9.,1818 Ferraz RB, Tavares H, Zilberman ML. Happiness: a review. Rev Psiquiatr Clin. 2007;34(5):234-42.. Negative emotions, such as fear and anger, are recognizably beneficial as they help people to ensure their survival and safety. Nevertheless, these are short-term benefits; the Broaden and Build Theory states that positive emotions amplify cognition and behavior, providing intellectual, social and physical resources for optimum performance. Thus, the long term benefits of positive emotions contribute to the individual’s ability to continue his/her development1414 Kobau R, Seligman MEP, Peterson C, Diener E, Zack MM, Chapman D, et al. Mental health promotion in public health: perspectives and strategies from positive psychology. Am J Public Health. 2011;101(8):e1-9..

Biology of happiness

Trying to understand the complex link between psychological factors and biological change, scientists have studied the effects on health of negative emotions. For example, it is known that stress, depression and anxiety generate changes in the hypothalamic-pituitary-adrenal axis, with a consequent increase of cortisol, sympathetic stimulation and elevation of proinflammatory markers. If these negative stimuli persist, the risk increases of developing cardiovascular disease, cancer and/or infections2222 Barak Y. The immune system and happiness. Autoimmun Rev. 2006;5(8):523-7.,2323 Steptoe A, Wardle J, Marmot M. Positive affect and health-related neuroendocrine, cardiovascular, and inflammatory processes. Proc Natl Acad Sci U S A. 2005;102(18):6508-12.. However, only recently has scientific interest focused on verifying that positive emotions could also induce biological changes. Some studies have demonstrated that the two types of happiness (eudaimonia and hedonia) can cause biological changes that promote positive emotions2424 Steptoe A, Demakakos P, de Oliveira C, Wardle J. Distinctive biological correlates of positive psychological well-being in older men and women. Psychosom Med. 2012;74(5):501-8.; however, most of this research has shown that only eudaimonia is statistically related to biological changes1212 Barak Y, Achiron A. Happiness and neurological diseases. Expert Rev Neurother. 2009;9(4):445-59.,2020 Ryff CD, Singer BH, Love GD. Positive health: connecting well-being with biology. Philos Trans R Soc Lond B Biol Sci. 2004;359(1449):1383-94.,2222 Barak Y. The immune system and happiness. Autoimmun Rev. 2006;5(8):523-7.. In general, the changes found in the neuroendocrine, immune and cardiovascular systems secondary to positive emotions are beneficial and protective effect1212 Barak Y, Achiron A. Happiness and neurological diseases. Expert Rev Neurother. 2009;9(4):445-59.,2323 Steptoe A, Wardle J, Marmot M. Positive affect and health-related neuroendocrine, cardiovascular, and inflammatory processes. Proc Natl Acad Sci U S A. 2005;102(18):6508-12..

First, positive emotions can quickly cancel the adverse effects of body stress reaction, and thus return the body to a steady state1414 Kobau R, Seligman MEP, Peterson C, Diener E, Zack MM, Chapman D, et al. Mental health promotion in public health: perspectives and strategies from positive psychology. Am J Public Health. 2011;101(8):e1-9.. It may be interesting to see how this biological characteristic of positive emotions corresponds to the observation that many people say they feel good, even through times of suffering, if adverse events are interpreted as having a purpose or meaning8Cloninger CR, Zohar AH. Personality and the perception of health and happiness. J Affect Disord. 2011;128(1-2):24-32.. Perhaps this search for meaning is a psychic attempt to maintain an emotional balance.

Second, higher levels of eudaimonia are related to lower levels of salivary cortisol and proinflammatory cytokines, a lower cardiovascular disease risk, longer duration of REM sleep2020 Ryff CD, Singer BH, Love GD. Positive health: connecting well-being with biology. Philos Trans R Soc Lond B Biol Sci. 2004;359(1449):1383-94.,2323 Steptoe A, Wardle J, Marmot M. Positive affect and health-related neuroendocrine, cardiovascular, and inflammatory processes. Proc Natl Acad Sci U S A. 2005;102(18):6508-12., higher levels of immunoglobulin A, and higher HDL cholesterol levels1212 Barak Y, Achiron A. Happiness and neurological diseases. Expert Rev Neurother. 2009;9(4):445-59. compared to those with low levels of eudaimonia. There are, however, differences between men and women in this regard; for example, inflammatory markers such as C-reactive protein and fibrinogen are lower in happy women than in happy men2424 Steptoe A, Demakakos P, de Oliveira C, Wardle J. Distinctive biological correlates of positive psychological well-being in older men and women. Psychosom Med. 2012;74(5):501-8..

These alterations have been found regardless of the presence of negative emotions, suggesting that happiness has a direct effect on the body, regardless of the absence of negative affect2323 Steptoe A, Wardle J, Marmot M. Positive affect and health-related neuroendocrine, cardiovascular, and inflammatory processes. Proc Natl Acad Sci U S A. 2005;102(18):6508-12.. On the other hand, in the same manner as tobacco and some physical leisure activities are found in stressed individuals, depression and anxiety and their associated behaviors contribute to increased rates of diseases and adverse biological changes; part of the positive biological findings in happy individuals is also due to their tendency towards healthier habits and more prudent lifestyles2323 Steptoe A, Wardle J, Marmot M. Positive affect and health-related neuroendocrine, cardiovascular, and inflammatory processes. Proc Natl Acad Sci U S A. 2005;102(18):6508-12..

Another important point is that studies of monozygotic twins, separated and raised in different environments, have shown that happiness has a genetic component of 35%-50% in humans6Tay L, Kuykendall L. Promoting happiness: the malleability of individual and societal subjective wellbeing. Int J Psychol. 2013;48(3):159-76.,1414 Kobau R, Seligman MEP, Peterson C, Diener E, Zack MM, Chapman D, et al. Mental health promotion in public health: perspectives and strategies from positive psychology. Am J Public Health. 2011;101(8):e1-9.,2525 Chen H, Pine DS, Ernst M, Gorodetsky E, Kasen S, Gordon K, et al. The The MAOA gene predicts happiness in women. Prog Neuropsychopharmacol Biol Psychiatry. 2013;40:122-5.. In this regard, it is suggested that the long allele of the promoter region of the 5-HTT gene (5-HTTLPR long) could be associated with optimism. The 5-HTT gene encodes serotonin transporters; this type of polymorphism in the promoter region is called a functional polymorphism2626 De Neve JE. Functional polymorphism (5-HTTLPR) in the serotonin transporter gene is associated with subjective well-being: evidence from a US nationally representative sample. J Hum Genet. 2011;56(6):456-9.. De Neve found that individuals satisfied or very satisfied with life have a statistically significant higher percentage of this genotype (long 5-HTTLPR homozygous), compared to people dissatisfied with life. Recently, it was discovered that, in women, a low MAO gene expression is significantly associated with increased levels of happiness. This finding, however, was not present in men2626 De Neve JE. Functional polymorphism (5-HTTLPR) in the serotonin transporter gene is associated with subjective well-being: evidence from a US nationally representative sample. J Hum Genet. 2011;56(6):456-9..

It is important to consider that many of these studies have some limitations such as small sample sizes, cross-sectional designs or bivariate analyses. Still, the studies are promising and already point us in several directions.

Psychology of happiness

If 35%-50% of happiness depends on a genetic influence, at least 30%-40% are represented other variables, suggesting that the environment and life events also have a large influence on subjective well-being. However, this influence varies from event to event; personal interpretations may be the key to understanding the link between life events and subjective well-being6Tay L, Kuykendall L. Promoting happiness: the malleability of individual and societal subjective wellbeing. Int J Psychol. 2013;48(3):159-76.. In this sense, character has a strong impact on the perception of all aspects of health, including physical, social and emotional well-being. For example, self-direction is measured by levels of responsibility, ingenuity and ability to find meaning, and has a strong connection with all aspects of health. Changes in self-direction explain about 32% of the variations in the risk of disease and about 45% of the variations in subjective well-being.

The way in which an individual sees life can predict his/her health outcomes. For example, pessimists need to visit four times as many doctors in one year than optimists1717 Allen D, Carlson D, Ham C. Well-being: new paradigms of wellness – inspiring positive health outcomes and renewing hope. Am J Health Promot. 2007;21(3):1-9, iii.. Similarly, the link between success and happiness exists not only because success makes people happy, but because positive attitudes engender success2727 Lyubomirsky S, King L, Diener E. The benefits of frequent positive affect: does happiness lead to success? Psychol Bull. 2005;131(6):803-55.. A concept that may explain these relationships is emotional competence (EC), also known as emotional intelligence. This concept relates to how the individual deals with emotional information, intrapersonally and interpersonally. High EC is associated with greater happiness, and higher mental and physical health, greater professional success and greater satisfaction in social relationships and marriage2828 Brasseur S, Grégoire J, Bourdu R, Mikolajczak M. The Profile of Emotional Competence (PEC): development and validation of a self-reported measure that fits dimensions of emotional competence theory. PLoS One. 2013;8(5):e62635..

Christakis and Fowler used the Framingham study to try to answer the following question: can the happiness of others influence personal happiness? The study was based on the theory that emotional states can be transferred interpersonally through mimicry, by copying emotionally relevant bodily actions, especially facial expressions, and it concluded positively. The authors suggested that happiness may be seen as a network phenomenon; happiness clusters resulted from the spread of happiness and not only by the tendency of people to associate with similar individuals2929 Christakis NA, Fowler JH. Social contagion theory: examining dynamic social networks and human behavior. Stat Med. 2013;32(4):556-77.. Although this theory of social contagion has also been replicated in disorders such as depression, a study involving roommates in college resulted in different findings, arguing that happiness and mental disorders have low social contagion3030 Eisenberg D, Golberstein E, Whitlock JL, Downs MF. Social contagion of mental health: evidence from college roommates. Health Econ. 2013;22(8):965-86.. Perhaps the last word on the subject has not yet been given, but there is no doubt that this is an exciting area.

Sociodemography of happiness

Several factors associated with happiness have been studied. Below we describe some that appear in more recent studies and have not been reported in other review articles on happiness.

Economic factors

The first modern economist to study happiness found a paradox (i.e., the Easterlin paradox) in which groups of richer countries are happier than groups of poorer countries, but this difference is not so clear between rich and Latin American countries where there are larger social differences. Even in poor countries, the relationship between money and happiness is not linear. Deprivation and poverty are less associated with happiness3131 Mitchell L, Frank MR, Harris KD, Dodds PS, Danforth CM. The geography of happiness: connecting twitter sentiment and expression, demographics, and objective characteristics of place. PLoS One. 2013;8(5):e64417.however, after reaching a level of care that meets basic needs, other factors, such as people’s increased aspirations and concerns about their own heritage come into play1010 Graham C. Happiness and health: lessons – and questions – for public policy. Health Aff (Millwood). 2008;27(1):72-87.,3232 Smith DM, Langa KM, Kabeto MU, Ubel PA. Health, wealth, and happiness: financial resources buffer subjective well-being after the onset of a disability. Psychol Sci. 2005;16(9):663-6.. Indeed, despite the economic changes, happiness levels have remained relatively stable in countries such as Ireland and the United States1717 Allen D, Carlson D, Ham C. Well-being: new paradigms of wellness – inspiring positive health outcomes and renewing hope. Am J Health Promot. 2007;21(3):1-9, iii.,3333 Doherty AM, Kelly BD. When Irish eyes are smiling: income and happiness in Ireland, 2003-2009. Ir J Med Sci. 2013;182(1):113-9.; a study linking retirement and welfare showed that monetary gain increased financial well-being, but the benefits of retirement on health and subjective and social welfare were transient3434 Schatz E, Gómez-Olivé X, Ralston M, Menken J, Tollman S. The impact of pensions on health and wellbeing in rural South Africa: does gender matter? Soc Sci Med. 2012;75(10):1864-73.. Another binding factor between economic issues and happiness seems to be social inequality, since individuals living in areas of great social inequality tend to describe themselves as unhappy and unhealthy3535 Oshio T, Kobayashi M. Income inequality, perceived happiness, and self-rated health: evidence from nationwide surveys in Japan. Soc Sci Med. 2010;70(9):1358-66.. From the individual point of view, however, people who are paid by the hour appear to be happier3636 DeVoe SE, Pfeffer J. When is happiness about how much you earn? The effect of hourly payment on the money – happiness connection. Pers Soc Psychol Bull. 2009;35(12):1602-18.. In addition, informal workers tend to report higher levels of happiness related to their professional activity3737 Diaz E, Guevara R, Lizana J. Trabajo informal: motivos, bienestar subjetivo, salud, y felicidad en vendedores ambulantes. Psicol Estud. 2008;13(4):693-701.. Another factor that may explain this lack of linearity between economic issues and subjective well-being levels is that happy people tend to focus more on social ideals and moral goals than just monetary achievement7Veenhoven R. Questions on happiness: classical topics, modern answers, blind spots. In: Strack F, Argyle M, Schwarz N, editors. Subjective wellbeing, an interdisciplinary perspective. London: Pergamon Press; 1991. p. 7-26..

Age

With increasing age, happiness tends to decrease in the population as a whole3838 Bjørnskov C. Healthy and happy in Europe? On the association between happiness and life expectancy over time. Soc Sci Med. 2008;66(8):1750-9.,3939 Lehmann BA, Bos AE, Rijken M, Cardol M, Peters GJ, Kok G, et al. Ageing with an intellectual disability: the impact of personal resources on well-being. J Intellect Disabil Res. 2013;57(11):1068-78.. However, from the individual point of view, centenarians who have high levels of satisfaction with their lives in the past tend in their old age to make the best personal assessments of their own health, economic security and happiness4040 Bishop AJ, Martin P, MacDonald M, Poon L; Georgia Centenarian Study. Predicting happiness among centenarians. Gerontology. 2010;56(1):88-92.. Therefore, there is a protective relationship between happiness and physical decline that occurs in old age4141 Collins AL, Goldmán N, Rodríguez G. Is positive well-being protective of mobility limitations among older adults? J Gerontol B Psychol Sci Soc Sci. 2008;63(6):P321-7.,4242 Lima MG, Barros MBA, Alves MCGP. Sentimento de felicidade em idosos: uma abordagem epidemiológica, ISA-Camp 2008. Cad Saude Publica. 2012;28(12):2280-92.. In this age group, contentment related to the children and the health of the family is associated with a higher level of happiness4343 Llobet MP, Ávila NR, Farràs J, Canut MTL. Qualidade de vida, felicidade e satisfação com a vida em anciãos com 75 anos ou mais, atendidos num programa de atenção domiciliária. Rev Latino-Am Enfermagem. 2011;19(3).. Moreover, happiness is related to longevity, independent of family genetic and environmental issues4444 Sadler ME, Miller CJ, Christensen K, McGue M. Subjective well-being and longevity: a cotwin control study. Twin Res Hum Genet. 2011;14(3):249-56.. Finally, a rather curious result was obtained from a longitudinal study that found a positive association between chocolate consumption, optimism, better health and greater psychological well-being4545 Strandberg TE, Strandberg AY, Pitkälä K, Salomaa VV, Tilvis RS, Miettinen TA. Chocolate, well-being and health among elderly men. Eur J Clin Nutr. 2008;62(2):247-53..

Interpersonal relationships

People living in minority groups tend to report less happiness than those who belong to majority groups7Veenhoven R. Questions on happiness: classical topics, modern answers, blind spots. In: Strack F, Argyle M, Schwarz N, editors. Subjective wellbeing, an interdisciplinary perspective. London: Pergamon Press; 1991. p. 7-26.. For example, after the tragic events of September 11, 2001 in the United States, Arab Americans reported a greater perception of abuse and discrimination; this perception was related to higher levels of psychological stress, worse health outcomes and a lower sense of happiness4646 Padela AI, Heisler M. The association of perceived abuse and discrimination after September 11, 2001, with psychological distress, level of happiness, and health status among Arab Americans. Am J Public Health. 2010;100(2):284-91..

Married people tend to experience better health and happiness than unmarried people. This relationship has been found in various countries, within various health parameters and in both men and women4747 Proulx CM, Snyder-Rivas LA. The longitudinal associations between marital happiness, problems, and self-rated health. J Fam Psychol. 2013;27(2):194-202.. This association, however, extends beyond marital status, because the quality of marriage also has a great influence on it4747 Proulx CM, Snyder-Rivas LA. The longitudinal associations between marital happiness, problems, and self-rated health. J Fam Psychol. 2013;27(2):194-202.

48 Lam WW, Fielding R, McDowell I, Johnston J, Chan S, Leung GM, et al. Perspectives on family health, happiness and harmony (3H) among Hong Kong Chinese people: a qualitative study. Health Educ Res. 2012;27(5):767-79.
-4949 Chan SS, Viswanath K, Au DW, Ma CM, Lam WW, Fielding R, et al. Hong Kong Chinese community leaders’ perspectives on family health, happiness and harmony: a qualitative study. Health Educ Res. 2011;26(4):664-74.. There is also a positive relationship between happiness and sexual satisfaction in women and men, although that relationship is stronger in women5050 Rosen RC, Bachmann GA. Sexual well-being, happiness, and satisfaction, in women: the case for a new conceptual paradigm. J Sex Marital Ther. 2008;34(4):291-7..

Religiosity and volunteering

It is well established that people who identify themselves as religious tend to report better health and more happiness, regardless of their religious affiliation, performance of the religious activities, work, family, social support or financial situation5151 Green M, Elliott M. Religion, health, and psychological well-being. J Relig Health. 2010;49(2):149-63.. The studies that have reached these conclusions were mostly carried out in the western population. However, research on Islamic and Egyptian students also found a positive relationship between religious affiliation and happiness5252 Abdel-Khalek AM. Quality of life, subjective well-being, and religiosity in Muslim college students. Qual Life Res. 2010;19(8):1133-43.

53 Sahraian A, Gholami A, Javadpour A, Omidvar B. Association between religiosity and happiness among a group of Muslim undergraduate students. J Relig Health. 2013;52(2):450-3.
-5454 Abdel-Khalek AM. Subjective well-being and religiosity in Egyptian college students. Psychol Rep. 2011;108(1):54-8.. Seen as human dimensions by many researchers, these aspects tend to be increasingly taken into consideration in the treatment and development of people1515 Cloninger CR. The science of well-being: an integrated approach to mental health and its disorders. World Psychiatry. 2006;5(2):71-6.,5555 Vayalilkarottu J. Holistic health and well-being: a psycho-spiritual/religious and theological perspective. Asian J Psychiatr. 2012;5(4):347-50., especially considering that the humans are religious beings, since they spend more time praying than having sex1515 Cloninger CR. The science of well-being: an integrated approach to mental health and its disorders. World Psychiatry. 2006;5(2):71-6..

Another related aspect is the issue of volunteering and altruism. People who engage in volunteer work and altruistic behaviors tend to be healthier, live longer, and to be happier5656 Post SG. Altuism, happiness, and health: it’s good to be good. Int J Behav Med. 2005;12(2):66-77.

57 Borgonovi F. Doing well by doing good. The relationship between formal volunteering and self-reported health and happiness. Soc Sci Med. 2008;66(11):2321-34.
-5858 van Campen C, de Boer AH, Iedema J. Are informal caregivers less happy than noncaregivers? Happiness and the intensity of caregiving in combination with paid and voluntary work. Scand J Caring Sci. 2013;27(1):44-50.. However, when this type of activity becomes too arduous, occupying more than 11 hours per week, the happiness levels tend to decrease5656 Post SG. Altuism, happiness, and health: it’s good to be good. Int J Behav Med. 2005;12(2):66-77.,5858 van Campen C, de Boer AH, Iedema J. Are informal caregivers less happy than noncaregivers? Happiness and the intensity of caregiving in combination with paid and voluntary work. Scand J Caring Sci. 2013;27(1):44-50..

Educational level, sports and leisure

The positive relationship has long been recognized between education levels, intelligence quotient (IQ) and health levels. More recently, a positive relationship has also been found between educational levels, IQ and the happiness index1010 Graham C. Happiness and health: lessons – and questions – for public policy. Health Aff (Millwood). 2008;27(1):72-87.,5959 Ali A, Ambler G, Strydom A, Rai D, Cooper C, McManus S, et al. The relationship between happiness and intelligent quotient: the contribution of socio-economic and clinical factors. Psychol Med. 2013;43(6):1303-12.,6060 Judge TA, Ilies R, Dimotakis N. Are health and happiness the product of wisdom? The relationship of general mental ability to educational and occupational attainment, health, and well-being. J Appl Psychol. 2010;95(3):454-68..

Other factors studied in recent years include physical leisure activities that have been shown to increase subjective well being, both in the short and long term6161 Wang F, Orpana HM, Morrison H, de Groh M, Dai S, Luo W. Long-term association between leisure-time physical activity and changes in happiness: analysis of the Prospective National Population Health Survey. Am J Epidemiol. 2012;176(12):1095-100.. Involvement in sport also appears to have a causal relationship with higher levels of happiness6262 Ruseski JE, Humphreys BR, Hallman K, Wicker P, Breuer C. Sport participation and subjective well-being: instrumental variable results from German survey data. J Phys Act Health. 2014;11(2):396-403..

Finally, it is worth remembering the psychological theory of the set point of happiness, according to which people have a basal level of happiness that they tend to return to over time, even after major events such as winning the lottery or divorce. However, unemployment is one of the events that has a negative impact on happiness that people tend not to adapt to1010 Graham C. Happiness and health: lessons – and questions – for public policy. Health Aff (Millwood). 2008;27(1):72-87..

Health, mental health and happiness

Happiness and health are closely related, both on an individual and population basis; happier people and communities tend to be healthier, and the inverse relationship is also true6363 Subramanian S, Kim D, Kawachi I. Covariation in the socioeconomic determinants of self rated health and happiness: a multivariate multilevel analysis of individuals and communities in the USA. J Epidemiol Community Health. 2005;59(8):664-9.. This relationship was also found in adolescents6464 Mahon NE, Yarcheski A, Yarcheski TJ. Happiness as related to gender and health in early adolescents. Clin Nurs Res. 2005;14(2):175-90., the young6565 Piqueras JA, Kuhne W, Vera-Villarroel P, van Straten A, Cuijpers P. Happiness and health behaviours in Chilean college students: a cross-sectional survey. BMC Public Health. 2011;11:443.,6666 Silva RA, Horta BL, Pontes LM, Faria AD, Souza LDM, Cruzeiro ALS, et al. Bem-estar psicológico e adolescência: fatores associados. Cad Saude Publica. 2007;23(5):1113-8. and the elderly6767 Angner E, Ray MN, Saag KG, Allison JJ. Health and happiness among older adults: a community-based study. J Health Psychol. 2009;14(4):503-12.. However, in the elderly, a study found that health predicted subjective well-being, but the reverse was not true6868 Gana K, Bailly N, Saada Y, Joulain M, Trouillet R, Hervé C, et al. Relationship between life satisfaction and physical health in older adults: a longitudinal test of cross-lagged and simultaneous effects. Health Psychol. 2013;32(8):896-904., perhaps because, in this population, other factors previously listed in the sociodemography of happiness subsection3Aristóteles. Ética à Nicômaco. 1ª ed. Tradução do grego: Antonio de Castro Caeiro. São Paulo: Atlas; 2009. 280p.,4Sêneca. Da vida retirada, da tranquilidade da alma e da felicidade. 1ª ed. Tradução: Lúcia Sá Rebello. Porto Alegre: L&PM Pocket; 2009. came into play. As examples, the happiest nations tend to have lower levels of blood pressure6969 Blanchflower DG, Oswald AJ. Hypertension and happiness across nations. J Health Econ. 2008;27(2):218-33.; a study of coronary artery disease (CAD) found that optimistic men had a lower risk of developing CAD1717 Allen D, Carlson D, Ham C. Well-being: new paradigms of wellness – inspiring positive health outcomes and renewing hope. Am J Health Promot. 2007;21(3):1-9, iii.; and happier people recovered better from sickness7070 Cooper C, Bebbington P, King M, Jenkins R, Farrell M, Brugha T, et al. Happiness across age groups: results from the 2007 National Psychiatric Morbidity Survey. Int J Geriatr Psychiatry. 2011;26(6):608-14..

It is well known that chronic diseases are associated with negative impacts on various aspects of the quality of life, including happiness, and increase the risk of depression7171 Wikman A, Wardle J, Steptoe A. Quality of life and affective well-being in middle-aged and older people with chronic medical illnesses: a cross-sectional population based study. PLoS One. 2011;6(4):e18952.. However, different chronic diseases seem to impact differently on subjective well-being7171 Wikman A, Wardle J, Steptoe A. Quality of life and affective well-being in middle-aged and older people with chronic medical illnesses: a cross-sectional population based study. PLoS One. 2011;6(4):e18952.. In the elderly, for example, the physical diseases that impose decreased happiness were disabling pain and urinary incontinence; these disturb the activities of daily living and are associated with social stigmas6767 Angner E, Ray MN, Saag KG, Allison JJ. Health and happiness among older adults: a community-based study. J Health Psychol. 2009;14(4):503-12..

Furthermore, mental disorders in general, and specifically depression, alcohol and drug abuse7272 Binder M, Coad A. “I’m afraid I have bad news for you…” Estimating the impact of different health impairments on subjective well-being. Soc Sci Med. 2013;87:155-67. and anxiety7272 Binder M, Coad A. “I’m afraid I have bad news for you…” Estimating the impact of different health impairments on subjective well-being. Soc Sci Med. 2013;87:155-67.,7373 Graham C, Higuera L, Lora E. Wich health conditions cause the most unhappiness? Health Econ. 2011;1447:1431-47. more negatively affect happiness than does physical illness. Similarly, there is an inverse relationship between suicide and the subjective well-being index, and also between the presence of mental disorders and happiness7474 Bray I, Gunnell D. Suicide rates, life satisfaction and happiness as markers for population mental health. Soc Psychiatry Psychiatr Epidemiol. 2006;41(5):333-7.. For this reason, it has been proposed that happiness indices could be used as population markers for mental disorders7474 Bray I, Gunnell D. Suicide rates, life satisfaction and happiness as markers for population mental health. Soc Psychiatry Psychiatr Epidemiol. 2006;41(5):333-7.. In this sense, the ability to exercise control over adaptive negative emotions is associated with beneficial results in mental health7575 Kang Y, Gruber J. Harnessing happiness? Uncontrollable positive emotion in bipolar disorder, major depression, and healthy adults. Emotion. 2013;13(2):290-301.. However, excessively large or small variations in positive emotions are associated with poorer mental health, particularly depression and anxiety disorders, lower life satisfaction and more unhappiness7676 Gruber J, Kogan A, Quoidbach J, Mauss IB. Happiness is best kept stable: positive emotion variability is associated with poorer psychological health. Emotion. 2013;13(1):1-6.. Perhaps this issue of emotional control can also explain the association between mental disorders and unhappiness, and the large presence of negative emotions that mental disorders cause.

Positive implications for psychiatry

Given all of the above, a question must be raised: is possible and is it desirable to promote happiness? The evidence appears to say yes. Happiness does not cure the disease but makes people less sick and the size of this effect appears to be comparable to smoking or not7777 Veenhoven R. Healthy happiness: effects of happiness on physical health and the consequences for preventive health care. J Happiness Stud. 2007;9(3):449-69.. In mental health, in particular, the study of factors that lead to happiness can be particularly beneficial in those at higher risk of developing mental disorders1818 Ferraz RB, Tavares H, Zilberman ML. Happiness: a review. Rev Psiquiatr Clin. 2007;34(5):234-42.. In fact, positive psychological interventions have already been successfully tested in patients with depressive disorders7878 Layous K, Chancellor J, Lyubomirsky S, Wang L, Doraiswamy PM. Delivering happiness: translating positive psychology intervention research for treating major and minor depressive disorders. J Altern Complement Med. 2011;17(8):675-83.. Furthermore, investment in approaches that increase subjective well-being may be cheaper for the public purse. For example, a study comparing psychotherapy versus paying monetary damages in legal compensation cases showed that psychological approaches may be up to 32 times cheaper than financial compensation, as well as being more effective in promoting health and happiness in patients potentially involved in litigation7979 Boyce CJ, Wood AM. Money or mental health: the cost of alleviating psychological distress with monetary compensation versus psychological therapy. Health Econ Policy Law. 2010;5(4):509-16.. The understanding of what promotes happiness in people can also be useful for mental health professionals themselves since they are at risk of decreased life satisfaction and burnout syndrome; this can have negative consequences for psychiatric patients, since high levels of stress in these professionals predict therapeutic problems in general8080 Baruch Y, Swartz M, Sirkis S, Mirecki I, Barak Y. Staff happiness and work satisfaction in a tertiary psychiatric centre. Occup Med (Lond). 2013;63(6):442-4..

Positive psychology contains the concept of flourish. This concept suggests five features found in happy people (PERMA) that should be promoted to increase levels of subjective well-being in people in general:

  1. Positive emotions (P)

  2. Engagement (E; being in the flow)

  3. Relationships (R; having healthy relationships)

  4. Meaning (M; purpose in life)

  5. Accomplishment (A)

Investment in any of these areas promotes the others and helps develop happiness8181 Croom AM. Music, neuroscience, and the psychology of well-being: a précis. Front Psychol. 2012;2:393.,8282 Seligman MEP. Flourish: a visionary new understanding of happiness and well-being. Policy. 2011;27(3):60-1..

In addition to increasing happiness, feeding positive emotions such as gratitude, kindness, perseverance, optimism and creativity, contributes to increased resilience, buffers psychological stress and promotes mental health. Programs such as the Penn Resiliency Program (PRP), developed for this purpose, have been successfully implemented in the United States, the United Kingdom, Australia, Portugal and China. In this program, participants learn to adopt more optimistic explanatory styles, detecting inaccurate thoughts, challenging negative beliefs and considering alternative interpretations. In addition, a task force made up of several positive psychology professionals developed an inventory to help people identify their character strengths; this is called the Values in Action Inventory of Strengths (VIA-IS). Despite its limitation of being based on self-report, the simple application of this instrument has been shown to be therapeutic in itself and has brought positive results. The VIA -IS and the PRP are intended for use by adults and children. There is also a tool named Appreciative Inquiry, used in institutions, that aligns with positive psychology. By means of this instrument, groups are helped to refocus problems towards the identification of existing strengths in group members, thus providing a starting point for positive change1414 Kobau R, Seligman MEP, Peterson C, Diener E, Zack MM, Chapman D, et al. Mental health promotion in public health: perspectives and strategies from positive psychology. Am J Public Health. 2011;101(8):e1-9..

Discussion

We have critically reviewed the literature on the relationship between happiness and health in order to identify the most relevant information for psychiatry. We especially considered data that were also being studied in the latest research, and not only the findings of classical studies. Studies are numerous; nevertheless, we realize that many studies on the topic of happiness are transversal; this, despite the use of large samples, diminishes the robustness of some conclusions. In addition, the measurement scales are often limited by being of the self-report variety. In a sense, we already find this difficulty in psychiatry itself in its use of subjective medical measurements, such as pain. However, analysis of the concept of happiness and its associated emotions may be more complex than describing the symptoms of psychiatric disorders, which can expose us to some difficult biases that are difficult to bypass. Another limitation of some studies seems to lie in their contained psychotherapeutic interventions. Although there are well-established interventions within positive psychology (some have been reported in this article) as well an interesting proposal for psychoeducation made by Clonniger (2006), progress in the expansion of clinical approaches seems to be necessary. In addition, most therapeutic interventions proposed have comprised a more psychoeducative approach. Certainly, some of these limitations exist because the interest of the health sciences in this topic is relatively recent. Moreover, is an area that is more linked to the formulation of psychotherapeutic approaches and this tends to discourage investment in the development of new psychoactive drugs.

The study of happiness from a scientific perspective, together with a realization of its implications for health is promising and fascinating, especially if we believe our medical indices of good health are not always in agreement with the perceptions of the patient or society. For example, consider the population of Matsigenka in the Peruvian Amazon; over the past 30 years health indicators have improved greatly, but during the same time period this population reported itself as sicker and unhappier8383 Izquierdo C. When “health” is not enough: societal, individual and biomedical assessments of well-being among the Matsigenka of the Peruvian Amazon. Soc Sci Med. 2005;61(4):767-83.. Perhaps for similar reasons psychiatry has failed to increase subjective well-being in the general population, despite extensive pharmacological advances and new psychotherapeutic techniques. Probably, the focus has been almost exclusively pathological1515 Cloninger CR. The science of well-being: an integrated approach to mental health and its disorders. World Psychiatry. 2006;5(2):71-6..

The immediate goal of all medicine is to alleviate suffering. To achieve this in psychiatry, accurate diagnostic, psychopharmacological advances and psychotherapeutic techniques are fundamental. However, identify what makes life happy can be useful in various types of health prevention (primary, secondary and tertiary)8484 Tessier P, Lelorain S, Bonnaud-Antignac A. A comparison of the clinical determinants of health-related quality of life and subjective well-being in long-term breast cancer survivors. Eur J Cancer Care (Engl). 2012;21(5):692-700.. This particularly applies to promoting mental health as specified in the WHO parameters: a state of well-being in which people can understand and use their own skills, deal with the stresses of life, work and love, and may contribute to their communities8Cloninger CR, Zohar AH. Personality and the perception of health and happiness. J Affect Disord. 2011;128(1-2):24-32.,9WHO. The world health report 2001. Mental health: new understanding, new hope. Geneva: World Health Organization; 2001. 5p.. Furthermore, the promotion of mental health may contribute to reducing the stigma towards psychiatry and psychiatric patients1515 Cloninger CR. The science of well-being: an integrated approach to mental health and its disorders. World Psychiatry. 2006;5(2):71-6..

Conclusion

Positive emotions related to happiness generate beneficial alterations in the neuroendocrine, immune and cardiovascular systems. Aspects of character, such as self-direction, are strongly linked to higher levels of happiness. According to the Easterlin paradox, the relationship between money and happiness is not linear. Levels of happiness tend to fall with increasing age; however, the previous level of subjective well-being is a major predictor of happiness in this age group. Religious people who practice physical leisure activities, who have high educational levels or higher IQs, who are married, who are involved in sports, or do up to 11 hours of volunteer work per week tend to report higher levels of happiness. In addition, higher levels of happiness are related to lower physical and mental illness, as well better coping abilities in adversity For this reason, the study of happiness brings several positive implications for psychiatry that should be considered in clinical practice and in future research.

Acknowledgements

The corresponding author thanks Dr. Rodrigo Tavares, Ph.D., for the academic tips.

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Publication Dates

  • Publication in this collection
    Jul-Aug 2015

History

  • Received
    4 July 2015
  • Accepted
    29 Apr 2015
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