88 Ageing International/Winter 2005

2005, Ageing
International,
30(1), 88-104 Invited Paper

CHRONIC PHYSICAL CONDITIONS

AND AGING: IS MENTAL HEALTH A
POTENTIAL PROTECTIVE FACTOR?
COREY L. M. KEYES
EMORY UNIVERSITY

Research has shown that risk of chronic disease increases with age. Mental disorders
and chronic disease are highly comorbid, with studies showing reciprocal causal
relations. However, research focuses exclusively on combinations of, or a specific,
mental illness. This study investigates the hypothesis that complete mental health is
a protective factor against, while mental illness is a risk factor for, chronic (physical)
conditions with age. Mental health is conceived of as a syndrome of subjective well-
being consisting of symptoms of hedonia (positive feelings toward life) and
eudaimonia (positive functioning in life). A categorical diagnosis of the presence of
mental health, described as flourishing, and the absence of mental health, character-
ized as languishing, are described and applied to data from the MIDUS study of
3,032 adults, 25-74 years old. Data were also collected regarding 12-month preva-
lence of major depressive episode (MDE), and complete mental health is the ab-
sence of any of MDE and the presence of flourishing. Descriptive findings revealed
a strong association of the complete mental health diagnostic categories with 23 of
the 27 self-reported chronic conditions. In multivariate regression, quantity of chronic
disease increased with age and was higher among moderately mentally healthy and
adults with MDE, compared with the completely mentally healthy. Chronic condi-
tions increased exponentially with age among adults with pure languishing and
adults with languishing and a MDE. At all ages, completely mentally healthy adults
reported the fewest chronic conditions, suggesting it may act as a protective factor
in aging.

Does level of mental health and mental illness influence the risk of chronic
physical disease in adulthood? This study investigates whether high levels of
positive mental health act as a protective factor against the accumulation of
chronic physical diseases with age. Conversely and importantly, this paper
investigates whether mental illness—specifically major depressive episode—
Send correspondence to C.L.M. Keyes, Department of Sociology, Emory University, Room 225,
Tarbutton Hall, 1555 Dickey Drive, Atlanta, GA 30322.
Ageing International, Winter 2005, Vol. 30, No. 1, pp. 88-104.

88
Keyes 89

and whether the absence of mental health—a condition described as “lan-

guishing”—act as a risk factors for chronic physical disease throughout adult-
hood.
Life expectancy in the United States increased dramatically during the twen-
tieth century. Though individuals are living longer lives, rates of many chronic
health conditions have increased. As such, the expansion of life expectancy
has increased the number of years spent living with chronic physical disease
and therefore disability (Olshanky et al., 1991). This has happened for at least
two reasons. First, and by definition, biological aging consists of cellular de-
generation. With time, all individuals will experience some physical decay,
disorder, or disease. Thus, the risk of any physical disease increases with age,
and the number of physical diseases increases with age.1 Second, although
risk of physical disease is rather low in youth and younger adults, the occur-
rence of some chronic disorders such as diabetes, asthma, and even cardio-
vascular diseases are now occurring at younger ages (Nusselder et al., 1996).
Risk factors are measurable characteristics or qualities of individuals, in-
terpersonal relationships, contexts, and institutions that can elevate the prob-
ability of the occurrence of a discrete and undesirable outcome (e.g., alcohol
abuse, physical inactivity) or the probability of change in levels of an undesir-
able outcome (e.g., severity of disease; Kraemer et al., 1997). Age has been
shown to be an independent risk factor for the onset, severity, and duration of
chronic physical disease. With increased age, individuals of all backgrounds
(i.e., gender and race) exhibit higher rates of most chronic diseases—ranging
from oral health problems (e.g., gum and teeth), arthritis, cancers, to cardio-
vascular disease (Jette, 1996). With regard to cardiovascular disease, for ex-
ample, age has been consistently shown to be among the most potent risk
factors (Grundy, 1999; Lakatta, 1999). In turn, chronic physical disease is a
burden to society in terms of direct costs (e.g., healthcare, rehabilitation) and
indirect costs (e.g., productivity losses and workdays missed). Using data from
the National Institutes of Health, Keyes and Lopez (2002) computed the com-
bined—direct and indirect—costs of specific chronic disorders. Cardiovascu-
lar disease was most costly, resulting in approximately $180 billion dollars in
combined costs. Diabetes resulted in about $95 billion, cancers cost about
$94 billion, arthritis costs about $61 billion, digestive disorders about $53
billion, stroke cost approximately $40 billion, while HIV-AIDS costs about
$22 billion in combined costs.
In addition to age, mental illness—particularly major depression—has been
shown to be an independent risk of chronic disease that has received little
attention by the medical community traditionally focused on physiological
rather than psychosocial causes and treatment of illness. In particular, major
depression has been shown to be a cause and outcome of cardiovascular dis-
ease (Ford et al., 1998; Frasure-Smith & Lesperance, in press; Glassman &
Shapiro, 1998; Mussleman et al., 1998). Heart attack survivors with and with-
out a prior history of depression are at a high risk of an episode of major
90 Ageing International/Winter 2005

depression (Lesperance et al., 1996), with some studies (Carney et al., 1997)
showing that as much as two-thirds of patients are diagnosed with depression
following myocardial infarction. In addition, depression has been implicated
in the onset and course of asthma (Mancuso et al., 2000), stroke (Jonas &
Mussolino, 2000), arthritis (Musil et al., 2001), diabetes (Anderson et al., 2001),
cancer (Bodurka-Bevers et al., 2000), and obesity (McElroy et al., 2004).
Whether it is cause or an effect of chronic physical conditions, mental
illness is also a social and economic burden to society. In fact, data show that,
in terms of combined direct and indirect costs, mental illness is among the
three most costly conditions in the United States (Keyes & Lopez, 2002).
Worldwide, mental illness has been shown to be among the top five causes of
“disability-adjusted life years” (DALYs), a composite measure of the burden
of specific health conditions in terms of the number of years of life lost pre-
maturely to death and the number of years lived with disability in a population
(Murray & Lopez, 1996, 1997). Within the category of mental illness, major
(unipolar) depressive episode has been shown to be among the leading spe-
cific causes of DALYs, second only to coronary artery disease (Murray &
Lopez, 1996, 1997) and it is projected to become the second leading cause of
DALYs in developing and developed nations by the year 2020. In the United
States, major depressive episode has been estimated to cost in excess of $40 bil-
lion in combined direct and indirect costs (Greenberg et al., 1993). Mental illness
in general, but depression in particular, is a burden whether it is causing chronic
physical condition or it is the outcome of chronic physical conditions.
However, studies of the comorbidity of physical disease and mental illness
suffer from an incomplete conception and diagnosis of mental health. Hereto-
fore, research compared individuals diagnosed as mentally ill against indi-
viduals who did not meet the Diagnostic and Statistical Manual (DSM—Ameri-
can Psychiatric Association, 2000) criteria for a specific mental illness. In
other words, individuals who are free of a mental illness diagnosis are treated
as mentally healthy and as the reference group against which the risk and
burden of physical conditions is compared with individuals deemed currently
mentally ill. However, research shows that only 20% of individuals who had
not suffered an episode of major depression fit the criteria for mental health as
operationalized by Keyes (2002). Instead, nearly two-thirds of non-depressed
adults were moderately mentally healthy, while 14% diagnosed as languish-
ing in life with very low levels of subjective well-being (Keyes, 2002). More-
over, individuals who were mentally healthy missed fewer days of work and
had fewer limitations of activities of daily living than moderately mentally
healthy individuals. In turn, moderately mentally healthy adults missed fewer
days of work and had fewer limitations of activities of daily living than lan-
guishing adults.
Therefore, Keyes (2002, 2003, 2005) has conceptualized and measured
mental health as a complete state consisting of not merely the presence and
absence of mental illnesses such as major depression, but the presence and
Keyes 91

absence of levels of specific dimensions of subjective well-being (i.e., emo-

tional well-being, psychological well-being, and social well-being). The com-
plete mental health diagnosis classifies individuals into one of five states of
mental health. Complete mental health is a state of mental health in which
people are free of a major depressive episode and fit the criteria for flourish-
ing in life with high levels of emotional, psychological, and social well-being.
In contrast, languishing is a state of being mentally unhealthy in which indi-
viduals have lows levels of emotional, psychological, and social well-being
but do not fit the criteria for major depression or even minor depression. Indi-
viduals who are moderately mentally healthy are not depressed, nor are they
languishing, but they have not reached the diagnostic level of flourishing.
Some individuals may fit the criteria for languishing in life but also the criteria
for a major depressive episode during the past year. Last, some individuals
may fit the criteria for moderately mentally healthy but also fit the criteria for
a major depressive episode, the combination of which is labeled as “pure”
episode of depression (Note: because there are so few individuals who are
flourishing and also report a major depression, these individuals are collapsed
into the category of “pure depression.”)
Based on this diagnosis of complete mental health, recent research shows
that barely one-quarter of individuals who had not suffered an episode of
major depression during the past year fit the criteria for flourishing. Most non-
depressed adults were moderately mentally healthy, while nearly one-quarter
of non-depressed adults were diagnosed as languishing in life. Moreover, studies
reveal that adults who were diagnosed as completely mentally healthy func-
tioned superior to all others in terms of fewest workdays missed or cutback,
lowest level of limitation of activities of daily living, and the lowest risk of
cardiovascular disease (Keyes, 2002, 2004a).
A protective factor is connected directly with the concept of resilience
(Keyes, 2004b; Masten, 2001), because it acts to avert or mitigate a risk fac-
tor, which in the present study is the rise of physical health conditions with
age. Studies show that the presence of emotional well-being, an important
component of the complete mental health diagnosis, prevents the onset of
disability among older adults. In a sample of older (65 to 99 years old) His-
panic community-dwelling adults without limitations of daily life at baseline,
Ostir and colleagues (Ostir et al., 2000; see also Danner et al., 2001; Penninx
et al., 1998) found that those with high positive affect were half as likely as
the adults with low positive affect to have died or to have acquired limitations
of activities of daily life two years later. These findings controlled for
sociodemographic variables, functional physical status, lifestyle (i.e., smok-
ing and drinking), and negative affect scores at baseline.
Using the complete mental health diagnosis and the Midlife in the United
States (i.e., MIDUS) data, findings revealed that adults with complete mental
health had the lowest prevalence and adjusted risk of any cardiovascular dis-
ease (Keyes, 2004a). Why complete mental health (e.g., the absence of de-
92 Ageing International/Winter 2005

pression and the presence of flourishing) may act as a protective factor is

suggested by findings from a recent paper that examined the psycho–social
resources of mentally healthy adults (Keyes, 2005). In this study, and com-
pared with adults diagnosed as moderately mentally healthy, languishing, or
depressed, adults who were completely mentally healthy reported the highest
levels of psychosocial resources. That is, completely mentally healthy adults
report the highest levels of direction in life (e.g., they know what they want
out of life), intimacy (e.g., they feel really cared for by a friend or family
member), resilience (e.g., they can change bad situations for the better and
learn from difficult situations), and they report the lowest levels of helpless-
ness (e.g., I cannot change important things in one’s life).
In sum, the purpose of the current study is to extend the previous research
on the nexus of mental illness with chronic physical conditions. Does com-
plete mental health operate as a protective factor against the accumulation of
chronic physical conditions with age? Current empirical understanding of the
functioning and psychosocial resources of adults who are completely men-
tally healthy suggests the hypothesis that mental health may act as a protec-
tive factor against the accumulation of chronic physical conditions with age.
Thus, the primary hypothesis is that adults who are completely mentally healthy
should report significantly fewer chronic physical conditions at all ages than
adults who are moderately mentally health, languishing, depressed, or lan-
guishing and depressed.

Methods

Sample

Data are from the MacArthur Foundation’s Midlife in the United States
survey. This survey was a random-digit-dialing sample of non–institutional-
ized English-speaking adults age 25 to 74 living in the 48 contiguous states,
whose household included at least one telephone. In the first stage of the
multistage sampling design, investigators selected households with equal prob-
ability via telephone numbers. At the second stage, they used disproportion-
ate stratified sampling to select respondents. The sample was stratified by age
and sex, and males between ages 65 and 74 were oversampled.
Field procedures were initiated in January of 1995 and lasted 13 months.
Respondents were contacted and interviewed by trained personnel, and those
who agreed to participate in the entire study took part in a computer-assisted
telephone interview lasting 30 minutes, on average. Respondents then were
mailed two questionnaire booklets requiring 1.5 hours, on average, to com-
plete. Respondents were offered $20, a commemorative pen, periodic reports
of study findings, and a copy of a monograph on the study.
The sample consists of 3,032 adults. With a 70% response rate for the
telephone phase and an 87% response rate for the self-administered question-
Keyes 93

naire phase, the combined response is 61% (.70 × .87 = .61). Descriptive
analyses are based on the weighted sample to correct for unequal probabilities
of household and within household respondent selection. The sample weight
post-stratifies the sample to match the proportions of adults according to age,
gender, education, marital status, race, residence (i.e., metropolitan and non-
metropolitan), and region (Northeast, Midwest, South, and West) based on the
October 1995 Current Population Survey.

Measures

Chronic Physical Conditions. During the telephone interview, respondents

were asked whether they suspected, or had a medical doctor confirm, that
they had any of 27 chronic physical health problems (Table 1). The measure-
ment of chronic conditions in the MIDUS was adapted from the Medical Out-
comes Study (Brazier et al., 1992), which provides validated measures of self-
reported physical morbidity that have been used in epidemiological studies of
comorbid psychiatric and physical conditions (Wells et al., 1989).
Mental Illness. The Midlife in the United States survey employed the Com-
posite International Diagnostic Interview Short Form (CIDI-SF) scales, which
was designed to measure most common mental disorders (Kessler et al., 1998),
demonstrated excellent diagnostic sensitivity and specificity when compared
with diagnoses based on the complete CIDI in the National Comorbidity Study
(Kessler et al., 1999). During the telephone interview, the CIDI-SF was used
to assess whether respondents exhibited symptoms indicative of major de-
pression episode (MDE) during the past 12 months. Respondents were classi-
fied as having had a major depressive episode based on the criteria estab-
lished by the DSM-III-R (American Psychiatric Association, 1987).
Complete mental health was measured with three established multi-item
scales of subjective well-being and based on Keyes (2002, 2005).
Emotional Well-Being. By self-administered questionnaire, respondents
indicated how much of the time during the past 30 days—”all,” “most,” “some,”
“a little,” or “none of the time”—they felt six symptoms of positive affect.
The positive affect symptoms are (1) cheerful, (2) in good spirits, (3) ex-
tremely happy, (4) calm and peaceful, (5) satisfied, and (6) full of life. The
internal reliability of the positive affect scale is .91. Respondents also evalu-
ated their life satisfaction as follows: “rate their life overall these days” on a
scale from 0 to 10, where 0 meant the “worst possible life overall” and 10
meant “the best possible life overall.”
Psychological Well-Being. Ryff’s (1989) measures of psychological well-
being operationalize how much individuals see themselves thriving in their
personal life. The scales represent distinctive dimensions (Ryff & Keyes, 1995)
of subjective well-being. The scales with a representative item in parenthesis
are as follows: self-acceptance (“I like most parts of my personality”), posi-
tive relations with others (“maintaining close relationships has been difficult
94 Ageing International/Winter 2005

and frustrating for me”), personal growth (“For me, life has been a continual
process of learning, changing, and growth”), purpose in life (“I sometimes
feel as if I’ve done all there is to do in life”), environmental mastery (“I am
good at managing the responsibilities of daily life”), and autonomy (“I tend to
be influenced by people with strong opinions”).
Each scale consisted of three items with a relative balance of positive and
negative items self-administered via the questionnaire. On a scale from 1 to 7
(with 4 as a middle category of neither agree nor disagree), respondents indi-
cated whether they agreed or disagreed strongly, moderately, or slightly that
an item described how they functioned (i.e., thought or felt). Negative items
were reverse-coded. The three-item scales have shown modest internal con-
sistency (i.e., around .50; see Ryff & Keyes, 1995), and the internal consis-
tency of the combined 18 items is .81.
Social Well-Being. Keyes’ (1998) measures of social well-being
operationalize how much individuals see themselves thriving in their social
life. The scales with a representative item in parentheses are as follows: so-
cial-acceptance (“People do not care about other peoples’ problems”), social
actualization (“Society isn’t improving for people like me”), social contribu-
tion (“My daily activities do not create anything worthwhile for my commu-
nity”), social coherence (“I cannot make sense of what’s going on in the world”),
and social integration (“I feel close to other people in my community”).
Each scale consisted of three items with a relative balance of positive and
negative items and was self-administered. On a scale from 1 to 7 (with 4 as a
middle category of neither agree nor disagree), respondents indicated whether
they agreed or disagreed strongly, moderately, or slightly that an item de-
scribed how they functioned (i.e., thought or felt). Negative items were re-
verse-coded. The three-item scales have shown modest-to-excellent internal
consistency (Keyes, 1998), and the internal consistency of the social well-
being scale with all items combined is .81.
To diagnose mental health, all scales of well-being were divided by the
number of constituent items, standardized, and tertiles were computed for
each scale. Individuals with scores in the upper tertiles of one of the two
emotional well-being scales and six of the 11 scales of psychological and
social well-being were classified as flourishing. Individuals with scores in the
lower tertiles of one of the two emotional well-being scales and six of the 11
scales of psychological and social well-being were classified as languishing.
Adults who were neither flourishing nor languishing were classified as mod-
erately mentally healthy.
Complete mental health status was constructed by cross–tabulating the
depression diagnosis with the mental health diagnosis. This resulted in the
following categories of complete mental health: complete mental health (i.e.,
absence of depression and the diagnosis of flourishing), moderately mentally
healthy, languishing (i.e., without MDE), major depressive episode (MDE),
and languishing and MDE.
Keyes 95

Sociodemographic, Control Variables. Chronological age was coded as a

continuous variable. Sex, race (white versus minority), marital status (cur-
rently married versus all other), whether the respondent engages in any physi-
cal exercise, and whether the respondent current smokes or ever smoked were
coded dichotomously. Total household income was measured continuously,
as was education, which was the highest grade or year or schooling com-
pleted.
Lastly, body mass index (BMI) was obtained from the self-report of a
respondent’s current weight, waist size, hip size, and height. The BMI mea-
surements were obtained by including a tape measure with each self report
questionnaire, which included instructions in both picture and word format.
All respondents were instructed to take the measurements standing, to avoid
taking measurements over clothing, to record their answers to the nearest one-
fourth of an inch, and the use the provided diagram to specify the location of
hips and waist. The BMI is an individual’s weight in kilograms divided by
height in meters squared. (BMI=kg/m2), and is an indicator of body fat.

Results

Table 1 presents the unadjusted association of each of the 27 self-reported

chronic physical conditions with the complete mental health diagnosis. The
percentage of chronic disease is computed within each category of mental
health. Findings reported in Table 1 strongly support the hypothesis that the
mental health diagnosis is associated with chronic conditions, as mental health
was associated with 23 of the 27 conditions (i.e., 85% of the chronic physical
conditions). The risk of chronic conditions was highest among adults who are
languishing and had an episode of major depression. In sharp contrast, adults
who were completely mentally healthy reported the lowest risk of chronic
physical conditions, even less than adults diagnosed as moderately mentally
healthy. Compared with moderately mentally healthy adults, those who were
languishing reported more chronic conditions and, in most cases, about the
same amount of conditions as adults with a pure episode of depression.
Next, the count of the number of chronic physical condition (out of 27
possible) was treated as a dependent variable in a simple ANOVA with age
coded into three groups (young = 25-39, midlife = 40-59, older = 60-74) and
the categories from the complete mental health diagnosis. Results revealed a
main effect of age (F(2,2990) = 47.8, p < .001) and for complete mental health
(F(4,2990) = 63.9, p < .001). The average number of chronic physical conditions
among young adults was 1.8 (SD = 2.2), among midlife adults it was 2.5 (SD
= 2.6), and among older adults it was 3.1 (SD = 2.6). The mean number of
chronic physical conditions was 4.5 (SD = 3.4) among adults who were lan-
guishing and had MDE, 3.1 (SD = 3.2) among adults with only MDE, 3.1 (SD
= 3.0) among adults who were languishing, 2.1 (SD = 2.2) among adults who
were moderately mentally healthy, and 1.5 (SD = 1.7) among adults who were
96 Ageing International/Winter 2005

Table 1
Prevalence of Chronic Physical Conditions by Complete Mental Health

Complete Mental Health Status

Languishing and
Major Depressive Pure Major Moderately CompletelyMent
Episode Depressive Mentally ally Healthy
Physical Condition N = 143 Episode Languishing Healthy N = 520
Prevalence N = 285 N = 368 N = 1,716 χ?22(df=4)
1
Stomach Problems
20.6% 50.3% 24.2% 29.8% 18.6% 10.2% 136.7***

Back Problems2
20.5% 36.9% 26.7% 26.3% 18.8% 13.9% 54.1***

Arthritis3
19.6% 31.5% 21.9% 23.5% 18.8% 14.6% 25.9***

High Blood Pressure

18.1% 18.9% 18.9% 20.9% 18.1% 15.6% 4.3

Hayfever
15.8% 25.9% 19.4% 17.9% 15.0% 12.1% 21.0***

Urinary Problems
13.6% 20.4% 15.1% 16.5% 13.4% 9.3% 16.9**

Chronic Sleep Problems

12.9% 41.7% 25.3% 20.7% 9.4% 4.2% 217.4***

Asthma, Other Lung4

12.7% 25.2% 18.2% 13.5% 11.5% 9.8% 34.2***

Foot Problems5
11.7% 22.5% 11.5% 17.1% 10.7% 8.1% 34.5***

Piles or Hemorrhoids
11.5% 14.0% 14.7% 13.3% 11.0% 9.2% 7.9

Migraine Headaches
11.3% 28.0% 20.0% 12.4% 9.8% 5.8% 81.4***

Skin Problems6
10.6% 16.8% 16.8% 13.5% 9.1% 8.1% 28.2***

Teeth Problems7
10.4% 23.2% 10.2% 16.5% 10.1% 3.7% 43.8***

Gum Problems8
8.3% 23.1% 9.8% 13.5% 7.1% 3.9% 71.4***

Persistent Constipation
7.0% 11.1% 8.4% 9.6% 6.6% 4.4% 14.4**
Keyes 97

Table 1 (cont.)

Gall Bladder
2.6% 8.4% 3.9% 1.9 2.6% 1.0% 26.7***

Neurological Disorder9
1.7% 0.7% 4.2% 2.2% 1.6% 0.8% 14.7**

Varicose Veins10
1.6% 2.8% 2.5% 2.5% 1.3% 1.0% 6.9

Autoimmune Disorder11
1.1% 2.8% 1.4% 0.8% 0.9% 1.0% 4.9

Stroke
1.0% 2.1% 2.1% 2.8% 0.6% 0.4% 20.9***

HIV/AIDS
0.4% 1.4% 1.1% 1.4% 0.1% 0.0% 24.4***

Tuberculosis
0.3% 0.0% 1.4% 1.1% 0.1% 0.0% 24.7***

Note: * p < .05; ** p < .01; *** p < .001 (two-tailed).

1
"Recurring stomach trouble, indigestion, or diarrhea”
2
"Sciatica, lumbago, or recurring backache”
3
"Arthritis, rheumatism, or other bone or joint disease”
4
"Asthma, bronchitis, or emphysema”
5
"Persistent foot trouble (e.g., bunions, ingrown toenails)”
6
"Persistent skin trouble (e.g., eczema)”
7
"Persistent trouble with your teeth”
8
"Persistent trouble with your gums or mouth”
9
"Multiple sclerosis, epilepsy, or other neurological disorder”
10
"Trouble with varicose veins requiring medical treatment”
11
"Lupus or other autoimmune disorders”

complete mentally healthy. In addition to the main effects, the ANOVA re-
vealed an interaction of age and complete mental health (F(8,2990) = 3.1, p <
.002).
The interaction of age and complete mental health was scrutinized with
multivariate regression using the number of chronic conditions as the depen-
dent variable. Here, complete mental health was coded into dummy variables
with complete mental health as the reference category. Age was treated con-
tinuously and multiplicative interaction terms were computed with each
mental health category. Using the various controls, Table 2 reports the results
of the multivariate regression model. Even with controls, moderately mentally
healthy adults reported more chronic physical conditions than adults who were
completely mentally healthy. Moreover, adults who had a major depressive
episode reported an average of 1.4 more chronic physical conditions than
completely mentally healthy adults. Both pure languishing and languishing
with MDE interacted with age.
98 Ageing International/Winter 2005

Table 2
Ordinary Least Squares Regression of Number of Chronic
Physical Health Conditions onto Complete Mental Health Status and Controls
(sample unweighted; N = 2,930)

Predictor b β

Languishing with MDE .91 .06

Pure Major Depressive Episode (MDE) 1.4*** .16

Pure Languishing -.30 -.04

Moderately Mentally Healthy .39*** .08

Pure Languishing × Age .03* .19

Languishing with MDE × Age .04** .15

Completely Mentally Healthy ----- -----

Control Variables:

Females (vs. males) .45*** .09

Caucasians (vs. all ethnic minorities) -.13 -.03

Married (vs. unmarried) -.02 -.01

Level of Education -.08*** -.04

Household Income -.02 -.02

Age .02*** .12

Does Not Exercise (vs. exercises) .34*** .07

Whether Smokes (vs. never smoked) .38*** .08

Body Mass Index .06*** .13

α
α -.79 -----

R2 .18

Note: * p < .05; **p < .01; *** p < .001 (two-tailed).

The interaction terms indicate that the number of chronic conditions in-
crease exponentially with age if one has pure languishing or is languishing
and has an episode of major depression. Figure 1 portrays the interaction
effects of pure languishing and languishing with MDE by age, showing the
unadjusted mean level of chronic physical conditions. Young languishing adults
have an average of one more chronic condition than flourishing young adults;
midlife languishing adults report an average of about 1.7 more conditions
than flourishing midlife adults; and languishing older adults have an average
of 2.8 more chronic conditions than flourishing older adults. Similarly, young
Keyes 99

Figure 1
Unadjusted Number of Chronic Physical Health Conditions by Age Group and
Complete Mental Health Diagnosis

languishing adults with MDE report an average of 2.8 more chronic condi-
tions than flourishing young adults; midlife languishing adults with MDE have
an average of 3.5 more conditions than flourishing midlife adults; and lan-
guishing older adults who also had MDE have an average of 4.6 more chronic
conditions than flourishing older adults.2
In addition, and with adjustments in the multivariate regression, the main
effects of moderate mental health and pure major depressive episode provide
support for the hypothesis that all levels of mental health are associated with
chronic physical conditions. While chronic conditions increased an average
of 0.02 for each yearly increment in age, findings also show that at all ages,
moderately mentally healthy adults report 0.39 more chronic conditions than
flourishing adults. Compared with flourishing adults, those with a pure epi-
sode of major depression report 1.4 more chronic health conditions at all ages.

Discussion

This study investigated whether mental health influences the risk of chronic
physical disease throughout adulthood. Prior studies that have addressed this
question have treated mental health dichotomously; that is, compared with
adults not diagnosed and depressed, adults with depression are at elevated
risk of a host of chronic physical conditions. In this study, mental health is
conceived of and measured as a complete state consisting of five distinctive
categories of mental health and illness. This study sought to extend past re-
search by investigating whether flourishing—absence of depression and pres-
100 Ageing International/Winter 2005

ence of emotional, psychological and social well-being—acts as a protective

factor against the accumulation of chronic physical diseases with age.
The complete mental health diagnosis permits distinguishing between adults
otherwise free of major depression but having moderate mental health or lan-
guishing in life with low levels of subjective well-being. This study, then,
investigated whether the absence of mental health (i.e., languishing and mod-
erate mental health) are risk factors for the chronic conditions with age in the
same way that the presence of mental illness (i.e., major depressive episode
with and without languishing) have been shown to be risk factors for chronic
conditions.
Findings support the thesis that complete mental health is a potential pro-
tective factor against the rise of chronic physical disease with age. Descriptive
analyses revealed that flourishing adults reported the lowest prevalence of 23
of a possible 27 chronic conditions, compared with all other adults. Com-
pared with flourishing adults, moderately mentally healthy adults reported a
higher prevalence of specific chronic conditions, and in the multivariate re-
gression, reported slightly more chronic conditions on average. As in previ-
ous research (Keyes, 2002, 2005), the condition of pure languishing was as-
sociated with levels of impairment that were comparable to levels associated
with major depressive episode. In turn, and similar to those previous studies,
the condition of languishing with an episode of major depression was associ-
ated with the highest level of impairment. That is, individuals who were lan-
guishing and reported an episode of major depression reported the highest
prevalence of specific chronic conditions and the highest total number of
chronic conditions.
The interactions of pure languishing with age and of the condition of lan-
guishing and MDE with age revealed that the rate of accumulation of chronic
physical conditions among these individuals increases with age. For example,
young adults with pure languishing reported an average of 1.0 more chronic
physical condition than completely mentally healthy young adults. By com-
parison, older adults with pure languishing reported an average of 2.7 more
chronic physical conditions than completely mentally healthy older adults.
Thus, older languishing adults had nearly three times as many chronic condi-
tions as languishing younger adults. Moreover, completely mentally healthy
young adults reported an average of 1.1 chronic conditions, compared with
an average of 2.2 among completely mentally healthy older adults. That is,
completely mentally healthy older adults had about one more chronic physi-
cal condition than completely mentally younger adults.
While the findings of this study suggest that flourishing may be a protec-
tive factor against chronic disease, several limitations warrant caution with
any strict causal conclusion. First, the MIDUS data are cross-sectional, which
preclude disentangling causal direction between mental and physical health.
It is plausible that the incidence and presence of chronic conditions adversely
affect emotional, psychological and social well-being. Regardless of causal-
Keyes 101

ity, however, the conclusions of this study support the growing literature high-
lighting the importance of including mental health and mental illness into
studies of population aging. Second, the measures and diagnosis of complete
mental health and the chronic physical conditions were subjective, self-re-
ports. Telephone interviews, furthermore might have biased self-reports of
CIDI assessment criteria. While both sets of measures have shown excellent
measurement qualities, the ability to buttress this research with clinical studies
that use experts clinician assessment of a patient’s complete mental health
status with medical records of chronic conditions (and severity) would be
important next steps.

Notes

1. Reasons for why age is a risk factor for physical health conditions are well established in the
research literature on biological, cellular (e.g., free radicals and oxidative stress) and genetic (e.g.,
telomere shortening) response to stress and the normal adaptation to life’s demands that produce
long-term wear-and-tear (see Epel et al., 2004; McEwen, 1998).
2. Because neither of the main effects for pure languishing or languishing with MDE were statistically
significant in the multivariate regression, this means that the average number of chronic conditions
among young adults with languishing or who were languishing and had MDE were not different.

Biographical Note

Dr. Corey L.M. Keyes was a member of the prestigious MacArthur Foundation interdisciplinary
research network on successful midlife development, and was co-chair (with then American Psy-
chological Association President, Martin Seligman) of the historic First Summit of Positive Psy-
chology held at the Gallup Organization in 1999. He is a founding steering committee member of
the interdisciplinary Society for the Study of Human Development.
His recent work includes edited volumes entitled Flourishing: Positive Psychology and the Life Well-
Lived (APA Press, 2003), and Well-Being: Positive Development Through the Life-Course (Erlbaum,
2003)), a special journal issue entitled Risk and Resilience in Human Development (in Research on
Human Development), and Women and Depression: A Handbook of Medical, Psychological and
Social Perspectives (Cambridge University Press, in press).

Acknowledgments

This research was supported by membership in the John D. and Catherine

T. MacArthur Foundation Research Network on Successful Midlife Develop-
ment (Director, Dr. Orville Gilbert Brim). Dr. Keyes is jointly appointed to the
Department of Behavioral Sciences and Health Education of the Rollins School
of Public Health, and he is an adjunct Professor of Psychology. The author
gratefully acknowledges the outside reviews of Rosemarie Kobau (Centers
for Disease Control and Prevention) and Glenn Ostir (University of Texas
Medical Branch).
102 Ageing International/Winter 2005

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* Invited paper. Revised manuscript accepted for publication in January, 2005. Action
editor: P.S. Fry.