Depression, Hopelessness, And Health Research Paper

Depression develops in people who initially were not depressed. Though the experience can be long-lasting or repeated, it does not usually last for the person’s entire lifetime. Certain personality traits, however, have overtones of qualities that are part of depression. Consider the dimension of optimism vs. pessimism. Optimists are people who expect good things to happen to them; pessimists expect bad things to happen. Pessimism thus has a link to depression. Unlike depression, however, pessimism is an enduring personality trait. The personality dimension of optimism vs. pessimism has been studied a good deal in health psychology. Some of that research has found that this aspect of personality has consequences for physical well-being.

The concept of hopelessness has links to both depression and pessimism. Sometimes hopelessness is used to refer to a state; sometimes it is used to refer to personality qualities. One might view the concept of hopelessness as representing a conceptual bridge between the (usually temporary) state of depression and longer-lasting traits of personality such as pessimism. People who are experiencing depression often feel hopeless about the future; people who are pessimistic are more broadly and consistently lacking in hope for the future.

This research paper describes some of the research that links depression, hopeless, and pessimism to health problems. As background to that research, the next section describes the conceptual basis for examining how these variables may be involved in health.

1. Pessimism, Hopelessness, And Disengagement

The concepts of optimism and pessimism are rooted in centuries of folk wisdom about the consequences of people’s expectations for the future. Contemporary research on optimism and pessimism also has its roots in people’s expectations for the future. In adopting that starting point, this research connects to more than a century of psychological theory (Carver and Scheier 1998, 1999). That is, the expectancy construct links this research to a collection of theories of motivation and action that are called expectancy-value theories. This link, in turn, provides a rationale for examining the way in which the traits of optimism and pessimism are expressed in motivation, behavior, and feelings. These expressions of optimism and pessimism represent a set of potential pathways by which this personality disposition may relate to health.

Expectancy-value models begin with the idea that behavior is aimed at attaining desired goals (values). Without a valued goal, there is no reason to act. The other element is expectancy: confidence or doubt about being able to attain the goal. If a person lacks confidence, again there will be no action. Only with sufficient confidence do people exert efforts and remain engaged in those efforts. These principles pertain to specific values and focused confidence, and they also apply to the more general traits of optimism and pessimism. In optimism and pessimism the ‘confidence’ involved is simply broader in scope.

These principles provide the basis for many predictions about optimists and pessimists: when confronting a challenge, optimists should take a posture of confidence and persistence, even if progress is difficult or slow. Pessimists should be more doubtful and hesitant. This divergence should be amplified under conditions of adversity. Optimists are likely to believe the adversity can be handled successfully, pessimists are likely to anticipate disaster. These differences in orientation can lead to differences in persistence, differences in active efforts to take precautions, differences in many decisions and actions that pertain to health risks.

People’s behavioral responses to adversity are important, but overt behavior is not the only response that occurs when people confront adversity. People also experience emotions in such situations. Difficulties elicit a mixture of feelings, and variables such as optimism influence the balance among the feelings. Again, predictions are easily derived from theory. Optimists expect to have good outcomes, even when things are difficult. This confidence should yield a more positive mix of feelings. Pessimists expect bad outcomes. This should be related to more intense negative feelings—anxiety, sadness, or despair. Though these emotional responses are not the focus of this research paper, a good deal of research has found evidence of such emotional differences between optimists and pessimists (Carver and Scheier 1999).

The experiences of intense distress, hopelessness, and disengagement from effort have physical concomitants; so do positive emotions and engagement in positive efforts. A number of psychologists believe that these physiological responses can play a role in health outcomes. Such processes may influence a person’s probability of getting a disease in the first place, they may influence the progression of diseases, they may even influence mortality. There is a good deal of evidence that personality differences in optimism–pessimism relate to differences in health related outcomes. Research on the precise pathways of influence is at an early stage, but enough evidence has emerged to suggest that the questions are worth examining further.

Researchers have studied the effects of pessimism and hopelessness in two ways. In some studies the variables are measured as generalized personality dispositions. In other studies they are measured as attitudes toward particular contexts or particular health outcomes. Studies that examine both sorts of pessimism typically find a moderate correlation between the two, but sometimes the relation is much weaker (raising interesting questions about the organization of personality that go beyond the scope of this research paper). Whether deriving from a generalized or a context-specific approach, however, evidence suggests that pessimism and hopelessness have adverse implications for health.

In the review that follows, some studies used generalized measures, others used more focused measures. A few of the studies did not measure pessimism or hopelessness directly, but rather the psychological responses they are believed to induce, such as disengagement vs. active effort.

2. Pessimism, Hopelessness, Depression, And Health

How do pessimism, hopelessness, and depression relate to health outcomes? This selective review of studies is organized as follows. First are examples of how behavioral reflections of optimism vs pessimism, in the form of effort vs disengagement, can influence health risk and thus well-being. Then comes a more extensive section dealing with disease processes themselves—disease promotion, progression, and mortality—and their relations to pessimism and depression.

2.1 Optimism And Health Related Actions

Sometimes being persistent in one’s goal related effort is itself an important determinant of health and well-being. An example of the relevance of behavioral persistence comes from work on active health promotion. Optimists, who are confident about attaining and maintaining the goal of good health, should be more likely than pessimists to continue pursuit of health promotion activities even if it entails a good deal of effort. Evidence from several studies supports this hypothesis.

One study looking at potential individual differences in health promotion followed a group of heart patients who were involved in a cardiac rehabilitation program (Shepperd et al. 1996). Optimism among participants was related to increases in exercise levels across the study period. Optimism also related to greater success in lowering levels of saturated fat, lowering body fat, and lowering an index of global coronary risk.

Another study followed coronary artery bypass patients during the period immediately after surgery (Scheier et al. 1989) and then re-examined them five years later (described in Scheier and Carver 1992). The early part of the project focused mostly on patients’ responses to the surgery as an event in their lives; the later part of the project investigated their lifestyles five years postsurgery. In the early part of the project, optimists gave several indications of focusing their efforts on getting back on their feet quickly. They were viewed by the hospital staff as recuperating faster, and they reported concentrating on the rehabilitation process. Pessimists, in contrast, were more likely to be avoiding even thinking about the future. Five years later, optimists were more likely than pessimists to be taking vitamins, to be eating low-fat lunches, and to be enrolled in a cardiac rehabilitation program. Thus, both initially and later on, pessimists were less persistent than optimists in health promoting behaviors.

Heart disease is one aspect of health to which behavioral efforts are relevant. Another health risk that is related to behavior, though in a different manner, is HIV infection. Infection can occur from engaging in sexual activities with partners who are not known to be disease free. By taking steps to avoid such sexual practices—for example, avoiding sex with unknown partners— people reduce their risk of infection. One study of HIV negative gay men found that optimists reported having fewer anonymous partners than pessimists (Taylor et al. 1992). This finding suggests that optimists were making efforts to reduce their risk, thereby safeguarding their health.

Another study relevant to this issue concerned health behavior and intentions among a group of hospital employees at risk for skin cancer (Friedman et al. 1995). Optimists were significantly more likely than pessimists to report intentions to engage in skin cancer-relevant health prevention behaviors (e.g., regular sunscreen use). In addition, among those identified at screening as having suspicious lesions, those who were more optimistic were more likely to comply with recommended follow-up care.

Other studies have examined the health-related habits reported by groups of people with no particular salient health concerns. At least two such projects have found associations such that optimists reported more health-promoting behaviors than did pessimists (Robbins et al. 1991, Steptoe et al. 1994). In sum, these various studies suggest that optimism is associated with behaviors aimed at promoting health and reducing health risk.

It is important to note, in this regard, that optimists are not simply people who stick their heads in the sand and ignore threats to their well-being. Rather, they display a pattern of attending selectively to risks— risks that both are applicable to them and also are related to serious health problems (Aspinwall and Brunhart 1996). If the potential health problem is minor, or if it is unlikely to bear on them personally, optimists show no elevated vigilance. Only when the threat matters does it emerge. This fits the idea that optimists scan their surroundings for threats to their well-being, but save their active coping efforts for threats that are truly meaningful.

2.2 Pessimism And Disengagement

This discussion derives from the idea that optimism leads to effort and pessimism leads to giving up. Thus far the focus has been on persistence. What about giving up? Several kinds of health-relevant behaviors seem to reflect a giving up tendency. One of them is alcohol consumption, which at high levels is a health risk. Excessive alcohol consumption is often seen as occurring in the service of an escape from one’s problems. If so, pessimists should be more vulnerable than optimists to alcohol abuse.

Results from at least two studies fit this picture. A study of women with a family history of alcoholism found that pessimists were more likely than optimists to report drinking problems (Ohannessian et al. 1993). Another study (Strack et al. 1987) examined people who had already been treated for alcoholism and were now entering an aftercare program. This study found that pessimists were more likely to drop out of the aftercare program and to return to drinking than optimists. These two studies converge in showing that pessimists display a form of disengagement—alcohol consumption—more than optimists.

People can give up in many ways, of course. Alcohol dulls awareness of failures and problems. People can also turn their backs on their problems by distracting themselves. Even sleeping can help people escape from situations they do not want to face. Sometimes, though, giving up is more complete. Sometimes people give up not just on specific goals, but on all the goals that define their lives, by committing suicide. Pessimism has been found in several studies to be a key indicator of suicide risk (Beck et al. 1985, Fawcett et al. 1987, Petrie and Chamberlain 1983). Although most people might not think of suicide as a ‘health’ outcome, suicide clearly does interfere with the maintenance of good health.

2.3 Disease Susceptibility

The examples just described all concern how people varied in their efforts to protect themselves against health risks, or how hard they tried to maintain good health, or the extent to which they engaged in behaviors reflecting a disengagement from such efforts. Such behavioral factors are important underpinnings to disease susceptibility. That is, people who take steps to avoid health risks will generally be healthier in the long run than people who do not. But are there more direct associations? Are there cases in which people differ in their susceptibility to diseases apart from their actions?

It is difficult to study initial vulnerability to disease, because doing so requires recruiting participants who are all healthy, and waiting until some of them become ill. An alternative strategy that some have employed is to recruit persons who are all in the same category of risk for a disease. One study using this procedure produced results suggesting that people’s orientation to life can play a role in whether they develop cervical cancer. This study (Antoni and Goodkin 1988) examined women who were undergoing testing after an abnormal PAP smear. Some of the women later proved to have cancer, some had a precancerous condition that might eventually develop into cancer, and others showed little or no abnormality. Before testing, these women completed measures of tendencies toward hopelessness and despair about the future. Women whose abnormality ultimately proved to be more severe were the women who had reported more hopelessness.

Another study examined potential associations of pessimism with blood pressure elevation (Raikkonen et al. 1999). This study involved three days of ambulatory monitoring of blood pressure during normal activities. Results indicated that pessimists were more likely to have elevations in blood pressure than optimists. Although this study should not be taken as clear evidence of disease initiation, it suggests that further examination of the role of pessimism in hypertension is warranted.

2.4 Health Following Medical Procedures

A little research has examined pessimism and the initiation of disease, but a good deal more has examined differences in well-being that follow the initial diagnosis or treatment of disease. Some of this work looks at responses to medical procedures. For example, the study by Scheier et al. (1989) of men undergoing coronary bypass surgery (which was described a little earlier) included measures of the patients’ progress through the surgery itself. Two kinds of indirect evidence suggested that pessimists fared more poorly than optimists even on the operating table. Specifically, pessimists were more likely to display two markers during surgery that are widely taken as indicants of myocardial infarction (MI). Thus, pessimists may have been at greater physical risk during the bypass surgery itself.

Scheier et al. (1999) have more recently collected data on a second sample of bypass patients. The first analyses of data from that project focused on a problem that often arises after major surgery: the need for rehospitalization, due either to infection from the surgery or to complications from the disease underlying the surgery. Scheier et al. (1999) found that optimistic persons were significantly less likely to be rehospitalized either for problems related to postsurgical infection or for problems related to the coronary artery disease, even after controlling for medical variables and other personality measures.

Another research group has explored how positive expectations before heart transplant surgery related to later medical adherence, and health (Leedham et al. 1995). In this case, optimism vs. pessimism was assessed at several levels of abstraction. Patients completed measures of optimism prior to surgery; they were then evaluated at discharge and at 3 and 6 months postsurgery. Initial scales assessed patients’ confidence about the efficacy of treatment, their expectations about their future health and survival, and broader expectations for the future. Confidence about the future predicted better adherence to the postoperative medical regimen, and strongly predicted nurses’ ratings of the patients’ physical health at six months after surgery. There was also a tendency for positive expectations to predict longer delays before development of infection (which is a near-universal side effect of heart transplantation).

2.5 Disease Progression

The successful management of disease can be reflected in many ways. In addition to examining responses to medical procedures, researchers have also looked at the process of disease progression. Many chronic, or incurable, diseases produce a sequence of new symptoms. An example is HIV infection, which initially has no observable symptoms, but eventually produces symptoms of a variety of types, which become increasingly debilitating.

At least two studies have examined the development of symptoms in men who were HIV-positive but symptom-free, as a function of psychological variables related to hopelessness and pessimism. In one study (Reed et al. 1999), the men completed a measure which included an index of stoic acceptance. This index reflects a fatalistic mental preparation for the worst and acceptance of the inevitable, and has been characterized as reflecting pessimistic disease-specific expectancies (Reed et al. 1994). In this sample of men who were initially free of symptoms, responses to this measure indicating greater pessimism predicted earlier symptom onset (Reed et al. 1999).

Another study (Ironson et al. 1994) examined the effect of the giving-up response that was linked to pessimism in earlier sections. This project followed asymptomatic HIV-positive men for two years after informing them of their positive serostatus. Measures of coping reactions (including a measure of disengagement—the giving-up response) were collected 5 weeks after diagnosis. Those who at the postdiagnosis assessment reported greater disengagement were more likely to have developed AIDS symptoms two years later.

2.6 Recurrence And Death

Another body of work moves the discussion from management of disease and progression of disease to disease recurrence and even mortality. Greer and coworkers have for some time studied individual differences among breast cancer patients. Some patients react to their diagnosis and surgery with what has been termed ‘fighting spirit,’ a focused engagement with the struggle of living and regaining strength. Others react instead with stoic acceptance (fatalism) or feelings of hopelessness and helplessness. Patients who reacted to the initial cancer with fighting spirit were more likely to have recurrence-free survival at five-year follow-up than women who reacted with hopelessness and helplessness (Greer et al. 1979). This pattern held up at both 10-year follow-up (Pettingale et al. 1985) and 15-year follow-up (Greer et al. 1990).

One project bearing on psychosocial variables and survival tested a six-week group intervention in a sample of malignant melanoma patients (Fawzy et al. 1993). Among measures collected was a measure of active-behavioral coping with the illness. Active- behavioral coping was defined as trying to alter the course of the disease by activities such as exercise, relaxation, and frequent consultations with physicians. People with this coping pattern appeared to be staying engaged with the struggle to stay alive, consistent with the picture of optimism described earlier. Fawzy et al. found that higher initial levels of this pattern predicted lower rates of recurrence and death.

In the previous section a study was described in which stoic acceptance of bad outcomes had adverse effects on symptom development in HIV patients. Further evidence of the ill effects of that attitude comes from research on survival time among patients whose disease had already progressed to AIDS (Reed et al. 1994). By the end of that study, 82 percent had died from complications related to the disease. Higher scores on the index of stoic acceptance (reflecting negative disease-specific expectancies) related to shorter survival times. It was as though individuals with this attitude were preparing to die, and death then came to them more quickly.

Another project bearing on the role of doubt and disengagement in disease progression examined a sample of recurrent cancer patients (Schulz et al. 1996). Patients were followed for 8 months, by which time approximately one-third had died. All had earlier completed a measure of pessimism about the future. Controlling for levels of symptoms at baseline, greater pessimism predicted shorter survival time. Further, the findings were specific to pessimism. Depression did not predict mortality.

One last study, conducted in Finland (Everson et al. 1996), examined the relationship between a sense of hopelessness about the future and mortality in a sample of over 2,000 middle-aged Finnish men who had been treated for cancer or heart attacks. Hopelessness was assessed by two items: ‘I feel that it is impossible to reach the goals I would like to strive for’ and ‘The future seems for me to be hopeless, and I can’t believe things are changing for the better.’ These men were followed for 6 years. Those who had reported higher degrees of hopelessness had greater disease-specific mortality—and all-cause mortality— than men with less hopelessness.

2.7 Associations Between Depression And Health Outcomes

Most of the foregoing has dealt with pessimism or hopelessness. What about depression and health outcomes (see Scheier and Bridges 1995 for broader review).

Links between depression and health are best documented for various kinds of cardiac-related events. For example, Ladwig et al. (1991) gathered psychological data from over 500 male survivors of MIs during the third week after the MI, including a measure of depression. By six-month follow-up, 12 of these patients had died from cardiac events. Death was predicted significantly by post-MI depression levels. When the data were adjusted for medical variables, the association between depression and cardiac death was weakened, but remained marginally significant.

Stronger findings relating depression to post-MI mortality have been reported by Frasure-Smith et al. (1993), using a more standardized measure of depression. They interviewed over 200 men and women who had been hospitalized for MI, during the week after the MI. Depression was assessed using an interview that gathers information used to make psychiatric diagnosis. In addition, a large number of medical variables were collected. By six months after the initial interview, 12 cardiac-related deaths had occurred, and depression was a significant predictor. Patients meeting criteria for clinical depression during the week after their MI were five times more likely than nondepressed patients to have died by the six-month follow-up. The effect of depression remained significant even after the data were adjusted for all clinical predictors of death.

Frasure-Smith et al. (1999) have more recently reported a larger (896 patients) and longer-term (one-year) study of men and women who had been hospitalized for MI. Analysis of survival data indicated that both men and women who were depressed while in the hospital were more than three times as likely to die of cardiac causes than were otherwise comparable patients who were not depressed. Again, these effects were independent of medical risk factors.

As noted, much of the evidence that depression has adverse health effects bear on cardiac disease. Some data also hint that depression may hasten HIV disease progression, though other findings have failed to confirm this (see Scheier and Bridges 1995).

Is depression a risk factor for premature death more generally? Wulsin et al. (1999) reviewed a wide range of studies in an effort to address that question. They concluded that the evidence for mortality effects is most compelling for cardiac disease, in line with studies described earlier. They also concluded that most research bearing on the question failed to include important control variables, such as degree of physical illness at baseline, smoking status, and alcohol abuse. All of these are known correlates of depression and potential predictors of premature death. This obviously is an area of investigation in which more information is needed.

It is tempting to view the evidence on depression and premature death as reflecting physical manifestations of a loss of desire to continue living. Perhaps the depressed MI patients in the studies reviewed above simply gave up the struggle to go on. This would represent a kind of disengagement response, albeit one that is quite different from the overt actions represented by suicide or alcohol abuse.

3. Potential Moderators

The focus of this research paper has been on the direct associations between health and the psychological variables of depression, hopelessness, and pessimism. However, some attention should also be paid to limitations on—or moderators of—such effects. One limitation may be extent of disease. It is possible that the effects of the psychological variables under discussion (and others) are greater among persons with disease that is less severe than among persons whose disease is advanced. That is, perhaps advancing disease affords less opportunity for psychological variables to gain leverage over the impact of the disease.

Another potential moderator is the age of the person whose health is under study. In their review of the literature, Scheier and Bridges (1995) noted that several studies had found that variables such as personality and depression had stronger influences on health among younger than older persons. For example, Schulz et al. (1996) found that pessimism predicted increased mortality among a group of recurrent cancer patients, but only among patients under age 60.

Indeed, every age difference that Scheier and Bridges (1995) encountered was one in which stronger associations between personality and health outcome occurred among younger than older persons. This observation led Scheier and Bridges to suggest that biological factors may become more important in determining disease outcomes as people grow older, and psychological factors correspondingly less important. This is another issue that should receive greater attention in the years to come.

4. Closing Comment

This research paper reviewed some associations that have been observed between pessimism, hopelessness, depression, and subsequent health outcomes. Evidence of associations between these psychological variables and health is fairly robust. On the other hand, it would be wrong to conclude that the mechanisms underlying these effects are well understood. In some cases the mechanism is obvious: persisting in a health-promoting exercise activity, taking steps to control one’s weight, acting to lower one’s health risks—all these are behavioral ways in which optimism and hopefulness can enhance health outcomes through overt behavior. In other cases, though, the mechanism is far more speculative, involving potential neuroendocrine and immune responses as mediators. The role of such mediators is presently under active investigation, but there remain many uncertainties. Despite the many questions remaining, though, the pattern seems consistent with a picture in which continued optimistic engagement with life goals promotes better health outcomes, and in which the loss of such engagement—giving up—promotes poorer outcomes.

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