Emotional health is increasingly viewed as a multidimensional construct that includes both positive and illness-related dimensions. Hendrie et al. (1) characterized emotional health as self-efficacy, depression, hostility and anger, anxiety, psychological stress, optimism, self-esteem, quality of life, and other domains assessed by multidimensional measures. A report (2) using data from the Behavioral Risk Factor Surveillance System (BRFSS) (3) identified six indicators reflecting positive and illness-related emotional health outcomes in older adults: social and emotional support; life satisfaction; frequent mental distress; current depression; lifetime diagnosis of depression; and lifetime diagnosis of anxiety disorders.

Mental health is increasingly viewed as part of public health’s mission, as important as physical health in contributing to overall health and well being (2). Epidemiologic data links a range of health outcomes, particularly mortality and cardiovascular disease, to emotions (1). Despite the public health importance, little is currently known about the effectiveness of interventions to promote emotional health in community-dwelling older adults. One of the few available reports (4) reviews studies from UK, finding some evidence to support significant small-to-moderate improvements in emotional health from select exercise programs including mixed exercise programs, strength and resistance, aerobic, walking, and individually targeted health promotion interventions. However, it also indicated a clear shortage of robust evidence for effective programs to improve late-life emotional health.

Although this review (4) addressed several important questions, a more rigorous review of the scientific literature is warranted. The primary objective of this systematic literature review was to identify interventions to promote emotional health of older adults aged 50 years and older. We sought to expand Windle and colleagues work by encompassing a wider range of community-based interventions, including more than UK-based studies, examining multiple domains of emotional health incorporating both positive and illness-related dimensions, and addressing community-dwelling older adults.

A total of 3,926 articles were identified in the initial search (1,250 from PubMed, 1,025 from PsycINFO, 1,631 from CINAHL, and 20 from reference lists of review articles or meta-analyses). 553 articles were duplicates and were eliminated (Figure 2). Two hundred ninety-two articles were eligible for inclusion, with the majority of the ineligible being excluded due to having too young of a sample size, not being an intervention study, or not having an emotional health outcome. Of the 292 eligible articles, the expert panel focused on three types of interventions relevant to public health practice and with ample studies for rating the evidence. These comprised a total of 148 of the 292 found articles: physical activity and/or exercise (n = 83), skills training (n = 40), and social support (n = 25) (Table 3). More than half of the studies (57%) were from the US or Canada, 19% were from European studies, 12% were from Australia or New Zealand, and 11% were from Asia. Thirty-nine percent of the articles specified that a theoretical framework that was used to inform the development of the intervention – one-third of the studies that evaluate an exercise or a social support intervention used a theoretical framework, while two-thirds of skills training interventions used a theoretical framework. Across interventions, the most common frameworks used across interventions were social cognitive theory, self-efficacy, and social learning theory. Other theories include the progressively lowered stress threshold model, the self-care deficit nursing theory of Orem, mindfulness meditation, self-management model of illness behavior, stress and coping theoretical framework, stress process models of caregiving, the transtheoretical model of behavior change, stages of change, negotiated adherence model, motivational interviewing, transforming hope theory, and Yalom group theory.

The physical activity and/or exercise interventions included aerobic activity, strength training, balance and flexibility interventions, motivational strategies, and a combination of exercise types. The skills training group included self-management [e.g., Chronic Disease Self-Management Program (CDSMP)], psycho-education, anger management, and stress management interventions. The social support group included interventions targeting direct or indirect provision of social support (e.g., interventions designed to improve ability to obtain support).

The 148 studies were subsequently grouped into 64 intervention type–outcome pairings, or categories, for rating the evidence, such as social support interventions aimed at elevating mood (Table 3). For quality, 53 (83%) of the intervention–outcome pairings were rated as having “at least fair” quality; only 11% of these had good quality. For effectiveness, a majority of pairings (89%) were deemed to have insufficient evidence, due to lack of studies (two or fewer) or inconclusive evidence (mixed results within or across studies). Herein, we will report findings for the three intervention–outcome pairings for which sufficient evidence was found. For further information about categories not presented or on detailed summary data tables, please contact the corresponding author.

This review examined three broad types of interventions designed to promote emotional health: physical activity and/or exercise, skills training, and social support. Among the interventions rated as having at least fair quality and sufficient evidence, we found that skills training interventions reduced anxiety; enhanced self-efficacy; and improved vitality, role functioning related to emotional limitations, and emotional health as measured in quality of life subscales. Skills training interventions are theorized to promote positive domains of emotional health through cognitive reframing, strengthening coping resources, and increasing the amount of support (or quality of support). We acknowledge that skills training may improve emotional health through improved self-efficacy, though the panel chose to view self-efficacy as its own emotional health domain. These interventions are designed for older adults with chronic conditions (e.g., arthritis, heart disease, physical disabilities) or informal caregivers (e.g., spouses, adult children) of older adults coping with dementia, stroke survivors, or mental illness making them quite generalizable. These populations were targeted by these interventions because chronic conditions or caregiving responsibilities increase the need for skills training, support, information, and resources.

The CDSMP was used as an intervention in seven of the skills training studies that showed sufficient evidence for improving quality of life or self-efficacy or decreasing anxiety. CDSMP has been shown to enhance stress management techniques, improve communication with physicians, increase confidence in ability to manage the condition, and improve role function (32, 42, 155–159). Improving self-management skills has been shown to impact other aspects of participants’ lives, such as their ability to manage their emotions, choose healthy foods and exercise activities, and activate their social network (158). This review is limited by its end date of June 2008. While it is beyond the scope of this project to conduct an updated systematic literature review, we recently searched for other review papers on skills training, exercise and/or physical activity, and social support interventions to promote emotional health. We found two review papers (160, 161) that reported similar findings as we report above, namely, sufficient evidence for skills training interventions impact on self-efficacy and quality of life and insufficient evidence for other emotional health outcomes. We also searched for intervention studies for those areas where sufficient evidence was found. Our search yielded 10 recently published articles (162–171), none of which reported different findings than reported above.

We defined “insufficient evidence of effectiveness” in two ways: either there were not enough studies of at least fair quality, or there were multiple studies with inconclusive data. Insufficient evidence did not mean that interventions were clearly ineffective. Very few intervention–outcome pairings were rated as at least fair quality. The expert panel identified the following common quality limitations: lack of descriptive information about the interventions, limited information about the statistical methods and analyses, and small sample sizes or underpowered studies. Additionally, features of some of the study designs made it difficult to detect changes in emotional health. For example, many studies included emotional health outcome measures that may not be responsive to small changes from programs of limited intensity and duration, and sampling “emotionally healthy” subjects that created ceiling effects. In fact, many of the reviewed aerobic physical activity interventions did not meet current national guidelines (140) for 150 min per week of moderate-intensity activity (though all reviewed strength/resistance interventions did meet existing criteria of 2 days per week).

Our review included a wide range of emotional health constructs. Some outcomes were entirely emotional (e.g., anxiety), whereas others included a mix of cognitive, emotional, and behavioral domains (e.g., self-efficacy). In addition, some studies included emotional health outcomes as their primary outcomes, whereas others included emotional health as intermediate outcomes or mediators of other health outcomes. Finally, there was a dearth of intervention studies on certain emotional health constructs, such as hopelessness, shame, guilt, regret, fear, neuroticism, boredom, positive energy, contentment, hardiness, resilience, emotional stability, emotional regulation/control, altruism, capacity to care, and happiness. In particular, positive constructs were underrepresented in the available literature. We were not surprised that there was limited evidence on interventions to promote emotional health, and particularly any studies lacking in positive emotional health constructs given the tendency (up until recently) to focus on disease prevention over health promotion. We anticipate that more research will include emotional health outcomes as models such as the socio-ecological model (67, 172) and guidelines such as the Public Health Action Plan to Integrate Mental Health Promotion and Mental Illness Prevention with Chronic Disease Prevention, 2011–2015 (74) emphasize the importance of emotional health in the larger public health goals.

Future research needs to address these quality concerns by attending to limitations with both internal and external validity. One way to do so is to use the RE-AIM framework, a conceptual approach for evaluating the translation of research into practice in “real-world” settings (141). RE-AIM stands for reach, effectiveness, adoption, implementation fidelity, and maintenance – five areas, which, if addressed, ensure that essential program goals are retained during the implementation process, resulting in greater external validity. More research is also needed to investigate the longer term, maintenance effects of interventions to promote positive emotional health, and address illness-related domains in older adults as most of the studies here were of short-term effectiveness. The prominence of theories such as social cognitive theory, social learning theory, and self-efficacy theory in those interventions with sufficient evidence may also be helpful to consider in future intervention design and development as they may have contributed to the optimization of participants’ quality of life and self-efficacy and minimization of anxiety symptoms.

Despite the gaps in the current research, our systematic review provides important information about interventions that can promote emotional health outcomes in community-dwelling older adults. Specifically, we found that skills training interventions resulted in improvements in both illness-related (anxiety) and positive (quality of life and self-efficacy) domains of emotional health. Given that more than one in four Americans lives with two or more concurrent chronic conditions, the challenges of managing multiple chronic conditions among the growing numbers of older persons are significant (50). One of the overarching goals of the U.S. Department of Health and Human Services’ Strategic Framework (58), Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions, is to “maximize the use of proven self-care management and other services by individuals with multiple chronic conditions.” As shown in this review, skills training interventions can offer important benefits in the realm of promoting emotional health in older adults. Given the expanding proportion of older adults in the US and globally, we hope this review will help in addressing some of challenges identified in this important area of study.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health (Public Health Education and Promotion section) panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.