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The Mental Health Continuum: From Languishing to Flourishing in Life
Author(s): Corey L. M. Keyes
Source:
Journal of Health and Social Behavior,
Vol. 43, No. 2, Selecting Outcomes for the
Sociology of Mental Health: Issues of Measurement and Dimensionality, (Jun., 2002), pp. 207-
222
Published by: American Sociological Association
Stable URL: http://www.jstor.org/stable/3090197
Accessed: 24/07/2008 16:32
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The
Mental Health
Continuum:
From
Languishing
to
Flourishing
in
Life*
COREY L. M. KEYES
Emory University
Journal
of
Health
and Social
Research
2002,
Vol 43
(June):
207-222
This
paper
introduces
and
applies
an
operationalization
of
mental
health
as
a
syndrome
of
symptoms of positive
feelings
and
positive
functioning
in
life.
Dimensions and
scales
of
subjective
well-being
are
reviewed and
conceived
of
as mental health
symptoms.
A
diagnosis of
the
presence
of
mental
health,
described as
flourishing,
and the
absence
of
mental
health,
characterized as
languishing,
is
applied
to
data
from
the
1995
Midlife
in the
United States
study
of
adults between
the
ages
of25
and
74
(n
=
3,032).
Findings
revealed
that
17.2
percent
fit
the
criteria
for
flourishing,
56.6
percent
were
moderately
mentally
healthy,
12.1
percent
of
adults
fit
the
criteria
for
languishing,
and 14.1
percent
fit
the
criteria
for
DSM-III-R
major
depressive
episode
(12-month),
of
which
9.4
percent
were not
languishing
and 4.
7percent
were also
languishing.
The
risk
of
a
major
depressive
episode
was two
times more
likely
among
languishing
than
moderately
mentally healthy
adults,
and
nearly
six times
greater
among
lan-
guishing
than
flourishing
adults.
Multivariate
analyses
revealed that
languish-
ing
and
depression
were
associated with
significant
psychosocial
impairment
in
terms
ofperceived
emotional
health,
limitations
of
activities
of daily
living,
and
workdays
lost or
cutback.
Flourishing
and
moderate
mental
health
were
asso-
ciated with
superior profiles
of
psychosocial
functioning.
The
descriptive
epi-
demiology
revealed
that
males,
older
adults,
more
educated
individuals,
and
married adults
were more
likely
to be
mentally
healthy. Implications
for
the
con-
ception
of
mental
health and
the
treatment
and
prevention
of
mental
illness are
discussed.
The
Mental Health
Continuum:
From
Languishing
to
Flourishing
in
Life*
COREY L. M. KEYES
Emory University
Journal
of
Health
and Social
Research
2002,
Vol 43
(June):
207-222
This
paper
introduces
and
applies
an
operationalization
of
mental
health
as
a
syndrome
of
symptoms of positive
feelings
and
positive
functioning
in
life.
Dimensions and
scales
of
subjective
well-being
are
reviewed and
conceived
of
as mental health
symptoms.
A
diagnosis of
the
presence
of
mental
health,
described as
flourishing,
and the
absence
of
mental
health,
characterized as
languishing,
is
applied
to
data
from
the
1995
Midlife
in the
United States
study
of
adults between
the
ages
of25
and
74
(n
=
3,032).
Findings
revealed
that
17.2
percent
fit
the
criteria
for
flourishing,
56.6
percent
were
moderately
mentally
healthy,
12.1
percent
of
adults
fit
the
criteria
for
languishing,
and 14.1
percent
fit
the
criteria
for
DSM-III-R
major
depressive
episode
(12-month),
of
which
9.4
percent
were not
languishing
and 4.
7percent
were also
languishing.
The
risk
of
a
major
depressive
episode
was two
times more
likely
among
languishing
than
moderately
mentally healthy
adults,
and
nearly
six times
greater
among
lan-
guishing
than
flourishing
adults.
Multivariate
analyses
revealed that
languish-
ing
and
depression
were
associated with
significant
psychosocial
impairment
in
terms
ofperceived
emotional
health,
limitations
of
activities
of daily
living,
and
workdays
lost or
cutback.
Flourishing
and
moderate
mental
health
were
asso-
ciated with
superior profiles
of
psychosocial
functioning.
The
descriptive
epi-
demiology
revealed
that
males,
older
adults,
more
educated
individuals,
and
married adults
were more
likely
to be
mentally
healthy. Implications
for
the
con-
ception
of
mental
health and
the
treatment
and
prevention
of
mental
illness are
discussed.
The
Mental Health
Continuum:
From
Languishing
to
Flourishing
in
Life*
COREY L. M. KEYES
Emory University
Journal
of
Health
and Social
Research
2002,
Vol 43
(June):
207-222
This
paper
introduces
and
applies
an
operationalization
of
mental
health
as
a
syndrome
of
symptoms of positive
feelings
and
positive
functioning
in
life.
Dimensions and
scales
of
subjective
well-being
are
reviewed and
conceived
of
as mental health
symptoms.
A
diagnosis of
the
presence
of
mental
health,
described as
flourishing,
and the
absence
of
mental
health,
characterized as
languishing,
is
applied
to
data
from
the
1995
Midlife
in the
United States
study
of
adults between
the
ages
of25
and
74
(n
=
3,032).
Findings
revealed
that
17.2
percent
fit
the
criteria
for
flourishing,
56.6
percent
were
moderately
mentally
healthy,
12.1
percent
of
adults
fit
the
criteria
for
languishing,
and 14.1
percent
fit
the
criteria
for
DSM-III-R
major
depressive
episode
(12-month),
of
which
9.4
percent
were not
languishing
and 4.
7percent
were also
languishing.
The
risk
of
a
major
depressive
episode
was two
times more
likely
among
languishing
than
moderately
mentally healthy
adults,
and
nearly
six times
greater
among
lan-
guishing
than
flourishing
adults.
Multivariate
analyses
revealed that
languish-
ing
and
depression
were
associated with
significant
psychosocial
impairment
in
terms
ofperceived
emotional
health,
limitations
of
activities
of daily
living,
and
workdays
lost or
cutback.
Flourishing
and
moderate
mental
health
were
asso-
ciated with
superior profiles
of
psychosocial
functioning.
The
descriptive
epi-
demiology
revealed
that
males,
older
adults,
more
educated
individuals,
and
married adults
were more
likely
to be
mentally
healthy. Implications
for
the
con-
ception
of
mental
health and
the
treatment
and
prevention
of
mental
illness are
discussed.
There are
grave
reasons for
concern
about
the
prevalence
and
etiology
of
mental
illness.
Unipolar depression,
for
example,
strikes
many
individuals
annually
and
recurrently
throughout
life
(Angst
1988;
Gonzales,
Lewinsohn,
and
Clarke
1985).
Upwards
of
one-half of
adults
may experience
a
serious
mental
illness in
their
lifetime;
between
10
per-
cent
and 14
percent
of
adults
experience
an
*This
research
was
supported by
John D.
and
Catherine
T. MacArthur
Foundation's
Mental
Health
and
Human
Development
Program
through
mem-
bership
in its
Research
Network
on
Successful
Midlife
Development,
directed
by
Dr.
Orville
Gilbert
Brim,
Jr.
Direct
correspondence
to
the
Department
of
Sociology,
Emory
University,
Room
225,
Tarbutton
Hall,
1555 Pierce
Drive,
Atlanta,
GA
30322;
email:
ckeyes@emory.edu.
There are
grave
reasons for
concern
about
the
prevalence
and
etiology
of
mental
illness.
Unipolar depression,
for
example,
strikes
many
individuals
annually
and
recurrently
throughout
life
(Angst
1988;
Gonzales,
Lewinsohn,
and
Clarke
1985).
Upwards
of
one-half of
adults
may experience
a
serious
mental
illness in
their
lifetime;
between
10
per-
cent
and 14
percent
of
adults
experience
an
*This
research
was
supported by
John D.
and
Catherine
T. MacArthur
Foundation's
Mental
Health
and
Human
Development
Program
through
mem-
bership
in its
Research
Network
on
Successful
Midlife
Development,
directed
by
Dr.
Orville
Gilbert
Brim,
Jr.
Direct
correspondence
to
the
Department
of
Sociology,
Emory
University,
Room
225,
Tarbutton
Hall,
1555 Pierce
Drive,
Atlanta,
GA
30322;
email:
ckeyes@emory.edu.
There are
grave
reasons for
concern
about
the
prevalence
and
etiology
of
mental
illness.
Unipolar depression,
for
example,
strikes
many
individuals
annually
and
recurrently
throughout
life
(Angst
1988;
Gonzales,
Lewinsohn,
and
Clarke
1985).
Upwards
of
one-half of
adults
may experience
a
serious
mental
illness in
their
lifetime;
between
10
per-
cent
and 14
percent
of
adults
experience
an
*This
research
was
supported by
John D.
and
Catherine
T. MacArthur
Foundation's
Mental
Health
and
Human
Development
Program
through
mem-
bership
in its
Research
Network
on
Successful
Midlife
Development,
directed
by
Dr.
Orville
Gilbert
Brim,
Jr.
Direct
correspondence
to
the
Department
of
Sociology,
Emory
University,
Room
225,
Tarbutton
Hall,
1555 Pierce
Drive,
Atlanta,
GA
30322;
email:
ckeyes@emory.edu.
episode
of
major depression
annually (Cross-
National
Collaborative
Group
1992;
Kessler et
al.
1994;
Robins and
Regier
1991;
U.S.
Department
of
Health
and
Human
Services
1999).
As a
persistent
and
substantial
deviation
from normal
functioning,
mental
illness
impairs
the
execution of
social
roles
(e.g.,
employee)
and
it
is
associated with
emotional
suffering
(Keyes
2001;
Spitzer
and
Wilson
1975).
Depression
costs
billions
each
year
due
to
work
absenteeism,
diminished
productivity,
healthcare
costs
(Greenberg
et
al.
1993;
Keyes
and
Lopez
2002;
Murray
and
Lopez
1996;
Mrazek and
Haggerty 1994),
and it
accounts
for
at least
one-third of
completed
suicides
(Rebellon,
Brown,
and
Keyes
2001;
U.S.
Department
of
Health
and
Human
Services
1998).
episode
of
major depression
annually (Cross-
National
Collaborative
Group
1992;
Kessler et
al.
1994;
Robins and
Regier
1991;
U.S.
Department
of
Health
and
Human
Services
1999).
As a
persistent
and
substantial
deviation
from normal
functioning,
mental
illness
impairs
the
execution of
social
roles
(e.g.,
employee)
and
it
is
associated with
emotional
suffering
(Keyes
2001;
Spitzer
and
Wilson
1975).
Depression
costs
billions
each
year
due
to
work
absenteeism,
diminished
productivity,
healthcare
costs
(Greenberg
et
al.
1993;
Keyes
and
Lopez
2002;
Murray
and
Lopez
1996;
Mrazek and
Haggerty 1994),
and it
accounts
for
at least
one-third of
completed
suicides
(Rebellon,
Brown,
and
Keyes
2001;
U.S.
Department
of
Health
and
Human
Services
1998).
episode
of
major depression
annually (Cross-
National
Collaborative
Group
1992;
Kessler et
al.
1994;
Robins and
Regier
1991;
U.S.
Department
of
Health
and
Human
Services
1999).
As a
persistent
and
substantial
deviation
from normal
functioning,
mental
illness
impairs
the
execution of
social
roles
(e.g.,
employee)
and
it
is
associated with
emotional
suffering
(Keyes
2001;
Spitzer
and
Wilson
1975).
Depression
costs
billions
each
year
due
to
work
absenteeism,
diminished
productivity,
healthcare
costs
(Greenberg
et
al.
1993;
Keyes
and
Lopez
2002;
Murray
and
Lopez
1996;
Mrazek and
Haggerty 1994),
and it
accounts
for
at least
one-third of
completed
suicides
(Rebellon,
Brown,
and
Keyes
2001;
U.S.
Department
of
Health
and
Human
Services
1998).
207 207 207
JOURNAL OF
HEALTH
AND
SOCIAL
BEHAVIOR
JOURNAL OF
HEALTH
AND
SOCIAL
BEHAVIOR
JOURNAL OF
HEALTH
AND
SOCIAL
BEHAVIOR
Yet about one-half of the
adult
population
should
remain free of
serious
mental
illnesses
over its
lifespan,
and as much
as 90
percent
should remain free of
major depression
annu-
ally.
Are adults who remain
free
of mental
ill-
ness
annually
and over
a
lifetime
mentally
healthy
and
productive?
This is a
pivotal ques-
tion
for
proponents
of the
study
of
mental
health
(Keyes
and
Shapiro
forthcoming),
and
it
is the
guiding
question
to this
study.
Mental
health
is,
according
to the
Surgeon
General
(U.S. Department
of Health
and Human
Services
1999),
". ..
a state
of
successful
per-
formance of
mental
function,
resulting
in
pro-
ductive
activities,
fulfilling relationships
with
people,
and
the
ability
to
adapt
to
change
and
to
cope
with
adversity" (p.
4).
Social scientists
have lobbied over 40
years
for
a definition of
mental health
as more than the absence of
mental illness
(Jahoda 1958).
M.
Brewster
Smith
(1958)
lamented
that
"positive"
mental
health is
a
"slogan"
and
a
"rallying
call"
rather
than the
empirical concept
and
variable it
deserves
to
be.
Despite
the
Surgeon
General's
definition
41
years
later,
mental
health remains
the
antonym
of mental illness and
a catchword
of
inert
good
intentions.
This
paper
introduces
and
applies
an
opera-
tionalization of mental
health
as a
syndrome
of
symptoms
of
positive
feelings
and
positive
functioning
in
life.
It
summarizes the
scales
and
dimensions
of
subjective
well-being,
which
are
symptoms
of mental health.
Whereas
the
presence
of mental health is
described
as
flourishing,
the
absence
of mental
health is characterized as
languishing
in
life.
Subsequently,
this
study
addresses four
research
questions.
First,
what is the
preva-
lence of
flourishing,
languishing,
and
moder-
ate mental health
in
the United States?
Second,
what is the burden of
languishing
relative to
major
depression
episode
and
to
flourishing
in
life?
Third,
is
mental health
(flourishing)
asso-
ciated
with
better
psychosocial functioning
rel-
ative to
major depression
and
languishing
in
life?
Fourth,
is mental
health,
like most mental
illnesses,
unequally
distributed
in the
popula-
tion; who,
in
other
words,
is
mentally healthy?
MENTAL HEALTH AND ITS
SYMPTOMS
Like mental
illness,
mental
health
is defined
here
as
an
emergent
condition based
on
the
concept
of
a
syndrome.
A
state of
health,
like
Yet about one-half of the
adult
population
should
remain free of
serious
mental
illnesses
over its
lifespan,
and as much
as 90
percent
should remain free of
major depression
annu-
ally.
Are adults who remain
free
of mental
ill-
ness
annually
and over
a
lifetime
mentally
healthy
and
productive?
This is a
pivotal ques-
tion
for
proponents
of the
study
of
mental
health
(Keyes
and
Shapiro
forthcoming),
and
it
is the
guiding
question
to this
study.
Mental
health
is,
according
to the
Surgeon
General
(U.S. Department
of Health
and Human
Services
1999),
". ..
a state
of
successful
per-
formance of
mental
function,
resulting
in
pro-
ductive
activities,
fulfilling relationships
with
people,
and
the
ability
to
adapt
to
change
and
to
cope
with
adversity" (p.
4).
Social scientists
have lobbied over 40
years
for
a definition of
mental health
as more than the absence of
mental illness
(Jahoda 1958).
M.
Brewster
Smith
(1958)
lamented
that
"positive"
mental
health is
a
"slogan"
and
a
"rallying
call"
rather
than the
empirical concept
and
variable it
deserves
to
be.
Despite
the
Surgeon
General's
definition
41
years
later,
mental
health remains
the
antonym
of mental illness and
a catchword
of
inert
good
intentions.
This
paper
introduces
and
applies
an
opera-
tionalization of mental
health
as a
syndrome
of
symptoms
of
positive
feelings
and
positive
functioning
in
life.
It
summarizes the
scales
and
dimensions
of
subjective
well-being,
which
are
symptoms
of mental health.
Whereas
the
presence
of mental health is
described
as
flourishing,
the
absence
of mental
health is characterized as
languishing
in
life.
Subsequently,
this
study
addresses four
research
questions.
First,
what is the
preva-
lence of
flourishing,
languishing,
and
moder-
ate mental health
in
the United States?
Second,
what is the burden of
languishing
relative to
major
depression
episode
and
to
flourishing
in
life?
Third,
is
mental health
(flourishing)
asso-
ciated
with
better
psychosocial functioning
rel-
ative to
major depression
and
languishing
in
life?
Fourth,
is mental
health,
like most mental
illnesses,
unequally
distributed
in the
popula-
tion; who,
in
other
words,
is
mentally healthy?
MENTAL HEALTH AND ITS
SYMPTOMS
Like mental
illness,
mental
health
is defined
here
as
an
emergent
condition based
on
the
concept
of
a
syndrome.
A
state of
health,
like
Yet about one-half of the
adult
population
should
remain free of
serious
mental
illnesses
over its
lifespan,
and as much
as 90
percent
should remain free of
major depression
annu-
ally.
Are adults who remain
free
of mental
ill-
ness
annually
and over
a
lifetime
mentally
healthy
and
productive?
This is a
pivotal ques-
tion
for
proponents
of the
study
of
mental
health
(Keyes
and
Shapiro
forthcoming),
and
it
is the
guiding
question
to this
study.
Mental
health
is,
according
to the
Surgeon
General
(U.S. Department
of Health
and Human
Services
1999),
". ..
a state
of
successful
per-
formance of
mental
function,
resulting
in
pro-
ductive
activities,
fulfilling relationships
with
people,
and
the
ability
to
adapt
to
change
and
to
cope
with
adversity" (p.
4).
Social scientists
have lobbied over 40
years
for
a definition of
mental health
as more than the absence of
mental illness
(Jahoda 1958).
M.
Brewster
Smith
(1958)
lamented
that
"positive"
mental
health is
a
"slogan"
and
a
"rallying
call"
rather
than the
empirical concept
and
variable it
deserves
to
be.
Despite
the
Surgeon
General's
definition
41
years
later,
mental
health remains
the
antonym
of mental illness and
a catchword
of
inert
good
intentions.
This
paper
introduces
and
applies
an
opera-
tionalization of mental
health
as a
syndrome
of
symptoms
of
positive
feelings
and
positive
functioning
in
life.
It
summarizes the
scales
and
dimensions
of
subjective
well-being,
which
are
symptoms
of mental health.
Whereas
the
presence
of mental health is
described
as
flourishing,
the
absence
of mental
health is characterized as
languishing
in
life.
Subsequently,
this
study
addresses four
research
questions.
First,
what is the
preva-
lence of
flourishing,
languishing,
and
moder-
ate mental health
in
the United States?
Second,
what is the burden of
languishing
relative to
major
depression
episode
and
to
flourishing
in
life?
Third,
is
mental health
(flourishing)
asso-
ciated
with
better
psychosocial functioning
rel-
ative to
major depression
and
languishing
in
life?
Fourth,
is mental
health,
like most mental
illnesses,
unequally
distributed
in the
popula-
tion; who,
in
other
words,
is
mentally healthy?
MENTAL HEALTH AND ITS
SYMPTOMS
Like mental
illness,
mental
health
is defined
here
as
an
emergent
condition based
on
the
concept
of
a
syndrome.
A
state of
health,
like
illness,
is
indicated when
a set of
symptoms
at
a
specific
level are
present
for a
specified
duration
and
this
constellation of
symptoms
coincides with
distinctive
cognitive
and
social
functioning
(cf.
Keyes
2001;
Mechanic
1999).
Mental
health
may
be
operationalized
as
a
syn-
drome of
symptoms
of an
individual's
subjec-
tive
well-being.
During
the last
40
years,
social
scientists
have
conceptualized,
measured,
and
studied the
measurement
structure
of
mental
health
through
the
investigation
of
subjective
well-being
(e.g., Headey,
Kelley,
and
Wearing
1993;
Keyes
Shmotkin,
and
Ryff
forthcom-
ing).
Subjective
well-being
is
individuals'
per-
ceptions
and evaluations of
their own
lives
in
terms of
their
affective states and their
psycho-
logical
and social
functioning
(Keyes
and
Waterman,
forthcoming).
Emotional
well-being
is
a
cluster
of
symp-
toms
reflecting
the
presence
or
absence
of
pos-
itive
feelings
about life.
Symptoms
of
emo-
tional
well-being
are ascertained from
individ-
uals'
responses
to
structured scales
measuring
the
presence
of
positive
affect
(e.g.,
individuals
is in
good
spirits),
the
absence
of
negative
affect
(e.g.,
individual is not
hopeless),
and
perceived
satisfaction with
life.
Measures
of
the
expression
of
emotional
well-being
in
terms of
positive
affect and
negative
affect are
related
but
distinct dimensions
(e.g.,
Bradbur
1969;
Watson and
Tellegen
1985).
Last,
mea-
sures
of
avowed
(e.g.,
"I am
satisfied
with
life")
and
expressed
(i.e.,
positive
and
negative
affect)
emotional
well-being
are related but
distinct dimensions
(Andrews
and
Withey
1976;
Bryant
and
Veroff
1982;
Diener
1984;
Diener,
Sandvik,
and
Pavot
1991;
Diener et al.
1999).
Like
mental
illness
(viz.
depression),
mental
health
is more than
the
presence
and
absence
of
emotional states. In
addition,
subjective
well-being
includes measures of the
presence
and
absence of
positive
functioning
in life.
Since
Ryff's
(1989)
operationalization
of clin-
ical
and
personality
theorists'
conceptions
of
positive functioning
(Jahoda 1958),
the
field
has moved toward
a
broader
set
of measures
of
well-being.
Positive
functioning
consists of six
dimensions of
psychological
well-being:
self-
acceptance,
positive
relations
with
others,
per-
sonal
growth,
purpose
in
life,
environmental
mastery,
and
autonomy
(see
Keyes
and
Ryff's
1999
review).
That
is,
individuals
are
function-
ing
well
when
they
like most
parts
of them-
selves,
have warm and
trusting relationships,
illness,
is
indicated when
a set of
symptoms
at
a
specific
level are
present
for a
specified
duration
and
this
constellation of
symptoms
coincides with
distinctive
cognitive
and
social
functioning
(cf.
Keyes
2001;
Mechanic
1999).
Mental
health
may
be
operationalized
as
a
syn-
drome of
symptoms
of an
individual's
subjec-
tive
well-being.
During
the last
40
years,
social
scientists
have
conceptualized,
measured,
and
studied the
measurement
structure
of
mental
health
through
the
investigation
of
subjective
well-being
(e.g., Headey,
Kelley,
and
Wearing
1993;
Keyes
Shmotkin,
and
Ryff
forthcom-
ing).
Subjective
well-being
is
individuals'
per-
ceptions
and evaluations of
their own
lives
in
terms of
their
affective states and their
psycho-
logical
and social
functioning
(Keyes
and
Waterman,
forthcoming).
Emotional
well-being
is
a
cluster
of
symp-
toms
reflecting
the
presence
or
absence
of
pos-
itive
feelings
about life.
Symptoms
of
emo-
tional
well-being
are ascertained from
individ-
uals'
responses
to
structured scales
measuring
the
presence
of
positive
affect
(e.g.,
individuals
is in
good
spirits),
the
absence
of
negative
affect
(e.g.,
individual is not
hopeless),
and
perceived
satisfaction with
life.
Measures
of
the
expression
of
emotional
well-being
in
terms of
positive
affect and
negative
affect are
related
but
distinct dimensions
(e.g.,
Bradbur
1969;
Watson and
Tellegen
1985).
Last,
mea-
sures
of
avowed
(e.g.,
"I am
satisfied
with
life")
and
expressed
(i.e.,
positive
and
negative
affect)
emotional
well-being
are related but
distinct dimensions
(Andrews
and
Withey
1976;
Bryant
and
Veroff
1982;
Diener
1984;
Diener,
Sandvik,
and
Pavot
1991;
Diener et al.
1999).
Like
mental
illness
(viz.
depression),
mental
health
is more than
the
presence
and
absence
of
emotional states. In
addition,
subjective
well-being
includes measures of the
presence
and
absence of
positive
functioning
in life.
Since
Ryff's
(1989)
operationalization
of clin-
ical
and
personality
theorists'
conceptions
of
positive functioning
(Jahoda 1958),
the
field
has moved toward
a
broader
set
of measures
of
well-being.
Positive
functioning
consists of six
dimensions of
psychological
well-being:
self-
acceptance,
positive
relations
with
others,
per-
sonal
growth,
purpose
in
life,
environmental
mastery,
and
autonomy
(see
Keyes
and
Ryff's
1999
review).
That
is,
individuals
are
function-
ing
well
when
they
like most
parts
of them-
selves,
have warm and
trusting relationships,
illness,
is
indicated when
a set of
symptoms
at
a
specific
level are
present
for a
specified
duration
and
this
constellation of
symptoms
coincides with
distinctive
cognitive
and
social
functioning
(cf.
Keyes
2001;
Mechanic
1999).
Mental
health
may
be
operationalized
as
a
syn-
drome of
symptoms
of an
individual's
subjec-
tive
well-being.
During
the last
40
years,
social
scientists
have
conceptualized,
measured,
and
studied the
measurement
structure
of
mental
health
through
the
investigation
of
subjective
well-being
(e.g., Headey,
Kelley,
and
Wearing
1993;
Keyes
Shmotkin,
and
Ryff
forthcom-
ing).
Subjective
well-being
is
individuals'
per-
ceptions
and evaluations of
their own
lives
in
terms of
their
affective states and their
psycho-
logical
and social
functioning
(Keyes
and
Waterman,
forthcoming).
Emotional
well-being
is
a
cluster
of
symp-
toms
reflecting
the
presence
or
absence
of
pos-
itive
feelings
about life.
Symptoms
of
emo-
tional
well-being
are ascertained from
individ-
uals'
responses
to
structured scales
measuring
the
presence
of
positive
affect
(e.g.,
individuals
is in
good
spirits),
the
absence
of
negative
affect
(e.g.,
individual is not
hopeless),
and
perceived
satisfaction with
life.
Measures
of
the
expression
of
emotional
well-being
in
terms of
positive
affect and
negative
affect are
related
but
distinct dimensions
(e.g.,
Bradbur
1969;
Watson and
Tellegen
1985).
Last,
mea-
sures
of
avowed
(e.g.,
"I am
satisfied
with
life")
and
expressed
(i.e.,
positive
and
negative
affect)
emotional
well-being
are related but
distinct dimensions
(Andrews
and
Withey
1976;
Bryant
and
Veroff
1982;
Diener
1984;
Diener,
Sandvik,
and
Pavot
1991;
Diener et al.
1999).
Like
mental
illness
(viz.
depression),
mental
health
is more than
the
presence
and
absence
of
emotional states. In
addition,
subjective
well-being
includes measures of the
presence
and
absence of
positive
functioning
in life.
Since
Ryff's
(1989)
operationalization
of clin-
ical
and
personality
theorists'
conceptions
of
positive functioning
(Jahoda 1958),
the
field
has moved toward
a
broader
set
of measures
of
well-being.
Positive
functioning
consists of six
dimensions of
psychological
well-being:
self-
acceptance,
positive
relations
with
others,
per-
sonal
growth,
purpose
in
life,
environmental
mastery,
and
autonomy
(see
Keyes
and
Ryff's
1999
review).
That
is,
individuals
are
function-
ing
well
when
they
like most
parts
of them-
selves,
have warm and
trusting relationships,
208 208 208
LANGUISHING
AND
FLOURISHING LANGUISHING
AND
FLOURISHING LANGUISHING
AND
FLOURISHING
see themselves
developing
into better
people,
have a direction
in
life,
are
able
to
shape
their
environments to
satisfy
their
needs,
and
have
a
degree
of
self-determination.
The
psychologi-
cal
well-being
scales
are well-validated
and
reliable
(Ryff
1989),
and the
six-factor
struc-
ture
has been confirmed in
a
large
and
repre-
sentative
sample
of U.S.
adults
(Ryff
and
Keyes 1995).
However,
there is
more
to
functioning
well
in
life than
psychological
well-being.
Elsewhere
(Keyes
1998)
I
have
argued
that
positive
functioning
includes
social
challenges
and
tasks,
and I
proposed
five
dimensions
of
social
well-being.
Whereas
psychological
well-being
represents
more
private
and
person-
al criteria for
evaluation of
one's
functioning,
social
well-being epitomizes
the
more
public
and
social criteria
whereby
people
evaluate
their
functioning
in life.
These
social dimen-
sions consist
of social
coherence,
social actu-
alization,
social
integration,
social
acceptance,
and
social
contribution.
Individuals are
func-
tioning
well
when
they
see
society
as
mean-
ingful
and
understandable,
when
they
see soci-
ety
as
possessing
potential
for
growth,
when
they
feel
they
belong
to
and
are
accepted
by
their
communities,
when
they accept
most
parts
of
society,
and when
they
see
themselves
contributing
to
society.
The
social
well-being
scales have
shown
good
construct
validity
and
internal
consistency,
and the
five-factor
struc-
ture
has been
confirmed
in
two
studies
based
on
data from
a
nationally representative
sam-
ple
of
adults
(Keyes
1998).1
It
is
probably
less
evident
that
the dimen-
sions of
social
well-being,
compared
with
emotional
and
psychological
well-being,
are
indicative of
an
individual's
mental
health.
However,
the
Surgeon
General's definition
of
mental
health
included
particular
reference
to
criteria
such
as
"productive
activities,"
"fulfill-
ing
relationships,"
and "the
ability
to
adapt
to
change,"
all of
which
imply
the
quality
of an
individual's
complete
engagement
in
society
and
life.
Measures of
emotional
well-being
often
identify
an
individual's
satisfaction
or
positive
affect with
"life
overall,"
but
rarely
with
facets of
their
social
lives.
The
dimen-
sions of
psychological
well-being
are
intra-
personal
reflections of
an
individual's
adjust-
ment
to
and outlook
on their
life.
Only
one of
the six
scales
of
psychological
well-being-
positive
relations with
others-reflects
the
ability
to
build and
maintain
intimate
and
see themselves
developing
into better
people,
have a direction
in
life,
are
able
to
shape
their
environments to
satisfy
their
needs,
and
have
a
degree
of
self-determination.
The
psychologi-
cal
well-being
scales
are well-validated
and
reliable
(Ryff
1989),
and the
six-factor
struc-
ture
has been confirmed in
a
large
and
repre-
sentative
sample
of U.S.
adults
(Ryff
and
Keyes 1995).
However,
there is
more
to
functioning
well
in
life than
psychological
well-being.
Elsewhere
(Keyes
1998)
I
have
argued
that
positive
functioning
includes
social
challenges
and
tasks,
and I
proposed
five
dimensions
of
social
well-being.
Whereas
psychological
well-being
represents
more
private
and
person-
al criteria for
evaluation of
one's
functioning,
social
well-being epitomizes
the
more
public
and
social criteria
whereby
people
evaluate
their
functioning
in life.
These
social dimen-
sions consist
of social
coherence,
social actu-
alization,
social
integration,
social
acceptance,
and
social
contribution.
Individuals are
func-
tioning
well
when
they
see
society
as
mean-
ingful
and
understandable,
when
they
see soci-
ety
as
possessing
potential
for
growth,
when
they
feel
they
belong
to
and
are
accepted
by
their
communities,
when
they accept
most
parts
of
society,
and when
they
see
themselves
contributing
to
society.
The
social
well-being
scales have
shown
good
construct
validity
and
internal
consistency,
and the
five-factor
struc-
ture
has been
confirmed
in
two
studies
based
on
data from
a
nationally representative
sam-
ple
of
adults
(Keyes
1998).1
It
is
probably
less
evident
that
the dimen-
sions of
social
well-being,
compared
with
emotional
and
psychological
well-being,
are
indicative of
an
individual's
mental
health.
However,
the
Surgeon
General's definition
of
mental
health
included
particular
reference
to
criteria
such
as
"productive
activities,"
"fulfill-
ing
relationships,"
and "the
ability
to
adapt
to
change,"
all of
which
imply
the
quality
of an
individual's
complete
engagement
in
society
and
life.
Measures of
emotional
well-being
often
identify
an
individual's
satisfaction
or
positive
affect with
"life
overall,"
but
rarely
with
facets of
their
social
lives.
The
dimen-
sions of
psychological
well-being
are
intra-
personal
reflections of
an
individual's
adjust-
ment
to
and outlook
on their
life.
Only
one of
the six
scales
of
psychological
well-being-
positive
relations with
others-reflects
the
ability
to
build and
maintain
intimate
and
see themselves
developing
into better
people,
have a direction
in
life,
are
able
to
shape
their
environments to
satisfy
their
needs,
and
have
a
degree
of
self-determination.
The
psychologi-
cal
well-being
scales
are well-validated
and
reliable
(Ryff
1989),
and the
six-factor
struc-
ture
has been confirmed in
a
large
and
repre-
sentative
sample
of U.S.
adults
(Ryff
and
Keyes 1995).
However,
there is
more
to
functioning
well
in
life than
psychological
well-being.
Elsewhere
(Keyes
1998)
I
have
argued
that
positive
functioning
includes
social
challenges
and
tasks,
and I
proposed
five
dimensions
of
social
well-being.
Whereas
psychological
well-being
represents
more
private
and
person-
al criteria for
evaluation of
one's
functioning,
social
well-being epitomizes
the
more
public
and
social criteria
whereby
people
evaluate
their
functioning
in life.
These
social dimen-
sions consist
of social
coherence,
social actu-
alization,
social
integration,
social
acceptance,
and
social
contribution.
Individuals are
func-
tioning
well
when
they
see
society
as
mean-
ingful
and
understandable,
when
they
see soci-
ety
as
possessing
potential
for
growth,
when
they
feel
they
belong
to
and
are
accepted
by
their
communities,
when
they accept
most
parts
of
society,
and when
they
see
themselves
contributing
to
society.
The
social
well-being
scales have
shown
good
construct
validity
and
internal
consistency,
and the
five-factor
struc-
ture
has been
confirmed
in
two
studies
based
on
data from
a
nationally representative
sam-
ple
of
adults
(Keyes
1998).1
It
is
probably
less
evident
that
the dimen-
sions of
social
well-being,
compared
with
emotional
and
psychological
well-being,
are
indicative of
an
individual's
mental
health.
However,
the
Surgeon
General's definition
of
mental
health
included
particular
reference
to
criteria
such
as
"productive
activities,"
"fulfill-
ing
relationships,"
and "the
ability
to
adapt
to
change,"
all of
which
imply
the
quality
of an
individual's
complete
engagement
in
society
and
life.
Measures of
emotional
well-being
often
identify
an
individual's
satisfaction
or
positive
affect with
"life
overall,"
but
rarely
with
facets of
their
social
lives.
The
dimen-
sions of
psychological
well-being
are
intra-
personal
reflections of
an
individual's
adjust-
ment
to
and outlook
on their
life.
Only
one of
the six
scales
of
psychological
well-being-
positive
relations with
others-reflects
the
ability
to
build and
maintain
intimate
and
trusting interpersonal
relationships.
I
have
argued
elsewhere
and
have
shown
empirically
(Keyes 1998)
that
an
individual's
adjustment
to
life
includes the
aforementioned facets
of
social
well-being.
That
is,
factor
analyses
showed
that
the
mental
health
measures
formed
three
correlated
but
distinct
factors:
emotional,
psychological,
and
social
well-
being.
Last,
some
dimensions
of
social
well-being
(viz.
social
integration)
are
identical
with
the-
oretical
explanations
of
interpersonal
and soci-
etal
level
causes
of
mental
health
(e.g.,
social
support
and
social
networks).
We
have
argued
elsewhere
(Keyes
and
Shapiro
forthcoming)
that
constructs
such as
social
integration
exist
at
multiple
levels
of
analysis
(i.e.,
societal,
interpersonal,
and
individual).
However,
I
con-
cur with
Larson
(1996),
who
said
that "The
key
to
deciding
whether a
measure of
social
well-being
is
part
of
an
individual's
health is
whether
the
measure
reflects
internal
respons-
es
to
stimuli-feelings,
thoughts
and
behaviors
reflecting
satisfaction
or lack of
satisfaction
with the
social
environment"
(p. 186).
From
this
perspective,
the
measures of
social well-
being,
like the
measures of
psychological
and
emotional
well-being,
should
be
viewed
as
indicators of
an
individual's
mental
health sta-
tus.
TOWARD
A
DIAGNOSIS
OF
MENTAL
HEALTH
Empirically,
mental health
and
mental
ill-
ness are
not
opposite
ends
of
a
single
measure-
ment
continuum.
Measures of
symptoms
of
mental
illness
(viz.
depression)
correlate
nega-
tively
and
modestly
with
measures
of
subjec-
tive
well-being.
In
two
separate
studies
reviewed
by
Ryff
and
Keyes (1995),
the
mea-
sures
of
psychological
well-being
correlated,
on
average,
-.51 with
the
Zung depression
inventory
and
-.55
with
the
Center
for
Epidemiological
Studies
depression
(CESD)
scale.
Indicators
and
scales of
life
satisfaction
and
happiness (i.e.,
emotional
well-being)
also
tend
to
correlate
around -.40
to
-.50
with
scales of
depression
symptoms
(see
Frisch
et
al.
1992).
Confirmatory
factor
analyses
of
the
sub-
scales
of
the
CESD and
the
scales
of
psycho-
logical
well-being
scales in a
sample
of
U.S.
adults
supported
the
two-factor
theory (Keyes,
trusting interpersonal
relationships.
I
have
argued
elsewhere
and
have
shown
empirically
(Keyes 1998)
that
an
individual's
adjustment
to
life
includes the
aforementioned facets
of
social
well-being.
That
is,
factor
analyses
showed
that
the
mental
health
measures
formed
three
correlated
but
distinct
factors:
emotional,
psychological,
and
social
well-
being.
Last,
some
dimensions
of
social
well-being
(viz.
social
integration)
are
identical
with
the-
oretical
explanations
of
interpersonal
and soci-
etal
level
causes
of
mental
health
(e.g.,
social
support
and
social
networks).
We
have
argued
elsewhere
(Keyes
and
Shapiro
forthcoming)
that
constructs
such as
social
integration
exist
at
multiple
levels
of
analysis
(i.e.,
societal,
interpersonal,
and
individual).
However,
I
con-
cur with
Larson
(1996),
who
said
that "The
key
to
deciding
whether a
measure of
social
well-being
is
part
of
an
individual's
health is
whether
the
measure
reflects
internal
respons-
es
to
stimuli-feelings,
thoughts
and
behaviors
reflecting
satisfaction
or lack of
satisfaction
with the
social
environment"
(p. 186).
From
this
perspective,
the
measures of
social well-
being,
like the
measures of
psychological
and
emotional
well-being,
should
be
viewed
as
indicators of
an
individual's
mental
health sta-
tus.
TOWARD
A
DIAGNOSIS
OF
MENTAL
HEALTH
Empirically,
mental health
and
mental
ill-
ness are
not
opposite
ends
of
a
single
measure-
ment
continuum.
Measures of
symptoms
of
mental
illness
(viz.
depression)
correlate
nega-
tively
and
modestly
with
measures
of
subjec-
tive
well-being.
In
two
separate
studies
reviewed
by
Ryff
and
Keyes (1995),
the
mea-
sures
of
psychological
well-being
correlated,
on
average,
-.51 with
the
Zung depression
inventory
and
-.55
with
the
Center
for
Epidemiological
Studies
depression
(CESD)
scale.
Indicators
and
scales of
life
satisfaction
and
happiness (i.e.,
emotional
well-being)
also
tend
to
correlate
around -.40
to
-.50
with
scales of
depression
symptoms
(see
Frisch
et
al.
1992).
Confirmatory
factor
analyses
of
the
sub-
scales
of
the
CESD and
the
scales
of
psycho-
logical
well-being
scales in a
sample
of
U.S.
adults
supported
the
two-factor
theory (Keyes,
trusting interpersonal
relationships.
I
have
argued
elsewhere
and
have
shown
empirically
(Keyes 1998)
that
an
individual's
adjustment
to
life
includes the
aforementioned facets
of
social
well-being.
That
is,
factor
analyses
showed
that
the
mental
health
measures
formed
three
correlated
but
distinct
factors:
emotional,
psychological,
and
social
well-
being.
Last,
some
dimensions
of
social
well-being
(viz.
social
integration)
are
identical
with
the-
oretical
explanations
of
interpersonal
and soci-
etal
level
causes
of
mental
health
(e.g.,
social
support
and
social
networks).
We
have
argued
elsewhere
(Keyes
and
Shapiro
forthcoming)
that
constructs
such as
social
integration
exist
at
multiple
levels
of
analysis
(i.e.,
societal,
interpersonal,
and
individual).
However,
I
con-
cur with
Larson
(1996),
who
said
that "The
key
to
deciding
whether a
measure of
social
well-being
is
part
of
an
individual's
health is
whether
the
measure
reflects
internal
respons-
es
to
stimuli-feelings,
thoughts
and
behaviors
reflecting
satisfaction
or lack of
satisfaction
with the
social
environment"
(p. 186).
From
this
perspective,
the
measures of
social well-
being,
like the
measures of
psychological
and
emotional
well-being,
should
be
viewed
as
indicators of
an
individual's
mental
health sta-
tus.
TOWARD
A
DIAGNOSIS
OF
MENTAL
HEALTH
Empirically,
mental health
and
mental
ill-
ness are
not
opposite
ends
of
a
single
measure-
ment
continuum.
Measures of
symptoms
of
mental
illness
(viz.
depression)
correlate
nega-
tively
and
modestly
with
measures
of
subjec-
tive
well-being.
In
two
separate
studies
reviewed
by
Ryff
and
Keyes (1995),
the
mea-
sures
of
psychological
well-being
correlated,
on
average,
-.51 with
the
Zung depression
inventory
and
-.55
with
the
Center
for
Epidemiological
Studies
depression
(CESD)
scale.
Indicators
and
scales of
life
satisfaction
and
happiness (i.e.,
emotional
well-being)
also
tend
to
correlate
around -.40
to
-.50
with
scales of
depression
symptoms
(see
Frisch
et
al.
1992).
Confirmatory
factor
analyses
of
the
sub-
scales
of
the
CESD and
the
scales
of
psycho-
logical
well-being
scales in a
sample
of
U.S.
adults
supported
the
two-factor
theory (Keyes,
209 209 209
JOURNAL OF
HEALTH AND
SOCIAL
BEHAVIOR
JOURNAL OF
HEALTH AND
SOCIAL
BEHAVIOR
JOURNAL OF
HEALTH AND
SOCIAL
BEHAVIOR
Ryff,
and Lee
2001).
That
is,
the
best-fitting
model was one
where
the
CESD subscales
were
indicators
of
the
latent
factor
that
repre-
sented the
presence
and absence
of mental ill-
ness
(see
also
Headey
et
al.
1993).
The
psy-
chological well-being
scales were indicators of
a second
latent factor that
represented
the
pres-
ence and absence of mental health.
In
short,
mental health is not
merely
the
absence
of
mental
illness;
it is
not
simply
the
presence
of
high
levels of
subjective
well-being.
Mental
health is best viewed as a
complete
state con-
sisting
of the
presence
and the
absence
of
men-
tal illness and
mental health
symptoms.
The mental health continuum consists
of
complete
and
incomplete
mental health. Adults
with
complete
mental health are
flourishing
in
life with
high
levels
of
well-being.
To
be
flour-
ishing,
then,
is to be
filled with
positive
emo-
tion
and
to be
functioning
well
psychological-
ly
and
socially.
Adults
with
incomplete
mental
health
are
languishing
in
life
with low
well-
being.
Thus,
languishing may
be
conceived
of
as
emptiness
and
stagnation, constituting
a life
of
quiet despair
that
parallels
accounts
of
indi-
viduals who describe
themselves and life
as
"hollow,"
"empty,"
"a
shell,"
and "a void"
(see
Cushman
1990;
Keyes
forthcoming; Levy
1984;
Singer
1977).
Conceptually
and
empirically,
measures
of
subjective
well-being
fall into
two clusters
of
symptoms:
emotional
and functional well-
being.
The
measures
of emotional
well-being
comprise
a
cluster
that reflects emotional
vital-
ity.
In
turn,
the measures of
psychological
well-being
and
social
well-being
reflect a mul-
tifaceted
cluster of
symptoms
of
positive
func-
tioning.
These two clusters of
mental health
symptoms
mirror the
symptom
clusters
used
in
the DSM-III-R
(American
Psychiatric
Association
1987)
to
diagnose
major depres-
sion
episode.
Major
depression
consists
of
symptoms
of
depressed
mood or anhedonia
(e.g.,
loss of
pleasure
derived
from
activities)
and
a multifaceted cluster
of
symptoms
(i.e.,
vegetative
and
hyperactive)
of
malfunctioning
(e.g.,
insomnia
or
hypersomnia).
Of the
nine
symptoms
of
major depression,
a
diagnosis
of
depression
is warranted
when
a
respondent
reports
five or more
symptoms,
with at least
one
symptom
coming
from the affective clus-
ter.
The
DSM
approach
to
the
diagnosis
of
major depression
is
employed
as a theoretical
guide
for the
diagnosis
of
mental
health,
whose
Ryff,
and Lee
2001).
That
is,
the
best-fitting
model was one
where
the
CESD subscales
were
indicators
of
the
latent
factor
that
repre-
sented the
presence
and absence
of mental ill-
ness
(see
also
Headey
et
al.
1993).
The
psy-
chological well-being
scales were indicators of
a second
latent factor that
represented
the
pres-
ence and absence of mental health.
In
short,
mental health is not
merely
the
absence
of
mental
illness;
it is
not
simply
the
presence
of
high
levels of
subjective
well-being.
Mental
health is best viewed as a
complete
state con-
sisting
of the
presence
and the
absence
of
men-
tal illness and
mental health
symptoms.
The mental health continuum consists
of
complete
and
incomplete
mental health. Adults
with
complete
mental health are
flourishing
in
life with
high
levels
of
well-being.
To
be
flour-
ishing,
then,
is to be
filled with
positive
emo-
tion
and
to be
functioning
well
psychological-
ly
and
socially.
Adults
with
incomplete
mental
health
are
languishing
in
life
with low
well-
being.
Thus,
languishing may
be
conceived
of
as
emptiness
and
stagnation, constituting
a life
of
quiet despair
that
parallels
accounts
of
indi-
viduals who describe
themselves and life
as
"hollow,"
"empty,"
"a
shell,"
and "a void"
(see
Cushman
1990;
Keyes
forthcoming; Levy
1984;
Singer
1977).
Conceptually
and
empirically,
measures
of
subjective
well-being
fall into
two clusters
of
symptoms:
emotional
and functional well-
being.
The
measures
of emotional
well-being
comprise
a
cluster
that reflects emotional
vital-
ity.
In
turn,
the measures of
psychological
well-being
and
social
well-being
reflect a mul-
tifaceted
cluster of
symptoms
of
positive
func-
tioning.
These two clusters of
mental health
symptoms
mirror the
symptom
clusters
used
in
the DSM-III-R
(American
Psychiatric
Association
1987)
to
diagnose
major depres-
sion
episode.
Major
depression
consists
of
symptoms
of
depressed
mood or anhedonia
(e.g.,
loss of
pleasure
derived
from
activities)
and
a multifaceted cluster
of
symptoms
(i.e.,
vegetative
and
hyperactive)
of
malfunctioning
(e.g.,
insomnia
or
hypersomnia).
Of the
nine
symptoms
of
major depression,
a
diagnosis
of
depression
is warranted
when
a
respondent
reports
five or more
symptoms,
with at least
one
symptom
coming
from the affective clus-
ter.
The
DSM
approach
to
the
diagnosis
of
major depression
is
employed
as a theoretical
guide
for the
diagnosis
of
mental
health,
whose
Ryff,
and Lee
2001).
That
is,
the
best-fitting
model was one
where
the
CESD subscales
were
indicators
of
the
latent
factor
that
repre-
sented the
presence
and absence
of mental ill-
ness
(see
also
Headey
et
al.
1993).
The
psy-
chological well-being
scales were indicators of
a second
latent factor that
represented
the
pres-
ence and absence of mental health.
In
short,
mental health is not
merely
the
absence
of
mental
illness;
it is
not
simply
the
presence
of
high
levels of
subjective
well-being.
Mental
health is best viewed as a
complete
state con-
sisting
of the
presence
and the
absence
of
men-
tal illness and
mental health
symptoms.
The mental health continuum consists
of
complete
and
incomplete
mental health. Adults
with
complete
mental health are
flourishing
in
life with
high
levels
of
well-being.
To
be
flour-
ishing,
then,
is to be
filled with
positive
emo-
tion
and
to be
functioning
well
psychological-
ly
and
socially.
Adults
with
incomplete
mental
health
are
languishing
in
life
with low
well-
being.
Thus,
languishing may
be
conceived
of
as
emptiness
and
stagnation, constituting
a life
of
quiet despair
that
parallels
accounts
of
indi-
viduals who describe
themselves and life
as
"hollow,"
"empty,"
"a
shell,"
and "a void"
(see
Cushman
1990;
Keyes
forthcoming; Levy
1984;
Singer
1977).
Conceptually
and
empirically,
measures
of
subjective
well-being
fall into
two clusters
of
symptoms:
emotional
and functional well-
being.
The
measures
of emotional
well-being
comprise
a
cluster
that reflects emotional
vital-
ity.
In
turn,
the measures of
psychological
well-being
and
social
well-being
reflect a mul-
tifaceted
cluster of
symptoms
of
positive
func-
tioning.
These two clusters of
mental health
symptoms
mirror the
symptom
clusters
used
in
the DSM-III-R
(American
Psychiatric
Association
1987)
to
diagnose
major depres-
sion
episode.
Major
depression
consists
of
symptoms
of
depressed
mood or anhedonia
(e.g.,
loss of
pleasure
derived
from
activities)
and
a multifaceted cluster
of
symptoms
(i.e.,
vegetative
and
hyperactive)
of
malfunctioning
(e.g.,
insomnia
or
hypersomnia).
Of the
nine
symptoms
of
major depression,
a
diagnosis
of
depression
is warranted
when
a
respondent
reports
five or more
symptoms,
with at least
one
symptom
coming
from the affective clus-
ter.
The
DSM
approach
to
the
diagnosis
of
major depression
is
employed
as a theoretical
guide
for the
diagnosis
of
mental
health,
whose
symptom
clusters mirror
theoretically
and
empirically
the
symptom
clusters
for
depres-
sion.
That
is,
mental
health is best
operational-
ized as
syndrome
that
combines
symptoms
of
emotional
well-being
with
symptoms
of
psy-
chological
and
social
well-being.
In
the
present
study, respondents
completed
a
structured
scale
of
positive
affect and a
question
about
life satisfaction
(i.e.,
emotional
well-being).
Respondents
also
completed
the
six
scales
of
psychological well-being
and
the
five
scales of
social
well-being. Altogether,
this
study
included two
symptom
scales of
emotional
vitality,
and
11
symptom
scales
of
positive
functioning (i.e.,
six
psychological
and five
social).
The
diagnostic
scheme for
mental health
parallels
the
scheme
employed
to
diagnose
major
depression
disorder
wherein
individuals
must exhibit
just
over half
of the total
symp-
toms
(i.e.,
at least five of
nine).
To be lan-
guishing
in
life,
individuals must exhibit
a low
level
(low
=
lower
tertile)
on one of the
two
measures
of
emotional
well-being,
and
low
levels
on six
of
the 11
scales
of
positive
func-
tioning.
To
be
flourishing
in
life,
individuals
must exhibit a
high
level
(high
=
upper tertile)
on one of the two measures of
emotional well-
being
and
high
levels on six of the
11
scales of
positive functioning.
Adults
who
are
moderate-
ly mentally healthy
are neither
flourishing
nor
languishing
in life. In
short,
individuals who
are
languishing
or
flourishing
must
exhibit,
respectively,
low or
high
levels on at
least
seven or more of the 13
symptom
scales.
Thus,
as with the
diagnosis
of
major depression,
symptoms
of
emotional
vitality
are
essential
for
the
diagnosis
of mental
health insofar as
individuals must exhibit
specific
levels
of
sat-
isfaction
or
positive
affect
(cf.
Penninx
et al.
1998).
Moreover,
as with
depression,
in
which
individuals must exhibit at least five of the
nine
(i.e.,
over 50
percent)
of the
symptoms,
the
diagnostic
criteria for mental health
require
over 50
percent
of the
symptoms
to be
present
at
specific
levels for
a
diagnosis.
In the
absence
of a clear criterion for
symptom
level
comparable
to
depression (i.e., symptom
must
be
present
"all"
or "most"
of
the time for at
least two
weeks),
this
paper employs
the scale
tertile,
which
operationalizes
symptom
level
somewhat
arbitrarily
and
relative to the
sample
respondents.
This
diagnosis
is
employed
to
investigate
and
compare
the
prevalence
and
psychosocial
symptom
clusters mirror
theoretically
and
empirically
the
symptom
clusters
for
depres-
sion.
That
is,
mental
health is best
operational-
ized as
syndrome
that
combines
symptoms
of
emotional
well-being
with
symptoms
of
psy-
chological
and
social
well-being.
In
the
present
study, respondents
completed
a
structured
scale
of
positive
affect and a
question
about
life satisfaction
(i.e.,
emotional
well-being).
Respondents
also
completed
the
six
scales
of
psychological well-being
and
the
five
scales of
social
well-being. Altogether,
this
study
included two
symptom
scales of
emotional
vitality,
and
11
symptom
scales
of
positive
functioning (i.e.,
six
psychological
and five
social).
The
diagnostic
scheme for
mental health
parallels
the
scheme
employed
to
diagnose
major
depression
disorder
wherein
individuals
must exhibit
just
over half
of the total
symp-
toms
(i.e.,
at least five of
nine).
To be lan-
guishing
in
life,
individuals must exhibit
a low
level
(low
=
lower
tertile)
on one of the
two
measures
of
emotional
well-being,
and
low
levels
on six
of
the 11
scales
of
positive
func-
tioning.
To
be
flourishing
in
life,
individuals
must exhibit a
high
level
(high
=
upper tertile)
on one of the two measures of
emotional well-
being
and
high
levels on six of the
11
scales of
positive functioning.
Adults
who
are
moderate-
ly mentally healthy
are neither
flourishing
nor
languishing
in life. In
short,
individuals who
are
languishing
or
flourishing
must
exhibit,
respectively,
low or
high
levels on at
least
seven or more of the 13
symptom
scales.
Thus,
as with the
diagnosis
of
major depression,
symptoms
of
emotional
vitality
are
essential
for
the
diagnosis
of mental
health insofar as
individuals must exhibit
specific
levels
of
sat-
isfaction
or
positive
affect
(cf.
Penninx
et al.
1998).
Moreover,
as with
depression,
in
which
individuals must exhibit at least five of the
nine
(i.e.,
over 50
percent)
of the
symptoms,
the
diagnostic
criteria for mental health
require
over 50
percent
of the
symptoms
to be
present
at
specific
levels for
a
diagnosis.
In the
absence
of a clear criterion for
symptom
level
comparable
to
depression (i.e., symptom
must
be
present
"all"
or "most"
of
the time for at
least two
weeks),
this
paper employs
the scale
tertile,
which
operationalizes
symptom
level
somewhat
arbitrarily
and
relative to the
sample
respondents.
This
diagnosis
is
employed
to
investigate
and
compare
the
prevalence
and
psychosocial
symptom
clusters mirror
theoretically
and
empirically
the
symptom
clusters
for
depres-
sion.
That
is,
mental
health is best
operational-
ized as
syndrome
that
combines
symptoms
of
emotional
well-being
with
symptoms
of
psy-
chological
and
social
well-being.
In
the
present
study, respondents
completed
a
structured
scale
of
positive
affect and a
question
about
life satisfaction
(i.e.,
emotional
well-being).
Respondents
also
completed
the
six
scales
of
psychological well-being
and
the
five
scales of
social
well-being. Altogether,
this
study
included two
symptom
scales of
emotional
vitality,
and
11
symptom
scales
of
positive
functioning (i.e.,
six
psychological
and five
social).
The
diagnostic
scheme for
mental health
parallels
the
scheme
employed
to
diagnose
major
depression
disorder
wherein
individuals
must exhibit
just
over half
of the total
symp-
toms
(i.e.,
at least five of
nine).
To be lan-
guishing
in
life,
individuals must exhibit
a low
level
(low
=
lower
tertile)
on one of the
two
measures
of
emotional
well-being,
and
low
levels
on six
of
the 11
scales
of
positive
func-
tioning.
To
be
flourishing
in
life,
individuals
must exhibit a
high
level
(high
=
upper tertile)
on one of the two measures of
emotional well-
being
and
high
levels on six of the
11
scales of
positive functioning.
Adults
who
are
moderate-
ly mentally healthy
are neither
flourishing
nor
languishing
in life. In
short,
individuals who
are
languishing
or
flourishing
must
exhibit,
respectively,
low or
high
levels on at
least
seven or more of the 13
symptom
scales.
Thus,
as with the
diagnosis
of
major depression,
symptoms
of
emotional
vitality
are
essential
for
the
diagnosis
of mental
health insofar as
individuals must exhibit
specific
levels
of
sat-
isfaction
or
positive
affect
(cf.
Penninx
et al.
1998).
Moreover,
as with
depression,
in
which
individuals must exhibit at least five of the
nine
(i.e.,
over 50
percent)
of the
symptoms,
the
diagnostic
criteria for mental health
require
over 50
percent
of the
symptoms
to be
present
at
specific
levels for
a
diagnosis.
In the
absence
of a clear criterion for
symptom
level
comparable
to
depression (i.e., symptom
must
be
present
"all"
or "most"
of
the time for at
least two
weeks),
this
paper employs
the scale
tertile,
which
operationalizes
symptom
level
somewhat
arbitrarily
and
relative to the
sample
respondents.
This
diagnosis
is
employed
to
investigate
and
compare
the
prevalence
and
psychosocial
210 210 210
LANGUISHING
AND
FLOURISHING LANGUISHING
AND
FLOURISHING LANGUISHING
AND
FLOURISHING
functioning
associated with
the
categories
of
mental health
and with
major
depression.
Moreover,
this
paper
examines
the
descriptive
epidemiology
of mental health and
major
depression by
gender,
age,
education,
and
mar-
ital
status,
which
are variables that have
been
consistently
linked with the
risk of
depression
(see
Horwitz
and
Scheid
1999).
METHODS
Sample
Data
are
from the
MacArthur
Foundation's
Midlife
in
the
United States
survey.
This sur-
vey
was a
random-digit-dialing
sample
of
non-
institutionalized
English-speaking
adults
age
25 to 74
living
in
the 48
contiguous
states,
whose household
included
at least
one
tele-
phone.
In
the first
stage
of
the
multistage
sam-
pling
design,
investigators
selected
households
with
equal
probability
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
over-sam-
pled.
Field
procedures
were
initiated in
January
of
1995 and
lasted
13
months.
Respondents
were
contacted
and
interviewed
by
trained
person-
nel,
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
complete.
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
percent
response
rate
for
the
telephone
phase
and
an 87
percent
response
rate for
the
self-administered
questionnaire
phase,
the
combined
response
is 61
percent
(.70
x
.87
=
.61).
Descriptive
analyses
are
based
on
the
weighted
sample
to
correct for
unequal proba-
bilities 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.,
metropoli-
tan and
non-metropolitan),
and
region
(Northeast,
Midwest, South,
and
West)
based
functioning
associated with
the
categories
of
mental health
and with
major
depression.
Moreover,
this
paper
examines
the
descriptive
epidemiology
of mental health and
major
depression by
gender,
age,
education,
and
mar-
ital
status,
which
are variables that have
been
consistently
linked with the
risk of
depression
(see
Horwitz
and
Scheid
1999).
METHODS
Sample
Data
are
from the
MacArthur
Foundation's
Midlife
in
the
United States
survey.
This sur-
vey
was a
random-digit-dialing
sample
of
non-
institutionalized
English-speaking
adults
age
25 to 74
living
in
the 48
contiguous
states,
whose household
included
at least
one
tele-
phone.
In
the first
stage
of
the
multistage
sam-
pling
design,
investigators
selected
households
with
equal
probability
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
over-sam-
pled.
Field
procedures
were
initiated in
January
of
1995 and
lasted
13
months.
Respondents
were
contacted
and
interviewed
by
trained
person-
nel,
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
complete.
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
percent
response
rate
for
the
telephone
phase
and
an 87
percent
response
rate for
the
self-administered
questionnaire
phase,
the
combined
response
is 61
percent
(.70
x
.87
=
.61).
Descriptive
analyses
are
based
on
the
weighted
sample
to
correct for
unequal proba-
bilities 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.,
metropoli-
tan and
non-metropolitan),
and
region
(Northeast,
Midwest, South,
and
West)
based
functioning
associated with
the
categories
of
mental health
and with
major
depression.
Moreover,
this
paper
examines
the
descriptive
epidemiology
of mental health and
major
depression by
gender,
age,
education,
and
mar-
ital
status,
which
are variables that have
been
consistently
linked with the
risk of
depression
(see
Horwitz
and
Scheid
1999).
METHODS
Sample
Data
are
from the
MacArthur
Foundation's
Midlife
in
the
United States
survey.
This sur-
vey
was a
random-digit-dialing
sample
of
non-
institutionalized
English-speaking
adults
age
25 to 74
living
in
the 48
contiguous
states,
whose household
included
at least
one
tele-
phone.
In
the first
stage
of
the
multistage
sam-
pling
design,
investigators
selected
households
with
equal
probability
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
over-sam-
pled.
Field
procedures
were
initiated in
January
of
1995 and
lasted
13
months.
Respondents
were
contacted
and
interviewed
by
trained
person-
nel,
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
complete.
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
percent
response
rate
for
the
telephone
phase
and
an 87
percent
response
rate for
the
self-administered
questionnaire
phase,
the
combined
response
is 61
percent
(.70
x
.87
=
.61).
Descriptive
analyses
are
based
on
the
weighted
sample
to
correct for
unequal proba-
bilities 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.,
metropoli-
tan and
non-metropolitan),
and
region
(Northeast,
Midwest, South,
and
West)
based
on
the
October
1995
Current
Population
Survey.
Measures
Mental
illness. The
Midlife
in the
United
States
survey employed
the
Composite
International
Diagnostic
Interview
Short Form
(CIDI-SF)
scales
(Kessler
et al.
1998),
which
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
exhib-
ited
symptoms
indicative
of
major depression
episode
during
the
past
12
months.
Respondents
were
classified
as
having
had
a
major
depressive
episode
based on the
criteria
establish
by
the
DSM-III-R
(American
Psychiatric
Association
1987).
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)
extremely
happy,
(4)
calm and
peaceful,
(5)
satisfied,
and
(6)
full
of life. The
internal
reliability
of
the
positive
affect scale
is
.91
(see
also
Mroczek
and
Kolarz
1998).
Respondents
also
evaluated
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
opera-
tionalize how much
individuals
see
themselves
thriving
in
their
personal
life.
The
scales
repre-
sent
distinctive
dimensions
(Ryff
and
Keyes
1995)
of
subjective
well-being.
The
scales with
a
representative
item
in
parenthesis
are
as fol-
lows:
self-acceptance ("I
like
most
parts
of
my
personality"),
positive
relations
with
others
("maintaining
close
relationships
has
been
dif-
ficult 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
responsi-
bilities of
daily
life"),
and
autonomy
("I
tend to
on
the
October
1995
Current
Population
Survey.
Measures
Mental
illness. The
Midlife
in the
United
States
survey employed
the
Composite
International
Diagnostic
Interview
Short Form
(CIDI-SF)
scales
(Kessler
et al.
1998),
which
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
exhib-
ited
symptoms
indicative
of
major depression
episode
during
the
past
12
months.
Respondents
were
classified
as
having
had
a
major
depressive
episode
based on the
criteria
establish
by
the
DSM-III-R
(American
Psychiatric
Association
1987).
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)
extremely
happy,
(4)
calm and
peaceful,
(5)
satisfied,
and
(6)
full
of life. The
internal
reliability
of
the
positive
affect scale
is
.91
(see
also
Mroczek
and
Kolarz
1998).
Respondents
also
evaluated
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
opera-
tionalize how much
individuals
see
themselves
thriving
in
their
personal
life.
The
scales
repre-
sent
distinctive
dimensions
(Ryff
and
Keyes
1995)
of
subjective
well-being.
The
scales with
a
representative
item
in
parenthesis
are
as fol-
lows:
self-acceptance ("I
like
most
parts
of
my
personality"),
positive
relations
with
others
("maintaining
close
relationships
has
been
dif-
ficult 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
responsi-
bilities of
daily
life"),
and
autonomy
("I
tend to
on
the
October
1995
Current
Population
Survey.
Measures
Mental
illness. The
Midlife
in the
United
States
survey employed
the
Composite
International
Diagnostic
Interview
Short Form
(CIDI-SF)
scales
(Kessler
et al.
1998),
which
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
exhib-
ited
symptoms
indicative
of
major depression
episode
during
the
past
12
months.
Respondents
were
classified
as
having
had
a
major
depressive
episode
based on the
criteria
establish
by
the
DSM-III-R
(American
Psychiatric
Association
1987).
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)
extremely
happy,
(4)
calm and
peaceful,
(5)
satisfied,
and
(6)
full
of life. The
internal
reliability
of
the
positive
affect scale
is
.91
(see
also
Mroczek
and
Kolarz
1998).
Respondents
also
evaluated
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
opera-
tionalize how much
individuals
see
themselves
thriving
in
their
personal
life.
The
scales
repre-
sent
distinctive
dimensions
(Ryff
and
Keyes
1995)
of
subjective
well-being.
The
scales with
a
representative
item
in
parenthesis
are
as fol-
lows:
self-acceptance ("I
like
most
parts
of
my
personality"),
positive
relations
with
others
("maintaining
close
relationships
has
been
dif-
ficult 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
responsi-
bilities of
daily
life"),
and
autonomy
("I
tend to
211 211 211
JOURNAL OF
HEALTH
AND
SOCIAL
BEHAVIOR
JOURNAL OF
HEALTH
AND
SOCIAL
BEHAVIOR
JOURNAL OF
HEALTH
AND
SOCIAL
BEHAVIOR
be influenced
by
people
with
strong opin-
ions").
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
indicated
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-items scales have
shown
modest internal
consistency
(i.e.,
around
.50;
see
Ryff
and
Keyes
1995),
and
the internal
consistency
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:
social-
acceptance
("People
do
not care about other
peoples'
problems"),
social
actualization
("Society
isn't
improving
for
people
like
me"),
social contribution
("My daily
activities
do not
create
anything
worthwhile
for
my
communi-
ty"),
social
coherence
("I
cannot make sense
of
what's
going
on
in the
world"),
and
social inte-
gration
("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
described
how
they
functioned
(i.e.,
thought
or
felt).
Negative
items
were reverse-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
con-
stituent
items,
standardized,
and tertiles
were
computed
for each
s