psychological distress and premature mortality in the general Population: a prospective study
Introduction
Although the reported levels of psychiatric morbidity within the general population vary in relation to the precise definitions used for case identification, the prevalence of psychiatric disorders is known to be high 1., 2.. In addition to the high social and economic costs 3., 4., a less obvious consequence of mental illness appears to be a reduction in life expectancy. In a recent meta-analysis examining mortality across a wide variety of mental disorders, higher risks of premature mortality were observed for every type of mental disorder that was examined (5). While high rates of mortality were observed for causes of death such as suicide and violence, premature mortality was not limited to unnatural deaths. In the case of affective disorders such as depression, for example, increased risk of death was observed for natural causes including infections, nervous disorders, and diseases of the circulatory and respiratory systems (5).
However, previous studies have tended to be conducted within clinic populations 5., 6. where subjects are more likely to have co-morbidities that may themselves influence mortality rates. A growing body of evidence appears to support a relationship amongst general population subjects 7., 8., 9. although these findings are not consistent 10., 11..
Beyond the realm of distinct psychiatric symptoms and disorders, less specific symptoms of psychological distress have also been associated with an increased risk of mortality. Using a sub-scale of the Health Opinion Survey, defined as a distress symptom score, Somervell et al. (12) found that psychological distress was a predictor of all-cause mortality when subjects with high levels of distress were compared with individuals with average scores. Psychological distress, as measured by the General Health Questionnaire (GHQ), was also found to predict all-cause mortality (6).
Rather than assessing mortality in relation to specific symptoms or psychiatric illnesses, the current study sought to examine the relationship between non-specific symptoms of psychological distress and mortality in more detail. In doing so, the aim was to include individuals who might have sub-clinical diseases or symptoms, therefore giving rise to a better insight into the overall influence that psychological disorders and distress might have on mortality within the general population. Specifically, the study aimed to extend previous findings 6., 12. by investigating the association between psychological distress and cause-specific mortality in addition to all-cause mortality. Another key aim was to establish if a gradient of risk of mortality existed in relation to degree of psychological distress. In addition, a novel feature of the present study was the consideration of widespread pain as a potential confounder of the relationship between psychological distress and mortality. An association between widespread pain and psychological distress has been reported previously (13), and recent research indicates that individuals reporting widespread pain also experience premature mortality (14).
Section snippets
Study population
This study examines the mortality experience of participants in a population-based study, the details of which have been described previously (15). The study had appropriate ethics committee approval and conforms to the principles embodied in the Declaration of Helsinki. Briefly, the study was conducted in a suburban area of north-west England and commenced at the beginning of 1992. All adults aged 18 to 75 years who were registered with two general practices in the study area were eligible to
Results
For the study population, the tertile thresholds of increasing severity of psychological distress corresponded to: first tertile, GHQ score 0 (no reported psychological distress, 40%, n = 1820); second tertile, GHQ scores 1 to 3 (intermediate psychological distress, 28%, n = 1271); third tertile, GHQ scores 4 to 12 (high psychological distress, 28%, n = 1269). Age distributions were fairly similar within these categories of psychological distress (Table 1), which was reflected in the median ages for
Discussion
Compared with individuals who reported no psychological distress, those reporting intermediate or high levels of distress had increased risks of mortality during the 8-year follow-up period. These patterns of mortality appeared to be due largely to an excess of deaths from IHD, respiratory diseases, and external causes although in the last case the excess was not statistically significant.
Before evaluating whether or not a true relationship existed between psychological distress and excess
Acknowledgements
The authors thank Peter Croft, Alan Silman, and Ann Papageorgiou of the Arthritis Research Campaign Epidemiology Unit, University of Manchester, UK, who designed and conducted the population survey described in this study. The authors are also indebted to the staff of the Office for National Statistics, UK, who identified subjects on the NHS Central Register, and to the staff and patients of the participating general practices in Wythenshawe in Greater Manchester. The baseline population survey
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