Elsevier

Annals of Epidemiology

Volume 14, Issue 7, August 2004, Pages 467-472
Annals of Epidemiology

psychological distress and premature mortality in the general Population: a prospective study

https://doi.org/10.1016/j.annepidem.2003.11.007Get rights and content

Abstract

Purpose

To determine whether higher rates of mortality are observed in people reporting psychological distress, to establish the nature of any excess, and to examine the possible existence of a dose response relationship.

Methods

We conducted a prospective follow-up study of mortality over an eight-year period in the North West of England. A total of 4,501 adults were recruited from two general practices during a population-based survey conducted at the start of 1992. At baseline psychological distress was assessed using the General Health Questionnaire (12-item version, GHQ-12). The relationship between levels of distress and subsequent mortality was examined using Cox proportional hazard models.

Results

Risk of all-cause mortality was greatest in subjects reporting the highest levels of distress (hazard ratio (HR) 1.71, 95% CI 1.32–2.23) but was also raised in subjects reporting intermediate distress (HR 1.38 95% CI 1.06–1.79) when compared to those reporting no distress. Increased risk of mortality in subjects reporting distress appeared to be due largely to an excess of deaths from ischaemic heart disease (high distress, HR 1.90, 95% CI 1.08–3.35; intermediate distress, HR 1.58, 95% CI 0.90–2.76) and respiratory diseases (high distress, HR 5.39, 95% CI 2.70–10.78; intermediate distress, HR 2.33, 95% CI 1.12–4.22).

Conclusions

The association between mortality and psychological distress observed in this study seems to arise largely because of premature deaths from ischaemic heart disease and respiratory diseases. The existence of a dose-response effect between distress and mortality provides further evidence to support the existence of a casual relationship.

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

References (32)

  • M.L. Bruce et al.

    Psychiatric status and 9-year mortality data in the New Haven Epidemiological Catchment Area Study

    Am J Psychiatry

    (1994)
  • A. Kouzis et al.

    Psychopathology and mortality in the general population

    Soc Psychiatry Psychiatr Epidemiol

    (1995)
  • E.L. Goldberg et al.

    Depressed mood and subsequent physical illness

    Am J Psychiatry

    (1979)
  • P.D. Somervell et al.

    Psychological distress as a predictor of mortality

    Am J Epidemiol

    (1989)
  • I.M. Hunt et al.

    The prevalence and associated features of chronic widespread pain in the community using the “Manchester” definition of chronic widespread pain

    Rheumatol

    (1999)
  • G.J. Macfarlane et al.

    Widespread body pain and mortality: Prospective population-based study

    BMJ

    (2001)
  • Cited by (86)

    • Associations among resilience, hope, social support, stress, and anxiety severity in Chinese women with abnormal cervical cancer screening results

      2022, Heliyon
      Citation Excerpt :

      In this regard, it is recommended that medical staff encourage family members and friends to offer more companionship and support, thereby improving resilience and women's ability to adapt to their state of hardship or affliction. Stress significantly affects people's quality of life [62] and is connected with many adverse health outcomes, such as cardiovascular events [63, 64], mental illness [65], metabolic syndrome [66, 67, 68], and mortality [69, 70, 71]. We herein found that perceived stress by women with abnormal cervical cancer screening results had a significant negative impact on their resilience.

    • Psychological distress, life expectancy, and all-cause mortality in the United States: results from the 1997–2014 NHIS-NDI record linkage study

      2021, Annals of Epidemiology
      Citation Excerpt :

      There is an average 3.8 years of potential life lost for a person with SPD, compared with those without SPD [5]. Psychological distress, a general term for symptoms of anxiety and depression, has been found to be associated with morbidity and mortality [5–25]. Previous morbidity studies have found that depression or anxiety is associated with increased risks for cardiovascular disease [6,17], cancer [18,19], Alzheimer's disease [20,21], and unintentional injury [22].

    • Association of Psychosocial Factors With Risk of Chronic Diseases: A Nationwide Longitudinal Study

      2020, American Journal of Preventive Medicine
      Citation Excerpt :

      The findings of a positive association between psychological distress and heart disease or circulatory diseases in men and women are consistent with previous studies,28–30 although the patterns of the sex-specific associations differ between studies. Meta-analysis and cohort studies reported that psychological distress can increase the risk of myocardial infarction, stroke,30 and death from CVD28,29 and circulatory diseases in men and women.29 However, some studies have found a positive association only in men.11,13

    View all citing articles on Scopus
    View full text