Intended for healthcare professionals


Emotional wellbeing and its relation to health

BMJ 1998; 317 doi: (Published 12 December 1998) Cite this as: BMJ 1998;317:1608

Physical disease may well result from emotional distress

  1. Sarah Stewart-Brown, Director
  1. Health Services Research Unit, Department of Public Health, University of Oxford, Oxford OX3 7LF

    In 1947 the World Health Organisation defined health as “a state of complete physical, mental and social wellbeing.”1 Until now the NHS has given precedence to promoting physical wellbeing, but the green paper Our Healthier Nationsignals that this may need to change.2 It emphasises the importance of emotional wellbeing for health: indeed, health is defined as “being confident and positive and able to cope with the ups and downs of life.” These statements are supported by an increasing body of epidemiological, social science, and experimental research that is beginning to suggest that initiatives which aim to promote physical wellbeing to the exclusion of mental and social wellbeing may be doomed to failure.

    The concept of mental and social wellbeing is less well defined than that of physical wellbeing. Debate still continues about the meaning of the term mental health. A recent study in Scotland showed that lay people were more comfortable with the terms psychological and emotional wellbeing because they equated the term mental health with mental illness.3 The concepts of social wellbeing and social disease (misuse of alcohol and drugs, domestic violence, child abuse) and the extent to which they are the responsibility of the NHS is also controversial.

    Nevertheless, some research shows that emotional distress creates susceptibility to physical illness. Exam stress increases susceptibility to viral infection,4 and stress from lack of control in the workplace5 or from life events6 creates susceptibility to cardiovascular disease. Animal studies reviewed by Wilkinson7 and Brunner8 provide supporting evidence that emotional distress can lead to physical illness by affecting the immune response. Health related lifestyles provide the basis for an alternative, potentially complementary, causal hypothesis. Smoking, drinking, and the consumption of high fat foods are all valued by the public for their ability to relieve emotional distress.9 Collectively these studies are beginning to lend credence to the widespread public belief that physical disease may be the consequence of emotional distress.

    Several epidemiological studies have shown that social and emotional support can protect against premature mortality, prevent illness, and aid recovery. 10 11 It is plausible that these could act by reducing emotional distress. Various different types of study have suggested that as important for health as income differentials is social capital—that is, features of social organisation (civic participation, social trust) that facilitate cooperation for mutual benefit.7 One of these studies examined the relation between income differentials and responses to the question “Do you think that most people would try to take advantage of you if they got the chance?” in a representative survey.12 The collective response of communities to these questions predicted age adjusted mortality rates better than the Robin Hood index, a well validated measure of income differentials. Income differentials vary over time and from place to place,7 suggesting that they are not just a fact of life. It could be argued that wide income differentials are an economic manifestation of people taking advantage of each other, and that it is the latter that causes premature mortality—through the emotional distress it generates.

    Solutions to apparently intractable public health problems like inequalities in health and unhealthy lifestyles may therefore lie in research into emotional wellbeing. A broad range of studies is needed to test the hypothesis that emotional distress creates susceptibility to physical illness and a further range is to research interventions which can prevent emotional distress and promote mental and social health.

    Two of the most promising approaches depend on a further body of research which shows that unresolved emotional distress in childhood is an important cause of emotional distress in adulthood. 13 14 These approaches are parenting programmes and mental health promotion programmes in schools. The evidence showing that parenting programmes can both reverse emotional and behavioural problems15 and prevent their emergence16 is robust. Several school mental health promotion programmes have been subject to controlled trials which show a positive impact on emotional wellbeing.17 Through developing empathy and respect, both types of programmes improve self esteem in children and parents and increase their ability to give and receive social and emotional support. Long term follow up studies are needed to test the hypothesis that these programmes affect adult physical and mental health, but the epidemiological evidence suggesting that they could is strong.

    Successful implementation of the agenda defined in Our Healthier Nation will depend on research and development of such programmes. For this to happen doctors, and others who determine the allocation of NHS funds, will need to believe that emotional and social wellbeing are at least as important for health as physical wellbeing and invest both development and research funds accordingly.


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