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Association between psychological distress and mortality: individual participant pooled analysis of 10 prospective cohort studies

BMJ 2012; 345 doi: (Published 31 July 2012) Cite this as: BMJ 2012;345:e4933
  1. Tom C Russ, alzheimer scotland clinical research fellow123,
  2. Emmanuel Stamatakis, senior research associate and national institute for health research career development fellow4,
  3. Mark Hamer, principal research associate4,
  4. John M Starr, professor of health and ageing1235,
  5. Mika Kivimäki, professor of social epidemiology4,
  6. G David Batty, reader in epidemiology/wellcome trust fellow34
  1. 1Scottish Dementia Clinical Research Network, NHS Scotland, Murray Royal Hospital, Perth, UK
  2. 2Alzheimer Scotland Dementia Research Centre, University of Edinburgh, Edinburgh EH8 9JZ, UK
  3. 3Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh
  4. 4Department of Epidemiology and Public Health, University College London, London, UK
  5. 5NHS Lothian, Edinburgh
  1. Correspondence to: T C Russ tom.russ{at}
  • Accepted 4 July 2012


Objective To quantify the link between lower, subclinically symptomatic, levels of psychological distress and cause-specific mortality in a large scale, population based study.

Design Individual participant meta-analysis of 10 large prospective cohort studies from the Health Survey for England. Baseline psychological distress measured by the 12 item General Health Questionnaire score, and mortality from death certification.

Participants 68 222 people from general population samples of adults aged 35 years and over, free of cardiovascular disease and cancer, and living in private households in England at study baseline.

Main outcome measures Death from all causes (n=8365), cardiovascular disease including cerebrovascular disease (n=3382), all cancers (n=2552), and deaths from external causes (n=386). Mean follow-up was 8.2 years (standard deviation 3.5).

Results We found a dose-response association between psychological distress across the full range of severity and an increased risk of mortality (age and sex adjusted hazard ratio for General Health Questionnaire scores of 1-3 v score 0: 1.20, 95% confidence interval 1.13 to 1.27; scores 4-6: 1.43, 1.31 to 1.56; and scores 7-12: 1.94, 1.66 to 2.26; P<0.001 for trend). This association remained after adjustment for somatic comorbidity plus behavioural and socioeconomic factors. A similar association was found for cardiovascular disease deaths and deaths from external causes. Cancer death was only associated with psychological distress at higher levels.

Conclusions Psychological distress is associated with increased risk of mortality from several major causes in a dose-response pattern. Risk of mortality was raised even at lower levels of distress.


  • Contributors: GDB conceived and designed the study. ES, MH, and GDB were responsible for acquisition of data. TCR, MK, and GDB were responsible for analysis and interpretation of data. TCR and GDB drafted the manuscript. TCR, ES, MH, JMS, MK, and GDB critically revised the manuscript for important intellectual content. TCR, ES, MK, and GDB did the statistical analysis. GDB obtained funding. MH, MK, and GDB were responsible for study supervision. TCR and GDB are the study guarantors. All authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Funding: The study did not receive any specific funding. TCR is supported by Alzheimer Scotland and employed in the NHS by the Scottish Dementia Clinical Research Network, which is funded by the Chief Scientist Office (part of the Scottish Government Health Directorates). TCR and JMS are members of the Alzheimer Scotland Dementia Research Centre funded by Alzheimer Scotland. TCR, JMS, and GDB are members of the University of Edinburgh Centre for Cognitive Ageing and Cognitive Epidemiology, part of the cross council Lifelong Health and Wellbeing Initiative (G0700704/84698). The Biotechnology and Biological Sciences Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, and United Kingdom Medical Research Council provided funding. ES is supported by a National Institute for Health Research career development fellowship. MK is supported by the UK Medical Research Council, the Academy of Finland, and the United States National Institutes of Health (R01HL036310; R01AG034454). GDB is a Wellcome Trust Fellow. All researchers are independent from the funders.

  • Ethical approval: Ethical approval was obtained from the London Research Ethics Council.

  • Data sharing: no additional data available.

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