Stress, psychiatric disorders, and cardiovascular diseaseBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1577 (Published 10 April 2019) Cite this as: BMJ 2019;365:l1577
All rapid responses
Re: Stress, psychiatric disorders, and cardiovascular disease: comments on this article and on Dr Tiley’s response
1. Inequalities of income and ability to spend are muti-faceted. No simple correlation with what defines health.
2. There are people who accept, who have accepted from infancy, that “ poverty”’ is the will of a superior, divine, force. They do not suffer psychiatric disorders. The label of a mental disorder is a social construct.
In some societies, what passes for murder in my eyes, is regarded there as obeying Divine orders. We, in the capitalist WESTERN DEMOCRACIES, regarded the exile of non-conforming individuals punished according to THEIR LAWS, by the Soviet Regime as immoral, and their incarceration in mental hospitals as unethical.
3. Sudden loss of livelihood can have a traumatic effect. However, where the person concerned has, knowing the possible outcome, in effect, courted dismissal, the cardiovascular system is unlikely to suffer.
4. We tend to look at major disasters involving hundreds of people as having great effect. Yet, when one knows that one is ALONE, in a tragedy, where hundreds have escaped, this is far more likely to result in mental trauma. "Why me?", you ask. But here too, if one believes that it was the will of the Superior Being, one might find it easier to adjust.
5. PTSD is a term coined scarcely fifty years ago. I have applied this diagnostic label often enough.
But look back at the history of religious wars, back to the Crusades. The antagonists had clear, black and white, or Christian and Saracen identities. No mental conflict. You killed the enemy. No feelings of guilt. You were injured. The Will of Your God. Was there Post-Traumatic Stress? I know of no evidence that there was.
Competing interests: My comments are based on my interpretation of history as well as my conclusions of religious, economic, and political events in my life-time. I worked in London, many years ago, at the Medical Foundation for the Care of Victims of Torture (set up by the late Helen Bamber).
Bacon’s interesting article BMJ 2019; 365:11577 contributes to existing evidence that stress and cardiovascular disease are linked.
A small scale study by Witte (1) looking at coronary events in Dutch cardiac units has supported a causal link between the two and the association between social hierarchies, markers of stress and heart disease is well established both in humans and other primates (2,3). We are very sensitive to our place in society and this impacts significantly on our health (4).
The underlying consistency is that most illness and adverse social determinants of health (including stress from whatever source) are distributed along a social gradient.
There are some practical implications of this research; for example should self-reported stress be included in the next iteration of the Qrisk score for cardiovascular disease?
The risk of such research is to separate specific areas of medicine from the larger picture of health inequalities - this is a bigger subject and is harder to tackle, but it offers a joined up solution for the future in a way that the traditional medical model with its disintegrated concept of health cannot.
1) Witte et al BMJ 2000; 321:1552
2) Whitehall study, Marmot et al, Lancet 337: 8554: 1387-1393
3) Sapolsky https://www.ncbi.nih.gov/books/NBK242456
4) Status syndrome, Marmot https://bloomsbury.com/uk/status-syndrome-9781408834180
Competing interests: No competing interests