The influence of psychosocial factors on survival after myocardial infarction

A systematic review and meta-analysis of 90 cohort studies of social isolation, loneliness and mortality

The associations between social isolation, loneliness and the risk of mortality from all causes, cardiovascular disease (CVD) and cancer are controversial. We systematically reviewed prospective studies on the association between social isolation, loneliness and mortality outcomes in adults aged 18 years or older, as well as studies on these relationships in individuals with CVD or cancer, and conducted a meta-analysis. The study protocol was registered with PROSPERO (reg. no. CRD42022299959). A total of 90 prospective cohort studies including 2,205,199 individuals were included. Here we show that, in the general population, both social isolation and loneliness were significantly associated with an increased risk of all-cause mortality (pooled effect size for social isolation, 1.32; 95% confidence interval (CI), 1.26 to 1.39; P < 0.001; pooled effect size for loneliness, 1.14; 95% CI, 1.08 to 1.20; P < 0.001) and cancer mortality (pooled effect size for social isolation, 1.24; 95% CI, 1.19 to 1.28; P < 0.001; pooled effect size for loneliness, 1.09; 95% CI, 1.01 to 1.17; P = 0.030). Social isolation also increased the risk of CVD mortality (1.34; 95% CI, 1.25 to 1.44; P < 0.001). There was an increased risk of all-cause mortality in socially isolated individuals with CVD (1.28; 95% CI, 1.10 to 1.48; P = 0.001) or breast cancer (1.51; 95% CI, 1.34 to 1.70; P < 0.001), and individuals with breast cancer had a higher cancer-specific mortality owing to social isolation (1.33; 95% CI, 1.02 to 1.75; P = 0.038). Greater focus on social isolation and loneliness may help improve people's well-being and mortality risk.

Association of depression with all-cause and cardiovascular mortality among US adults with high and low baseline risk of cardiovascular disease

The intervention of depression was considered a prevention and treatment option for cardiovascular disease (CVD). However, evidence regarding whether association of depression with mortality differed among people at high or low risk of CVD yielded conflicting results. We aimed to investigate associations between depression and all-cause and CVD mortality among 3854 and 3044 US adults at high and low baseline risk of CVD, respectively. Among participants at high risk of CVD, depression and per 5-point increase in PHQ-9 score were associated with 81% (HR=1.81, 95%CI: 1.15-2.86) and 33% (HR=1.33, 95%CI: 1.14-1.55) increased all-cause mortality, respectively. We did not find statistically significant associations between depression (HR=1.40, 95%CI: 0.67-2.95) and PHQ-9 score (HR=1.28, 95%CI: 1.00-1.63) with CVD mortality due to a small number of mortality events. Among people with low risk of CVD, each 5-point increment in PHQ-9 score was associated with all-cause mortality (HR=1.26, 95%CI: 1.02-1.56), while there was no statistically significant association of depression with all-cause mortality (HR=1.69, 95%CI: 0.75-3.81) and CVD mortality (HR=1.99, 95%CI: 0.83-4.81). This study found that depression was associated with all-cause mortality among individuals at a high baseline risk of CVD, but no significant association was observed in people at a low baseline risk of CVD.

Social isolation as a risk factor for all-cause mortality: Systematic review and meta-analysis of cohort studies

BACKGROUND

Although several epidemiological studies have linked social isolation to increased risk of mortality, the magnitude of any effect is unclear, in part because of the use of different measures of social isolation.

OBJECTIVE

To examine the association between social isolation and all-cause mortality and investigate whether it differs in various subgroups or populations.

DATA SOURCES

We searched for relevant studies in electronic databases: MEDLINE (1946 to December 31, 2021), EMBASE (1974 to December 31, 2021), and PsycINFO (1806 to December 31, 2021).

SELECTION CRITERIA

We included both prospective and retrospective cohort studies that examined the association between social isolation and all-cause mortality among adults.

DATA COLLECTION AND ANALYSIS

Two reviewers screened and extracted data independently. We contacted study authors to obtain missing information whenever possible. Data were pooled using a random effect model to calculate estimates of the effects of social isolation on all-cause mortality.

RESULTS

Data from studies involving 1.30 million individuals were included. The pooled hazard ratio of social isolation for all-cause mortality was 1.33 (95% confidence interval; 1.26-1.41, heterogeneity: Chi² = 112.51, P < 0.00001, I² = 76%).

CONCLUSION

Social isolation is associated with increased risk for all-cause mortality.

REGISTRATION

PROSPERO (CRD42020152351).

Loneliness, Social Isolation, and Living Alone Associations With Mortality Risk in Individuals Living With Cardiovascular Disease: A Systematic Review, Meta-Analysis, and Meta-Regression

OBJECTIVE

This study aimed to conduct a systematic review and meta-analysis of associations between loneliness, social isolation, and living alone and risk of mortality among individuals with established cardiovascular disease.

METHODS

Five electronic databases were searched (MEDLINE [Ovid], PsycINFO, EMBASE, PubMed, and SCOPUS) from inception to November 25, 2021. In all, 35 studies were included in a narrative synthesis and, where appropriate, a meta-analytic evaluation using a random-effects model.

RESULTS

Living alone was associated with increased risk of all-cause mortality ( k = 15, n = 80,243, hazard ratio [HR] = 1.48, 95% confidence interval [CI] = 1.20-1.83, I2 = 83%), and meta-regressions found that the effects were stronger in studies from Europe and with longer follow-up. However, there was evidence of publication bias. Social isolation was associated with increased risk of all-cause mortality, measured both as a dichotomous variable ( k = 3, n = 2648, HR = 1.46, 95% CI = 1.08-2.04, I2 = 31%) and as a continuous variable ( k = 5, n = 2388, HR = 1.11, 95% CI = 1.02-1.24, I2 = 51%). Meta-analysis was not feasible for loneliness as exposure, but narrative synthesis of four studies suggested a tentative association between loneliness and increased risk of all-cause mortality.

CONCLUSIONS

Supporting public health concerns, our review finds that loneliness, social isolation, and living alone are associated with premature mortality among individuals with established cardiovascular disease. However, evidence of publication bias and large methodological differences across studies point to the need for more rigorous research.

"Is My Heart Healing?" A Meta-synthesis of Patients' Experiences After Acute Myocardial Infarction

BACKGROUND

Recovery from acute myocardial infarction (AMI) has been primarily understood in a narrow medical sense. For patients who survive, secondary prevention focuses largely on enhancing clinical outcomes. As a result, there is a lack of descriptive accounts of patients' experiences after AMI and little is known about how people go about the challenge of recovering from such an event.

OBJECTIVE

We conducted a meta-synthesis of the available literature on qualitative accounts of patients' experiences after AMI.

METHODS

We searched for relevant papers that were descriptive, qualitative accounts of participants' experiences after AMI across 4 electronic databases (April 2016). Using an adapted meta-ethnography approach, we analyzed the findings by translating studies into one another and synthesizing the findings from the studies.

RESULTS

After a review of titles/abstracts, reading each article twice in full, and cross-referencing articles, this process resulted in 17 studies with 224 participants (48% women) aged 23 to 90 years. All participants provided a first-person account of an AMI within the 3-day to 25-year time frame. Two major themes emerged that characterized patients' experiences: navigating lifestyle changes and navigating the emotional reaction to the event-consisting of various subthemes.

CONCLUSION

Although AMI tends to be seen as a discrete event, participants are left with little professional guidance as to how to negotiate significant, and often discordant, psychosocial changes that have long-lasting effects on their lives, similar to persons with chronic illnesses but without research in place to figure out how to best support them.

Oxytocin: Potential to mitigate cardiovascular risk

Cardiovascular disease (CVD) remains the leading cause of death worldwide, despite multiple treatment options. In addition to elevated lipid levels, oxidative stress and inflammation are key factors driving atherogenesis and CVD. New strategies are required to mitigate risk and most urgently for statin-intolerant patients. The neuropeptide hormone oxytocin, synthesized in the brain hypothalamus, is worthy of consideration as a CVD ancillary treatment because it moderates factors directly linked to atherosclerotic CVD such as inflammation, weight gain, food intake and insulin resistance. Though initially studied for its contribution to parturition and lactation, oxytocin participates in social attachment and bonding, associative learning, memory and stress responses. Oxytocin has shown promise in animal models of atherosclerosis and in some human studies as well. A number of properties of oxytocin make it a candidate CVD treatment. Oxytocin not only lowers fat mass and cytokine levels, but also improves glucose tolerance, lowers blood pressure and relieves anxiety. Further, it has an important role in communication in the gut-brain axis that makes it a promising treatment for obesity and type 2 diabetes. Oxytocin acts through its receptor which is a class I G-protein-coupled receptor present in cells of the vascular system including the heart and arteries. While oxytocin is not used for heart disease at present, residual CVD risk remains in a substantial portion of patients despite multidrug regimens, leaving open the possibility of using the endogenous nonapeptide as an adjunct therapy. This review discusses the possible role for oxytocin in human CVD prevention and treatment.

Misery loves company? A meta-regression examining aggregate unemployment rates and the unemployment-mortality association

PURPOSE

Individual-level unemployment has been consistently linked to poor health and higher mortality, but some scholars have suggested that the negative effect of job loss may be lower during times and in places where aggregate unemployment rates are high. We review three logics associated with this moderation hypothesis: health selection, social isolation, and unemployment stigma. We then test whether aggregate unemployment rates moderate the individual-level association between unemployment and all-cause mortality.

METHODS

We use six meta-regression models (each using a different measure of the aggregate unemployment rate) based on 62 relative all-cause mortality risk estimates from 36 studies (from 15 nations).

RESULTS

We find that the magnitude of the individual-level unemployment-mortality association is approximately the same during periods of high and low aggregate-level unemployment. Model coefficients (exponentiated) were 1.01 for the crude unemployment rate (P = .27), 0.94 for the change in unemployment rate from the previous year (P = .46), 1.01 for the deviation of the unemployment rate from the 5-year running average (P = .87), 1.01 for the deviation of the unemployment rate from the 10-year running average (P = .73), 1.01 for the deviation of the unemployment rate from the overall average (measured as a continuous variable; P = .61), and showed no variation across unemployment levels when the deviation of the unemployment rate from the overall average was measured categorically. Heterogeneity between studies was significant (P < .001), supporting the use of the random effects model.

CONCLUSIONS

We found no strong evidence to suggest that unemployment experiences change when macroeconomic conditions change. Efforts to ameliorate the negative social and economic consequences of unemployment should continue to focus on the individual and should be maintained regardless of periodic changes in macroeconomic conditions.

Psychosocial factors are preventive against coronary events in Japanese men with coronary artery disease: The Eastern Collaborative Group Study 7.7-year follow-up experience

Background

The Japanese Coronary-prone Behaviour Scale (JCBS) is a questionnaire developed by the Eastern Collaborative Group Study (ECGS), a multi-centre study of coronary-prone behaviour among Japanese men. Subscale C of the JCBS consists of 9 items that have been independently associated with the presence of coronary artery disease (CAD) in patients undergoing coronary angiography (CAG). There have been no reports of a relationship between any behavioural factor and the prognosis of CAD in Japan. The purpose of the current study was to investigate behavioural correlations with the prognosis of CAD as a part of the ECGS.

Methods

We examined the mortality and coronary events of 201 men (58 ± 10, 27-86 years) enrolled in the ECGS from 1990 to 1995, who underwent diagnostic coronary angiography and were administered the JCBS and the Japanese version of the Jenkins Activity Survey (JAS) Form C. Their health information after CAG was determined by a review of their medical records and by telephone interviews that took place from 2002 to 2003.

Results

Cardiac events during the follow-up period (7.7 ± 4.2 years) included 13 deaths from CAD, 25 cases of new-onset myocardial infarction, 26 cases of percutaneous coronary intervention, and 19 cases of coronary artery bypass graft surgery. There was no difference in established risk factors between groups with and without cardiac events. Seven factors were extracted by principal component analysis in order to clarify which factors were measured by the JCBS. Stepwise multivariate Cox-hazard regression analysis, in which 9 standard coronary risk factors were forced into the model, showed that Factor 4 from the JCBS (namely, the Japanese spirit of ‘Wa’) was independently associated with coronary events (hazard ratio: 0.21; p = 0.01). By other Cox-hazards regression analyses of coronary events using each set of JAS scores and the JCBS Scale C score instead of Factor 4 as selectable variables, the JAS scores or the JCBS Scale C score were not entered into the models.

Conclusion

The Japanese spirit of ‘Wa’ is a preventive factor against coronary events for Japanese men with CAD.

Meta-analysis of perceived stress and its association with incident coronary heart disease

Most studies examining potential associations between psychological factors and cardiovascular outcomes have focused on depression or anxiety. The effect of perceived stress on incident coronary heart disease (CHD) has yet to be reviewed systematically. We conducted a systematic review and meta-analysis of the association between perceived stress and incident CHD. Ovid, MEDLINE, and PsycINFO were searched as data sources. Prospective observational cohort studies were selected that measured self-reported perceived stress and assessed incident CHD at ≥6 months. We extracted study characteristics and estimates of the risk of incident CHD associated with high perceived stress versus low perceived stress. We identified 23 potentially relevant articles, of which 6 met our criteria (n = 118,696). Included studies measured perceived stress with validated measurements and nonvalidated simple self-report surveys. Incident CHD was defined as new diagnosis of, hospitalization for, or mortality secondary to CHD. Meta-analysis yielded an aggregate risk ratio of 1.27 (95% confidence interval 1.12 to 1.45) for the magnitude of the relation between high perceived stress and incident CHD. In conclusion, this meta-analysis suggests that high perceived stress is associated with a moderately increased risk of incident CHD.

Widowhood and mortality: a meta-analysis and meta-regression

The study of spousal bereavement and mortality has long been a major topic of interest for social scientists, but much remains unknown with respect to important moderating factors, such as age, follow-up duration, and geographic region. The present study examines these factors using meta-analysis. Keyword searches were conducted in multiple electronic databases, supplemented by extensive iterative hand searches. We extracted 1,377 mortality risk estimates from 123 publications, providing data on more than 500 million persons. Compared with married people, widowers had a mean hazard ratio (HR) of 1.23 (95% confidence interval (CI), 1.19-1.28) among HRs adjusted for age and additional covariates and a high subjective quality score. The mean HR was higher for men (HR, 1.27; 95% CI, 1.19-1.35) than for women (HR, 1.15; 95% CI, 1.08-1.22). A significant interaction effect was found between gender and mean age, with HRs decreasing more rapidly for men than for women as age increased. Other significant predictors of HR magnitude included sample size, geographic region, level of statistical adjustment, and study quality.

Meta-analysis of marital dissolution and mortality: reevaluating the intersection of gender and age

The study of marital dissolution (i.e. divorce and separation) and mortality has long been a major topic of interest for social scientists. We conducted meta-analyses and meta-regressions on 625 mortality risk estimates from 104 studies, published between 1955 and 2011, covering 24 countries, and providing data on more than 600 million persons. The mean hazard ratio (HR) for mortality in our meta-analysis was 1.30 (95% confidence interval [CI], 1.23-1.37) among HRs adjusted for age and additional covariates. The mean HR was higher for men (HR, 1.37; 95% CI, 1.27-1.49) than for women (HR, 1.22; 95% CI: 1.13-1.32), but the difference between men and women decreases as the mean age increases. Other significant moderators of HR magnitude included sample size; being from Western Europe, Israel, the United Kingdom and former Commonwealth nations; and statistical adjustment for general health status.

Losing life and livelihood: a systematic review and meta-analysis of unemployment and all-cause mortality

Unemployment rates in the United States remain near a 25-year high and global unemployment is rising. Previous studies have shown that unemployed persons have an increased risk of death, but the magnitude of the risk and moderating factors have not been explored. The study is a random effects meta-analysis and meta-regression designed to assess the association between unemployment and all-cause mortality among working-age persons. We extracted 235 mortality risk estimates from 42 studies, providing data on more than 20 million persons. The mean hazard ratio (HR) for mortality was 1.63 among HRs adjusted for age and additional covariates. The mean effect was higher for men than for women. Unemployment was associated with an increased mortality risk for those in their early and middle careers, but less for those in their late career. The risk of death was highest during the first 10 years of follow-up, but decreased subsequently. The mean HR was 24% lower among the subset of studies controlling for health-related behaviors. Public health initiatives could target unemployed persons for more aggressive cardiovascular screening and interventions aimed at reducing risk-taking behaviors.

New onset depression following myocardial infarction predicts cardiac mortality

OBJECTIVE

Studies investigating the effects of depression on mortality following myocardial infarction (MI) have produced heterogeneous findings. We report on a study investigating whether the timing of the onset of depression, with regard to the MI, affected its impact on subsequent cardiac mortality.

METHODS

Five hundred and eighty-eight subjects admitted following MI underwent assessments of cardiac status, cardiac risk factors, and noncardiac illness. We identified separately subjects who were depressed before their MI (pre-MI depression) and those who developed depression in the 12 months after MI (new-onset depression), using a standardized questionnaire and a research interview. Patients dying of cardiac cause were identified during 8-year follow-up using information from death certificates.

RESULTS

Multivariate predictors of cardiac death during follow-up included: greater age (hazards ratio (HR) = 1.06, p = .007), previous angina (HR = 4.15, p < .0005), high Killip Class (HR = 2.21, p = .013), prescription of beta-blockers on discharge (HR = 0.37, p = .02), and new-onset depression (HR = 2.33, p = .038). Pre-MI depression did not convey any additional risk of cardiac mortality.

CONCLUSION

We have shown increased cardiac mortality in patients who develop depression after suffering MI. Further observational studies need to separate pre- and post-MI depression if we are to determine underlying mechanisms by which depression is associated with mortality following MI.

Depression Is a Risk Factor for Mortality After Myocardial Infarction

OBJECTIVES

This study sought to investigate the long-term impact of depression on cardiac mortality after myocardial infarction (MI) and to assess whether the timing of depression influences the findings.

BACKGROUND

Previous studies have shown that depression increases the risk of cardiac death after MI, although some studies with robust methodology have failed to show this effect. Clinical trials of depression treatments have failed to improve mortality. Until the relationship between depression and post-MI mortality is understood fully, clinical trials aimed at reducing mortality by treating depression remain premature.

METHODS

We recruited 588 subjects after MI and followed up their cases for up to 8 years. Patients underwent detailed assessments of cardiac status, conventional cardiac risk factors, and noncardiac illness at baseline. Depression was assessed for the period immediately preceding MI and at 12 months after MI, using a standardized questionnaire and a research interview. At follow-up, the mortality status, cause, and date of death were recorded for 587 subjects using population records.

RESULTS

Multivariate predictors of cardiac death included older age (hazard ratio [HR] = 1.04, p = 0.007), previous angina (HR = 1.8, p = 0.03), previous MIs (HR = 1.6, p = 0.004), Killip class (HR = 1.8, p = 0.005), beta-blockers (HR = 0.5, p = 0.023), and angiotensin-converting enzyme inhibitors (HR = 0.6, p = 0.047) prescribed on discharge. Depression was not associated with cardiac mortality, whether detected immediately before MI (p = 0.48), 12 months after MI (p = 0.27), or at both time points (p = 0.97).

CONCLUSIONS

The association between depression and post-MI mortality is complex, possibly being limited to depression immediately after MI. Defining the window when intervention for depression might benefit survival is crucial for the design of future trials.

Social support and coronary heart disease: epidemiologic evidence and implications for treatment

OBJECTIVE

The present paper reviews theories of social support and evidence for the role of social support in the development and progression of coronary heart disease (CHD).

METHODS

Articles for the primary review of social support as a risk factor were identified with MEDLINE (1966-2004) and PsychINFO (1872-2004). Reviews of bibliographies also were used to identify relevant articles.

RESULTS

In general, evidence suggests that low social support confers a risk of 1.5 to 2.0 in both healthy populations and in patients with established CHD. However, there is substantial variability in the manner in which social support is conceptualized and measured. In addition, few studies have simultaneously compared differing types of support.

CONCLUSIONS

Although low levels of support are associated with increased risk for CHD events, it is not clear what types of support are most associated with clinical outcomes in healthy persons and CHD patients. The development of a consensus in the conceptualization and measurement of social support is needed to examine which types of support are most likely to be associated with adverse CHD outcomes. There also is little evidence that improving low social support reduces CHD events.

Negative impact of depression on outcomes in patients with coronary artery disease: mechanisms, treatment considerations, and future directions

Depressive symptoms are common in coronary artery disease (CAD) patients, and are associated with increased cardiac risk. Although an important relation exists between depression and CAD prognosis, the underlying pathophysiological mechanisms are poorly understood. Additionally, evidence including the recently published ENRICHD (Enhancing Recovery in Coronary Heart Disease Patients) trial suggests that depression treatments do not lower recurrent cardiac risk. The reason for the observed lack of benefit with depression treatment in CAD patients is unclear. In this review, we discuss the impact of depression in CAD patients, the possible mechanisms involved, the studies that have examined the effects of psychological and antidepressant therapies on recurrent cardiac events, and the direction that future research should take.

Depression, stress, and coronary heart disease: the need for more complex models

Depression has been related both to the development of coronary heart disease and to prognosis in patients following acute myocardial infarction, but the clinical significance of these associations remains uncertain.

Anger, Anxiety, and Depression as Risk Factors for Cardiovascular Disease: The Problems and Implications of Overlapping Affective Dispositions

Several recent reviews have identified 3 affective dispositions--depression, anxiety, and anger-hostility--as putative risk factors for coronary heart disease. There are, however, mixed and negative results. Following a critical summary of epidemiological findings, the present article discusses the construct and measurement overlap among the 3 negative affects. Recognition of the overlap necessitates the development of more complex affect-disease models and has implications for the interpretation of prior studies, statistical analyses, prevention, and intervention in health psychology and behavioral medicine. The overlap among the 3 negative dispositions also leaves open the possibility that a general disposition toward negative affectivity may be more important for disease risk than any specific negative affect.

Perceived social support as a predictor of mortality in coronary patients: effects of smoking, sedentary behavior, and depressive symptoms

OBJECTIVE

Numerous studies have shown network assessments of social contact predict mortality in patients with coronary artery disease (CAD). Fewer studies have demonstrated an association between perceived social support and longevity in patient samples. It has been suggested that 1 of the mechanisms linking social support with elevated risk for mortality is the association between social support and other risk factors associated with decreased longevity such as smoking, failure to exercise, and depressive symptoms. The present study examined an assessment of perceived support as a predictor of all-cause and CAD mortality and examined the hypothesis that smoking, sedentary behavior, and depressive symptoms may mediate and/or moderate this association.

METHODS

Ratings of social support and the risk factors of smoking, sedentary behavior, and depressive symptoms were examined as predictors of survival in 2711 patients with CAD, and associations between support and these risk factors were assessed. Smoking, sedentary behavior, and depressive symptoms were examined as mediators and/or moderators of the association between social support and mortality.

RESULTS

Social support, smoking, sedentary behavior, and depressive symptoms were predictors of mortality (p's <.01). Results also indicated that sedentary behavior, but not smoking status or depressive symptoms, may substantially mediate the relationship between support and mortality. No evidence for moderation was found.

CONCLUSIONS

The relation between social support and longevity may be partially accounted for by the association between support and sedentary behavior.

Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis

OBJECTIVE

To assess the association of depression following myocardial infarction (MI) and cardiovascular prognosis.

METHODS

The authors performed a meta-analysis of references derived from MEDLINE, EMBASE, and PSYCINFO (1975-2003) combined with crossreferencing without language restrictions. The authors selected prospective studies that determined the association of depression with the cardiovascular outcome of MI patients, defined as mortality and cardiovascular events within 2 years from index MI. Depression had to be assessed within 3 months after MI using established psychiatric instruments. A quality assessment was performed.

RESULTS

Twenty-two papers met the selection criteria. These studies described follow up (on average, 13.7 months) of 6367 MI patients (16 cohorts). Post-MI depression was significantly associated with all-cause mortality (odds ratio [OR], fixed 2.38; 95% confidence interval [CI], 1.76-3.22; p <.00001) and cardiac mortality (OR fixed, 2.59; 95% CI, 1.77-3.77; p <.00001). Depressive MI patients were also at risk for new cardiovascular events (OR random, 1.95; 95% CI, 1.33-2.85; p = .0006). Secondary analyses showed no significant effects of follow-up duration (0-6 months or longer) or assessment of depression (self-report questionnaire vs. interview). However, the year of data collection (before or after 1992) tended to influence the effect of depression on mortality (p = .08), with stronger associations found in the earlier studies (OR, 3.22; 95% CI, 2.14-4.86) compared with the later studies (OR, 2.01; 95% CI, 1.45-2.78).

CONCLUSIONS

Post-MI depression is associated with a 2- to 2.5-fold increased risk of impaired cardiovascular outcome. The association of depression with cardiac mortality or all-cause mortality was more pronounced in the older studies (OR, 3.22 before 1992) than in the more recent studies (OR, 2.01 after 1992).

NF-kappaB as a molecular link between psychosocial stress and organ dysfunction

It is well accepted that psychosocial stress contributes to the pathogenesis of hypertension, cardiovascular disease, and renal disease. Although even lay persons are aware that stress can be dangerous to health, the molecular mechanisms by which psychosocial events contribute to cellular dysfunction have hitherto been poorly understood by scientists. The pro-inflammatory transcription factor NF-kappaB has recently been identified as a potential critical bridge between stress and cellular activation. NF-kappaB activation, in turn, is known to play a pivotal role in vascular and renal disease. Activation of NF-kappaB, evoked by psychosocial stress, may directly target vessels and kidneys and thus represent an additional risk factor for cardiovascular and renal disease.

Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis

BACKGROUND

Prospective studies on physically healthy subjects have shown an association between depression and the subsequent development of coronary heart disease (CHD). The relative risk in meta-analytic aggregation is 1.64 (confidence interval [CI], 1.29-2.08) for any CHD event. However, the adverse impact of depression on CHD patients has not yet been the subject of a meta-analysis.

OBJECTIVE

To quantify the impact of depressive symptoms (eg, BDI, HADS) or depressive disorders (major depression) on cardiac or all-cause mortality. We analyzed the strength of the relationship, the time dependency, and the differences in studies using depressive symptoms or a clinical diagnosis as predictors of mortality.

METHOD

English and German language databases (Medline, PsycInfo, PSYNDEX) from 1980 to 2003 were searched for prospective cohort studies. Sixty-two publications were identified. The inclusion criteria were met by 29 publications reporting on 20 studies. A random model was used to estimate the combined overall effect as crude odds ratios (OR) or adjusted hazard ratios (HR [adj]).

RESULTS

Depressive symptoms increase the risk of mortality in CHD patients. The risk of depressed patients dying in the 2 years after the initial assessment is two times higher than that of nondepressed patients (OR, 2.24; 1.37-3.60). This negative prognostic effect also remains in the long-term (OR, 1.78; 1.12-2.83) and after adjustment for other risk factors (HR [adj], 1.76; 1.27-2.43). The unfavorable impact of depressive disorders was reported for the most part in the form of crude odds ratios. Within the first 6 months, depressive disorders were found to have no significant effect on mortality (OR, 2.07; CI, 0.82-5.26). However, after 2 years, the risk is more than two times higher for CHD patients with clinical depression (OR, 2.61; 1.53-4.47). Only three studies reported adjusted hazard ratios for clinical depression and supported the results of the bivariate models.

CONCLUSIONS

Depressive symptoms and clinical depression have an unfavorable impact on mortality in CHD patients. The results are limited by heterogeneity of the results in the primary studies. There is no clear evidence whether self-report or clinical interview is the more precise predictor. Nevertheless, depression has to be considered a relevant risk factor in patients with CHD.

Health-related social disengagement in elderly diabetic patients: association with subsequent disability and survival

OBJECTIVE

We examined the relationship between health-related social disengagements, as opposed to disengagements related to financial and other non-health-related factors, and subsequent risk of disability and death among initially nondisabled elderly diabetic patients enrolled in Medicare Managed Care plans.

RESEARCH DESIGN AND METHODS

We used data from the Medicare Health Outcomes Survey (HOS) Cohort 1 Baseline (1998) and Cohort 1 Follow-Up (2000). Through mail and telephone surveys, trained interviewers collected information on sociodemographic variables, physical and mental health functioning (using Medical Outcomes Study Short Form-36 [SF-36]), activities of daily living (ADL), and medical conditions. This study reported on diabetic subjects aged >or=65 years with no ADL disability at baseline (n = 8949). Health-related social disengagement (degree to which physical health or emotional problems interfere with social activities) was derived from the social functioning subscale of SF-36 (range 0-100; higher scores depicting better social functioning).

RESULTS

For each 10-point increase in social functioning score at baseline, older diabetic subjects in our study experienced an 18% less chance of any ADL disability (odds ratio [OR] 0.82, 95% CI 0.75-0.89; P < 0.001) and a 12% less chance of death (0.88, 0.78-1.00; P = 0.043) over a 2-year period, adjusting for demographic factors, comorbidities, depression, and general health (assessed by the SF-36).

CONCLUSIONS

Among initially nondisabled older diabetic subjects, health-related interferences with social activities at baseline may be early warning signs of subsequent ADL disability and premature death, independent of other measures of health status.

Health status and social risk correlates of extended length of stay following coronary artery bypass surgery

BACKGROUND

Preoperative severity of illness in patients undergoing coronary artery bypass grafting (CABG) surgery is a major determinant of clinical postoperative outcomes and surgical length of stay (SLOS). Preoperative patient reported health status and social risk have not been quantified as predictors of SLOS post-CABG. Our hypothesis was that poorer self-reported health and greater social risk, as measured by standardized instruments, are significantly associated with extended SLOS defined as greater than or equal to 7 days.

METHODS

In the pilot phase of the Washington State Clinical Outcomes Assessment Program (COAP) patients in a case series between 1995 and 1996 at all hospitals with a cardiac surgery program were administered preoperative SF-36 and Seattle Angina Questionnaires (SAQ) in addition to the collection of prospective clinical data with Society of Thoracic Surgeons' compatible definitions (n = 1073). Factors found significant from bivariate analysis were incorporated into a logistic regression model to assess relative association with extended SLOS (>/= 7 days).

RESULTS

The final model included the following elements in descending order of significance: site, SF-36 health perceptions (HP) scale, social risk factors, age, intraaortic balloon pump, congestive heart failure, comorbidity score more than 2, preoperative days more than 2, emergency operation, prior CABG, and gender.

CONCLUSIONS

The HP subscore of the SF-36 and the composite social risk factors score were significantly associated with extended SLOS after controlling for other standard clinical variables. "Hospital site" remained the factor with the greatest variance independent of patient severity of illness.

Depression and cardiovascular disease: mechanisms of interaction

This article explores the relationship between depression and cardiovascular disease from a mechanistic standpoint. Depression and cardiovascular disease are two of the most prevalent health problems in the United States and are the two leading causes of disability both in the United States and worldwide. Although depression is a known risk factor for the development of cardiovascular disease, as well as an independent predictor of poor prognosis following a cardiac event, the mechanistic relationship between the two remains unclear. Depression is associated with changes in an individual's health status that may influence the development and course of cardiovascular disease, including noncompliance with medical recommendations, as well as the presence of cardiovascular risk factors such as smoking and hypertension. In addition, depression is associated with physiologic changes, including nervous system activation, cardiac rhythm disturbances, systemic and localized inflammation, and hypercoagulability, that negatively influence the cardiovascular system. Further, stress may be an underlying trigger that leads to the development of both depression and cardiovascular disease. This article reviews seven potential mechanisms for the relationship between depression and cardiovascular disease and presents the available evidence surrounding each mechanism. Finally, future directions for research are discussed.

[Influence of social support on patients with essential hypertension]

OBJECTIVE

To determine whether social support affects blood pressure control in patients diagnosed with essential Hypertension.

DESIGN

Observational, prospective study, with a year's follow-up. SERRING: Mariñamansa-A Cuña Health Centre, Ourense (Galicia), Spain.

PARTICIPANTS

236 patients diagnosed with essential hypertension in health centre controls.

MEASUREMENTS

During the one-year follow-up the following clinical variables were measured: age, sex, blood pressure, severity of hypertension, tobacco consumption, alcohol consumption, presence of diabetes mellitus, hypercholesterolaemia, Body Mass Index and compliance with treatment. Social and family variables were: marital status, cultural level, economic and social status, type of family, stressful vital events and social support.

RESULTS

Mean age was 63.51 (62.05-64.96); 66.1% were women. Predominant kind of family was nuclear (64.3%). 30.2% had low social network (0-1 social contacts). We found 22% poor functional social support. Social support remained stable throughout the study. Hypertense patients with poor social networks had, after control for possible confusing variables, their systolic pressure 9.59 mm Hg (2.6716,51) and diastolic pressure 4.29 mm Hg (0.448.15) higher than hypertense patients with broader social networks.

CONCLUSION

Hypertense patients with a poor social network had higher blood pressure figures than hypertense patients with wider social networks.

In-hospital symptoms of depression do not predict mortality 3 years after myocardial infarction

BACKGROUND

The main aim of this study was to examine the relationship between symptoms of depression following myocardial infarction (MI) and 3-year survival status.

METHODS

The Beck Depression Inventory was completed by 288 patients hospitalized for MI. Patients' cardiological status, including indices of disease severity, were recorded or derived from hospital notes. Three-year survival status was determined using patient information systems and cause of death ascertained from death certificates.

RESULTS

During the 3 years of follow-up, 38 patients (13%) died, 33 (11%) from cardiac causes. Symptoms of depression did not predict either cardiac-specific or all-cause mortality. Similarly, in-hospital levels of anxiety were not associated with prognosis. In contrast, measures of disease severity and discharge medication status were strong prognostic indicators. Depression was not related to measures of disease severity at entry to the study.

CONCLUSIONS

Symptoms of depression following MI do not predict longer-term survival, although measures of disease severity and discharge medication status do. Previous positive results for depression and cardiac mortality in MI patients could reflect the occasional confounding of depression with disease severity.

Depression as a predictor for coronary heart disease. a review and meta-analysis

OBJECTIVE

To review and quantify the impact of depression on the development of coronary heart disease (CHD) in initially healthy subjects.

DATA SOURCES

Cohort studies on depression and CHD were searched in MEDLINE (1966-2000) and PSYCHINFO (1887-2000), bibliographies, expert consultation, and personal reference files.

DATA SELECTION

Cohort studies with clinical depression or depressive mood as the exposure, and myocardial infarction or coronary death as the outcome.

DATA EXTRACTION

Information on study design, sample size and characteristics, assessment of depression, outcome, number of cases, crude and most-adjusted relative risks, and variables used in multivariate adjustments were abstracted.

DATA SYNTHESIS

Eleven studies met the inclusion criteria. The overall relative risk [RR] for the development of CHD in depressed subjects was 1.64 (95% confidence interval [CI]=1.29-2.08, p<0.001). A sensitivity analysis showed that clinical depression (RR=2.69, 95% CI=1.63-4.43, p<0.001) was a stronger predictor than depressive mood (RR=1.49, 95% CI=1.16-1.92, p=0.02).

CONCLUSION

It is concluded that depression predicts the development of CHD in initially healthy people. The stronger effect size for clinical depression compared to depressive mood points out that there might be a dose-response relationship between depression and CHD. Implications of the findings for a broader bio-psycho-social framework are discussed.

Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety

OBJECTIVE

The purpose of this study was to determine the impact of symptoms of depression and anxiety on mortality and quality of life in patients hospitalized for acute myocardial infarction (MI).

METHODS

The Beck Depression Inventory and the State-Trait Anxiety Inventory were completed by 288 patients hospitalized for MI. Twelve-month survival status was ascertained, and quality of life among survivors was assessed at 12 months using the Dartmouth COOP charts.

RESULTS

Thirty-one (10.8%) patients died, 27 of cardiac causes, during the 12-month follow-up. Symptoms of depression and anxiety predicted neither cardiac nor all-cause mortality. Severity of infarction and evidence of heart failure predicted both cardiac and all-cause mortality. The same findings emerged from supplementary analyses of data from patients who died after discharge from the hospital. Symptoms of depression and anxiety, measured at entry, predicted 12-month quality of life among survivors, as did gender, partner status, employment status, living alone, previous frequency of exercise, and indices of disease severity (Killip class and Peel Index). In a multiple regression model in which all of these variables were entered, initial depression scores provided the best independent prediction of quality of life, although living alone, severity of infarction, and state anxiety also entered the model.

CONCLUSIONS

Symptoms of depression and anxiety did not predict either cardiac or all-cause mortality after MI, but they did predict quality of life among those who lived to 12 months.

Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality

OBJECTIVES

Social isolation has been linked to poor survival in patients with coronary artery disease (CAD). Few studies have closely examined the psychosocial characteristics of CAD patients who lack social contact.

METHODS

Social isolation was examined as a predictor of mortality in 430 patients with significant CAD. More isolated patients were compared with their less isolated counterparts on factors that might help explain the association between isolation and survival.

RESULTS

The mortality rate was higher among isolated individuals. Those with three or fewer people in their social support network had a relative risk of 2.43 (p = .001) for cardiac mortality and 2.11 (p = .001) for all-cause mortality, controlling for age and disease severity. Adjustments for income, hostility, and smoking status did not alter the risk due to social isolation. With the exception of lower income, higher hostility ratings, and higher smoking rates, isolated patients did not differ from nonisolated patients on demographic indicators, disease severity, physical functioning, or psychological distress. Isolated patients reported less social support and were less pleased with the way they got along with network members, but they did not report less satisfaction with the amount of social contact received.

CONCLUSIONS

Patients with small social networks had an elevated risk of mortality, but this greater risk was not attributable to confounding with disease severity, demographics, or psychological distress. These findings have implications for mechanisms linking social isolation to mortality and for the application of psychosocial interventions.

Effects of depression and anxiety on mortality and quality-of-life 4 months after myocardial infarction

OBJECTIVE

The purpose of this study was to determine the impact of depression and anxiety on mortality and quality-of-life in patients hospitalized for an acute myocardial infarction (MI).

METHODS

Questionnaire measures of depression and anxiety were completed during hospitalization by 288 MI patients. The main outcomes were mortality and quality-of-life, assessed by the Dartmouth COOP charts, at 4 months.

RESULTS

A total of 25 patients died, 22 from cardiac causes, during the 4-month follow-up. Symptoms of depression and anxiety did not predict either cardiac or all-cause mortality. Severity of infarction, extent of heart failure, and a longer stay in hospital predicted mortality. Symptoms of depression and anxiety predicted 4-month quality-of-life among survivors, as did gender, partner status, occupational status, living alone, previous exercise behaviour, length of hospital admission, and Peel Index scores. In a multiple regression model, depression emerged as the strongest predictor of quality-of-life. State anxiety, severity of infarction, and partner status also entered the model.

CONCLUSION

Neither depression nor anxiety predicted mortality 4 months after MI. Both depression and anxiety predicted quality-of-life at 4 months among survivors.

Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy

Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.

Family support and cardiovascular responses in married couples during conflict and other interactions

This study examined the relation between perceived support from family and cardiovascular (CV) responses to interaction in 45 married couples, 24 to 50 years old. Gender-specific median splits on Family Support scores from the Brief Social Support Questionnaire defined high versus low support groups. CV responses were obtained from both spouses during baseline and 3 stressors: reading control, conversing about events of the day, and conflict discussion. Men with low support had higher systolic (SBP) and diastolic pressure (DBP) than men with high support or either group of women at baseline and during all task periods (p < .004 and .05). Women with high support did not differ in blood pressure (BP) from women with low support. Men and women with low support had higher vascular resistance indexes (VRI) than those with high support, during all periods (p < .0015), and reported lower dyadic satisfaction and total dyadic adjustment. Because a disproportionate number of non-White participants reported low family support, secondary analyses that included race as a covariate were conducted. Covarying for race did not produce substantial results for any of the measures (SBP, p < .05; DBP, p < .058; VR1, p < .021). Post-hoc analyses were also conducted, in which the marital dyad was considered the unit of analysis. For these analyses, in which both spouses' perceptions of family support as high or low were considered together, the wife's perceived support did not influence the husband's BP, whereas his perceived support did influence his BP (ps < .03). For VRI in both men and women, the spouses' support level, as well as the participant's own support level, affected responses (ps < .02). Thus, high family support is associated with both marital and CV benefits for both husbands and wives, although husbands may benefit more.

The relationship between admission to hospital with chest pain and psychiatric disorder

OBJECTIVE

Psychosocial variables have been identified as important predictors of outcome in patients with chest pain. Most attention has focused on patients with ischaemic heart diseases or those in outpatient settings. This paper compares focuses on inpatients, and compares patients with ischaemic heart disease to those with non-specific chest pain.

METHOD

A search of the literature on chest pain and psychiatric disorder from 1972 onwards using Medicine, Index Medicus and the bibliographies of retrieved articles.

RESULTS

One-third of patients admitted with acute chest pain have psychiatric disorder as measured by standardised interviews. Patients who have had psychiatric symptoms prior to admission and those with non-specific pain appear to be most at risk of continuing psychiatric morbidity. In patients with ischaemic heart disease, psychiatric symptoms on admission are more strongly related to subsequent social outcome than variables such as severity of infarct or the presence of angina. Psychiatric symptoms may also effect physical morbidity and possibly mortality, although further research is required to clarify the latter finding. In patients with nonspecific pain, further research is indicated to identify aetiological and maintaining factors for continued non-specific pain. There is, however, a strong association with alcohol and cigarette use.

CONCLUSIONS

The prediction of outcome requires careful assessment of previous or current psychiatric symptoms in patients admitted with chest pain, irrespective of underlying diagnosis. Early intervention with psychological treatment for patients with non-specific chest pain is indicated; this may also involve help to reduce smoking. There is also further evidence that mortality following myocardial infarction is closely linked to psychiatric disorder, although prior psychiatric disorder may be more important than 'post-infarction' depression. Larger and more methodologically rigorous studies are required to further clarify these findings.

Perceived adequacy of tangible social support and health outcomes in patients with coronary artery disease

OBJECTIVE

Health outcomes of patients with chronic disease might be influenced by assistance from others in performing daily activities. We examined whether perceived adequacy of such tangible support was associated with prognosis in a cohort of patients with coronary artery disease.

DESIGN

Longitudinal cohort study.

SETTING/PARTICIPANTS

In spring 1993, a cohort of 1,468 patients with chronic artery disease was identified using claims data. The cohort consisted of all surviving residents of Manitoba, Canada, who had been hospitalized for acute myocardial infarction from 1991 to 1992: 820 patients completed the initial survey, and 734 completed a follow-up survey approximately 1 year later.

MEASUREMENTS AND MAIN RESULTS

Adequacy of tangible support was assessed by asking if respondents needed help at home because of health problems, and whether these needs were met. We examined the association between perceived adequacy of tangible support and health outcomes at 1 year (mortality, physical function). Of 820 participants, 74% perceived no need for help, 13% had sufficient help, 9% needed more help, and 5% needed much more help; 31 patients died during follow-up. After adjustment for age and initial health status, odds ratios (95% confidence interval) for death were: sufficient help 1.8 (0.61, 5.8); need more help 3.2 (1.1, 9.4); and need much more help 6.5 (2.0, 21.6) compared with respondents with no perceived need. Decline in physical function was also linearly related to perceiving less-adequate tangible support. Sensitivity analyses indicated it is highly improbable that results were due to selection bias.

CONCLUSIONS

Perceived lack of needed assistance was related to mortality and to decline in physical functioning. Adequacy of tangible support was an important prognostic factor for these patients with coronary artery disease and may be a determinant of health outcomes.

Social support and hostility interact to influence clinic, work, and home blood pressure in black and white men and women

The effects of hostility and social support on clinic, work, and home systolic (SBP) and diastolic (DBP) blood pressures were evaluated in 129 healthy adults. High hostility was related to higher SBP and DBP in Whites; low hostility was related to higher SBP and DBP in Blacks. These relationships were significant for men at home and at work and for women at screening. The relationship between low hostility and higher BP in Blacks was largely due to Black men who reported low hostility plus high anger-in (suggesting suppressed hostility). In contrast, high hostile Black men with high tangible support tended to exhibit lower BP than all other Black men. In White women, high belonging support was related to lower BP, independent of hostility, and low tangible support plus high hostility was related to higher clinic BP. In high hostile subjects, regardless of ethnicity or gender, high appraisal support was related to lower overall BP. These data suggest that the adverse BP effects of hostility and the beneficial effects of social support interact in a complex manner, reflecting contextual, ethnic, and gender specificities.

Alcohol consumption, life context, and coping predict mortality among late-middle-aged drinkers and former drinkers

This study examined mortality risk for individuals in four alcohol consumption categories and identified life context and coping factors that independently predicted mortality among late-middle-aged drinkers and former drinkers (n = 1869). Compared with light drinkers, former drinkers (current abstainers) were at increased mortality risk; moderate drinkers were at decreased risk. Consistent with previous research on older samples, heavy drinkers were not at increased risk. Abstainers' increased risk was reduced in a model that controlled for life context and coping factors. Other independent predictors of mortality included reporting an illness stressor, stressor severity, less participation in activities with friends, greater use of resigned acceptance and alternative rewards coping, and less use of cognitive avoidance and emotional discharge coping. The findings support previous research on the alcohol-mortality relationship among older adults, and highlight the fact that abstainers' life stressors and avoidance coping responses may be more important predictors of their mortality than their abstention.

Stress, social support, and stopping smoking after myocardial infarction in England

STUDY OBJECTIVE

To examine the effect on mortality of stopping smoking after myocardial infarction and the psychosocial factors that influence the decision to stop.

DESIGN

Analysis of smokers in a large prospective study. Self completed questionnaires provided information on psychosocial factors.

SETTING

Coronary care units at six English hospitals participating in a multicentre clinical trial.

SUBJECTS

These comprised consenting myocardial infarction survivors who had been identified as smokers and who completed questionnaires within seven days of infarct at six hospitals participating in the Anglo-Scandinavian study of early thrombolysis. The 532 patients identified have been followed for over five and a half years. The main outcome measure was five year all cause mortality.

MAIN RESULTS

Smokers who stopped within one month showed significantly reduced mortality compared with those who persisted, adjusting for other prognostic indicators (odds ratio 0.56, 95% confidence interval 0.33, 0.98). Overall, 74% stopped smoking. Being married, low life stress levels before infarct, and higher social class were associated with stopping smoking but the differentials were small. Of the clinical variables, a final diagnosis of definite myocardial infarction was associated with stopping smoking. All associations remained after multiple logistic regression.

CONCLUSION

Smoking cessation can halve the smokers' odds of dying after myocardial infarction and psychosocial factors play a small but important role in the important decision to stop smoking. Health professionals should continue to stress the importance of stopping smoking to all patients as there is little evidence to support specific directing of advice to relatively "stress or "socially isolated" groups.

Interpreting self reported limiting long term illness

OBJECTIVE

To examine the association between self reported limiting long term illness and other dimensions of self reported health.

DESIGN

Stratified random sample of general population.

SETTING

Lothian region, Scotland, in 1993.

SUBJECTS

6212 men and women aged 16 and over.

MAIN OUTCOME MEASURES

Limiting long term illness was assessed by the same question as used in the 1991 United Kingdom census. The short form 36 health survey was used to assess other dimensions of health.

RESULTS

Rates of limiting long term illness were much higher than reported in the census. Scores on general and physical health scales had strong associations with limiting long term illness, but after adjustment for these associations psychosocial health measures had little influence on limiting long term illness. Being at the lower rather than the upper quartile on the physical functioning scale more than doubled the odds of having limiting long term illness. Reported prevalence of many common illnesses was between two and three times higher among those with limiting long term illness.

CONCLUSIONS

A positive response to the question used by the census to define limiting long term illness was strongly associated with physical limitations on activity and less strongly influenced by scores on scales of mental and social wellbeing. Socioeconomic effects on limiting long term illness seem largely mediated through measures of general health and physical limitations on health.