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Psychological distress and ischaemic heart disease: cause or consequence? Evidence from a large prospective cohort study
  1. Jennifer Welsh1,
  2. Rosemary J Korda1,
  3. Grace Joshy1,
  4. Peter Butterworth2,3,
  5. Alex Brown4,5,
  6. Emily Banks1,6
  1. 1 National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, Australia
  2. 2 Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
  3. 3 Melbourne Institute of Applied Economic and Social Research, University of Melbourne, Melbourne, Australia
  4. 4 South Australian Health & Medical Research Institute, Adelaide, Australia
  5. 5 Sansom Institute, University of South Australia, Adelaide, Australia
  6. 6 The Sax Institute, Sydney, Australia
  1. Correspondence to Jennifer Welsh, National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT 2601, Australia; jennifer.welsh{at}


Background Ischaemic heart disease (IHD) incidence is elevated in people reporting psychological distress. The extent to which this relationship is causal or related to reverse causality—that is, undiagnosed disease causing distress—is unclear. We quantified the relationship between psychological distress and IHD, with consideration of confounding and undiagnosed disease.

Methods Questionnaire data (2006–2009) from 151 811 cardiovascular disease-free and cancer-free Australian general population members aged ≥45years (45 and Up Study) were linked to hospitalisation and mortality data, to December 2013. A two-stage approach estimated HRs for incident IHD (IHD-related hospitalisation or death) for low (Kessler-10 scores: 10–<12), mild (12–<16), moderate (16–<22) and high (22–50) psychological distress, adjusting for demographic and behavioural characteristics, and then restricting to those with no/minor functioning limitations (likely free from undiagnosed disease).

Results Over 859 396 person-years, 5230 incident IHD events occurred (rate: 6.09/1000person-years). IHD risk was increased for mild (age-adjusted and sex-adjusted HR: 1.18, 95% CI 1.11 to 1.26), moderate (1.36, 1.25 to 1.47), and high (1.69, 1.52 to 1.88) versus low distress. HRs attenuated to 1.15 (1.08 to 1.22), 1.26 (1.16 to 1.37) and 1.41 (1.26 to 1.57) after adjustment for demographic and behavioural characteristics and were further attenuated by 35%–41% in those with no/minor limitations, leaving a significant but relatively weak dose-response relationship: 1.11 (1.02 to 1.20), 1.21 (1.08 to 1.37) and 1.24 (1.02 to 1.51) for mild, moderate and high versus low distress, respectively. The observed adjustment-related attenuation suggests measurement error/residual confounding likely contribute to the remaining association.

Conclusion A substantial part of the distress-IHD association is explained by confounding and functional limitations, an indicator of undiagnosed disease. Emphasis should be on psychological distress as a marker of healthcare need and IHD risk, rather than a causative factor.

  • mental health

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  • Contributors JW conducted the analyses and drafted the manuscript. EB, RK and AB designed the analyses. GJ and PB provided statistical and methodological support. All authors interpreted the data, and critically revised and approved the final manuscript.

  • Funding The research was funded by a National Health and Medical Research Council of Australia Partnership Grant (GNT1092674). JW is supported by an Australian Government Research Training Program Scholarship. EB issupported by the National Health and Medical Research Council (1042717). PB is supported by the Australian Research Council Future Fellowship FT13101444. AB is supported by a Veirtel Senior Medical Research Fellowship.

  • Competing interests None declared.

  • Ethics approval The conduct of the 45 and Up Study was approved by the University of New South Wales Human Research Ethics Committee (HREC). Ethics approval for this study was obtained from the Australian National University Human Ethics Committee (2010/513) and the NSW Population and Health Services Research Ethics Committee (HREC/10/CIPHS/33; CI NSW Study Reference 2010/05/234).

  • Provenance and peer review Not commissioned; externally peer reviewed.