Article Text

Download PDFPDF
Association between psychological distress and mortality: the case of Israel
  1. Alexander Michael Ponizovsky1,
  2. Ziona Haklai2,
  3. Nehama Goldberger2
  1. 1 Mental Health Services, Ministry of Health, Jerusalem, Israel
  2. 2 Department of Health Information, Ministry of Health, Jerusalem, Israel
  1. Correspondence to Professor Alexander Michael Ponizovsky, Mental Health Services, Ministry of Health, Jerusalem, 91000, Israel; alexpon8{at}


Background Previous studies have demonstrated the association between psychological distress (measured by the 12-item General Health Questionnaire, GHQ-12) and risks of all-cause mortality and deaths from cardiovascular, cancer and other causes. We hypothesised that in the Israeli population permanently exposed to war/terror stressors, this relationship is absent.

Methods We performed an analysis of data from participants in the Israel National Health Survey conducted in 2003–2004, who died during the follow-up decade. Subjects were assigned to groups based on GHQ-12 score: 0–10 (asymptomatic), 11–14 (subclinically symptomatic), 15–19 (symptomatic) and 20–36 (highly symptomatic). Data were weighted to the total population.

Results We analysed data from 4843 individuals, median age 40.5 (IQR 28–54); 473 participants died during the follow-up. We found a significant increase in total mortality, cardiovascular and other causes of mortality (but not cancer deaths) with increase in GHQ-12 score (P for linear trend of ungrouped GHQ scores <0.0001, 0.0015 and <0.0001, respectively). The age–sex-adjusted HR for the highest GHQ-12 compared with the lowest asymptomatic category was 2.1 (95% CI 1.6 to 2.7) for all-cause deaths, 2.3 (95% CI 1.3 to 4.1) for cardiovascular disease deaths and 2.7 (95% CI 1.9 to 3.9) for other deaths. The HR remained significant after adjustment for education, smoking, alcohol consumption and diabetes. The HR even increased after excluding participants with baseline cardiovascular diseases and cancer.

Conclusion Contrary to our hypothesis, psychological distress was associated with all-cause and cardiovascular but not cancer mortality. The absence of reverse causality provides evidence for the direct deleterious effects of psychological distress on mortality outcomes.

  • psychology
  • distress
  • mortality
  • cardiovascular disease
  • cancer

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors All authors equally contributed to the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval Experimentation on Human Subjects Committee of the Israeli Ministry of Health approved the study.

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