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Psychological distress and mortality among US adults: prospective cohort study of 330 367 individuals
  1. Lili Yang1,
  2. Min Zhao2,
  3. Costan G Magnussen3,4,
  4. Sreenivas P Veeranki5,6,
  5. Bo Xi1
  1. 1 Department of Epidemiology, School of Public Health, Shandong University, Jinan, Shandong, China
  2. 2 Department of Nutrition and Food Hygiene, School of Public Health, Shandong University, Jinan, Shandong, China
  3. 3 Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
  4. 4 Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
  5. 5 Precision Health Economics and Outcomes Research, Los Angeles, CA, USA
  6. 6 Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  1. Correspondence to Dr Bo Xi, Department of Epidemiology, School of Public Health, Shandong University, Jinan 250012, China; xibo2007{at}


Background Previous studies have shown inconsistent findings on the association between psychological distress and risk of mortality. This study aimed to address this inconsistent association using a large US population-based cohort.

Methods This study used data from 1997 to 2009 US National Health Interview Survey, which were linked with National Death Index through 31 December 2011. Psychological distress was measured using Kessler-6 scale and was categorised into six groups based on scores as 0, 1–3, 4–6, 7–9, 10–12 and ≥13. Main outcomes were all-cause, cancer-specific and cardiovascular disease (CVD)-specific mortality. Analyses were completed in 2019. Cox proportional hazards models were used to determine the association between psychological distress and mortality.

Results A total of 330 367 participants aged ≥18 years were included. During a mean follow-up of 8.2 years, 34 074 deaths occurred, including 8320 cancer-related and 8762 CVD-related deaths. There was a dose–response association between psychological distress and all-cause mortality. Compared with the 0 score category, adjusted HRs (95% CIs) for other categorical psychological distress scores, that is, 1–3, 4–6, 7–9, 10–12 and ≥13, were 1.09 (1.05 to 1.12), 1.22 (1.17 to 1.27), 1.38 (1.31 to 1.46), 1.49 (1.40 to 1.59) and 1.57 (1.47 to 1.68), respectively. Corresponding values for cancer-specific mortality were 1.06 (0.99 to 1.12), 1.13 (1.04 to 1.23), 1.27 (1.14 to 1.42), 1.38 (1.22 to 1.57) and 1.32 (1.15 to 1.51), respectively; those for CVD-specific mortality were 1.11 (1.05 to 1.18), 1.22 (1.12 to 1.32), 1.30 (1.17 to 1.45), 1.38 (1.20 to 1.58), and 1.46 (1.27 to 1.68), respectively.

Conclusions We found a dose–response relationship between psychological distress and all-cause and cause-specific mortality, emphasising the need for early prevention strategies among individuals with potential psychological distress.

  • psychological stress
  • mental health
  • mortality
  • cohort studies

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  • LY and MZ are joint first authors.

  • Contributors This study was conceived of and planned by BX and MZ. MZ undertook the data analysis. CGM and SPV contributed to the interpretation of the results and major revisions. LY wrote the first draft of the manuscript. All authors approve the final version of the manuscript. BX is the guarantor for the study.

  • Funding CGM is supported by a National Heart Foundation of Australia Future Leader Fellowship (100849).

  • Disclaimer The sponsors had no role in the study design, survey process, data analysis or manuscript preparation.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The data are publicly available and exempt under the ethical board review of the corresponding author’s institution.

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

  • Data availability statement Data are available in a public, open access repository. Data are available in a public, open access repository.