Pauline Heslop

Psychological stress and cardiovascular disease: empirical demonstration of bias in a prospective observational study of Scottish men.

Abstract Objectives: To examine the association between self perceived psychological stress and cardiovascular disease in a population where stress was not associated with social disadvantage. Design: Prospective observational study with follow up of 21 years and repeat screening of half the cohort 5 years from baseline. Measures included perceived psychological stress, coronary risk factors, self reported angina, and ischaemia detected by electrocardiography. Setting: 27 workplaces in Scotland. Participants: 5606 men (mean age 48 years) at first screening and 2623 men at second screening with complete data on all measures Main outcome measures: Prevalence of angina and ischaemia at baseline, odds ratio for incident angina and ischaemia at second screening, rate ratios for cause specific hospital admission, and hazard ratios for cause specific mortality. Results: Both prevalence and incidence of angina increased with increasing perceived stress (fully adjusted odds ratio for incident angina, high versus low stress 2.66, 95% confidence interval 1.61 to 4.41; P for trend <0.001). Prevalence and incidence of ischaemia showed weak trends in the opposite direction. High stress was associated with a higher rate of admissions to hospital generally and for admissions related to cardiovascular disease and psychiatric disorders (fully adjusted rate ratios for any general hospital admission 1.13, 1.01 to 1.27, cardiovascular disease 1.20, 1.00 to 1.45, and psychiatric disorders 2.34, 1.41 to 3.91). High stress was not associated with increased admission for coronary heart disease (1.00, 0.76-1.32) and showed an inverse relation with all cause mortality, mortality from cardiovascular disease, and mortality from coronary heart disease, that was attenuated by adjustment for occupational class (fully adjusted hazard ratio for all cause mortality 0.94, 0.81 to 1.11, cardiovascular mortality 0.91, 0.78 to 1.06, and mortality from coronary heart disease 0.98, 0.75 to 1.27). Conclusions: The relation between higher stress, angina, and some categories of hospital admissions probably resulted from the tendency of participants reporting higher stress to also report more symptoms. The lack of a corresponding relation with objective indices of heart disease suggests that these symptoms did not reflect physical disease. The data suggest that associations between psychosocial measures and disease outcomes reported from some other studies may be spurious. What is already known on this topic Higher psychological stress has predicted coronary heart disease in several observational studies Exposure to stress and heart disease outcomes were often based on self report so that a general tendency to negative perceptions may have generated a spurious association between higher perceived stress and heart disease symptoms What this study adds Perceived stress was strongly related to subjective symptoms of heart disease, including those leading to hospital admission However, stress showed a weakly inverse relation to all objective indices of heart disease: socially advantaged men perceived themselves to be most stressed, and the “protective” effect of stress was probably attributable to residual confounding Suggestions that psychological stress is an important determinant of heart disease may be premature

Sleep duration and mortality: the effect of short or long sleep duration on cardiovascular and all-cause mortality in working men and women

BACKGROUND There is evidence to suggest that insufficient sleep may have an adverse effect on physical and psychological health. Previous studies have reported that when adjusting for major risk factors for cardiovascular disease and a number of demographic and social variables, sleeping 7-8 h each night is associated with lower mortality. These studies, however, have excluded any consideration of stress, which is known to be related to a number of behavioural risk factors for disease and, like sleep, may influence neurochemical, hormonal and immunological functioning. METHODS This study revisits the associations between sleep duration, cardiovascular disease risk factors and mortality, taking into account the perceived stress of individuals. The data come from a cohort of working Scottish men and women recruited between 1970 and 1973; approximately half of the cohort was screened for a second time, 4-7 years after the baseline examination. RESULTS For both men and women, higher self-perceived stress was associated with a reduction in the hours of sleep reported. The pattern of mortality from all causes and the pattern of mortality from cardiovascular disease were consistent for both men and women. When sleep was measured on one occasion only, the risk of dying was reduced for men sleeping more than 8 h in every 24 h compared with those sleeping 7-8 h over the same period. This was after adjustment had been made for age, marital status, social class, cardiovascular risk factors and stress. The risk of dying was increased for women sleeping less than 7 h in every 24 h compared with those sleeping 7-8 h over the same period, after similar adjustments. When the data from the 1st and 2nd screening were considered longitudinally, both men and women who reported that they slept less than 7 h on both occasions that they were questioned, had a greater risk of dying from any cause than those who had reported sleeping 7-8 h at both screenings, after adjusting for age, marital status, social class and stress. CONCLUSIONS Short sleep over a prolonged period may be associated with an increased risk of mortality: men and women who reported sleeping fewer than 7 h in 24 on two occasions between 4 and 7 years apart, had greater risk of dying from any cause over a 25 year period than those who reported sleeping 7-8 h on both occasions that they were questioned.

Are the effects of psychosocial exposures attributable to confounding? Evidence from a prospective observational study on psychological stress and mortality

STUDY OBJECTIVES To examine the association between perceived psychological stress and cause specific mortality in a population where perceived stress was not associated with material disadvantage. DESIGN Prospective observational study with follow up of 21 years and repeat screening of half the cohort five years from baseline. Measures included perceived psychological stress, coronary risk factors, and indices of lifecourse socioeconomic position. SETTING 27 workplaces in Scotland. PARTICIPANTS 5388 men (mean age 48 years) at first screening and 2595 men at second screening who had complete data on all measures. MAIN OUTCOME MEASURES Hazard ratios for all cause mortality and mortality from cardiovascular disease (ICD9 390–459), coronary heart disease (ICD9 410–414), smoking related cancers (ICD9 140, 141, 143–9, 150, 157, 160–163, 188 and 189), other cancers (ICD9 140–208 other than smoking related), stroke (ICD9 430–438), respiratory diseases (ICD9 460–519) and alcohol related causes (ICD9 141, 143–6, 148–9, 150, 155, 161, 291, 303, 571 and 800–998). RESULTS At first screening behavioural risk (higher smoking and alcohol consumption, lower exercise) was positively associated with stress. This relation was less apparent at second screening. Higher stress at first screening showed an apparent protective relation with all cause mortality and with most categories of cause specific mortality. In general, these estimates were attenuated on adjustment for social position. This pattern was also seen in relation to cumulative stress at first and second screening and with stress that increased between first and second screening. The pattern was most striking with regard to smoking related cancers: relative risk high compared with low stress at first screening, age adjusted 0.64 (95% CI 0.42, 0.96), p for trend 0.016, fully adjusted 0.69 (95% CI 0.45, 1.06), p for trend 0.10; high compared with low cumulative stress, age adjusted 0.69 (95% CI 0.44, 1.09), p for trend 0.12, fully adjusted 0.76 (95% CI 0.48, 1.21), p for trend 0.25; increased compared with decreased stress, age adjusted 0.65 (95% CI 0.40, 1.06), p for trend 0.09, fully adjusted 0.65 (95% CI 0.40, 1.06), p for trend 0.08. CONCLUSIONS This implausible protective relation between higher levels of stress, which were associated with increased smoking, and mortality from smoking related cancers, was probably a product of confounding. Plausible reported associations between psychosocial exposures and disease, in populations where such exposures are associated with material disadvantage, may be similarly produced by confounding, and of no causal significance.

Perceived stress and coronary heart disease risk factors: The contribution of socio-economic position

OBJECTIVES The aim of this study was to explore the relationship between risk factors for coronary heart disease (CHD) and perceived stress, adjusted for socio-economic position. DESIGN Cross-sectional analysis of CHD risk factors, perceived stress and socio-economic position. METHOD A cohort of employed Scottish men (N = 5848) and women (N = 984) completed a questionnaire and attended a physical examination. RESULTS Higher socio-economic groups registered higher perceived stress scores. Perceived stress was associated with the following CHD risk factors in the expected direction: high plasma cholesterol, little recreational exercise, cigarette smoking, and high alcohol consumption. Contrary to expectations, stress was related negatively to high diastolic blood pressure, body mass index (BMI) and low forced expiratory volume. Correction for socio-economic position tended to abolish the associations between stress and physiological risk factors; the associations between stress and behavioural risk factors withstood such correction. The residual patterns of associations between perceived stress and CHD risk were broadly similar for men and women. A lower BMI, a greater number of cigarettes smoked, and greater alcohol consumption were associated with higher levels of perceived stress for both sexes. Lower levels of recreational exercise were associated with higher levels of stress for men only. CONCLUSIONS Self-reported stress is related to health-related behaviours and to physiological CHD risk factors. The direction of the association with physiological risk was often contrary to expectation and appeared to be largely due to confounding by socio-economic position. In contrast, the association with health-related behaviours was in the expected direction and was largely independent of such confounding.

The socioeconomic position of employed women, risk factors and mortality

Many studies have demonstrated the graded association between socioeconomic position and health. Few of these studies have examined the cumulative effect of socioeconomic position throughout the lifecourse, and even fewer have included women. Those that have explored gender differences affirm the importance of studying the factors that predict women and mens health separately. This study addresses the associations between cross-sectional and longitudinal socioeconomic position, risk factors for cardiovascular disease and mortality from various causes. Analyses are based on data from a cohort of working Scottish women recruited between 1970 and 1973. Five socioeconomic measures were explored in relation to diastolic blood pressure, plasma cholesterol concentration, body mass index, forced expiratory volume in 1 s (FEV1). amount of recreational exercise taken, cigarette smoking and alcohol consumption. In general, for each of the five measures of socioeconomic position, there were significant differences in at least one of the age-adjusted physiological risk factors for cardiovascular disease (diastolic blood pressure, plasma cholesterol concentration, body mass index, FEV1). There were also significant differences in the percentage of current cigarette smokers according to different measures of socioeconomic position, although this was not the case for the other behavioural risk factors for cardiovascular disease (amount of recreational exercise taken, and alcohol consumption). Measures of socioeconomic position were also examined in relation to cause of death for the women who died before 1 January 1999. After adjusting for age and risk factors, a composite measure of lifetime socioeconomic experience was a more potent predictor of all cause mortality and mortality from cardiovascular disease than other measures of socioeconomic position. It therefore seems that conventional measurcs of socioeconomic position, estimated at one point in time, do not adequately capture the effects of socioeconomic circumstances on the risk of mortality among employed women. Thus, a broader range of explanatory factors for mortality differentials than currently exists must be considered, and must include consideration of factors operating throughout the lifecourse.

Change in job satisfaction, and its association with self-reported stress, cardiovascular risk factors and mortality.

Many studies have suggested that occupational stress may be related to the development of cardiovascular disease (CVD), independently of other known risk factors. Despite the recognition of job satisfaction as a particular form of stress, however, few studies have examined its association with CVD. Those studies that have explored the associations between job satisfaction and CVD risk factors, or job satisfaction and CVD mortality, have been largely cross-sectional in approach and report contradictory findings. This study revisits the associations between job satisfaction, self-reported stress. CVD risk factors and CVD mortality using longitudinal data from a cohort of working Scottish men and women recruited between 1970 and 1973. Approximately half of the cohort was screened for a second time, 4-7yr after the baseline examination. Job satisfaction at baseline was strongly associated with low or moderate perceived stress at 2nd screening. Men and women reporting decreased satisfaction in their jobs between baseline and 2nd screening tended to report moderate or high perceived stress at 2nd screening. Job satisfaction was associated with own occupational class in different directions for men and women. Men in the manual social classes reported more satisfaction with their jobs than their peers, whilst it was women in the non-manual social classes who reported more satisfaction with their jobs than their peers. There was limited evidence of an association between job satisfaction and age-adjusted CVD risk factors (diastolic blood pressure; blood cholesterol; body mass index; forced expiratory volume in 1st amount of recreational exercise undertaken; cigarette smoking and alcohol consumption) for men, after adjustment for occupational class, but there was no evidence of any association for women. There was also no evidence to suggest that men or women reporting job dissatisfaction on one occasion or on two occasions several years apart, had a significantly greater risk of mortality from CVD.

A contemporary validation of the Reeder Stress Inventory

OBJECTIVES To examine the construct validity of the RSI in a contemporary cohort. DESIGN A cross-sectional investigation of 1,717 employed individuals who responded to the second stage of a study of occupational stress. METHODS Scores on the RSI are compared to smoking and drinking habits, social class, and two measures of health (number of days sick leave, and number of visits to a GP during the previous year). The RSI was compared to three questionnaires measuring concepts related to stress: the 12-item General Health Questionnaire (GHQ-12), the Hospital Anxiety and Depression Scale (HADS), and the Karasek Job Strain Questionnaire. RESULTS Higher levels of stress, as measured by the RSI, were associated with smoking a greater number of cigarettes, and, if the respondent drank alcohol, greater consumption of alcoholic drinks. High levels of stress were also associated with having taken more days sick leave, having made more frequent visits to a GP, and, somewhat unexpectedly, with being a teetotaller, and with holding a non-manual occupation. Of the questionnaire measures, the strongest association was between the RSI and HADS anxiety subscale, consistent with an overlap between the concepts of stress and anxiety. CONCLUSIONS This study supports the construct validity of the RSI in a sample of employed individuals.

Assessment of an incentivised scheme to provide annual health checks in primary care for adults with intellectual disability: a longitudinal cohort study

BACKGROUND People with intellectual disabilities (ID) have many comorbidities but experience inequities in access to health care. National Health Service England uses an opt-in incentive scheme to encourage annual health checks of patients with ID in primary care. We investigated whether the first 3 years of the programme had improved health care of people with ID. METHODS We did a longitudinal cohort study that used data from The Health Improvement Network primary care database. We did multivariate logistic regression to assess associations between various characteristics and whether or not practices had opted in to the incentivised scheme. FINDINGS We assessed data for 8692 patients from 222 incentivised practices and those for 918 patients in 48 non-incentivised practices. More blood tests (eg, total cholesterol, odds ratio [OR] 1·88, 95% CI 1·47-2·41, p<0·0001) general health measurements (eg, smoking status, 6·0, 4·10-8·79, p<0·0001), specific health assessments (eg, hearing, 24·0, 11·5-49·9, p<0·0001), and medication reviews (2·23, 1·68-2·97, p<0·0001) were done in incentivised than in non-incentivised practices, and more health action plans (6·15, 1·41-26·9, p=0·0156) and secondary care referrals (1·47, 1·05-2·05, p=0·0256) were made. Identification rates were higher in incentivised practices for thyroid disorder (OR 2·72, 95% CI 1·09-6·81, p=0·0323), gastrointestinal disorders (1·94, 1·03-3·65, p=0·0390), and obesity (2·49, 1·76-3·53, p<0·0001). INTERPRETATION Targeted annual health checks for people with ID in primary care could reduce health inequities. FUNDING National Institute for Health Research.

Mental health support needs of people with a learning difficulty: a medical or a social model?

People with learning difficulties, like all disabled people, face social oppression. Much recent policy and practice are underpinned by at least some understanding of this oppression, and the social model of disability has been influential in discussions of services and supports for people with learning difficulties. However, in the area of mental health, the picture is somewhat different. This paper argues that the medical model has predominated in discussions of mental health support for people with learning difficulties, and that a social model approach could have much to offer. The paper draws on an ongoing action research study in which service providers, families and young people with learning difficulties are working together to articulate what is needed, in order to find routes to improve the support offered to young people with learning difficulties and mental health support needs.

Mortality in people with intellectual disabilities in England

BACKGROUND People with intellectual disabilities (IDs) die at younger ages than the general population, but nationally representative and internationally comparable mortality data about people with ID, quantifying the extent and pattern of the excess, have not previously been reported for England. METHOD We used data from the Clinical Practice Research Datalink database for April 2010 to March 2014 (CPRD GOLD September 2015). This source covered several hundred participating general practices comprising roughly 5% of the population of England in the period studied. General practitioner (GP) records identified people diagnosed by their GP as having ID. Linked national death certification data allowed us to derive corresponding mortality data for people with and without ID, overall and by cause. RESULTS Mortality rates for people with ID were significantly higher than for those without. Their all-cause standardised mortality ratio was 3.18. Their life expectancy at birth was 19.7 years lower than for people without ID. Circulatory and respiratory diseases and neoplasms were the three most common causes of death for them. Cerebrovascular disease, thrombophlebitis and pulmonary embolism all had standardised mortality ratios greater than 3 in people with ID. This has not been described before. Other potentially avoidable causes included epilepsy (3.9% of deaths), aspiration pneumonitis (3.6%) and colorectal cancer (2.4%). Avoidable mortality analysis showed a higher proportion of deaths from causes classified as amenable to good medical care but a lower proportion from preventable causes compared with people without ID. International comparison to areas for which data have been published in sufficient detail for calculation of directly standardised rates suggest England may have higher death rates for people with ID than areas in Canada and Finland, and lower death rates than Ireland or the State of Massachusetts in the USA. CONCLUSIONS National data about mortality in people with ID provides a basis for public health interventions. Linked data using GP records to identify people with ID could provide comprehensive population-based monitoring in England, unbiased by the circumstances of illnesses or death; to date information governance constraints have prevented this. However, GPs in England currently identify only around 0.5% of the population as having ID, suggesting that individuals with mild, non-syndromic ID are largely missed. Notably common causes of death suggest control of cardiovascular risk factors, epilepsy and dysphagia, management of thrombotic risks and colorectal screening are important areas for health promotion initiatives.