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Original research article
Persistent psychological distress and mortality in patients with stable coronary artery disease
  1. Ralph A H Stewart1,
  2. David M Colquhoun2,
  3. Simone L Marschner3,
  4. Adrienne C Kirby3,
  5. John Simes3,
  6. Paul J Nestel4,
  7. Nick Glozier5,
  8. Adrienne O’Neil6,7,
  9. Brian Oldenburg8,
  10. Harvey D White1,
  11. Andrew M Tonkin9
  12. on behalf of the LIPID Study Investigators
  1. 1 Green Lane Cardiovascular Service, Auckland City Hospital, University of Auckland, Auckland, New Zealand
  2. 2 Cardiology Department, Greenslopes Hospital, Brisbane, Queensland, Australia
  3. 3 National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
  4. 4 Division of Human Nutrition, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
  5. 5 Department of Psychiatry, Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
  6. 6 Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
  7. 7 School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia
  8. 8 Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
  9. 9 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  1. Correspondence to Dr Ralph A H Stewart, Green Lane Cardiovascular Service, Auckland City Hospital, Park Road, Grafton, Auckland 1142, New Zealand; rstewart{at}


Background A single assessment of psychological distress, which includes depression and anxiety, has been associated with increased mortality in patients with coronary heart disease, but the prognostic importance of persistence of distress symptoms is less certain.

Aim To determine whether intermittent and/or persistent psychological distress is associated with long-term cardiovascular (CV) and total mortality in patients with stable coronary artery disease.

Methods 950 participants in the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) trial completed at least four General Health Questionnaires (GHQ-30) at baseline and after ½, 1, 2 and 4 years. In a landmark analysis from 4 years, Cox proportional hazards models evaluated the risk of CV and total mortality by increasing levels of psychological distress: never distressed, sometimes any severity (GHQ score >5), persistent mild (GHQ score >5 on three or more occasions) and persistent moderate distress (GHQ score >10) on three or more occasions, over a median of 12.1 (IQR 8.6–12.5) years. The models were both unadjusted and adjusted for known baseline risk factors.

Results Persistent moderate or greater psychological stress was reported on three or more assessments by 35 (3.7%) subjects. These patients had a higher risk of both CV death (adjusted HR 3.94, 95% CI 2.05 to 7.56, p<0.001) and all-cause mortality (adjusted HR 2.85, 95% CI 1.74 to 4.66, p<0.001) compared with patients with no distress. In contrast, patients who reported persistent mild distress (n=73, 7.7%) on three or more visits, and those who met criteria for distress on only one or two assessments (n=255, 26.8%), did not have an increased risk of CV or all-cause mortality during follow-up.

Conclusion In patients with stable coronary artery disease, persistent psychological distress of at least moderate severity is associated with a substantial increase in CV and all-cause mortality.

  • coronary heart disease
  • psychological distress
  • depression
  • anxiety

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  • Available on request to the corresponding author

  • Contributors The manuscript was drafted by RS. All coauthors contributed to the design and management of the LIPID trial and psychological substudy. All authors contributed to critical review of the manuscript.

  • Funding The LIPID trial was originally funded by Bristol-Myers Squibb. The psychological substudy was undertaken independently as an investigator initiated project. The design analysis and drafting of the manuscript were all undertaken independently of the study sponsor.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Ethics Committees for all participating centers.

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

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with ’BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.

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