title: The combined association of psychological distress and socioeconomic status with all-cause mortality: a national cohort study.
abstract: BACKGROUND
  Psychological distress and low socioeconomic status (SES) are recognized risk factors for mortality. The aim of this study was to test whether lower SES amplifies the effect of psychological distress on all-cause mortality.
  
  
  METHODS
  We selected 66 518 participants from the Health Survey for England who were 35 years or older, free of cancer and cardiovascular disease at baseline, and living in private households in England from 1994 to 2004. Selection used stratified random sampling, and participants were linked prospectively to mortality records from the Office of National Statistics (mean follow-up, 8.2 years). Psychological distress was measured using the 12-item General Health Questionnaire, and SES was indexed by occupational class.
  
  
  RESULTS
  The crude incidence rate of death was 14.49 (95% CI, 14.17-14.81) per 1000 person-years. After adjustment for age and sex, psychological distress and low SES category were associated with increased mortality rates. In a stratified analysis, the association of psychological distress with mortality differed with SES (likelihood ratio test-adjusted P < .001), with the strongest associations being observed in the lowest SES categories.
  
  
  CONCLUSIONS
  The detrimental effect of psychological distress on mortality is amplified by low SES category. People in higher SES categories have lower mortality rates even when they report high levels of psychological distress.
authors.affiliation: Department of Epidemiology and Public Health, University College London, London, England. a.lazzarino@ucl.ac.uk
authors.forename: Antonio Ivan
authors.initials: AI
authors.lastname: Lazzarino
authors.forename: Mark
authors.initials: M
authors.lastname: Hamer
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Stamatakis
authors.forename: Andrew
authors.initials: A
authors.lastname: Steptoe
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004739:England / Q000453:epidemiology; D005260:Female; D006306:Health Surveys / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D016016:Proportional Hazards Models; D011897:Random Allocation; D012307:Risk Factors; D012923:Social Class; D013315:Stress, Psychological / Q000453:epidemiology / Q000401:mortality; D011795:Surveys and Questionnaires