Perceived Stress and Cause-specific Mortality Among men and Women: Results From a Prospective Cohort Study

Naja Rod Nielsen; Tage S. Kristensen; Peter Schnohr; Morten Grønbæk


Am J Epidemiol. 2008;168(5):481-491. 

In This Article

Abstract and Introduction


The authors assessed the effect of psychological stress on total and cause-specific mortality among men and women. In 1981-1983, the 12, 128 Danish participants in the Copenhagen City Heart Study were asked two questions on stress intensity and frequency and were followed in a nationwide registry until 2004, with <0.1% loss to follow-up. Sex differences were found in the relations between stress and mortality (p = 0.02). After adjustments, men with high stress versus low stress had higher all-cause mortality (hazard ratio (HR) = 1.32, 95% confidence interval (CI): 1.15, 1.52). This finding was most pronounced for deaths due to respiratory diseases (high vs. low stress: HR = 1.79, 95% CI: 1.10, 2.91), external causes (HR = 3.07, 95% CI: 1.65, 5.71), and suicide (HR = 5.91, 95% CI: 2.47, 14.16). High stress was related to a 2.59 (95% CI: 1.20, 5.61) higher risk of ischemic heart disease mortality for younger, but not older, men. In general, the effects of stress were most pronounced among younger and healthier men. No associations were found between stress and mortality among women, except among younger women with high stress, who experienced lower cancer mortality (HR = 0.51, 95% CI: 0.28, 0.92). Future preventive strategies may be targeted toward stress as a risk factor for premature death among middle-aged, presumably healthy men.


Acute stressors such as earthquakes or loss of a child may trigger death,[1,2] but there has been less focus on how chronic "low-key" stress of everyday life affects mortality in a general population. The human body responds to stress by activating the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis, which may in turn affect the cardiovascular, the metabolic, and the immune systems.[3] Prolonged activation of these systems may lead to stress-related disease and possibly increase the risk of premature death. Stress may also contribute to a higher frequency of adverse health behaviors, which may affect health. Previous studies have found stress to increase the risk of ischemic heart disease[4] and possibly decrease the risk of some hormonedependent cancers,[5,6,7] but the combined effect of everyday stress on total and cause-specific mortality remains unknown.

Some studies have suggested that the effects of stress on health outcomes are different for men and women,[8,9,10] which may be explained by sex differences in vulnerability, stress response, or coping strategies. To our knowledge, the suggested sex differences remain to be studied in a large community sample. In addition, the stress response may have a different impact on different diseases, making it important to differentiate between causes of deaths. However, previous studies have not had sufficient statistical power to address uncommon causes of death such as those due to respiratory diseases, external causes, and suicide.[8,10,11,12,13,14]

We aimed to address the effects of stress on all-cause and cause-specific mortality as well as possible sex differences in vulnerability to stress in a large, population-based cohort study. Nationwide registries allowed for sound adjustment for baseline morbidity as well as almost complete assessment of long-term mortality.


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