Has the mortality of male doctors improved with the reductions in their cigarette smoking?

From 1951 to 1971 male doctors reduced their cigarette smoking more than did men in social classes I and II combined. In 1970-2, 665 male doctors died aged under 65. Had they shown the same improvements in cause-specific death rates over the 20 years as men in classes I and II, 699 deaths would have been expected. This "saving" of 34 deaths in the doctors comprised savings from coronary heart disease (83), stroke (16), and lung cancer (8) balanced by 60 "losses" from three stress-related causes--namely, accident, poisonings, etc (30); suicide (26); and cirrhosis of the liver (4)--plus 13 from other causes. As a relative reduction in mortality from heart disease in doctors (as compared with that in social classes I and II) also occurred during 1931-51--that is, before they began to give up smoking--some of the saving in heart-disease deaths in 1951-71 was probably not related to changes in smoking habits. The relative worsening in mortality from stress-related diseases may have been due partly to a possible adverse effect of giving up smoking if smoking had acted to reduce stress. From these findings, the benefits of giving up smoking may not be so great as has commonly been assumed.     

Mortality in men admitted to hospital with acute urinary retention: database analysis

Objectives To investigate mortality in men admitted to hospital with acute urinary retention and to report on the effects of comorbidity on mortality.Design Analysis of the hospital episode statistics database linked to the mortality database of the Office for National Statistics.Setting NHS hospital trusts in England, 1998-2005.Participants All men aged over 45 who were admitted to NHS hospitals in England with a first episode of acute urinary retention.Main outcome measures Mortality in the first year after acute urinary retention and standardised mortality ratio against the general population.Results During the study period, 176 046 men aged over 45 were admitted to hospital with a first episode of acute urinary retention. In 100 067 men with spontaneous acute urinary retention, the one year mortality was 4.1% in men aged 45-54 and 32.8% in those aged 85 and over. In 75 979 men with precipitated acute urinary retention, mortality was 9.5% and 45.4%, respectively. In men with spontaneous acute urinary retention aged 75-84, the most prevalent age group, the one year mortality was 12.5% in men without comorbidity and 28.8% in men with comorbidity. The corresponding figures for men with precipitated acute urinary retention were 18.1% and 40.5%. Compared with the general population, the highest relative increase in mortality was in men aged 45-54 (standardised mortality ratio 10.0 for spontaneous and 23.6 for precipitated acute urinary retention) and the lowest for men 85 and over (1.7 and 2.4, respectively).Conclusions Mortality in men admitted to hospital with acute urinary retention is high and increases strongly with age and comorbidity. Patients might benefit from multi-disciplinary care to identify and treat comorbid conditions.     

Illness in the family

OBJECTIVE: To update reports of increases in the rates of admission to hospital and death from asthma among children and young adults in Canada during the 1970s by examining data for the 1980s. DESIGN: Age-standardized rates were calculated from data for people less than 35 years of age at the time of death from asthma, bronchitis or other respiratory conditions (from 1980 through 1989) and at the time of admission to hospital for treatment of these diseases (from 1980 through 1988). Standardized mortality ratios were calculated with the death rate for Canada as the expected rate. SETTING: Data for all of Canada were examined by sex, age group and province. RESULTS: In contrast to sharp increases in the rate of death from asthma observed from 1970 through the early 1980s among Canadians less than 35 years of age, the rate showed no net change between 1980 and 1989; on average, there were 58 deaths in this age group annually. During the decade, the rates of death from asthma were three times higher in Saskatchewan and Alberta than in Newfoundland. The national rate of hospital admission/separation for asthma, however, increased greatly, though changes in the rate varied by province. Increases of over 90% were observed in Prince Edward Island and New Brunswick, whereas little overall change occurred in Newfoundland, Manitoba and Saskatchewan. The rate of hospital admission/separation for asthma was highest in Prince Edward Island and lowest in Manitoba and British Columbia. Although the rates of hospital admission/separation for asthma among boys aged less than 15 years of age were consistently 50% higher than those among girls of that age, the rate among people aged 15 through 34 years was twice as high among females as males. A slight decrease in the rates of death from respiratory conditions other than asthma was observed, together with a steady, fairly substantial decline in the rates of hospital admission/separation for these conditions. CONCLUSIONS: Whether there is any relation between increases in rates of admission to hospital for asthma and trends in the rates of death from asthma during the decade will require further study.     

Health in China. From Mao to market reform.

After the Liberation by Mao Ze Dong''s Communist army in 1949, China experienced massive social and economic change. The dramatic reductions in mortality and morbidity of the next two decades were brought about through improvements in socioeconomic conditions, an emphasis on prevention, and almost universal access to basic health care. The economic mismanagement of the Great Leap Forward brought about a temporary reversal in these positive trends. During the Cultural Revolution there was a sustained attack on the privileged position of the medical profession. Most city doctors were sent to work in the countryside, where they trained over a million barefoot doctors. Deng Xiao Ping''s radical economic reforms of the late 1970s replaced the socialist system with a market economy. Although average incomes have increased, the gap between rich and poor has widened.     

Hospital admission for acute pancreatitis in an English population, 1963-98: database study of incidence and mortality

Objectives To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998.Design Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates.Setting Southern England.Subjects 5312 people admitted to hospital with acute pancreatitis.Main outcome measures Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100 000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women.Conclusions Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.     

Social class,non-employment,and chronic illness: continuing the inequalities in health debate.

The 1981-2 General Household Survey showed steep class gradients in limiting longstanding illness for men and women aged 20-59 that were very similar to the class gradients in mortality in the 1979-83 decennial supplement. The class gradient for women classified by their husband''s occupation was stronger than that when they were classified by their own occupation. Men and women who lacked paid employment reported poorer health than the employed and were concentrated in the lower social classes. Inequalities in ill health due to class were partly caused by the higher proportion in the lower social classes who were without work. Class differences in ill health still existed, however, among the currently employed, with unskilled men reporting particularly poor health and women manual workers reporting poorer health than women in non-manual jobs. Class differences were greater for the occupationless than for the currently employed. Thus class remains an important indicator of health inequalities despite the current high level of unemployment.     

Reservation and non‐reservation American Indian mortality in 1970 and 1978

Abstract

Mortality rates by age and sex of American Indians living in reservation and non‐reservation counties were compared for 1970 and 1978. An apparent overcount in the 1980 census enumeration of American Indians curtails rigorous comparisons, but broad differences can be delineated. The main improvement in American Indian mortality during the decade was in age group 0–4. In 1970, non‐reservation death rates were not different from reservation rates. By the end of the decade, non‐reservation death rates had diverged downward from reservation deaths. An analysis of 1978 death rates by poverty status showed that non‐reservation death rates are sensitive to county poverty level, whereas reservation death rates are not.     

Educational differences in obesity in the United States: a closer look at the trends

Both body weight and educational attainment have risen in the United States. Empirical evidence regarding educational differences in obesity (BMI ≥30) is inconsistent. According to some widely cited claims, these differences have declined since the 1970s, and the most educated have experienced the greatest gain in obesity. Prior research was limited in grouping college graduates with nongraduates, combining men and women in the same analysis, and using self-reported rather than measured anthropometric information. Using the National Health and Nutrition Examination Surveys (NHANES), we address these issues and examine changing educational differences in obesity from 1971-1980 to 1999-2006 for non-Hispanic whites and blacks in two separate age groups (25-44 vs. 45-64 years). We find that (i) obesity differentials by education have remained largely stable, (ii) compared with college graduates, less educated whites and younger black women continue to be more likely to be obese, (iii) but the differentials are larger for women than men, and weak or nonexistent among black men and older black women. There are exceptions to the overall trend. The obesity gap has widened between the two groups of college-educated younger women, but disappeared between the least and most educated younger white men. Thus, the increase in obesity was similar for most educational groups, but significantly greater for younger women with some college and smaller for younger white men without a high-school degree. Lumping together the two distinct college groups has biased previous estimates of educational differences in obesity.     

Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study

Objectives To investigate time trends in mortality after admission to hospital for fractured neck of femur from 1968 to 1998, and to report on the effects of demographic factors on mortality.Design Analysis of hospital inpatient statistics for fractured neck of femur, incorporating linkage to death certificates.Setting Four counties in southern England.Subjects 32 590 people aged 65 years or over admitted to hospital with fractured neck of femur between 1968 and 1998.Main outcome measures Case fatality rates at 30, 90, and 365 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results Case fatality rates declined between the 1960s and the early 1980s, but there was no appreciable fall thereafter. They increased sharply with increasing age: for example, fatality rates at 30 days in 1984-98 increased from 4% in men aged 64-69 years to 31% in those aged ≥ 90. They were higher in men than women, and in social classes IV and V than in classes I and II. In the first month after fracture, standardised mortality ratios in women were 16 times higher, and those in men 12 times higher, than mortality in the same age group in the general population.Conclusions The high mortality rates, and the fact that they have not fallen over the past 20 years, reinforce the need for measures to prevent osteoporosis and falls and their consequences in elderly people. Whether post-fracture mortality has fallen to an irreducible minimum, or whether further decline is possible, is unclear.     

Unemployment and mortality among Finnish men, 1981-5.

OBJECTIVE--To ascertain whether, after controlling for several relevant background variables simultaneously, unemployment is related to mortality and to assess whether this relation is causal or whether unhealthy people are more likely to become unemployed. DESIGN--Prospective study of mortality in Finland during 1981-5 based on 1980 census data on 30-54 year old wage earner men and with particular attention to unemployment in the year before the census. SETTING--Research project at the University of Helsinki. SUBJECTS--All wage earner men in Finland aged 30-54 at the 1980 census. MAIN OUTCOME MEASURES--Causes of death during 1981-5 and duration of unemployment in the year before the census. Background variables controlled for were age, socioeconomic state, marital state, and health. The data were analysed by log linear regression models. RESULTS--During the study period 1981-5, which covered almost 2.7 million person years, there were 9810 deaths. After controlling for all background variables relative total mortality among unemployed versus employed men was 1.93 (95% confidence interval 1.82 to 2.05). The excess mortality was highest in accidental and violent causes of death (relative mortality 2.51; 95% confidence interval 2.28 to 2.76). For circulatory diseases the relative death rate was 1.54 (95% confidence interval 1.40 to 1.70), but among neoplasms only lung cancer was associated with excess mortality. Selection for unemployment based on age, socioeconomic state, and marital state was evident but no such selection was detected based on health. Effects of unemployment on mortality were more pronounced with increasing duration of unemployment. CONCLUSIONS--The relative excess mortality of unemployed men in Finland cannot fully be explained by demographic, social, and health variables preceding unemployment. Unemployment therefore seems to have an independent causal effect on male mortality. Further studies are needed to elucidate the mechanisms between unemployment and mortality.     

Widening inequality of health in northern England, 1981-91.

OBJECTIVE--To identify relative and absolute changes in mortality in the Northern region of England between 1981 and 1991. DESIGN--1981 and 1991 census data were used to rank 678 wards on an index of material deprivation composed of four variables (unemployment, car ownership, housing tenure, household overcrowding). Standardised mortality ratios (all causes) were calculated for various periods between 1981 and 1991 and for different age categories. SETTING--Counties of Cleveland, Cumbria, Durham, Northumberland, and Tyne and Wear. RESULTS--During 1981-91 mortality differentials widened between the most affluent and deprived fifths of wards in all age categories under 75 years. The decline in the relative position of the poorest areas was particularly great, and there was no narrowing of inequalities across the remainder of the socioeconomic spectrum. In absolute terms, there were improvements in mortality in all age categories in the most affluent areas. In the poorest areas improvements in the 55-64 age group were balanced by increased mortality among men aged 15-44, a slight rise among women aged 65-74, and static rates among men aged 45-54. CONCLUSIONS--These results re-emphasise the case for linking mortality patterns with material conditions rather than individual behaviour.     

Stressful life events,social support,and mortality in men born in 1933.

OBJECTIVE--To examine relations between stressful life events and mortality in middle aged men. DESIGN--Prospective population study. Data on stressful life events, social network, occupation, and other psychosocial factors derived from self administered questionnaires. Mortality data obtained from official registers. SETTING--City of Gothenburg, Sweden. SUBJECTS--752 men from a random population sample of 1016 men aged 50. MAIN OUTCOME MEASURE--Mortality from all causes during seven years'' follow up. RESULTS--Life events which had occurred in the year before the baseline examination were significantly associated with mortality from all causes during seven years'' follow up. Of the men who had experienced three or more events during the past year 10.9% had died compared with 3.3% among those with no life events (odds ratio 3.6; 95% confidence interval 1.5 to 8.5). The association between recent life events and mortality remained true after smoking, self perceived health, occupational class, and indices of social support were controlled for. Many of the deaths were alcohol related, but the number of deaths was too small to allow for analyses of specific causes of death. The association between life events and mortality was evident only in men with low emotional support. CONCLUSION--Stressful life events are associated with high mortality in middle aged men. Men with adequate emotional support seem to be protected.     

Lifetime socioeconomic position and mortality: prospective observational study.

OBJECTIVES: To assess the influence of socioeconomic position over a lifetime on risk factors for cardiovascular disease, on morbidity, and on mortality from various causes. DESIGN: Prospective observational study with 21 years of follow up. Social class was determined as manual or non-manual at three stages of participants'' lives: from the social class of their father''s job, the social class of their first job, and the social class of their job at the time of screening. A cumulative social class indicator was constructed, ranging from non-manual social class at all three stages of life to manual social class at all three stages. SETTING: 27 workplaces in the west of Scotland. PARTICIPANTS: 5766 men aged 35-64 at the time of examination. MAIN OUTCOME MEASURES: Prevalence and level of risk factors for cardiovascular disease; morbidity; and mortality from broad causes of death. RESULTS: From non-manual social class locations at all three life stages to manual at all stages there were strong positive trends for blood pressure, body mass index, current cigarette smoking, angina, and bronchitis. Inverse trends were seen for height, cholesterol concentration, lung function, and being an ex-smoker. 1580 men died during follow up. Age adjusted relative death rates in comparison with the men of non-manual social class locations at all three stages of life were 1.29 (95% confidence interval 1.08 to 1.56) in men of two non-manual and one manual social class; 1.45 (1.21 to 1.73) in men of two manual and one non-manual social class; and 1.71 (1.46 to 2.01) in men of manual social class at all three stages. Mortality from cardiovascular disease showed a similar graded association with cumulative social class. Mortality from cancer was mainly raised among men of manual social class at all three stages. Adjustment for a wide range of risk factors caused little attenuation in the association of cumulative social class with mortality from all causes and from cardiovascular disease; greater attenuation was seen in the association with mortality from non-cardiovascular, non-cancer disease. Fathers having a manual [corrected] occupation was strongly associated with mortality from cardiovascular disease: relative rate 1.41 (1.15 to 1.72). Participants'' social class at the time of screening was more strongly associated than the other social class indicators with mortality from cancer and from non-cardiovascular, non-cancer causes. CONCLUSIONS: Socioeconomic factors acting over the lifetime affect health and risk of premature death. The relative importance of influences at different stages varies for the cause of death. Studies with data on socioeconomic circumstances at only one stage of life are inadequate for fully elucidating the contribution of socioeconomic factors to health and mortality risk.     

Career preferences of doctors who qualified in the United Kingdom in 1993 compared with those of doctors qualifying in 1974, 1977, 1980, and 1983.

OBJECTIVE--To report the career preferences of doctors who qualified in the United Kingdom in 1993 and to compare their choices with those of earlier cohorts of qualifiers. DESIGN--Postal questionnaires with structured questions, including questions about choice of future long term career, were sent to doctors a year after qualification. SETTING--United Kingdom. SUBJECTS--All medical qualifiers of 1993, comparing their replies with those from earlier studies of the qualifiers of 1974, 1977, 1980, and 1983. MAIN OUTCOME MEASURES--Choice of future long term career and certainty of choice expressed at the end of the first year after qualification. RESULTS--Questionnaires were sent to 3657 doctors. 2621 (71.7%) replied. Of the 2621 respondents, 70.5% (1849) stated that their first preference was for a career in hospital practice, 25.8% (677) specified general practice, 1.0% (25) specified public health medicine or community health, 1.4% (36) specified careers outside medicine, and 1.3% (34) did not state a choice. By contrast, 44.7% (1416/3168) of the doctors in the 1983 cohort had specified that their first preference was general practice. Among the 1993 qualifiers, general practice was the first career choice of 17.5% of men (227/1297) and 34.0% of women (450/1324). Only 7.4% of men (96/1297) stated that they definitely wanted to enter general practice. Only 7.8% (103/1324) of women qualifiers in 1993 expressed a career preference for surgical specialties. Within hospital practice, comparing 1993 with 1983, choices for the medical specialties and for accident and emergency medicine rose and those for pathology fell. Women were less definite than men about their choice of future long term career. CONCLUSIONS--If the 1993 cohort is typical of the current generation of young doctors, there has been a substantial shift away from general practice as a career choice expressed at the end of the preregistration year. General practice was much more popular among women than men. Few women opted for surgery. The sex imbalance in the percentage of doctors who choose different mainstreams of medical practice seems set to continue.     

The impact of unemployment on health: a review of the evidence.

OBJECTIVE: To review the scientific evidence supporting an association between unemployment and adverse health outcomes and to assess the evidence on the basis of the epidemiologic criteria for causation. DATA SOURCES: MEDLINE was searched for all relevant articles with the use of the MeSH terms "unemployment," "employment," "job loss," "economy" and a range of mortality and morbidity outcomes. A secondary search was conducted for references from the primary search articles, review articles or published commentaries. Data and definitions of unemployment were drawn from Statistics Canada publications. STUDY SELECTION: Selection focused on articles published in the 1980s and 1990s. English-language reports of aggregate-level research (involving an entire population), such as time-series analyses, and studies of individual subjects, such as cross-sectional, case-control or cohort studies, were reviewed. In total, the authors reviewed 46 articles that described original studies. DATA EXTRACTION: Information was sought on the association (if any) between unemployment and health outcomes such as mortality rates, specific causes of death, incidence of physical and mental disorders and the use of health care services. Information was extracted on the nature of the association (positive or negative), measures of association (relative risk, odds ratio or standardized mortality ratio), and the direction of causation (whether unemployment caused ill health or vice versa). DATA SYNTHESIS: Most aggregate-level studies reported a positive association between national unemployment rates and rates of overall mortality and mortality due to cardiovascular disease and suicide. However, the relation between unemployment rates and motor-vehicle fatality rates may be inverse. Large, census-based cohort studies showed higher rates of overall mortality, death due to cardiovascular disease and suicide among unemployed men and women than among either employed people or the general population. Workers laid off because of factory closure have reported more symptoms and illnesses than employed people; some of these reports have been validated objectively. Unemployed people may be more likely than employed people to visit physicians, take medications or be admitted to general hospitals. A possible association between unemployment and rates of admission to psychiatric hospitals is complicated by other institutional and environmental factors. CONCLUSIONS: Evaluated on an epidemiologic basis, the evidence suggests a strong, positive association between unemployment and many adverse health outcomes. Whether unemployment causes these adverse outcomes is less straightforward, however, because there are likely many mediating and confounding factors, which may be social, economic or clinical. Many authors have suggested mechanisms of causation, but further research is needed to test these hypotheses.     

Social-economic inequality in mortality among older mem amd women. Research on the role of health, life style, parental socio-economic status and psychosocial conditions

This article describes to what degree socio-economic differences exist among community living older men and women, and to what degree these differences are to be explained by health, behaviour, childhood and psychosocial conditions. The data are available from 1427 men and 1503 women (aged 55-85), participating in the Longitudinal Aging Study Amsterdam (LASA) in 1992/1993. As indicators of socio-economic status (ses) we used the highest level of education and net monthly income. Age-adjusted mortality risks for men and women with low income and for men with a low level of education are about 1.5 times as high as for to the persons with high income and educational level. Among men, but not among women, the difference in mortality risk between low and high status persons remains after adjustment for age, health status, and several risk factors. Differences in lifestyle, parental ses and psychosocial characteristics explain little to nothing of the age-adjusted ses-differentiation in mortality. It is concluded that ses-inequalities in mortality are present among Dutch men and, to a lesser extent among women, until high age, and are partly explained by the relatively large health problems of the lower status group.     

Mortality among male anaesthetists in the United Kingdom, 1957-83.

A cohort of 3769 male anaesthetists resident in the United Kingdom between 1957 and 1983 was followed up for a total of 51,431 person years of observation. All subjects were fellows of the Faculty of Anaesthetists and held full registration with the General Medical Council. With all men in social class I being taken as the standard, the standardised mortality ratio among anaesthetists for all causes of death was 68 (95% confidence interval 59 to 77) and the standardised mortality ratio for all cancers was 50 (95% confidence interval 36 to 67). There was no significant excess mortality from lymphomas or leukaemias, but 16 of the 221 deaths in anaesthetists were due to suicide, giving a standardised mortality ratio of 202 (95% confidence interval 115 to 328). When anaesthetists were compared with all doctors the standardised mortality ratio for suicide was only 114, a nonsignificant excess. These findings confirm that the risk of suicide among anaesthetists is twice as high as among other men in social class I but suggest that the risk does not differ significantly from that among doctors as a whole. There was no evidence of a significant excess risk of cancer, and, in particular, the small excess of cancer of the pancreas reported previously could not be confirmed.     

Demographic and health patterns in a rural community from the Basque area in Spain (1800-1990)

In this work, the evolution of demographic and health patterns in a Basque rural population from Spain is analysed, as they relate to progress in demographic and epidemiological transition. For this purpose, parochial record data on 13,298 births and 9,215 deaths, registered during the 19th and 20th centuries (1800-1990), were examined. The study area is a rural community called Lanciego, which is located at the southern end of the Rioja Alavesa area (Alava Province, Basque Country). In Lanciego, demographic transition began in the final decade of the 19th century, when a definite, irreversible trend began towards a reduction in mortality. The decrease in the birth rate came later than that in the death rate, and did not start until the 1930s. The post-transitional stage seemed to be reached in the 1970s, when the birth and death rates showed values below 20 per 1,000. Other characteristics observed for the post-transitional stage in Lanciego are: (i) very low rates of infant mortality achieved at the expense of effective control of exogenous mortality; (ii) the mortality curve by ages changes from a U-shape (typical of populations with a high infant mortality rate and low life expectancy at birth) to a J-shape more characteristic of modern societies where longevity and life expectancy are considerably higher; (iii) a certain level of over-mortality among women in the senior age group (>65); and (iv) a significant proportion of mortality in recent times (1970-90) resulting from cardiovascular diseases and malignant neoplasms (post-transition causes). This last point is in contrast with observations from the first four decades of the 20th century, when infectious diseases and respiratory ailments were determining factors in mortality among this population. The data provided by the study of the variation over time in demographic and health patterns indicate that reducing the risk of mortality is one of the most important preconditions for fertility decline.     

Stress,anxiety, and depression in hospital consultants,general practitioners,and senior health service managers.

OBJECTIVE--To study stress, anxiety, and depression in a group of senior health service staff. DESIGN--Postal survey. SUBJECTS--81 hospital consultants, 322 general practitioners, and 121 senior hospital managers (total 524). MAIN OUTCOME MEASURES--Scores on the general health questionnaire and the hospital anxiety and depression scale. RESULTS--Sixty five (80%) consultants, 257 (80%) general practitioners, and 67 (56%) managers replied. Of all 389 subjects, 183 (47%) scored positively on the general health questionnaire, indicating high levels of stress. From scores on the hospital anxiety and depression scale only 178 (46%) would be regarded as free from anxiety, with 100 (25%) scoring as borderline cases and 111 (29%) likely to be experiencing clinically measurable symptoms. The findings for depression were also of some concern, especially for general practitioners, with 69 (27%) scoring as borderline or likely to be depressed. General practitioners were more likely to be depressed than managers (69 (27%) v 4 (6%) scored > or = 8 on hospital anxiety and depression scale-D; P = 0.004) with no significant difference between general practitioners and consultants. General practitioners were significantly more likely to show suicidal thinking than were consultants (36 (14%) v 3 (5%); P = 0.04) but not managers (9 (13%)). No significant difference could be found between the three groups on any other measure. CONCLUSIONS--The levels of stress, anxiety, and depression in senior doctors and managers in the NHS seem to be high and perhaps higher than expected.