Current issues of ACP Journal Club are published in Annals of Internal Medicine


Mortality increased with loss of employment in middle-aged men

ACP J Club. 1994 Sept-Oct;121:52. doi:10.7326/ACPJC-1994-121-2-052

Source Citation

Morris JK, Cook DG, Shaper AG. Loss of employment and mortality. BMJ. 1994 Apr 30;308:1235-9.



To determine if loss of employment and early retirement increases the risk for death in middle-aged British men.


Cohort analytic study. Men in the British Regional Heart Study were questioned for employment information 5 years after screening and then were followed for a mean of 5.5 years.


1 general practice in each of 24 towns in the United Kingdom.


6191 men (mean age, 50 y) who had been continuously employed during the 5 years before the initial screening.

Assessment of Risk Factors

At enrollment into the Heart Study, geographic distribution, occupational history, employment status, social class, cigarette smoking, alcohol consumption, weight, and pre-existing disease were ascertained. After 5 years a questionnaire was mailed to obtain detailed information regarding employment status during the 5 years before screening and the 5 years between screening and the questionnaire.

Main Outcome Measures

All-cause mortality, cardiovascular death, and noncardiovascular death.

Main Results

4412 men were continuously employed full-time throughout the 5 years after the initial screening. 1779 men experienced some unemployment or retired during the 5 years after screening. 379 men died during follow-up; of them 174 had been continuously employed and 205 had experienced unemployment or had retired. Men who had experienced unemployment or retired were twice as likely to die as the continuously employed men (age-adjusted relative risk [RR], 2.13; 95% CI, 1.71 to 2.65). After adjustment for geographic location, social class, smoking, alcohol intake, and preexisting disease, the RR for death was slightly reduced (RR, 1.95; CI, 1.57 to 2.43). Men who stated that their unemployment was because of ill health had the highest adjusted RR, 3.14 (CI, 2.35 to 4.21). Men who were unemployed for reasons other than ill health also had an increased adjusted risk for death (RR, 1.47;CI, 1.10 to 1.96). Men who were unemployed or retired had a higher adjusted risk for death from cancers and cardiovascular diseases compared with the continuously employed men (RR, 2.07; CI, 1.45 to 2.97 and RR, 2.13; CI, 1.57 to 2.89, respectively).


Loss of employment and early retirement were risk factors for death in middle-aged British men.

Sources of funding: British Heart Foundation and the Department of Health, and Medical Research Council.

For article reprint: Dr. D.G. Cook, Department of Public Health Sciences, St. George's Hospital Medical School, London SW17 0RE, United Kingdom. FAX 44-81-725-3584.


The study by Morris and colleagues adds to our knowledge of the probable causal effects of unemployment on mortality. The study was limited by its reliance on self-assessments (questionnaires), the population studied (middle-aged men only), the inability to adjust for crossovers between employment groups during follow-up, and the lack of morbidity data. For example, was the incidence of cancer and cardiovascular disease increased as well as mortality? The study's advantage over other studies is that the health status before unemployment was known.

Although the authors feel that the observed increased cancer mortality somewhat undermines their hypothesis that unemployment causes increased mortality, I believe no inconsistency exists. Most previous studies have supported increased overall mortality associated with unemployment. I believe that the stress of unemployment, its possible effect on immune system functioning, and increased cancer deaths are consistent with the overall findings.

This study and recent reviews (1-3) point to the need for clinicians to be especially vigilant in patients who are unemployed or retire. Greater vigilance may lead to improved counseling, better diet, and appropriate medications, such as antidepressants, for selected patients. Studies that look at the effects of clinical intervention are much needed.

Arnold Leff, MD
Santa Cruz Family Medicine Santa Cruz, California, USA