Commentary

Consensus committees are a critical element in the chain of basic research leading to improved clinical practice. The review by Bunker et al is well researched and written and provides clear conclusions. Although “stress” is widely understood, it is a fuzzy concept and the authors focus on better defined psychological constructs that represent emotional distress. However, they do not discriminate between individual characteristics (eg, anxiety or depression) and objective environmental features (eg, life events or job control). This distinction is critical because the environmental stimuli are often impossible to change.

The authors reviewed previously published (1960–2001) review articles. Comprehensiveness (a strength) can result from this strategy, but there also is a cost; if the most recent review was published in 2001, it means that the past 4–5 years of published research were not considered in this 2003 article because of cumulative publication lag. On the whole, it is not a major problem for trustworthiness of the conclusions given the known consistency in research linking depression and social isolation to CHD.

What do the results mean clinically? Importantly, the most salient distress variables have a risk ratio similar in size to biological risk factors (hypertension and dyslipidaemia) with a 3–4 fold relative risk. Unfortunately for patients, we lack consensus on how to screen for emotional distress, and few insurance carriers pay for treating it despite impressive data about effectiveness. Bunker et al’s conclusions challenge us to swiftly find consensus on psychological screening tools and to aggressively market non-drug distress treatment to third-party payers.