Psychological distress involves an alteration in an individual’s emotional state because of one’s inability to respond to life pressures or unmet demands (1). Psychological distress generally can be expressed in various forms such as depression, anxiety, and anhedonia. Moreover, these negative symptoms tend to overlap, which leads to the cooccurrence of various symtoms (2, 3). Drapeau et al. (2) estimated that the general population’s prevalence of psychological distress ranges from 5% to 27%. The 12-item general health survey (GHQ-12) has been examined in the literature as a reliable measure of psychological distress (11, 13, 23, 31, 41, 42) and has good specificity, reliability, and sensitivity (4, 5). The GHQ-12’s dimensionality has been a topic of controversy, with advocates for the unidimensional scale citing the high correlation between the identified factors (6, 7) and many others supporting the use of the 3-factor model, including GHQ-12A, GHQ-12B, and GHQ-12C (6–13). Recent studies have demonstrated that the imposition of a simple structure may artificially generate high correlations between modeled factors [e.g., (14)]. Thus, as suggested by Griffith and Jones (15), “taking these correlations as justification for unidimensionality risks a self-fulfilling prophecy of simplicity begetting simplicity.” In light of the ongoing debates regarding the structure of the GHQ-12, the present study investigates both the unidimensional and multidimensional models of the measure.

Angina is a prevalent symptom of coronary artery disease; however, it may also arise from other non-coronary artery related conditions, such as respiratory disease, valvular disease, anemia, and hyperthyroidism. These conditions can predict the occurrence rates of cardiovascular diseases and myocardial infarction independently of age. Moreover, alterations in pain sensitivity and stimuli via the vagal nerve fibers that are shared with the heart can result in non-cardiac chest pain resembling angina, which can be induced by gastrointestinal disorders. A meta-analysis revealed a wide prevalence range of angina, ranging from 0.7% to 15% (16–19).

It is important to understand psychological distress in angina given poorer cardiovascular disease outcome in people with higher psychological distress (20). Research has demonstrated that individuals who experience higher levels of psychological distress tend to have a greater number of comorbidities and physical disabilities (21), which may indicate the psychological distress is associated with severe disease, which in turn leads to poorer outcomes (22). Other studies have also looked at the possible biological mechanisms between psychological distress and poor outcome (23, 24), and suggested that secondary prevention may explain such a relationship. For instance, people with higher levels of psychological distress may be unlikely to participate in cardiac rehabilitation programs and change their lifestyles such as quitting smoking and increasing physical activities (25, 26), which then leads to adverse outcomes.

Indeed, there are some studies that have looked at the association between psychological distress and angina [e.g., (1, 21, 27–32)]. However, previous studies have primarily examined small clinical samples and focused on specific psychological distress such as depression and anxiety. There is limited research on the impact of angina on general psychological distress and different dimensions of psychological distress in population-based studies. Therefore, this study aims to investigate the relationship between angina and dimensions of psychological distress. Specifically, the study hypothesizes that there are three underlying factor structures of the GHQ-12: GHQ-12A (social dysfunction and anhedonia), GHQ-12B (depression and anxiety), and GHQ-12C (loss of confidence). Additionally, the study predicts that participants with angina will experience higher levels of both general psychological distress and dimensions of psychological distress.

The results of the factor analysis produced three distinct factors that were labeled as GHQ-12A, GHQ-12B, and GHQ-12C. GHQ-12A consisted of six items related to social dysfunction and anhedonia, GHQ-12B included four items related to depression and anxiety, and GHQ-12C consisted of two items related to loss of confidence. The specific loadings for each item can be found in Table 2.

The current study found a main effect of age [F(1, 8,814) = 23.88, p < 0.01], sex [F(1, 8,814) = 25.12, p < 0.001], monthly income [F(1, 8,814) = 16.36, p < 0.001], highest educational qualification [F(1, 8,814) = 12.39, p < 0.001], legal marital status [F(1, 8,814) = 57.09, p < 0.001] and residence [F(1, 8,814) = 7.98, p < 0.01] on GHQ-12 summary score in healthy controls. Similarly, there was a main effect of age [F(1, 8,814) = 58.47, p < 0.001], monthly income [F(1, 8,814) = 16.42, p < 0.001], highest educational qualification [F(1, 8,814) = 6.41, p < 0.01], legal marital status [F(1, 8,814) = 19.73, p < 0.001] and residence [F(1, 8,814) = 6.51, p < 0.05] on GHQ-12A (social dysfunction & anhedonia). However, the main effect of sex was insignificant. Moreover, there was a main effect of age [F(1, 8,814) = 120.38, p < 0.001], sex [F(1, 8,814) = 69.70, p < 0.001], monthly income [F(1, 8,814) = 6.38, p < 0.05], highest educational qualification [F(1, 8,814) = 5.54, p < 0.05], legal marital status [F(1, 8,814) = 11.87, p < 0.001] and residence [F(1, 8,814) = 10.96, p < 0.001] on GHQ-12B (depression & anxiety). Finally, there was a main effect of monthly income [F(1, 8,814) = 12.47, p < 0.001], highest educational qualification [F(1, 8,814) = 12.07, p < 0.001], and legal marital status [F(1, 8,814) = 75.91, p < 0.001]. However, the main effect of age, sex, and residence was not significant.

Additionally, it was observed that individuals with angina had a significantly higher level of psychological distress, based on the GHQ-12 summary score [t(1080) = 11.75, p < 0.001, Cohen’s d = 0.40, 95% C.I. (0.33, 0.47)], GHQ-12A [t(1080) = 12.01, p < 0.001, Cohen’s d = 0.35, 95% C.I. (0.30, 0.41)], GHQ-12B [t(1080) = 10.57, p < 0.001, Cohen’s d = 0.31, 95% C.I. (0.26, 0.37)], GHQ-12C [t(1080) = 7.37, p < 0.001, Cohen’s d = 0.22, 95% C.I. (0.16, 0.28)]. Further, Figure 1 provides a visual representation of the mean and standard error of predicted and actual standardized scores.

The aim of this research was to examine the influence of angina on individuals’ psychological distress, including its impact on three distinct dimensions of psychological distress, namely GHQ-12A (comprising social dysfunction and anhedonia), GHQ-12B (encompassing depression and anxiety), and GHQ-12C (reflecting loss of confidence). Using a predictive normative modeling approach with one-sample t-tests, a total of 1,081 participants with angina and 8,821 without angina were examined through the UKHLS dataset. Results revealed that individuals with angina experience greater levels of psychological distress compared to those without angina, as demonstrated by higher GHQ-12 summary scores (Cohen’s d = 0.31), GHQ-12A (Cohen’s d = 0.34), GHQ-12B (Cohen’s d = 0.21), and GHQ-12C (Cohen’s d = 0.20). To the best of my knowledge, this study is the first one that demonstrated the feasibility of using the GHQ-12 to screen psychological distress in individuals with angina and looked at how dimensions of psychological distress are affected by angina.

In this study, a CFA was conducted to identify underlying factors in the GHQ-12 scale. The analysis revealed a three-factor solution, including GHQ-12A (consisting of 6 items related to social dysfunction and anhedonia), GHQ-12B (consisting of 4 items related to depression and anxiety), and GHQ-12C (consisting of 2 items related to loss of confidence). The results of this study are consistent with previous research studies which also identified three factors in the GHQ-12 scale, as reported in studies by Campbell and Knowles (8), El-Metwally et al. (6), Gao et al. (7), Graetz (9), Martin et al. (10), Padrón et al. (11), Penninkilampi-Kerola et al. (12), and Rajabi et al. (13). Furthermore, the factor loadings in the current study were found to be high, as presented in Table 2.

The results showed that participants with angina have higher psychological distress is also consistent with previous studies [e.g., (1, 21, 27–32)]. Moreover, it has been demonstrated that the presence of new or persistent psychological distress can considerably heighten the likelihood of a future diagnosis of angina, as evidenced by follow-up research (32). Moreover, a large-scale study discovered that there are positive associations between psychological distress and self-reported clinical diagnoses of angina or heart attack (21). Another more recent study found that angina is associated with more psychological distress (1). The finding that participants with angina have more social dysfunction & anhedonia is consistent with studies that found a positive association between cardiovascular disease and social dysfunction & anhedonia [e.g., (35)]. Moreover, the effect size as indicated by Cohen’s d was the biggest for social dysfunction & anhedonia, which may indicate that dysfunction & anhedonia is the most pronounced psychological distress problem in people with angina but was largely ignored in the literature. The finding that participants with angina have more depression & anxiety problems is also consistent with several studies [e.g., (28, 30)]. Finally, participants with angina had more loss of confidence problems, which is of particular importance given that confidence in patients is closely related to clinical outcomes. Furthermore, the varying effect size of distinct dimensions of psychological distress suggests that the impact of angina on different dimensions of psychological distress may differ. This implies that an examination of specific dimensions of psychological distress is warranted in addition to assessing general psychological distress.

Angina has been found to be linked to psychological distress through various pathways. Psychological distress has been found to have a significant impact on the risk of myocardial ischemic changes, as observed through exercise electrocardiography or nuclear medical imaging examinations, as well as on the frequency of angina in patients with acute myocardial infarction. This is attributed to a combination of behavioral and biological factors, with negative emotions experienced during psychological distress leading to a decrease in medical compliance and health-promoting behaviors. Moreover, psychological distress can affect various biological activities, including those of the hypothalamic-pituitary-adrenal axis, autonomic nerves, platelets, and inflammatory cytokines, potentially increasing the risk of coronary artery disease such as angina. These factors can induce endothelial dysfunction and atherosclerosis, cause vasoconstriction, accelerate heartbeat, increase ventricular load, and raise the incidence of angina symptoms. The association between psychological distress and angina is also influenced by the interactions between behavioral and biological factors. For example, non-adherence to antidepressant medications and physical inactivity can increase inflammation and depressive symptoms in individuals with angina.

Although the current study has several strengths, it also has some limitations that need to be acknowledged. Firstly, the study’s cross-sectional design hinders the ability to establish causality due to the possible bidirectional association between psychological distress and angina. Longitudinal studies would be useful in determining the causal relationship between these two variables. Secondly, angina was evaluated using self-reported responses, thus the study cannot confirm the association between angina and clinical medical evidence or diagnoses. Hence, the current study does not establish whether angina was caused by cardiac or noncardiac factors. Future research could investigate how different types of angina, grouped by their causes, may relate to psychological distress differently. The study’s exclusive focus on individuals with angina in the United Kingdom presents a challenge in generalizing the findings to other cultural or national contexts. As a result, it is imperative that future research endeavors aim to reproduce the current results in diverse settings.

The current study aimed to investigate the impact of angina on general and dimensional aspects of psychological distress. The results indicated that psychological distress, both general and dimensional, was affected by angina. These findings support the validity of using GHQ-12 as a measure of psychological distress in individuals with angina. Moreover, the study suggests that it is crucial to consider all dimensions of psychological distress rather than solely focusing on specific dimensions, such as depression or anxiety, in individuals with angina. Clinicians should come up with interventions to reduce psychological distress in people with angina, which can then lead to better outcomes.

Publicly available datasets were analyzed in this study. This data can be found at: https://www.understandingsociety.ac.uk.

The studies involving human participants were reviewed and approved by University of Essex. The patients/participants provided their written informed consent to participate in this study.

WK: conceptualization, data curation, formal analysis, investigation, methodology, resources, software, writing—original draft, and writing—review and editing.

This work was supported by the Imperial Open Access Fund.

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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