Self-reported Life Satisfaction and 20-Year Mortality in Healthy Finnish Adults
H. Koivumaa-Honkanen1,
R. Honkanen2,
H. Viinamäki1,
K. Heikkilä3,
J. Kaprio3,4 and
M. Koskenvuo5
1 Department of Psychiatry, University of Kuopio and Kuopio University Hospital, Kuopio, Finland.
2 Research Institute of Public Health, University of Kuopio, Kuopio, Finland.
3 Department of Public Health, University of Helsinki, Helsinki, Finland.
4 Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland.
5 Department of Public Health, University of Turku, Turku, Finland.
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ABSTRACT
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The authors investigated the role of self-reported life satisfaction in mortality with a prospective cohort study (19761995). A nationwide sample of healthy adults (1864 years, n = 22,461) from the Finnish Twin Cohort responded to a questionnaire about life satisfaction and known predictors of mortality in 1975. A summary score for life satisfaction (LS), defined as interest in life, happiness, loneliness, and general ease of living (scale range, 420), was determined and used as a three-category variable: the satisfied (LS, 46) (21%), the intermediate group (LS, 711) (65%), and the dissatisfied (LS, 1220) (14%). Mortality data were analyzed with Cox regression. Dissatisfaction was linearly associated with increased mortality. The age-adjusted hazard ratios of all-cause, disease, or injury mortality among dissatisfied versus satisfied men were 2.11 (95% confidence interval (CI): 1.68, 2.64), 1.83 (95% CI: 1.40, 2.39), and 3.01 (95% CI: 1.94, 4.69), respectively. Adjusting for marital status, social class, smoking, alcohol use, and physical activity diminished these risks to 1.49 (95% CI: 1.16, 1.92), 1.35 (95% CI: 1.01, 1.82), and 1.93 (95% CI: 1.19, 3.12), respectively. Dissatisfaction was associated with increased disease mortality, particularly in men with heavy alcohol use (hazard ratio = 3.76, 95% CI: 1.61, 8.80). Women did not show similar associations between life satisfaction and mortality. Life dissatisfaction may predict mortality and serve as a general health risk indicator. This effect seems to be partially mediated through adverse health behavior. Am J Epidemiol 2000;152:98391.
cohort studies; happiness; health; mortality; personal satisfaction; quality of life
Abbreviations:
CI, confidence interval; HR, hazard ratio; ICD-8, International Classification of Diseases, Eighth Revision; ICD-9, International Classification of Diseases, Ninth Revision; LS, life satisfaction score; SD, standard deviation
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INTRODUCTION
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Increasing evidence suggests that the promotion of physical health without paying attention to mental and social well-being is an inadequate strategy (1
). It has been noticed that mental and social well-being benefit the health of the elderly (2
) and adults in general (3
), as well as the health of those already sick (4
) or injured (5
). Moreover, a relation between poor mental health, depression, hopelessness, neuroticism, stress, adverse life events, and increased morbidity/mortality has been reported (3
, 6






14
). Furthermore, persons with a diagnosed mental disorder have a considerably increased risk of premature death due to both disease and injury (15
).
We hypothesized that even a self-reported low subjective well-being without a verified mental disorder may predict a poor health outcome. Life satisfaction is a desired subjective feeling indicating general well-being. It has therefore interested researchers from a variety of disciplines. However, previous research has mainly focused only on its determinants while longitudinal studies have been lacking. Our preliminary results with follow-up extending to 10 years suggested that life satisfaction is able to predict longevity and psychiatric morbidity (16
, 17
). Now it is possible to study the predictive value of life satisfaction with 20 years of follow-up.
Life satisfaction is related to other health predictors such as self-reported health, social support, and health behavior (17

20
). Consequently, the associations between dissatisfaction and other health risk factors, such as poor health behavior or adverse psychosocial factors, need further clarification to identify causal pathways in predicting mortality.
We investigated the role of self-reported life satisfaction in mortality including all-cause, disease, and injury mortality among healthy Finnish adults in a 20-year follow-up study that evaluated the possible mechanisms of actions using multivariate methods.
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MATERIALS AND METHODS
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This longitudinal cohort study was based on the Finnish Twin Cohort consisting of a nationwide sample of all Finnish adults who were same-sex twin pairs born before 1958 with both members alive in 1975. Twin candidate pairs were selected by forming sets of persons with the same birthday, same surname at birth, same community of birth, and same sex. Data were compiled from the Central Population Registry of Finland (21
) in 1974. A baseline postal questionnaire was sent in the autumn of 1975 to all twin candidates. It included information on health, psychosocial and health-related factors, and a scale for assessing life satisfaction (22
). A total of 31,133 subjects responded to the questionnaire. The response rate for all those aged 1864 years in 1975 was 84 percent. It was lower for singletons than for twins, because nonrespondent singletons were no longer sent a reminder once the twin status of a candidate pair was ascertained either from the response of the first respondent in a pair or from local parish records.
Eligible for the present study were those 1) aged 1864 years on January 1, 1976 (n = 29,444), 2) who had a baseline life satisfaction score available (n = 29,173), 3) who were alive at the start of the follow-up on May 1, 1976 (n = 29,137), and 4) who were healthy (see below) at baseline (n = 22,461). Thus, the study population consisted of 11,339 men and 11,122 women, of whom 3,295 were singletons and 19,166 were twins. Those sick at baseline were excluded to eliminate the effect of poor health on mortality and on life satisfaction. We excluded subjects who:
- reported angina pectoris as defined by standard chest pain history items (23
, 24
); reported physician-diagnosed angina pectoris, myocardial infarction, stroke, or diabetes; reported having had severe chest pain lasting half an hour or more (23
, 24
); reported the use of hypnotics and/or tranquilizers for more than 10 days during the last year; or reported being on work disability pension because of any cause, all based on the postal questionnaire in 1975; or
- had inpatient admissions due to diabetes (International Classification of Diseases, Eighth Revision (ICD-8), code 250), cardiovascular diseases except hypertension and venous diseases (ICD-8 codes 390399 or 410449), chronic obstructive pulmonary diseases (ICD-8 codes 490493), or psychiatric disorders (ICD-8 codes 290309) between 1972 and April 30, 1976, based on record linkage to the National Hospital Discharge Registry (25
, 26
); or
- had free medication for 34 selected chronic diseases other than hypertension (including psychoses) before 1977 (27
), as determined by information from the National Registry of Specially Refunded Medication; or
- had incident malignant cancer before 1977 (28
) as indicated by the Finnish Cancer Registry.
The national registries used in this study are based on the unique personal identification code assigned for each citizen and cover the entire Finnish population. The discharge registry has a coverage and diagnostic accuracy of about 95 percent (26
). Furthermore, a large national psychiatric survey in 19771980 indicated that in Finland over 98 percent of persons with a psychotic disorder had received psychiatric treatment (29
) and that nearly all have the right for free medication. Finally, every citizen, regardless of former work status, is entitled to a work disability pension if unable to work because of disease or injury.
A self-reported life satisfaction score (LS) was determined by means of a scale with four questions (30
) modified from a questionnaire developed for measuring the quality of life (31
, 32
). The four items comprised the following: Do you feel that your life at present is
- very interesting (LS, 1), fairly interesting (LS, 2), fairly boring (LS, 4), or very boring (LS, 5)?
- very happy (LS, 1), fairly happy (LS, 2), fairly sad (LS, 4), or very sad (LS, 5)?
- very easy (LS, 1), fairly easy (LS, 2), fairly hard (LS, 4), or very hard (LS, 5)?
Do you feel that at the present moment you are
- 4. very lonely (LS, 5), fairly lonely (LS, 4), or not at all lonely (LS, 1)?
The item responses "cannot say" as well as missing data were scored as 3. Thus, the range of the sum score for life satisfaction was 420, with increasing values indicating a decrease in life satisfaction. If a response was missing for three or four items, the sum score was recorded as "missing data" (16
, 33
). All four questions concerning life satisfaction were answered by 98.2 percent (n = 28,906) and at least two questions by 99.1 percent (n = 29,173) of all respondents aged 1864 years. Furthermore, 70 percent chose response alternatives other than "cannot say" for all items. Correlation coefficients between each item and the life satisfaction score ranged from 0.63 to 0.80 (p < 0.001). Cronbach's alpha (34
) was 0.74 (16
). Distribution of the life satisfaction score was skewed, with lower scores representing greater life satisfaction predominating irrespective of gender, health status, or age group. The mean life satisfaction score was 8.76 (standard deviation (SD), 2.93); the median, 8; and the mode, 7 (16
).
Life satisfaction scores were categorized as follows: satisfied (LS, 46), intermediate (LS, 711), and dissatisfied (LS, 1220). The intermediate group consisted of those with a life satisfaction score within one standard deviation from the mean (16
, 33
). The stability of the life satisfaction score was tested for 21,329 twins by comparing the score in 1975 with the score in 1981 (16
). It was good on both the individual and the group levels. Only 2.2 percent had changed from being satisfied (LS, 46) to being dissatisfied (LS, 1220) or vice versa.
The scale has been used for research purposes in Nordic countries (30
), for all adult groups (16
, 17
) and for psychiatric patients (19
). Cross-sectionally, life dissatisfaction has been associated in the general population with poor health, poor health behavior, living alone, and some personality features (16
, 20
, 22
, 35
, 36
). It has also been strongly associated with depressive symptoms (21-item Beck Depression Inventory) (37
). In psychiatric patients, the Beck Depression Inventory alone accounted for 48 percent of the variation in life satisfaction score (19
, 38
). In 1990, when both scores were available for a sample of healthy twins from this study (n = 8,783), the Pearson correlation coefficient was 0.61 (p < 0.001). A total of 97.7 percent of the satisfied had a Beck Depression Inventory score of less than 10, a cutoff point for mild depressiveness, while 85.9 percent of the twins with at least moderate depressive symptoms (Beck Depression Inventory score, more than 18) were dissatisfied.
Age was used in the analyses as a five-category variable: 1824, 2534, 3544, 4554, and 5564 years. Marital status was classified as either living with a partner (married or cohabiting) or living alone (single, divorced, or widowed). The upper social class consisted of high school graduates having
1 year of vocational training or university education (i.e.,
13 years of education) and being in sedentary work. The lower social class consisted of those with primary school education (<10 years) and ambulatory work involving at least standing and walking (16
, 33
, 35
). The frequency of physical activity during leisure time for a mean duration of
30 minutes with a mean intensity corresponding to at least vigorous walking was a three-category variable: <1, 15, and
6 times a month (16
). Smoking status was defined by current smoking: nonsmoker, currently smoking 119, and currently smoking
20 cigarettes daily. Alcohol use was a two-category variable: a man was a heavy drinker if he used
800 g of pure alcohol per month (two drinks a day), with the corresponding limit for women being 400 g (one drink a day) (39
).
The follow-up period extended from May 1, 1976, to December 31, 1995. Mortality data were derived from the Finnish National Registry for Cause of Death, which has 100 percent coverage (40
). These data were linked with the Finnish Twin Cohort data. The cause of death was classified according to ICD-8 codes for 19761986 (25
) and International Classification of Diseases, Ninth Revision (ICD-9), codes for 19871995 (41
): disease mortality (codes 001799) and injury mortality (codes 800999). During the follow-up period, 1,408 deaths occurred, 974 for men and 434 for women. Of these, 1,105 (men/women, 720/385) were due to disease and 303 (254/49) were due to injury, including 125 suicides (107/18) (codes 950959).
Statistical analyses were carried out with BMDP (Statistical Software, Inc., Los Angeles, California) and SPSS (SPSS, Inc., Chicago, Illinois) computer software. The adjusted effects of life dissatisfaction on mortality were studied with Cox regression by comparing the proportional hazards of the dissatisfied (LS, 1220) and the intermediate group (LS, 711) with those of the satisfied (LS, 46). The effect of life satisfaction on mortality was also examined by using life satisfaction as both a continuous variable and a four-category variable (LS, 46, 711, 1215, and 1620). The interactions between life satisfaction and covariates in men were tested using life satisfaction with three categories.
Since 32 percent of the study subjects were age-matched siblings of another study subject, the assumption of independent observations in the analyses was not strictly true. To assess the possible bias due to twinship, we randomly selected only one member of each twin pair for separate subanalyses. In addition, the effects of life satisfaction on mortality between the singletons and the twins were compared.
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RESULTS
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The mean age at baseline was 31.8 (SD, 11.5) years for women and 31.6 (SD, 10.8) years for men. Distributions of the baseline characteristics for men and women differed significantly (p < 0.001) for all variables except for marital status (table 1). Men were less satisfied, were more often current smokers, and consumed alcohol much more than did women. The mean alcohol consumption was 391 (SD, 49.1) g/month for men and 125 (SD, 19.5) g/month for women. The mean life satisfaction score was 8.45 (SD, 2.73), but it differed significantly among the categories of all these baseline characteristics except for alcohol use in women. Better life satisfaction (i.e., a lower mean LS) was associated with being married, physically active, and a nonsmoker in both sexes and with the absence of heavy drinking in men. However, when alcohol use was used as a five-category variable (no use, 199 g, 100399 g, 400799 g,
800 g/month), the life satisfaction scores produced a j-shaped curve in both sexes, indicating better life satisfaction with low or moderate use compared with teetotalers or heavy users.
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TABLE 1. Distribution and mean life satisfaction with 95% confidence intervals (CIs) for characteristics of the study population (n = 22,461) at baseline, the Finnish Twin Cohort Study, 19761995
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After age adjustment, the dissatisfied (LS, 1220) had an increased all-cause mortality compared with the satisfied (LS, 46) in both the total study population (n = 22,461; hazard ratio (HR) = 1.74, 95 percent confidence interval (CI): 1.44, 2.09) and men (HR = 2.11, 95 percent CI: 1.68, 2.64) but not in women (table 2). After further adjustments for marital status, social class, physical activity, smoking, and alcohol use, life satisfaction still exerted an independent effect on all-cause mortality among the total study population (HR = 1.27, 95 percent CI: 1.04, 1.56) and men (HR = 1.49, 95 percent CI: 1.16, 1.92).
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TABLE 2. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for death due to any cause during 20 years related to life satisfaction* and other risk factors, the Finnish Twin Cohort Study, 19761995
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The dissatisfied (LS, 1220) had increased age-adjusted disease mortality compared with the satisfied (LS, 46) in the total study population (HR = 1.47, 95 percent CI: 1.19, 1.82) and in men (HR = 1.83, 95 percent CI: 1.40, 2.39) (table 3). After further adjustments for marital status and social class (HR = 1.58, 95 percent CI: 1.20, 2.07) or physical activity, smoking, and alcohol use (HR = 1.49, 95 percent CI: 1.12, 1.99), life satisfaction predicted male disease mortality. Moreover, when both sets of covariates were entered simultaneously with age in the model, the association persisted. A significant interaction (p = 0.03) was found between dichotomous alcohol consumption and life satisfaction in men. Dissatisfaction increased the age-adjusted risk of disease death among heavily drinking men (HR = 3.76, 95 percent CI: 1.61, 8.80) significantly more than among the other men (HR = 1.40, 95 percent CI: 1.04, 1.89). After adjustment for age, marital status, social class, smoking, and physical activity, the corresponding risks were 3.16 (95 percent CI: 1.32, 7.59) and 1.13 (95 percent CI: 0.81, 1.58).
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TABLE 3. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for disease death during 20 years related to life satisfaction* and other risk factors, the Finnish Twin Cohort Study, 19761995
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Life dissatisfaction had an adverse effect on injury mortality (table 4). Among the dissatisfied (LS, 1220), the age-adjusted risk of death from injury was significantly increased in the total study population (HR = 2.97, 95 percent CI: 2.00, 4.39) and in men (HR = 3.01, 95 percent CI: 1.94, 4.69) compared with the satisfied (LS, 46) (table 4). In addition, after all adjustments, these risks remained elevated (HR = 1.90, 95 percent CI: 1.24, 2.90 and HR = 1.93, 95 percent CI: 1.19, 3.12). In women this association was not significant.
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TABLE 4. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for injury death during 20 years related to life satisfaction* and other risk factors, the Finnish Twin Cohort Study, 19761995
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When injuries not including suicides (n = 178) were separately studied, the respective age-adjusted hazard ratios were 3.01 (95 percent CI: 1.79, 5.07) for the total study population, 2.97 (95 percent CI: 1.68, 5.24) for men, and 1.84 (95 percent CI: 0.49, 6.90) for women. After all adjustments, the hazard ratios were 2.16 (95 percent CI: 1.24, 3.77), 2.18 (95 percent CI: 1.18, 4.03), and 1.68 (95 percent CI: 0.44, 6.39), respectively.
The age-adjusted hazard ratio in men related to dissatisfaction as a continuous variable was 1.09 (95 percent CI: 1.06, 1.11) for all-cause mortality, 1.07 (95 percent CI: 1.04, 1.10) for disease mortality, and 1.13 (95 percent CI: 1.09, 1.18) for injury mortality. After all adjustments, these changed to 1.04 (95 percent CI: 1.02, 1.07), 1.03 (95 percent CI: 1.00, 1.06), and 1.08 (95 percent CI: 1.03, 1.13), respectively. A linear dose-response relation between four-category life satisfaction and mortality is shown in figure 1.

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FIGURE 1. File-adjusted mortality risk (HR) related to life satisfaction in healthy adults, the Finnish Twin Cohort Study, 19761995. Increasing score indicates descreasing life satisfaction.
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The age-adjusted effect of life satisfaction on early and late mortality in men was studied during the periods 19761985 and 19861995. The effect was not significantly different in these periods for either disease or injury mortality, with hazard ratios of 1.64 (95 percent CI: 1.21, 2.21) and 1.80 (95 percent CI: 1.43, 2.26) for disease mortality and hazard ratios of 4.25 (95 percent CI: 2.31, 7.77) and 2.59 (95 percent CI: 1.60, 4.19) for injury mortality, respectively, when the dissatisfied (LS, 1220) were compared with the satisfied (LS, 46).
When the effect of life satisfaction on mortality was studied with the study population including singletons and only one randomly sampled member of each twin pair, the age-adjusted hazard ratios for all-cause, disease, and injury mortality were 1.72 (95 percent CI: 1.34, 2.19), 1.43 (95 percent CI: 1.09, 1.89), and 3.40 (95 percent CI: 1.94, 5.99), respectively. For men these hazard ratios were 2.09 (95 percent CI: 1.55, 2.82), 1.73 (95 percent CI: 1.23, 2.45), and 3.59 (95 percent CI: 1.91, 6.73), respectively. Thus, no significant differences were found in comparison with the analyses of the total study population.
Furthermore, when the study group consisted of only the singletons, the effect of satisfaction on male mortality was not significantly different from that of the twins. However, dissatisfaction (LS, 1220) increased the risk of disease mortality among female singletons (HR = 2.28, 95 percent CI: 0.97, 5.35) but not among female twins (HR = 0.85, 95 percent CI: 0.57, 1.26). Among female twins no difference was seen by zygosity (mono-/dizygous). Furthermore, the frequency of intrapair contact (in person or by telephone) did not affect the relation between life satisfaction and mortality in female twins.
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DISCUSSION
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Our study provides prospective evidence about the ability of self-reported life satisfaction to predict mortality in a large sample of the healthy Finnish general population aged 1864 years at baseline. Dissatisfaction increased all-cause, disease, and injury mortality in a dose-response way. Adjusting for age, marital status, social class, physical activity, smoking, and alcohol use weakened this association. The main adverse effects of dissatisfaction were in male injury mortality and in disease mortality among heavily drinking men. Life satisfaction does not appear to be associated with female mortality.
Our study population originated from the Finnish Twin Cohort, which has been found to be reasonably representative of the general population of Finland with respect to sex, geographic distribution, and social class. Twins were somewhat more often unmarried and younger than the general population (21
). Moreover, the mortality among twins and the general population has been reported to be similar (42
). Since dissatisfaction similarly or more strongly predicted mortality in singletons as compared with twins, our results would appear to be generalizable to the whole population.
The strengths of this study include a large nationwide sample with a high response rate. The follow-up time was long enough for even effects with a delayed onset to become evident. The criterion of ill health was comprehensive and based on both self-reports and several national registries with high coverage and validity.
A limitation is that information on covariates such as alcohol use, smoking, and physical activity was from self-reported baseline data, and we could not take into account the changes during the follow-up period.
We studied the role of life satisfaction in mortality among healthy persons without any evidence of severe mental disorders and found that dissatisfaction was independently related to increased injury mortality. Previous findings have indicated a link between poor mental health and injuries (14
, 15
). Our study indicates that even subjectively felt life dissatisfaction (i.e., difficulty in life, unhappiness, loneliness, and a lack of interest in life) in the absence of mental disorders that have yielded to psychiatric intervention is associated with increased injury mortality, especially in men. Since heavy alcohol use (table 1) and depressive symptoms are more common among the dissatisfied than among the satisfied (Materials and Methods), they may explain part of this high mortality. Apparently, dissatisfaction may result in decreased interest in personal safety. However, the association between depression and suicide does not explain the found association between life satisfaction and injury mortality, since the association was found even after the suicides were excluded from injury deaths.
Life satisfaction was also associated with male disease mortality, though this was mainly true in heavily drinking men. Thus, heavy drinking together with poor well-being seems to be especially deleterious in men. Do heavily drinking satisfied men have more energy and interest to guard their health than the dissatisfied heavy drinkers? Dissatisfaction might also have a relation with certain specific diseases, though this possibility was not investigated in this study. This view is supported by studies that reveal a connection between depression and immunologic changes (43
) and between psychological factors (9
, 14
, 44
) and cardiovascular diseases. Clearly, this field needs more research.
We hypothesized that life satisfaction might particularly predict early injury mortality and late disease mortality, since the disease process may require several years to become fatal, whereas injury deaths do not require such a latent period. However, only a slight trend in that direction was found. Thus, it seems that life dissatisfaction has adverse effects on both disease and injury male mortality throughout the follow-up.
The finding that life satisfaction did not predict mortality in women is interesting, especially in light of the previous finding that life dissatisfaction predicts increased work disability among female twins (45
). However, this gender difference is in agreement with the finding that differences in injury mortality in Finland by social class and by marital status are clearly higher for men than for women (46
). Similarly, in earlier analyses of the current sample, hostility predicted suicide mortality among men but not among women (47
). Still, in injury mortality statistical power may be compromised by the small number of injury deaths in women. In disease mortality the increased risk was seen especially in heavy alcohol users, who are mainly men in Finland (48
). However, personal coping strategies may also play a role (49
). One could speculate that female twins may be more capable of coping with psychic distress than male twins or female singletons, thus avoiding fatal consequences. This leads us to consider the possibility that female twins have a better ability to gain social support from their twin sisters. However, life dissatisfaction did not increase disease mortality in those female twins who currently were in infrequent contact (less than weekly) with their twin sister. Intrapair interactions during childhood could not be studied with these data.
The effect of psychic well-being on health may act either through other health risk factors, independently though mediated partly by social factors and health behavior, or through unmeasured other factors such as hostility or coping strategies (47
, 49
). Like self-rated health, self-reported life satisfaction seems, thus, to provide us with important information about cumulative health risks giving, however, a better picture of mental health (16
, 30
). The use of self-reports of subjective well-being as an early indicator of poor health prognosis should be encouraged in health promotion, in injury prevention, and in clinical practice.
One can ask what is being measured by the life satisfaction scale used in this study. It seems to be related to personality because of its stability but also to depressiviness (19
, 37
). The complexities and overlap in the concepts of well-being should not keep us from studying subjective well-being. As Veenhoven stated, "We can always ask people how they feel" (50, p. 19). She focused on experiential happiness since, according to her, ". . . arbitrary definitions may reflect the investigator's ideas on what life ought to be rather than how people actually appreciate their life" (50, p. 19).
The life satisfaction scale used in the present study has previously been used in several study groups (16
, 17
, 19
, 30
) without evidence of any weaknesses that would question its use as a measure of subjective well-being. On the contrary, its brevity (four items), ease of administration, and acceptance by respondents make it useful in population studies and as a screening tool. The notion that questions concerning life satisfaction and happiness are widely accepted by people (51
, 52
) was also supported by our study. Moreover, the previous notion that subjective well-being is stable (53
) has been verified with this life satisfaction scale (16
), thus confirming the usefulness of this scale as a predictor of long-term health.
In summary, life satisfaction is not only a desired subjective feeling but also a health predictor. The relations of life dissatisfaction to increased mortality and to adverse health behavior support its use as a cumulative health risk indicator. Life satisfaction could prove useful as a research tool, in health promotion programs, and in clinical practice.
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ACKNOWLEDGMENTS
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This study was supported by the Academy of Finland (grants 38332 and 42044).
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NOTES
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Reprint requests to Dr. Heli Koivumaa-Honkanen, Department of Psychiatry, 4975 Kuopio University Hospital, P.O.B. 1777, FIN-70211 Kuopio, Finland (e-mail address: heli.koivumaa{at}kuh.fi).
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Received for publication September 21, 1999.
Accepted for publication January 27, 2000.