Carrière et al’s study shows an interesting association between anxiety and mortality in elderly women.^{Reference Carrière, Ryan, Norton, Scali, Stewart and Ritchie1} The authors propose a series of possible biological mechanisms for this association, suggesting a direction of causality in which mortality is the consequence of the impact that anxiety has on the endocrine and cardiovascular systems. However, anxiety can be the psychiatric expression of vascular changes in the brain that may eventually lead to death. Failing health in old age is also a painful reminder of the proximity of death, which will frequently induce feelings of anxiety in the individual. The fact that this association was only significant for women could be an artefact due to the much higher prevalence of anxiety among women. Thus, anxiety may well be - at least in a proportion of the cases - the consequence, rather than the cause of ill health.