Cultural Engagement and Hospital-Treated Mental Disorders in Older Adults

Abstract

Importance Cultural engagement is associated longitudinally with better mental health and reduced depression incidence, but evidence has largely relied on self-reported symptoms and diagnoses, leaving uncertainty about clinically recorded disorders, and residual confounding remains a concern. Objective To examine whether cultural engagement is associated with incident hospital-treated mental disorders. Design, Setting, and Participants This prospective cohort study included adults aged 50 years and older from the English Longitudinal Study of Aging (wave 4, May 2008 to July 2009), with follow-up through March 2024. Data were analyzed from November 2025 to March 2026. Exposures Frequency of engagement with any of the receptive arts activities (ie, watching or consuming performances or exhibitions) was categorized as never, infrequent (less than once a year up to once or twice a year), or frequent (every few months up to monthly or more). Main Outcomes and Measures Participant records were linked to diagnostic codes in Hospital Episode Statistics and mortality records with follow-up of up to 20 years. The primary outcomes were mental disorders overall and 4 main mental disorders (dementia, substance misuse, mood disorders, and neurotic disorders). Cox proportional hazard regression models were used to estimate the hazard ratios (HRs) and 95% CIs, with a false discovery rate (FDR) approach for significance. To further probe causality, eye disease, ear disease, and traumatic brain injury—which share similar sociodemographic profiles to mental disorders—were prespecified as negative control outcomes. Results This study included 8274 adults (mean [SD] age, 65.4 [9.6] years; 4672 female [55.2%]). After fully adjusting for sociodemographic, lifestyle, and social factors and multiple testing, frequent cultural engagement was associated with lower risk of any mental disorders (HR, 0.71; 95% CI, 0.62-0.82; P FDR < .001), dementia (HR, 0.71; 95% CI, 0.56-0.89; FDR-adjusted P = .01), substance misuse (HR, 0.75; 95% CI, 0.59-0.95; FDR-adjusted P = .04), and mood disorders (HR, 0.73; 95% CI, 0.56-0.95; FDR-adjusted P = .04), but not neurotic disorders. Associations persisted after excluding early incident cases and adjusting for baseline depressive symptoms and cognition and showed robustness to unmeasured confounders. Cultural engagement was not associated with any negative control outcomes. Conclusions and Relevance In this nationally representative cohort of older adults, cultural engagement was associated with a lower hazard of subsequent hospital-treated mental disorders, with particularly consistent associations for dementia, substance misuse, and mood disorders. These findings provide triangulated statistical data to suggest that cultural engagement is associated with reduced risk of several clinically recorded mental disorders and support further testing of cultural engagement as a population mental health strategy.