['To investigate whether levels of psychosocial impairment and psychological distress at diagnosis in those with vasovagal syncope (VVS) predict subsequent response to conventional treatment.', 'This is a prospective, observational new patient cohort study, which includes consecutive patients with head-up tilt-confirmed VVS (September 2004-March 2006). Subjects completed the Hospital Anxiety and Depression Scale, State and trait anxiety inventory, and an Adapted Syncope Functional Status Questionnaire at diagnosis and at 3 months. A total of 108 participants [mean (SD) age 52 (21) years, 70.4% were female] completed baseline assessments. Response status was ascertained for 103 individuals; 70 were responders and 33 non-responders. Eighty-three of 103 participants (81%) completed the follow-up questionnaires. At follow-up, compared with responders, non-responders reported higher levels of Impairment (P = 0.001), negative cognitions (P = 0.01), and depression scores (P = 0.006). At diagnosis those who ultimately did not respond to treatment reported significantly higher levels of Impairment (P < 0.001) and negative cognitions (P = 0.03). Those who did not respond to treatment were significantly more depressed (P = 0.001) with higher Trait anxiety scores (P = 0.007). Multivariate analysis confirmed increased impairment predicted poor response status (z = 9.82, P = 0.002) with participants being 3% more likely to be a non-responder with each 1% increase in self-reported level of impairment.'] Does level of psychosocial impairment predict early response to treatment in vasovagal syncope?