# Physical multimorbidity and wish to die among adults aged ≥65 years: A cross-sectional analysis of the Irish Longitudinal Study on Ageing

Lee Smith, Jae-Il Shin, Josep María Haro, Louis Jacob, Guillermo Felipe

López Sánchez, Mark A. Tully, Hans Oh, Andrè Ferrer Carvalho, Yvonne

Annette Barnett, Laurie T. Butler, et al.

► To cite this version:

Lee Smith, Jae-Il Shin, Josep María Haro, Louis Jacob, Guillermo Felipe López Sánchez, et al. Physical multimorbidity and wish to die among adults aged ≥65 years: A cross-sectional analysis of the Irish Longitudinal Study on Ageing. Journal of Affective Disorders, 2022, 313, pp.263-269. 10.1016/j.jad.2022.06.063. hal-03837375

HAL Id: hal-03837375

https://hal.science/hal-03837375

Submitted on 25 Nov 2022

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
<figure><img src="image_2.png" /></figure>

# Physical multimorbidity and wish to die among adults aged ≥65 years: A cross-sectional analysis of the Irish Longitudinal Study on Ageing

Lee Smith<sup>a</sup>, Jae Il Shin<sup>b</sup>, Josep Maria Haro<sup>c</sup>, Louis Jacob<sup>c,d</sup>, Guillermo F. López Sánchez<sup>e,f</sup>, Mark A. Tully<sup>f</sup>, Hans Oh<sup>g</sup>, Andre F. Carvalho<sup>h</sup>, Yvonne Barnett<sup>a</sup>, Laurie Butler<sup>a</sup>, Ai Koyanagi<sup>c,i</sup>

<figure><img src="image_3.png" /></figure>

## ARTICLE INFO

**Keywords:**

Chronic conditions
Multimorbidity
Wish to die
Older adults
Ireland
Epidemiology

## ABSTRACT

**Background:** Physical multimorbidity (i.e., ≥2 chronic conditions) may induce feelings of wish to die (WTD), but there is limited literature on this topic, while the mediators in this association are largely unknown. Thus, the aim of the present study was to investigate this association and its mediators among older Irish adults.

**Methods:** Cross-sectional, nationally representative data from Wave 1 of the Irish Longitudinal Study on Ageing 2009–2011 were analyzed. Information on self-reported lifetime diagnosis of 14 chronic physical conditions were obtained. WTD was defined as answering affirmatively to the question “In the last month, have you felt that you would rather be dead?” Multivariable logistic regression and mediation analyses were conducted.

**Results:** Data on 2941 adults aged ≥65 years [mean (SD) age 73.2 (5.2) years; 45.0 % males] were analyzed. Physical multimorbidity was associated with 3.39 (95%CI 1.58, 7.28) times higher odds for WTD. This association was largely explained by pain (% mediated 28.1 %), followed by depression (19.4 %), sleep problems (18.4 %), perceived stress (13.0 %), loneliness (10.4 %), anxiety (8.1 %), and disability (7.2 %).

**Conclusions:** Multimorbidity was associated with increased odds for WTD among Irish older adults. Addressing the identified mediators may contribute to reducing feelings of WTD among older adults with multimorbidity.

## 1. Introduction

Wish to die (WTD), also known as passive death ideation or a death wish, involves thoughts of one's own death, that one would be better off dead, or wishing for one's death (Silverman et al., 2007). It is important to highlight that WTD is a distinct construct from suicidal ideation as it does not neccasarily involve thoughts or plans of taking one's own life (Szanto et al., 1996). WTD is a relatively new phenomenon under study and limited data exists on the concept in comparison to sucidial ideation. However, research suggests that the prevalence of WTD in the European older adult population is high. For example, in a European cohort of 6791 community-dwelling older adults (mean age 80 years) from 12

countries, the prevalence of WTD was over 12% (Stolz et al., 2016). Moreover, other research has identified that rates of WTD are higher in selected groups, such as those who utilize ageing services (O'Riley et al., 2014).

The high prevalence of WTD in old age is of concern as it has been associated with multiple negative health outcomes. For example, in one study of 1202 older adult participants from 20 US primary care practices, WTD was associated with an increased risk of 5-year mortality regardless of depressive status (adjusted hazard ratios ranging from 1.62 to 1.71) (Raue et al., 2010). Moreover, another study of older Irish adults observed that those who reported a WTD had double the risk of death from cardiovascular disease in the following 9 years (Ragab et al.,

<footnote><sup>a</sup> Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge, UK</footnote>

<footnote><sup>b</sup> Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, 8044, 120-752 Seoul, Seoul, Republic of Korea</footnote>

<footnote><sup>c</sup> Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, 08830 Barcelona, Spain</footnote>

<footnote><sup>d</sup> Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, 78000 Versailles, France</footnote>

<footnote><sup>e</sup> Division of Preventive Medicine and Public Health, Department of Public Health Sciences, School of Medicine, University of Murcia, Murcia, Spain</footnote>

<footnote><sup>f</sup> School of Health Sciences, Institute of Mental Health Sciences, Ulster University, Newtownabbey BT15 1ED, Newtownabbey, UK</footnote>

<footnote><sup>g</sup> Suzanne Dworak Peck School of Social Work, University of Southern California, Los Angeles, CA 90007, USA</footnote>

<footnote><sup>h</sup> IMPACT (Innovation in Mental and Physical Health and Clinical Treatment) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, 3220, Australia</footnote>

<footnote><sup>i</sup> ICREA, Pg. Lluis Companys 23, 08010 Barcelona, Spain</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>E-mail address: gfls@um.es (G.F. López Sánchez).</footnote>
2021). In addition, in a sample of 232 patients from an acute care in-
ternal medicine ward in a Swiss university hospital, quality of life was
negatively associated with the likelihood of WTD (OR: 0.54, 95 % CI
0.39–0.75, P < 0.001) (Bornet et al., 2020). Associations between WTD
and negative outcomes may be explained by the influence of WTD on
psychological factors and health behaviors (e.g., limited help-seeking,
self-neglect, poor treatment adherence, reduction in self-efficacy,
sense of control over self-care activities, and environmental safety)
that contribute to heightened risk of medical illnesses (Raue et al.,
2010). Owing to the high prevalence of WTD and the consequent
negative outcomes, it is of upmost importance to identify correlates of
WTD to inform targeted interventions. One potentially important but
understudied correlate is that of physical multimorbidity.

Physical multimorbidity may be defined as the presence of two or
more long-term physical health conditions (NICE | The National Insti-
tute for Health and Care Excellence, 2018). Physical multimorbidity can
feasibly be associated with WTD through several mechanisms. For
example, via physical symptoms, psychological distress (including
anxiety and depression), existential suffering and pain, social depriva-
tion, or sleep problems (Balaguer et al., 2016; Lapierre et al., 2012; Sindi
et al., 2020). However, there is limited literature on the relationship
between multimorbidity and WTD. In one study including a represen-
tative sample of community living Canadian adults aged 65 years and
over (N = 2777), an increase in one chronic condition was associated
with 1.14 (95%CI 1.04, 1.25) times higher odds for WTD (Lapierre et al.,
2012). However, the focus of this Canadian study was not specifically on
multimorbidity (i.e., ≥2 chronic conditions). To the best of our knowl-
edge, there are no other studies on chronic disease counts or multi-
morbidity and WTD. Clearly, more research is required to identify
associations between physical multimorbidity with WTD. Moreover, to
date, no study has investigated potential mediators (i.e., factors that can
be the result of multimorbidity, and also be the cause of WTD). It is
important to identify such variables as they can be targeted in in-
terventions to prevent or address WTD.

Given this background, the aim of the present study was to investi-
gate the association of individual chronic conditions and physical mul-
timorbidity with WTD, in a large representative sample of Irish adults
aged ≥65 years. A further aim was to explore to what extent sleep
problems, pain, depression, anxiety, loneliness, perceived stress, and
disability mediate the association.

## 2. Methods

### 2.1. *The survey*

We analyzed data from the first wave of the Irish Longitudinal Study on Ageing (TILDA) survey. We used data from wave 1 as it included all the variables of interest, while it is also the wave which is least biased in terms of representativeness as there is no loss to follow-up. Full details of the survey, including its sampling methods, have been described in detail elsewhere (Barrett et al., 2011; Kenny et al., 2010; Nolan et al., 2014). Briefly, this was a community-based survey of older adults residing in Ireland conducted by Trinity College Dublin. The survey was conducted between October 2009 and February 2011. The target sample consisted of all individuals living in private households aged 50 and over in Ireland. Clustered random sampling was used to obtain nationally representative samples. Specifically, the TILDA sampling frame was based on a comprehensive record of all residential addresses in Ireland. The initial sampling frame was made up of 3155 clusters (500–1180 addresses per cluster). A total of 640 clusters were randomly selected using proportionate stratification by socio-economic group (three categories) and geography. The second stage consisted of a random selection of a sample of 40 addresses from each of the 640 clusters, resulting in a total of 25,600 addresses. The survey excluded institutionalized individuals, anyone with known dementia or anyone unable to personally provide written informed consent to participate due to severe cognitive

impairment. Trained personnel conducted interviews with the use of
Computer Assisted Personal Interviewing (CAPI). For sensitive ques-
tions, participants were asked to fill in a self-completion questionnaire
(SCQ), which was returned after the interview. The response rate was 62
%, and of those who participated, 84 % returned the SCQ. Sampling
weights were generated with respect to age, sex and educational
attainment to the Quarterly National Household Survey 2010. Ethical
approval for TILDA was obtained by the Faculty of Health Sciences
Ethics Committee of Trinity College Dublin. Written informed consent
was obtained from all participants.

### 2.2. *Wish to die (WTD)*

As in previous publications using the same dataset (Briggs et al., 2021; Ragab et al., 2021), WTD was defined as answering affirmatively to the question “In the last month, have you felt that you would rather be dead?”

## 2.3. Chronic physical conditions and physical multimorbidity

Chronic physical conditions were assessed by the question “Has a
doctor ever told you that you have any of the conditions on this card?”
The total number of the following 14 conditions were summed: asthma,
arthritis, cancer, chronic lung disease (chronic bronchitis or emphy-
sema), cirrhosis, diabetes, eye disease (cataracts, glaucoma, age-related
macular degeneration, or other eye disease), heart disease (angina, heart
attack, congestive heart failure, heart murmur, abnormal heart rhythm,
or other heart disease), high cholesterol, hypertension, osteoporosis,
stomach ulcer, stroke, and varicose ulcer. Physical multimorbidity was
defined as having at least two chronic conditions, in line with previously
used definitions (Jacob et al., 2019).

## 2.4. *Mediators*

The potential mediators in the association between multimorbidity
and WTD were selected based on previous literature that suggest that
they can be the result of multimorbidity, while they can also potentially
be the cause of WTD. Specifically, potential mediators included sleep
problems, pain, depression, anxiety, loneliness, perceived stress, and
disability (Briggs et al., 2021; Lapierre et al., 2012). A composite sleep
score (range 0–7 with higher scores representing more sleep problems)
was created based on three questions on the likelihood of dozing off or
falling asleep during the day, frequency of trouble falling asleep, and
trouble with waking up too early and not being able to fall asleep again
(Scarlett et al., 2021). Those who answered affirmatively to the question
“Are you often troubled with pain?” were considered to have pain. The
scale used for depressive symptoms was the 20-item Center for Epide-
miologic Studies Depression (CES–D) (Radloff, 1977), which assesses
symptoms experienced in the seven days preceding the survey (Cron-
bach's alpha 0.88). A positive screen for depression was defined as a
cutoff score ≥ 16. This cut-off point has been associated with 100 %
sensitivity and 88 % specificity for major depression in community-
dwelling older adults (Beekman et al., 1997). Anxiety was assessed
with the anxiety subscale of the Hospital Anxiety and Depression Scale
(HADS-A) (Zigmond and Snaith, 1983) (Cronbach's alpha 0.84). A pos-
itive screen for generalized anxiety disorder was defined as a score of
≥8. This cut-off point has been associated with 89 % sensitivity and 75
% specificity for the screening of generalized anxiety disorder (Bjelland
et al., 2002; Olsson et al., 2005). The short form of the University of
California, Los Angeles (UCLA) Loneliness Scale (Russell et al., 1980)
was used to assess feelings of loneliness, and this was a scale ranging
from 3 to 9 with higher scores representing higher levels of loneliness
(Cronbach's alpha 0.82). The 4-item version of the Perceived Stress Scale
was used to assess the level of stress over the past month (Cohen et al.,
1983). This scale ranged from 0 to 16 with higher scores indicating
greater levels of perceived stress. Difficulties with six types of activities
of daily living (ADL) (dressing, walking, bathing, eating, getting in or
out of bed, and using the toilet) were assessed by asking participants to
indicate whether they had any difficulty performing these activities
(Santini et al., 2017). ADL disability was defined as having difficulty
with at least one of these ADLs.

## 2.5. Control variables

The selection of control variables was based on past literature (Huh et al., 2019), and included age, sex, education, alcohol consumption (non-drinkers, light/moderate drinkers, heavy drinkers) (Cousins et al., 2014), and smoking (never, past, current). Education was classified as: primary (some primary/not complete, primary or equivalent); secondary (intermediate/ junior/group certificate or equivalent, leaving certificate or equivalent); and tertiary (diploma/certificate, primary degree, postgraduate/higher degree).

## 2.6. Statistical analysis

The analysis was done with Stata version 14.2 (Stata Corp LP, College Station, Texas). A total of 3499 people aged ≥65 years participated in the survey. Of these individuals, 2941 returned the SCQ. We restricted our analysis to those who returned the SCQ as some information used in the current analysis were obtained via this mode (e.g., anxiety, alcohol consumption). Differences in baseline characteristics were tested by Chi-squared tests and Student's t-tests for categorical and continuous variables, respectively. Multivariable logistic regression analysis was done to assess the association of individual chronic physical conditions and physical multimorbidity (exposures) with WTD (outcome). Finally, in order to assess the degree to which the association between physical multimorbidity and WTD can be explained by sleep problems, pain, depression, anxiety, loneliness, perceived stress, and disability, we conducted mediation analysis using the khb (Karlson Holm Breen) command in Stata (Breen et al., 2013). This method can be applied in logistic regression models and decomposes the total effect (i.e., unadjusted for the mediator) of a variable into direct (i.e., the effect of multimorbidity on WTD adjusted for the mediator) and indirect effects (i.e., the mediational effect). Confidence intervals were calculated with the delta method (Sobel, 1982). Using this method, the percentage of the main association explained by the mediator can also be calculated (mediated percentage). The mediated percentage is the percent attenuation in the log odds of physical multimorbidity after the inclusion of the potential mediator in the model, compared to the model without the mediator. Details on the circumstances under which the indirect effect becomes significant are provided in the article by Kohler et al. (2011). The mediators were included individually in the models as it is possible for the mediators to be intertwined in the potential causal pathway between physical multimorbidity and WTD. For example, it is possible for physical multimorbidity to induce pain, which can cause sleep problems or perceived stress, and these factors in turn can lead to WTD. Thus, we did not adjust for other mediators in the mediation analysis to avoid overadjustment. All regression analyses including the mediation analysis were adjusted for age, sex, education, alcohol consumption, and smoking. All variables were included in the analysis as categorical variables, except for age, sleep problems, loneliness, and perceived stress. The sample weighting and the complex study design including clustering within households were taken into account to obtain nationally representative estimates using the Stata svy command. Results are expressed as odds ratios (ORs) and their 95 % confidence intervals (95%CIs). A P-value <0.05 was considered to be statistically significant.

# 3. Results

The analytical sample consisted of 2941 adults aged ≥65 years [mean (SD) age 73.2 (5.2) years; 45.0 % males]. The prevalence of WTD and physical multimorbidity were 3.3 % and 69.4 %, respectively. The

percentage of those with 2, 3, and ≥4 chronic conditions were 24.2 %, 19.1 %, and 26.1 %, respectively. The sample characteristics are provided in Table 1. The prevalence of pain, depression, anxiety, and disability were higher, and sleep problems, loneliness, and perceived stress worse in those with WTD and also among those with physical multimorbidity. People with both WTD and physical multimorbidity (vs. people with do not have both WTD and physical multimorbidity) were significantly more likely to be females, have lower levels of education, and to have smoked, with higher prevalence of pain, depression, anxiety, and depression, while they also scored worse for sleep problems, loneliness, and perceived stress (Appendix Table S1). Arthritis (39.4 %), high cholesterol (39.6 %), and hypertension (49.2 %) were the most common individual chronic conditions, while high cholesterol with hypertension (24.5 %), and arthritis with hypertension (21.8 %) were the most common pairs of chronic conditions (Table 2). In terms of individual chronic conditions, after adjustment for potential confounders, arthritis, chronic lung disease, eye disease, heart disease, hypertension, osteoporosis, stroke, and varicose ulcer were all significantly associated with increased odds for WTD (OR = 2.00-4.10) (Fig. 1). Physical multimorbidity was associated with 3.39 (95%CI 1.58, 7.28) times higher odds for WTD. Pain (%mediated 28.1 %) was the factor that explained the largest proportion of the association between physical multimorbidity and WTD, followed by depression (19.4 %), sleep problems (18.4 %), perceived stress (13.0 %), loneliness (10.4 %), anxiety (8.1 %), and disability (7.2 %) (Table 3). For example, after the inclusion of pain in the model, the OR was attenuated from OR = 3.33 (95%CI = 1.55-7.15) (total effect) to OR = 2.38 (95%CI = 1.07-5.26) (direct effect). The remaining portion of the total effect (i.e., the indirect effect) was OR = 1.40 (95%CI = 1.22-1.61), and the mediated percentage, which is derived from log odds, was 28.1 %.

# 4. Discussion

## 4.1. Main findings

In this large representative sample of Irish adults aged ≥65 years, arthritis, chronic lung disease, eye disease, heart disease, hypertension, osteoporosis, stroke, and varicose ulcer were all significantly associated with increased odds for WTD. Arthritis, high cholesterol, and hypertension were the most common individual chronic conditions in our study. Reflecting the high prevalence of these conditions, the most common combinations of chronic conditions also often included these three conditions. Physical multimorbidity (i.e., ≥2 chronic conditions) was associated with 3.39 times higher odds for WTD. Of the investigated mediating variables, pain explained the largest proportion of the association between multimorbidity and WTD (%mediated 28.1 %), followed by depression (19.4 %), sleep problems (18.4 %), perceived stress (13.0 %), loneliness (10.4 %), anxiety (8.1 %), and disability (7.2 %). To the best of our knowledge, this is the first study specifically on multimorbidity and WTD, while the identification of the mediators in this association is a particular novelty of this study.

## 4.2. Interpretation of the findings

The association between multimorbidity and WTD may be explained by the cumulative effects of individual chronic conditions on WTD. Indeed, many of the individual conditions which were associated with WTD in our study are directly associated with symptoms (e.g., functional limitation, disability), which can all lead to perceived burden, loss of meaning and purpose, hopelessness, loss of control, low self-worth (Robinson et al., 2017) and other factors that can increase risk for WTD.

In our study, pain explained nearly 30 % of the association between multimorbidity and WTD, followed by depression, and sleep problems, which explained nearly 20 % of the association each. Pain can lead to an increased risk for WTD, as patients with this condition may perceive death as the only solution to this problem (Hooley et al., 2014). For
<figure><img src="image_4.png" /><figcaption>**Fig. 1.** Association of individual chronic physical conditions and physical multimorbidity with wish to die (outcome) estimated by multivariable logistic regression</figcaption></figure>

Abbreviation: OR Odds ratio; CI Confidence interval

Models are adjusted for age, sex, education, alcohol consumption, and smoking.

Estimates for cirrhosis could not be obtained due to the small number.

<table><caption>**Table 1**
Sample characteristics (overall and by presence of wish to die or physical multimorbidity).</caption><thead><tr><th rowspan="2">Characteristic</th><th rowspan="2"></th><th rowspan="2">Overall</th><th colspan="3">Wish to die</th><th colspan="3">Physical multimorbidity</th></tr><tr><th>No (N = 3381)</th><th>Yes (N = 106)</th><th>P-value<sup>a</sup></th><th>No (N = 1126)</th><th>Yes (N = 2373)</th><th>P-value<sup>a</sup></th></tr></thead><tbody><tr><td>Age (years)</td><td>Mean (SD)</td><td>73.2 (5.2)</td><td>73.2 (5.2)</td><td>73.1 (5.1)</td><td>0.945</td><td>72.4 (5.3)</td><td>73.5 (5.1)</td><td>&lt;0.001</td></tr><tr><td rowspan="2">Sex</td><td>Female</td><td>55.0</td><td>54.7</td><td>64.0</td><td>0.095</td><td>47.1</td><td>58.5</td><td>&lt;0.001</td></tr><tr><td>Male</td><td>45.0</td><td>45.3</td><td>36.0</td><td></td><td>52.9</td><td>41.5</td><td></td></tr><tr><td rowspan="3">Education</td><td>Primary</td><td>56.9</td><td>56.3</td><td>72.9</td><td>0.003</td><td>55.1</td><td>57.6</td><td>0.371</td></tr><tr><td>Secondary</td><td>30.9</td><td>31.3</td><td>18.4</td><td></td><td>32.5</td><td>30.3</td><td></td></tr><tr><td>Tertiary</td><td>12.2</td><td>12.3</td><td>8.6</td><td></td><td>12.4</td><td>12.1</td><td></td></tr><tr><td rowspan="3">Alcohol consumption</td><td>Non-drinker</td><td>46.3</td><td>45.9</td><td>56.5</td><td>0.109</td><td>44.9</td><td>46.9</td><td>0.488</td></tr><tr><td>Light/moderate drinker</td><td>37.8</td><td>38.2</td><td>25.8</td><td></td><td>38.0</td><td>37.7</td><td></td></tr><tr><td>Heavy drinker</td><td>16.0</td><td>15.9</td><td>17.7</td><td></td><td>17.1</td><td>15.4</td><td></td></tr><tr><td rowspan="3">Smoking</td><td>Never</td><td>44.6</td><td>44.9</td><td>37.3</td><td>0.152</td><td>47.5</td><td>43.4</td><td>0.005</td></tr><tr><td>Quit</td><td>41.6</td><td>41.6</td><td>41.5</td><td></td><td>36.9</td><td>43.6</td><td></td></tr><tr><td>Current</td><td>13.8</td><td>13.5</td><td>21.1</td><td></td><td>15.7</td><td>13.0</td><td></td></tr><tr><td>Sleep problems</td><td>Mean (SD)</td><td>2.4 (1.7)</td><td>2.4 (1.6)</td><td>4.0 (1.8)</td><td>&lt;0.001</td><td>2.1 (1.6)</td><td>2.6 (1.7)</td><td>&lt;0.001</td></tr><tr><td rowspan="2">Pain</td><td>No</td><td>62.6</td><td>63.9</td><td>26.4</td><td>&lt;0.001</td><td>80.1</td><td>54.9</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>37.4</td><td>36.1</td><td>73.6</td><td></td><td>19.9</td><td>45.1</td><td></td></tr><tr><td rowspan="2">Depression</td><td>No</td><td>91.5</td><td>93.2</td><td>42.1</td><td>&lt;0.001</td><td>96.6</td><td>89.2</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>8.5</td><td>6.8</td><td>57.9</td><td></td><td>3.4</td><td>10.8</td><td></td></tr><tr><td rowspan="2">Anxiety</td><td>No</td><td>80.7</td><td>81.8</td><td>44.6</td><td>&lt;0.001</td><td>85.1</td><td>78.7</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>19.3</td><td>18.2</td><td>55.4</td><td></td><td>14.9</td><td>21.3</td><td></td></tr><tr><td>Loneliness</td><td>Mean (SD)</td><td>4.2 (1.5)</td><td>4.1 (1.5)</td><td>5.8 (1.9)</td><td>&lt;0.001</td><td>4.0 (1.5)</td><td>4.3 (1.5)</td><td>&lt;0.001</td></tr><tr><td>Perceived stress</td><td>Mean (SD)</td><td>4.2 (3.0)</td><td>4.2 (3.0)</td><td>7.3 (3.2)</td><td>&lt;0.001</td><td>3.9 (2.9)</td><td>4.4 (3.1)</td><td>&lt;0.001</td></tr><tr><td rowspan="2">Disability</td><td>No</td><td>86.0</td><td>86.6</td><td>68.0</td><td>&lt;0.001</td><td>94.1</td><td>82.4</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>14.0</td><td>13.4</td><td>32.0</td><td></td><td>5.9</td><td>17.6</td><td></td></tr></tbody></table>

Abbreviation: SD Standard deviation.

Data are % unless otherwise stated.

Ns are unweighted figures.

example, it has been observed that chronic pain can engender hopelessness, facilitate a desire for escape through death, and erode the natural fear of dying (Hooley et al., 2014). Depression is common in people with multimorbidity (Read et al., 2017), and multimorbidity may lead to depression through factors such as increasing symptom burden, disability, decreasing quality of life, pain, beliefs about disease, and coping style (Read et al., 2017). Depression is likely associated with WTD owing to anhedonia (i.e., lack of joy and pleasure), cognitive

impairment (e.g., ability to concentrate), and hopelessness (e.g., unpleasant future expectations), as well as feelings of worthlessness and guilt (Pompili, 2019).

Previous studies have shown that sleep problems are common in people with multimorbidity due to factors such as anxiety, stress, depression, or the symptoms per se (e.g., pain, nocturia in diabetes, and breathing problems in chronic lung disease) (Charles et al., 2011; Cheatle et al., 2016; Ferguson et al., 2020; Nutt et al., 2008; Ronaldson

<footnote><sup>a</sup> P-values were obtained by Chi-squared tests and Student's t-tests for categorical and continuous variables, respectively.</footnote>
<table><caption>**Table 2**
Prevalence of chronic physical diseases and each pair of chronic physical diseases.</caption><thead><tr><th></th><th>Prevalence (%)</th><th>Arthritis</th><th>Asthma</th><th>Cancer</th><th>Chronic lung disease</th><th>Cirrhosis</th><th>Diabetes</th><th>Eye disease</th><th>Heart disease</th><th>High cholesterol</th><th>Hypertension</th><th>Osteoporosis</th><th>Stomach ulcer</th><th>Stroke</th></tr></thead><tbody><tr><td>Arthritis</td><td>39.35</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Asthma</td><td>9.68</td><td>4.76</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Cancer</td><td>8.19</td><td>3.32</td><td>0.85</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Chronic lung disease</td><td>5.34</td><td>2.51</td><td>1.59</td><td>0.64</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Cirrhosis</td><td>0.46</td><td>0.29</td><td>0.04</td><td>0.03</td><td>0.05</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Diabetes</td><td>10.85</td><td>4.22</td><td>1.33</td><td>0.87</td><td>0.43</td><td>0.07</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Eye disease</td><td>29.19</td><td>13.85</td><td>3.51</td><td>2.95</td><td>2.12</td><td>0.14</td><td>3.88</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Heart disease</td><td>27.89</td><td>13.37</td><td>3.43</td><td>2.30</td><td>2.04</td><td>0.12</td><td>4.00</td><td>10.34</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>High cholesterol</td><td>39.56</td><td>18.39</td><td>3.98</td><td>3.92</td><td>2.56</td><td>0.29</td><td>5.27</td><td>12.56</td><td>13.76</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Hypertension</td><td>49.24</td><td>21.84</td><td>5.25</td><td>4.56</td><td>2.76</td><td>0.21</td><td>7.08</td><td>15.91</td><td>15.55</td><td>24.48</td><td></td><td></td><td></td><td></td></tr><tr><td>Osteoporosis</td><td>13.10</td><td>6.78</td><td>2.25</td><td>1.20</td><td>1.32</td><td>0.12</td><td>0.72</td><td>5.20</td><td>3.16</td><td>6.43</td><td>5.82</td><td></td><td></td><td></td></tr><tr><td>Stomach ulcer</td><td>6.97</td><td>3.41</td><td>1.01</td><td>0.79</td><td>0.50</td><td>0.07</td><td>0.74</td><td>1.95</td><td>2.71</td><td>3.18</td><td>3.78</td><td>1.26</td><td></td><td></td></tr><tr><td>Stroke</td><td>2.61</td><td>0.93</td><td>0.24</td><td>0.21</td><td>0.31</td><td>0.03</td><td>0.44</td><td>0.71</td><td>1.23</td><td>1.23</td><td>1.78</td><td>0.24</td><td>0.08</td><td></td></tr><tr><td>Varicose ulcer</td><td>5.43</td><td>2.97</td><td>0.85</td><td>0.66</td><td>0.38</td><td>0.08</td><td>0.56</td><td>2.47</td><td>1.80</td><td>2.08</td><td>3.04</td><td>1.09</td><td>0.45</td><td>0.13</td></tr></tbody></table>

<table><caption>**Table 3**
Mediators in the association between physical multimorbidity and wish to die.</caption><thead><tr><th>Mediator</th><th>Effect</th><th>OR [95%CI]</th><th>P-value</th><th>%Mediated</th></tr></thead><tbody><tr><td rowspan="3">Sleep problems</td><td>Total</td><td>3.29 [1.50,7.19]</td><td>0.003</td><td rowspan="3">18.4</td></tr><tr><td>Direct</td><td>2.64 [1.22,5.70]</td><td>0.013</td></tr><tr><td>Indirect</td><td>1.25 [1.12,1.38]</td><td>&lt;0.001</td></tr><tr><td rowspan="3">Pain</td><td>Total</td><td>3.33 [1.55,7.15]</td><td>0.002</td><td rowspan="3">28.1</td></tr><tr><td>Direct</td><td>2.38 [1.07,5.26]</td><td>0.033</td></tr><tr><td>Indirect</td><td>1.40 [1.22,1.61]</td><td>&lt;0.001</td></tr><tr><td rowspan="3">Depression</td><td>Total</td><td>2.91 [1.25,6.75]</td><td>0.013</td><td rowspan="3">19.4</td></tr><tr><td>Direct</td><td>2.36 [1.02,5.47]</td><td>0.044</td></tr><tr><td>Indirect</td><td>1.23 [1.15,1.32]</td><td>&lt;0.001</td></tr><tr><td rowspan="3">Anxiety</td><td>Total</td><td>2.96 [1.37,6.41]</td><td>0.006</td><td rowspan="3">8.1</td></tr><tr><td>Direct</td><td>2.71 [1.25,5.87]</td><td>0.011</td></tr><tr><td>Indirect</td><td>1.09 [1.03,1.16]</td><td>0.004</td></tr><tr><td rowspan="3">Loneliness</td><td>Total</td><td>3.32 [1.48,7.42]</td><td>0.004</td><td rowspan="3">10.4</td></tr><tr><td>Direct</td><td>2.93 [1.32,6.50]</td><td>0.008</td></tr><tr><td>Indirect</td><td>1.13 [1.05,1.22]</td><td>0.001</td></tr><tr><td rowspan="3">Perceived stress</td><td>Total</td><td>2.96 [1.33,6.59]</td><td>0.008</td><td rowspan="3">13.0</td></tr><tr><td>Direct</td><td>2.57 [1.17,5.61]</td><td>0.018</td></tr><tr><td>Indirect</td><td>1.15 [1.06,1.26]</td><td>0.001</td></tr><tr><td rowspan="3">Disability</td><td>Total</td><td>3.34 [1.55,7.19]</td><td>0.002</td><td rowspan="3">7.2</td></tr><tr><td>Direct</td><td>3.06 [1.40,6.70]</td><td>0.005</td></tr><tr><td>Indirect</td><td>1.09 [1.02,1.17]</td><td>0.013</td></tr></tbody></table>

Abbreviation: OR Odds ratio; CI Confidence interval.
Models are adjusted for age, sex, education, alcohol consumption, and smoking.

et al., 2021; Sleep Foundation, 2020; Stubbs et al., 2018). In turn, sleep problems can increase risk for WTD, for example, through emotional dysregulation enhancing sleep difficulties, which can further enhance emotional problems, or genetic vulnerability: the same genes are involved in the regulation of circadian rhythm and in affective disorders (Koyanagi and Stickley, 2015; Mirsu-Paun et al., 2017). Moreover, reduced sleep time has been associated with impaired decision making (McCall and Black, 2013). In particular, insomnia is associated with deficient problem-solving capacity, especially when involving complex tasks.

Other potential mediators identified in our study but which had less influence in the multimorbidity-WTD association include perceived stress, loneliness, anxiety, and disability.

Loneliness in people with multimorbidity may be common. Indeed, a previous study found that levels of social participation in people with multimorbidity is low, possibly due to factors such as limitations in physical function, pain, and discomfort (Ma et al., 2021), and this may result in feeling of loneliness. Furthermore, increased stress and anxiety

may arise not only from the distressing symptoms of chronic conditions but also by other factors such as increased costs and complexity of care to treat multiple conditions. In turn, anxiety and stress may result in higher odds of WTD owing to mechanisms such as central neurotransmitter system dysfunction including dopamine, norepinephrine and serotonin (Grippo and Johnson, 2009).

### 4.3. Implications of the study findings

Findings from the present study indicate that people with multimorbidity are much more likely to have WTD compared to those without multimorbidity. Health care workers should be aware of this, and screening for WTD and addressing the potential mediators assessed in our study may be important in reducing WTD among people with multimorbidity. In our study, pain, sleep problems, and depression were identified as the most important mediators.

Non-pharmacological interventions for these conditions may be ideal for people with multimorbidity as polypharmacy is already common. For example, physical activity interventions have been shown to be efficacious in pain management (Geneen et al., 2017), and these may also reduce feelings or loneliness as well as stress, sleep problems, anxiety and depression, which were also identified as significant mediators in the physical multimorbidity/WTD relationship (Smith and Merwin, 2021). Moreover, evidence suggests that mind-body exercises may be most efficacious and have been shown to be feasible among those with chronic conditions (Salmoirago-Blotcher et al., 2017). Furthermore, cognitive behavioral therapy, mindfulness training, and relaxation have been shown to be beneficial in the management of mental health complications (Gautam et al., 2020) and addressing sleep problems (McCurry et al., 2015), and thus may form a beneficial component for an intervention to prevent or manage WTD among those with physical multimorbidity.

### 4.4. Strengths and limitations

The large representative sample of older Irish adults and the identification of mediating variables in the physical multimorbidity/WTD relationship are key strengths of the present study. However, findings must be interpreted considering the study limitations. First, the study was cross-sectional in nature, and thus the direction of the association cannot be determined. Future research of a longitudinal nature is required to confirm the direction of the association. Second, most variables were self-reported, and thus, reporting bias (e.g., social
desirability, recall bias) may have been introduced. Third, we were unable to assess the mediating effect of social deprivation due to lack of data, despite the fact that this can theoretically be a potential mediator. This is an area for future research. Next, it is possible for the mediating effect to be an overestimation given the various ways in which multimorbidity, WTD, and the mediators can be linked. Finally, the list of chronic conditions included conditions that are common in old age, but the results of the study could have differed with the use of a different set of chronic conditions.

## 5. Conclusions

Physical multimorbidity was associated with a more than three-fold increased risk for WTD among older Irish adults, and this association was mediated by factors such as pain, sleep problems, and depression. Future longitudinal and intervention studies are warranted to clarify temporal associations and the impact of addressing the identified mediators on WTD among people with physical multimorbidity.

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jad.2022.06.063.

## Contributors

All authors have made a substantial, direct and intellectual contribution to the work. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors.

## Role of the Funding source

Dr. Guillermo F. López Sánchez is funded by the European Union – Next Generation EU.

## Ethics

Ethical approval for TILDA was obtained by the Faculty of Health Sciences Ethics Committee of Trinity College Dublin. Written informed consent was obtained from all participants.

## Conflict of Interest

The authors wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.

## Acknowledgements

Researchers interested in using TILDA data may access the data for free from the following sites: Irish Social Science Data Archive (ISSDA) at University College Dublin http://www.ucd.ie/issa/data/tilda/; Interuniversity Consortium for Political and Social Research (ICPSR) at the University of Michigan (Kenny, 2014).

## References

Balaguer, A., Monforte-Royo, C., Porta-Sales, J., Alonso-Babarro, A., Altisent, R., Aradilla-Herrero, A., Bellido-Pérez, M., Brexitart, W., Centeno, C., Cuervo, M.A., 2016. An international consensus definition of the wish to hasten death and its related factors. PLoS One 11, e0146184.

Barrett, A., Burke, H., Cronin, H., Hickey, A., Kamiya, Y., Kenny, R.A., Layte, R., Maty, S., McGee, H., Morgan, K., 2011. Fifty Plus in Ireland 2011: First Results From the Irish Longitudinal Study on Ageing (TILDA).

Beekman, A.T., Deeg, D., Van Limbeek, J., Braam, A.W., De Vries, M.Z., Van Tilburg, W., 1997. Brief communication.: criterion validity of the Center for Epidemiologic Studies Depression scale (CES-D): results from a community-based sample of older subjects in the Netherlands. Psychol. Med. 27, 231–235.

Bjelland, I., Dahl, A.A., Haug, T.T., Neckelmann, D., 2002. The validity of the hospital anxiety and depression scale: an updated literature review. J. Psychosom. Res. 52, 69–77.

Bornet, M., Rubli Truchard, E., Waeber, G., Vollenweider, P., Bernard, M., Schmied, L., Marques-Vidal, P., 2020. Life worth living: cross-sectional study on the prevalence and determinants of the wish to die in elderly patients hospitalized in an internal medicine ward. BMC Geriatr. 20, 1–9.

Breen, R., Karlson, K.B., Holm, A., 2013. Total, direct, and indirect effects in logit and probit models. Sociol. Methods Res. 42, 164–191.

Briggs, R., Ward, M., Kenny, R.A., 2021. The 'Wish to Die' in later life: prevalence, longitudinal course and mortality. Data from TILDA. Age Ageing 50 (4), 1321–1328. https://doi.org/10.1093/ageing/afab010.

Charles, L.E., Slaven, J.E., Mnatsakanova, A., Ma, C., Violanti, J.M., Fekedulegn, D., Andrew, M.E., Vila, B.J., Burchfiel, C.M., 2011. Association of perceived stress with sleep duration and sleep quality in police officers. Int. J. Emerg. Ment. Health 13, 229.

Cheatle, M.D., Foster, S., Pinkett, A., Lesneski, M., Qu, D., Dhingra, L., 2016. Assessing and managing sleep disturbance in patients with chronic pain. Anesthesiol. Clin. 34, 379–393.

Cohen, S., Kamarck, T., Mermelstein, R., 1983. A global measure of perceived stress. J. Health Soc. Behav. 24.

Cousins, G., Galvin, R., Flood, M., Kennedy, M., Motterlini, N., Henman, M.C., Kenny, R., Fahey, T., 2014. Potential for alcohol and drug interactions in older adults: evidence from the irish longitudinal study on ageing. BMC Geriatr. 14, 1–10.

Ferguson, M., Svendrovski, A., Katz, J., 2020. Association between multimorbid disease patterns and pain outcomes among a complex chronic care population in Canada. J Pain Res. 13, 3045.

Gautam, M., Tripathi, A., Deshmukh, D., Gaur, M., 2020. Cognitive behavioral therapy for depression. Indian J. Psychiatry 62, S223.

Geneen, L.J., Moore, R.A., Clarke, C., Martin, D., Colvin, L.A., Smith, B.H., 2017. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst. Rev. (4), CD011279 https://doi.org/10.1002/14651858. CD011279.pub3. Accessed 04 July 2022.

Grippo, A.J., Johnson, A.K., 2009. Stress, depression and cardiovascular dysregulation: a review of neurobiological mechanisms and the integration of research from preclinical disease models. Stress 12, 1–21.

Hooley, J.M., Franklin, J.C., Nock, M.K., 2014. Chronic pain and suicide: understanding the association. Curr. Pain Headache Rep. 18, 435.

Huh, Y., Nam, G.E., Kim, Y., Lee, J.H., 2019. Relationships between multimorbidity and suicidal thoughts and plans among korean adults. J. Clin. Med. 8, 1094.

Jacob, L., Haro, J.M., Koyanagi, A., 2019. Physical multimorbidity and subjective cognitive complaints among adults in the United Kingdom: a cross-sectional community-based study. Sci. Rep. 9, 1–11.

Kenny, R.A., 2014. In: The Irish Longitudinal Study on Ageing (TILDA), 2009-2011. ICPSR34315-v1. Interuniversity Consortium for Political and Social Research, Ann Arbor, MI, p. 7 [distributor].

Kenny, R.A., Whelan, B.J., Cronin, H., Kamiya, Y., Kearney, P., O'Regan, C., Ziegel, M., 2010. The Design of the Irish Longitudinal Study on Ageing.

Kohler, U., Karlson, K.B., Holm, A., 2011. Comparing coefficients of nested nonlinear probability models. Stata J. 11, 420–438.

Koyanagi, A., Stickley, A., 2015. The association between sleep problems and psychotic symptoms in the general population: a global perspective. Sleep 38, 1875–1885.

Lapierre, S., Boyer, R., Desjardins, S., Dubé, M., Lorrain, D., Prévillé, M., Brassard, J., 2012. Daily hassles, physical illness, and sleep problems in older adults with wishes to die. Int. Psychogeriatr. 24, 243–252.

Ma, R., Romano, E., Vancampfort, D., Firth, J., Stubbs, B., Koyanagi, A., 2021. Physical multimorbidity and social participation in adult aged 65 years and older from six low-and middle-income countries. J. Gerontol. Ser. B 76, 1452–1462.

McCall, W.V., Black, C.G., 2013. The link between suicide and insomnia: theoretical mechanisms. Curr. Psychiatry Rep. 15, 389.

McCurry, S.M., Song, Y., Martin, J.L., 2015. Sleep in caregivers: what we know and what we need to learn. Curr. Opin. Psychiatry 28, 497–503.

Mirsu-Paun, A., Jaussent, I., Komar, G., Courtet, P., Lopez-Castroman, J., 2017. Sleep complaints associated with wish to die after a suicide crisis—an exploratory study. J. Sleep Res. 26, 726–731.

NICE | The National Institute for Health and Care Excellence, 2018. Multimorbidity. 2021.

Nolan, A., O'Regan, C., Dooley, C., Wallace, D., Hever, A., Cronin, H., Hudson, E., Kenny, R.A., 2014. The Over 50s in a Changing Ireland: Economic Circumstances, Health and Well-being. The Irish Longitudinal Study on Ageing, Dublin: Trinity College.

Nutt, D., Wilson, S., Paterson, L., 2008. Sleep disorders as core symptoms of depression. Dialogues Clin. Neurosci. 10, 329.

Olsson, I., Mykletun, A., Dahl, A.A., 2005. The hospital anxiety and depression rating scale: a cross-sectional study of psychometrics and case finding abilities in general practice. BMC Psychiatry 5, 1–7.

O'Riley, A.A., Van Orden, K.A., He, H., Richardson, T.M., Podgorski, C., Conwell, Y., 2014. Suicide and death ideation in older adults obtaining aging services. Am. J. Geriatr. Psychiatry 22, 614–622.

Pompili, M., 2019. Critical appraisal of major depression with suicidal ideation. Ann. General Psychiatry 18, 1–5.

Radloff, L.S., 1977. The CES-D scale: a self-report depression scale for research in the general population. Appl. Psychol. Meas. 1, 385–401.

Ragab, I., Ward, M., Moloney, D., Kenny, R.A., Briggs, R., 2021. 'Wish to die' is independently associated with cardiovascular mortality in later life. Data from TILDA. Int. J. Geriatr. Psychiatry 36, 1004–1010.
Raue, P.J., Morales, K.H., Post, E.P., Bogner, H.R., Ten Have, T., Bruce, M.L., 2010. The wish to die and 5-year mortality in elderly primary care patients. Am. J. Geriatr. Psychiatry 18, 341-350.

Read, J.R., Sharpe, L., Modini, M., Dear, B.F., 2017. Multimorbidity and depression: a systematic review and meta-analysis. J. Affect. Disord. 221, 36-46.

Robinson, S., Kissane, D.W., Brooker, J., Hempton, C., Burney, S., 2017. The relationship between poor quality of life and desire to hasten death: a multiple mediation model examining the contributions of depression, demoralization, loss of control, and low self-worth. J. Pain Symptom Manag. 53, 243-249.

Ronaldson, A., de la Torre, Arias, Jorge, Prina, M., Das-Munshi, J., Hatch, S., Stewart, R., Hotopf, M., Dregan, A., Armstrong, D., 2021. Associations between physical multimorbidity patterns and common mental health disorders in middle-aged adults: a prospective analysis using data from the UK Biobank. Lancet Reg. Health-Europe 8, 100149.

Russell, D., Peplau, L.A., Cutrona, C.E., 1980. The revised UCLA loneliness scale: concurrent and discriminant validity evidence. J. Pers. Soc. Psychol. 39, 472.

Salmoirago-Blotcher, E., Wayne, P.M., Dunsiger, S., Krol, J., Breault, C., Bock, B.C., Wu, W., Yeh, G.Y., 2017. Tai chi is a promising exercise option for patients with coronary heart disease declining cardiac rehabilitation. J. Am. Heart Assoc. 6, e006603.

Santini, Z.I., Nielsen, L., Hinrichsen, C., Tolstrup, J.S., Vinther, J.L., Koyanagi, A., Donovan, R.J., Koushede, V., 2017. The association between act-belong-commit indicators and problem drinking among older Irish adults: findings from a prospective analysis of the Irish longitudinal study on ageing (TILDA). Drug Alcohol Depend. 180, 323-331.

Scarlett, S., Kenny, R.A., O'Connell, M.D., Nolan, H., De Looze, C., 2021. Associations between cognitive function, actigraphy-based and self-reported sleep in older community-dwelling adults: findings from the Irish longitudinal study on ageing. Int. J. Geriatr. Psychiatry 36, 731-742.

Silverman, M.M., Berman, A.L., Sanddal, N.D., O'carroll, P.W., Joiner Jr., T.E., 2007. Rebuilding the tower of babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 2: suicide-related ideations, communications, and behaviors. Suicide Life Threat. Behav. 37, 264-277.

Sindi, S., Pérez, L.M., Vetrano, D.L., Triolo, F., Kåreholt, I., Sjöberg, L., Darin-Mattsson, A., Kivipelto, M., Inzitari, M., Calderón-Larrañaga, A., 2020. Sleep disturbances and the speed of multimorbidity development in old age: results from a longitudinal population-based study. BMC Med. 18, 1-10.

Sleep Foundation, 2020. Anxiety and Sleep. 2021.

Smith, P.J., Merwin, R.M., 2021. The role of exercise in management of mental health disorders: an integrative review. Annu. Rev. Med. 72, 45-62.

Sobel, M.E., 1982. Asymptotic confidence intervals for indirect effects in structural equation models. Sociol. Methodol. 13, 290-312.

Stolz, E., Fux, B., Mayerl, H., Rásky, É., Freidl, W., 2016. Passive suicide ideation among older adults in Europe: a multilevel regression analysis of individual and societal determinants in 12 countries (SHARE). J. Gerontol. B Psychol. Sci. Soc. Sci. 71, 947-958.

Stubbs, B., Vancampfort, D., Veronese, N., Schofield, P., Lin, P., Tseng, P., Solmi, M., Thompson, T., Carvalho, A.F., Koyanagi, A., 2018. Multimorbidity and perceived stress: a population-based cross-sectional study among older adults across six low- and middle-income countries. Maturitas 107, 84-91.

Szanto, K., Reynolds III, C.F., Frank, E., Stack, J., Fasiczka, A.L., Miller, M., Mulsant, B. H., Mazumdar, S., Kupfer, D.J., 1996. Suicide in elderly depressed patients: is active vs. passive suicidal ideation a clinically valid distinction? Am. J. Geriatr. Psychiatry 4, 197-207.

Zigmond, A.S., Snaith, R.P., 1983. The hospital anxiety and depression scale. Acta Psychiatr. Scand. 67, 361-370.