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Life-Weariness, Wish to Die, Active Suicidal Ideation, and All-Cause Mortality in Population-Based Samples of Older Adults

  • Mattias Jonson
    Correspondence
    Send correspondence and reprint requests to Mattias Jonson, M.D., Department of Psychiatry and Neurochemistry, University of Gothenburg Institute of Neuroscience and Physiology, Wallinsgatan 6, 431 41 Mölndal, Sweden.
    Affiliations
    Center for Ageing and Health (Age Cap), Department of Psychiatry and Neurochemistry (MJ, RS, MMF, IS,MW), Gothenburg University, Gothenburg, Sweden

    Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, (MJ, RS, MMF,MW), University of Gothenburg, Sweden

    Region Västra Götaland, Sahlgrenska University Hospital, Department of Affective Psychiatry, (MJ) Gothenburg, Sweden
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  • Robert Sigström
    Affiliations
    Center for Ageing and Health (Age Cap), Department of Psychiatry and Neurochemistry (MJ, RS, MMF, IS,MW), Gothenburg University, Gothenburg, Sweden

    Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, (MJ, RS, MMF,MW), University of Gothenburg, Sweden

    Region Västra Götaland, Sahlgrenska University Hospital, Department of Cognition and Old Age Psychiatry, (RS, IS), Gothenburg, Sweden
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  • Kimberly A. Van Orden
    Affiliations
    School of Medicine and Dentistry, (KAVO), University of Rochester Medical Center
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  • Madeleine Mellqvist Fässberg
    Affiliations
    Center for Ageing and Health (Age Cap), Department of Psychiatry and Neurochemistry (MJ, RS, MMF, IS,MW), Gothenburg University, Gothenburg, Sweden

    Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, (MJ, RS, MMF,MW), University of Gothenburg, Sweden
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  • Ingmar Skoog
    Affiliations
    Center for Ageing and Health (Age Cap), Department of Psychiatry and Neurochemistry (MJ, RS, MMF, IS,MW), Gothenburg University, Gothenburg, Sweden

    Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, (MJ, RS, MMF,MW), University of Gothenburg, Sweden

    Region Västra Götaland, Sahlgrenska University Hospital, Department of Cognition and Old Age Psychiatry, (RS, IS), Gothenburg, Sweden
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  • Margda Waern
    Affiliations
    Center for Ageing and Health (Age Cap), Department of Psychiatry and Neurochemistry (MJ, RS, MMF, IS,MW), Gothenburg University, Gothenburg, Sweden

    Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, (MJ, RS, MMF,MW), University of Gothenburg, Sweden

    Region Västra Götaland, Sahlgrenska University Hospital, Psychosis Department, (MW), Gothenburg, Sweden
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Open AccessPublished:October 20, 2022DOI:https://doi.org/10.1016/j.jagp.2022.10.003

      Highlights

      • What is the primary question addressed by this study?
      • Are different levels of passive and active suicidal ideation differently associated with all-cause mortality in older adults?
      • What is the main finding of this study?
      • A wish to die, but neither life-weariness nor active suicidal ideation was associated with increased all-cause mortality.
      • What is the meaning of the finding?
      • A wish to die may be a more important marker of mortality risk than other levels of suicidal ideation in older adults.

      ABSTRACT

      Objectives

      To investigate potential differences in the strength of associations between different levels of passive and active suicidal ideation and all-cause mortality in older adults.

      Design

      Prospective cohort study.

      Setting

      Population-based samples of older adults in Gothenburg, Sweden.

      Participants

      Older adults aged 79 and above who participated in any wave of the Gothenburg H70 Birth Cohort Studies or the Prospective Population Study of Women between 1986 and 2015 (n = 2,438; 1,737 women, 701 men; mean age 86.6).

      Measurements

      Most intense level of passive or active suicidal ideation during the past month: life-weariness, wish to die, or active suicidal ideation. The outcome was all-cause mortality over 3 years.

      Results

      During follow-up, 672 participants (27.6%) died. After adjustments for sex, age, and year of examination, participants who reported a wish to die (HR 2.01; 95% CI 1.55–2.60) as the most intense level of ideation, but not participants who reported life-weariness (HR 1.40; 95% CI 0.88–2.21) or active suicidal ideation (HR 1.10; 95% CI 0.69–1.76) were at increased risk of all-cause mortality. Reporting a wish to die remained associated with mortality in a fully adjusted model, including somatic conditions, dementia, depression, and loneliness (HR 1.70; 95% CI 1.27–2.26).

      Conclusion

      In older adults, reporting a wish to die appears to be more strongly associated with all-cause mortality than either life-weariness or active suicidal ideation

      Key Words

      OBJECTIVE

      Suicidal ideation can be conceptualized as varying along a continuum,
      • Paykel ES
      • Myers JK
      • Lindenthal JJ
      • et al.
      Suicidal feelings in the general population: a prevalence study.
      from life-weariness (feeling that life is not worth living), to a wish to die, to thoughts of actively ending one's life (active suicidal ideation). Different forms of suicidal ideation have been associated with all-cause mortality. A wish to die or active suicidal ideation was associated with a 35% increase in mortality in an Australian population sample of older adults.
      • Batterham PJ
      • Calear AL
      • Mackinnon AJ
      • et al.
      The association between suicidal ideation and increased mortality from natural causes.
      The increased risk was attenuated to 23% after adjusting for demographics, physical and mental health at baseline. Similar results were found in a recent Irish study on adults over the age of 50.
      • Ragab I
      • Ward M
      • Moloney D
      • et al.
      'Wish to die' is independently associated with cardiovascular mortality in later life. Data from TILDA.
      In a clinical sample of middle-aged veterans from the United States, the higher all-cause mortality among suicide ideators was not explained by differences in physical or mental health, nor by differential suicide rates.
      • Shiner B
      • Riblet N
      • Westgate CL
      • et al.
      Suicidal ideation is associated with all-cause mortality.
      Studies that have shown associations between suicidal ideation and mortality have defined suicidal ideation in various ways: Life-weariness, a wish to die, or active suicidal ideation,
      • Skoog I
      • Aevarsson O
      • Beskow J
      • et al.
      Suicidal feelings in a population sample of nondemented 85-year-olds.
      life-weariness or active suicidal ideation,
      • Fagerström C
      • Welmer AK
      • Elmståhl S
      • et al.
      Life weariness, suicidal thoughts and mortality: a sixteen-year longitudinal study among men and women older than 60 years.
      wish to die,
      • Ragab I
      • Ward M
      • Moloney D
      • et al.
      'Wish to die' is independently associated with cardiovascular mortality in later life. Data from TILDA.
      ,
      • Macdonald AJ
      • Dunn G
      Death and the expressed wish to die in the elderly: an outcome study.
      • Ashby D
      • Ames D
      • West RC
      • et al.
      Psychiatric morbidity as predictor of mortality for residents of local authority homes for the elderly.
      • Dewey ME
      • Davidson IA
      • Copeland JR
      Expressed wish to die and mortality in older people: a community replication.
      • Raue PJ
      • Morales KH
      • Post EP
      • et al.
      The wish to die and 5-year mortality in elderly primary care patients.
      wish to die or active suicidal ideation,
      • Batterham PJ
      • Calear AL
      • Mackinnon AJ
      • et al.
      The association between suicidal ideation and increased mortality from natural causes.
      and active suicidal ideation.
      • Shiner B
      • Riblet N
      • Westgate CL
      • et al.
      Suicidal ideation is associated with all-cause mortality.
      ,
      • Khang YH
      • Kim HR
      • Cho SJ
      Relationships of suicide ideation with cause-specific mortality in a longitudinal study of South Koreans.
      Research comparing levels of passive or active suicidal ideation in their association with all-cause mortality is scarce. Skoog et al.
      • Skoog I
      • Aevarsson O
      • Beskow J
      • et al.
      Suicidal feelings in a population sample of nondemented 85-year-olds.
      found that 85-year-olds with life-weariness or a wish to die had increased mortality but not those with active ideation, but only 15 participants reported active ideation in that study. Raue et al.
      • Raue PJ
      • Morales KH
      • Post EP
      • et al.
      The wish to die and 5-year mortality in elderly primary care patients.
      found no difference in mortality between participants with a wish to die and participants with a suicidal desire, but only 13 participants reported a suicidal desire. Shiner et al.
      • Shiner B
      • Riblet N
      • Westgate CL
      • et al.
      Suicidal ideation is associated with all-cause mortality.
      found a non-significant tendency of higher all-cause mortality with increasing intensity of suicidal ideation, but only 23 participants reported the most intense level.
      As previous research is inconclusive, further investigation of the association between suicidal ideation and mortality might shed more light on mechanisms. While it is possible that there is a dose-response relationship, with higher mortality as the severity of suicidal ideation increases, various types of ideation might be differentially associated with mortality, in a non-ordinal manner. We aimed to investigate this in a large, population-representative sample of older adults. A secondary aim was to examine possible confounders. We hypothesized that the highest mortality would be observed among those with the most severe suicidal ideation. Further, we hypothesized that differential mortality rates would be partly accounted for by demographic and psychosocial factors, and mental, and physical health.

      METHODS

      Sample

      We drew participants, 79 years and older, from all examination waves of the Gothenburg H70 Birth Cohort Studies and the Prospective Population study of Women between 1986 and 2015 (Fig. 1). Examination procedures have been extensively described previously.
      • Rinder L
      • Roupe S
      • Steen B
      • et al.
      Seventy-year-old people in Gothenburg. A population study in an industrialized Swedish city.
      ,
      • Bengtsson C
      • Ahlqwist M
      • Andersson K
      • et al.
      The prospective population study of women in gothenburg, sweden, 1968-69 to 1992-93. A 24-year follow-up study with special reference to participation, representativeness, and mortality.
      Briefly, we invited persons living in both private households and in institutions, who were born on specific days each month, yielding a systematic population sample. Participation rates varied between 57.9% and 73.4% across waves.
      • Fassberg MM
      • Vanaelst B
      • Jonson M
      • et al.
      Epidemiology of suicidal feelings in an ageing Swedish population: from old to very old age in the Gothenburg H70 birth cohort studies.
      ,
      • Jonson M
      • Sigström R
      • Mellqvist-Fässberg M
      • et al.
      Passive and active suicidal ideation in Swedish 85-year-olds: time trends 1986-2015.
      Eleven examination waves, including 3,264 unique participants aged 79 years or older, took place between 1986 and 2015. For participants who had more than one examination (e.g. examined at ages 79 and 85) we utilized data from the first examination. Three hundred eighty-three participants lacked data on the Paykel questions at their baseline examination, and a further 443 lacked data on covariates, leaving 2,438 participants (1,737 women, 701 men). Participants were born between 1901 and 1930 and were between 79 and 101 years of age (mean 86.6, SD: 6.1) at baseline. To yield a similar follow-up time for all participants, we censored follow-up at 3 years past their first examination. Death dates were retrieved on 04-20-2021 from the Swedish Tax Agency.
      FIGURE 1
      FIGURE 1Included cohorts and examination waves.

      Measures

      The psychiatric interview included the Paykel questions
      • Paykel ES
      • Myers JK
      • Lindenthal JJ
      • et al.
      Suicidal feelings in the general population: a prevalence study.
      which consists of five questions of increasing intensity that assess passive suicidal ideation of two forms (life-weariness and a wish to die) as well as active suicidal ideation: 1) Have you ever felt that life was not worth living? 2) Have you ever wished that you were dead – for instance, that you could go to sleep and not wake up? 3) Have you ever thought of taking your own life, even if you would not really do it? 4) Have you ever reached the point where you seriously considered taking your own life, or perhaps made plans on how you would go about doing it? 5) Have you ever made an attempt to take your own life? In case of a positive response to any of these questions, the participant was asked about the last time this occurred (past week, past month, past year, or longer than a year ago). For the main analysis, we categorized responses into three levels based on the most intense passive or active suicidal ideation experienced during the past month: Life-weariness (positive response to question 1, but not to question 2–5), wish to die (positive response to question 2, but not to question 3–5), active suicidal ideation (positive response to any of questions 3–5). For a sensitivity analysis, we categorized responses in the same manner, for any point in life (any of: past week, past month, past year, or longer than a year ago). The suicide item on the Montgomery Åsberg Depression Rating Scale (MADRS)
      • Montgomery SA
      • Asberg M
      A new depression scale designed to be sensitive to change.
      was also applied. The response options for that item are: 0) Enjoys life or takes it as it comes. 2) Weary of life. Only fleeting suicidal thoughts. 4) Probably better off dead. Suicidal thoughts are common, and suicide is considered a possible solution, but without specific plans or intention. 6) Explicit plans for suicide when there is an opportunity. Active preparations for suicide. Levels 1, 3, and 5 are midpoints between the other options. We categorized levels 0–1 as no suicidal ideation, 2–3 as passive ideation, and 4–6 as active ideation. Loneliness was assessed by the interviewer asking whether the participant felt lonely. Responses “never”, “seldom” and “sometimes” were regarded as not lonely while “often” was regarded as lonely. As this question was not included in two of the examination waves, for these waves we instead examined responses to the following two questions: Have you felt lonelier during the past 5 years due to functional decline or deaths of relatives? Do you find it hard to be alone? A participant with an affirmative response to either of these questions was regarded as lonely.

      Diagnostics

      Dementia was diagnosed as described previously
      • Skoog I
      • Nilsson L
      • Palmertz B
      • et al.
      A population-based study of dementia in 85-year-olds.
      based on the Diagnostic and Statistical Manual of Mental Disorders, revised third edition (DSM-IIIR).
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders: DSM III-R.
      Major and minor depression were diagnosed according to research criteria in the text-revised DSM-IV.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders: DSM-IV TR.
      Information on somatic conditions (myocardial infarction, fracture of the hip, diabetes) was retrieved during the interviews by the interviewer asking the participant whether a nurse or a doctor ever had informed them that they had any of those conditions. In case of missing data on somatic conditions from the participant, information from close informants was used. Cause of death data were retrieved from the Swedish Cause of Death Register. We considered the underlying cause and categorized based on Swedish versions of ICD-9 or ICD-10

      National Board of Health and Welfare. Klassifikationen ICD 10. 2022. Available at: https://www.socialstyrelsen.se/statistik-och-data/klassifikationer-och-koder/icd-10/.

      codes: Cancer (140-208 or C00-C97); Respiratory disorders (460-519 or J00-J99); Ischaemic heart disease (410-414 or I20-I25); Stroke (430-438 or I60-I69); Dementia (290-294/330-337 or F00-F03); Suicide (including uncertain suicides) (E950-E959/E980-E989 or X60-X84/Y10-Y34).

      Statistical Analysis

      We used Pearson χ2 to test for group differences in proportions. We employed the Spearman rank-order correlation coefficient to test correlation between ordinal data. p-values were two-tailed and considered significant <0.05. We used Kaplan-Meier curves to plot survival by level of passive/active suicide ideation and Cox regression models to calculate Hazard Ratios (HRs) with 95% confidence intervals (CI) for mortality. Passive/active suicidal ideation was entered as a categorical variable with no passive/active suicidal ideation as reference. We conducted three models: 1) including sex, age, and examination year, 2) adding somatic conditions (history of myocardial infarction, history of hip fracture, diabetes) and dementia, and 3) adding also loneliness, and depression status (no/minor/major) as a categorical variable with no depression as reference. The proportional hazards assumption was tested by calculating Shoenfeld residuals; no obvious violations were found. In sensitivity analyses, we reran Cox regression models a-c using highest level of lifetime ideation. Further, we reran model a (using past month ideation) stratified by age category, and stratified by decade of examination. Finally, we ran models a-c above replacing levels based on the Paykel questions with levels based on the MADRS suicide item. Four participants had missing data on the MADRS suicide item and were excluded in this analysis. All statistical analyses were performed with IBM SPSS Statistics for Windows (Version 25), except for Shoenfeld residuals which were calculated in StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP.

      RESULTS

      Of all participants, 240 (9.8%) reported some type of passive or active suicidal ideation during the past month. A wish to die was most frequently the highest level reported (Table 1). Within three years of the baseline examination, 672 participants (27.6%) had died. Of those, 102 (15.2%) had reported any level of passive/active suicidal ideation at the baseline examination. Passive/active suicidal ideation tended to be more prevalent in older age categories, in earlier examinations, among women, among participants with a history of hip fracture, among participants with dementia, among those with minor or major depression, and among those who felt lonely (Table 1). The most common cause of death was ischaemic heart disease (22.5%), followed by cancer (14.4%), stroke (10.4%), respiratory disorders (7.9%), and dementia (4.5%). No participant died by suicide. Causes of death did not differ significantly by level of passive/active suicidal ideation (Pearson χ2 (df: 15): p = 0.876) (Supplementary material, Table S1).
      TABLE 1Characteristics of Participants at Baseline Examination in Population-Based Samples of Older Adults, by Most Intense Level of Passive/Active Suicidal Ideation Reported During the Past Month
      TotalNo Passive or Active Suicide IdeationLife-WearinessWish to DieActive Suicide Ideation
      nn (%)n (%)n (%)n (%)dfp
      Pearson χ2
      All24382198 (90.2)63 (2.6)132 (5.4)45 (1.8)
      Sex30.006
       Men701652 (93.0)13 (1.9)22 (3.1)14 (2.0)
       Women17371546 (89.0)50 (2.9)110 (6.3)31 (1.8)
      Age groups6<0.001
       79-84853810 (95.0)18 (2.1)19 (2.2)6 (0.7)
       85-941091948 (86.9)38 (3.5)82 (7.5)23 (2.1)
       95+494440 (89.1)7 (1.4)31 (6.3)16 (3.2)
      Decade of baseline examination9<0.001
       1980s414340 (82.1)18 (4.3)42 (10.1)14 (3.4)
       1990s220188 (85.5)11 (5.0)17 (7.7)4 (1.8)
       2000s932852 (91.4)11 (1.2)50 (5.4)19 (2.0)
       2010s872818 (93.8)23 (2.6)23 (2.6)8 (0.9)
      History of myocardial infarction30.745
       No21801963 (90.0)59 (2.7)118 (5.4)40 (1.8)
       Yes258235 (91.1)4 (1.6)14 (5.4)5 (1.9)
      History of hip fracture3<0.001
       No20621883 (91.3)50 (2.4)98 (4.8)31 (1.5)
       Yes376315 (83.8)13 (3.5)34 (9.0)14 (3.7)
      Diabetes30.414
       No21711955 (90.1)54 (2.5)119 (5.5)43 (2.0)
       Yes267243 (91.0)9 (3.4)13 (4.9)2 (0.7)
      Dementia30.007
       No19731798 (91.1)48 (2.4)93 (4.7)34 (1.7)
       Yes465400 (86.0)15 (3.2)39 (8.4)11 (2.4)
      Depression status<0.001
       No depression18621789 (96.1)30 (1.6)30 (1.6)13 (0.7)
       Minor depression390326 (83.6)17 (4.4)39 (10.0)8 (2.1)
       Major depression18683 (44.6)16 (8.6)63 (33.9)24 (12.9)
      Loneliness6<0.001
       No22452073 (92.3)51 (2.3)99 (4.4)22 (1.0)
       Yes193125 (64.8)12 (6.2)33 (17.1)23 (11.9)
      a Pearson χ2
      As illustrated in Figure 2, participants who reported a wish to die had the lowest survival. Adjusted for age, sex, and examination year (Table 2, model a), only a wish to die was associated with increased mortality. The hazard ratio for a wish to die compared to no ideation was slightly attenuated after including somatic conditions and dementia (model b). In the final model (c) that included also major and minor depression and loneliness, the hazard ratio was further attenuated, although still significantly elevated.
      FIGURE 2
      FIGURE 2Kaplan-Meier plot of survival by most intense level of passive/active suicidal ideation reported during the past month, in population-based samples of Swedish older adults (n = 2,438).
      TABLE 2Cox Regression Models for Time to Death From all Causes Within 3 Years, in a Population Sample of Older Adults (n = 2,438), by Most Intense Level of Passive/Active Suicidal Ideation Reported During the Past Month
      ParticipantsEventsModel a: Including Sex, Age, and Year of Examination.Model b: Model a + Somatic Conditions
      History of myocardial infarction, history of hip fracture, diabetes
      and Dementia
      Model c: Model b + Minor and Major Depression and Loneliness
      nnHR95% CIHR95% CIHR95% CI
      No ideation2198570refrefref
      Life-weariness63191.400.88-2.211.350.85-2.141.210.76-1.93
      Wish to die132652.011.55-2.601.961.51-2.541.701.27-2.26
      Active suicide ideation45181.100.69-1.761.170.73-1.881.030.63-1.69
      Total2438672
      a History of myocardial infarction, history of hip fracture, diabetes

      Sensitivity Analysis

      Replacing level of ideation during the past month with highest level during lifetime in the Cox regression (Supplementary material, Table S2), attenuated the hazard ratios for wish to die somewhat, but did not change the overall pattern. In Cox regressions by age category (Supplementary material, Table S3), a wish to die was associated with mortality in age categories 85–94 and 95+, but not in those under 85 years. Both life-weariness and a wish to die were associated with mortality in those examined in the 1980s. Only a wish to die was associated with mortality in those examined in the 2000s and the 2010s. Active suicidal ideation was not associated with mortality in any decade or age category (Supplementary material, Table S4).
      As responses on the MADRS suicide item and most intense level of ideation based on the Paykel questions differed somewhat (Spearman correlation coefficient 0.69, p <0.001), we reran Cox regression models a-c replacing the exposure variable with one based on the MADRS question. Passive suicidal ideation (MADRS levels 2–3) was associated with mortality in models a–c with successively attenuated hazard ratios (Supplementary material, Table S5). Active suicidal ideation (MADRS levels 4–6) was not associated with mortality in any model.

      CONCLUSION

      Contrary to our hypothesis of a dose-response relationship, only a wish to die was associated with all-cause mortality, after taking age, sex, and examination year into account. Although the hazard ratio was attenuated, a wish to die was still associated with a 70% increased risk of all-cause mortality compared to no ideation in the fully adjusted model including somatic conditions, dementia, depression, and loneliness. Results were corroborated by sensitivity analyses using an alternate measure of suicidal ideation, indicating that passive suicidal ideation was associated with mortality, while active suicidal ideation was not. Results were also corroborated by examining lifetime levels of suicidal ideation, with a wish to die conferring increased risk of mortality.
      Our findings might seem somewhat counterintuitive as passive suicidal ideation is often considered less severe than active suicidal ideation, for example in suicide assessment scales.
      • Posner K
      • Brown GK
      • Stanley B
      • et al.
      The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults.
      However, the clinical importance of passive suicidal ideation has been underlined in previous research. Szanto et al.
      • Szanto K
      • Reynolds 3rd, CF
      • Frank E
      • et al.
      Suicide in elderly depressed patients: is active vs. passive suicidal ideation a clinically valid distinction?.
      found that among older adults with major depression, clinical presentation did not differ in those with passive versus active suicidal ideation. Baca-Garcia et al.
      • Baca-Garcia E
      • Perez-Rodriguez MM
      • Oquendo MA
      • et al.
      Estimating risk for suicide attempt: are we asking the right questions? Passive suicidal ideation as a marker for suicidal behavior.
      found, in a study on U.S. adults, that desire for death and suicidal ideation were associated with similar risk of lifetime suicide attempt. Studies on Swedish,
      • Van Orden KA
      • Simning A
      • Conwell Y
      • et al.
      Characteristics and comorbid symptoms of older adults reporting death ideation.
      and U.S. older adults
      • Van Orden KA
      • O'Riley AA
      • Simning A
      • et al.
      Passive suicide ideation: an indicator of risk among older adults seeking aging services?.
      have emphasized the importance of passive suicidal ideation as it seldom occurs in the absence of previous active suicidal ideation or current anxiety or depression. Further, a recent systematic review and meta-analysis found that passive and active suicidal ideation were associated with similar psychiatric morbidity and sociodemographic characteristics.
      • Liu RT
      • Bettis AH
      • Burke TA
      Characterizing the phenomenology of passive suicidal ideation: a systematic review and meta-analysis of its prevalence, psychiatric comorbidity, correlates, and comparisons with active suicidal ideation.
      There are several possible explanations for the increased mortality among persons who wish to die. Firstly, we note that no participant died by suicide. Perhaps the most intuitive explanation is that those who wish to die also have poor physical health. This partly explained the excess mortality in the previously mentioned Australian
      • Batterham PJ
      • Calear AL
      • Mackinnon AJ
      • et al.
      The association between suicidal ideation and increased mortality from natural causes.
      and Irish
      • Ragab I
      • Ward M
      • Moloney D
      • et al.
      'Wish to die' is independently associated with cardiovascular mortality in later life. Data from TILDA.
      studies. Mirroring those results, we could see that the hazard ratio for a wish to die decreased, although only very slightly, after including somatic conditions in the model. There is of course a possibility of unmeasured and residual confounding, as our measurements of somatic health were limited. Another explanation is that a wish to die can be a symptom of depression, which is consistently associated with mortality,
      • Cuijpers P
      • Vogelzangs N
      • Twisk J
      • et al.
      Comprehensive meta-analysis of excess mortality in depression in the general community versus patients with specific illnesses.
      a major part of which may be due to its causally reciprocal relation with ischaemic heart disease.
      • Stapelberg NJ
      • Neumann DL
      • Shum DH
      • et al.
      A topographical map of the causal network of mechanisms underlying the relationship between major depressive disorder and coronary heart disease.
      A study from the United States on older adults found that among those with minor or major depression, those who also wished to die had higher mortality, if receiving treatment as usual. This difference was not observed in those who were treated at centers randomized to having depression care managers who helped physicians optimize depression treatment.
      • Raue PJ
      • Morales KH
      • Post EP
      • et al.
      The wish to die and 5-year mortality in elderly primary care patients.
      This supports an explanation that some of the excess mortality in older adults with a wish to die may be due to inadequate treatment of depression. However, also those who wished to die in the absence of depression in that study were at increased risk of mortality, controlling for functional disability and smoking status. This is in line with our results where a wish to die was associated with mortality also after controlling for minor and major depression.
      A further possibility is that a wish to die is associated with mortality due to associations with social determinants of health, such as social support and feelings of belonging.
      • Fassberg MM
      • van Orden KA
      • Duberstein P
      • et al.
      A systematic review of social factors and suicidal behavior in older adulthood.
      ,
      • Cui R
      • Gujral S
      • Galfalvy H
      • et al.
      The role of perceived and objective social connectedness on risk for suicidal thoughts and behavior in late-life and their moderating effect on cognitive deficits.
      We were able to partly control for this through perceived loneliness, which is associated with mortality in older adults.
      • Barnes TL
      • Ahuja M
      • MacLeod S
      • et al.
      Loneliness, social isolation, and all-cause mortality in a large sample of older adults.
      However, a wish to die remained significant in the fully adjusted model. This remaining increased risk must then either be due to unmeasured or residual confounding, or due to one or several mechanisms, behavioral or biological, through which a wish to die shortens life.
      Concerning causality between psychological states (such as a wish to die) and physical illness, Engel
      • Engel GL
      A life setting conducive to illness. The giving-up–given-up complex.
      suggested a psychological state he called the “giving up, given up”-complex, which may increase the risk of physical illness. This was based on observations that such a state often preceded physical illness. However, the direction of causality is not known, it is possible that undiagnosed physical illness presents as a negative psychological state. A Danish study suggested that mental stress may play a causal role in excess mortality based on a population-based study on bereavement. They found an increased risk of mortality, particularly during the first month after bereavement (HR 2.50; 95% CI 2.37–2.63), after controlling for demographic factors and physical and mental disorders.
      • Prior A
      • Fenger-Grøn M
      • Davydow DS
      • et al.
      Bereavement, multimorbidity and mortality: a population-based study using bereavement as an indicator of mental stress.
      As a wish to die may be perceived as stressful, this finding to some extent supports causality between a wish to die and death, although we cannot say if the mechanism is behavioral or biological. A further possibility is internalized ageism, which has been associated with premature mortality,
      • Rakowski W
      • Hickey T
      Mortality and the attribution of health problems to aging among older adults.
      and also shown to weaken the will to live in older adults in an experimental setting.
      • Levy B
      • Ashman O
      • Dror I
      To be or not to be: the effects of aging stereotypes on the will to live.
      It could be that a wish to die is an indicator of internalized ageism. If so, this has clear implications for intervention.
      We cannot say why the mechanisms discussed above may only, or more strongly operate for those with a wish to die, and not for those with other types of suicidal ideation. Cause of death did not differ by type of ideation, but the study was underpowered for such an analysis. Although we adjusted for some measurements of physical health, it is still possible that persons with a wish to die are more physically ill than persons with life-weariness or active suicidal ideation.
      Another question is whether our results are clinically meaningful. The 70% increased mortality in the present study for persons with a wish to die can be compared to the 23% increased risk for older adults with a wish to die or suicidal ideation in the previously mentioned Australian study.
      • Batterham PJ
      • Calear AL
      • Mackinnon AJ
      • et al.
      The association between suicidal ideation and increased mortality from natural causes.
      The authors of that study found that the population attributable mortality risk for suicidal ideation/a wish to die was similar to that of depression. As we found an even higher hazard ratio for a wish to die, we argue that our results are clinically meaningful. Older adults who report a wish to die require careful clinical assessment, for instance regarding poor self-care or demoralization even if they do not present with the typical major depressive picture.

      Strengths and Limitations

      Strengths of the study include the large and representative sample of the general older adult population in Sweden, the good response rate, and the comprehensive assessment of passive and active suicidal ideation.
      Some limitations should be mentioned. First, fewer participants reported life-weariness and active suicidal ideation as highest level than who reported a wish to die as highest level. This might have underpowered the analyses in these groups. Although the difference in mortality between a wish to die and active ideation was fairly robust, the confidence intervals for life-weariness and a wish to die had a larger overlap, in line with the sensitivity analysis employing the MADRS question, indicating a higher risk for passive ideation. Second, the frailest participants, with the highest risk of death, are more likely to have not participated, based on the previously published slightly higher mortality among non-participants in some,
      • Jonson M
      • Sigström R
      • Mellqvist-Fässberg M
      • et al.
      Passive and active suicidal ideation in Swedish 85-year-olds: time trends 1986-2015.
      but not all
      • Andersson M
      • Guo X
      • Börjesson-Hanson A
      • et al.
      A population-based study on dementia and stroke in 97 year olds.
      of the samples included in this study. This may have led to an under-estimation of the association between passive/active suicidal ideation and mortality, as we expect this group to have a higher prevalence of suicidal ideation. Third, some of the data emanate from interviews carried out several decades ago and might therefore not be generalizable to today's older adults. We note, however, that the association between death wishes and mortality was observed across examination decades. Fourth, loneliness was based on different questions in some examination waves, which might have affected analyses of that factor. Fifth, depression diagnoses were not specific for geriatric depression. This may have underestimated the contribution of depression on mortality. Sixth, as we only had cross-sectional data, we were unable to investigate the potentially mediating effect of health-related behavior. It is possible that those who wish to die make less healthy decisions regarding lifestyle, seek less healthcare and adhere less to treatment. Also due to the cross-sectional nature of our data, we cannot examine how changes in suicidal ideation and depression over time might influence mortality. However, the sensitivity analysis using lifetime ideation instead of past month yielded similar results.

      DATA STATEMENT

      The data has previously been presented as a digital poster, to conference attendees, at the International Summit on Suicide Research in October 25-27, 2021. It has also been presented orally, to conference attendees, at the Swedish Psychiatry Conference in Stockholm, March 17, 2022.

      AUTHOR CONTRIBUTIONS

      MJ, RS, KAVO and MW designed this substudy. MW was main supervisor. IS designed the original population study and supervised data collection. MJ and RS carried out the data analyses. MJ prepared the first draft of the manuscript. All authors contributed to data interpretation and manuscript preparation, and all have approved the final manuscript.

      DISCLOSURE

      MW has received Textbook royalties from Liber Förlag and Studentlitteratur (three textbooks). She has also provided consultation regarding Suicide assessment scales for Jansen Pharmaceuticals, provided local, regional, and national education for care professionals and social workers, and also educational activities through NGOs (Gothenburg University was remunerated for these services). For the remaining authors no conflicts of interest were declared.
      The study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (ALF965812, ALF 716681, ALFGBG-942684, ALFGBG-715841, ALFGBG-965525, ALFGBG 147361, ALFGBG 433511), the Swedish Research Council (2012-5041, 2013-8717, 2013-02699, 2015-02830, 2016-01590, 2017-00639, 2019-01096), the Swedish Research Council for Health, Working Life and Welfare (Forte) (2012-1138, 2013-1202, AGECAP 2013-2300, 2013-2496, 2013-0475, 2016-07097, 2017-1604, 2018-00471), Konung Gustaf V:s och Drottning Victorias Frimurarestiftelse (Waern, Skoog), Hjärnfonden/Swedish Brain Foundation (FO2014-0207, FO2016-0214, FO2018-0214, FO2019-0163, FO2020-0235), Alzheimerfonden (AF-554461, AF-647651, AF-743701, AF-844671, AF-930868, AF940139, AF-968441), Eivind och Elsa K:son Sylvans stiftelse, the Alzheimer's Association (IIRG-09-131338), Stiftelsen Söderström-Königska Sjukhemmet, Stiftelsen för Gamla Tjänarinnor, Göteborg Center for person-centered care, Dahren's fund for schizophrenia research, and the Hjalmar Svensson Foundation.

      Appendix. SUPPLEMENTARY MATERIALS

      References

        • Paykel ES
        • Myers JK
        • Lindenthal JJ
        • et al.
        Suicidal feelings in the general population: a prevalence study.
        Br J Psychiatry. 1974; 124: 460-469
        • Batterham PJ
        • Calear AL
        • Mackinnon AJ
        • et al.
        The association between suicidal ideation and increased mortality from natural causes.
        J Affect Disord. 2013; 150: 855-860
        • Ragab I
        • Ward M
        • Moloney D
        • et al.
        'Wish to die' is independently associated with cardiovascular mortality in later life. Data from TILDA.
        Int J Geriatr Psychiatry. 2021; 36: 1004-1010
        • Shiner B
        • Riblet N
        • Westgate CL
        • et al.
        Suicidal ideation is associated with all-cause mortality.
        Mil Med. 2016; 181: 1040-1045
        • Skoog I
        • Aevarsson O
        • Beskow J
        • et al.
        Suicidal feelings in a population sample of nondemented 85-year-olds.
        Am J Psychiatry. 1996; 153: 1015-1020
        • Fagerström C
        • Welmer AK
        • Elmståhl S
        • et al.
        Life weariness, suicidal thoughts and mortality: a sixteen-year longitudinal study among men and women older than 60 years.
        BMC Public Health. 2021; 21: 1359
        • Macdonald AJ
        • Dunn G
        Death and the expressed wish to die in the elderly: an outcome study.
        Age Ageing. 1982; 11: 189-195
        • Ashby D
        • Ames D
        • West RC
        • et al.
        Psychiatric morbidity as predictor of mortality for residents of local authority homes for the elderly.
        Int J Geriatr Psychiatry. 1991; 6: 567-575
        • Dewey ME
        • Davidson IA
        • Copeland JR
        Expressed wish to die and mortality in older people: a community replication.
        Age Ageing. 1993; 22: 109-113
        • Raue PJ
        • Morales KH
        • Post EP
        • et al.
        The wish to die and 5-year mortality in elderly primary care patients.
        Am J Geriatr Psychiatry. 2010; 18: 341-350
        • Khang YH
        • Kim HR
        • Cho SJ
        Relationships of suicide ideation with cause-specific mortality in a longitudinal study of South Koreans.
        Suicide Life Threat Behav. 2010; 40: 465-475
        • Rinder L
        • Roupe S
        • Steen B
        • et al.
        Seventy-year-old people in Gothenburg. A population study in an industrialized Swedish city.
        Acta Med Scand. 1975; 198: 397-407
        • Bengtsson C
        • Ahlqwist M
        • Andersson K
        • et al.
        The prospective population study of women in gothenburg, sweden, 1968-69 to 1992-93. A 24-year follow-up study with special reference to participation, representativeness, and mortality.
        Scand J Prim Health Care. 1997; 15: 214-219
        • Fassberg MM
        • Vanaelst B
        • Jonson M
        • et al.
        Epidemiology of suicidal feelings in an ageing Swedish population: from old to very old age in the Gothenburg H70 birth cohort studies.
        Epidemiol Psychiatr Sci. 2019; : 1-14
        • Jonson M
        • Sigström R
        • Mellqvist-Fässberg M
        • et al.
        Passive and active suicidal ideation in Swedish 85-year-olds: time trends 1986-2015.
        J Affect Disord. 2021; 290: 300-307
        • Montgomery SA
        • Asberg M
        A new depression scale designed to be sensitive to change.
        Br J Psychiatry. 1979; 134: 382-389
        • Skoog I
        • Nilsson L
        • Palmertz B
        • et al.
        A population-based study of dementia in 85-year-olds.
        N Engl J Med. 1993; 328: 153-158
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders: DSM III-R.
        3 ed. American Psychiatric Association, Washington DC1987
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders: DSM-IV TR.
        4 ed. American Psychiatric Association, Washington, DC2000
      1. National Board of Health and Welfare. Klassifikation av sjukdomar. 1987. Available at: https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/dokument-webb/klassifikationer-och-koder/icd9-ks87-inledning-1987.pdf1986.

      2. National Board of Health and Welfare. Klassifikationen ICD 10. 2022. Available at: https://www.socialstyrelsen.se/statistik-och-data/klassifikationer-och-koder/icd-10/.

        • Posner K
        • Brown GK
        • Stanley B
        • et al.
        The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults.
        Am J Psychiatry. 2011; 168: 1266-1277
        • Szanto K
        • Reynolds 3rd, CF
        • Frank E
        • et al.
        Suicide in elderly depressed patients: is active vs. passive suicidal ideation a clinically valid distinction?.
        Am J Geriatr Psychiatry. 1996; 4: 197-207
        • Baca-Garcia E
        • Perez-Rodriguez MM
        • Oquendo MA
        • et al.
        Estimating risk for suicide attempt: are we asking the right questions? Passive suicidal ideation as a marker for suicidal behavior.
        J Affect Disord. 2011; 134: 327-332
        • Van Orden KA
        • Simning A
        • Conwell Y
        • et al.
        Characteristics and comorbid symptoms of older adults reporting death ideation.
        Am J Geriatr Psychiatry. 2013; 21: 803-810
        • Van Orden KA
        • O'Riley AA
        • Simning A
        • et al.
        Passive suicide ideation: an indicator of risk among older adults seeking aging services?.
        Gerontologist. 2015; 55: 972-980
        • Liu RT
        • Bettis AH
        • Burke TA
        Characterizing the phenomenology of passive suicidal ideation: a systematic review and meta-analysis of its prevalence, psychiatric comorbidity, correlates, and comparisons with active suicidal ideation.
        Psychol Med. 2020; 50: 367-383
        • Cuijpers P
        • Vogelzangs N
        • Twisk J
        • et al.
        Comprehensive meta-analysis of excess mortality in depression in the general community versus patients with specific illnesses.
        Am J Psychiatry. 2014; 171: 453-462
        • Stapelberg NJ
        • Neumann DL
        • Shum DH
        • et al.
        A topographical map of the causal network of mechanisms underlying the relationship between major depressive disorder and coronary heart disease.
        Aust N Z J Psychiatry. 2011; 45: 351-369
        • Fassberg MM
        • van Orden KA
        • Duberstein P
        • et al.
        A systematic review of social factors and suicidal behavior in older adulthood.
        Int J Environ Res Public Health. 2012; 9: 722-745
        • Cui R
        • Gujral S
        • Galfalvy H
        • et al.
        The role of perceived and objective social connectedness on risk for suicidal thoughts and behavior in late-life and their moderating effect on cognitive deficits.
        Am J Geriatr Psychiatry. 2022; 30: 527-532
        • Barnes TL
        • Ahuja M
        • MacLeod S
        • et al.
        Loneliness, social isolation, and all-cause mortality in a large sample of older adults.
        J Aging Health. 2022; 8982643221074857
        • Engel GL
        A life setting conducive to illness. The giving-up–given-up complex.
        Bull Menninger Clin. 1968; 32: 355-365
        • Prior A
        • Fenger-Grøn M
        • Davydow DS
        • et al.
        Bereavement, multimorbidity and mortality: a population-based study using bereavement as an indicator of mental stress.
        Psychol Med. 2018; 48: 1437-1443
        • Rakowski W
        • Hickey T
        Mortality and the attribution of health problems to aging among older adults.
        Am J Public Health. 1992; 82: 1139-1141
        • Levy B
        • Ashman O
        • Dror I
        To be or not to be: the effects of aging stereotypes on the will to live.
        Omega (Westport). 1999; 40: 409-420
        • Andersson M
        • Guo X
        • Börjesson-Hanson A
        • et al.
        A population-based study on dementia and stroke in 97 year olds.
        Age Ageing. 2012; 41: 529-533