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Association of objective visual impairment with suicidal ideation and suicide attempts among adults aged ≥50 years in low/middle-income countries
  1. Lee Smith1,
  2. Jae Il Shin2,
  3. Yvonne Barnett3,
  4. Peter M Allen4,
  5. Rosie Lindsay4,
  6. Damiano Pizzol5,
  7. Louis Jacob6,
  8. Hans Oh7,
  9. Lin Yang8,
  10. Mark A Tully9,
  11. Nicola Veronese10,
  12. Ai Koyanagi11
  1. 1The Cambridge Centre for Sport and Exercise Science, Anglia Ruskin University—Cambridge Campus, Cambridge, UK
  2. 2Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
  3. 3Faculty of Science and Engineering, Anglia Ruskin University—Cambridge Campus, Cambridge, UK
  4. 4Vision and Hearing Sciences Research Centre, Anglia Ruskin University, Cambridge, UK
  5. 5Italian Agency for Development Cooperation, Khartoum, Sudan
  6. 6Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux, France
  7. 7School of Social Work, University of Southern California, Los Angeles, California, USA
  8. 8Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Calgary, Alberta, Canada
  9. 9Institute of Mental Health Sciences, Ulster University, Coleraine, Londonderry, UK
  10. 10Department of Medicine, University of Palermo, Palermo, Italy
  11. 11Research and development unit, Parc Sanitari Sant Joan de Déu/CIBERSAM, Universitat de Barcelona, Fundació Sant Joan de Déu, Barcelona, Spain
  1. Correspondence to Dr Lee Smith, The Cambridge Centre for Sport and Exercise Science, Anglia Ruskin University - Cambridge Campus, Cambridge, Cambridgeshire, UK; lee.smith{at}


Background There is currently limited literature on the association between visual impairment and suicidal thoughts and behaviours, especially among older adults from low/middle-income countries (LMICs). Thus, we aimed to investigate the associations of objectively measured distance visual impairment with suicidal ideation and suicide attempts among adults aged ≥50 years from six LMICs and to identify potential mediators.

Methods Cross-sectional, community-based, nationally representative data from the WHO Study on global AGEing and adult health were analysed. Objective distance visual acuity was measured using the tumbling E logMAR chart, and vision impairment was categorised as none, mild, moderate and severe. Self-reported information on past 12-month suicidal ideation and suicide attempts was also collected. Multivariable logistic regression and mediation analysis were conducted.

Results Data on 34 129 individuals aged ≥50 years (mean (SD) age, 62.4 (16.0) years; 47.9% men) were analysed. After adjustment for potential confounders, compared with no visual impairment, severe visual impairment was significantly associated with suicidal ideation (OR=9.50; 95% CI=2.47 to 36.52). Moderate and severe visual impairment were significantly associated with a 2.22 (95% CI=1.14 to 4.35) and 11.50 (95% CI=1.44 to 91.88) times higher odds of suicide attempts, respectively. Disability, poor self-rated health, mobility and loneliness explained 14.0%, 9.3%, 7.2% and 6.3% of the association between moderate/severe visual impairment and suicide attempts, respectively.

Conclusion Interventions to reduce suicidal ideation and suicide attempts among older adults with visual impairment in LMICs are required, targeting identified mediators, while using tested strategies for suicide prevention per se in LMICs may yield beneficial outcomes.

  • vision
  • epidemiology
  • public health

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request.

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  • Contributors LS prepared and analysed the data, and wrote the first draft of the manuscript. All authors contributed to the study design, analysis and writing of the final manuscript. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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