ArticleInternational journal of women's health2026
The Ripple Effect: A Serial Mediation Analysis of Multimorbidity and Depressive Symptoms Among Women in Midlife in China.
Article in International journal of women's health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Purpose: Multimorbidity is a primary risk factor for depressive symptoms, particularly among women in midlife. Guided by stress process theory, this study investigated the underlying mechanisms of this association by testing a serial mediation model involving functional limitations, self-rated health, and life satisfaction. Methods: This study conducted a secondary analysis using data from the fifth wave of the China Health and Retirement Longitudinal Study (CHARLS)-2020. The final analysis included 4,106 women aged 45-60 years. Multimorbidity was defined as a self-reported diagnosis of two or more out of 14 chronic somatic conditions, and depressive symptoms were assessed using the Center for Epidemiological Studies-Depression (CES-D) scale. The serial mediation analysis was conducted in SPSS using the PROCESS macro via bootstrapping. Results: The prevalence of multimorbidity and depressive symptoms among women in midlife was 10.35% and 41.50%, respectively. Our findings highlight a specific cascade of effects, where functional limitations, self-rated health, and life satisfaction serially and partially mediated the association between multimorbidity and depressive symptoms (total effect c=1.206, 95% CI=0.986 to 1.426; direct effect c'=0.421, 95% CI=0.220 to 0.622; total indirect effect ab=0.785, 95% CI=0.655 to 0.918). However, life satisfaction alone showed no significant mediating effect on the association between multimorbidity and depressive symptoms (a3b3=0.046, 95% CI: -0.022 to 0.113). Among the seven mediation pathways, self-rated health accounted for the largest mediation effect of the total effect (30.60%), followed by functional limitations (14.26%) and a combination of self-rated health and life satisfaction (8.04%). Conclusion: Our findings offer a comprehensive insight into the complex relationship between multimorbidity and depressive symptoms through various mediating mechanisms under a well-developed theoretical framework. These findings hold significant implications for the prevention and intervention efforts for depressive symptoms among women in midlife, underscoring the pivotal role of alleviating functional limitations, improving self-rated health, and enhancing life satisfaction.
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